what's the sign of levator aponeurosis and why do you see that?
"high eyelid crease; levator sends attachemnts to skin to create eyelid crease so when it slips, you no longer get that"
what do cocaine and hydroxyamphethamine do to neurons?
cocaine prevents reuptake of epinephrine; hydroxy forces release of more epinephrine fron non-damaged 3rd order neurons
black discoloration of nasopharnyx should make you suspcious of?
phycomycosis (most common are mucor and rhizopus)
"what is jones I, II, and III"
jones I (place fluoresceine in eye and swab nose at 2 and 5 mins) jones II (irrigate the lacrimal system with cannula and swab the nose) jones III (find fluorescien in nose after DCR)
what is lens particle glaucoma
when lens material is left behind after cataract surgery which then directly clog the TM
what is phacoanaphylactic uveitis
capsular bag is violated which leads to inflammation
what ecc level should you be worried that corneal endothelium may not survive after sx
what type of cataracts develop in atopic dermatitis
"shield like anterior subcapsular and less often, PSC (due to steroids)"
what is the term for the amount of surface area of nuclear material in contact with phaco tip
what is the power in phaco terms
percentage of length that a phaco tip can move relative to the maximal possible length
what is duty cycle
porportion of time phaco energy is applied during a specified period of time
what is cavitation
formation of bubbles at phaco tip which leads to lens breakdown
what is the pathophysiology of diabetic cataracts
"excess of glucose causes activation of sorbitol pathway, sorbitol gets trapped in the lens and creates osmotic gradient for water"
when do you do surgery on a baby with b/l catacts? Unilateral cataracts?
3 months; 6 weeks
glaucomflecken are caused by?
high IOP during angle closure glaucoma causes lens epithelial death with resultant opacities
what is tass and how do you manage
toxic anterior segment syndrome -> sterile inflammatory reaction generally secondary to continaminants (especially from reusuable cannulas) entering the eye or incorrect ph of irrigating solutions -> tap and inject to r/o endolphthalmitis then start steroids
what is the avg anterior-posterior depth of lens at birth and adult
3.5 mm and 5 mm
what is the size of phaco tip
1.6mm (so you need to groove 2-3x the phaco tip to crack)
what is the presentation of p acnes
"chronic infection usually occuring 6 weeks after surgery, typically respond to steroids with apperance of PCO"
whats the best sign or test to see if k edema will resolve after cataract surgery
peripheral cornea is clear
what are the differences in cataract surgery in 1 month old vs adult
"you should do posterior capsuolotmy at time of surgery (kids cannot tolerate yag), scleral-corneal tunnel incision (incision is more stable, children will likely rub their eyes), anterior vitrectomy (more likely to have inflammatory response and tendency to form membranes)"
what is bowen's disease
"squamous cell carcinoma in situ of the skin, usually treated with surgical excision, maybe 5FU"
what structure is analogous to the levator aponeurosis in the upper lid? What is it?
"capsulopalpebral fascia, which originates from muscle fibers of inferior rectus, extends forward, wraps around inferior oblique and then inserts into the inferior tarsal border"
describe bick procedure
direct resection and then repair of the lower eyelid margin just before the lateral canthal angle -> this traction causes rounding of the lateral canthal angle
describe lateral tarsel strip
"shortening the lower eyelid and then suturing it to the periosteum, which maintains the sharp lateral canthal angle"
describe the medial spindle procedure
removing a diamond shaped piece of conjunctiva and lower lid retractors 4mm inferior to the inferior canaliciuls and then putting in everting sutures to correct medial entropion
describe cutler-beard procedure
"used to correct upper eyelid defects > 50% of the margin, lower eyelid full thickness flap is advanced into the upper eyelid defect, allowed to vasculiarize for 6 weeks and then upper and lower eyelids separated (mneumonic: CUT from Lower (beard)"
"for dermatocholasis repair, what is the pinch method and how much skin do you want to leave behind"
"put forceps in lid crease, pinch the excess skin between lid crease and margin until the eyelashes start to evert; as a rule of thumb, leave 10mm from the incision to the brow and 10 mm from incision to margin"
is the levator elevation affected in ptosis 2/2 aponeurosis
what is the risk of melanoma if blue nevi affecting the eye
how does metastatic cancer affect the orbit
associated with bone erosion and expansion of the orbit -> enolphthalmos
what valve seperates lacrimal sac to common canaliculus
valve of rosenmuller
what is the location of venous drainage of lateral pretarsal eyelid tissues
superficial temporal veins
what is the normal configuration of the lateral canthal tendon insertion in relation to medial canthal tendon insertion
lateral inserts 2mm superior to medial (important for doing lateral tarsal strips)
what is the ideal candidate for fasanella-sevat procedure (tarsoconjunctival mullerectomy)
mild amount of ptosis
what muscles are responsible for involuntary blinking? Forced eyelid closure? Vertical wrinkles between eyebrows? Horizontal wrinkles inferior to heads of eyebrows?
pretarsal part of obicularis; orbital part of oblicularis; corrugators (mneumonic: corrugated roofs have vertical wrinkles); procerus
what are lengths of vertical canaliculus? Horizontal canaliculus? Nasolacrimal sac? Nasolacrimal duct?
2mm; 8-10mm; 12-15mm; 12mm
what are side effects of tensilon test and what can you give to prevent it?
heart block; atropine
describe tenzel procedure
"aka tarsal fracture operation -> make posterior horizontal tarsal incision 2mm inferior to the eyelid margin, eyelid margin rotated away from the eye and stabilized with everting sutures "
which part of the lacrimal gland should you only biopsy and why
"orbital part; the ductules that empty the lacrimal gland pass through palpepbral part, so if scarring occurs when biopsying the palpebral part can cause DES"
what is epiblepharon? Ankyloblepharon? Euryblepharon?
when pretarsal skin and obic override margin; partial failure of eyelid to complete developmental seperation with residual strands of tissue connecting the eyelids; lengthening of the horizontal palpebral fissure and generally involves lower lateral eyelid
what percent of NLDO clear in first year of life
70-90%; treat with massages and topical abx
what is a low grade squamous cell carcinoma? Premalignant lesion that can lead to SCC
keratoacanthoma; actinic keratosis
how do you repair defect < 33% of the lid? 33-50% of the lid? > 50% of upper lid and lower lid?
"1. direct closure 2. eyelid can be freed with lateral canthotomy and semicircular flap is rotated into the defect; 3. upper eyelid- cutler beard procedure, lower eyelid- modified hughes procedure"
what is modified hughes procedure
upper eyelid flap of conj and tarsus are sewen into the lower eyelid posterior lamellae and the anterior lamellae is filled in with free skin graft
what do you have increased risk of with b/l retinoblastoma s/p radiation
"osteosarcoma, chondrosarcoma, fibrosarcoma"
what is epicanthus inversus? Epicanthus tarsalis? Epicanthus supraciliaris? Epicanthus palpebrus?
1. medial eyelid skin fold that is more prominent in the lower eyelid (inferior) 2. medial eyelid skin fold more prominent in upper eyelid (tarsus) 3. medial eyelid skin fold more prominent from the eyebrow to the lacrimal sac (above the cilius) 4. medial eyelid skin fold equally prominent in teh upper and lower lid (equal in palpebrae)
what is CI in laser skin resurfacing and why?
accutane (isoretinoin) because it causes delayed epithelial healing -> scarring
"if you have orbital cellulitis and high IgE, what organism?"
what causes vascular congestion at the rectus muscle insertions? Conjunctival vascular congestion?
TRO; dural shunt
what is the location of superior orbital fissure
between the greater and lesser wings of sphenoid
what is the annulus of zinn
circle overlying the superior orbital fissure and divides it into 2
what nerves are inside the annulus of zinn? Which outside
"inside: III, VI, V1 (nasociliary branch); outside: V1 (lacrimal and frontal branches), IV, sup ophthalmic vein (mneumo: LFT + sup ophthalmic vein)"
what is myotomy
incomplete horizontal incisions in the muscle to weaken and lengthen in
what should you first treat sympotomatic hyperthryoids with?
what is the first line treatment for hyperthyroidism and how does it work
methimazole and PTU (inhibits the addition of iodine to thyroglobulin by the enzyme TPO)
how many fat pads in the upper eyelids? Lower lids?
2 and 3
why is mri better for tumors
"xray is readily absorbed by bone but in MRI, you can see soft tissue well because it's not being absorbed by bone"
what is the site of most common presentatin of orbital lymphoma
"lacrimal fossa (the one in the frontal bone, not the one housing lacrimal sac)"
what is the most prognostic in terms of survival of eyelid melanoma
"tumor thickness, tumors > 4mm means <50% survival at 5 years, you should do sentinel lymph node biopsy for eyelids >1mm thick"
what can cause a mass superior and medial to the medial canthus?
"herniation of neurological tissues (meningocele, encephalocele, meningoencephlocele), dacryocystocele presents inferior and medial to the medial canthal tendon"
what type of bacterial is actinomycoses
filamentous gram positive rod
what is most common orbital mets in men
what is gray line
muscle of riolan
where do tissue from medial pretarsal tissue drain? Temporal pretarsal tissue? Post-tarsal tissue?
"angular vein; superficial temporal vein; orbital veins, deeper branchers of the anterior facial vein, and pterygoid plexus"
what is another name for area of superior orbital fissue inside annulus of zinn
where are krause glands found? Gland of wolfring?
"fornices, non-marginal tarsal border"
what is axial displacement? What is ddx of axial displacement?
what are differences between congenital ptosis when looking down and presence of lag between involutional ptosis and why do you get that difference
"in congenital ptosis, the ptotic lid is higher when looking downgaze and rarely get lagophthalmos because the muscle belly is fibrous and fatty and this extra bulk can prevent it from moving down and from closing "
what is management for keratoacanthoma
pagetoid spread of sebaceous cell carcinoma can mimic what
papillary palpebral conjunctiitis
what is pagetoid spread of sebaceous cell carcinoma
"occurs intraepidermally, whereby cells proliferate singly or in nests at all levels of epidermis"
what is management for sebaceous cell carcinoma
excision with sentinel lymph node biopsy
what stain will identify sebaceous cell carcinoma and what does it look like on path
tumor cells appear vacuolated due to the fat/lipid that is removed by alcohol during processing
what is the weakest part of the maxillary bone
what functions do the orbital portion and the pretarsal/preseptal obic perform? What nerve is responsible
voluntary eyelid closure (squeezing); unconscious blinking; innervated by CN VII
what are the eyelid protractor muscles
"obicularis, procerus, corrugator superciliaris"
what type of nevus has most malignant potential?: least malignant
when would you do probing in a dacryocystocele
if digital compression fails to resolve it in 1-2 weeks
what eyelid procedure is most likely to result in visual loss
lower lid blepharoplasty associated with retrobulbar hemorrahge
what surgery do you do if someone is born without canalciular system and puncta
what artery do you have to avoid on initial incision for DCR
how do you distinguish choroidal artery occulsions from CRAO
choroidal artery occulsions you get no perfusion of short posterior ciliary arteries so you get no choroidal flush
what artery does angular artery arise from
"facial artery, which comes from external carotid artery circulation (not ophthlamic artery, which branches from internal carotid)"
how do you send specimen to lab for salmon plaque in conjunctiva? What path tests?
fresh tissue without preservatives to get flow cytometry and cell surface markers
what percentage of hyperthyroids get TRO? What percentage of TRO has high thyroid? Euthyroid?
"30%; 90% have high thyroid, 6% euthyroid, 3% have hashimotos 1% have primary hypothyroidism"
meibomian glands secrete by what mechanism? Lacrimal glands? Glands of moll? Glands of krause/wolfring?
"holocrine, exocrine, apocrine (Molly is a sweaty Ape), exocrine"
"what is holocrine, exocrine and apocrine?"
cells produce the product in the cytoplasm and release the product into the lumen of the gland duct by disruption of cellular membranes thereby destroying the cell releasing the product; exocrine glands releae aqueous; apocrine glands secrete via a merocrine mechanism like sweat glands -> decapitation secretion
where are glands of krause located?
inferior fornix (jerry KRAUSE is a lowlife hiding in the bottom)
"lesion causing proptosis in a kid that acutely enlarges, also history of increasing with URI what is the mechanism"
lymphangioma; spontaneous hemorrhage intralesionally (lymphatic component can be deduced by history of enlarging with URIs)
which muscles dont contribute to annulus of zinn
"levator, Inf oblique, sup oblique"
what is the order of tissue going from superficial to deep in the upper face
"skin and subcutaneous tissue, temporoparietal fascia (SMAS), loose areolar tissue, deep temporal fascia, temporalis muscle"
what is the difference between nevus and freckle?
"nevus is from undifferentiated melanocytes found at the epidermal/dermal border, freckle is from melanocytes producing too much pigment"
what characteristics distinguish capillary hemangioma from rhabdo
"slow growing lesion, no ecchymosis typical for capillary hemangioma"
how do you distniguish epidermal inclusion cyst vs apocrine hidrocystoma
EIC has central pore and filled with keratin while hidrocystoma is smooth and filled with fluid
what does clear vs mucopurulent discharge and tearing from a infant tell you
"clear tearing is caused by obstruction of upper system: puncta, canaliculus, common canaliculus while mucopurulent discharge is caused by NLDO"
how does botox work
prevents release of acetylcholine into neuromuscular junction
what are signs of tumor of lacrimal sac? What are most common tumors of lacrimal sac?
enlargment of lacrimal sac above medial canthus tendon and bloody discharge; squamous cell papillomas and carcinomas
"what 2 findings will reasure you that you have IOI and not infection, mets, ruptured dermal cyst so you don't have to do biopsy and systemic workup?"
normal CBC and muscle tendon inflammation
whats the difference in asian vs caucasion eyelids?
"lower insertion of levator to septum; in asians, the septum fuses with the levator between the superior border of the tarsal plate and the eyelid margin whereas in caucasians the septum fuses with the levator 2-5mm above the tarsal plate, allowing more fat to occupy a higher position than in asians"
how many meibomian glands occupy upper vs lower eyelids
"old man hears swishing sound in his eye and you can auscultate a bruit, what is it?"
carotid cavernous fistua
at what week do you notice congenital NLDO? Why?
6 weeks; lacrimal gland become fully formed and functions at 6 weeks
when are first tears made?
20 days after birth (contradiction with 6 weeks when lacrimal gland formed?)
what size cuts is head CT:? Orbital CT?
5mm cuts/3mm cuts
when should you do anterior incision for chalazion?
if you suspect it involves mainly skin and obicularis (tarsus appears normal)
what is silent sinus syndrome?
due to hypoventilation of the maxillary sinus from obstructino of ostiomeatal complex -> chronic subclinical inflammation which things the maxillary bone -> collpase of maxillary sinus and displacement of orbital globe downward
what is treatmetn for silent sinus syndrome?
releaving the ostial occlusion and reconstructino of orbital floor
what causes the optic neuropathy and APD in retrobulbar hemorrhage
compression of the posterior ciliary arteries (more compressible than central retinal artery)
what is the least common site for basal cell carcinoma
lateral canthus (most common is lesions of lower eyelid > medial canthus > upper eyelid > lateral canthus= mneumo: IMSL im slow)
what is the length of orbital part of optic nerve? Length from posterior globe to orbital foramen?