Ohp Ii - Lacrimal System And Fb Removal

Front 1

List the components of a DE evaluation

Back 1

1. Clinical Hx
2. Sx questionnaire
3. TBUT w/ NaFl
4. Shirmer Test
5. Ocular surface staining w/ NaFl
6. Lid and Meibomian gland morphology
7. MG expression
8. Special testing: Fluorimetry, Interferometry, osmolarity

Front 2

What is the purpose of a NaFl stain?

Back 2

Evaluates corneal integrity by penetrating thru epithelial defects

Front 3

List some clinical applications for using NaFl

Back 3

1. CL fit assessment
2. Corneal/Conj dz:
a. Abrasions
b. Simplex
c. RCE
d. Dellens
3. Tear film eval

Front 4

During a NaFl stain, areas of darkness or non-fluoresced indicate what?

Back 4

Uneven distribution of tears OR areas of elevated tissue
-If area is highly fluorated = depression or defects

Front 5

What is the purpose for using Rose Bengal?

Back 5

1. Useful in pts w/ DE
2. Stains epithelial surfaces that are deprived of mucin protein protection, exposed cell membrane

Front 6

List some clinical situations in which you might want to use RB

Back 6

1. KCS
2. Filamentary keratitis
3. Herpes Dendritic keratitis

Front 7

T or F? Lissamine Green is more irritating than RB

Back 7

False.
-Lissamine Green is also more easily visible w/ conjunctival injection - it does not stain mucous

Front 8

Which Wratten filter can you use for Lissamine Green stains

Back 8

Wratten # 25
-You can use Wratten 12 for NaFl

Front 9

What is the purpose of TBUT

Back 9

To assess mucin layer stability

Front 10

If during a TBUT test the pt blinks, does this end the test?

Back 10

Yes - either black lines or spots appear in the tear film OR the patient blinks
-Calculate mean for 3 trials

Front 11

What is considered abnormal for TBUT

Back 11

Less than 10 secs

Front 12

What is considered abnormal for TBUT

Back 12

Less than 10 secs

Front 13

What factors decrease TBUT time? Increase TBUT?

Back 13

Decrease: Ung, Preservatives, Anesthesia, Estrogen phase of menstrual cycle
Increase: AT
No effect: Temp/Humidity

Front 14

What is the formula for Ocular Protection Index?

Back 14

TBUT/Time between blinks in secs
-OPI < 1 = Risk for ocular damage
-OPI > 1 = patient is not at risk

Front 15

List the tests for assessing Tear Secretion

Back 15

1. Schirmer Test
2. Jones Basal Secretion Test
3. Short Basal Secretion Test
4. Shirmer II
5. Sno-Strips
6. Phenol Red Thread
7. Lactoferrin
8. Punctal Occlusion

Front 16

What is the purpose of the Shirmer Test I (w/o anesthetic)

Back 16

Measures Reflex and Basal secretions, Max amount of TEAR production and to test for KCS

Front 17

How long do you leave the Shirmer strip in the lower lateral lid?

Back 17

5 min
-Interpret: 5 mm or less = abnormal
5-10 = mild to mod KCS
>10 = normal
Influenced by Anesthetic, Temp, Humidity, Evaporation

Front 18

List 3 purposes of the Jones Basal Secretion test (*w/ anesthetic)

Back 18

1. Basal secretion
2. Eval of the minimal amount of tear secretion
3. Suspected mild KCS or CL dry eye

Front 19

How do you interpret the Jones Basal Secretion?

Back 19

The same as Shirmer

Front 20

What is the difference b/w the Jones Basal and the SHORT Jones Basal?

Back 20

Instead of leaving the strip in for 5 minutes - you leave it in for 1 min and the results are multiplied by a factor of THREE. Interpret the same as Shirmer

Front 21

What is the purpose of the Shirmer II test?

Back 21

To test REFLEX secretions
-Instill anesthetic, blot extra and tickle nasal mucosa for 10-15 secs.

Front 22

How do you interpret the results of Shirmer II?

Back 22

< 10mm of wetting strip after 2 minutes suggests impaired reflex tearing

Front 23

How are Sno-Strips different from Shirmer?

Back 23

They both measure the same thing but you time how long it takes to wet 10mm of the strip with tears.

Front 24

Interpretation of Sno-Strips

Back 24

3-5 min = sufficient secretion
5-10 = borderline
> 10 min = insufficient

Front 25

Phenol Red Thread Test meaures reflex tearing.. T or F?

Back 25

False. It measures basal secretion
-Thread placed in lower lid for 15 secs. Less irritating
Interpret: Normal 9-18 mm

Front 26

Which test measures level of Lactoferrin in the tears?

Back 26

Lactoplate (tear quality test)
-lactoferrin associated with lysozyme and lacrimal gland sensitivity

Front 27

Describe the procedure for performing the Lactoplate

Back 27

1. Place filter paper disc in inferior fornix ~ 5 min
2. Place disc on lactoplate pad
3. After 2-3 days - measure size of precipitate ring with the template provided and convert into mg/ml

Front 28

How do you interpret the results of the lactoplate?

Back 28

Average = 1.4mg/ml
Levels < 0.9 are considered to be abnormal and suggestive of insufficient lacrimal secretory acitivity

Front 29

What other procedure analyzes Lactoferrin in the tear film?

Back 29

Touch tear microassay (Lactocard)
-more accurate at determining the presence of aqueous deficiency
-results in 10-15 min

Front 30

What is the purpose of Punctal occlusion?

Back 30

help increase the time that the tears remain in contact with the eye by blocking drainage duct

Front 31

What is the followup time for someone you got collage punctal plugs for the first time?

Back 31

Pt returns in 7-10 days - inserts dissolve. If symptoms improved - consider long term therapy such as silicone plugs or cautery

Front 32

List 4 tear drainage tests

Back 32

1. Fluorescein disappearance test
2. Jones #1
3. Jones #2
4. Lacrimal Probing

Front 33

Describe the NaFl disappearance test

Back 33

1. NaFl instilled into the patients eyes - two strips
2. After 5 minutes - examine inferior cul-de-sac to determine the amount of dye in lacrimal lake
3. Graded on a 1-4 scale
-1+ = little retention
-4+ = Maximum retention
-Asymmetry or prolonged presence suggests poor drainage

Front 34

Describe the Jones #1 (Primary Dye Test)

Back 34

1. NaFL instilled into both eyes
2. After 5 minutes - dye should appear under the inferior turbinate in the nose - retrieved with a cotton swab
-May require more time with older patients: 10 min
-May be enhanced with a burton lamp or having patient blow nose
Interpretation: Dye = POSITIVE
No dye - Perform Jones #2

Front 35

Describe the Jones #2 (Secondary Test)

Back 35

1. Lacrimal system is dilated and irrigated
2. If dye does not appear during Jones 1 but does appear during Jones 2 = Functional Block
-If no dye appears during either test = Anatomical Block

Front 36

During Lacrimal Irrigation how far down is the 23 gauge cannula inserted, and then how far nasally is it pushed till it meets the lacrimal sac?

Back 36

It is inserted 2 mm down, tipped 15 degrees horizontally and pushed nasally 8 mm. ~ 1 cc of saline is flushed

Front 37

If the patient tastes saline during the Jones II test - what does this mean?

Back 37

This indicated that there was a functional block
-If the drainage system is blocked - the patient will feel pressure, do not FORCE IT

Front 38

During the Jones II test - if fluid comes out of the Opposite puncta (top punta) - how is this interpreted?

Back 38

There is an anatomical block DISTAL to the common canaliculus

Front 39

During the Jones II test - if the cannula cannot be pushed in OR if fluid is regurgitated thru the SAME puncta - how is this interpreted?

Back 39

There is an anatomical block PROXIMAL to the common canaliculus

Front 40

What is the purpose of Lacrimal Probing? When should it be done?

Back 40

Should be done when irrigation reveals a blockage

Front 41

How is Lacrimal Probing performed?

Back 41

1. Topical Anesthesia
2. Lacrimal probe (Bowman Probe) inserted into puncta and canaliculus - once resistance is felt - measure length of probe inserted

Front 42

What is considered a "hard stop" during Lacrimal Probing?

Back 42

When the probe contacts the medial wall of the lacrimal fossa - normal

-"Soft stop" when probe hits and obstruction or collapses the lacrimal sac against lacrimal fossa = abnormal

Front 43

When is topical anesthetic recommended during VA testing if the patient comes in with FB complaints?

Back 43

If the patient has severe blepharospasm

Front 44

When would you consider referring a patient to an OMD for a FB?

Back 44

If the FB is in the visual axis and is in Bowman's layer or deeper (will scar)

Front 45

What tests can you do if you suspect corneal perforation?

Back 45

1. Seidel Test - positive if aqueous dilutes NaFl
2. IOP - decreased IOP is positive for perforation
3. DFE to check for intraocular FB
4. Orbital x-rays may be necessary to locate a metallic intraocular FB
5. If pt has a corneal perforation - they should be shielded and referred to OMD

Front 46

T or F? A moistened sterile swab may be used on the cornea as well as the conjunctiva to remove a FB

Back 46

False, it is not recommended on the cornea

Front 47

What type utensils can you use to remove a deeper FB?

Back 47

1. Hypodermic needle; inexpensive, sterile, disposable
2. FB spud; variety of shapes, $45 each, disinfect with zephirin chloride w. anti-rust tablets. Can also autoclave or flame

Front 48

How is a rust ring removed?

Back 48

With a Alger Brush - epithelium is spun off. Bowman's is tough to penetrate - ends up puckering up like saran wrap

Front 49

What are the post-removal procedures?

Back 49

CAP
1. Cycloplegic agent (5% homatropine) - to treat or prevent 2nd Uveitis
-Beware of inducing angle-closure glaucoma b/c signs maye be similiar to FB induced uveitis
2. Recommend analgesic/anti-inflammatory agent like aspirin. Tylenol w/ codeine for stronger cases.
2b. Prevent infection
-Small injuries: Gentamicin sol 1-2 gtts q 4hrs
-Large injuries: Polysporin, gentamicin or tobramycin ung
3. Pressure Patch for 24 hours

Front 50

List 3 analgesics that are not OTC

Back 50

1. Tylenol w/ codeine
-300 mg Acetaminophen
-30 mg codeine
- 1-2 tab q 4h
2. Ultram (Tramadol)
- 50-100 mg q4-6H
- max = 400 mg/day
3. Vicodin (Hydrocodone/Acetaminophen)
-1-2 tabs PO QID

Front 51

List 2 OTC or prescribed NSAIDS

Back 51

1. Extra-strength Tylenol
-500 mg qid
-max dosage = 4000 mg/day
2. Advil or Motrin (Ibuprofen)
-400 mg qid
-Max dosage is 3200 mg/day
-Watch out for pts with kidney dz, alcohol, risk of hemorrhaging, GI dz

Front 52

List some alternatives to Pressure patching and some advantages of each

Back 52

1.Bandage CL
-Tight Fitting
-Improves Binocularity
-Continuous Drop Therapy - BS Ab QID
-Cost -expensive due to drops
2. Collagen Shields
-12, 24, 72 hr dissolvable lenses
-Soak in Ab solution and use with drops
-Cost: 20-40 each
-Analgesia: 2-5% Homatropine gtt, Topical NSAIDS - Voltaren or Acular, Orals: NSAIDS, Ultram
-Disadvantages: cost, lenses fall out

Front 53

How often should you have the patient return after a FB removal?

Back 53

RTC in 24 hours - no exceptions
-update history
-remove patch and rinse eye
-check VA
-do SLE, NaFl staining
-if corneal integrity still compromised - instill Ab ung and repatch for 24 hours
-recall q 1-2 days until staining disppears (typically 24-48 healing)

Front 54

List some indications for Lid Eversion

Back 54

1. Suspected FB
2. Lost CL
3. Ant. Seg infections
4. Prior to CL fitting
5. Eval for GPC
6. Routine baseline lid eversion also recommended

Front 55

Which lid eversion technique reveals the conjunctiva between the edge of the tarsal plate and the superior fornix?

Back 55

Double lid eversion.

Front 56

What is the name of the retractor used in double lid eversion?

Back 56

Desmarres retractor

Front 57

Prior to pressure patching, what should you administer to the patient to minimize ciliary spasm and associated ant. uveitis?

Back 57

Cycloplegic agent. Also if the cornea is compromised - a broad spectrum Ab can be used to prevent a secondary infection

Front 58

Describe the procedure for pressure patching

Back 58

1. Clean area around forehead and cheek with alcohol pad
2. Place folded patch over eyelid
3. Place several strips of surgical tape to hold pad in place (no more than 5 strips)
4. F/U in 24 hours

Front 59

How should you tx corneal abrasions?

Back 59

1. Debride loose epithelium - retards healing
2. Avoid hypertonic saline drops
3. CL related abrasions should NOT be patched
4. False fingernail or tree branch injuries should NOT be patched

Front 60

What should you use if the skin under the taped area is irritated

Back 60

Hydrocortisone cream

Front 61

T or F? It is uncommon to see striae in Descemet's resulting from pressure patch

Back 61

False. It is common to see these striae. These typically resolve in 48-72 hours and require no tx.