dermatology …or “is this a boil?” dan cushman. intro to dermatology what is the most common...

Dermatology

…or “Is this a boil?”Dan Cushman

03/10/2008 13:00 2

Intro to Dermatology

What is the most common skin diagnosis for

non-dermatologists?

Dermatitis > Pyoderma >

Warts

What is the most common skin diagnosis for

dermatologists?

Acne vulgaris > Dermatitis >

Actinic keratosis

Are nevi primary or secondary

lesions?Primary

Are nevi benign or malignant?

Benign

Which portion of the skin is

damaged in scar formation?

The dermis

03/10/2008 13:00 3


Flat or raised?Flat Macule

What is the larger sized

version called?Patch

What size are they?<1cm

General lesion type

03/10/2008 13:00 4


Flat or raised?Raised Papule


version called?Plaque

What size are they?<1cm

General lesion type

03/10/2008 13:00 5


Flat or raised?Raised Nodule


version called?Tumor

What size are they?>1cm

General lesion type

03/10/2008 13:00 6

Intro to DermatologyHow do they differ from papules?

Fluid-filled Vesicle


version called?Bullae

What size are they?>1cm

General lesion type

03/10/2008 13:00 7


What are the flakes?

Compacted desquamated

layers of stratum

corneum

ScaleGeneral lesion

type

03/10/2008 13:00 8


What causes excoriation?

Mechanical means (e.g. scratching)

ExcoriationGeneral lesion

type

03/10/2008 13:00 9

Intro to DermatologyWhich portion of the skin is

affected?

Epidermis + dermis Ulcer

General lesion type

03/10/2008 13:00 10


Benign or malignant?Benign Nevi

Congenital or developed?Either

Similar to which animal?The shrew

Name of lesion

03/10/2008 13:00 11


Benign or malignant?Benign Seborrheic

Keratosis

Younger or older patients?Older

Name of lesion

Where are they commonly

found?Face and trunk

03/10/2008 13:00 12


Benign or malignant?Benign Skin Tags

Where are they commonly

found?

Neck, groin, axilla

Name of lesion

03/10/2008 13:00 13


Benign or malignant?Benign Cyst

What is contained

inside?Keratin

Do they affect the sebaceous

glands?Nope

Name of lesion

03/10/2008 13:00 14


Benign or malignant?Benign Solar Lentigo

Cause?Sun exposure

Name of lesion

03/10/2008 13:00 15


Benign or malignant?Malignant Basal Cell

Carcinoma

Common or Rare?Common

From which layer of skin do

they derive?

Basal layer of epidermis

Is it aggressive?Very rarely metastasizes

Name of lesion

03/10/2008 13:00 16


Benign or malignant?Precancerous Actinic Keratosis

To which type of cancer can they

transform?

Squamous cell carcinoma

Name of lesion

03/10/2008 13:00 17


Benign or malignant?Malignant Squamous Cell

Carcinoma

Common or rare?

2nd-most common form of

skin cancer

Aggressive?2-3% risk of metastasis

Name of lesion

03/10/2008 13:00 18


Benign or malignant?Benign Dysplastic Nevi

Clinical relevance?

People who have them are at an increased

risk of melanoma

Name of lesion

03/10/2008 13:00 19


Benign or malignant?Malignant Melanoma

Originates from…?Melanocytes

Prognosis correlates

with…?Depth

Is it aggressive?High risk of metastasis

Name of lesion

03/10/2008 13:00 20


• A• B• C• D• E

symmetryorder: irregularolor: multiple colorsiametervolution

03/10/2008 13:00 21


Patho-physiology?Autoimmune Psoriasis

Common sites?Knees & elbows

Name of lesion

03/10/2008 13:00 22


Patho-physiology?Fungus Tinea Corporis

Name that fungus

Trichophyton rubrum

Name of lesion

03/10/2008 13:00 23


Patho-physiology?Fungus Tinea Versicolor

Name that fungus

Pityrosporum ovale

Name of lesion

03/10/2008 13:00 24


Patho-physiology?Strep or Staph Impetigo

Common in which age

group?Children

Name of lesion

03/10/2008 13:00 25


Patho-physiology?

Usually medications

Toxic Epidermal Necrolysis

Treatment?IV Ig

Name of lesion

03/10/2008 13:00 26


Also known as…?

Inflammatory dermatitis Atopic dermatitis

Name of lesion

03/10/2008 13:00 27


Polar Bear CutitisName of

lesion

03/10/2008 14:00 28

Function & Structure of Skin

What makes up the

integumentary system?

Hair

Skin

Nails From which emybronic layer

does the epidermis

derive?

Ectoderm

From which embryonic layer does the dermis

derive?

Mesoderm

What type of tissue makes up the epidermis?

Stratified squamous epithelium

Which is the deepest

epidermal layer?Stratum Basale

What types of cells mostly make

up the stratum basale?

Stem cells

03/10/2008 14:00 29


What are the four layers of the skin from the surface down?

• Stratum corneum• Stratum granulosum• Stratum spinosum• Stratum basale

03/10/2008 14:00 30


What structures are present in high amounts

within the stratum

spinosum?

Desmosomes,Osland bodies

What is the purpose of the

keratohyalin granules in the

stratum granulosum?

They crosslink the layer

Where is the stratum lucidum

found?Palms & Soles

What type of cells are present in the stratum

corneum?

Dead ones

What molecule is present in high amounts in the

stratum corneum?

Keratin

How long is the maturation period for a

keratinocyte?

28 days

03/10/2008 14:00 31


Where are melanocytes

found?Basal cell layer

Are there more keratinocytes or

melanocytes?

Keratinocytes (10x)

What is the difference in melanocytes

between caucasian and african skin-

types?

Caucasian – smaller

melanosomes only in the mid-epidermal layer

With which body system are

Langerhans cells associated?

Immune System

Where are Langerhans cells

found?

Above the basal cell layer

What do Langerhans cells

do?

They are the first cells in antigen

detection

03/10/2008 14:00 32


What are Merkel cells?

Neuroendocrine cells with unknown function

What is the clinical relevance to Merkel Cells?

Merkel Cell Carcinoma

What is the difference between

desmosomes and hemi-

desmosomes?

Des = cell-cell;Hemi = cell-basement membrane

What is the main cell present in the dermis?Fibroblasts

What is the main source of blood vessels to the

epidermis?

The epidermis receives no blood flow (it’s indirect from the dermis)

What are the two sections of

the dermis? Which is bigger?

Reticular > papillary

03/10/2008 14:00 33


Which is a pressure receptor

– Pacinian or Meissner’s Corpuscle?

Pacinian

Where in the body are Pacinian

Corpuscles found?

External genitalia,

mammary glands, internal

organs

In which layer are Meissner’s Corpuscles

found?

Papillary dermis

Where are Meissner’s Corpuscles abundant?

Fingertips and lips

What are the three phases of

hair growth?

Anagen

Catagen

Telogen

In which phase are most hairs?

Anagen

03/10/2008 14:00 34


What is the purpose of

sebum?

Lubricates hair

↓ Water evaporation

Kills bacteria Where on the body are

sebaceous glands found?

Everywhere except for palms

& soles

Which sweat glands respond

to emotional stress?

Apocrine

Where are apocrine sweat

glands found mostly?

Axillae

Groin

Perianal region

What do eccrine glands do?

Produce sweat in response to heat

and humidity

What are nails made from?

Keratin

How fast do fingernails grow?

…Toenails?

Fingernails = 3mm/month

Toenails = 1mm/month

03/11/2008 09:00 35

Clinical Pathological Correlation

Where do junctional nevi sit

in the skin?

At the junction of the epidermis

and dermis

Where does a blue nevus sit?In the dermis

Where on the body are spider angiomas not

found?

Below the umbilicus, usually

What is the histological

presentation of a neurofibroma?

Comma-shaped nuclei; pink appearance

Where on the body are lipomas

usually found?

The upper trunk, thighs, and neck

Are seborrheic keratoses well-

or poorly-defined?

Well-defined

03/11/2008 09:00 36


What color is predominant

under the microscope in

basal cell carcinoma?

Purple (lots of chromaffin)

What is Bowen’s Disease?

Squamous Cell Carcinoma In Situ

What type of immune cell is

present in allergic contact

dermatitis?

Eosinophils

What type of hypersensitivity

takes place in allergic contact

dermatitis?

Type IV

Where on the body does psoriasis

normally occur?

ElbowsKnees

What is missing histologically in

psoriasis?A granular layer

Stay away from girls with

psoriatic kneesCENSORED

(Joke about psoriatic knees)

03/11/2008 09:00 37

Clinical Pathological CorrelationWhat is the histologic difference between

pemphigus and pemphigoid

lesions?

Pemphigus = suprabasal

Pemphigoid = subepidermal

Which of the two has eosinophilia?

Pemphigoid

Which of the two often has oral

mucosa blisters?Pemphigus

Which of the two is more severe?

PemphigusWhat is the histologic

appearance of Malassezia

furfur? What is the name of the

skin lesion it causes?

Tinea versicolor

Spaghetti & Meatballs!

What type of immune cell is

found in syphilis?Plasma cells

03/11/2008 09:00 38


What is the causative agent for Molluscum Comtagiosum?

A poxvirus

What do Molluscum

Contagiosum lesions look like?

Inverted (umbilicated) dome-shaped

papules

What color are the lesions

associated with Kaposi’s

Sarcoma?

Purple

What is the causative agent

of Kaposi’s Sarcoma?

HHV-8

Where is spongiosis

commonly seen?

Allergic contact dermatitis

03/11/2008 10:00 39

Viral exanthems

RubeolaCausative Agent Virus type Type of

exanthem

Direction of spread

Enanthem present? Significant labs

Clinical presentation

Special Treatment

Paramyxovirus ssRNA Morbiliform

Centrifugally Koplik’s spotsLeukopenia, ↑

hemagglutination inhibition Ab’s

Cough, coryza, conjunctivitis, Koplik’s

spotsVit A

First Disease

What are the main

complications of rubeola?

Pneumonia

Encephalitis

03/11/2008 10:00 40

Viral exanthems

Scarlet FeverCausative Agent Type of

exanthem

Direction of spread

Enanthem present?


Prodrome present?

Special Treatment

Streptococcus Pinpoint papules, Pastia’s lines

Neck trunk Strawberry tongue

Pharyngitis, palatal petechia, strawberry

tongue48h before rash Penicillin, erythromycin,

cloxacillin

Second Disease

03/11/2008 10:00 41

Viral exanthems

German MeaslesCausative Agent Virus type Type of

exanthem

Direction of spread



Prodrome present?

Togavirus ssRNA Dark pink macules and papules

Face centrifugal spread

Soft palate petechiae Neutropenia

Malaise, sore throat, cough, fever,

lymphadenopathyNo

Third Disease

What are the main

complications of rubella?

Congenital rubella (low birth

weight, extramedullary hematopoiesis,

etc.)

03/11/2008 10:00 42

Viral exanthems

Erythema InfectiosumCausative Agent Virus type Type of

exanthem

Direction of spread



Prodrome present?

Parvovirus B19 ssDNA Lacy erythema

Face centrifugal spread No Can lead to aplastic

crisis or hydrops fetalis

Rash is not contagious No

Fifth Disease

03/11/2008 10:00 43

Viral exanthems

RoseolaCausative Agent Virus type Type of

exanthem



Prodrome present?

HHV6 and 7 dsDNA Non-pruritic rose pink macules

No Trophism for CD4+ T-cells

High fever, heavy eyelids + periorbital

edema

Abrupt onset of rash after fever

Sixth Disease

03/11/2008 10:00 44

Viral exanthems

Pityriasis RoseaCausative Agent Virus type Type of

exanthem

Direction of spread

Enanthem present?


Prodrome present?

Special Treatment

HHV6 and 7 dsDNASalmon-colored

papules & plaques; plaques run parallel to

line of cleavage

Usually starts as herald patch No

Spares sun-exposed skin No UVB,

antihistamines

03/11/2008 10:00 45

Viral exanthems

Varicella ZosterCausative Agent Virus type Type of

exanthem

Enanthem present?

Contagious period

Post-exanthem pathology

Vaccine available?

HHV3 dsDNAPruritic macules, papules, vesicles,

and crusts

No

4 days pre-exanthem until all

lesions crust

Virus migrates to sensory nerves Yes

What are the main

complications of varicella zoster?

Shingles

Hepatitis

Varicella pneumonitis

03/11/2008 10:00 46

Viral exanthems

What is the causative agent

of Erythema Multiforme

(EM)?

HSV

Drugs

Idiopathic

What do the lesions of EM

look like?

Target or iris lesion

What immune cells are

involved?

CD8+ cells in epidermis

CD4+ cells in dermis

Should immuno-suppressive

agents be used?

No – they add to the moribidity!

What histological

presentations are present in Kawasaki’s Disease?

Increased toxic granulations,

vacuoles in PMNs

What is the treatment for

Kawasaki’s Disease?

High dose aspirin + IVIg

03/11/2008 10:00 47

Viral exanthems

Which portions of the body are

swollen in Kawasaki’s

disease?

Lymph nodes

Hands/feet

Is the fever high, low, or normal in

Kawasaki’s disease?

Very high

What is the enanthem

associated with Kawasaki’s Disease?

Mucosal injection

Fissured lipsWhat is the exanthem

associated with Kawasaki’s Disease?

Generalized macular

erythema

03/11/2008 10:00 48

Viral exanthems

What is the causative agent of Hand, Foot,

and Mouth Disease?

Coxsackievirus (picorna)

Where do the lesions appear?

Tongue, hard palate, buccal

mucosa, hands, feet

Which patients are especially at risk for serious complications?

Pregnant women spontaneous

abortion possible during first trimester

Who gets Molluscum

Contagiosum (MC)?

Kids or immuno-suppressed

patients


MC?

Cryosurgery, curettage, etc.

03/11/2008 11:00 49

Benign Neoplasms of the Skin

What is the pathophysiology of solar lentigo?

Increased keratinocytes at the epidermal

base

To what lesion can solar lentigo

progress?

Seborrheic Keratosis

In which layers are keratinocytes

increased in seborrheic keratosis?

All layers

What are the borders like in

junctional nevi?Uniform

Are intradermal nevi raised or

flat?Raised

Where are melanocytes

present in compound nevi?

Dermal-epidermal

junction and the dermis

03/11/2008 11:00 50


What is the relationship

between congenital nevi and melanoma?

Large nevi (>20cm) increase

one’s risk for melanoma

What is the pathophysiology

of halo nevi?

An immunologic event where lymphocytes attempt to

destroy a nevus

What histology is seen in blue

nevi?

Spindle-cell melanocytes

Are dysplastic nevi

premalignant?

No, but their presence

increases one’s risk of other melanomas

Which blood vessels are

increased in spider angiomas?

The superficial plexus

Will hemangiomas

continue to increase in size?

No, most spontaneously

regress

03/11/2008 11:00 51


What’s that?

Port-Wine Stain

03/11/2008 11:00 52


What is the pathophysiology of a Port-Wine

Stain?

Increased number of blood

vessels in the superficial plexus

With which syndrome can

Port Wine Stains be associated?

Sturge-Weber Syndrome


Spider Angiomas be associated?

Osler-Weber Rendu

What do follicular cysts contain? How

are they associated with

sebaceous glands?

Keratin

They are not associated with

sebaceous glandsWhere is sebaceous hyperplasia

usually seen on the body?

FaceForehead

CheeksNose


sebaceous adenomas be associated?

Muir-Torres (malignancies of the GI and GU

tract)

03/11/2008 11:00 53


What is a syringoma?

Proliferation of apocrine ducts

Where on the body are

syringomas usually found?

Periorbital

Which layer of the skin is

affected by a syringoma?

Upper ½ of dermis

What is a neurofibroma?A neoplasm of

the Schwann Cell

Which layer of fat proliferates in a

lipoma?Subcutaneous fat

03/12/2008 09:00 54

Aging & Skin Cancer

What are the main sources of extrinsic aging?

SunSmoking

PollutantsDiet

What happens to the epidermis

with age?

Decreased cell growth

Flattening of rete ridges

What happens to the dermis with

age?

Decreases in collagen, elastin,

etc.What

wavelengths of UV are

dangerous to humans?

UVA and UVB (290-400nm)

What are some good things

about UV light?

↓ Immune function

Vit D synthesis

Warmth

What is the relationship

between Langerhans cells

and sun?

UV light will decrease the

number of Langerhans cells

Optical engineers know this, which

helps explain their buttery-soft skin and staggering good looks

03/12/2008 09:00 55

Aging & Skin Cancer

Will the dermis increase or

decrease in size with UV

exposure? …the epidermis?

Epidermis = ↑

Dermis = ↓

Where is UVB absorbed?

The epidermis and superficial

dermis

What is the pathophysiology of the damage that UV light does to DNA?

CC TT tandem mutations

(pyrimidine dimers) What is the

pathophysiology of the damage that UV light

does with respect to ROS’s?

UV is absorbed by trans-urocanic acid and creates reactive oxygen

speciesWhich two

vitamins can be used to prevent

UV damage?

Vit E

Vit C

What are risk factors for skin

cancer?

Light skinBlue eyes

Blond/red hairAge

Male

03/12/2008 09:00 56

Aging & Skin Cancer

Which causes more skin

cancer, UVA or UVB?

UVB

Which causes more DNA

damage, UVA or UVB?

UVB

Which causes more

photoaging, UVA or UVB?

UVA

Which layer of the skin is

affected in actinic keratosis?

The superficial epidermis

Which layer is affected in Bowen’s Disease?

The full epidermis

Which layer is affected in

squamous cell carcinoma?

Epidermis + invasion into

dermis

03/12/2008 09:00 57

Aging & Skin CancerOn which

portion of the body is

squamous cell carcinoma most

commonly found?

Lower lip > ear, scalp

From which portion of the

skin do basal cell carcinomas originate?

Basal epidermis, around the hair

follicle

Which gene is most commonly

mutated in squamous &

basal cell carcinomas?

p53

What is the treatment for all

of the skin cancers?

Removal!

Which ingredients

should you look for when buying

a sunscreen?

Titanium oxideZinc oxide

AvobenzoneMexoryl

When should a chemical-blocking

sunscreen be applied?

At least 30 minutes before sun exposure

How often should sunscreen be

reapplied?

At least every two hours

03/12/2008 10:00 58

Drug/Contact Dermatitis

Who are more likely to have a drug reaction ,

men or women?

Women

What is the most common type of drug reaction?Morbilliform

What are the most common

causative agents of morbilliform drug reactions?

PenicillinCephalosporinsSulfonamides

NSAIDsAnti-convulsants

What is the pathophysiology of a morbilliform

drug reaction?

Type IV, cell-mediated

What do the morbilliform

drug reactions look like?

Red macules & papules

coalescing into plaques

Which areas of the body are affected by

morbilliform reactions?

Everything but the face or

mucosa

03/12/2008 10:00 59


What are the most common

causes of DRESS?

Allopurinol

Sulfas

Anti-convulsants


of DRESS?

There is an inability to

detoxify arene oxide

metabolites

How quickly does DRESS develop?

It begins 2-6 weeks after

starting culprit medication

What is the main danger

associated with DRESS?

Visceral involvement

(acute hepatitis)

How is DRESS treated (beside

stopping the medication)?

Oral or IV steroids

What is the most common type of

medication associated with a

fixed drug reaction?

Over-the-counter meds

03/12/2008 10:00 60


Where do fixed drug reactions

tend to show up?

Lips, hands/feet, genitalia, face

What is special about the second

fixed drug reaction a

patient acquires?

It occurs in the same place as

the first

Which age group is most

commonly affected by

Stevens Johnson Syndrome (SJS)?

Children


of SJS?

Type IV hypersensitivity

leading to a cytokine

perpetuation

Where does SJS tend to appear on the body?

Mucosa, everywhere (including viscera)

What differentiates SJS

from TEN?

SJS has less than 10%

desquamation

03/12/2008 10:00 61


What type of rash is present in

TEN?

Symmetric, painful, poorly-

defined, erythematous macules with

purpuric centers

Does TEN affect the mucosa?

Yes

What is the treatment for TEN? Why?

IVIg – it blocks the Fas receptor

to inhibit Fas-FasL apoptosis of

keratinocytes Which is more common –

irritant or allergic contact

dermatitis?

Irritant (80%)

How many exposures are

required for ICD to occur?

It can occur at the first exposure

Which type of immune reaction

is the cause of ACD?

What else…? Type IV!

03/12/2008 10:00 62


How long does it take for ACD to

develop?

10-21 days for sensitization

48-120 hours for challenge

What are the two most

common causes of ACD?

Poison Ivy

Nickel

How can ACD be diagnosed in the

clinic?Patch testing

What is the median income

for a dermatologist

(2007)?

$390,000. Seriously.

03/13/2008 09:00 63

Acne

What is a closed comedone?A republican

What is the main initiator in the formation of

acne?

Androgens

What do androgens do (in the formation of

acne)?

They activate sebum

production, which can lead to

abnormal follicular

keratinizationWhat topical

antibiotics are available for the

treatment of acne?

Erythromycin

Clindamycin

What systemic antibiotics are

most commonly used?

Doxycycline

Minocycline

Trimethoprim-sulfamethoxazole

Which antibiotic should be

attempted first, doxycycline or minocycline?

Doxycycline, because

minocycline has more serious

adverse effects

A whitehead

03/13/2008 09:00 64

Acne

What is the physiology of

topical retinoid therapy?

Inhibition of the formation of the

microcomedo (the precursor)

How quickly do retinoids begin

working?Months

What are the three general

types of systemic medications used

to treat acne?

OC’s

Antibiotics

Isotretinoin What is the purpose of

antibiotics in acne therapy?

Kill Propriobacterium

acnesWhat are the three main

general mechanisms of

oral contraceptives

for reducing acne?

↑ SHBP

↑ Estrogen

↓ Androgens (Yaz)

What should be considered in an

obese female with acne?

PCOS

03/13/2008 09:00 65

Acne

What should be considered in an

obese young man with acne?

Cushing’s

What is the main adverse effect of

isotretinoin?

Teratogenic effects

How do isotretinoins

work?

Sebum suppression

Chronic inflammation suppression How is a high-

glycemic index diet thought to increase acne?

↑ IGF-1, which can stimulate androgens &

induce hyperkeratosis

How is milk thought to cause

acne?↑ IGF-1

What is the other evidence linking ↑ IGF-1

with acne?

PCOS has elevated IGF-1

03/13/2008 09:00 66

Acne

Will oral diabetic drugs reduce

acne in patients with PCOS?

Yes

Will chocolate increase

incidence of acne?

No

Does stress cause an increase in the severity of acne?

Probably

…how?

Substance P, other

neuroendocrine factors

Is rosacea common?

Yes – it affects 13 million

Americans

What are the main risk factors

for rosacea?

Sun

Fair skin

Family history

03/13/2008 09:00 67

Acne

Which type of rosacea is

characterized by thick skin and nodularities?

Phymatous rosacea

Should corticosteroids be used for the

treatment of rosacea?

No – they can aggravate it

What are the topical

treatments for rosacea?

Metronidazole, Sulfurs, Azeleic acid, Immuno-

modulators

What is the cause of perioral dermatitis?

Pretty much the same as rosacea

What oral therapies can be used for rosacea?

TetracyclinesTrim-SulfaMacrolidesIsotretinoin

What increases flushing in

people with rosacea?

Wine

Hot drinks

Spicy foods

03/13/2008 09:00 68

Rosacea – four types

• P• O• P• E

hymatous – thick skin, nodularitiescular – inflamed eyelids, styesapulopustular – central facial edemarythematotelangiectatic – flushing, central

edema with/without telangectasias

03/13/2008 10:00 69

Hair & Nails

What is hair made of?

Keratin

What receptors are present on hair follicles?

Androgen receptors

Will estrogens increase or

decrease hair growth rate? …

how?

Decrease; they prolong the

anagen phase

How many hairs are shed per

day?100-200

What happens during catagen?

The lower 2/3 of the follicle undergoes

apoptosis and regresses

How long does telogen last?

5-6 weeks

03/13/2008 10:00 70

Hair & Nails

When is the club hair shed?

Exogen

Is alopecia areata scarring or non-

scarring?Non-scarring

What is the pattern of hair loss in alopecia

areata?

Patchy


of alopecia areata?

T-lymphocyte-mediated

autoimmune disease

What is the most prevalent type of hair loss affecting

men?

Androgenetic Alopecia (AGA)

What is the most prevalent type of hair loss affecting

women?

Androgenetic Alopecia (AGA)

03/13/2008 10:00 71

Hair & Nails

What is the pattern of male

hair loss in AGA?

Frontoparietal and vertex

thinning

What is the pattern of female hair loss in AGA?

Widening of the part width

vertex thinning

What is the pattern of hair

loss in trichotillomania?

Areas of alopecia with irregular

borders, containing hairs

of various lengths with stubble What type of

hairstyle is associated with

traction alopecia?

Cornrows

How can a high fever result in

hair loss?

Telogen effluvium (conversion of

hairs from anagen to

telogen phase)

What is the pattern of hair loss associated with syphilitic

alopecia?

“Moth-eaten”

If you haven’t been counting, this is

reason #342 not to get syphilis

03/13/2008 10:00 72

Hair & Nails

Is discoid lupus erythematosus associated with scarring or non-

scarring alopecia?

Scarring

Can the hair regrow after

scarring alopecia?

No

What other superficial

feature is seen with discoid

lupus erythematosus?

Dyspigmentation

Does lichen planus result in scarring or non-

scarring alopecia?

Scarring

What is the cause of lichen planus?

Unknown; it’s an inflammatory

disorder

What are nails made from?

Tightly layered keratinized cells –

onychocytes

03/13/2008 10:00 73

Hair & Nails

5

6

89

43

21

7

03/13/2008 10:00 74

Hair & Nails

How long does it take for

fingernails to be completely

replaced? …toenails?

Fingernails =4-6 months

Toenails =9-12 months

From where do nails get their blood supply?

Digital arteries that run lateral to

the phalanges

What is the clinical

presentation of paronychia?

Loss of cuticle, lateral nail folds,

pus

What causes infectious

paronychia?

Usually staph or strep

What usually causes chronic

paronychia?

A contact reaction to an

irritant or allergen (e.g.

chronically wet hands)

What are the three main

general causes of onychomycosis?

CandidaSaprophytes

Dermatophytes

03/13/2008 10:00 75

Hair & Nails

How can psoriasis present

on the fingernails?

Pitting

“Oil drop”

How can lichen planus present on the nails?

Thinning

Ridging

Fissuring

What causes clubbing of the

fingernails?

Enlargement of the soft tissue of

the distal digit

What are the main general

causes of clubbing?

Cardiopulmonary disorders

What is koilonychia?

Spoon-shaped nail

What are the main two causes of koilonychia?

Iron deficiency anemia

Hypothyroidism

03/13/2008 10:00 76

Hair & Nails

What are Beau’s Lines?

Transverse depressions

across the nail plate

What is the pathophysiology of Beau’s Lines?

Temporary interruption of

the mitotic activity of the proximal nail

matrix

What does mild longitudinal

ridging (onychorrhexis)

of the nails suggest?

It’s normal with aging

What causes leukonychia?

Disturbance of the distal nail

matrix keratinization

(usually traumatic)What are the

causes for:Muehrcke’s,Terry’s Nails,½ & ½ nails?

Muehrcke Hypoalbuminemia

Terry’sCirrhosis, CHF

½ & ½ Uremia

What can a single band of

melanonychia suggest?

Melanoma or melanocytic nevi

What causes yellow nail syndrome?

An arrest in nail growth

03/13/2008 11:00 77

Parasites & Arthropods

What is the histologic

hallmark of Leishmaniasis?

Donovan bodies

What is the vector for

Leishmaniasis?Sandfly

What is the cause of

onchocerciasis?Nematode

How do the nematodes enter

the human in onchocerciasis?

Via blackflies

What causes river blindness?

Microfilariae produced by the

nematodes scarring

Which stage of the nematode

lifecycle causes clinical

symptoms?

The dead microfilariae

03/13/2008 11:00 78


What causes the symptoms of

elephantiasis?

Adult worms in the lymphatics

How is elephantiasis diagnosed?

Microfilariae in the blood

How is shistosomiasis

contracted?

Fresh-water circadia burrow

into hostWhat must be present for a

complete Schistosoma

lifecycle?

Fresh water

Snails

Your tasty feet-meatWhich areas of

the human skin are affected by the parasite?

Areas exposed to water

What is the vector for

elephantiasis?Mosquito

03/13/2008 11:00 79


How else can Schistosomiasis present beside

skin manifestations?

Hematuria

What is the vector for tungiasis?

Flea that burrows into the skin

How is scabies diagnosed?

Scrape

How are scabies spread?

Just skin-to-skin contact

What are the three types of

lice?

Head

Body

Pubic

Which type of lice do not live on

the body?

Body lice (they lay eggs on the

clothes)

Bonus points! What cancer can

schistosomiasis cause?

Squamous cell carcinomaof the urinary tract

03/13/2008 11:00 80


What is a potential

complication of a bedbug bite?

Hepatitis B

What types of venom are

present in black widow and

brown recluse spiders?

BW = latrotoxin

BR = sphyngo-myelinase D

What does the venom of fire ants contain?

What does it do?

Dialkylpiperidine hemolytic

factors, which induce the release of histamines Which type of

venom kills the most people in the US than any

other type?

Hymenoptera (bee) stings

Are caterpillars pet-able?

Yes, but their irritating hairs may be toxic

What are the vectors for

Chagas disease and Sleeping

Sickness?

Chagas = Reduvig (Kissing) bug

SS = Tsetse fly

Where are larval migrans often

contracted in the US?

The sand (which is contaminated by animal feces)

03/14/2008 09:00 81

Autoimmune Blistering Diseases

What do the autoimmune

blistering diseases target

(generally)?

Epidermal keratinocyte

adhesion

Which are more common,

subepidermal or intraepidermal

blisters?

Subepidermal

Which is more common,

pemphigoid or pemphigus?

Pemphigoid

Which type of pemphigus is

more common? Which is deeper?

Pemphigus vulgaris (both)

Which is the more dangerous

type of pemphigus?

Pemphigus vulgaris

What is the general

treatment for the autoimmune

blistering diseases?

Immuno-suppressive

agents

03/14/2008 09:00 82

Bullous Pemphigoid Pemphigus Vulgaris Pemphigus

Foliaceous

Age Elderly Adults Elderly

Depth Subepidermal (Lamina lucida) Intra-epidermal (suprabasal) Intra-epidermal (Gran. layer)

Type of blister Tense Flaccid Flaccid/crusts

Nikolsky sign - + +

Histology Eosinophils Acantholysis Acantholysis

IF Linear Chicken-wire Chicken-wire?

Antigen Hemidesmosome Desmoglein 3 Desmoglein 1

Prognosis Good Poor, ↑ mortality Hard to treat

Pathophysiology ? Pathogenic Ab’s Pathogenic Ab’s

Autoimmune Blistering Diseases

03/14/2008 10:00 83

Inherited Blistering DisordersBasement Membrane DefectsKeratin Defects

Epidermolytic Hyperkeratosis

Junctional Epidermolysis

Bullosa

Epidermolysis Bullosa Simplex

Dystrophic Epidermolysis

Bullosa

03/14/2008 10:00 84

Inherited Blistering Disorders

What is the most common cause of neonatal blisters?

Prematurity

Are there a greater or lesser density of rete

ridges in neonates?

Decreased

Does epidermolytic hyperkeratosis affect basal or

suprabasal keratinocytes?

Suprabasal

Which types of keratins are present in suprabasal

keratinocytes?

K1 & K10

Which disease is associated with

disorders in Keratins 5 & 14?

EBSIs EBJ associated with defects in

K1 or K5?

Neither – it’s associated with

basement membrane defects, not

keratin

03/14/2008 10:00 85


With what factor does disease severity in EB

correlate?

Depth of blister

In which skin layer does EBS

occur?Intraepidermal

Are keratins intra- or

extracellular?Intracellular

What are the two general types of

keratins?

I (K1-K8)

II (K9-K20)

What are the two types of JEB?

Which is worse?

Herlitz (lethal)

Non-Herlitz

With which type of defect are the

two JEB’s associated?

Laminin 5 for both

03/14/2008 10:00 86


What is the molecular defect associated with

DEB?

A mutation in collagen VII production

Does AD DEB increase or decrease in

severity with age?

Decreases

What is the clinical

presentation of AR DEB?

Mitten deformity of the hands


EB?

There is no cure, so it is all

supportive

What type of nutrition is required for

neonates with EB?

High-calorie, high-protein diet

Does DEB occur above or below the basement membrane?

Below

03/14/2008 10:00 87

Keratins?Keratins?


JEB DEB

?Keratin defects

?BM defects

K1 & K10 K5 & K14

Basal or suprabasal?Basal or suprabasal?

Suprabasal Basal

EHK EBS

03/14/2008 11:00 88

HIV Dermatoses

What is the cause of most

HIV dermatoses?CD4 depletion

What causes Kaposi’s

Sarcoma?HHV-8

How can HPV be highly indicative

of HIV?

Highly florid verruca vulgaris

How can HSV be highly indicative

of HIV?

Chronic herpetic ulcers

How can EBV be highly indicative

of HIV?

Oral hairy leukoplakia

How can molluscum

contagiosum be highly indicative

of HIV?

Multiple facial molluscum

contagiosum lesions

03/14/2008 11:00 89

HIV Dermatoses

How can herpes zoster suggest

HIV?

Atypical manifestations

(bilateral, multiple

dermatomes, etc.)

How can candidiasis

suggest HIV?

Oropharyngeal or recurrent

vulvovaginal candidiasis

How can onychomycosis

be highly indicative of HIV

infection?

Proximal subungual

onychomycosis

Which bacterial infection is

highly indicative of HIV infection?

Bacillary angiomatosis

What bacteria is responsible for

bacillary angiomatosis?

Bartonella

What is the testing

procedures associated with

HIV and syphilis?

Test all syphilis patients for HIV

Test all HIV patients for

syphilis

03/14/2008 11:00 90

HIV Dermatoses

• B• O• O• K• H• M

acillary angiomatosisral hairy leukoplakianychomycosis (proximal subungual)aposi’s sarcomaerpes simplex – chronic ulcersolluscum contagiosum – multiple facial

lesions

03/14/2008 13:00 91

Melanoma

What type of sunburns will put

you at an increased risk of

melanoma?

Any, but especially blistering sunburns

What happens to keratinocytes in a

sunburn?

They apoptose

(Is “to apoptose” a verb? It is now)

What do melanocytes do in reaction to a

sunburn?

They proliferate

Does UVA light promote immuno-

suppression in just the skin or systemically?

Both

What is the most common clinical

subtype of melanoma?

Superficial spreading melanoma

What is the most important

predictor of survival in a melanoma

lesion?

Depth of

invasion

03/20/2008 09:00 92

Wound Healing

What is the most common type of chronic wound?Pressure ulcer

Which type of wound is the

quickest to heal?A clean incision

What are the three phases of wound healing?

Inflammatory

Proliferative

Remodeling What are the main factors at play during the inflammatory

phase?

Growth factors

Which type of cell is arguably

the most important in

wound healing?

Macrophages

Which will scar more – full or

partial thickness wounds?

Full-thickness wounds

03/20/2008 09:00 93

Wound Healing

How much of the dermis is

composed of adnexal

structures?

40%

What is the term for the removal of epidermis?

Erosion

How deep is a full thickness wound?

It contains the entire dermis and

the epidermis

Which types of wounds have

complete regeneration?

Fetal wounds

ErosionsWhich

contributes more to wound healing – proliferation of new epithelium or migration?

MigrationShould wounds be kept moist or

dry?Moist

03/20/2008 09:00 94

Wound Healing

Which heals faster – an open

or unopened blister?

Unopened

What are the three main benefits of occlusive

dressings?

Faster healing

Better healing

Less pain

Are there more infections in a

covered wound?Nope

How quickly should a wound

be covered? When should the

dressing be removed?

Before 2 hours

After 48 hours

What are the main two general

mechanisms of action for skin

grafts?

Tissue replacement

Stimulus to healing

Which should not be used on a

wound chronically, hydrogen

peroxide or ethanol?

Neither should be used

chronically

03/20/2008 10:00 95

Psoriasis

Which age group usually contracts

psoriasis?

Around 20 and 55 (bimodal distribution)

What is the Koebner

phenomenon?

Skin lesions appearing along

the lines of trauma

Which type of rheumatic

disorder can arise from psoriasis?

Psoriatic arthritis

Does psoriasis cause CV risk factors or CV outcomes?

Both (it’s an independent risk

factor for MI)

What is Auspitz’s sign?

Punctate bleeding spots

that appear after the removal of psoriatic scales

Does psoriasis cause other CV events beside

MI?

Yes

03/20/2008 10:00 96

Psoriasis

What are the two general types of

psoriasis?

Pustular & non-pustular

What are the subtypes of non-

pustular psoriasis?

Vulgaris

Guttate

Erythrodermic

What are the subtypes of

pustular psoriasis?

Localized

GeneralizedWhat are the

three ways that nails are generally

affected by psoriasis?

Pitting

Onycholysis

Onychodystrophy

Is psoriasis inherited or acquired?

Probably some of each

Which infection is associated with the initiation of

psoriasis?

GAβHS (that means group-a beta-hemolytic

strep)

03/20/2008 10:00 97

Psoriasis

Which medications are

classically associated with

psoriasis?

Lithium

β-blockers

Which type of organism is

commonly found in pustular

psoriasis lesions?

None – it’s sterile

What is the method of action

for retinoids in psoriasis

treatment?

They normalize epidermal

proliferation

What is the approximate

epidermal transit time in psoriasis?

6 days

What is the immunologic mechanism of

psoriasis?

T-cell mediatedWhat are the

main treatments for psoriasis?

UV light

Biologics

Methotrexate

98

Ophthalmology

Or… is it one or two h’s?

03/17/2008 09:00 99

Intro to Ophthalmology

What is the first step in the eye

exam?Wash your hands

What is the “disc” in the back

of the eye?The optic nerve

Where is the retinal damage for an inferior field defect?

Superior retina

03/17/2008 10:00 100

Ocular Anatomy

What are the three layers of the tear film?

Lipid

Aqueous

Mucinous

What is the main artery to the

cornea?

There is no blood supply to the

cornea

What are the five layers of the

cornea?

EpitheliumBowman’s Layer

StromaDescemet’s Mem

EndotheliumWhich layer is

highly innervated?Epithelium

Which layer will scar – the

epithelium or Bowman’s Layer?

Bowman’sWhat is the

largest layer of the cornea?

Stroma (90%)

03/17/2008 10:00 101

Site of Secretion Function Dysfunctions

Lipid Meibomian glands Prevents evaporation Blepharitis, rosacea

Aqueous Lacrimal gland Fluidity Sjogren’s

Mucinous Goblet cells Wettability

Ocular Anatomy

03/17/2008 10:00 102

Ocular Anatomy

What is the main consituent in Descemet’s Membrane?

Type IV Collagen

Which layer of the cornea

decreases in cell number with

age?

Endothelium

Where does aqueous humor

come from?

Ciliary processes of the ciliary

bodyWhat is the name

of the region between the

cornea and the sclera?

The limbus

What are the two regions of the

conjunctiva called?

Bulbar

Palpebral

Where can accessory

lacrimal glands be found?

In the conjunctiva

03/17/2008 10:00 103

Ocular Anatomy

54

32

1

03/17/2008 10:00 104

Ocular Anatomy

Why do we have irises?

To control retinal illumination

What are the two layers of the iris?

Stroma

Pigment epithelium

Which portion of the autonomic nervous system constricts the

pupil?

Parasympathetic

How many layers are present in the

lens?6

What is the main blood supply for

the lens?

None – it gets its glucose &

nutrients from the aqueous

humor

What are the two main layers of

the retina?

Neural retina (7 sub-layers)

Retinal Pigment Epithelium

03/17/2008 10:00 105

Ocular Anatomy

What’s so special about the fovea?

It has the highest concentration of

cones, which allows for

maximal acuity

What layer of the retina absorbs

light?

The retinal pigment

epithelium

What is the main pathology

associated with the RPE?

Macular degeneration

Where does the choroid lay?

Between the sclera and the

retina

Where do the extraocular

muscles originate?

The annulus of Zinn

03/17/2008 11:00 106

Common Ocular ProblemsViral Conjunctivitis

Distinguishing symptoms?Watery discharge, pain, photophobia, foreign body sensation

Etiologic agent?Most commonly adenovirus

Precautions?Highly infectious – sanitize everything!

Bacterial Conjunctivitis

Distinguishing symptoms?Purulent discharge, redness, lid edema

Treatment?Ceftriaxone, empirically

Precautions?If gonococcal, systemic antibiotics necessary

03/17/2008 11:00 107

Common Ocular ProblemsBacterial-Fungal

Corneal Ulcer

Distinguishing symptoms?History of trauma, contact lenses, pain, foreign body sensation

Treatment?Anesthetize, scrape, and culture

Herpetic Corneal Ulcer

Distinguishing symptoms?Acute onset, pain, photophobia, foregin body sensation

What test is used for diagnosis?Fluorescein stain

Etiologic agent?HSV-1

Treatment?Acyclovir, hyoscine (cycloplegic drop)

03/17/2008 11:00 108

Common Ocular Problems

Which portion of the cornea is damaged in

corneal abrasions?

Epithelium

What is the treatment of a corneal foreign

body?

Removal, antibiotic drops

What is the treatment for an

intraocular foreign body?

Surgery!

Will vitreous hemorrhage

regress without treatment?

Yep

Which should be examined – floaters or

flashing lights?

Both – they could be the sign of

retinal damage or detachment

Should a person with a

subconjunctival hemorrhage

undergo surgery?

No, if truly subconjunctival, it’s no big deal

03/17/2008 11:00 109

Common Ocular Problems

What is the main risk of dry eyes?

Increased risk for infectious keratitis

Which layer of the tear film is

the closest to the surface of the

eye?

The mucous layer

What is the treatment for blepharitis?

Warm compress

What the hell is blepharitis?

Inflammation of the eyelids

What is the treatment for a

chalazion?Warm compress

What is the usual condition

associated with an inflammation of the posterior eyelid margin?

Meibomitis

03/17/2008 13:00 110

Ophthalmic Pathology

What is the histology present

in a chalazion?

Lipo-granulomatous inflammation

with multi-nucleated giant

cellsWhat is the

pathophysiology of a chalazion?

Obstruction of the Meibomian

glands


presentation of a pyogenic

granuloma?

Exuberant granulation

tissueWhat is the most common tumor of the eyelid? Which eyelid is

more commonly affected?

Basal cell carcinoma

Lower eyelidIf you had an

eyelid tumor that took out your

eyelashes, would you be worried?

I would – it’s probably

malignant

If a biopsy of a brown spot on

the sclera shows the epithelium

being pulled down, what is the most likely

diagnosis?

Nevus

03/17/2008 13:00 111


If a brown spot on the eye is

elevated, what is the most likely

diagnosis?

Melanoma – it could also have feeder vessels

What is the cause of

Conjunctival Intraepithelial

Neoplasia (CIN)?

Faulty epithelial maturational sequencing

What are the three hallmarks

of corneal dystrophies?

Inherited

Bilateral

Symmetric What are the depositions for

each of the three corneal

dystrophies?

Lattice = amyloid

Granular = hyaline

Macular = mucopolysacch.

Which type of corneal

dystrophy is inherited in an

autosomal recessive pattern?

Macular

How deep in the retina does a proliferative disease take

place?

On the surface of the retina

03/17/2008 13:00 112


What is Drusen?Deposits in

Bruch’s membrane

Which layer of the retina is affected by

macular degeneration?

The retinal pigment

epithelium

What are the three main conditions

associated with leukocoria?

Retinoblastoma

Coat’s Disease

Retinal detachment With which

condition are Homer-Wright

Rosettes associated?

Retinoblastoma

How does retinoblastoma

spread?

It extends by optic nerve infiltration

What does a mushroom

shaped lesion in the eyeball

suggest?

Fung-eyeI mean, choroidal melanoma

03/17/2008 13:00 113


Which type of histology is

suggestive of a worse prognosis in melanoma?

Epitheloid cells

Is a melanoma of the iris low- or

high-grade?Low grade

03/17/2008 14:00 114

Retinal Disease

543

21

678910

In which direction does the light go in this diagram?↑

03/17/2008 14:00 115

Retinal Disease

How does the retina get its

blood?

Retinal & Choroidal

Circulations

What can be seen in

fluorescein angiography?

Areas of leakage in the retina

What would a flame-shaped hemorrhage

suggest?

A superficial leak

How would a deep

hemorrhage appear?

As a dot blot

Who would be the stereotypic

patient with hard exudate

appearing on their retina?

A diabeticWhat does a Hollenhorst

Plaque indicate?An embolus

03/17/2008 14:00 116

Retinal Disease

Is this the left or the right eye?Right

03/17/2008 14:00 117

Retinal Disease

What is the best method of

reducing the risk of vision loss

from diabetes?

Tight glucose control

What is the hallmark

histologic feature of diabetic

retinopathy?

Capillary nonperfusion

Is age-related macular

degeneration uni- or bilateral?

Bilateral, but can have significant

asymmetry Which type of AMD is

characterized by a thickened

Bruch’s membrane and

Drusen?

Dry AMD

What comes after dry AMD?

Wet AMD…What happens

in wet AMD?

New abnormal blood vessels

proliferate and penetrate Bruch’s

membrane

03/17/2008 14:00 118

Condition Proliferative or Non-proliferative

NVD Proliferative

Vitreous hemorrhage Proliferative

Venous beading Non-proliferative

Microaneurysms Non-proliferative

Cotton Wool Spots Non-proliferative

NVE Proliferative

Small blot intraretinal hemorrhages Non-proliferative

Preretinal hemorrhage Proliferative

Hard exudates Non-proliferative

Retinal Disease

03/17/2008 14:00 119

Retinal Disease

What happens to wet AMD without

treatment?

Scarring

What can help prevent AMD?

Vitamins (especially Vit C

& E)

What is the best treatment for

macular degeneration?

Anti-VEGF

Will anti-VEGF therapy improve

visual acuity?Yes

Is CRVO painful?No – it’s painless

loss of vision


hallmark of CRAO? Is it treatable?

A cherry red spot

There is no known effective

therapy; it’s like a stroke

03/17/2008 15:00 120

Cataracts

What treatment is used to prevent

cataracts?

There is no preventative

medical treatment

What modifiable risk factors exist

for cataracts?

Sun (UVB)DiabetesSmokingRadiation

What are the three main

functions of the lens?

Maintain its own clarity

Refract light

AccommodationWhich

contributes a greater refractive power in the eye,

the lens or the cornea?

Cornea (2/3)

What are the layers of the

lens?

Nucleus

Cortex

Capsule

What is the purpose of the lens capsule?

It is the point of attachment for

the zonular fibers

03/17/2008 15:00 121

Cataracts

What is presbyopia?

Loss of accommodation

with age

Does the lens soften or harden

with age?

Hardens (and thus resists

deformation)

Which two diseases are

most commonly associated with

lens abnormalities?

Marfan Syndrome

RubellaWhat is the lens

abnormality associated with

Marfan Syndrome?

Ectopia Lentis

Which type of drug most

commonly causes cataracts?

Corticosteroids

Which type of lens defect is

associated with congenital

rubella syndrome?

Cataracts

03/18/2008 09:00 122

Pediatric Ophthalmology

Which muscles originate at the

annulus of Zinn?

The four rectus muscles

Is the superior oblique on the

medial or lateral side of the orbit?

Medial

Is the nerve-to-muscle fiber ratio high or low in the

extraocular muscles?

High

What nerve innervates the lateral rectus

muscle?

Abducens (CN VI)

What is the significance of

the difference in fast and slow

movements of the eye?

They have different

innervations

How long does visual

development occur?

Roughly through the first decade

of life

03/18/2008 09:00 123

Which muscles are used?

1


2 3

4 5

6 7 8

03/18/2008 09:00 124


Which will grow stronger – the

strong eye or the weak eye?

The strong eye

How long does it take until a

neonate’s visual acuity

approaches adult levels?

3 years

Who will have worse

consequences from an eye

disease – children or

adults?

Usually children

How should a 4-year old patient

be tested for visual acuity?

Special subjective test

At what age can a child receive a standard adult

visual acuity test?

Around the age of 6

What do “C,” “S,” and “M” stand for in the CSM

technique?

Central fixation

Steady Fixation

Maintained Fixation

03/18/2008 09:00 125


EsotropiaExotropiaHypertropiaHypotropia

1

2

3

4

03/18/2008 09:00 126


What is the difference

between phoria and tropia?

Phoria is a latent tendency to

deviate the eyes, while tropia is

manifest deviation

What is amblyopia?

Decreased visual acuity in one eye

Is it reversible?

It can be, depending on the cause and age of

onset

When are children sensitive

to amblyopia?Up to age 6 or 7

What is strabismus?

A condition in which the eyes

are not properly aligned with each

other

What is esotropia? How

is it treated?

Inward turning of the eye

Tx: glasses, surgery

Which portions of the brain are

primarily affected by ambylopia?

Lateral geniculate nucleus

Primary visual cortex

03/18/2008 10:00 127

Intro to Glaucoma

What causes glaucoma?

Multiple factors; it’s a group of

diseases

Damage to what structure is present in glaucoma?

The optic nerve

What is the main modifiable risk

factor in glaucoma?

Intraocular pressure (IOP)

What is the general focus of

treatment for glaucoma?

IOP

What is the most common type of glaucoma in the US? …In Asia?

US: Primary Open Angle

Asia: Angle-Closure

Which type of glaucoma is

associated with hyperopia?

Angle-Closure Glaucoma

03/18/2008 10:00 128

Intro to Glaucoma

What are the main four

systemic risk factors for glaucoma?

Age

Family History

Diabetes

Race (African-American) Is it possible to

have glaucoma without IOP?

Yes

Where is the structural weak

point in the globe?

Optic Nerve

What does a high cup:disc ratio

indicate?

Loss of nerve fibers

Where is aqueous humor

produced?

Non-pigmented epithelium of the

ciliary body

What is the path of flow through the trabecular

meshwork?

Ciliary body

Trabecular meshwork

Episcleral vein

03/18/2008 10:00 129

Drug type ↓ Aqueous Production? ↑ Aqueous Outflow?

Prostaglandin Derivatives X

β-antagonists X

α-agonists X X

C. Anhydrase Inhibitors X

Cholinergic agonists X

Intro to Glaucoma

03/18/2008 10:00 130

Intro to Glaucoma

What is the pathophysiology associated with

open-angle glaucoma?

Decreased outflow through the trabecular

meshworkWhat is the

pathophysiology associated with

angle-closure glaucoma?

The aqueous can not get around

the iris

Can blindness be prevented with

treatment?Usually, yes

What symptoms are associated

with acute angle closure

glaucoma?

Unilateral pain, blurry vision,

haloes around lights

What is the treatment for acute angle

closure glaucoma?

Laser peripheral iridotomy

Which medications can cause glaucoma?

Cold remedies

Steroids

Sulfa-based

Dilation

Which is an emergency –

open-angle or angle-closure

glaucoma?

Angle closure

03/18/2008 11:00 131

Condition Definition

Emmetropia No refractive error

Myopia Nearsightedness

Hyperopia Farsightedness

Astigmatism Blurry/Warped Focus

Presbyopia Unable to focus

Refractive Eye Surgery

03/18/2008 11:00 132


What are the four main surgical

techniques for correcting

refractive errors?

IncisionalLamellarThermal

IntraocularWhich interface

provides the majority of the

optical power of the eye?

The air/tear-film interface

What is the main risk of radial keratotomy?

Weakened cornea

progressive hyperopia

What is the wavelength of

the excimer laser?

193nm. Duh.

What is the main advantage &

disadvantage of surface ablation?

Adv.: Decreased risk due to lack of

flap

Disadv.: Delayed healing

How could Lasik be better than

surface ablation?

Faster healing

Less pain

No haze

“Laser”

03/18/2008 11:00 133


Will Lasik correct presbyopia?

Nope

For how many years will a LASIK

patient have perfect vision, post-surgery?

It will never be perfect

Will lasik correct uncorrected

vision?Yes

03/19/2008 09:00 134

Intro to Neuro-Ophthalmology

What is monocular diplopia?

Covering one eye does not correct

diplopia

What are the main two causes

of monocular diplopia?

Cataracts

Refractive error

What is incomitant diplopia?

Looking one way causes diplopia, the other way is

fineWhat are the

main two symptoms

associated with a CN III palsy?

Ptosis

Diplopia (incomitant)

What are the main three

causes of a CN III palsy?

Trauma

Ischemia

Compression

How can a CNIII palsy be

associated with anisocoria?

A compression of the oculomotor

nerve me impinge on

parasympathetic fibers to the iris

03/19/2008 09:00 135

Condition Vertical or Horizontal Diplopia

CN III Palsy Vertical & Horizontal

CN IV Palsy Vertical

CN VI Palsy Horizontal

Myasthenia Gravis Vertical or Horizontal

Eso- or Exophoria Horizontal

Thyroid eye disease Vertical or Horizontal


03/19/2008 09:00 136


What is the most common cause

of a CN IV palsy?Trauma

What is the main symptom of a CN

VI palsy?

Incomitant horizontal diplopia

What are the main three causes of

multiple cranial palsies

Tumor

Aneurysm

TraumaWhat is the

general treatment for

diplopia?

Prism

Eye muscle surgery

How is myasthenia

gravis treated?Anti-Achesterase

What is a reversible cause of myasthenia

gravis?

Thymoma

03/19/2008 09:00 137


What is the first step after the diagnosis of

papilledema?

Immediate CT or MRI What should be

investigated after the

diagnosis of an Anterior

Ischemic Optic Neuropathy

(AION)?

Giant Cell Arteritis

What are the main symptoms associated with

giant cell arteritis?

Jaw pain

Arthralgias

FeverWhat is the

treatment for giant cell arteritis?

Immediate steroids

Can a brain tumor lead to papilledema?

Yes

Which should cause more worry – a

comitant or an incomitant

strabismus?

Incomitant!

03/19/2008 10:00 138

Intro to Oculoplastics


of congenital ptosis?

Isolated dystrophy of the levator muscle


congenital ptosis?

Nothing immediate,

unless amblyopia develops

What is the most common form of acquired ptosis?

Involutional (aponeurotic) – careful of those contact lenses!

Will a CN VII palsy cause an ectropion or entropion?

Ectropion

Where is eyelid retraction

commonly seen?

Thyroid eye disease

What is inflammation of

the anterior eyelid margin

called? …Posterior?

Anterior = blepharitis

Posterior = meibomitis

03/19/2008 10:00 139

Condition Definition

Blepharoptosis Drooping of eyelid

Dermatochalasis Excess skin on the eyelid

Ectropion Lower eyelid turns outwards

Entropion Lower eyelid turns inwards

Retraction Widening of eyelid space

Lagophthalmos Inability to close eye


03/19/2008 10:00 140


What is a hordeolum?

A stye – an inspissation and

secondary infection of

sebaceous glands Is preseptal cellulitis

generally from a superficial or a deep source?

Superficial

Which nerve is commonly affected by

Herpes Zoster Ophthalmicus?

CN V1

What is the main concern with molluscum

contagiosum near the eye?

Follicular conjunctivitis

What are the four main signs

of malignancy in eyelid lesions?

Rapid growth,Loss o’ eyelashes,Change in color,Destruction of

meibomian gland orifices

Which type of cancer of the eye

can show a Pagetoid spread?

Sebaceous Cell Carcinoma

03/19/2008 10:00 141


What is the general

procedure for the evaluation of the

tear drainage system?

Dilation and irrigation

What is the main type of lacrimal

disease?

Nasolacrimal duct (NLD) obstruction

What is the main serious disease associated with

tearing in infants?

Congenital glaucoma


of congenital NLD obstruction?

Failure in the opening of the Valve of Hasner

How urgently should a

congenital NLD obstruction be

treated?

Most resolve without surgery

What are the two main types of

orbital infection?

Orbital cellulitis

Mucormycosis

03/19/2008 10:00 142


How is orbital cellulitis generally

contracted?

From an adjacent sinusitis (usually

ethmoid)

What are the main

complications of an orbital cellulitis?

Cavernous sinus thrombosis

Meningitis

How do the symptoms of a

preseptal cellulitis differ

from those of an orbital cellulitis?

Orbital: Proptosis,

reduced vision, restricted

motility, pain on motion How is

mucormycosis generally

contracted?

An immuno-suppressed

patient with an infection of the sinuses or nasal

cavityWhat happens to the ocular muscles in thyroid eye

disease?

They become large and inflamed

Which area of the orbit is most

commonly affected in a

blow-out fracture? Which

muscle?

Floor & medial wall of the orbit

Inferior rectus

03/21/2008 09:00 143

Ophtho Review

What is the main indication for

cataract surgery?

Loss of vision affecting ADL’s

Is the Intraocular Lens (IOL) placed in the anterior or

posterior chamber of the

lens during cataract surgery?

Usually the posterior chamber

Which type of eyesight is more

likely to be associated with

retinal detachment?

Myopia

What type of eyesight has a

flattened cornea?

Hyperopia

Who has a longer eyeball – a myopic person or a hyperopic?

MyopicAre there nerves

present in the cup or the disc?

Disc

03/21/2008 09:00 144

Ophtho Review

What age group is affected by

temporal arteritis?

65+

Which lab tests can help identify

temporal arteritis?

CRP

ESR

What is used as the definitive diagnosis of

temporal arteritis?

Biopsy (within one week of

starting steroids)Which is more likely to occur

intermittently in a child – exo- or

enotropia?

Exotropia

If a child presents with strabismus at

age 3, by what age should she be examined?

Promptly (same for any young

age) – amblyopia could develop

What virus is responsible for herpes simplex

keratitis?

HSV-1

03/21/2008 09:00 145

Ophtho Review

Which medication can

predispose a patient to the

development of HS Keratitis?

Steroids

What is the next step in the

management of a patient with diplopia with

pupillary involvement?

Immediate neuroimaging

What is seen in the vitreous biopsy of a

patient with a primary CNS lymphoma?

B cells

What is the treatment for a

primary CNS lymphoma?

Whole brain irradiation,

chemotherapy

What should be considered with

chronic chalazion or blepharitis?

Sebaceous cell carcinoma

What is the most common

intraocular malignancy in

adults?

Metastatic disease

Choroidal melanoma is the

most common primary

03/21/2008 09:00 146

Ophtho Review

Is orbital cellulitis anterior

or posterior to the septum?

Posterior

Which is more likely the cause

of ocular paralysis –

preseptal or orbital cellulitis?

Orbital cellulitis


orbital cellulitis?

IV antibiotics

Surgical drainage if abscess is

presentWho gets thyroid eye disease more

– men or women?

Women

What causes the enlarged

extraocular muscles in thyroid eye

disease?

Glycosamino-glycan deposition

What is the chance for a

progression to malignancy in

primary acquired melanosis

without atypia?

Low

dermatology …or “is this a boil?” dan cushman. intro to dermatology what is the most common...

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