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 .

fibrin.Staphylococcal Blepharitis Lid margin erythema and ulceration. 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 .

often an infected gland of Zeis .Hordeolum and Chalazion External hordeolum  focal. erythematous swelling of the anterior eyelid margin.

Hordeolum and Chalazion Chalazion : chronic lipogranuloma of an occluded meibomian gland .

usually without inflammation .Viral Papilloma Painless. keratanized cutaneous lesion.

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

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

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 .

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

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

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

LACRIMAL SYSTEM DISORDERS Section B .

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

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

Aqueous layer.Normal Tear Film Three layer : Mucin 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 .

marked conjunctival hyperemia and chemosis.Gonococcal Keratoconjunctivitis Rapid progression. copiously purulent conjunctival discharge. 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 Herbert’s 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 .

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

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 .

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 .Superior Limbic Keratoconjunctivitis Fine papillary reaction on the superior tarsal conjunctiva.

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

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

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. gradually enlarge . subepithelial deposits. most often nasally Yellow-white amorphous.

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

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

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

Conjunctival Viral Papilloma Pedunculated or sessile appearance .

sessile appearance with numerous tiny superficial corkscrewlike blood vessels typically located at the limbus .Conjunctival/Cornea Intraepithelial Neoplasia Gelatinous.

white.Conjunctival/Cornea Intraepithelial Neoplasia If CIN spreads onto the adjacent cornea. intraepithelial opacities and a central fimbriated edge . the cornea epithelim will typically have an irregular opalescent appearance with small.

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

brown. intermittently changing patches of unilateral pigmentation within the superficial conjunctiva .Primary Acquired Conjunctival Melanosis (PAM) Intraepithelial melanocytes proliferate to produce multiple flat.

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 .

sometimes with overhanging edges .Bacterial Keratitis : Streptococcus Pneumoniae Corneal ulcers with relatively distinct borders.

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 Descemet’s folds and underlying keratitic precipitates .

thinning. corneal neovascularization. and sometimes stromal necrosis and perforation .Herpes Simplex Virus Necrotizing Stromal Keratitis Severe stromal inflammation.

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

with a clear zone between the infiltrate and the limbus .Marginal Keratitis Associated with Staphylococcal Blepharitis These marginal ulcers are usually seen near the inferior limbus.

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

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

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

thinning. and ghost vessels in the mid-to-deep stroma .Luetic Interstitial Keratitis Corneal scarring.

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

irregular.Macular Corneal Dystrophy Deposits of glycosaminoglycans.  grayish white. but ultimately involving the cornea at all levels . feathery lesions originating in the axial stroma.

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

Fuchs’Endothelial Dystrophy Significant density of cornea guttae .

which leads to corneal edema .Fuchs’Endothelial Dystrophy Attenuation and dysfunction of endothelial cells.

Posterior Polymorphous Dystrophy Scattered asymptomatic vesicles. or broad bands with scalloped edges on Descemet’s membrane . extensive polymorphous and geographic lesions.

Fleischer’s ring.Keratoconus The central or paracentral cornea undergoes progressive thinning and bulging so that the cornea takes on the shape of a cone Vogt’s striae. irregular scissoring retinoscopic relex . apical anterior stromal scarring.

Posterior Embryotoxon Thickened and anteriorly displace Schwalbe’s ring .

Rieger’s Anomaly and Rieger’s Syndrome Congenital condition consisting of a centrally displaced Schwalbe’s ring. and atrophy of the iris stroma . prominent iris processes.

CORNEAL DEGENERATIONS Section C .

Corneal Arcus Deposition of lipid in the peripheral corneal stroma .

Vogt’s Limbal Girdle Corneal degeneration consisting of chalky white. superficial opacity located just anterior to and parallel to the limbus in the interpalpebral fissure .

golden brown globular deposit in the cornea .Spheroidal Degeneration Translucent.

with a lucid interval between the limbus and the deposit .Calcific Band Keratopathy Band-shaped opacity seen in the interpalpebral fissure in typical cases First presents with fine. dust like deposites in the peripheral Bowman’s layer. white.

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

Salzmann’s Nodular Corneal Degeneration One or more bluish gray. raised nodules on the corneal surfaces More commonly seen in the midperphery .

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

Mooren’s Ulcer Chronic. idiopathic ulceration of the peripheral corneal stroma and epithelium . progressive.

Peripheral Corneal Ulceration from Rheumatoid Arthritis Noninfectious corneal ulcers begin within 2 mm of the limbus. often show minimal cellular infiltrate .

Terrien’s 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 .

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

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 .