You are on page 1of 105

American Academy of Ophthalmology

PART I : EXTERNAL DISEASE

EYELID DISEASE
Section A

Meibomian Gland Dysfunction


Enlargement , Irregularity, Inspissation, Plugging of the meibomian gland orificies

Meibomian Gland Dysfunction


Concomitant involvement of the sebaceous glands of Zeis produces oily debris (scurf) along the eye lash

Staphylococcal Blepharitis
Lid margin erythema and ulceration, fibrin, collaretes, and crusts at the base of the lashes

Angular Blepharitis
Maceration and crusting of the skin at the lateral (sometimes medial) canthus

Molluscum Contagiosum
Papule and enlarging to a waxy nodule with an umbilical center

Hordeolum and Chalazion


External hordeolum focal, erythematous swelling of the anterior eyelid margin, often an infected gland of Zeis

Hordeolum and Chalazion


Chalazion : chronic lipogranuloma of an occluded meibomian gland

Viral Papilloma
Painless, keratanized cutaneous lesion, usually without inflammation

Seborrheic Keratosis
Pigmented, well demarcated and slightly elevated Warty and crusted, oftern has a stuck on appearance, with visible keratotic plugs

Xanthelasma
Yellow to-tan plaque that often involves the medial portion of the upper and lower eyelids Superficial dermis contains foamy histiocytes, filled with cholesterol esters

Basal Cell Carcinoma


Nodular lesion with teleangiectic vessels at its border Larger lesions umbilicated with smooth, pearly borders.

Squamous Cell Carcinoma


Keratinized lesion, often affecting the eyelid margin

Sturge-Weber Syndrome
Facial port-wine stain, with or without leptomeningeal angiomatosis Choroidal hemangioma is most common intraocular abnormality associated with SturgeWeber syndrome.

Capillary Hemangioma
Reddish purple tumor strawberry nevus Ambliopia can occur secondary to ptosis, strabismus, or astigmatism and anisometropia

Allergic Contact Dermatitis


Development of acute irritation, erythema, swelling and dry or wet (eczema) of the skin around the lids, with application of a preparation to the periocular facial skin or the eye

LACRIMAL SYSTEM DISORDERS


Section B

Canaliculitis
Tearing, a prominent punctum, and swelling and tenderness over the canaliculus Milking the canaliculus

Dacryocystitis
Tender swelling over the lacrimal sac, accompanied by pain, erythema, and discharge

Normal Tear Film


Three layer : Mucin layer, Aqueous layer, Oil layer

Keratoconjunctivitis Sicca
Diffuse ppunctate erosions and conjunctivitis over the interpalpebral area

Keratoconjunctivitis Sicca
The cornea and conjunctiva often stain brightly with rose bengal in an exposure pattern

CONJUNCTIVAL DISEASE
Section c

Follicular Conjunctival Reaction


Conjunctival vascular dilation, sometimes accompanied by conjunctival edema and discharge

Papillary Conjunctival Reaction


Upper tarsal conjunctiva, a papillary response is a fine mosaic pattern of dilated, telangiectatic blood vessels.

Adenoviral Conjunctivitis
Hyperemic and congestive conjunctival reaction Serous discharge and preauricular lymphadenopathy

Epidemic Keratoconjunctivitis
External ocular adenovirus infection Preauriculer lymphadenopathy and a mixed papillary-follicular conjunctivitis

Membranous Conjunctivitis
Inflammatory discharge of fibrin with polymorphonuclear leukocytes and fibrin coagulates of the conjunctival surface

Gonococcal Keratoconjunctivitis
Rapid progression, copiously purulent conjunctival discharge, marked conjunctival hyperemia and chemosis, and eyelid edema

Chlamydial Keratoconjunctivitis
Prominent follicular response with nontender preauricular lymphadenopathy

Trachoma
conjunctival scarring can subsequently lead to a dry eye, trichiasis, and entropion

Trachoma
Herberts pits are small depressions at the limbus that represent areas of slight thinning at the site of necrotic follicles

Allergic (Hay Fever) Conjunctivitis


Conjunctival hyperemia, chemosis and mucoid discharge

Atopic Keratoconjunctivitis
Small to medium-sized papillae that are equally prominent on the upper and lower palpebral conjunctiva, milky bulbar conjunctival edema

Vernal Keratoconjunctivitis
Palpebral vernal diffuse papillary hypertrophy develops with giant (cobblestone) papillae

Vernal Keratoconjunctivitis
Sterile epithelial ulcers with an oval or shield shape, and underlying stromal opacification, may also develop in the midsuperior cornea

Giant Papillary Conjunctivitis


Chronic inflammation of the conjunctiva with prominent papillary hypertrophy of the superior tarsus

Superior Limbic Keratoconjunctivitis


Fine papillary reaction on the superior tarsal conjunctiva; injection and thickening of the superior bulbar conjunctiva and hypertrophy of the superior limbus; and fine punctate fluorescein and rose bengal staining of the superior bulbar conjunctiva above the limbus and of the superior cornea just below the limbus

Stevens-Johnson Syndrome
Acute, inflammatory, vesicobullous reaction of the skin and mucous Mucopurulent conjunctival discharge

Conjunctival Nevus
Congenital hamartomas that consist of nests of modified melanocytes Junctional, compound, and subepithelial nevi occur in the conjunctiva

Adrenochrome Deposits
Conjunctival or corneal darkly pigmented deposits can occur in patients who are using topical epinephrine compounds for glaucoma

Pinguecula
Degenerative lesion of the bulbar conjunctiva that occurs adjacent to the limbus in the interpalpebral zone, most often nasally Yellow-white amorphous, subepithelial deposits, gradually enlarge

Pterygium
Benign proliferation of fibrovascular tissue covered by conjunctivallike epithelium extending onto the peripheral cornea

Pyogenic Granuloma
This raised, fleshy, red pedunculated lesion can arise from skin or conjunctiva usually accompanied by mucopurulent or purulent discharge

Phlyctenulosis
Focal, translucent lymphocytic nodules generally located at the limbus and usually accompanied by significant inflammation

Conjunctival Viral Papilloma


Pedunculated or sessile appearance

Conjunctival/Cornea Intraepithelial Neoplasia


Gelatinous, sessile appearance with numerous tiny superficial corkscrewlike blood vessels typically located at the limbus

Conjunctival/Cornea Intraepithelial Neoplasia


If CIN spreads onto the adjacent cornea, the cornea epithelim will typically have an irregular opalescent appearance with small, white, intraepithelial opacities and a central fimbriated edge

Conjunctival Lymphoma
Both bening reactive lymphoid hyperplasia and malignant lymphoma of the conjunctiva can produce a salmon-colored tumor

Primary Acquired Conjunctival Melanosis (PAM)


Intraepithelial melanocytes proliferate to produce multiple flat, brown, intermittently changing patches of unilateral pigmentation within the superficial conjunctiva

SCLERAL DISEASE
Section d

Episcleritis
Inflammation and vasodilation of the episclera Ocular pain -, tenderness -

Scleritis
Active inflammation violaceous hue best seen in natural sunlight Engorgement of the deep vascular plexus is evident

Scleromalacia Perforans
Painless necrotizing scleritis Bluish color in affected regions as uveal pigment begins to show through the thinned sclera

Congenital Melanosis Oculi


Congenital blue nevus of the episclera and sclera associated with increased pigmentation of the uveal tract

American Academy of Ophthalmology

PART II : CORNEA

INFECTIOUS & INFLAMMATORY CORNEAL DISEASE


Section A

Bacterial Keratitis : Streptococcus Pneumoniae


Corneal ulcers with relatively distinct borders, sometimes with overhanging edges

Bacterial Keratitis : Pseudomonas Aeruginosa


Rapid evolution ulcers and a marked tendency to spread Frequently a tenacious, mucopurulent discharge adheres to the ulcer surface

Fungal Keratitis
Gray-white, dry-appearing infiltrate that has a delicately filamentous or feathery edge

Acanthamoeba Keratitis
Stromal infection occurs central cornea gray white superficial infiltrates Partial or complete ring infiltrate in the paracentral cornea

Primary Herpes Simplex Virus Infection


Unilateral vesicular blepharoconjunctivitis Typical epithelial dendrites are seen in some cases, but mostly scattered punctate epithelial lesions or only a follicular conjunctivitis

Herpes Simplex Virus Dendritic and Geographic Epithelial Keratitis


HSV dendrites most commonly occur in the center of the corne; their branches have a characteristic morphology referred to as terminal bulbs

Herpes Simplex Virus Dendritic and Geographic Epithelial Keratitis


Centrifugal spread of HSV infection from a central dendrite toward the peripheral cornea

Herpes Simplex Virus Disciform Keratitis


Nonnecrotizing keratits focal, circular area of microcystic edema overlying a mild (lymphocytic) stromal inflammatory infiltrate and stromal edema wit Descemets folds and underlying keratitic precipitates

Herpes Simplex Virus Necrotizing Stromal Keratitis


Severe stromal inflammation, corneal neovascularization, thinning, and sometimes stromal necrosis and perforation

Trophic Epithelial Defect Following HSV Stromal Keratitis


Postinfectious keratopathy trophic, indolent, or metaherpetic ulcer Round or oval ulcer with smooth, thickened edges that often overlie an area of stromal inflammation or inactive stromal scarring

Herpes Zoster Dendritiform Keratitis


Dendritiform keratitis, in which the pseudodendites differ in appearance from the dendrites that characterize HSV keratits Have heaped-up epithelium with unusual branching patterns, but they lack terminal bulbs

Herpes Zoster Ophthalmicus Mucous Plaque Keratopathy


Elevated mucous plaques resembling dendrites can occur weeks to months after resolution of cutaneous lesions

Marginal Keratitis Associated with Staphylococcal Blepharitis


These marginal ulcers are usually seen near the inferior limbus, with a clear zone between the infiltrate and the limbus

Rosacea Keratitis
Oculodermatologic disease characterized by facial telangiectasia and erythema; sebaceous gland dysfunction of the face, neck and shoulders; and vasomotor instability

Rosacea Keratitis
Corneal neovascularization and scarring can follow repeated bouts of ocular surface inflammation

Thygesons Superficial Punctate Keratitis


Recurrent episodes of tearing, foreign body sensation, photophobia and reduced vision. Corneal epithelial lesions are round or vertically oral conglomerates of gray, granular opacities that tend to cluster in the central cornea

Luetic Interstitial Keratitis


Corneal scarring, thinning, and ghost vessels in the mid-to-deep stroma

CORNEAL DYSTROPHIES/ECTATIC DISORDER/INHERITED DISEASES


Section B

Corneal Epithelial Basement Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy)


Gray patches in the central epihtelium

Corneal Epithelial Basement Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy)


Fine lines in the central epithelium

Lattice Corneal Dystrophy


Lattice lines refractile lines, small white dots, and haze in the central supercial stroma

Granular Corneal Dystrophy


Discrete, chaly, granular opacities in the axial cornea with clar areas of intervening stroma

Macular Corneal Dystrophy


Deposits of glycosaminoglycans, grayish white, irregular, feathery lesions originating in the axial stroma, but ultimately involving the cornea at all levels

Cornea Guttata
Round, dark, drop like prominences at the level of Descemets membarane and the corneal endothelium The guttae represent thickening and localize anvil-shaped excrescences of Descemets membrane

FuchsEndothelial Dystrophy
Significant density of cornea guttae

FuchsEndothelial Dystrophy
Attenuation and dysfunction of endothelial cells, which leads to corneal edema

Posterior Polymorphous Dystrophy


Scattered asymptomatic vesicles, extensive polymorphous and geographic lesions, or broad bands with scalloped edges on Descemets membrane

Keratoconus
The central or paracentral cornea undergoes progressive thinning and bulging so that the cornea takes on the shape of a cone Vogts striae, Fleischers ring, apical anterior stromal scarring, irregular scissoring retinoscopic relex

Posterior Embryotoxon
Thickened and anteriorly displace Schwalbes ring

Riegers Anomaly and Riegers Syndrome


Congenital condition consisting of a centrally displaced Schwalbes ring, prominent iris processes, and atrophy of the iris stroma

CORNEAL DEGENERATIONS
Section C

Corneal Arcus
Deposition of lipid in the peripheral corneal stroma

Vogts Limbal Girdle


Corneal degeneration consisting of chalky white, superficial opacity located just anterior to and parallel to the limbus in the interpalpebral fissure

Spheroidal Degeneration
Translucent, golden brown globular deposit in the cornea

Calcific Band Keratopathy


Band-shaped opacity seen in the interpalpebral fissure in typical cases First presents with fine, white, dust like deposites in the peripheral Bowmans layer, with a lucid interval between the limbus and the deposit

Secondary Lipid Keratopathy


Deposition of yellow white lipids in the corneal stroma as a result of long standing deep corneal vascularization

Salzmanns Nodular Corneal Degeneration


One or more bluish gray, raised nodules on the corneal surfaces More commonly seen in the midperphery

Neurotrophic Keratopathy
Keratopathy that generally involves the central or inferior paracentral cornea Surrounded by raised, rolled up, gray edges

Moorens Ulcer
Chronic, progressive, idiopathic ulceration of the peripheral corneal stroma and epithelium

Peripheral Corneal Ulceration from Rheumatoid Arthritis


Noninfectious corneal ulcers begin within 2 mm of the limbus, often show minimal cellular infiltrate

Terriens Marginal Degeneration


Nonulcerated depression at the superior (rarely inferior) limbus and progresses slowly

CORNEAL INJURIES
Section D

Corneal Foreign Body


Common and the patient usually has an appropiate history

Alkali Burn
Extensive limbal epithelial damage and ischemia, stromal opacification, and intraocular chemical penetration

Alkali Burn
Blanching of the inferior perilimbal conjunctiva and sclera with a few scattered conjunctiva hemorrhages and chemosis

Miscellaneous
New vessels formation on chronic ulcer of the cornea