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Ophthalmology BOARD REVIEW Second Edition
Richard R. Tamesis, M.D.
McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2006 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-181159-0 MHID: 0-07-181159-1 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-146439-0, MHID: 0-07-146439-5. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a representative please e-mail us at [email protected] Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
DEDICATION
To Dr. Michael Griffith, who first suggested this project to me. I hope this makes a difference in your review for the board exams. To Drs. Jack and Milagros Arroyo, Benjamin Cabrera, Victor Caparas, Cesar Espiritu, and Alnette Tan for their friendship and support. Special thanks to Christine A. Cork, whose tireless dedication, hard work, and sunny optimism was always a source of inspiration. And to my father, Dr. Jesus V. Tamesis, who first got me interested in ophthalmology. This is for you. Richard
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EDITOR IN CHIEF Richard R. Tamesis, M.D. Assistant Professor Department of Ophthalmology University of Nebraska Medical Center Omaha, NE FIRST EDITION CONTRIBUTORS: Katherine L. Bergwerk, M.D. Fellow in Comprehensive Ophthalmology Jules Stein Eye Institute Department of Ophthalmology UCLA School of Medicine Los Angeles, CA Brian A. Bonanni, M.D. Clinical Associate Department of Ophthalmology Duke University Durham, NC Jon M. Braverman, M.D. Assistant Professor University of Colorado School of Medicine Director Denver Health Medical Center Denver, CO Paul W. Brazis, M.D. Consultant Department of Ophthalmology and Neurology Mayo School of Medicine Mayo Clinic Jacksonville, FL Willie Y.W. Chen, M.D. Department of Ophthalmology and Visual Sciences University of Louisville Louisville, KY
Thomas W. Hejkal, M.D., Ph.D. Associate Professor Department of Ophthalmology University of Nebraska Medical Center Omaha, NE Cameron G. Javid, M.D. Department of Ophthalmology Tulane University New Orleans, LA Mark Juzych, M.D. Department of Ophthalmology Wayne State University Detroit, MI James W. Karesh, M.D. Zanvyl Krieger Chairman The Krieger Eye Institute The Sinai Hospital of Baltimore Associate Professor The Wilmer Eye Institute The Johns Hopkins Medical Institutions Baltimore, MD Albert S. Khouri, M.D. Opthalmology Service Consulting Clinics Riyadh Riyadh, Saudi Arabia Ali M. Khorrami, M.D., Ph.D. Assistant Professor Health Science Center of Syracuse State University of New York Syracuse, NY
Andrew G. Lee, M.D. Assistant Professor Ophthalmology, Neurology and Neurosurgery Baylor College of Medicine Residency Training Director Cullen Eye Institute Consultant Neuro-Ophthalmology Division of Neurosurgery M.D. Anderson Cancer Center The University of Texas Houston, TX Donald P. Maxwell, M.D. Department of Ophthalmology Tulane University New Orleans, LA Kevin M. Miller, M.D. Associate Professor of Clinical Ophthalmology Jules Stein Eye Institute Department of Ophthalmology UCLA School of Medicine Los Angeles, CA Brian Mulrooney, M.D. Director Oculoplastic Services University of Kansas Kansas City, KS Sumit K. Nanda, M.D. Clinical Associate Professor Dean A. McGee Eye Institute University of Oklahoma Oklahoma City, OK Scott E. Olitsky, M.D. Associate Professor Residency Program Director Department of Ophthalmology State University of New York at Buffalo and the Children’s Hospital of Buffalo Buffalo, NY
Tony Realini, M.D. Assistant Professor Jones Eye Institute University of Arkansas for Medical Sciences Little Rock, AR Nelson R. Sabates, M.D. Associate Clinical Professor Director, Residency Training Program Director, Retina Service Department of Ophthalmology University of Missouri-Kansas City Kansas City, MO Carla J. Siegfried, M.D. Assistant Professor Department of Ophthalmology and Visual Sciences Washington University School of Medicine St. Louis, MO Michael J. Taravella, M.D. Department of Ophthalmology University of Colorado Health Sciences Center Denver, CO Menno Ter Riet, M.D. Department of Anesthesia Veterans Affairs Medical Center Miami, FLs Kristen C. Zeller, M.D. Department of Ophthalmology Naval Medical Center Portsmouth, VA
INTRODUCTION
Congratulations! Ophthalmology Board Review: Pearls of Wisdom will help you pass ophthalmology and improve your board scores. This unique format differs from all other review and test preparation texts. Let us begin, then, with a few words on purpose, format, and use. The primary intent of this book is to serve as a rapid review of ophthalmology principles and serve as a study aid to improve performance on ophthalmology written and practical examinations. With this goal in mind, the text is written in a rapid-fire, question/answer format. The student receives immediate gratification with a correct answer. Questions themselves often contain a “pearl” reinforced in association with the question/answer. Additional hooks are often attached to the answer in various forms, including mnemonics, evoked visual imagery, repetition and humor. Additional information not requested in the question may be included in the answer. The same information is often sought in several different questions. Emphasis has been placed on evoking both trivia and key facts that are easily overlooked, are quickly forgotten, and yet somehow always seem to appear on ophthalmology exams. Many questions have answers without explanations. This is done to enhance ease of reading and rate of learning. Explanations often occur in a later question/answer. It may happen that upon reading an answer the reader may think – “Hmm, why is that?” or, “Are you sure?” If this happens to you, GO CHECK! Truly assimilating these disparate facts into a framework of knowledge absolutely requires further reading in the surrounding concepts. Information learned, as a response to seeking an answer to a particular question is much better retained than that passively read. Take advantage of this. Use this book with your ophthalmology text handy and open, or, if you are reviewing on train, plane, or camelback, mark questions for further investigation. Ophthalmology Board Review risks accuracy by aggressively pruning complex concepts down to the simplest kernel. The dynamic knowledge base and clinical practice of medicine is not like that! This text is designed to maximize your score on a test. Refer to your mentors for direction on current practice. Ophthalmology Board Review is designed to be used, not just read. It is an interactive text. Use a 3×5 card and cover the answers; attempt all questions. A study method we strongly recommend is oral, group study, preferably over an extended meal or pitchers. The mechanics of this method are simple and no one ever appears stupid. One person holds the book, with answers covered, and reads the question. Each person, including the reader, says “Check!” when he or she has an answer in mind. After everyone has “checked” in, someone states his or her answer. If this answer is correct, on to the next one. If not, another person states his or her answer, or the answer can be read. Usually, the person who “checks” in first gets the first shot at stating the answer. If this person is being a smarty-pants answer-hog, then others can take turns. Try it–it’s almost fun!
Ophthalmology Board Review is also designed to be re-used several times to allow, dare we use the word, memorization. I suggest putting a check mark every time a question is missed. A hollow bullet has been arbitrarily provided. If you fill the bullets on re-uses of this book, forget this question! You will get it wrong on the exam! Another suggestion is to place a check mark when the question is answered correctly once; skip all questions with check marks thereafter. Utilize whatever scheme of using the bullets you prefer. We welcome your comments, suggestions, and criticism. Great effort has been made to verify these questions and answers. There will be answers we have provided that are at variance with the answer you would prefer. Most often this is attributable to the variance between original sources (previously discussed). Please make us aware of any errata you find. We hope to make continuous improvements in future editions and would greatly appreciate any input with regard to format, organization, content, presentation, or about specific questions. Please write to Richard R. Tamesis, M.D. at [email protected] We look forward to hearing from you. Study hard and good luck! R.R.T.
TABLE OF CONTENTS FUNDAMENTALS OF OPHTHALMOLOGY ……………………………………………………………………..11 EXTERNAL DISEASE AND CORNEA……………………………………………………………………………….37 GLAUCOMA ………………………………………………………………………………………………………………………75 LENS AND CATARACT …………………………………………………………………………………………………. 105 NEURO-OPHTHALMOLOGY…………………………………………………………………………………………. 133 OPTICS AND REFRACTION ………………………………………………………………………………………….. 163 ORBIT AND OCULOPLASTICS……………………………………………………………………………………… 183 PEDIATRIC OPHTHALMOLOGY AND STRABISMUS …………………………………………………. 209 RETINA AND VITREOUS ………………………………………………………………………………………………. 239 UVEITIS………………………………………………………………………………………………………………………….. 289 OCULAR PHARMACOLOGY AND THERAPEUTICS……………………………………………………. 309 OCULAR TRAUMA………………………………………………………………………………………………………… 319 BIBLIOGRAPHY …………………………………………………………………………………………………………….. 325
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FUNDAMENTALS OF OPHTHALMOLOGY
What is the volume of the adult orbit?
Slightly less than 30 cc or one ounce.
What are the average dimensions of the orbital entrance?
35 mm in height and 45 mm in width.
Where does the maximum width of the bony orbit occur?
1 cm behind the anterior orbital margin.
What is the depth range of the adult orbit?
40-45 mm.
Name the seven bones that make up the orbit.
Frontal, sphenoid, ethmoid, lacrimal, maxilla, palatine, zygoma.
What bones form the orbital roof?
Frontal (orbital plate) and lesser wing of sphenoid— (Front-less).
What bones form the lateral orbital wall?
Greater wing of sphenoid and zygoma— (Great-Z).
What bones form the orbital floor?
Palatine, maxilla, and zygoma (orbital plate)— (PaM-Z).
What bones form the medial orbital wall?
Ethmoid (orbital plate), lacrimal, maxilla (frontal process) and lesser wing of sphenoid— (ELMS). “2-2-3-4, all have sphenoid except the floor”— order is roof, lateral, floor, medial.
What bone forms the anterior lacrimal crest?
Lacrimal. 11
12
OPHTHALMOLOGY BOARD REVIEW
What bone forms the posterior lacrimal crest?
Maxilla. What structure lies 4 mm behind the superior orbital margin medially and of what is it composed? The trochlea is composed of hyaline cartilage.
Which bone makes up the largest portion of the medial wall?
Ethmoid.
What is another name for the ethmoid bone in the medial wall?
Lamina papyracea.
The nasolacrimal canal extends into what part of the nose?
Inferior meatus. What muscle arises from the orbital floor just lateral to the opening of the nasolacrimal canal? Inferior oblique.
Name clinical features of a blowout fracture.
Diplopia, enophthalmos, hypesthesia of the intraorbital nerve, positive forced ductions, fluid level in maxillary sinus, periorbital crepitus.
Which wall of the orbit is thickest and strongest?
Lateral wall.
What four structures attach to the lateral orbital tubercle?
Check ligament of the lateral rectus. Suspensory ligament of the eyeball (Lockwood’s ligament). Lateral palpebral ligament. Levator aponeurosis.
What structures pass through the optic foramen?
Optic nerve, ophthalmic artery, sympathetic fibers from the carotid plexus.
What bone does the optic foramen pass through?
Lesser wing of the sphenoid.
What travels through the supraorbital foramen?
FUNDAMENTALS OF OPHTHALMOLOGY
13
Blood vessels and the supraorbital nerve (branch of V1).
What travels through the zygomatic foramen?
Zygomaticofacial and zygomaticotemporal branches of the zygomatic nerve and the zygomatic artery.
The infraorbital nerve is a branch of which division of CN V?
V2— maxillary.
What passes through the superior part of the superior orbital fissure?
Lacrimal and frontal branches of CN V and the trochlear nerve (LFT).
What divides the inferior and superior parts of the superior orbital fissure?
Origin of the lateral rectus muscle.
What passes through the inferior division of the superior orbital fissure?
Superior and inferior divisions of CN III, nasociliary branch of CN V, CN VI, superior ophthalmic vein, and the sympathetic nerve plexus.
What passes through the inferior orbital fissure?
Maxillary and pterygoid parts of CN V, a nerve from the pterygopalitine ganglion and the inferior ophthalmic vein.
Where do the axons of the optic nerve originate?
Ganglion cell layer of the retina.
How many axons comprise the optic nerve?
1-1.2 million.
What is the length of the optic nerve?
35-55 mm, averages 40 mm.
Name the four parts of the optic nerve and their respective lengths.
Intraocular Intraorbital Intracanalicular Intracranial
1 mm 25 mm 4-10 m 10 mm
What are the dimensions of the optic nerve head?
1.5 mm horizontally by 1.75 mm vertically.
14
OPHTHALMOLOGY BOARD REVIEW
When do the optic nerve axons become myelinated?
Normally, after they pass posterior to the lamina cribosa. Because the optic nerve is developmentally part of the brain, what type of cells surround its fibers? Glial cells.
What arises from the Annulus of Zinn?
The rectus muscles. Which muscles originate partially from the sheath of the optic nerve and why is this clinically important? The superior rectus and medial rectus partially originate from the sheath of the optic nerve, and this may explain why patients with retrobulbar neuritis complain of pain with EOMs. Why is it clinically important that the dural sheath of the optic nerve is fused to the periosteum in the canal? Blunt trauma, especially to the brow, may be transmitted to the optic canal and cause a shearing of the dura and periosteum, compromising blood flow and causing ischemia.
What is the blood supply of the surface of the optic nerve head?
Central retinal artery or small cilioretinal arteries.
What is the blood supply of the prelaminar region and the lamina cribrosa?
Branches of the posterior ciliary arteries.
Discuss the watershed zone formed by the terminal posterior ciliary arteries.
When perfusion pressure drops, the area of the optic nerve contained within the watershed zone is prone to ischemic damage— e.g. anterior ischemic optic neuropathy.
What is the blood supply of the intraorbital part of the optic nerve?
Intraneural branches of the central retinal artery and pial branches from the peripapillary choroid, the central retinal artery and ophthalmic artery.
What is the blood supply of the intracanalicular part of the optic nerve?
Ophthalmic artery.
What is the blood supply of the intracranial part of the optic nerve?
Branches of the internal carotid and ophthalmic arteries.
FUNDAMENTALS OF OPHTHALMOLOGY
The superior division of CN III innervates what muscles?
Superior rectus and levator palpebrae superioris.
The inferior division of CN III innervates what muscles?
Medial rectus, inferior rectus, and inferior oblique. What else is carried on CN III, from where does it arise, and what does it innervate? Parasympathetics that arise from the ciliary ganglion innervate the pupillary sphincter and ciliary body.
How does a complete paralysis of CN III present?
Ptosis (levator), inability to move the eye up or in (eye looks down and out), mydriasis (pupillary sphincter). What is unique about the location of the cell bodies of the part of CN III that innervates the levator? They are found in a single midline nucleus.
What CN has the longest intracranial course and how long is it?
CN IV— 75mm
Which superior oblique does the right trochlear nucleus control?
The right trochlear nucleus controls the left superior oblique.
The motor portion of CN V innervates what structures?
The muscles of mastication.
Name the three sensory divisions of CN V and the three divisions of CN V1.
V1— ophthalmic (lacrimal, frontal, and nasociliary) V2— maxillary V3— mandibular
What, other than the lateral rectus muscle, does CN VI innervate?
Nothing.
Where is the ciliary ganglion located?
Within the muscle cone, 1 cm in front of the annulus of Zinn, between the optic nerve and the lateral rectus.
15
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OPHTHALMOLOGY BOARD REVIEW
Discuss the three roots of the ciliary ganglion.
Long (sensory) root— arises from the nasociliary branch of CN V and contains sensory fibers from the cornea, iris and ciliary body. Short (motor) root— arises from the inferior division of CN III, synapses in the ganglion, and carries parasympathetics to the iris sphincter and ciliary muscle. Sympathetic root— arises from the plexus around the internal carotid artery and innervates blood vessels of the eye and dilator fibers of the iris.
What three ganglions are represented in the short ciliary nerves?
Ciliary, superior cervical and trigeminal ganglions. Which muscle does not originate from the orbital apex and from which bone does it originate? The inferior oblique originates from the orbital plate of the maxilla.
What is the Spiral of Tillaux?
It is the shape formed by the insertions of the rectus muscles— 5.5, 6.5, 6.9, and 7.7 mm from the limbus (medial, inferior, lateral, superior). Remember that a suture placed through or under the superior rectus insertion that inadvertently penetrates the sclera could create a hole in the retina.
What is the blood supply of the lateral rectus muscle and why is it unique?
A single branch of the lacrimal artery supplies the lateral rectus, making it the only extraocular muscle supplied by only one vessel.
Which muscles receive blood supply from the infraorbital artery?
Inferior oblique and inferior rectus. What are the names of the two groups of fibers that make up eye muscles and what are their differences? 1. Fibrillenstruktur— fast or twitch movement, individual neuromuscular junctions, acetylcholine receptor (-). 2. Felderstruktur— slow or tonic movement, multiple neuromuscular junctions, acetylcholine receptor (+).
What are the dimensions of the normal adult palpebral fissure?
27-30 mm in width by 8-11 mm in height.
How far can a normal levator muscle raise the upper eyelid?
FUNDAMENTALS OF OPHTHALMOLOGY
17
15 mm.
How much can the frontalis muscle add to levator function?
2 mm.
What is the antagonist muscle of the levator?
Orbicularis oculi. Name the muscle responsible and the clinical feature of the palpebral fissure change that occurs with each of the following conditions: Thyroid disease, Horner syndrome, facial palsy, third nerve palsy. Thyroid disease Müller’s retraction Horner syndromeMüller’s ptosis Facial palsy Orbicularis oculi lagophthalmos Third nerve palsy Levator ptosis
What is special about the skin of the eyelid?
It is the thinnest in the body and has no subcutaneous fat.
Where does the levator aponeurosis form its firmest attachments?
On the anterior surface of the superior tarsus, 3 mm superior to the lid margin.
What is the name for the most superficial portion of the orbicularis oculi?
Gray line— also known as the muscle of Riolan. Where are the eyelashes and meibomian gland orifices found on the lid margin in relation to the gray line? Eyelashes arise anterior to the gray line. Meibomian gland orifices open posterior to the gray line. Name the respective secretions and locations of the secretory structures found in the eyelid and adenexa. Moll Lacrimal Krause and Wolfring Meibomian Zeis Goblet cells
apocrine eccrine eccrine holocrine holocrine holocrine
lid (Molly is a sweaty ape) superior lateral orbit and lid plica, caruncle and lid tarsus hair follicles, caruncle, and lid conjunctiva, plica and caruncle
Describe the anatomic and functional components of the orbicularis oculi muscle.
18
OPHTHALMOLOGY BOARD REVIEW
Orbital voluntary action Palpebral voluntary and involuntary actions (blinking) Preseptal Pretarsal
What is the orbital septum an extension of?
The periosteum of the roof and floor of the orbi
What is found just posterior to the orbital septum?
Orbital fa
What is an important distinction between orbital and preseptal cellulitis?
Pain with and restriction of EOMs is associated with orbital, but not preseptal cellulitis.
What happens to the levator muscle when it reaches Whitnall’s ligament?
It turns from a horizontal to a vertical direction and divides anteriorly into the levator aponeurosis and posteriorly into Müller’s muscle.
What forms Whitnall’s ligament?
A condensation of tissue surrounding the superior rectus and levator muscles.
What is the tarsus composed of?
Dense connective tissue, not cartilage.
What are the dimensions of the upper and lower tarsal plates?
Upper Lower
29 x 1 x 11 mm 29 x 1 x 4 mm
What is the name for misdirection of the orientation of the eyelids?
Trichiasis. What is the name for aberrant growth of eyelashes through the meibomian gland orifices? Distichiasis.
What type of muscle is Müller’s muscle and how is it innervated?
Smooth muscle that is sympathetically innervated.
What type of epithelium covers the conjunctiva?
Nonkeratinized squamous epithelium.
FUNDAMENTALS OF OPHTHALMOLOGY
19
What types of blood cells can be found in the substantia propria of the conjunctiva? Lymphocytes, macrophages, mast cells, and plasma cells.
Where are goblet cells most concentrated in the conjunctiva?
Inferior and medial conjunctiva, plica semilunaris and caruncle.
Where in the conjunctiva can we find no goblet cells?
In the limbal region. What structure is fused with the conjunctiva for 2 mm posterior to the limbus? Tenon’s capsule.
What two main arteries supply the eyelids?
External carotid via the facial artery system. Internal carotid via branches of the ophthalmic artery. What are the two portions of the venous drainage of the eyelids and into what structures do they drain? Pretarsal drains into the internal and external jugular veins. Posttarsal drains into the cavernous sinus.
Where are lymphatics found in the orbit and to what nodes do they drain?
Lymphatics are found in the conjunctiva paralleling vessels. They drain into the preauricular and submandibular lymph nodes. What is the name for the vestigial structure in the eyelids that is analogous to the nictitating membrane of lower animals? Plica semilunaris.
What divides the lacrimal gland into two parts?
The lateral expansion of the levator aponeurosis. Why do we biopsy the orbital portion of the lacrimal gland when biopsy is needed? To avoid sacrificing the excretory ducts that pass through the palpebral portion.
Where do the excretory ducts of the lacrimal gland empty?
20
OPHTHALMOLOGY BOARD REVIEW
In the superior fornix approximately 5 mm above the superior border of the tarsus.
When we measure basal tear secretion, what glands are we testing?
The accessory lacrimal glands of Krause and Wolfring are tested. The lacrimal gland is responsible for reflex tearing and its contribution is removed from this test by using topical anesthetic. In what percent of the population do the two canaliculi join to form a common canaliculus? 90%— the other 10% have two openings into their lacrimal sac.
What percent of full term neonates are born with a closed nasolacrimal duct?
30%— most resolve spontaneously within 6 months.
What structures penetrate Tenon’s capsule?
Optic nerve Posterior ciliary nerves Posterior ciliary vessels Vortex veins The fusion of the sheaths of the inferior rectus muscle, the inferior tarsal muscle, and the check ligaments of the medial and lateral rectus muscles form what structure? The suspensory ligament of the globe or Lockwood’s ligament.
What is the range of normal for AP diameter in the adult eye?
21-26 mm.
What is the normal AP diameter of the eye at birth?
16mm.
When does the eye normally reach its maximum size?
During puberty. What are the horizontal and vertical measurements of the adult cornea, anteriorly? Horizontal 12 mm Vertical 11 mm If viewed from behind, the normal cornea is spherical. Where is the sclera the thinnest? How thin is it? Why is this clinically important?
FUNDAMENTALS OF OPHTHALMOLOGY
The sclera is thinnest at the insertions of the rectus muscles, where it is only 0.3 mm thick. Inadvertent globe penetration can occur during strabismus surgery or the placement of bridle sutures.
Where is the sclera the thickest? How thick is it?
The sclera is 1 mm thick at the posterior pole.
Where does the inferior oblique insert?
The medial border inserts at the fovea and the lateral border inserts more anteriorly.
Describe the position of insertion of the superior oblique.
Posterior to the equator and temporal to the vertical meridian. What is the anatomic relationship between the superior oblique and superior rectus? The superior oblique lies beneath the superior rectus.
What is the function of the vortex veins? How many are there?
The vortex veins drain the choroid, ciliary body and iris. There is 4-7 per eye. How far are the ampullae of the vortex veins from the ora? What does the circle of veins represent? They lie 8-9 mm posterior to the ora. The circle of ampullae forms the equator of the fundus. How many of each of the following structures are normally found per eye: Short posterior ciliary arteries? Short posterior ciliary nerves? Long ciliary arteries? Long ciliary nerves? Short posterior ciliary arteries Short posterior ciliary nerves Long ciliary arteries Long ciliary nerves
~20 ~10 4 4
From where do the ciliary arteries arise?
Ophthalmic artery.
What are the layers of the tear film and what structures make them?
Superficial oily layer Middle aqueous layer Deep mucous layer
Zeis and Moll Krause and Wolfring Goblet cells
What is the main refractive part of the eye? What is its strength?
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The cornea, tear film and aqueous form a lens with a power of approximately 43 diopters in air.
What is the central thickness of a normal cornea? Peripheral thickness?
Central— 0.52 mm; Peripheral— 1.0 mm.
Where is the cornea normally steepest?
Centrally.
From what embryonic tissue is the corneal epithelium derived?
Surface ectoderm. What connects the basal cell layer of the corneal epithelium to its basement membrane? Hemidesmosomes.
What makes the corneal surface naturally irregular and what corrects this?
Microplicae and microvilli give the corneal surface a natural irregularity. This surface is made smooth by the precorneal tear film.
Where are the corneal epithelial stem cells located?
At the limbus.
How thick is Bowman’s layer and why is it called a layer and not a membrane?
Bowman’s layer is 8-14 microns thick. It is acellular and composed of random collagen fibrils.
What happens to Bowman’s layer after injury?
A scar forms because Bowman’s is not replaced.
What composes 90% of the corneal thickness? What is it made up of?
The corneal stroma accounts for 90% of the corneal thickness. It is composed of fibroblasts (keratocytes), ground substance and collagen lamellae.
What is the macroperiodicity of corneal collagen fibrils?
640 angstroms.
What is corneal ground substance composed of and what synthesizes it?
It is composed of mucoprotein and glycoprotein and is synthesized by the keratocytes.
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What is the basement membrane of the corneal endothelium called? What special stain identifies it? Descemet’s membrane is the basement membrane of the corneal epithelium. It is PASpositive.
Describe the two zones of Descemet’s membrane.
The anterior banded zone is created in utero. The posterior nonbanded zone is laid down by the corneal endothelium throughout life. What is the name for peripheral excrescences of Descemet’s membrane? What about central ones? Peripheral— Hassall-Henle warts (common); Central— guttata.
From which embryonic tissue is the corneal endothelium derived?
Neural crest.
How many cell layers make up the corneal endothelium?
One.
What do adjacent corneal epithelial cells share that endothelial cells lack?
Desmosomes.
What happens to corneal endothelial cells with age?
Their numbers decline and they lose mitochondria. Corneal endothelial cells normally do not undergo mitosis.
Where do traumatic scleral ruptures most frequently occur?
They occur most commonly at the supranasal limbus, but also occur frequently anywhere along limbus, at the rectus insertions and at the equator.
How are the sclera and cornea similar? How are they different?
Both made up of collagen and are essentially avascular. The sclera is opaque and white due to random collagen orientation and greater water content, while the cornea is clear because its collagen fibrils are arranged in an orderly fashion and its stroma is relatively dry.
What path does extraocular extension of choroidal melanoma take?
Scleral emissaria allow passage of cells out of the globe.
Name the structures of the anterior chamber angle from anterior to posterior.
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1. 2. 3. 4. 5. 1. 2. 3. 4. 5.
OPHTHALMOLOGY BOARD REVIEW
Schwalbe’s line. Trabecular meshwork. Scleral spur. Ciliary body. Peripheral iris. Name the structures included in the limbus. Conjunctiva. Tenon’s capsule. Episclera. Corneoscleral stroma. Aqueous outflow apparatus. Where, anatomically, does the cornea end and the sclera begin?
At a plane connecting the terminations of Descemet’s and Bowman’s that extends posteriorly to Schlemm’s canal. What is the cross sectional shape of the trabecular meshwork? What forms its corners? It is approximately triangular in cross section. Apex— Schwalbe’s line. Base— scleral spur and ciliary body. What are the three parts of the trabecular meshwork and name the part that is responsible for most of the resistance to aqueous outflow? Uveal, corneoscleral, and juxtacanalicular. The juxtacanalicular meshwork causes the greatest resistance to aqueous outflow.
What area of the trabecular meshwork is most pigmented?
Inferior chamber angle.
What type of endothelium lines the canal of Schlemm?
Nonfenestrated monolayer of endothelial cells connected by tight junctions.
Where is the thinnest part of the iris located?
At its junction to the ciliary body— the iris root.
What are posterior synechia?
Adhesions of the posterior iris surface to the anterior lens capsule.
What are peripheral anterior synechia (PAS)?
FUNDAMENTALS OF OPHTHALMOLOGY
Adhesions of the anterior peripheral iris to the posterior peripheral cornea.
What structure lies where the gonioscopic slit beam converges to a point?
Schwalbe’s line. What is the normal adult AP diameter of the lens up to about age 40? Equatorial diameter? AP— 4-5 mm; Equatorial— 9-10 mm.
What occurs during accommodation?
The ciliary muscle contracts, decreasing zonular tension, increasing AP lens diameter, and increasing the refractive power of the lens. The pupil also constricts due to stimulation of the pupillary sphincter muscle. Both of these muscles are innervated by parasympathetic fibers.
What nourishes the lens after regression of the hyaloid vascular system?
Aqueous and vitreous.
What is responsible for the innervation of the lens?
Nothing— the lens lacks innervation.
What is the PAS-positive basement membrane of the lens epithelial cells?
Lens capsule.
Where is the lens capsule thickest? Thinnest?
Thickest— midway between the anterior pole and the equator. Thinnest— posterior pole.
Where can you find dividing lens epithelial cells?
Beneath the anterior and equatorial lens capsule— not under the posterior capsule This is why extracapsular cataract extraction has the potential to leave a clear posterior capsule.
What causes posterior capsular opacification after cataract extraction?
Migration and proliferation of lens epithelial cells across the posterior capsule.
What forms the lens sutures?
Anterior sutures— interdigitations of apical lens fiber cell processes. Posterior sutures— interdigitations of basal cell processes.
Where do the zonules originate? Where do they insert?
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They originate from the basal laminae of the nonpigmented epithelium of the pars plana and pars plicata of the ciliary body in the valleys of the ciliary processes and insert on the lens capsule, anterior and posterior to the equator.
What makes up the uveal tract?
Iris, ciliary body, and choroid.
Where is the uveal tract firmly attached to the sclera?
Scleral spur, exit points of the vortex veins, and the optic nerve.
Where is the pigmentation located that is responsible for iris color?
Anterior border layer of the deep stroma.
What forms the bulk of the iris stroma?
Blood vessels.
What is the posterior pigmented layer of the iris continuous with?
The nonpigmented epithelium of the ciliary body and the neurosensory retina.
Describe physiologic ectropion.
The normal continuation of the posterior pigmented layer of the iris around the pupillary border and onto the anterior iris surface for a short distance.
What causes the dilator muscle of the iris to contract?
Alpha2 adrenergic sympathetic stimulation.
Describe the sympathetic innervation to the iris dilator muscle.
First-order neuron— originates in the ipsilateral posterolateral hypothalamus, travels through the brainstem and synapses in the intermediolateral gray matter of the spinal cord at C8 and T2. Second-order neuron— leaves the spinal cord, crosses over the pulmonary apex, through the stellate ganglion (no synapse) and synapses in the superior cervical ganglion. Third-order neuron— exits the superior cervical ganglion, unites with the internal carotid plexus, travels through the cavernous sinus, joins V1 to enter the orbit, and innervates the dilator muscle of the iris. The nerve to what muscle carries the post-ganglionic parasympathetic fibers to the iris sphincter? The nerve to the inferior oblique from the inferior division of CN III.
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In what nucleus do the parasympathetic fibers originate?
Edinger-Westphal subnucleus.
Where does the ciliary body attach to the sclera?
Its base attaches to the scleral spur.
What are the two functions of the ciliary body?
Aqueous humor formation and accommodation.
Where is the pars plana located in relation to the corneal limbus?
The pars plana is 3-4 mm posterior to the surgical limbus. What in the ciliary body is responsible for maintaining the blood-aqueous border? The zonulae occludentes along the apical border of the nonpigmented epithelium.
How thick is the choroid?
0.25 mm
Describe the unique features of choroidal blood flow?
The blood flow of the choroid is high compared to other tissues. Venous blood has only 2-3% less O2 than arterial blood.
Is Bruch’s membrane PAS-positive? Is it a true membrane?
Yes, it is PAS-positive. No, it is not a true membrane.
What are the five layers of Bruch’s membrane?
Basal lamina of the RPE. Inner collagenous layer. Middle elastic layer. Outer collagenous layer. Basal lamina of the choriocapillaris.
Is Bruch’s membrane permeable to fluorescein?
Yes.
What is a potential complication of a break in Bruch’s membrane?
Subretinal choroidal neovascular membranes.
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What forms the outer blood-retina barrier?
Zonulae occludentes and zonulae adherentes of the RPE.
What forms the inner blood-retina barrier?
Endothelium of the retinal blood vessels.
How are foveal RPE cells different from extrafoveal RPE cells?
Foveal RPE cells are taller and have more melanosomes than their extrafoveal counterparts. This is one of the reasons that choroidal flush is relatively dim under the fovea during IVFA.
What is the location of drusen?
Between basement membrane of the RPE and inner collagenous layer of Bruch’s membrane.
Where is 90% of cones found in the retina?
Almost all of the photoreceptors in the fovea are cones, but 90% of the total cones are found outside the fovea. A cilioretinal artery contributes to some portion of macular circulation in what percent of people? 15% of people have cilioretinal arteries that contribute to their macular circulation, but a cilioretinal artery may contribute to any part of the retina. They are found in 30% of eyes and 50% of individuals.
What do arterioles and venules in the retina share at their crossings?
They share a common basement membrane. This is the reason why AV nicking and venous occlusions at AV crossings.
What forms the external limiting membrane of the retina?
Attachment sites of adjacent photoreceptors and Muller cells.
Axons of what cells form the nerve fiber layer of the retina?
Ganglion cells. What forms the internal limiting membrane of the retina? What can happen if a break forms in the ILM? Foot processes of Muller cells. A break in the ILM is necessary for epiretinal membrane formation.
FUNDAMENTALS OF OPHTHALMOLOGY
Are the external and internal limiting membranes of the retina true membranes? No.
Where is the retina the thickest? How thick? The thinnest? How thin?
Thickest Thinnest
Papillomacular bundle Foveola Ora serrata
0.23 mm 0.10 mm 0.11 mm
Define the macula histologically and clinically.
Histologically, it is the area where there is more than one layer of ganglion cell nuclei. Clinically, it is commonly thought of as the area of retina between the arcades. What are the two major pigments found in the macula lutea (small yellow spot)? Zeaxanthin and lutein. We already discussed one reason for decreased choroidal fluorescence under the fovea— name another. Xanthophyll pigment found in the macula.
What is the size of the fovea?
1.5 mm = 1500 microns 1 disc diameter.
What is the foveola and what is found there?
It is the central depression in the fovea and is also known as the umbo. Only photoreceptors, glial cells and Müller cells are found there. What is the name for the cysts found in paraffin sections of the peripheral retina at the ora serrata? Blessig-Iwanoff cysts.
What is the weight, volume and make-up the vitreous?
Weight Volume Composition
4.0 g 4.0 ml 99% water
Hyaluronic acid is responsible for the increased viscosity of the vitreous compared to water.
How wide is the vitreous base and where does it attach?
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It is 6mm wide. It extends 2 mm anterior and 4 mm posterior to the ora serrata.
What forms Cloquet’s Canal?
Regression of the hyaloid vasculature before birth. Which cranial nerve has the distinction of having the fewest number of fibers, being the only one to completely decussate, and being the only motor nerve to exit the brainstem dorsally? CN IV. An aneurysm of the anterior communicating artery could effect which cranial nerve? Optic nerve.
Where is a common place for the occurrence of aneurysms that affect CN III?
At the junction of the posterior communicating and internal carotid arteries. Macular fibers from which quadrant cross anteriorly in the chiasm and bulge into the contralateral optic nerve? What is this bulge called? Fibers from the inferonasal macula form Wilbrand’s anterior knee.
What artery most frequently supplies the visual cortex?
The posterior cerebral artery.
What structures are found within the cavernous sinus?
Internal carotid artery. The sympathetic plexus surrounding the internal carotid artery. Cranial nerves III, IV, V1, V2, and VI. What three growth factors that mediate the process of induction in a developing embryo have been identified? Fibroblast growth factor Insulin-like growth factor-I Transforming growth factor-beta
FGF IGF-I TGF-ß
What is meant by the term induction?
This term is used to describe the process where one tissue directs the development of another tissue.
What is the name for the master genes that control the activity of other genes?
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Homeobox genes. These genes are found in all plants and animals and are conserved evolutionarily.
How many base pairs compose homeobox genes?
180 base pairs.
What is the name for the 60 amino acids encoded by a homeobox gene?
Homeodomain.
How does the homeodomain regulate gene expression?
These proteins bind to specific DNA sequences on other genes, causing either activation or repression. The homeodomain acts as a set of transcription factors. A mutation in the Pax-6 homeobox gene can produce what ocular abnormalities? Peter’s anomaly or aniridia. If the Pax-2 homeobox gene contains a mutation, what ocular abnormality can result? Optic nerve coloboma. What is the name for the group of anomalies resulting from defects in the migration or terminal differentiation of neural crest cells? Neurocristopathies. 1. 2. 3. 4.
What ocular structures are derived from mesoderm? Extraocular muscles. Schlemm’s canal. Vascular endothelium. Sclera, temporally. What ocular and orbital structures are derived from neural crest?
1. Cartilage 2. Corneal endothelium 3. Choroidal stroma 4. Corneal stroma 5. Ciliary body stroma 6. Iris stroma 7. Ciliary ganglions 8. Meninges of the optic nerve 9. Ciliary muscles 10. Orbital bones
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11. Connective tissue of the extraocular muscles 12. Sclera, other than temporally 13. Trabecular meshwork 14. Connective tissue of the orbit 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. 8.
What ocular structures are derived from neuroectoderm? Ciliary epithelium Neurosensory retina Iris posterior pigmented epithelium Optic nerve Iris dilator muscle Retinal pigment epithelium Iris sphincter muscle Vitreous What ocular structures are derived from surface ectoderm? Cilia Glands Conjunctival epithelium Lacrimal drainage system Corneal epithelium Lens Eyelids Vitreous On what day of gestation do the optic pits first appear?
Day 22 or 23.
On what day of gestation does the optic vesicle evaginate?
Day 25.
On what day of gestation is the lens placode induced by the optic vesicle?
Day 27 or 28.
On what day of gestation does the embryonic fissure close?
Day 33.
Where along the embryonic fissure does closure begin?
Closure begins inferiorly midway between the optic nerve and iris and proceeds anteriorly and posteriorly simultaneously. Complete fusion of the embryonic fissure encloses what artery within the globe?
FUNDAMENTALS OF OPHTHALMOLOGY
Hyaloid artery.
When does the retina complete its development?
Remodeling of foveal elements is not complete until approximately 4 years of age. What is the name for the inner plexiform layer of the retina prior to its maturation? Transient nerve fiber layer of Chievitz.
How many optic nerve axons are present at 16 weeks gestation?
3.7 million. By 33 weeks, however, attrition has decreased the number of optic nerve axons to the adult total of around 1.1 million.
Primary lens fibers form what part of the lens?
The embryonic nucleus.
By what day of gestation have the primary lens fibers filled the lens vesicle?
Day 45.
During which month of gestation do the eyelid folds meet and fuse together?
Third month.
During which month of gestation do the eyelids begin to separate?
Fifth month. During which month of gestation does the hyaloid vascular system begin to regress? Fourth month. During which month of gestation is the regression of the hyaloid vascular system complete? Eighth month.
During which month of gestation is the anterior chamber angle completed?
Eighth month. During which month of gestation do the retinal vessels reach the temporal periphery?
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Ninth month.
What remains of the primary vitreous in a normal adult?
Cloquet’s canal is the only normal remnant of the primary vitreous. Bergmeister’s papilla and Mittendorf’s dot are two other common remnants.
What structure does the secondary vitreous become?
The main vitreous body.
The tertiary vitreous is involved in the development of what structure?
The zonular apparatus.
At what age is the adult 68° angle of ocular alignment reached?
At about 3 years of age the globes reach their adult orientation. At birth the angle is 71°. What is the name for a substance or factor that causes or increases the incidence of physical anomalies in a developing embryo? Teratogen. 1. 2. 3. 4. 5. 6.
Name some classes of nongenetic teratogens. Developmental failures Nutritional deficiencies Drugs Radiation Maternal infections Toxins
During which trimester can teratogens cause major orbital and ocular structural abnormalities? First trimester. Exposure of the fetus to alcohol during certain critical periods can cause what ocular abnormalities? 1. 2. 3. 4.
Anterior lenticonus Microphakia Colobomas Microphthalmos What is the name for total absence of ocular tissues?
Anophthalmos.
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The diagnosis of this very rare condition can only be confirmed histologically.
Which type of anophthalmos is lethal and why?
Secondary anophthalmos is lethal because it is caused by complete suppression of the development of the forebrain.
What is the name given to a small, but otherwise normal globe?
Nanophthalmos.
How can nanophthalmos be inherited?
Autosomal dominant or autosomal recessive.
What is the name for a small malformed globe?
Microphthalmos. Most cases of clinical anophthalmos are actually severe cases of microphthalmos. Name two genetic aneuploidy (abnormal number of chromosomes) conditions that can result in microphthalmos. Trisomy 13 (Patau syndrome). Trisomy 18 (Edwards syndrome).
What is the name for a single midline eye?
Cyclopia.
Where is the proboscis (primitive nose) located in true cyclopia?
Above the midline ocular structure.
Is cyclopia compatible with life?
No, cyclopia is a lethal condition.
What is the name for two incomplete globes joined at the midline?
Synophthalmia.
Is synophthalmia compatible with life?
No, like cyclopia, synophthalmia is also lethal. What is the name for the condition caused when the optic vesicles remain in an embryonic state? Cystic eye.
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What is the name for the condition that occurs when faulty closure of the embryonic fissure causes a remnant of the optic vesicle to be displaced outside the globe? Cystic coloboma. What is the name for a cystic abnormality found in the orbit that contains elements from all primitive germ layers? Orbital teratoma. What is the name for a mass of cerebral tissue protruding through an orbital suture? Encephalocele. What is the name for the condition caused by failure of the eyelid folds to form, leaving a single layer of skin lying over a usually malformed eye? Cryptophthalmos. In cryptophthalmos, where can the eyebrows be found if they are present at all? Usually the eyebrows are completely absent, but if present, they will be small and displaced far temporally.
What causes the risk of a trisomy to increase?
Increasing maternal age. What is the name given to the meiotic abnormality that leads to monosomy or trisomy? Nondisjunction. What is the only sex chromosome aneuploidy that is known to have characteristic ocular findings? Turner syndrome (45,X).
EXTERNAL DISEASE AND CORNEA 1. 2. 3. 4. 5.
Describe the technique for performing a gram stain. Crystal violet x 1 minute, rinse with tap water. Gram’s iodine x 1 minute, rinse. Tilt and decolorize slide. Safranin solution x 1 minute, rinse, dry. Examine with oil-immersion. What are Hassall-Henle bodies?
Peripheral excrescences of Descemet’s membrane toward to anterior chamber.
What is the best slit lamp technique to see Hassall-Henle bodies?
Specular reflection.
When are Hassall-Henle bodies pathologic?
When they are found centrally (corneal guttata). Tiny dot and comma shaped opacities in the deep corneal stroma composed of lipofuscin are known as what? Corneal farinata.
What substance is deposited in band keratopathy and in what layer?
Calcium hydroxyapatite in Bowman’s layer. Why should thyroid function tests be requested for in superior limbic keratoconjunctivitis? SLK is associated with thyroid dysfunction in about half of all cases.
What is the definitive treatment for SLK?
Surgical resection of the superior bulbar conjunctiva. What is the average corneal endothelial cell count of a person between the ages of 40 and 90? 2400 cells/mm2 (range 1500-3500). 37
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What is defined as increased variability of corneal endothelial cell shape and size? Shape – pleomorphism. Size – polymegethism. What method of indirect illumination with the slit lamp uses total internal reflection in the cornea to highlight areas of reduced light transmission? Sclerotic scatter.
Describe techniques of qualitative and quantitative corneal esthesiometry.
Qualitative – use a wisp of cotton from a common CTA. Quantitative – an esthesiometer uses a filament that increases with rigidity as it is shortened to test sensation.
What cranial nerve is tested by corneal esthesiometry?
Trigeminal nerve. What assumption in keratometry makes it useless in evaluating irregular astigmatism, and what is a better tool for this? Keratometry assumes that the cornea is a spherocylindrical surface with two perpendicularly opposed curvatures that lie 3mm apart on the central cornea. Computerized videokeratoscopy is better at evaluating irregular astigmatism. What substances in our tears act to control the conjunctival flora and reduce bacterial adherence? Lactoferrin, lysozyme, beta-lysin, and secretory IgA.
What is stained by Rose bengal?
Devitalized cells and cells that have lost their mucin surface.
The bulbar conjunctiva vessels are terminal branches of which artery?
Ophthalmic artery.
What is an anterior embryotoxon?
This is arcus juvenilis characterized by a white ring in the anterior peripheral cornea present either at birth or up to middle age.
What is the difference between trichiasis and distichiasis?
Trichiasis is a misdirection of the lashes, while distichiasis is the presence of accessory lashes arising from the meibomian gland orifices.
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What is the difference between madarosis and poliosis?
Madarosis is patchy or diffuse loss of lashes – poliosis is patches of whiting in the lashes.
What is the difference between papillae and follicles?
Papillae have a vascular core, while follicles are collections of lymphocytes with a germinal center.
Why do giant papilla form?
After prolonged conjunctival inflammation the anchoring septae weaken and papillae become confluent.
What is the difference between membranes and pseudomembranes?
Membranes cause bleeding when stripped – pseudomembranes do not cause bleeding. They are both formed from fibrinous exudate.
To what nodes do the lymphatics from the eye drain?
Preauricular and Submandibular. What is the difference between punctate epithelial erosions (PEE) and punctate epithelial keratopathy (PEK)? PEE are depressions, while PEK are raised areas on the corneal epithelium.
What are corneal epithelial filaments?
Strands of mucous and degenerated epithelial cells attached to the cornea at one end that is pulled in the direction of movement of the upper eyelid.
What is the radius of curvature of the anterior cornea?
7.5 mm. What is a focal lymphocytic nodule lying on the limbus representing a cellmediated hypersensitivity reaction to staph? Phlyctenule. What syndrome is characterized by granulomatous conjunctivitis with an enlarged preauricular node? Oculoglandular syndrome.
What pathogens can stimulate the alternate complement pathway?
Gram negative bacteria contain endotoxins, which activate this pathway.
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Where are the accessory lacrimal glands located?
The glands of Wolfring are located in the tarsus, while the glands of Krause are in the conjunctival fornices.
What is the difference between micropannus and macropannus?
Micropannus is 1 mm
What cells are found in suppurative stromal keratitis? Nonsuppurative?
Suppurative – neutrophils; Nonsuppurative – monocytes.
What is the name for a circular pattern of nonsuppurative stromal keratitis?
Wessely ring.
Can xanthelasma occur despite the presence of normal serum cholesterol?
While xanthelasma occurs in patients with hypercholesterolemia, it is most common in female patients with normal serum cholesterol levels.
What ocular structure forms the mucous layer of tears?
Goblet cells.
What arthropods cause collarettes to form during extensive infestation?
Demodex folliculorum and Demodex brevis.
What is ophthalmia nodosa?
A focal conjunctival granuloma caused by insect and arachnid hairs.
What causes the blue coloration of the sclera after an episode of scleritis?
Thinning of the sclera allows the color of the uvea to come through.
What are Hudson-Stahli lines?
They are horizontal lines in the corneal epithelium and are associated with old age.
What are Haab’s striae?
They are splits in Descemet’s membrane and occur in congenital glaucoma. What are the differences between pedunculated and sessile papillomas with respect to location, corneal involvement, spontaneous resolution and papillomavirus strains?
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Pedunculated – inferior tarsal or fornix conjunctivitis, occasional punctate epithelial erosions, common spontaneous resolution, strains 6 and 11. Sessile – limbus may spread onto cornea, uncommon spontaneous resolution, strain 16 (18 rarely).
What are the different treatment choices when dealing with chalazia?
Hot compresses, intralesional steroids, surgical incision and drainage.
What are the most common causes of blepharitis?
Staph aureus infection, seborrhea and meibomian gland dysfunction. Where do the sensory afferents of the cornea run through to connect to the ciliary ganglion? They pass through the long ciliary nerves. What is the only bacteria causing conjunctivitis that commonly produce preauricular lymphadenopathy and conjunctival membranes? Gonococci. What percentage of patients with gonococcal conjunctivitis will also have concurrent chlamydial venereal disease? 30%.
Poliosis is associated with which type of blepharitis?
Staphylococcal blepharitis.
What external eye disease is associated with tuberculosis?
Phlyctenular keratoconjunctivitis has been associated with tuberculosis.
What is the leading cause of preventable blindness worldwide?
Trachoma – spread by the common housefly and other household fomites. What connective tissue disorder is characterized by sicca and anti-SSA and anti-SSB autoantibodies? Sjögren’s syndrome There are many tests to evaluate for dry eye syndrome/aqueous tear deficiency (ATD). Describe a few. 1. Inspection of the tear meniscus (normal is 1.0 mm). 2. Tear Breakup Time (normal greater than 10 seconds).
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3. Basic Secretion Test (with anesthesia)10 mm at 5 min is normal). 5. Schirmer II ((BST with nasal stimulation) > 15 mm after 5 min is normal). 6. Tear film osmolarity (increased in dry eye/aqueous tear deficiency).
What is Mikulicz’s syndrome?
Systemic diseases such as leukemia, lymphoma, or sarcoidosis are causing an enlargement of the lacrimal and/or salivary glands and aqueous tear deficiency.
What do the deposits of Schnyder’s crystalline corneal dystrophy consist of?
Cholesterol and neutral fats in the corneal stroma, which stain positive with, oil red O or Sudan red. Conjunctival autografts (patch grafts) have been found to be useful in the treatment of a variety of surface abnormalities. List some of these. 1. 2. 3. 4. 1. 2. 3. 4.
Primary or recurrent pterygium. Cicatricial strabismus. Repair after conjunctival excisional surgery (neoplasms). Fornix reconstruction. What are the clinical signs of keratoconjunctivitis sicca(KCS)? Conjunctival and corneal staining with rose bengal. Decreased tear lake. Mucous debris in tear film. Decreased tear breakup time.
Vitamin A deficiency results in changes in mucosal surfaces, including the conjunctiva. What two classic signs of this disease may be clinically apparent in the conjunctiva? 1. Bitot’s spots- triangular, grey, foamy, tangles of keratin and bacteria (usually Corynebacterium xerosis). 2. Xerosis- metaplasia of the conjunctival epithelium leads to a stratified squamous type with loss of goblet cells.
What forms the oily layer of tears?
Meibomian glands. What is the histopathological difference between herpes zoster iritis and herpes simplex iritis? Herpes zoster iritis is a lymphocytic vasculitis, whereas herpes simplex iritis is a diffuse lymphocytic infiltrate of the iris stroma.
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What antibiotic is an effective treatment for both the meibomian gland dysfunction and facial skin complications of acne rosacea? Oral doxycycline.
What is an alternative antibiotic to tetracycline for the treatment of rosacea?
Oral erythromycin. Which has a greater effect in enhancing drug absorption of topical medications through the cornea: increasing water solubility or increasing lipid solubility? Increasing lipid solubility increases drug absorption of topical medications by allowing the drug to penetrate the intact, lipid-rich corneal epithelium.
What is oculodermal melanocytosis (nevus of Ota)?
It is a congenital nevus of the conjunctiva and uvea with ipsilateral blue nevus of the periocular skin, most frequently in the distribution of the first and second divisions of the trigeminal nerve. Melanocytes in the episclera produce a blue color to the overlying conjunctiva. Ipsilateral iris hyperchromia is common, and melanomas of the uveal tract, optic nerve head, skin and CNS may occur in some patients.
How often does glaucoma occur in patients with nevus of Ota?
Glaucoma occurs in 10% of patients on the same side as the skin lesions. Trabecular hyperpigmentation is present. A 16-year-old female presents for a routine eye exam and refraction. Bestcorrected visual acuity is only 20/30 to 20/40 OU. High “with the rule” astigmatism, about 4 to 5 diopters is present in both eyes. Retinal exam is normal, and there is to cataract. Keratometry readings confirm high “with the rule” astigmatism and are slightly distorted. What are likely findings on slip lamp exam and retinoscopy? What other tests might be helpful in making the diagnosis? The most likely diagnosis is keratoconus. The drop in best-corrected acuity is due to irregular astigmatism. Retinoscopy can help confirm the presence of irregular astigmatism. A scissors reflect or teardrop reflex might be seen. Slit lamp exam may reveal central corneal thinning, vertical striae and iron line at the base of the cone and enlarged corneal nerves. Qualitative exam with a placido disc or computerized corneal topography will help confirm the diagnosis.
What gland is responsible for reflex tearing?
Main lacrimal gland.
What glands are responsible for basal tear secretion?
The accessory lacrimal glands of Krause and Wolfring.
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What are the most common organisms causing fungal keratitis in the United States? Fusarium and Aspergillus are the most common causes of fungal keratitis in the southern U.S. and warmer climates, while Candida is more common in the northern U.S. and in colder regions. What bacterial organisms are the most common causes of central corneal ulcers? Pseudomonas, pneumococcus, staphylococcus and Moraxella lacunata. Why do infants with chlamydial neonatal conjunctivitis require systemic erythromycin? They can develop a chlamydial pneumonitis. What stain would you request for on conjunctival scrapings of suspected chlamydial conjunctivitis, and what will this show? Giemsa stain to identify intracytoplasmic inclusion bodies.
What is “peculiar substance?”
It is a PAS-positive material found in Meesman’s dystrophy.
What is the pattern of inheritance of Meesman’s dystrophy?
Autosomal dominant.
Why is Reis-Bücklers’ dystrophy difficult to cure?
Recurrence in corneal grafts is very common. A 30-year old HIV positive male presents with the complaint of irritation in both eyes. Diffuse, grey-white opacities giving the corneal epithelium a granular appearance are present. Minimal conjunctivitis is present. The cornea is otherwise clear and the rest of the ocular exam is normal. What is the most likely diagnosis? What is the easiest test to perform to confirm this diagnosis? Microsporidial keratoconjunctivitis caused by an obligate intracellular protozoal parasite; either Nosema corneum or Encephalitozoon hellem. Gram stain of conjunctival scrapings will often reveal the gram positive spore form. Treatment with topical Amphotericin B and oral itraconazole have been reported to be successful. A 25-year-old HIV positive male presents with a complaint of bilateral ocular irritation and foreign body sensation. The cornea, anterior chamber, and retinal exam are normal. There is a very mild papillary conjunctivitis. What is the most likely diagnosis?
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Keratoconjunctivitis sicca. Dry eye is a well-known but poorly understood complication of HIV infection. What does Alcian blue stain for and what corneal dystrophy is it used to demonstrate in corneal specimens? It stains for mucopolysaccharides and is used to stain specimens with macular dystrophy.
What does the material found in corneas with lattice dystrophy consist of?
Amyloid. Bilateral corneal edema in a newborn with normal intraocular pressures and normal corneal diameters suggests what diagnosis? Congenital hereditary endothelial dystrophy. Two forms are recognized; one with an autosomal dominant pattern of inheritance, the other with a recessive pattern of inheritance. Deafness is sometimes an associated finding. Normal intraocular pressure and normal corneal diameter help distinguish this entity from congenital glaucoma.
What Chlamydial serotypes cause inclusion conjunctivitis?
Serotypes D to K.
What chlamydial serotypes cause trachoma?
Serotypes A to C. What is the recommended treatment for gonorrheal infection in an otherwise healthy adult? Ceftriaxone 1 gm IM for 5 consecutive days.
What are the main antibodies found in tears?
IgA and secretory IgA. If taken in high doses taken for long periods of time, what type of deposit can chlorpromazine produce in the cornea? It can produce a brownish, powder-like deposit in the deep stroma of the cornea.
What is Mooren’s ulcer?
It is a peripheral ulcerative keratitis caused by ischemic necrosis from vasculitis of limbal vessels.
Describe the two varieties of Mooren’s ulcer.
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The limited or torpid type is usually unilateral (75%) and seen in an older patient population with equal sex distribution. The second type is usually bilateral (75%), rapidly progressive and typically found in young Nigerian males, which may be an antigen-antibody reaction to helminthic toxins.
Which member of the herpes virus family does not produce a keratitis?
CMV.
What is Artl’s line?
It consists of subconjunctival scarring along the upper tarsal plate and is seen in trachoma.
What are Cogan’s patches?
Dellen anterior to horizontal rectus insertions in the elderly.
What is an easy way to distinguish episcleritis from scleritis?
Topical phenylephrine will blanch the inflamed episcleral vessels, but not the scleral ones. What is the most common cause of the 29% of deaths that occur within five years of the onset of necrotizing scleritis? Complications of systemic vasculitis. Patients with long-standing rheumatoid arthritis can develop a necrotizing scleritis without signs of inflammation known as what? Scleromalacia perforans.
What is the definition of giant papillae?
Papillae 1 mm.
What are Haab’s striae?
They are horizontal curvilinear lines representing healed breaks in Descemet’s membrane and occur in eyes with congenital glaucoma.
What are Vogt’s striae?
They are vertical stress lines in the corneal stroma which disappear with external pressure and are an early sign of keratoconus.
What is Munson’s sign?
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It is a late sign of keratoconus and characterized by indentation of the lower eyelid by the cornea in downgaze.
What are Tranta’s dots?
Tranta’s dots are white spots composed of eosinophils at the limbus of patients with the limbal form of vernal conjunctivitis and may also occur in atopic keratoconjunctivitis and soft contact lens wear.
What is a Bitot’s spot?
It is a foamy white lesion found at the limbus found in association with vitamin A deficiency.
What are Herbert’s pits?
They are regressed limbal follicles leaving behind depressed scars and are found in trachoma.
What is the inheritance pattern of Reiss-Bücklers’ dystrophy?
Autosomal dominant. 1. 2. 3. 4.
What are the causes of interstitial keratitis? Viral: herpes simplex, herpes zoster, mumps. Bacterial: syphilis, tuberculosis, leprosy, Lyme disease, brucellosis. Parasitic: acanthamoeba, trypanosomiasis, onchocerciasis, leishmaniasis, filariasis. Cogan’s syndrome. What type of hypersensitivity reaction occurs in phlyctenules?
Type IV hypersensitivity to microbial proteins, eg. Staphylococcal and tuberculin.
What is Cogan’s syndrome?
It is a bilateral interstitial keratitis associated with bilateral deafness, tinnitus and vertigo. Early diagnosis and treatment with systemic steroids may prevent permanent deafness.
What systemic disease may be associated with Cogan’s syndrome?
Polyarteritis nodosa. What other disease besides Cogan’s syndrome can cause interstitial keratitis associated with deafness? 4% of patients with syphilitic interstitial keratitis eventually become deaf months or years after the acute episode.
What are some causes of enlarged corneal nerves?
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1. Keratoconus. 2. Multiple endocrine adenomatosis (MEA). 3. Congenital ichthyosis. 4. Idiopathic. 5. Refsum’s disease. 6. Neurofibromatosis. 7. Leprosy. 8. Posterior polymorphous dystrophy. 9. Fuch’s endothelial dystrophy. 10. Reiss-Bückler’s dystrophy. Beading of corneal nerves or a string of pearls appearing to the corneal nerves suggests what systemic problem? Leprosy. Lid skin may be thickened and lashes can be absent. In addition, the iris may show characteristic creamy white “pearl” lesions.
What is Ferry’s line?
It is an iron deposit in the cornea near a filtering bleb. A 39-year-old nurse presents with a history of non-healing corneal abrasion that is associated with pain, redness and dense ring infiltrate. She was treated previously with two weeks of intense fortified antibiotics. Cultures performed prior to starting her topical antibiotics were negative for bacteria and fungus. What is the most likely diagnosis? Anesthetic abuse; more common in health care personnel that have access to proparacaine and tetracaine. Suspect the diagnosis in non-healing corneal ulcers or abrasions which are culture negative. Dense white ring infiltrates, corneal edema, and even a hypopyon are possible findings. What malignancies are associated with multiple endocrine adenomatosis type IIb (Sipple-Gorlin syndrome)? Medullary thyroid carcinoma, pheochromocytoma and mucosal neuromas. A 30-year-old male presents for a routine eye exam and refraction. Slit lamp exam reveals arc shaped superior corneal thinning with blood vessels extending from the limbus across the area of thinning. Lipid deposition is present at the central edge of the thinned cornea. The epithelium over the are of thinning is intact. The opposite eye appears normal on slit lamp exam. What is the diagnosis? Terrien’s marginal degeneration. Note that this is often bilateral but can be present unilaterally.
What would the refraction of the case above most likely show?
High “against the rule” astigmatism in the opposite axis of the thinning.
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What are the ocular features of Ehlers-Danlos syndrome?
1. Anterior segment: keratoconus, keratoglobus, blue sclera, lens subluxation. 2. Posterior segment: high myopia and retinal detachment.
What is Ehlers-Danlos syndrome?
It is a dominantly inherited collagen disorder caused by a deficiency in hydroxylysine. Its main systemic features are: 1. 2. 3. 4. 5.
Hyperelastic skin that bruises easily and heals slowly. Joint hypermobility. Cardiovascular disease. Daphragmatic hernia. Diverticuli of the respiratory and GI tracts. What are the ocular features of osteogenesis imperfecta?
1. Blue sclera. 2. Keratoconus. 3. Megalocornea.
What mucopolysaccharidoses are associated with corneal clouding?
Hurler’s, Scheie’s, Morquio’s and Maroteaux-Lamy’s but not in Hunter’s and Sanfilippo’s What is the primary antibiotic of choice for an identified Gram-positive keratitis? Fortified cephalosporins, eg. Cefazolin What is the significance of the presence of hypopyon in association with bacterial keratitis? Unless there has been ocular perforation, the presence of hypopyon is almost always a reactive phenomenon and does not signify endophthalmitis. Is an intraocular tap and systemic antibiotics indicated in patients with bacterial keratitis and reactive hypopyon? No. An intraocular tap may be hazardous in patients with this condition, since it runs the risk of introducing the organisms into the eye.
What are the systemic causes of scleritis?
1. Rheumatoid arthritis. 2. Collagen vascular disorders: Wegener’s granulomatosis, polyarteritis nodosa, systemic lupus erythematosus. 3. Relapsing polychondritis.
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4. Herpes zoster. 5. Porphyria.
What viruses usually cause acute hemorrhagic conjunctivitis?
Enterovirus 70 and coxsackie A24, although adenovirus type 11 and 37 have also been implicated.
What are some causes of corneal verticillata?
1. Drugs: amiodarone, anti-malarials, indomethacin, tamoxifen, chlorpromazine, meperidine, amodiaquine. 2. Fabry’s disease.
What is Fabry’s disease?
It is a disorder caused by a deficiency in the enzyme alpha-galactosidase. Patients develop angiokeratomas, cardiovascular and renal lesions and episodes of severe pain in the fingers and toes.
What other anterior segment findings are found in Fabry’s disease?
Spoke-like lens opacities. What does the material in granular dystrophy consist of, and what is the best stain for it? The granular material is composed of hyalin and stains bright red with Masson’s trichrome stain.
What is Salzmann’s nodular degeneration?
It is the late sequela of a keratitis and may not appear until years after the active disease. It presents as midperipheral, smooth, bluish gray nodules on the cornea.
What is the appearance of Salzmann’s nodules histopathologically?
Localized replacement of Bowman’s layer by hyaline and fibrillar material A middle-aged man presents with a peripheral ulcerative keratitis and a positive hepatitis B surface antigen (HbsAg) lab result. What systemic disease may this patient possibly have? Polyarteritis nodosa
What are the ocular features of polyarteritis nodosa?
1. Anterior segment: peripheral ulcerative keratitis, necrotizing scleritis, secondary Sjögren’s syndrome.
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2. Posterior segment: retinal artery occlusion, cotton wool spots, choroidal vasculitis, anterior ischemic optic neuropathy.
What is Stocker’s line?
It is an iron deposit on the cornea in front of a pterygium. 1. 2. 3. 4. 5.
What are some systemic associations of peripheral ulcerative keratitis? Rheumatoid arthritis. Wegener’s granulomatosis. Polyarteritis nodosa. Relapsing polychondritis. Systemic lupus erythematosus.
What is a Tzanck prep?
This is a Giemsa stain of corneal scrapings of HSV epithelial infection, revealing multinucleated giant cells. Do patients with central cloudy corneas of François complain of decreased vision? No. Central cloudy cornea of François is bilateral, hereditary, deep, central shagreen that has no effect on vision. What is the name for the noninflammatory, slowly progressive thinning of the peripheral cornea that begins superiorly and has an associated vascular pannus? Terrien’s marginal degeneration.
What type of astigmatism may develop from Terrien’s marginal degeneration?
“Against-the-rule” astigmatism.
Thinning in the lucid area posterior to corneal arcus is know as what?
Furrow degeneration.
What percent of patients with map-dot-fingerprint will have corneal erosions?
10%.
What percent of patients with corneal erosions will have map-dot-fingerprint?
50%. A 3 day old infant is noted to have progressive corneal edema with vertical posterior striae. What is the most likely cause of this ocular condition?
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Birth trauma (forceps delivery) with rupture of Descemet’s membrane and endothelium. 1. 2. 3. 4. 5. 6.
What are some systemic disorders associated with keratoconus? Atopic dermatitis. Down’s syndrome. Marfan’s syndrome. Ehlers-Danlos syndrome. Osteogenesis imperfecta. Mitral valve prolapse. What type of hypersensitivity reaction may be invoked in ocular rosacea?
Type IV hypersensitivity.
What stains can be used to identify fungi?
1. Gomori Metamine silver stain. 2. Periodic acid-Schiff. 3. Giemsa stain.
What is blood agar used to culture for?
It is used primarily for isolation of aerobic bacteria and will allow the growth of saprophytic fungi at room temperature. Which anti-Epstein-Barr virus antibody does not peak during the first 6 to 8 weeks of infection with EBV? EBNA (Epstein-Barr nuclear antigen). Which anti-EBV antibodies remain detectable for life after infection with EBV? EBNA and VCA-IgG. 1. 2. 3. 4. 5.
What are other ocular disorders associated with keratoconus? Vernal and atopic keratoconjunctivitis. Leber’s congenital amaurosis. Retinitis pigmentosa. Aniridia. Ectopia lentis.
What do the deposits in spheroidal degeneration represent, and what are they caused by? Spheroidal degeneration is characterized by golden brown spherules in the superficial corneal stroma. They are proteinaceous material resulting from the combined effects of genetic predisposition, aging, actinic exposure, and environmental trauma.
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1. 2. 3. 4. 5.
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What are the causes of corneal clouding in infants? Corneal edema (birth trauma, glaucoma). Infectious keratitis (rubella, intersitial, gonococcal). Metabolic abnormalities (mucopolysaccharidoses, mucolipidoses). Dystrophies (endothelial and stromal). Sclerocornea.
What is the appropriate management of malignant melanoma of the conjunctiva? Excision using a no-touch technique with care to include 3-4 mm of normal adjacent conjunctiva and double freeze-thaw applications to the surrounding conjunctiva.
What is a Kayser-Fleischer ring?
It consists of copper deposits in Descemet’s membrane and is found in Wilson’s disease.
What species is responsible for lice infection of the lids (ocular pediculosis)?
Phthirus pubis (crab louse).
What is the Ziehl-Neelsen stain used to stain for?
Mycobacteria and Nocardia.
What culture medium is used to grow mycobacteria?
Löwenstein-Jensen. 1. 2. 3. 4. 5. 6. 7. 8. 9.
What are the causes of band keratopathy? Juvenile rheumatoid arthritis. Hereditary band keratopathy. Chronic iridocyclitis in adults. Hypercalcemia and hyperphosphatemia. Chronic mercurial exposure. Congenital ichthyosis. Silicone oil in anterior chamber. Phthisis bulbi. Idiopathic in elderly. How do you remove band keratopathy?
Apply 0. 5 mol/L to 0.25 mol/L disodium EDTA solution topically to soften the calcium, then scrape the deposit off. The eye is then patched or a bandage contact lens is applied to allow the epithelium to heal.
What are the anterior segment features of Marfan’s syndrome?
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1. 2. 3. 4. 5. 6.
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Bilateral upward lens subluxation. Microspherophakia. Blue sclerae. Keratoconus. Angle anomalies. Hypoplastic dilator pupillae. How does Onchocerca volvulus cause blindness?
It produces a sclerosing keratitis.
What is the vector of Onchocerca volvulus?
Black fly.
What are Henderson-Patterson bodies?
They are intracytoplasmic inclusion bodies in the hyperplastic epithelium in umbilicated, nodular lesions caused by molluscum contagiosum. The bodies are small and eosinophilic deep inside the lesion but basophilic and larger near the surface. What type of polymorphonuclear leukocytes are usually present in the conjunctival epithelium of patients with vernal conjunctivitis? Eosinophils. What is the most appropriate surgical management of squamous cell carcinoma of the conjunctiva? Wide no-touch surgical excision with supplementary cryoablation. A patient with decompensated Fuch’s dystrophy presents with a wellcircumscribed, chalky white infiltrate with overlying ulceration associated with pain, photophobia and tearing for the past 4 days. What is the most likely organism in this case? Staphylococcus aureus. What stains can be used to identify the presence of amyloid deposits in the cornea, and what type of reaction do they exhibit? 1. Dichroism with Congo Red stain. 2. Metachromasia with crystal violet stain. 3. Fluorescence with thioflavin T. An alcoholic elderly patient who lives in the streets presents with a nonperforated corneal ulcer for the past week and a half and maceration of the skin at the lateral canthus. What will the gram stain of the corneal scraping likely show? Large gram negative diplobacilli of Moraxella lacunata.
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If Acanthamoeba keratitis is suspected, what type of culture media should be used? Nonnutrient agar with heat-killed E. coli overlay.
What culture media should be used for the growth of fungi?
Sabouraud’s agar. What condition associated with HLA-DR3 is characterized by recurrent episodes of tearing, foreign body sensation, photophobia, decreased vision, and multiple small corneal epithelial lesions? Thygeson’s superficial punctate keratitis. 1. 2. 3. 4. 5. 6. 7. 8.
What infectious diseases can cause interstitial keratitis (IK)? Syphilis. Tuberculosis. Leprosy. B. burgdorferi. Rubeola. EBV. C. trachomatis. Onchocerca volvulus.
A 44-year-old woman presents with intense eye irritation associated with hypertropic conjunctiva at the superior limbus with adjacent filamentary keratitis. What is your diagnosis? Superior limbic keratoconjunctivitis. What systemic disease may be associated with superior limbic keratoconjunctivitis (SLK)? Thyroid disease in 50% of patients with SLK.
What is the treatment for SLK?
In mild cases artificial tears and ointment may be sufficient. In more severe cases, 0.5 to 1% silver nitrate (in wax ampoules, not cautery sticks) applied to the superior bulbar and tarsal conjunctiva for 10-20 seconds. Thermal cautery, pressure patching, or bandage contact lenses may be employed. Conjunctival resection may be necessary. This is usually a seasonal recurring, bilateral inflammation of the conjunctiva, which occurs most commonly in male children and young adults. Vernal keratoconjunctivitis.
What type of ulcer is associated with vernal?
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Shield ulcer.
What is used as prophylaxis against seasonal recurrences of vernal?
4% Cromolyn sodium qid started at least one month prior to usual onset of symptoms. What type of keratoconjunctivitis may be associated with shield-shaped anterior subcapsular or posterior subcapsular lens opacities? Atopic keratoconjunctivitis.
What is a congenital syndrome associated with aqueous tear deficiency (ATD)?
Riley-Day (familial dysautonomia) or Shy-Drager (idiopathic autonomic dysfunction).
What is the most common cause of dacryocystitis in adults? In children?
Pneumococcus and Haemophilus influenza respectively.
What is the diagnostic value of Wright’s stain in regards to conjunctivitis?
It is a cytologic stain that highlights eosinophils and their granules – found in hay fever conjunctivitis.
What is a classic slit lamp finding of staphylococcal blepharitis?
Collarettes. What should always be on the differential of ocular surface inflammation in patients that have been using topical medication? Medicamentosa – toxic reaction that can occur after long-term use of topical medication. How do the dermoids of epidermal nevus syndrome differ from those of Goldenhar’s syndrome? They tend to be bilateral and more extensive.
What is the treatment for gonococcal conjunctivitis?
Ceftriaxone 1gm IM once (or IV). Copious irrigation with normal saline should be instituted. Since concurrent chlamydial infection has been reported in a third of patients, supplemental oral antibiotics should be given to treat chlamydia (tetracycline, doxycycline, minocycline, erythromycin, or azithromycin).
What organisms are most commonly associated with phlyctenulosis?
Chronic infection with Staphylococcus aureus is the most common cause of phlyctenulosis. Tuberculin antigen was most commonly linked to phlyctenulosis in the past.
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What is the classic slit lamp finding of Demodex infection?
Sleeving of eyelash bases.
How is Trichinella spiralis contracted?
Ingestion of raw or half-cooked pork.
What is the treatment for Trichinella infections?
Thiabendazole.
What are Schaumann bodies?
They are nonspecific intra-giant cell deposits commonly seen in sarcoid.
What does scurf on eyelashes indicate?
Seborrhea. What can be seen histopathologically at Descemet’s membrane in corneas with deep stromal involvement by herpes simplex? There is a granulomatous reaction to Descemet’s membrane. What type of staining pattern will likely be seen in a patient wearing rigid gaspermeable lenses who complains of a scratchy sensation after 6 to 8 hours of wearing time? 3 and 9 o’clock staining, which occurs in up to 80% of RGP-wearing patients.
What is Sattler’s veil?
This is central epithelial edema resulting from hypoxic stress, which may occur with either rigid or soft contact lenses, and is best seen with sclerotic scatter or retroillumination. This is usually associated with a tight lens fit. Patients will complain of hazy vision or blur after removing their contact lenses that usually dissipates after about an hour. What organism commonly causes infectious crystalline keratopathy and in what clinical setting is it usually seen? Streptococcus viridans usually causes infectious crystalline keratopathy. It most often occurs in the setting of a compromised host, such as a post-corneal graft patient on longstanding corticosteroid treatment. What antibiotic would be appropriate for a streptococcal infection of the cornea? Fortified cephalosporin or vancomycin.
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What is the recurrence rate of herpes simplex in the corneal graft following penetrating keratoplasty for herpetic corneal ulcers? Approximately 20%.
What is a Fleischer ring?
It is iron deposition at the basal epithelium and is diagnostic of keratoconus. Which disease produces greater corneal anesthesia in keratitis of comparable severity, herpes simplex or herpes zoster? Herpes zoster, which can markedly diminish corneal sensation even in the mildest cases of keratitis, produces greater corneal anesthesia than herpes simplex.
How does pellucid marginal degeneration differ from keratoconus?
In pellucid marginal degeneration, the thinnest area is not at the apex of the cone but in a crescentic distribution near the inferior limbus. What is the appropriate management for acute corneal hydrops in a patient with keratoconus? Cycloplegics are used to manage the mild iritis that may be present, and topical hypertonic saline drops and ointment may help to reduce the swelling of the corneal stroma and epithelium. What stain is used to identify the trophozoites and cysts of Acanthamoeba in corneal sections? Calcofluor white stain. What does immunofluorescent staining of conjunctival specimens from patients with ocular cicatricial pemphigoid (OCP) demonstrate? C3, IgG, IgM, and IgA are localized to the basement membrane.
What is the treatment for ocular cicatricial pemphigoid?
Systemic corticosteroids, diaminodiphenylsulfone (Dapsone), cyclophosphamide (Cytoxan), and azathioprine (Imuran) are all currently being tried. Epilation/cryotherapy for trichiasis, mucosal grafting for fornix reconstruction, and topical corticosteroids for acute exacerbations are adjunctive measures. What is the difference between pemphigus vulgaris and ocular cicatricial pemphigoid with regards to the conjunctival changes produced? Pemphigus vulgaris forms intraepithelial bullae, a mild, self-limiting conjunctivitis, and no scar formation nor involvement of the substantia propria or dermis. OCP produces
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subepithelial fibrosis, subconjunctival scarring, and fornix foreshortening and symblepharon formation. A 75-year-old female with history of open angle glaucoma presents with a pigmented lesion in the inferior fornix of the left eye. A biopsy is performed to rule out melanoma but comes back negative for melanin. What might this represent? Adrenochrome deposit from the use of epinephrine compounds for her glaucoma.
What is a pyogenic granuloma?
They are composed of granulation tissue and proliferating vascular endothelial cells in reaction to an inciting event such as strabismus surgery, inflammation (chalazion), chemical burns, limbal surgery, or foreign bodies. They are rapidly developing lesions onset is typically days to weeks.
What is thioglycolate broth used to culture for?
Anaerobic bacteria.
How thick is the central cornea?
0.5 mm.
What are Krukenberg’s spindles?
They are melanin deposits oriented vertically on the endothelium and are found in pigment dispersion syndrome or pigmentary glaucoma.
In what age group does ligneous conjunctivitis usually affect?
Ligneous conjunctivitis is an idiopathic chronic conjunctivitis that usually affects children.
What part of the conjunctiva is usually affected by ligneous conjunctivitis?
A fibrinous exudate first develops usually in the upper palpebral conjunctiva, which is then infiltrated by granulation tissue, although the bulbar conjunctiva can also be involved.
In what other extraocular locations can ligneous conjunctivitis manifest?
Nasopharynx, buccal mucosa, middle ear, tympanic membrane, vagina, and cervix.
What is the most dangerous complication of herpes zoster keratitis?
Neuroparalytic epithelial breakdown and diffuse stromal edema and infiltration, which can result in chronic trophic ulceration, corneal melting and perforation.
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How would you treat herpes zoster neuroparalytic keratitis that has resulted in a trophic ulcer? This may respond to soft contact lens wear or to cyanoacrylate gluing in advanced cases. Neovascularization is a sign of healing and should be allowed to take place. These eyes are poor surgical risks for keratoplasty. A patient with herpes zoster keratitis is fitted with a therapeutic bandage contact lens. Two days later, he presents with hypopyon. There is no corneal infiltrate seen. How would you manage this case? An infection is probably unlikely if the hypopyon follows the application of a bandage lens by only 2 or 3 days and if a stromal infiltrate is absent or of long duration. Sterile uveitis and hypopyon has been associated with lens fit too steeply and may be related to anterior segment ischemia. This complication can be managed by cycloplegia and lens removal.
What are the main indications for use of a Gunderson conjunctival flap?
1. Chronic sterile ulcerations, eg. Herpes simplex, herpes zoster, chemical and thermal burns, sicca, neurotrophic ulcers. 2. Bullous keratopathy. 3. Closed but unstable corneal wounds. 4. Eyes being prepared for a prosthetic shell.
What topical medications can produce a cicatrizing conjunctivitis?
Timolol, pilocarpine, echothiophate iodide and idoxuridine.
What is the importance of Hutchinson’s sign?
In patients with HZO, vesicles and itching at the tip of the nose indicates involvement of the nasociliary branch of the trigeminal nerve, which also supplies the cornea and other intraocular structures.
Where does most of the glucose for corneal epithelium comes from?
Aqueous humor. What type of collagen do Descemet’s membrane and Bowman’s membrane consist of? Descemet’s membrane consists of type IV collagen while Bowman’s membrane is made of type I collagen.
How far do myelinated nerve fibers extend into the normal cornea?
Myelination ends within 2 mm of the limbus.
What percentage of patients with Terrien’s marginal degeneration are male?
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75%. What type of astigmatism is usually associated with Terrien’s marginal degeneration? “Against-the-rule” astigmatism. A 58-year-old patient presents with bilateral interstitial keratitis and hearing problems. Serologic tests for syphilis are negative. What is the probable diagnosis and how could deafness be prevented? Cogan’s syndrome, which is a bilateral non-luetic interstitial keratitis associated with bilateral deafness. Early systemic steroid administration will prevent deafness. What percentage of patients with syphilitic interstitial keratitis will become deaf? 4% of patients with syphilitic interstitial keratitis will become deaf, which may occur months or years after the acute episode.
What are Leber cells?
Leber cells are macrophages that have phagocytosed debris and are found in the conjunctival stroma in patients with trachoma.
What is the definition of microcornea?
Corneal diameter 10 mm.
What type of astigmatism is produced by keratoconus?
Irregular astigmatism.
What sign is seen on retinoscopy of an eye with keratoconus?
Scissoring reflex.
What is Rizzuti’s sign?
It is a conical reflection on the nasal cornea when a light is shown from the temporal side in an eye with keratoconus. 1. 2. 3. 4. 5. 6.
What are causes of decreased corneal reflexes? Keratitis (herpes simplex, herpes zoster, leprosy). Corneal dystrophies (lattice, Reiss-Bückler’s, Schnyder’s). Diabetes, especially juvenile onset. Cerebello-pontine angle tumors, eg. Acoustic neuroma. Cavernous sinus and superior orbital lesions. Intracranial aneurysms.
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OPHTHALMOLOGY BOARD REVIEW
7. Iatrogenic (cataract and corneal surgery, prolonged contact lens wear, surgical section of the trigeminal nerve). 8. Riley-Day syndrome.
What systemic diseases are associated with lattice dystrophy types 1 and 2?
Lattice dystrophy type 1 is not associated with any systemic disease, but type 2 is associated with systemic amyloidosis (Meretoja syndrome). What is the relative risk of ulcerative keratitis among users of extended-wear contact lenses and daily wear soft contact lenses who wore them overnight as compared to users of such lenses who did not? Users of extended wear contact lenses who wore them overnight had a 10 to 15 times greater risk of microbial keratitis as users of daily wear lenses who did not. Users of daily wear soft contact lenses who sometime wore them overnight had 9 times the risk of the users of such lenses who did not.
What are corneal filaments composed of?
Mucus and desquamated epithelial cells.
What is the definition of megalocornea in a child age 1 year?
>12 mm horizontally. 1. 2. 3. 4. 5. 6.
What medications appear to be useful in treating Acanthamoeba keratitis? Neomycin-polymyxin B-gramicidin. Neomycin. Natamycin 5% topical suspension. Miconazole 1% topical solution. Propamidine isethionate 0.1% drops (Brolene). Dibromopropamidine 0.15% ointment.
What are the eosinophilic intranuclear inclusion bodies of HSV epithelial infection called? Lipschütz bodies. Which anti-viral agent may produce preauricular lymphadenopathy as a hypersensitivity reaction? Idoxuridine. Which anti-viral medications inhibit DNA synthesis by acting as thymidine analogs? Trifluridine and idoxuridine.
EXTERNAL DISEASE AND CORNEA
63
How does acyclovir inhibit HSV DNA synthesis?
Acyclovir, activated only by herpes virus-induced thymidine kinase, irreversibly binds to viral DNA polymerase and acts as a viral DNA chain terminator.
What abnormality of the eye is normally the cause of iron deposition?
Abnormalities of tear pooling.
Deep stromal deposition of gold is seen in what condition?
Chrysiasis. This syndrome is characterized by hyperkeratotic lesions of the palms, soles, and elbows, and nonstaining corneal pseudodendrites. Richner-Hanhart syndrome (tyrosinemia type II). Endothelial cells that ultrastructurally behave like epithelium and form contractile membranes are found in what syndrome? ICE syndrome (iridocorneal endothelial syndrome).
What is the distinctive corneal change seen in sphingolipidoses?
Corneal verticillata.
What is the most common corneal lipid deposition condition?
Arcus senilis.
Asymmetric arcus should lead to what kind of work-up?
Carotid artery work-up is indicated. A photophobic very short person with polychromatic conjunctival and corneal crystals and photophobia probably has what disease? Cystinosis. What topical medication could be used to reduce the density of crystals in the previously mentioned shot person? Cysteamine drops.
Which bacterial conjunctivitis can produce preauricular lymphadenopathy?
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Why waste time guessing at what you need to know for the ophthalmology board exam? Maximize your exam preparation time with this quick-hit question and answer review. The unique question and single-answer format eliminates the guesswork associated with traditional multiple-choice Q&A reviews and reinforces only the correct answers you’ll need to know on exam day. Emphasis is placed on distilling key facts and clinical pearls essential for exam success. Great for certification and re-certification, this high-yield review for the boards is the perfect compliment to larger texts for intense, streamlined review in the days and weeks before your exam.
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Richard R. Tamesis (Author)
Dr. Richard R. Tamesis is Assistant Professor in the Department of Ophthalmology at the University of Nebraska Medical Center in Omaha, Nebraska.
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Fundamentals Of Ophthalmology External Disease And Cornea Glaucoma Lens And Cataract Neuro-Ophthalmology Optics And Refraction Orbit And Oculoplastics Pediatric Ophthalmology And Strabismus Retina And Vitreous Uveitis Ocular Pharmacology And Therapeutics Ocular Trauma Bibliography
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Book Name : Ophthalmology Board Review: Pearls of Wisdom
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Ophthalmology Oral Board Review 1st Edition (2018) (PDF) by Dr. Damien M Luviano
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Packed with 65 sample cases covering all core topics, Ophthalmology Oral Board Review is an image-based case review designed to help you prepare—and succeed—on the American Board of Ophthalmology oral board certification exam. Regardless of your level of experience, the book features simple tools, advice, and tactics to become more organized, assertive, and confident in delivering case presentations.
• Provides an easy-to-understand methodology that’s proven an effective strategy for achieving exam success.
• Each case is presented in a simple two-page format that includes one historical vignette, photographs, and one suggested presentation.
• Ideally suited for use by two study partners in a role-playing situation, where one student acts as the examinee and the other as the examiner.
• Perfect for residents and students—as well as directors training residents on delivering oral presentations in the clinic, in the hospital, and on the wards.
• Includes two sample oral examinations of cases, with accompanying audio files available with the eBook.
The Ophthalmology Examinations Review [3rd Edition] 9789813221024
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This page contains presentations for ophthalmology residents to use in studying for the OKAP and Board exams. Please read this short introduction with details regarding how to use the presentations.
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“Thank you for this really fantastic resource, I’ve found your slides to be extremely well made and helpful for reviewing material, I wish I had found them earlier in my training!” – Nicholas Apostolopoulos, Resident, Yale University
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Basic Optics BO1. Vergence: Basics PDF | PPT BO2. Vergence: Lenses PDF | PPT BO3. Vergence: The Vergence Formula PDF | PPT BO4. Focal Points PDF | PPT BO5. The Far Point and Refractive Error PDF | PPT BO6. The Essence of Spectacle Correction PDF | PPT BO7. Vertex Distance PDF | PPT BO8. The Error Lens Concept PDF | PPT BO9. The Near Point PDF | PPT BO10. Astigmatic Refractive Error: Introduction PDF | PPT BO11. The Conoid of Sturm PDF | PPT BO12. Astigmatic Refractive Correction: Retinoscopy PDF | PPT BO13. Astigmatic Refractive Correction: Jackson Cross PDF | PPT BO14. Astigmatic Refractive Correction: Types of Astigmatism PDF | PPT BO15. Astigmatic Refractive Error: The Power Cross PDF | PPT BO16. Refraction Basics PDF | PPT BO17. Snell’s Law PDF | PPT BO18. Refraction: Points and Planes PDF | PPT BO19. Ray Tracing PDF | PPT BO20. Transverse Magnification PDF | PPT BO21. Axial Magnification PDF | PPT BO22. Angular Magnification PDF | PPT BO23. Telescopes PDF | PPT BO24. Bifocal Add: Image Jump and Image Displacement PDF | PPT BO25. Mirrors PDF | PPT BO26. Chromatic Aberration PDF | PPT
Cornea/External Disease K2. Adenoviral Conjunctivitis PDF | PPT K3. Acute/Hyperacute Conjunctivitis PDF | PPT K4. Regarding Interstitial Keratitis PDF | PPT K5. Horizontal corneal lines vs vertical corneal lines PDF | PPT K6. Vernal Keratoconjunctivitis (VKC) vs Atopic Keratoconjunctivitis (AKC) PDF | PPT K7. Superior Limbic Keratoconjunctivitis PDF | PPT K8. Re Stevens-Johnson Syndrome: True, False, or Controversial? PDF | PPT K9. The STUMPED Mnemonic for Infantile Cloudy Cornea PDF | PPT K10. Congenital/Developmental Cornea Issues PDF | PPT K11. Is it ICE, PPMD or Fuchs? PDF | PPT K12. Corneal Ectasias PDF | PPT K13. Selected Systemic Diseases of Childhood with Corneal Findings PDF | PPT K14. Re Contact Lenses: What Does the Term Dk Mean? PDF | PPT K15. Glands of the Orbit (But Not That One) PDF | PPT K16. Blepharitis: Staph, MGD, Seborrheic, Rosacea, Demodex? PDF | PPT K17. It’s Dendritiform Keratopathy, Haters PDF | PPT K18. Managing Blepharitis PDF | PPT K19. Dry Eye Syndrome: Dietary Factors PDF | PPT K20. Langerhans vs Langhans cells PDF | PPT K21. Hypersensitivity Reactions of the Ocular Surface PDF | PPT K22. Corneal Transparency PDF | PPT K23. Anterior HSV dz PDF | PPT K24. Surfer’s Eye? PDF | PPT K25. Conjunctival Neoplasms PDF | PPT K26. Iridocorneal Endothelial (ICE) Syndrome PDF | PPT K27. All the Following are Associated with Follicular Conjunctivitis Except… PDF | PPT K28. Corneal Wound Healing PDF | PPT K29. All the Following Concerning Mucous Membrane Pemphigoid (MMP) are True Except… PDF | PPT K30. Corneal Iron Lines PDF | PPT K31. Keratitis Bugs PDF | PPT K32. Infectious Keratitis PDF | PPT K33. Concerning PUK… PDF | PPT K34. Restasis PDF | PPT K35. Filamentary Keratitis PDF | PPT K36. Seasonal Allergic Conjunctivitis (SAC) vs Perennial Allergic Conjunctivitis (PAC) PDF | PPT K37. HZO Manifestations PDF | PPT K38. Koncerning Keratoconus PDF | PPT K39. Phlyctenulosis PDF | PPT K40. Corneal Dystrophies: READ ME FIRST PDF | PPT K41. Corneal Dystrophies: Epithelial and subepithelial dystrophies PDF | PPT K42. Corneal Dystrophies: Epithelial-stromal TGFBI Dystrophies PDF | PPT K43. Corneal Dystrophies: Stromal Dystrophies PDF | PPT K44. Corneal Dystrophies: The Big 3 PDF | PPT K45. Corneal Dystrophies: Endothelial Dystrophies PDF | PPT
Glaucoma G0. Glaucoma Overview PDF | PPT G2. Primary Congenital Glaucoma PDF | PPT G3. Childhood Glaucoma: Treatment PDF | PPT G4. Pseudoexfoliation Syndrome vs Pigment Dispersion Syndrome PDF | PPT G5. Beta-blocker Side Effects PDF | PPT G6. Post Filtering-Surgery Infection PDF | PPT G7. The Goldmann Equation PDF | PPT G8. Ocular Hypotensive Medicines PDF | PPT G9. Applanation Tonometry PDF | PPT G10. The Jacked-Up Angle PDF | PPT G11. Retinal Ganglion Cell Types and Visual Field Testing PDF | PPT G13. Open-Angle Glaucoma: Secondary PDF | PPT G14. Secondary Open-Angle Glaucoma After Intraocular Bleed PDF | PPT G15. Open-Angle Glaucoma Overview PDF | PPT G16. Secondary Angle-Closure Glaucoma Overview PDF | PPT G17. Acute Primary Angle-Closure Glaucoma PDF | PPT G18. Primary Angle-Closure Glaucoma PDF | PPT G19. Glaucoma Clinical Trials PDF | PPT G20. Unilateral Elevated IOP PDF | PPT G21. Normal Tension Glaucoma (NTG) PDF | PPT G22. Lens-Induced Secondary Open-Angle Glaucoma PDF | PPT
Lens/Cataract L2. Post-op Endophthalmitis After Cataract Surgery PDF | PPT L3. Re Microspherophakia PDF | PPT L4. Lenticonus: Wadda Ya Know? PDF | PPT L5. Lens Luxation/Subluxation in the Pediatric Population PDF | PPT L6. Choroidal Hemorrhage PDF | PPT L8. Shallow Anterior Chamber After Cataract Surgery PDF | PPT L9. Lens Proteins PDF | PPT L10. Lens Metabolism PDF | PPT L11. Property of a Dispersive or a Cohesive Viscoelastic PDF | PPT L12. IOLs PDF | PPT L13. Anterior vs Posterior polar cataracts PDF | PPT L14. Identify the Cataract Type: NSC, Cortical, and PSC PDF | PPT L15. Cataracts Associated with Blunt Trauma or Radiation PDF | PPT L16. IOL Calculations PDF | PPT
Neuro-Ophthalmology N1. Miscellaneous Neuro PDF | PPT N2. Visual Field Defects PDF | PPT N3. Horner Syndrome: Central, Pre-ganglionic or Post-ganglionic PDF | PPT N4. Anisocoria PDF | PPT N5. On Leber’s Hereditary Optic Neuropathy PDF | PPT N6. Apparent Optic Nerve Head Swelling in Childhood PDF | PPT N7. Idiopathic Intracranial Hypertension PDF | PPT N8. Typical Optic Neuritis PDF | PPT N9. Systemic Drugs and Ocular Toxicity: Acquired Optic Neuropathy PDF | PPT N10. Which of the Following Concerning CPEO are Incorrect? PDF | PPT N11. CHAMPS PDF | PPT N12. Nontraumatic Isolated CN6 Palsy PDF | PPT N13. Nontraumatic Isolated CN3 Palsy PDF | PPT N14. Motility Disorders: Fascicular Syndromes PDF | PPT N15. Optic Nerve Sheath Fenestration PDF | PPT N16. Parinaud Syndrome PDF | PPT N17. Ischemic Optic Neuropathy PDF | PPT N18. Motility Disorders: Overview PDF | PPT N19. Motility Disorders: The Sinus, the Fissure, and the Apex PDF | PPT N20. Motility Disorders: Internuclear Ophthalmoplegia+ PDF | PPT N21. Motility Disorders: Supranuclear Syndromes PDF | PPT
Oculoplastics O1. Congenital Lid Abnormalities PDF | PPT O2. Congenital Ptosis PDF | PPT O3. Is it Ectropion, or DES? PDF | PPT O4. Managing Paralytic Ectropion PDF | PPT O5. Graves (Thyroid Eye Disease) PDF | PPT O6. The Pathogenesis of Lower-lid Involutional Entropion vs Ectropion PDF | PPT O7. Congenital Ectropion PDF | PPT O8. Congenital Nasolacrimal Duct Obstruction and Dacryocele PDF | PPT O9. Melanocytic Eyelid and Epibulbar Lesions PDF | PPT O10. Vascular Lesions of the Orbit PDF | PPT O11. The ‘Vicious Cycle’ of Spastic Entropion PDF | PPT O12. Dermoid Cysts, and Dermoid Cysts PDF | PPT O13. Orbital Rhabdomyosarcoma PDF | PPT O14. Orbital Neuroblastoma PDF | PPT O15. Differential for an Intraconal Mass PDF | PPT O16. Lacrimal Gland Enlargement PDF | PPT O17. Dem Bones (Comprising the Orbit) PDF | PPT O18. Proptosis PDF | PPT O20. Cicatricial Ectropion, Cicatricial Entropion PDF | PPT O21. Acquired Ptosis PDF | PPT
Pediatrics/Strabismus P1. Pediatric Pre-septal Cellulitis PDF | PPT P2. Pediatric Orbital Cellulitis PDF | PPT P3. Intraocular Tumors in Childhood PDF | PPT P4. Nystagmus PDF | PPT P5. Comitant Esotropia PDF | PPT P6. Comitant Exotropia PDF | PPT P7. Vertical Deviations PDF | PPT P8. A or V Pattern Strabismus PDF | PPT P9. Duane’s Retraction Syndrome PDF | PPT P10. Phakomatoses PDF | PPT P11. Phakomatoses: Quick Hitters PDF | PPT P12. Shaken Baby Syndrome PDF | PPT P14. Sensory Response in Strabismus PDF | PPT P15. Pediatric Orbital Tumors PDF | PPT P16. Galactosemia PDF | PPT P17. Aniridia: True/False PDF | PPT P18. Albinism and the Eye PDF | PPT P19. Iris Issues in Kids: Cysts, nodules and ectropion PDF | PPT P20. Pediatric Leukemia and the Eye PDF | PPT P21. Botox: It’s Not Just for Vain Rich People Anymore! PDF | PPT P22. Craniofacial Malformations PDF | PPT
Refractive Surgery RS1. Refractive Surgery: Overview PDF | PPT RS2. Keratorefractive Surgery: Complications PDF | PPT RS3. Corneal Optics PDF | PPT RS4. Photoablative Refractive Surgery PDF | PPT RS5. Intraocular Refractive Surgery: Overview PDF | PPT RS6. Aberrations PDF | PPT RS8. Incisional Corneal Refractive Surgery PDF | PPT RS9. Corneal-inlay, Collagen-shrinkage, and Cross-linking Refractive Surgery PDF | PPT
Retina/Vitreous R1. Coats Disease vs Retinoblastoma PDF | PPT R2. Concerning Retinoblastoma PDF | PPT R3. Vitreoretinal Dystrophies PDF | PPT R5. Differential for a Retinitis Pigmentosa-like Fundus PDF | PPT R8. Retinopathy of Prematurity PDF | PPT R9. Congenital/stationary Retinal Disease PDF | PPT R10. Stargardt Disease vs Fundus Flavimaculatus PDF | PPT R11. Best Disease, and Adult-onset Foveomacular Vitelliform Dystrophy PDF | PPT R13. Coats Disease PDF | PPT R15. Diffuse Unilateral Subacute Neuroretinitis PDF | PPT R16. White Dot Syndromes PDF | PPT R17. Retinal Anatomy and Histology PDF | PPT R18. ARN vs PORN (vs CMV) PDF | PPT R19. Fluorescein Angiography: Basics PDF | PPT R23. Ocular Ischemic Syndrome (OIS) vs partial/mild CRVO PDF | PPT R24. Idiopathic Macular Hole PDF | PPT R25. Plaquenil Maculopathy PDF | PPT R26. HTNive Oculopathy PDF | PPT R27. Persistent Fetal Vasculature (PFV) PDF | PPT R30. Working Up a CWS in a Nondiabetic Patient PDF | PPT R31. Diabetic Retinopathy: The Basics PDF | PPT R32. Diabetic Retinopathy: DME PDF | PPT R35. Retinal Detachment Overview PDF | PPT R36. Retinal Lesions and Their Relationship to Rhegmatogenous Retinal Detachment PDF | PPT R37. Rhegmatogenous Retinal Detachment Repair PDF | PPT R38. RP PDF | PPT R39. Leber’s Congenital Amaurosis PDF | PPT R41. Valsalva, Terson and Purtscher’s Retinopathies PDF | PPT R42. Gyrate Atrophy vs Choroideremia PDF | PPT R44. RVO Overview PDF | PPT R45. PRP and Its Complications PDF | PPT R47. Central Serous Chorioretinopathy PDF | PPT R48. Pigment Epithelial Detachment (PED) PDF | PPT R49. ARMD: DDx PDF | PPT R50. ARMD: The AREDS PDF | PPT R52. Causes of CNVM PDF | PPT R53. MacTel For Short PDF | PPT R55. PDT PDF | PPT R61. Angioid Streaks PDF | PPT R62. Systemic Drugs and Ocular Toxicity: Matching PDF | PPT R64. Choroidal Nevi and Choroidal Melanoma PDF | PPT R65. Choroidal Melanoma: DDx PDF | PPT R67. Retinal Laser Lenses PDF | PPT R68. Eales Disease vs Susac Syndrome PDF | PPT R69. ARMD Overview PDF | PPT R70. Hereditary choroidal/retinal dystrophies PDF | PPT
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