Which bones make up the medial orbital wall?;"“SMEL” • Sphenoid, lesser wing bone • Maxillary bone • Ethmoid bone • Lacrimal bone" Which bones make up the orbital roof?;"• Frontal bone • Lesser wing of sphenoid bone" Which bones make up the orbital floor?;"“Zip My Pants” • Zygomatic • Maxillary • Palatine (thinnest)" Which bones make up the orbital lateral wall?;"• Greater wing of sphenoid • Zygomatic" What is a dermoid cyst?;"• Lined by keratinizing epidermis with dermal appendages • Common pediatric periorbital mass • Occurs when ectoderm tissue is pinched between closing bony sutures during embryologic development → trapped tissue forms cyst • Type of choristoma • 5% spontaneously rupture • Most commonly at the frontozygomatic suture (supratemporal) • Second most commonly at the frontoethmoidal suture (superomedially) • Dumbbell appearance if they straddle across the suture line with components inside and outside the orbit • Treatment: Remove entire cyst with its capsule because remnants left behind can induce severe inflammation" What is the most common presentation and treatment of benign orbital tumor in adults?;"• Cavernous hemangioma ○ Vascular tumor made of large endothelial-lined vascular spaces enclosed within fibrous capsule • Presents as painless progressive proptosis • Treatment: Surgical removal is indicated if mass is causing functional impairment (i.e. optic nerve compression, diplopia, strabismus, substantial proptosis)" What is the most common benign orbital tumor in children and its presentation?;"• Capillary hemangioma ○ Small endothelial-lined vascular spaces contained within fibrous capsule • Initially grows for several months then spontaneously involutes or regresses" What is the definition and example of a choristoma?;"Definition • Histologically normal tissue in an abnormal location Example • Dermoid cyst" What are the diagnostic tests for myasthenia gravis (MG)?;"• Ice pack testing • Tensilon testing • Anti-acetylcholine receptor antibodies (binding, blocking, modulating) → present in 90% of systemic MG and 70% of ocular MG" What are the clinical findings in blepharophimosis syndrome (BPES)?;"Common clinical findings • Blepharophimosis • Telecanthus • Severe ptosis → limited levator function • Epicanthus inversus • Deprivation, strabismic, or refractive amblyopia • Type 1 BPES have early ovarian failure Other less common clinical findings • Hypertelorism • Ectropion • Hypoplasia of superior orbital rims" What is acute dacryoadenitis?;"● Inflammation of lacrimal gland ● Most common cause overall is sterile inflammatory disease ○ Most common viral cause is EBV" What is the average volume of the adult orbit?;"30 mL (cubic centimeters)" What is the most commonly injured extraocular muscle in cosmetic eyelid surgery?;"● Inferior oblique ○ Inferior oblique divides central and medial fat pads of lower eyelids" What is a sub-orbicularis oculi fat (SOOF) lift?;"Suspends fat pad underneath orbicularis muscle in the lower eyelid and anterior to orbital septum to improve contour of lower eyelid, especially as part of midface lift." What is the most common malignant lacrimal gland tumor and associated common findings?;"• Adenoid cystic carcinoma Associated with • Lot of pain • Swiss cheese pattern on pathology" What is the definition of epilation? What is the rate and chance of eyelash regrowth?;"Definition • Removing misdirected lashes with forceps Rate of eyelash regrowth • Occurs in 3-6 weeks Chance of eyelash regrowth • 100% chance of regrowth" How is radiofrequency ablation to eyelashes performed and what are its side effects?;"• Uses a radiofrequency probe • Slides down individual hair follicle shafts • Energy delivered is concentrated to the hair follicle and limits collateral damage • If probe is moved during active treatment or several closely clustered lashes are treated, could create a notch in the lid margin" How is electrolysis to eyelashes performed and what are its side effects?;"• Similar to radiofrequency ablation • Fine wire is introduced into individual hair shaft • High frequency electrical current is used to coagulate the follicle • Causes more scarring and has higher risk of notching compared to radiofrequency ablation" How is argon laser treatment to eyelashes performed and what are its side effects?;"• Similar to radiofrequency • Focused argon laser beam is used to thermally destroy the individual hair follicle shafts • Thick, dark hairs growing from pale skin have the best uptake of energy and the highest success rates • Concentrated energy helps limit collateral damage • Result in notching if several closely clustered lashes are treated" How is cryotherapy to eyelashes performed and what are its side effects?;"• Uses sub-zero temperature to freeze eyelid margin • Prevents lashes regrowth by killing hair follicle cells • Best for treating broad areas of clusters of lashes (segmental trichiasis) • Can lead to thinning of eyelid, loss of meibomian glands and goblet cells, and skin depigmentation" What is the most common cause of necrotizing fasciitis and its treatment?;"● Group A streptococcus ○ Tracks along the fascia ○ Spreads more quickly than typical bacteria and causes more damage ● Treatment ○ Intravenous antibiotics and urgent surgical debridement" Where does the levator aponeurosis attach in relation to the tarsal plate for Caucasian patients?;"● Levator aponeurosis attaches to the lower one-half of the anterior surface of tarsal plate ○ Sends projections to skin and orbicularis, which help anchor the upper lid crease" What is the location and innervation of Muller’s muscle?;"• Originates at the under-surface of the levator muscle and extends a few millimeters down to the anterior surface tarsus • Inserts at superior border of tarsal plate • Innervated by the sympathetic nervous system and helps maintain the resting tone that holds the upper eyelid open" What are the seven diagnostic criteria for neurofibromatosis type 1 (NF1) and how many criteria have to be met for diagnosis?;"Criteria for NF1 diagnosis • Six or more cafe-au lait spots • Two or more axillary or inguinal freckles • Two or more typical neurofibromas or one plexiform neurofibroma • Optic nerve glioma • Two of more Lisch nodules or iris hamartomas • Sphenoid dysplasia (causes pulsatile exophthalmos) or long bone abnormalities • First degree relative with NF1 Diagnosis • Requires meeting 2 or more of the criteria above" What percentage of clinically symptomatic congenital nasolacrimal duct obstructions resolve in the first year of life?;"By 1 year of age, 70-90% will resolve on their own" What are the most and least common locations for periocular basal cell carcinoma?;"• Lower eyelid (50-60%) • Medial canthus (25-30%) • Upper eyelid (15%) • Lateral Canthus (5%)" What are common causes of bilateral proptosis in children?;"• Thyroid-associated ophthalmopathy • Idiopathic orbital inflammation • Metastatic neuroblastoma • Leukemic infiltrates" What is a Fasanella-Servat procedure and when is it used?;"• Tarsoconjunctival mullerectomy • Treats mild amounts of ptosis (< 2 mm)" What are the indications for orbital decompression in thyroid eye disease?;"• Exposure keratoconjunctivitis • Compressive optic neuropathy" What is the function of the pretarsal portion of the orbicularis?;"Reflex eyelid closure" What are the functions of the preseptal portion of the orbicularis?;"Voluntary and reflex blinking" What is the function of the orbital portion of the orbicularis?;"Voluntary eyelid closure" What are the classifications of eyelid melanoma and their descriptions?;"Tumor thickness Breslow Depth: 1. Melanoma in situ: fully within epidermis 2. Thin/early melanoma: depth < 0.8 mm 3. Intermediate melanoma: depth 0.8 mm to 4 mm, and/or ulceration. Higher risk of metastatic spread. Lymph node biopsy recommended 4. Thick melanoma: > 4 mm. High risk of metastatic spread. Obtain lymph node biopsy. < 50% survival at 5 years 5. Advanced melanoma: spread beyond original tumor site" How many millimeters does Muller's muscle elevate the eyelid?;"2 mm" How is Muller's muscle innervated?;"Sympathetic nervous system" What are the common causes, workup, and treatment of hemifacial spasm?;"Most common cause • Facial nerve compressed as it exits the brainstem by ectatic vertebral artery or anterior inferior cerebellar artery Other causes • Stroke • Multiple sclerosis • Trauma • Cerebellopontine tumor Workup • MRI/MRA of head and neck Treatment • Botox injections and Jannetta procedure to place sponge between nerve and vessel" What is the etiology of afferent pupillary defect in orbital compartment syndrome?;"Compression of posterior ciliary arteries which leads to optic nerve ischemia" What is the description and treatment of keratoacanthoma?;"Description • Nodule with crater like center • Low-grade tumor that originates in the pilosebaceous glands • Closely resembles squamous cell carcinoma Treatment • Complete excision" What is the definition of a nevus?;"Undifferentiated melanocytes found at the epidermal-dermal border" What is a description of ephelides (freckle)?;"• Flat pigmented skin change due to melanocytes producing too much pigment • Normal number of melanocyte cells → produce increased number of melanosomes filled with melanin" Actinic keratosis is what type of lesion and can lead to which type of cancer?;"• Premalignant lesion • Leads to squamous cell cancer" What are common signs of thyroid-associated orbitopathy?;"• Eyelid retraction (superior scleral show) in 90% • Exophthalmos in 60% • Lid lag in 50% • Positive Von Graefe sign: eyelid is slow to go down when patient looks down" What is the etiology, clinical findings, diagnosis, and treatment of "indirect" (dural) carotid-cavernous fistula?;"Etiology • Rupture of thin-walled dural arteries that normally cross the cavernous sinus → form fistula between branches of internal or external carotid and cavernous sinus Clinical findings: • Chronic red eye → corkscrew conjunctival and episcleral vessels • Lack history of trauma Diagnosis • Dilated superior ophthalmic vein and inferior ophthalmic vein • Enlarged or congested extraocular muscles Treatment • Endovascular placement of coils, glue, or occlusive devices to close the fistula" What is the etiology, clinical findings, and treatment of "direct" carotid-cavernous fistula (CCF)?;"Etiology • Caused by trauma - more common in young males • Fistula between internal carotid artery (ICA) and cavernous sinus Clinical findings • More fulminant, explosive symptoms compared to indirect CCF due to high blood flow between ICA and cavernous sinus • Very prominent proptosis • Chemosis • Ophthalmoplegia • Orbital pain • Vision loss Treatment • Endovascular placement of coils, glue or occlusive devices to close the fistula" What is a common presentation and workup of sebaceous carcinoma?;"Common presentation • Recurrent chalazion in the same location Workup • Full thickness biopsy of lesion → Oil red O or Sudan black stain on fresh tissue • If biopsy positive, then obtain map biopsy of surrounding conjunctiva • Sentinel lymph node biopsy after mapping • Commonly exhibits pagetoid spread • If the carcinoma spreads from conjunctival epithelium → progress very rapidly " What is the etiology, presentation, and causes of ankyloblepharon?;"Etiology • Normally eyelids are fused together from week 8 to week 20 of gestation, they separate prior to birth • In ankyloblepharon, upper and lower eyelids fail to completely separate Presentation • Partial or complete fusion of upper and lower lids by webs of skin Causes • Congenital • Acquired (trauma, inflammation)" What is the definition of epiblepharon?;"Pretarsal skin and orbicularis override eyelid margin, causing eyelashes to be pushed toward ocular surface." What is the description and associations of euryblepharon?;"Description • Horizontal lengthening of lower eyelid, combined with vertical shortening of lower eyelid skin → leads to lateral lower lid being pulled away from ocular surface Associations • Blepharophimosis syndrome • Isolated finding" What vascular structures are 8 mm medial to the medial canthal tendon?;"Angular artery and vein" What are common post-op complications of a facelift?;"• Post-op hematoma: Occurs first 12 hours after surgery. Must be drained • Skin flap necrosis: Risk factors are extensive cautery to flap, stretching the skin tightly, hematoma accumulation and poor patient vascularity. This takes days before frank necrosis is apparent • Nerve injury: Injury to sensory nerves (branches of trigeminal). May cause numbness of overlying skin. Self-limited and rarely painful • Infections: Rare, occur < 1% of time, typically occur > 3 days after surgery" What are the measurements of various components of the nasolacrimal duct?;"• Vertical portion of canaliculi: 2 mm • Horizontal portion: 8 to 10 mm • Nasolacrimal sac: 12 to 15 mm; extends 2 to 3 mm above medial canthal tendon • Nasolacrimal duct: 12 mm • Average length from punctum to nose: 35 mm" How much more common is thyroid eye disease (TED) in women compared to men?;"● TED 6x more common in women ○ TED in women - 86% ○ TED in men - 14% ● Peak incidence of TED in women follows bimodal pattern at ages 40-44 years and 60-64 years ● Peak incidence of TED in men is 60-69 years ● Side note: Relative risk of developing TED is 7 times higher in smokers compared to nonsmokers" Lateral pretarsal eyelid tissues drain into which vein?;"Lateral pretarsal eyelid tissues drain into which vein?;" Medial pretarsal eyelid tissues drain into which vein?;"Angular vein" Posterior tarsal eyelid tissues drain into which veins?;"• Orbital veins • Deeper branches of anterior facial vein • Pterygoid plexus" The angular artery is an extension of which artery?;"External carotid artery → facial artery → angular artery" What are the branches of the ophthalmic artery?;"• Central retinal artery • Short and long posterior ciliary arteries • Extraocular muscle arteries" What is the most common pathogen responsible for preseptal cellulitis resulting from trauma and its treatment?;"● Staphylococcus aureus ● Treatment ○ Broad spectrum → penicillin or cephalosporin ○ MRSA coverage → clindamycin or trimethoprim-sulfamethoxazole" What is fibrous dysplasia?;"● Benign disorder ● Normal bone is replaced with immature bone ○ Immature bone impinges on vital structures if it occurs in facial skeleton or orbit ● CT scan shows ground glass bony opacities or complete sclerosis of bone" What is an osteoma?;"● Abnormal growth of normal bone onto other sites ○ Can grow on other bones (homoplastic) ○ Can grow on other tissues (heteroplastic)" What is a sphenoid wing meningioma and its radiologic findings?;"• Hyperostosis of bone with sheet-like dural plaque • CT scan shows hyperostotic bone enhancement with contrast" What is the most common site, type, and method of diagnosis of orbital lymphoma?;"Most common site • Superotemporal, lacrimal gland fossa Type • 90% are non-Hodgkin B cell → 40-60% of which are MALT variety Diagnosis • Fresh biopsy not in fixation, enable flow cytometry" What are acute treatments for compressive optic neuropathy from thyroid associated ophthalmopathy?;"• High dose steroids (intravenous or oral) • Urgent orbital decompression" What is Crouzon syndrome?;"• Most common type of craniosynostosis • Autosomal dominant • Branchial arch syndrome • Occurs in 1.6 per 100,000 • Premature closure of one or more of metropic, sagittal, or lambdoidal sutures • Anatomically shallow orbits results in bilateral congenital proptosis and midface hypoplasia • Syndactyly absent" What is the mechanism of action of botulinum toxin?;"Prevents release of acetylcholine from presynaptic neuron from neuromuscular junction." What is the cellular origin, cause, and association of Kaposi sarcoma?;"Cellular origin • Endothelial cells Cause • HHV-8 (human herpes-8) infection in immunocompromised patients Association • AIDS-defining illness • Mistaken for subconjunctival hemorrhage when they occur in subconjunctiva" From where does orbital septum arise?;"Extension of periosteum." What is the normal configuration of the lateral canthal tendon insertion in relation to the medial canthal tendon insertion?;"Lateral canthal tendon inserts 2 mm more superior than medial canthal tendon." What is epicanthus supraciliaris?;"Medial eyelid skin fold that is more prominent from eyebrow to lacrimal sac" What is epicanthus tarsalis?;"Medial eyelid skin fold that is more prominent in upper eyelid" What is epicanthus inversus?;"Medial eyelid skin fold that is more prominent in the lower eyelid" What is epicanthus palpebralis?;"Medial eyelid skin fold that is equally prominent upper and lower eyelid" What is rhabdomyosarcoma?;"● Derived from undifferentiated pluripotent mesenchymal cells ● FOXO1 gene translocation ● Clinical findings ○ Increased fullness of eyelids ○ Periocular ecchymosis ○ Proptosis ○ Ocular misalignment ○ Typical age of presentation is 8 to 10 years ● Types (“embryonal everyone; pleomorphic please; alveolar awful) ○ Embryonal (80% cases, most common), common in supranasal quad, good survival rate Alveolar, most malignant, common in lower orbit ○ Pleomorphic, best prognosis ● Treatment ○ Radiation, chemotherapy" What conditions are comorbid with myasthenia gravis (MG)?;"• Graves disease (5-10% of MG) • Thymoma (10% of MG)" What is the most common pathogen, workup, and treatment of infectious canaliculitis?;"Pathogen • Actinomyces israelii, filamentous gram positive rods → stone formation within canalicular system Workup • Culture purulent material manually expressed from punctum Treatment • Warm compresses, lid massages, broad spectrum topical antibiotics • If unresponsive or if stone is present → canaliculotomy from conjunctival side and allow for healing by second intention. Stones protect microbes from antibiotics, therefore stones need to be surgically removed" What are the types, advantages, and disadvantages of non-porous ocular implants?;"Types of non-porous ocular implants • Glass • Silicone • Acrylic Advantages • Less expensive • Faster surgery Disadvantages • Higher risk of exposure or extrusion ○ Decrease risk of exposure by wrapping the implant in autogenous or donor sclera, or coat the implant with absorbable material" What are the types, advantages, and disadvantages of porous ocular implant?;"Types of porous ocular implants • Hydroxyapatite • Porous polyethylene • Aluminum oxide Advantages • Tiny pores that vascularize with surrounding orbital soft tissue • Allow for better implant motility • Less risk of implant migration • Lower infection rate Disadvantages • High risk of exposure or extrusion through conjunctiva" What does solar lentigo look like and what is it associated with?;"• Seen in older patients • Sun exposed skin • Flat, regular pigmentation resembling freckles but larger in size" What is lentigo maligna and what is it associated with?;"• Similar to solar lentigo except irregular pigmentation • 30-50% of these lesions progress to melanoma" What is lentigo simplex?;"• Resembles freckles but larger • Not related to sun exposure or age" In relation to superficial musculoaponeurotic system (SMAS), what is an appropriate plan for dissection to minimize risk of injury to the facial nerve?;"● Stay deep to SMAS in upper face, superficial to SMAS in lower face ○ In upper face, facial nerve lies superficial to SMAS ○ In lower face, facial nerve lies deep to SMAS" What is a description of caruncular oncocytoma and its clinical findings?;"Description • Transformed salivary-type epithelial cells with increased mitochondria • Benign tumors • Mimic conjunctival melanoma Clinical findings • Pigmented conjunctival lesion • Smooth cystic appearance • Slow growth" What are adrenochrome deposits?;"• Hyperpigmented spots • Occur on conjunctiva • Seen after chronic exposure to topical epinephrine or its analogues (dipivefrin)" What skin condition characterized by rough "sandpaper" texture with round and scaly appearance can progress to squamous cell cancer?;"Actinic keratosis • Premalignant lesion • Caused by UV damage • Most common premalignant skin lesion that progresses to squamous cell carcinoma occurring in 2% of cases at 4 years" What structures are innervated by the superior branch of cranial nerve 3?;"• Superior rectus • Levator palpebrae" What is the management of indirect traumatic optic neuropathy?;"• No good evidence based surgical or medical options available • Conservative management" What is the most common location and source of sebaceous gland carcinoma?;"• Location: Upper eyelid • Source: meibomian and Zeis glands" What are the Garcia-Harris guidelines?;"As a general recommendation, observation with intravenous antibiotics only is indicated when: • Under 9 years of age (likely to be culture negative or no more than one aerobic bacterial species) • No intracranial involvement • Medial wall abscess of moderate size • No vision loss or afferent pupillary defect (no signs of optic neuropathy) • No front sinus involvement • No dental abscess" What structures are located superior to the annulus of Zinn?;"“LFTs” • Lacrimal nerve of cranial nerve V1 • Frontal nerve of cranial nerve V1 • Trochlear cranial nerve IV • Superior ophthalmic vein" What structures are within the annulus of Zinn?;"• Superior and inferior divisions of cranial nerve III • Nasociliary branch of cranial nerve V1 • Sympathetic roots of ciliary ganglion • Cranial nerve VI" Which vascular structure is inferior to annulus of Zinn?;"Inferior ophthalmic vein" What is the step ladder management approach to congenital nasolacrimal duct obstruction?;"Crigler massage, topical antibiotics, and/or observation ↓ Probe and irrigate ↓ Repeat probe +/- inferior turbinate fracture, balloon dacryoplasty, intubating with silicone stents ↓ DCR, if canaliculi are imperforate or obliterated → conjunctivodacryocystorhinostomy (cDCR)" What are the various causes of ectropion?;"• Involutional: Most common due to horizontal lid laxity • Paralytic: Decreased facial nerve innervation to orbicularis oculi muscle • Mechanical: Mass physically weighing down the lid and pulling it away from globe • Congenital: Rare, association with blepharophimosis syndrome and lid defects (i.e. euryblepharon) • Cicatricial: Tightness of eyelid skin tethers the lid into everted position. Due to scarring, actinic damage, autoimmune, or chronic inflammation" What are the anatomical functions of medial canthal tendon?;"• The tendon splits into anterior and posterior limb go around lacrimal sac • Anterior limb inserts on the anterior lacrimal crest • Posterior limb inserts on to posterior lacrimal crest • Anterior portion is responsible for structural support of eyelid • Posterior portion is responsible for keeping eyelid and punctum opposed to globe" What is the distance between the two orbits?;"25 mm" What is the location of the widest section of the orbit?;"1 cm posterior to anterior orbital rim" What is the most common subtype of periorbital or orbital non-Hodgkin B cell lymphoma and its presentation, diagnosis, and treatment?;"Most common • Mucosa-associated lymphoid tissue (MALT) lymphomas • Arise within lacrimal gland, orbit, or eyelid Presentation • Indolent Diagnosis • Fresh and unpreserved specimens for cell surface markers and flow cytometry Treatment • Orbital radiation" How is the Jones I test performed?;"• Assess patency of nasolacrimal drainage system • Place topical fluorescein into conjunctival fornices • Then place cotton swab within inferior meatus at 2 and 5 minutes later • If cotton swab is stained with fluorescein → patent passages • If cotton swab is not stained with fluorescein → obstruction is present" How is the Jones II test performed?;"• Performed if Jones I test is unsuccessful • Irrigate lacrimal system with normal saline • Then collect fluid in nose with swab • If dye stained saline is retrieved → indicates functional obstruction of nasolacrimal system • If unstained saline is retrieved → indicates mechanical obstruction of nasolacrimal system" What is the appearance of trichofolliculoma?;"• Solitary, umbilicated lesion • Fine blonde hairlike structure at its center or sebum secreting pore" What is the appearance of trichoepithelioma?;"• Flesh-colored papules with overlying telangiectasias • Commonly confused with basal cell cancer" What is the appearance of pilomatricoma?;"Reddish-purple, often calcified subcutaneous mass attached to overlying skin" In the upper eyelid of Caucasian patients, where does the superior orbital septum fuse with the levator palpebrae superioris in relation to the tarsal plate?;"The septum fuses with levator 2 to 5 mm superior to the tarsal plate" In Asian upper eyelid, where does the superior orbital septum fuse with the levator palpebrae superioris in relation to the tarsal plate?;"Between the upper border of the tarsal plate and eyelid margin" Which periocular sites of origin of lymphoproliferative lesions have the highest risk for developing systemic non-Hodgkin’s lymphoma?;"● Eyelid lymphoma → 67% develop systemic lymphoma (highest risk) ● Orbital lymphoma → 35% develop systemic lymphoma ○ Lesions from lacrimal fossa have higher risk of systemic disease than those originating elsewhere in the orbit ● Conjunctival lymphoma → 20% develop systemic lymphoma" Which lower eyelid structure is analogous to the levator aponeurosis in the upper eyelid and where does this structure originate from?;"● Capsulopalpebral fascia ○ Originates from muscle fibers of inferior rectus, extends forward, wraps around inferior oblique, then inserts into inferior tarsal border" When would you consider using a frontalis sling in repairing eyelid ptosis?;"Levator function 4 mm or less" What is a lipodermoid and what might condition it be associated with?;"• Also known as dermolipoma • Form of congenital choristoma • Occasionally associated with Goldenhar syndrome (oculoauriculovertebral dysplasia)" What is the clinical presentation and demographics of conjunctival lymphoma?;"Presentation • Rubbery, salmon-colored subconjunctival mass • Sculpts around shape of sclera rather than adhering to it Demographics • Peak age 40 to 60 years • Slight female predominance" What is the incidence of uveal melanoma in patients with nevus of ota (oculodermal melanocytosis) versus Caucasian patients without nevus of ota?;"Patients with nevus of ota • Risk of uveal melanoma is 1 in 400 Caucasian patients without nevus of ota • Risk of uveal melanoma is 1 in 13,000" What is the risk of glaucoma in ocular or oculodermal melanocytosis?;"• 10% risk of glaucoma • Requires scleral involvement" Which structure does the lateral horn of the levator aponeurosis divide?;"Divides lacrimal gland into orbital and palpebral lobes" Which ligament changes the direction of force of the levator muscle?;"● Whitnall's ligament ○ Changes direction from anterior-posterior to superior-inferior" What is Whitnall's tubercle?;"Bony prominence on zygomatic bone on lateral orbital wall" Which cells are responsible for inflammatory manifestations of thyroid eye disease?;"● Orbital fibroblasts ○ Become dysregulated by autoantibodies → produce glycosaminoglycan → infiltrate extraocular muscles → induce extraocular muscle hypertrophy ○ During inactive state of disease → muscles are atrophic and fibrotic" Which diagnostic test for myasthenia gravis has the least side effects and how is this test conducted?;"● Ice pack test ○ Ice pack in placed on closed eyelids for 2 to 5 minutes ○ Ptosis improvement by 2mm or improvement in strabismus by at least 10 PD → positive test" What structures pass through the inferior orbital fissure?;"• Branch of cranial nerve V2 → infraorbital nerve • Zygomatic nerve • Inferior ophthalmic vein • Branches from sphenopalatine ganglion" What are signs and symptoms of floppy eyelid syndrome (FES) and its systemic association?;"Signs and symptoms of FES • Chronic papillary conjunctivitis • Flaccid upper eyelids • Nonspecific ocular irritation FES systemic association • Up to 96% have some degree of obstructive sleep apnea" Which extraocular muscles do not originate from annulus of Zinn?;"• Levator palpebrae superioris → originates from sphenoid bone • Superior oblique → originates from sphenoid bone at the orbital apex, medial to optic canal • Inferior oblique → originates maxillary bone" Which meatus does the sphenoid sinus drain into?;"Sphenoethmoid recess" Which meatus does the posterior ethmoid sinus drain into?;"Superior meatus" Which meatus do the maxillary, middle ethmoid, anterior ethmoid, and frontal sinuses drain into?;"Middle meatus" Which meatus does the nasolacrimal duct drain into?;"Inferior meatus" For blepharoplasty of the upper eyelid, what is a good rule of thumb for the amount of skin to be left behind?;"● 20 mm of total skin remaining ○ 10 mm from upper portion of incision to inferior border of eyebrow. 10 mm from inferior portion of incision to eyelid margin" What is the type, presentation, and treatment of entropion caused by chlamydia trachomatis?;"Type of entropion • Cicatricial entropion Presentation • Scarring and vertical shortening of posterior lamella results in cicatricial entropion • Arlt's line: scarring of upper lid posterior lamella causing a white line Treatment • Oral and topical antibiotic (i.e. PO azithromycin and topical tetracycline) • Horizontal tarsal fracture and bilamellar tarsal rotation procedure to evert the lashes away from cornea" How many meibomian glands are located in upper and lower eyelids?;"• Upper eyelid: 25-40 • Lower eyelid: 20-30" What creates the upper eyelid crease?;"Levator attachments to orbicularis and skin" What creates the gray line along the eyelid margin and where is it located?;"• Muscle of Riolan, also known as pretarsal orbicularis • Located anterior to tarsal plate" What is Muir-Torre syndrome?;"• Genetic syndrome, autosomal dominant • Combination of sebaceous tumors of skin plus one or more internal malignancies • Mutation in mismatch repair genes responsible for hereditary nonpolyposis colon cancer • Increased risk of colorectal cancer, endometrial cancer, stomach cancer, ovarian cancer, urinary tract cancer, and hepatobiliary cancer" What is Gorlin syndrome (basal cell nevus syndrome or nevoid basal cell carcinoma syndrome)?;"• Autosomal dominant • Develop basal cell carcinoma → typically appearing in adolescence or early adulthood • Develop benign jaw tumors (keratocystic odontogenic tumors) • Some develop childhood medulloblastoma, cardiac fibromas, or ovarian fibromas" What is the sign of Leser-Trelat?;"• Sudden onset of multiple seborrheic keratoses • Paraneoplastic finding due to internal organ malignancy → GI cancer, breast cancer, lung cancer, urinary tract cancer, and lymphoid tissue cancer" What are the branches of cranial nerve V1?;"• Nasociliary • Frontal • Lacrimal" What structural abnormality is the most common cause of congenital nasolacrimal duct obstruction?;"● Membranous obstruction of valve of Hasner ○ Valve between nasolacrimal duct and inferior meatus" What is a hidrocystoma?;"● Cystic lesions derived from sweat glands ● Types ○ Eccrine or apocrine ○ Eccrine hidrocystoma: Benign; cysts filled with clear fluid ○ Apocrine hidrocystoma: Benign; cysts filled with milky fluid ● Increase in size with heat and humidity ● Treatment ○ Complete excision of cyst lining" What is a xanthelasma?;"Description • Yellow discolored skin plaque Pathology • Infiltration with foam cells → lipid filled macrophages within dermis Common location • Medial canthal skin Associations • Hyperlipidemia Treatment: • Observation • YAG or CO2 laser • Topical trichloroacetic acid • Excision" What is the definition and treatment of Bowen's disease?;"Definition • In-situ squamous cell cancer of skin Treatment • Surgical excision or topical 5-FU" Which bony structure separates the superior orbital fissure from the optic canal?;"Optic (sphenoid) strut" What are the signs and symptoms of the fibrous reaction seen in metastatic breast cancer to the orbit?;"• Enophthalmos or proptosis • Restricted motility because tumor may elicit fibrous response in the orbit • Pain • Chemosis" Which orbital wall has the shortest anterior-posterior length?;"● Orbital floor ○ Does not extend into the orbital apex unlike the other orbital walls ○ Ends at the pterygopalatine fossa" Which vasculature is between Muller's muscle and the levator palpebrae superioris just superior to the tarsal plate?;"Peripheral arterial arcade" What is the location of the marginal arterial arcade?;"2 mm superior to cilia and anterior to the tarsal plate" What is the most common cause of acquired ptosis?;"Aponeurotic" What are the clinical findings in congenital ptosis?;"• Fibrofatty dysgenesis of levator muscle → weaker and stiffer eyelid • Lid crease is attenuated or absent • Ptosis in primary gaze • Retracted in downgaze" What are the causes of acquired nasolacrimal duct obstruction?;"• Prior dacryocystitis • Midfacial trauma involving bony nasolacrimal duct • Sinusitis • Stenosis due to medical treatment (i.e. radioactive iodine for thyroid ablation in Graves or docetaxel for breast cancer) • Manipulation during previous probe and irrigation • Malignancy (i.e. squamous cell cancer)" What is an indication for conjunctivodacryocystorhinostom y (cDCR) and how it this procedure performed?;"Indication • Obliterated canaliculi (trauma or surgical resection due to neoplasm) Procedure • External cDCR opening is made through caruncle → tract is created through the bone directly into middle meatus → straight posterior inferomedial trajectory • Rigid hollow tube is placed through the tract to maintain patency, otherwise 100% tendency for this pathway to obstruct" How is the procedure dacryocystorhinostomy performed?;"• Uses patient’s puncta and canaliculi but bypasses nasolacrimal duct • After surgery, tears flow through punta into canaliculi, then through surgically opened lacrimal sac and osteotomy into middle meatus" Which foramen does cranial nerve V1 pass through?;"Superior orbital fissure" Which foramen does cranial nerve V2 pass through?;"Foramen rotundum" Which foramen does cranial nerve V3 travel through?;"Foramen ovale" What percentage of patients with thyroid associated ophthalmopathy (TAO) will be in hyperthyroid state at some point?;"● 90% have Graves and will have hyperthyroidism at some point ○ Among hyperthyroid patients, only 30% develop TAO" Which types of thyroid conditions are seen with thyroid associated ophthalmopathy (TAO)?;"• 90% hyperthyroidism • 6% euthyroid • 3% Hashimoto's • 1% primary hypothyroidism" What are the thinnest bones of the orbit?;"• Lamina papyracea (part of ethmoid bone) • Maxillary bone" What is the strongest wall of the orbit?;"Lateral wall made up of zygomatic and greater wing of sphenoid" Which lobe of the lacrimal gland can be biopsied?;"Orbital lobe (avoid palpebral lobe)" What is the most common primary orbital malignancy of childhood and its presentation?;"• Rhabdomyosarcoma • Proptosis and spontaneous periorbital ecchymosis" What is Merkel cell carcinoma of the eyelid?;"• Neuroendocrine derived malignancy • Violaceous red color and well-circumscribed fusiform shape • 5-year survival rate is 50%" What are the complications of injecting corticosteroids subcutaneously into an eyelid?;"• Skin depigmentation • Elevation of intraocular pressure • Central retinal artery occlusion" What two orbital pathologies involve the sphenoid bone?;"● Sphenoid dysplasia in NF1 resulting in pulsatile proptosis of globe ● Sphenoid wing meningioma ○ Expansion of bony volume → proptosis, compressive optic neuropathy ○ 20% of cranial meningioma involve sphenoid wing" How soon should you place a conformer back in the eye in case it falls out after enucleation or evisceration?;"● Conformer should not be removed for > 24 hours ○ If left out for several days → fornices can adhere to each other ○ If a conformer is not placed back in → it will be difficult to place a prosthetic in the future, requiring mucous membrane grafting to reconstruct fornices" What is a junctional nevus?;"• Nests of nevus contained within epidermis • Along the rete ridges at the base of epidermis near its junction with dermis • High malignancy potential" What is an intradermal nevus?;"• Nests of nevus contained within dermis • Low malignant potential" What is a compound nevus?;"Nests of nevus cells spanning across dermis and epidermis" What is an epidermal inclusion cyst?;"• Benign • Ectoderm-derived • Cysts are lined with squamous epithelium and filled with keratin that is produced by cyst lining" What is a Le Fort I fracture?;"Low transverse maxillary fracture above teeth without orbital involvement" What is a LeFort II fracture?;"Fractures of bilateral nasal, lacrimal, maxillary bones and medial orbital floor" What is a LeFort III fracture?;"Fracture at the craniofacial disjunction in which entire facial skeleton is detached from the base of skull" What is the indication for lateral tarsal strip procedure and how is it performed?;"Indication • Correction of involutional ectropion Procedure • Shortening of the lower eyelid and then suturing it to the periosteum • Maintains a sharp lateral canthal angle" What is the indication for medial spindle procedure and how is it performed?;"Indication • Correction of medial ectropion or punctal ectropion Procedure • Removing diamond shaped piece of conjunctiva and lower lid retractors 4 mm inferior to inferior canaliculus → then placing inverting sutures" What is the indication for Cutler Beard procedure and how is it performed?;"Indication • Correction of upper eyelid defect that is > 50% of eyelid width Procedure • A full-thickness lower eyelid flap is moved into the defect of the upper eyelid by advancing the flap behind the remaining lower eyelid margin" What is the indication of the modified Hughes procedure and how is it performed?;"Indication • Correction of lower eyelid defects >50% of eyelid width Procedure • Advancement of a tarsoconjunctival flap from the upper eyelid into the posterior lamellar defect of the lower eyelid" What is the indication for direct closure of an eyelid defect?;"Eyelid defects that are <33% of eyelid width" How do you repair eyelid defects which are 33-50% of eyelid width?;"Eyelid is freed with lateral canthotomy and semicircular flap (Tenzel flap) is rotated into the defect" What is the most common metastatic orbital tumor in children? What is its presentation, workup, and treatment?;"● Metastatic orbital neuroblastoma ● Presentation ○ Proptosis ○ Spontaneous eyelid ecchymosis (raccoon eyes) ○ Horner's syndrome ○ Opsoclonus (sometimes) ● Work up ○ Urinary catecholamines ○ Imaging of neck, chest, and abdomen ● Treatment ○ Chemotherapy" What is the definition and types of Marcus Gunn Jaw Winking?;"Definition • Aberrant innervation connection (synkinesis) between muscles of (pterygoid) and levator muscle Types • Lateral (external) pterygoid synkinesis: most common; connection between external pterygoid and levator muscle. Eyelid opens with jaw opening, movement of jaw to contralateral side or forward movement of jaw • Medial (internal) pterygoid synkinesis: less common; connection between internal pterygoid and levator muscle. Eyelid opens with jaw closure" What is Whitnall's tubercle and what attaches to it?;"Definition • Bony prominence on zygomatic bone that 10mm inferior to the frontozygomatic suture, just posterior to lateral orbital rim Tubercle attachments ALL (""L""s) • Lockwood's ligament • Lateral rectus check ligament • Lateral horn of levator • Lateral canthal tendon Side note: Whitnall's ligament does not attach here, rather forms fibrous attachments to lateral wall near lacrimal gland, 10 mm superior to Whitnall's tubercle" What is the medical term for acute infection of meibomian gland orifices?;"Internal hordeolum" What is the medical term for acute infection of Zeis glands?;"External hordeolum" What is the definition of chalazion?;"• Chronic, sterile, lipogranulomatous inflammation of oil glands within the eyelid • Glands involved: meibomian glands, zeis glands" Where is the temporal artery located?;"Within superficial layers of temporoparietal fascia" What are some examples of septate fungi?;"• Fusari • Aspergillus • Curvularia" What are some examples of non-septate fungus?;"• Mucor • Rhizopus" What is the most common cause of nasolacrimal duct obstruction in adults?;"Involutional stenosis from either infectious or autoimmune process" What is the definition and most common cause of a dacryolith?;"Definition • Stone within canaliculus Most common cause • Actinomyces israelii: anaerobic gram positive filamentous" What is an indication for Quickert sutures?;"Indication • Temporary fix of entropion while waiting for more definitive intervention such as a lateral tarsal strip procedure" What is the definition and treatment of spastic entropion?;"Definition • Contraction of orbicularis → rolls eyelid margin inward → then relaxation of muscle → eyelid to reposition Treatment • Botox injection to weaken orbicularis contraction • May require surgery → orbicularis debulking +/- lateral tarsal strip +/- retractor reinsertion" What are the differential diagnosis for chronic dacryoadenitis?;"• Sarcoidosis • Thyroid eye disease • Orbital inflammatory syndrome • TB" What are the causes, origin, and presentation on imaging of optic nerve sheath meningioma?;"Causes • Occur in isolation • Association with neurofibromatosis-2 Origin • Arise from nerve sheath meninges and form dense mass encasing optic nerve Presentation on imaging • ""Tram track"" sign • Sheath tumor appears as two parallel lines resembling railroad tracks flanking optic nerve" What are the various types of and risk factors for basal cell cancers (BCC)?;"Types ● Nodular: Most common type. Firm, raised, pearly nodule and ""peripheral palisading"" ○ Ulcerative: Center of nodular BCC breaks down into an open ulcer ● Pigmented: Rare, hyperpigmented and resembles nodular ● Sclerosing: Morpheaform, infiltrating BCC; flat, depressed, shiny and scar-like plaque Risk factors • Sun exposure • Fair skin • Immunosuppression • Gorlin syndrome • Xeroderma pigmentosum" What are ways to remove basal cell cancer?;"• Mohs procedure: Preferred approach. Enables tighter margin and layer-by-layer margin surveillance • Complete excision: Done with 3 mm margins" Which periorbital location of basal cell cancer has the highest risk of orbital expansion?;"Medial canthal lesions" What are ways to potentiate lidocaine injection and their mechanisms of action?;"• Hyaluronidase: Disperses lidocaine to a greater degree • Epinephrine: Constricts blood vessels → prevents elimination of lidocaine and increases its time of action • Sodium bicarbonate: Buffers solution and decreases pain on injection" What are the most common types of melanoma around the eyelid?;"• Lentigo maligna melanoma: 90% of melanomas occurring on head and neck • Nodular melanoma: Second most common, 10% of melanomas occurring on head and neck" What is the definition and causes of distichiasis?;"Definition • Growth of eyelashes from abnormal site Causes • Severe blepharitis • Ocular cicatricial pemphigoid • Stevens Johnson syndrome • Chemical or thermal burns" What is the definition and causes of trichiasis?;"Definition • Lashes from normal location but misdirected Causes • Any cause of entropion • Prostaglandins" What are the types of holocrine glands and their mechanism of action?;"Types • Meibomian glands • Zeis glands Mechanism of action • Material that is made in the cytoplasm of these glands’ cells is released into lumen of the gland ducts by disruption of cellular membrane (cell is destroyed when its contents are released)" What is an example and mechanism of action of apocrine glands?;"Type • Glands of Moll Mechanism of action • Secrete via merocrine mechanism • Portion of cytoplasm containing the product is pinched off and expressed into a glandular duct → ""decapitation secretion""" What is the most common type, presentation, incidence, and treatment of primary malignancy of lacrimal sac?;"Most common type of primary lacrimal sac malignancy • Squamous cell carcinoma Presentation • Mass above medial canthal tendon • Bloody tears • Epiphora • Regional lymphadenopathy Incidence • 45% lacrimal sac tumors are benign; 55% are malignant Treatment • Dacryocystectomy followed by radiation. • Exenteration is sometimes necessary if there is orbital invasion" Which meatus is directly adjacent to the lacrimal sac fossa?;"Middle meatus" What is the life cycle of a nevus from early-in-life to old age?;"Junctional ↓ Compound ↓ Intradermal" What structure connects the recti muscles and forms a boundary between intraconal and extraconal space?;"Intermuscular septum" What are the insertion distances in spiral of Tillaux?;"Medial rectus: 5.5mm Inferior rectus: 6.5mm Lateral rectus: 6.9mm Superior rectus: 7.7mm " What are the risk factors for severe thyroid eye disease?;"• Smoking • Male (although women are 6x more likely to develop thyroid associated ophthalmopathy) • Pretibial myxedema • Radioactive iodine" What is the most common etiology for congenital blepharoptosis?;"Myogenic → abnormal development of levator muscle" What are causes of axial displacement?;"• Cavernous hemangioma • Arteriovenous malformation • Optic nerve sheath meningioma • Optic nerve glioma • Orbital metastases • Other intraconal tumors" What are causes of non-axial displacement?;"● Lacrimal gland tumors ○ Push globe inferomedially ● Frontoethmoidal masses (tumors or mucoceles) ○ Located in the superomedial orbit ○ Push globe inferotemporally ● Maxillary sinus tumors ○ Push globe superiorly" Sarcoidosis has greatest the affinity for which structures in head and neck?;"Lacrimal gland and parotid gland" What are clinical findings and associations in Heerfordt syndrome (uveoparotid fever)?;"Clinical findings • Uveitis • Facial palsy • Fever Associations • Sarcoidosis • Lyme disease • TB • Syphilis" What are clinical findings in Lofgren syndrome and what is it associated with?;"Clinical findings • Bilateral hilar adenopathy • Arthropathy • Fever • Erythema nodosum Association • Sarcoidosis" What are clinical findings in Mikulicz syndrome and what is it associated with?;"Clinical findings • Xerostomia (dry mouth) • Parotid gland enlargement • With or without lacrimal gland enlargement • Dry eye Associations • Sarcoidosis • Lymphoma • Sjogrens • TB" What is von Hippel Lindau disease?;"• Autosomal dominant • Mutation of VHL tumor suppressor gene, chromosome 3 • Multisystem tumor formation • Associated with retinal hemangiomas, hemangioblastomas, and pheochromocytomas • Usually develop in third decade of life or later" What is the etiology of congenital ectropion and what is it associated with?;"Etiology • Due to shortening of anterior lamella of eyelid • Most are mild and respond to conservative measures like lubrication Associations • Blepharophimosis syndrome • Downs syndrome • Ichthyosis • Ectodermal dysplasia" What is the appearance of molluscum lesions?;"Waxy, nodular lesions with central umbilication" What is the differential diagnosis for a “salmon pink" subconjunctival lesion and its origin?;"Differential diagnosis • Reactive lymphoid hyperplasia (benign) • Conjunctival lymphoma (malignant) Origin • Lymphoid origin" What is the mechanism of action and indication to use topical imiquimod?;"Mechanism of action • Stimulates cytokine release including interferon-alpha and TNF-alpha Indication • Cutaneous melanoma in situ and basal cell carcinoma" What are the definitions of telecanthus, hypertelorism, and exorbitism?;"• Telecanthus: greater than normal distance between medial canthi • Hypertelorism: excessive distance between medial orbital walls • Exorbitism: prominent eyes due to shallow orbits or increased angle of divergence of orbital walls" What are the most common antibodies found in thyroid disease?;"• Thyroid microsomal antibodies • Antibodies to thyroglobulin" What is Meige syndrome?;"Definition • Essential blepharospasm with facial grimacing • Can progress from benign essential blepharospasm • Unknown etiology Workup • CT/MRI to rule out posterior fossa lesions Treatment • Local: Botox • Systemic: Tetrabenazine, lithium, carbidopa, or clonazepam" What are the differences and similarities between hemifacial spasm and benign essential blepharospasm (BEP)?;"Hemifacial spasms • Persist during sleep • Unilateral • Spasms mostly due to vascular compression of cranial nerve 7 in the brain stem • MRI to evaluate for ectatic vessel and rule out cerebellopontine lesion BEP • Bilateral focal dystonia with increased blinking and involuntary spasms or periocular protractor muscles • Stops during sleep • Can progress to Meige syndrome with lower facial dystonia • Dysfunction of basal ganglia Treatment in hemifacial spasms and BEP • Botox in both conditions" What are the associations with craniosynostosis syndrome?;"• Strabismus • Astigmatism • Ptosis • Exophthalmos • Nasolacrimal duct obstruction • Amblyopia" What is the order of surgical therapy for thyroid eye disease?;"Orbital decompression ↓ Strabismus surgery ↓ Eyelid retraction repair ↓ Blepharoplasty" What are the types of eyelid ptosis and their findings?;"• Aponeurotic: Levator attenuation or disinsertion resulting in superior migration of orbital septum and preaponeurotic fat. Seen with elderly patients, long-standing hard contact lens use, good levator function, thin eyelid skin, high lid crease and deep superior sulcus. Associated with post trauma, long-standing edema and chronic allergies with eye-rubbing • Congenital: Absent or poorly formed eyelid eyelid crease. Associated with poor levator function • Neurogenic: Associated with Horner syndrome and cranial nerve 3 palsy • Myogenic: Seen with muscular dystrophy, chronic progressive external ophthalmoplegia, myasthenia gravis and oculopharyngeal dystrophy • Mechanical: Weighing or pulling down on upper eyelid. Seen with plexiform neurofibroma, hemangioma, acquired neoplasm, large chalazion, skin carcinoma, temporarily due to post surgical and post traumatic edema" What are the types of craniosynostosis and their unique findings?;"• Crouzon syndrome (most common): syndactyly is absent • Apert syndrome: syndactyly present • Treacher Collins syndrome: mandibulofacial dysostosis and underdeveloped lower jaw • Goldenhar syndrome (oculoauriculovertebral syndrome): ear, nose, soft palate, lip and mandible deformities, limbal dermoids, and strabismus" What is the definition of nanophthalmos and what is it associated with?;"Definition • Axial length 15 to 20 mm Associations • Normal or slightly enlarged lens • Thick sclera • Predisposed to uveal effusion and glaucoma" What is pleomorphic adenoma (benign mixed tumor)?;"• Most common epithelial lacrimal gland tumor • Slow growth → gradual proptosis without pain • Excavating lacrimal fossa • Stimulates new bone growth without erosion • Recurrences occur with incomplete excision or seeding of orbit from incisional biopsies; difficult to manage • Treatment: complete removal with adequate margin, violation of pseudocapsule and leaving remnants behind increases recurrence. • Pathology (see below): combination of epithelial and stromal lacrimal gland elements " What are the various forms of epicanthus?;"• Epicanthus tarsalis: fold most prominent along upper eyelid • Epicanthus inversus: fold most prominent along lower eyelid • Epicanthus palpebralis: fold involves both upper and lower eyelids • Epicanthus superciliaris: fold originates from brow and goes down to lacrimal sac" Which chemotherapy agents cause inflammation and scarring of canaliculi?;"• Docetaxel • 5FU • Idoxuridine • Eserine • Phospholine iodine" What are the differences between facial myokymia and hemifacial spasm?;"Facial myokymia • Continuous unilateral contraction of facial muscle bundles • Intramedullary disease of pons at cranial nerve 7 nucleus or fascicle • Result of pontine glioma or demyelination Hemifacial spasm • Unilateral episodic spasms involving facial musculature • Most commonly due to compression of cranial nerve 7 root exit zone by aberrant vessel" What are the associated findings in thyroid eye disease?;"• Spares extraocular muscle tendons • Eyelid retraction - most common ophthalmic feature (>90%) • Exophthalmos (60%) • Restrictive extraocular myopathy (40%) • Optic nerve dysfunction (5%) • Diplopia (17%) • Pretrial myxedema (4%) • Myasthenia gravis (<1%)" What is the presentation and cause of crocodile tears?;"Presentation ● Lacrimation while chewing Cause ● Aberrant facial nerve regeneration ● Due to severe injury to proximal cranial nerve 7" What is the depth of the orbit in an adult?;"40 to 45 mm from the orbital entrance to the orbital apex"