Differential Diagnosis

Variable vision

symptom that is suggestive of aqueous deficient dry eye

systemic disease and its treatment

The onset of aqueous deficient dry eye symptoms are commonly associated with...

duration of disease

The severity of aqueous deficient dry eye is highly dependent on the...

symptoms, signs

Early aqueous deficient dry eye presents with more _____ than it does ____

signs, symptoms

Chronic aqueous deficient dry eye presents with more ____ than it does _____

decreased blink rate, low humidity, low air flow, aqueous deficient dry eye

Both meibomian gland dysfunction and aqueous deficient dry eye will experienced increased discomfort with ____ (3) but patients with _____ will be uncomfortable even in the absence of these environmental factors

Irregularity, thickening, telangiectasis

three lid margin changes that are associated with chronic aqueous deficient dry eye.

meibomian gland loss

Aqueous deficient dry eye will not show ____ differentiating it from meibomian gland dysfunction

positive

Aqueous deficient dry eye will show will show ____ inflammadry/MMP9 results

conjunctival injection

A marked symptom in aqueous deficient dry eye versus meibomian gland dysfunction is...

end of the day

Symptoms of meibomian gland dysfunction are usually worst at the...

gradual

Unlike aqueous deficient dry eye, meibomian gland dysfunction onset is more ____. It is not as commonly associated with medications.

meibomian gland loss and decreased gland secretion upon expression

Chronic meibomian gland disease will present with lid changes similar to those seen in aqueous deficient dry eye, but there will be ____ (2)

at the end of the day

Meibomian gland disease may present with many of the clinical findings of aqueous dry eye if the testing is performed...

negative

Meibomian gland disease will show ____ inflammadry/MMP9 results

central and nasal, 80

It is most important to express the _____ meibomian glands as they secrete ____% of the tear film oils

dilation, splitting, and plugging

An absence of meibomian gland loss does not rule out meibomian gland dysfunction, individual gland irregularities such as _____ (3) can also be diagnostically significant

meibomian gland dysfunction, aqueous deficiency

Mixed form dry eye is likely a chronic form of _____ that is developing a secondary _____

20-40%

percentage of the population having allergic conjunctivitis

10%

percentage of allergic conjunctivitis patients having isolated ocular symptoms

IgE

immunoglobulin moderating the hypersensitivity reaction involved in allergic conjunctivitis

mast, histamine

In allergic conjunctivitis ____ cells of the conjunctiva release _____

Bilateral ocular itching, papillae

two strong diagnostic symptoms/signs of allergic conjunctivitis

Seasonal

allergic conjunctivitis triggered by outdoor allergens such as tree and grass pollen.

Perennial

allergic conjunctivitis triggered by indoor allergens such as dust mites, animal dander, and mold.

Polysensitization

allergic conjunctivitis having chronic perennial symptoms with season exacerbations.

morning, inferior staining

Lagophthalmos will present with symptoms that are worse in the ____. Signs include ____

flushing and skin changes

Patient with ocular rosacea will also present with ____

Neurotrophic Keratitis (neurotrophic keratopathy)

rare degenerative disease of the cornea resulting from impairment of corneal sensory innervation. Is characterized by decreased or absent corneal sensitivity resulting in epithelial keratopathy, ulceration and potential perforation.

<5/10k

estimated prevalence of neurotrophic keratitis

Corneal herpetic infection

most common cause of neurotrophic keratitis

6%

percentage of herpes simplex keratitis patients that develop neurotrophic keratitis

12.8%

percentage of herpes zoster keratitis patients that develop neurotrophic keratitis

2.8%

percentage of patients having surgical intervention of trigeminal neuralgia that develop neurotrophic keratitis

ocular

All ____ surgeries pose a risk for the development of neurotrophic keratitis

triggering blink reflex and stimulating tear production

Corneal innervation protects the cornea by ____ (2)

blink rate and tear production, hyperosmolarity and inflammation

Disruption in corneal innervation can cause dry eye due to a decrease in ____ (2). This then triggers ____ (2)

trophic factors

Corneal innervation maintains the health of the cornea by producing...

Tropic factors/neurotrophins

proteins produced by both the corneal epithelial cells and by the neural network of the cornea which support the survival of cells by the regulation of cellular metabolism.

decreases, impaired epithelial healing

When there is damage to corneal nerves, the production trophic factors _____ resulting in _____

decrease

When there is reduced tear production, this results in a destruction of corneal epithelial cells and a ____ in trophic factors

Nerve growth factor

neurotrophin that is essential for the maintaining the neural structure of the cornea, regulating proliferation of epithelial cells, and inducing stromal healing. Its decreased levels in conditions causing damage to corneal nerves or to corneal epithelial cells can lead to neurotrophic keratitis.

decreases, centrally, wettability

Lack of trophic factors _____ the rate of epithelial cell mitosis and maturation at the limbus resulting in an accumulation of old cells _____. These cells have poor _____ making them susceptible to damage caused by friction from the lids during blinking

central corneal epithelial defect

Corneal epithelial changes resulting due to neurotrophic keratitis ultimately lead to a...

poor adhesion of cells to the basement membrane

The rolled border of corneal epithelial defects seen in neurotrophic keratitis is due to...

lysis or melting, proteases

Exposure of the stroma in neurotrophic keratitis can lead to ____ (2). The degree of stromal damage is dependent on the regulation of ____

collagen deposition and scarring

In response to stromal damage in neurotrophic keratitis there is abnormal ____ (2)

corneal perforation

Ultimately, poorly managed neurotrophic keratitis results in...

Dryness, photophobia, inability to do near work

three early symptoms of neurotrophic keratitis

morning, decreased blink rate

Neurotrophic keratitis symptoms are typically worse in the ____ or with ____

decrease, corneal hypoesthesia

When severity of neurotrophic keratitis increases this tends to ____ the severity of symptoms related to pain or discomfort due to _____. This is a pathognomonic sign of neurotrophic keratitis

increase

When the severity of neurotrophic keratitis increases symptoms related to visual quality ____

clear

The bulbar conjunctiva of patients having neurotrophic keratitis is generally...

corneal opacity

Early neurotrophic keratitis presents similar to dry eye. It is often diagnosed when ____ begins to become apparent

Persistent epithelial defect

central epithelial defect seen in neurotrophic keratitis characterized by elevated opaque edges where the epithelium is loosely attached to the basement membrane.

epithelial healing, corneal exposure, inflammation, and risk of infection

The goal in the management of neurotrophic keratitis is to promote ____ while minimizing ____ (3)

Preserved

____ medications should be avoided in the treatment of neurotrophic keratitis as they can exacerbate corneal toxicity

Cyclosporin A

may reduce inflammation in neurotrophic keratitis but does not improve corneal sensitivity

decrease, corneal healing

A topical steroid may be used to ____ inflammation in neurotropic keratitis, but may inhibit ____

Autologous tear serum, platelet rich plasma

two treatments that may be considered in neurotrophic keratitis as they contain growth factors, neuromodulators, and anti-inflammatory cytokines

NSAID

should never be used in the treatment of neurotrophic keratitis as they can further decrease corneal sensitivity and interfere in wound healing

Prophylactic antibiotic

Bandage CL

Amniotic membrane

3 treatments in stage 2 neurotrophic keratitis

Oxervate (Dompe)

topical cenegermin solution that is a recombinant human growth factor identical to naturally occurring neurotrophic growth factor. It is dosed 6x/day for 8 weeks in the treatment of neurotrophic keratitis to improve corneal integrity and promote nerve regeneration. Significantly decreases the progression of neurotrophic keratitis.

72%

percentage of healing after 8 weeks of oxervate use in neurotrophic keratitis

80%

percentage of healing after 1 year of oxervate use in neurotrophic keratitis

stage 1

Oxervate is marketed for the treatment of (which stage) neurotrophic keratitis treatment, as research has shown increased corneal nerve density in these patients

corneal perforation

The focus in the treatment of stage 3 neurotrophic keratitis is the prevention of...

cyanoacrylate glue

Small perforations of the cornea in stage 3 neurotrophic keratitis can be sealed with...

lamellar or penetrating keratoplasty

Large perforations of the cornea in stage 3 neurotrophic keratitis can be addressed with ____. However, there is a high risk of recurrent ulceration

Tarsorrhaphy

procedure involving suturing of the lid in order to reduce corneal exposure in stage 3 neurotrophic keratitis

Botulinum, levator

____ injection into the ____ can induce a ptosis that reduces corneal exposure in stage 3 neurotrophic keratitis

Conjunctival Gunderson flap

procedure involving the creation of a flap of superior bulbar conjunctiva and suturing inferiorly for coverage of the cornea providing mechanical protection and nutrient support. Used in the treatment of stage 3 neurotrophic keratitis

Corneal neurotization

procedure involving the use of the patient's own nerve tissue to bypass the damaged trigeminal pathway to the eye.

supratrochlear or supraorbital

Direct corneal neurotization involves dissection of the contralateral ____ (2) nerve and connection to the affected eye

sural, calf, supratrochlear or supraorbital nerve

Indirect corneal neurotization involves dissection of the ____ nerve from the ____ which is then attached to allow communication between the contralateral ____ (2) and the affected eye

6-8 months, 80

Corneal neurotization shows improvement of corneal sensation within ____ in ____% of patients. Blink reflex may not be restored