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209 Cards in this Set
- Front
- Back
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Most prevalent orbital dz?
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Thyroid eye dz (60-70%)
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Ocular involvement in __% of thyroid dz, __ manifest signs.
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70-80%, 30-40%
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(Hyper/Hypo)thyroidsm tends to "burn out" to quiescent stage after 1-3 yrs
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Hyper
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Thyroid eye dz is commonly (unilat/bilat)
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bilat
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Thyroxine is aka ___.
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T4
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T3 is aka...
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triiodothyronine
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Top 3 signs of thyroid eye dz...
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1) Corneal exposure (lid retract)
2) EOMs - diplopia esp IR 3) ONH choked due to EOM swell |
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T/F - Most T4 is free and unbound.
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False - 99.9% of T4 bound to TBG and other proteins (TBPA and albumin)
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What happens to T4 in the peripheral tissues? What is the pharmacologic significance of this?
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Degraded to T3
Site of activity for oral anti-thyroid meds such as PTU |
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TSH from ___ stimulates ____, ___, and ___.
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ant pituitary, thyroid gland growth, hormone synth, release
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TSH secretion promoted by ___, inhibited by ___.
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TRF (from hypthalamus)
thyroxine (T4, from thyroid) |
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What hormone inhibits TSH secretion?
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T4 (thyroxine)
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State if incr or decr in Hyperthyroidism:
1. TSH level 2. Free thyroxine 3. Serum T3 4. Antithyroid antibodies |
1. TSH level = decr
2. Free thyroxine = incr 3. Serum T3 = incr 4. Antithyroid antibodies = incr |
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State if incr or decr in Hypothyroidism:
1. TSH level 2. Free thyroxine 3. Serum T3 4. Antithyroid antibodies |
1. TSH level = incr
2. Free thyroxine = decr 3. Serum T3 = decr 4. Antithyroid antibodies = decr |
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Thyroid hormone effects?
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Incr calorigenesis, protein synth, fat degredation, vitamin utilization. Also variety of changes in carb metabolism.
Basically, weight loss b/c incr metabolic activity |
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Graves' dz = hypo or hyperthyroidism?
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hyper
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Graves' dz mechanism in eye/orbit?
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Imm sys grabs orbital blasts in orbital fat, converts it to GAGS - causes taking up of water, thus puffiness & EOM swelling
Also inflam causes edema |
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What is goiter?
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Enlarged thyroid, happens in hyperthyroidism/Graves'
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Infiltrative dermopathy is a definitive sign of (hyper/hypo)thyroidism?
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hyper
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Graves' dz demographic?
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Women 20-50 yo
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When do the eye problems occur in Graves' dz?
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precede, coincide, or follow thyroid abnormality
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T/F - Ophthalmopathy can occur alone in Graves' dz
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True - but rare
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Graves' dz is an autoimm disorder with ___ producing immunoglobulins causing (insuff/excess) thyroid and hormone secretion.
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Beta lymphocytes, excess
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What orbital dz can be assoc w/ pernicious anemia?
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Graves' dz
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What is pretibial myxedema?
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Shiny, orange-peel like thickening of skin over lateral part of leg due to infiltration of MPS into dermis. Sx = itching. 5% Graves' dz. Highly diagnostic of Graves' dz.
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Most common neoplasm of thyroid? Results in...
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Follicular adenoma, causes hyperthyroid
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How does an ovarian tumor relate to thyroid dz?
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Ovarian tumors can produce thyroid hormone (Struma Ovarii), thus can cause hyperthyroidism
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How does a testicular or placental tumor relate to thyroid dz?
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testicular or placental tumors can produce thyroid hormone, thus can cause hyperthyroidism
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What is secondary hyperthyroidism?
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TSH-secreting tumor of pituitary, results in hyperthyroidism
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What is Thyrotoxicosis Factitia?
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Self-administration of thyroid hormone beyond normal (dieting), causes hyperthyroidism
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Glucocorticoid withdrawal or stress, parturition, and lithium therapy can cause (hyper/hypo)thyroidism?
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hyper
lithium can also cause hypothyroidism |
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(Hyper/Hypo)thyroidism = weight loss
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hyper
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(Hyper/Hypo)thyroidism = hyperactivity and insomnia but fatigue
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hyper
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(Hyper/Hypo)thyroidism = heat intolerance?
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hyper
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(Hyper/Hypo)thyroidism = velvety, warm, moist skin?
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hyper
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(Hyper/Hypo)thyroidism = brittle, coarse hair?
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hypo
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(Hyper/Hypo)thyroidism = oncholysis?
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hyper
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(Hyper/Hypo)thyroidism = bradycardia?
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hypo
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(Hyper/Hypo)thyroidism = constipation?
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hypo
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(Hyper/Hypo)thyroidism = normal body weight?
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hypo (can also be incr)
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(Hyper/Hypo)thyroidism = goiter?
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Either, hyper is usually, but hypo is sometimes present
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What kind of reproductive changes occur in hyperthyroidism?
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Amenorrhea, oligomenorrhea, (gynecomastia in men)
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(Hyper/Hypo)thyroidism = shortness of breath?
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hyper (high metabolism thus high O2 demand)
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Most common Tx for Graves'? Mech?
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Methimazole/Propylthiouracil (PTU), block periph conversion of T4 to T3
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Methimazole/PTU can cause these side effects. Sx?
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Mostly rash.
Also can cause agranulocytosis (rare). Sx = sore throat, fever |
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What Tx is appropriate for pregnant/nursing females with Graves'? What is NOT appropriate?
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PTU appropriate - does not cross placenta. Can also do surgery (ablate glands)
Do NOT use radioactive iodine |
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High incidence of secondary hypothyroid state with this Graves' Tx...
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radioactive iodine (131 I)
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Appropriate way to assess thyroid gland by palpation?
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Stand behind pt and move trachea to side, then let pt drink cup of water & palpate for nodule
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Radioactive iodine can Tx Graves' but the side effects are...
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high incidence of secondary hypothyroidsm, 10-15% have exacerbation of ocular Sx
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What Tx is good for the Sx of hyperthyroid?
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B-Blocker - makes sense b/c calms them down (hyperthyroid = high metabolism)
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What is Von Grafe's sign? Assoc w/?
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Lid lag on downgaze, assoc w/ Graves'
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Type I Graves' demographic? Involves...
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Mostly females. No myopathy, incr orbital fat, less proptosis; better prognosis when orbital fat removed
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Type II Graves' demographic? Involves...
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Mostly older males, worse prognosis. (+) myopathy, EOMs swell and fibrotic. (+) orbital fat, removal not as helpful. Tx by break bone to make room for edematous EOMs
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What is the worst (and preventable) risk factor for eye involvement of Graves'?
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Smoking
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Summarize the Graves' classification of ocular involvement (Werner's Classification)
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NOSPECS classes:
0 = No signs/Sx 1 = Only ocular signs, no Sx 2 = Soft tissue involvement 3 = Proptosis 4 = EOM involvement 5 = Corneal involvement 6 = Sight loss due to ON involvement |
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Graves' Class 1 signs limited to...
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upper lid retraction, stare w/ or w/o lid lag and proptosis
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Guanethedine is used for...
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causing ptosis in Graves' (to reverse lid retraction)
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Rev-eyes is used in Graves' to...
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cause ptosis for Graves' pts (to reverse lid retraction)
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T/F - Surgery is not indicated for Class 1 Graves'
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True
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What drugs are used to induce ptosis in Graves' pts?
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Guanethidine, Rev-eyes, topical Timoptic, Botox
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Class 2 Graves' involves...
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Soft tissue involvement - Sx excess lacrimation, sandy sensation, retrobulbar discomfort, photophobia. No diplopia
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Your pt complains of excess lacrimation, photophobia. You notice slight edema in the lids and lagophthalmos. This must be Graves' Class...
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2 (Moderate)
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Best Tx for Class 2 Graves'?
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Oral steroids (high dose 60-100 mg) - to rapidly reduce swelling
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T/F - Topical, oral, and IV steroids are used in Graves' Class 2.
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False - Topical not helpful
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T/F - Retrobulbar steroid injection is indicated for severe soft tissue involvement in Graves'.
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False - retrobulbar can exacerbate condition (incr proptosis b/c more fluid)
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If you see proptosis greater than ___ mm, ___ mm inequality b/w eyes, or ___ mm progression, your pt is at Class 3 Graves'.
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23, 2, 2
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T/F - Diplopia occurs in Class 3 Graves'.
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True - possible due to proptosis
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T/F - Botox is not useful for Tx proptosis in Graves' Class 3.
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True
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Steroids are more helpful for Type (I/II) Graves'?
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More helpful for Type I (fat) vs Type II (muscle)
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Orbital radiation is more effective for (acute/chronic) Class 3 Graves'?
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acute
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What is useful for reducing orbital volume in Class 3 Graves'?
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Adrenergic blocking agents
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Minimal Proptosis in Class 3 Graves'?
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21-23 mm
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Moderate Proptosis in Class 3 Graves'?
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24-27 mm
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Marked Proptosis in Class 3 Graves'?
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28 mm or more
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2nd most commonly involved EOM in Graves'?
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MR
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T/F - It is not appropriate to Tx Class 4 Graves' w/ prism.
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False - can use Fresnel prism
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A-scan in Class 4 Graves' is useful for...
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looking for EOM thickness
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B-scan in Class 4 Graves' is useful for...
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looking for EOM contour
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When is surgery for Class 4 Graves' indicated?
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If stable after 6 mos
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Stippling of the cornea is Class __ Graves' (be specific).
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5 (minimal)
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Orbital decompression is indicated for what Graves' class?
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5 (corneal involvement) - for 2nd-3rd bout of keratitis; orbit is pushed back to allow lids to close
Also for Class 6 - if steroid not working & VF not improving, to relieve ON choking |
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20% of Graves' pts can get this early corneal sign, even before thyroid manifests. Tx?
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SLK (redness @ limbus superiorly)
Tx = Silver nitrate |
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What causes Class 6 Graves'?
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Due to ON choking
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Class 6 Graves' (Minimal)?
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Disc pallor or choking, or VF defect: 20/20-60
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Class 6 Graves' (Moderate)?
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Disc pallor or choking, or VF defect: 20/70-200
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Class 6 Graves' (Marked)?
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Blindness, NLP, vision worse than 20/200
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Order of surgical intervention in Graves'?
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Decompression, EOM surgery, then lid surgery (in this order)
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5 step plan in Graves' Tx?
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1) Medical & supportive Tx
2) Botox & prism 3) Orbital surgery 4) Strab repair (PRN) 5) Lid repair (PRN) |
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#1 cause of hypothyroidism? #2?
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#1 = Hashimoto's
#2 = Tx Grave's |
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Incr risk of Class 6 Graves' with...
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males, shallow orbits, smoking
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Why are hypothyroid pts at higher risk for glaucoma?
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b/c produce hyaluronic acid
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What thyroid dz mimics aging?
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Hypothyroidism
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Hypothyroidism demographic?
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Older pts; incr female prevalence w/ incr age
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(high/low/normal) TSH w/ (high/low/normal) free T4 is diagnostic of hypothyroidism.
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high, low
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Pts w/ pituitary hypothyroidism show signs of (low/high) FSH and LH levels along with (low/high) sex hormone levels.
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low, low
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What syndrome can mimic hypothyroidism in kids?
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Down's
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Sacroidosis can cause (hyper/hypo)thyroidism?
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hypo
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TB can cause (hyper/hypo)thyroidism?
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hypo
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Sulfonamides can cause (hyper/hypo)thyroidism?
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hypo
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Loss of lateral 1/3 of eyebrow is a sign of...
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hypothyroidism
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(Hyper/Hypo)thyroidism = Menorrhagia?
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hypo
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(Hyper/Hypo)thyroidism = paresthesia, numbness?
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hypo
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(Hyper/Hypo)thyroidism = galactorrhea?
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hypo
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(Hyper/Hypo)thyroidism = brittle nails?
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hypo
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(Hyper/Hypo)thyroidism = alopecia?
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hypo
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T/F - Can have normal TSH in hypothyroidism.
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True - in secondary hypothyroidism (can be low/normal/mildly elev)
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(Hyper/Hypo)thyroidism = elevated cholesterol level.
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hypo
Think weight gain? |
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(Hyper/Hypo)thyroidism = proteinuria?
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hypo
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(Hyper/Hypo)thyroidism = low glucose and serum sodium
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hypo
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Tx hypothyroidism?
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Levothyroixine (T4)
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Coronary artery dz occurs in (hypo/hyper)thyroidism? Watch for this sign...
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hypo, watch for angina pectoris
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(Hyper/Hypo)thyroidism = low pitched, hoarse voice
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hypo
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SLE demographic?
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Black women, 15-40
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Procainamide and hydralazine can induce this autoimm dz.
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SLE
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What describes this dz? Antibodies to DNA and other nuclear contents are formed. ANAs result in inflammation to glomerular basement membranes.
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SLE
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A 30 yo black female patient comes in and you notice she is balding. She also is skinny, looks weak, and complains of muscle aches and arthritis. You suspect...
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SLE
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Malar "butterfly" erythematous rash is characteristic of ___. Tx?
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SLE, Tx = steroids
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SLE with manifestation limited to the skin is called...
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discoid lupus
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Major cause of morbidity and mortality in SLE?
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Renal involvement (either HTN or kidney dysfxn)
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Hematologic changes in SLE?
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anemia, leukopenia (decr WBCs), thrombocytopenia (decr platelets), clotting abnormalities
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T/F - SLE can affect EOMs.
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True - neurologic involvement
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Most common ocular sign of SLE? Tx for this?
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dry eye (KCS) - restasis useful
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Most characteristic retinal abnormality in SLE?
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Cotton wool exudates
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SLE is a vasculitis, thus you see these signs in the retina:
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Superficial hemes (flame shaped), retinal edema, pseudopapilledema, artery narrowing, A-V crossing abnormalities
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Bulls-eye retinopathy is possible in SLE...why?
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Plaquenil causing macula toxicity (the bulls-eye). Plaquenil is used to Tx SLE
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T/F - INO is possible in SLE.
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True
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T/F - AION is possible in SLE.
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True
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What tests are used to confirm SLE?
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ANA*, ESR, Ig electrophoresis, lupus erythematosus cell prep, Rh factor
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(+) Anti-Ro, (+) Anti-La, and (+) ANA is suggestive of...
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SLE
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Mycophenolate Mofetil is used for severe ___ but has problems with ____.
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SLE, liver issues
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Anti-malarials e.g. hydroxychloroquine and plaquenil are used for these autoimm dz...
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SLE, Rheum Arth
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Azasite is good for dry eye because...
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anti-inflammatory
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Rheumatoid arthritis demographic?
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Post-menopausal women >60 yo
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Rheum arth affects joints by...
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destruction of cartilage, adjacent bone, articular supporting structures
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Your pt complains of stiffness and pain that is worse in the morning, especially at the fingers and wrists. You suspect...
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Rheum arth
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Most freq affected joints in rheum arth?
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proximal interphalangeal and metacarpophalangeal joints
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Rheumatoid nodules in rheum arth can occur...
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along extensor surfaces (arms) and within various organs (eye)
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#1 ocular manifestation of rheum arth?
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KCS
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Filamentary keratitis is assoc w/ these autoimm dz
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Rheum arth, Sjogren's
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Most common scleritis type in rheum arth?
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Ant diffuse
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This scleritis has the highest morbidity/mortality rate...
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necrotising
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T/F - Scleromalacia perforans has a worse prognosis vs necrotising scleritis.
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False - vice versa
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T/F - Topical steroids are contraindicated for necrotising scleritis
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True - must use oral
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T/F - Scleromalacia perforans does not involve inflammation and is not painful.
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True
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2nd most common scleritis in rheum arthritis?
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nodular
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What test is highly diagnostic of rheum arth?
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X-ray of affected joints - articular cartilage destruction
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Rheumatoid factor is more useful in (late/early) rheum arthritis.
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early
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Whorl-like epithelopathy is assoc w/ this autoimmune dz (specifically a Tx used for this dz)...
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NSAIDs (rheum arth)
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Chewing gum or frequent drinking is an adjunct Tx for...
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Sjogren's (decr dental caries)
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What specific kind of tear layer deficiency is Sjogren's?
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Aqueous
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Primary vs Secondary Sjogren's?
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Primary = eye, mouth, no connective tissue
Secondary = eye, mouth, connective tissue |
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Sjogren's demographic?
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Older females
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Sjogren's has an incr risk of this type of lymphoma...
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non-Hodgkin's
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Parotid enlargment is involved in this autoimm dz...
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Sjogren's
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T/F - Sjogren's involves loss of taste and smell.
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True
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T/F - Corneal ulcers are possible in Sjogren's
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True
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#1 connective tissue dz assoc w/ Sjogren's?
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Rheum Arth
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Polymyositis and Polyarteritis are assoc w/ this autoimm dz
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Sjogren's
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(+) Anti-Ro, (+) Anti-La, and (-) ANA is suggestive of...
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Sjogren's
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To help incr salivary and lacrimal gland secretion in Sjogren's, you can use...
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Oral Pilo (Salagen)
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T/F - Can suck on candies to encourage salivation as adjunct Tx for Sjogren's.
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False - avoid sugar containing candies
Can chew gum for dental caries |
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Scleroderma is aka
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systemic sclerosis - "hard skin"
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The 2 forms of Scleroderma?
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Limited = hands + face
Diffuse = trunk + limbs, worse prognosis |
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Pathogenesis of Scleroderma?
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Primary fibrotic process or vasculitis secondarily promoting deposition of incr amts of collagen
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Scleroderma demographic?
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Middle-aged women
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T/F - Limited systemic sclerosis is more prevalent vs diffuse.
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True
Diffuse = 20% Limited = 80% |
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Raynaud's phenomenon is typical of this connective tissue disorder
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Scleroderma (both diffuse and limited)
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Polyarthralgia is typical of this connective tissue disorder (be specific)
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Diffuse Scleroderma
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T/F - Intestinal hypomotility occurs in limited systemic sclerosis.
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False - diffuse type
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Fibrotic changes of skin and internal organs, intestinal hypo-motility, pulmonary fibrosis, HTN, renal failure, and myopericarditis are characteristic of...
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Diffuse Scleroderma
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Crest syndrome is aka...
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Limited systemic sclerosis:
Calcinosis cutis (tight/hard skin) Raynaud's Phenomenon Esophageal HYPOmotility Sclerodacryly Telangiectasia |
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Skin tightening is limited to distal extremities in this form of Scleroderma
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limited systemic sclerosis
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Which of the two Scleroderma types have a better prognosis?
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Limited systemic sclerosis
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Describe how the lids look in Scleroderma
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Lose elasticity (become tight), thin, smooth, shiny, retracted
Involves ptosis [says this too despite retracted?] and lagophthalmos |
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Retinal signs in Scleroderma?
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CWS, hypertensive changes accompanying renal dz
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T/F - Scleroderma can be assoc w/ Sjogren's.
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True
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T/F - (+) ANA is helpful in Dx Scleroderma?
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True - 90% positive, but must DDx vs SLE
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Anticentromere antibody is more likely in (limited/diffuse) scleroderma?
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limited
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Tx Raynaud's phenomenon?
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Nifedipine (Ca channel blocker)
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Penicillamine is used to Tx...
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Rheum arth and scleroderma
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What is used to Tx the esophageal reflux in scleroderma?
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Omeprazole (proton pump inh)
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Digital ulcers Tx in scleroderma?
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Iloprost
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Raynaud's is exacerbated by...
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cold
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T/F - Smoking cessation is an adjunct Tx for Scleroderma
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True
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What dz is often assoc w/ Polymyalgia Rheumatica?
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Temporal arteritis
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Temporal arteritis demographic?
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Older folks (women slightly more than men)
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Pain and stiffness of the shoulder and pelvic girdle lasting 1 month or more w/o any other explanation is characterized by...
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Polymyalgia rheumatica
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T/F - Temporal arteritis assoc w/ malaise, night sweats, weight gain
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False - weight loss/anorexia
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T/F - Temporal arteritis has (+) APD
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True
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Why is Temporal arteritis an ocular emergency?
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b/c AION - good chance that other eye will go too within 24-72 hrs without steroids
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What vessel is involved that causes VF loss in Temporal arteritis?
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Short post ciliary a.
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What is an early visual sign of Temporal arteritis?
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color vision loss
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T/F - IV nerve palsy possible in Temporal arteritis
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False - VI nerve
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What is considered (+) Temporal arteritis in ESR?
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>50
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Calculate ESR for men?
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age/2
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Calculate ESR for women?
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age+10/2
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What two tests have high diagnostic value in Temporal arteritis?
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ESR and C-reactive protein
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Gold standard of Temporal arteritis testing?
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temporal artery biopsy
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When is it appropriate to do a temporal artery biopsy for Temporal arteritis pts?
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within 1 wk of starting steroids
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Tx Temporal arteritis?
|
IV steroids (Methylprednisone 250 mg q6h x12), then switch to oral steroids (prednisone 80-100 mg PO daily for 4 wks)
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Causative agent of Lyme dz?
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spirochete (Borrelia burgdorferi) transmitted by tick
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Erythema Chronicum Migrans (ECM) is diagnostic of...
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Lyme dz (early skin lesion)
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Erythema Chronicum Migrans begins as...
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red maculae or papule, 1 wk after tick bite
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Erythema Chronicum Migrans Sx?
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Summer flu-like Sx (chils, fatigue, fever, HA, stiff neck, myalgia, arthralgia); neurologic abnormalities possible; arthritis can occ wks to mos after ECM
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Two main ocular signs of Lyme dz?
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Bell's Palsy and Pars Planitis
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Main diagnostic tests for Lyme dz?
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IFA, ELISA, Western Blot
Best test = PCR but often not ordered |
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Tx Lyme dz in adults?
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#1 = Tetra or Doxy
#2 = Amoxicillin and Probenecid #3 = Erythromycin All about 21-28 days dosing |
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Lyme dz stages?
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1) Days-weeks = ECM (95%)
2) Weeks-mos = Neuro signs, ocular signs, derm signs 3) Mos-yrs = connective tiss signs (arthritis), encephalopathy, polyneuropathy, pars planitis |
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Your pt presents with bilateral ptosis, edematous skin on the lower lid, and lethargy. Dx?
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Sleepiness secondary to overstudying ocular disease!!!!!!
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