B. Mueller’s muscle is the culprit. Horner’s is known to affect the sympathetic nervous system. Mueller’s muscle is innervated by sympathetic input and acts to lift the eyelid 2-3mm. This is the reason for the mild ptosis in Horner’s patients.

B. Involutional. The most common cause of ectropion is a laxity of the muscles needed to adhere the lid to the globe that develops with age. Congenital and Cicatricial are quite rare in occurrence. Paralytic ectropion is caused by Bell’s Palsy.

B. A consequence of congenital aberrant degeneration, the motor branches of the trigeminal nerves will simultaneously communicate with the superior division of the oculomotor nerve which controls the levator.

B. Poliosis is the whitening of eyelashes often caused by chronic eye infections. Madarosis describes a loss of eyelashes. Tylosis is thickening of the lid margin. Trichiasis is an inward turned eyelash. Sudoriferous is a term used to describe a cyst.

D. Cholesterol. The condition we are seeing is known as Xanthelasma. The yellow plaques develop over time with elevated cholesterol levels. The patient can be referred for excision/cryotherapy after cholesterol levels are brought back to normal levels.

A. Basal cell carcinomas are the most common malignant eye tumors. Next is squamous, then sebaceous, and most rare is malignant melanoma. A nevus is a benign finding on the eyelid that requires monitoring.

E. Although staph epidermidis is a common cause, Staph Aureus is seen most frequently. H. influenza and N. gonorrhoeae are gram “-” bacteria more common in children’s bacterial eye infections. Moraxella is more common in angular blepharitis.

B, C, D are all findings that elevate the diagnosis from preseptal to orbital cellulitis. In orbital cellulitis, key findings include reduced VA, EOM restrictions, proptosis, and optic nerve involvement. These findings demonstrate the importance of proper treatment of adnexal infections.

D. Demodex folliculorum and D. brevis are the most common mites found on the human eye lash. Phthirus and pediculus are parasites that are contagious and easily spread. If seen in children it is a red flag! Molluscum, a DNA pox virus, is a viral infection of the skin common in children and immunocompromised patients.

D. Verruca is a painless, multi-lobulated lesion with a frondular appearance that may or may not regress over time. It is most believed to be a consequence of HPV. Molluscum is the result of a DNA pox virus that is seen in children or in immunocompromised populations. Contact dermatitis is caused by exposure to allergens. Papillomas are benign “skin tags” that develop spontaneously as we age.

E. Indirect illumination is used to assess non-opaque corneal lesions by focusing oculars adjacent to the beam of light (i.e EMBD). Sclerotic scatter is used to evaluate the clarity of the cornea. Optic section is used to determine depth (i.e. Van Herick, corneal scar). Conical beam is used to assess anterior chamber for cells and flare. Specular reflection is used to assess the corneal endothelial cells (i.e. Fuchs).

D. Chemical burns with alkali agents are more dangerous than acidic agents. This list is challenging. First, remove the two acids. Next, we know that fertilizers and pepper spray (PAVA) are both acidic. Calcium hydroxide is not only basic, but also the most common cause of alkali burns.

A. Limbal blanching indicates that the chemical burn has resulted in ischemia. Although the remaining options are of major importance, limbal blanching has the most long term consequences on the health of the eye.

B. It is imperative you DO NOT perform gonio or scleral depression until at least 1 month post-injury to avoid rebleeds. The most common cause of a hyphema is trauma so be sure to assess for iris sphincter tears, iridodialysis, rosette cataracts, lens subluxation, and other common traumatic findings.

A. The most common site of an orbital fracture is the maxillary bone; the posterior medial portion of the floor. The palatine and zygomatic bones are the other two bones that compose the floor of the orbit. Ethmoid and lamina papyracea are interchangeable and represent the THINNEST bone in the orbit. This bone prevents infections from moving into the sinuses.

C. In the case of a trapped inferior rectus, you would expect a POSITIVE forced duction. To perform a duction exam, you anesthetize the patient’s eye and use forceps (or two Q Tips) to move the eye. If the eye moves, it is most likely a palsy as the muscles are not restricted. This is a NEGATIVE forced duction. Limited upgaze and diplopia are due to the inferior rectus being stuck in a down position (no slack to move up). Hypoesthesia comes from possible damage to the infraorbital nerve. Crepitus is the “crunching” sound from bone fragments rubbing against the other.

D. H. influenzae is the most common culprit for cellulitis in children. Staph aureus is the most common cause of cellulitis in adults.

A, C, E: The three noted signs are Von graefe, Dalrymple, and Kocher. Von Graefe’s sign is upper eyelid lag during downgaze. Dalrymple’s sign is lid retraction resulting in the “look of surprise”. Kocher’s sign is globe lag compared to lid movement when looking up. Seidel’s sign is aqueous leakage seen in laceration/penetration of the globe. Munson’s sign is the peaked appearance of a cornea from a bird’s eye view of the (looking down from above).

C. The correct order is Inferior rectus, Medial rectus, Superior rectus, Lateral rectus, and then the obliques. The mnemonic for this condition is “IM SLO”.

B,C,D: The clinical triad for CCF is chemosis, pulsatile proptosis (the globe appearing to pulse in and out of the orbit), and ocular bruit (the sound of blood “whooshing” in the eye). CCF results from an abnormal communication of the vascular system within the cavernous sinus. It is most commonly caused by head trauma and can lead to elevated IOP, diplopia, and sensation loss of the face.

B. Cavernous hemangioma is the most common benign orbital tumor in adults. Cavernous hemangiomas develop slowly and lead to unilateral proptosis. Capillary hemangiomas are the most common benign orbital tumor in CHILDREN.

A,B,D: Telangiectasia is a critical finding in Coat’s, BCC, and ocular rosacea. Although these may begin to appear as we age, it is important to rule out these conditions on assessment. Molluscum appears as an umbilicated nodule without telangiectasia.

C: Ocular Cicatricial pemphigoid is an example of type II hypersensitivity as it involves autoantibodies that target basement membranes. Stevens-Johnson is considered either type 3 or 4 hypersensitivity that affects mucous membranes. Contact dermatitis is a type 4 hypersensitivity reaction as it takes 24-72 hours to develop after exposure. Atopic Keratoconjunctivitis is considered both Type 1 and 4. Phlyctenular keratoconjunctivitis is a type 4 hypersensitivity to staphylococcus.

A: Involutional, or aging, is the most common cause of entropion (an inward turning of the eyelid). Other causes include mechanical (tumor), cicatricial (trachoma, Stevens-Johnson, chemical burns), or congenital.

D. Floppy Eyelid Syndrome is the most likely diagnosis. Snoring is related to obstructive sleep apnea and FES. Patients with FES are known to have issues with elastin – specifically within the tarsal plate with regards to FES. Common signs/symptoms include dryness, papillary conjunctivitis and mild discharge. Recall that dry eye and redness in FES is related to FRICTION.

A. An S-shaped ptosis is classically associated with dacryoadenitis – inflammation of the lacrimal gland. Dacryoadenitis can occur acutely or chronically. Acute infections present with S-shaped ptosis, pain, redness, and preauricular lymphadenopathy. Acute infections are often bacterial or viral in nature. Chronic infections have a similar set of signs/symptoms, however, to a much lesser degree. Chronic infections are related to inflammatory disorders such as the other answer choices.

E. Canaliculitis is most often caused by Actinomyces israelii. First signs include a pouting puncta, epiphora, and sulfur granular discharge.

D. Negative Jones I and Positive Jones II. Jones I tests the patency of the nasolacrimal system. A Positive Jones I means a Patent system. With NLDO, you would expect a negative Jones I. Jones II is used to attempt to open an obstructed system. Saline is irrigated with pressure into the canal. If a patient is able to gag and taste the saline, you have opened the system – positive Jones II. If patient does not gag/taste and there is retrograde discharge with increased pressure is a negative Jones II. At this point it is important to refer for dacryocystorhinostomy

E. H. influenzae is the most common cause of simple bacterial conjunctivitis in children. The most common cause in adults is Staph aureus.

C. Ligneous conjunctivitis is caused by a systemic plasmin deficiency leading to development of thick mucous membranes. Other conditions associated with PAN include viral, inflammatory systemic, and hyperacute bacterial infections.

A. Cobblestone papillae are found on the UPPER palpebral conjunctiva. VKC is a form of seasonal allergies that most often affects young males. These young males present with complaints of intense itching and photophobia. Slit lamp examination reveals cobblestone papillae of the upper lid, trantas dots with gelatinous masses at the limbus, and redness of the eye. In extreme cases, epithelial keratitis leads to thinning and eventual ulceration of cornea – a shield ulcer.

B,C,E: Superior limbic keratoconjunctivitis (SLK) is related to FRICTION. Dry eye, thyroid eye disease, and contact lens hypersensitivity are most commonly associated with SLK.

D. Chlamydia is the leading cause of ophthalmia neonatorum in the US. HSV and gonorrhea may also lead to development of this condition.

C. Along with Arlt’s lines other common findings in Trachoma include both follicular and papillary reactions of the palpebral conjunctiva, PAN, and potential SEIs. Dennie’s line are extra creases in adnexal skin in Atopic Dermatitis. Scheie’s line describes pigment in pigment dispersion syndrome. Stocker’s line represents the leading of a pterygium.The Hudson-Stahli line is iron deposition within the cornea that normally occurs with age.

D. Necrotizing without inflammation. This is a unique form of Scleritis where the patient presents with minimal pain and injection. Often associated with rheumatoid arthritis, SP leads to scleral thinning that gives a blue appearance.

A,C,D: These conditions lead to development of trabeculitis and iritis that reduces aqueous outflow. This reduction in outflow leads to spikes in IOP as high as the 40s-50s. Sarcoidosis may cause inflammation anywhere in the body. Most often, Sarcoidosis leads to bilateral uveitis and may also include posterior or panuveitis. Toxoplasmosis does not often cause anterior uveitis, rather posterior or panuveitis.

C,D: Stellate KPs are unique to Herpes simplex and Fuch’s iridocyclitis. Other options listed here are also considered granulomatous. However, these conditions present with Koeppe (found at pupillary margin) or Busacca nodules (other locations on iris).

A: Toxoplasmosis is the most common cause of posterior uveitis. Toxoplasmosis presents with unilateral vitritis in presence of a yellow-white retinal lesion near an old inactive scar. When looking within the eye, findings appear as “headlights in the fog”. Other conditions listed also lead to development of posterior uveitis.

B. Histoplasmosis does NOT cause vitritis. This is one major distinguishing factor when comparing to toxoplasmosis. Histoplasmosis is a fungal infection that is common to the Ohio-Mississippi River Valley.

A,E: Either the nasociliary branch of the trigeminal (V1) and/or the facial nerve (VII). The nasociliary nerve is responsible for sensory information from the cornea. Corneal regeneration is reduced as there is little feedback from the corneal nerves that indicate damage. Common causes of damage include HSV, DM, LASIK, contact lens overwear, and chronic corneal injury. The facial nerve can also cause NK due to reduced reflex tearing and inability to close the eyelid leading to chronic damage of ocular surface and further damage to VI. The cotton-swab test is used for aid in diagnosis of NK.

D. The patient is most likely suffering from a recurrent corneal erosion which is caused by poor hemidesmosome attachment. This attachment problem is preceded by corneal abrasion, corneal dystrophies, and/or age-related changes to the basement membrane. Ultraviolet keratopathy is caused by the excessive absorption of short wavelengths – symptoms occur 6-12hrs after exposure. Dry eye is caused by increased levels of MMPs and can cause symptoms at any time of day. Poorly managed blood sugar may lead to neurotrophic keratopathy – patients will have no pain complaints.

A,D,E: A normal result for phenol red thread test is >10mm in 15 secs, Schirmer 1 test is >10mm in 5 minutes, Schirmer 2 testing (with anesthesia) is >5mm in 5 minutes. Tear osmolarity should be greater than 308 mOsm/L. Tear meniscus is measured under a slit lamp and should be greater than 0.2mm. Tear break up time (TBUT) is evaluated under slit lamp and blue light conditions. The tear film should remain intact for up to 10 secs.

B. Klinefelter syndrome is NOT associated with keratoconus. To recall these conditions, use the mnemonic “T-DOME”: Turner Syndrome, Down Syndrome (aka Trisomy 21), Osteogenesis Imperfecta (aka Brittle Bone disease), Marfan Syndrome, and/or Ehlers-Danlos Syndrome. Other lower yield conditions include atopic dermatitis (excessive rubbing) and mitral valve prolapse (can be correlated to Marfan syndrome).

D. Progression to late stage K-cone can cause tears in DM, otherwise known as corneal hydrops. Early signs include Fleischer’s ring (an IRON ring that develops early and best visualized with cobalt blue filter), scissor reflex on retinoscopy, and INFERIOR steepening of the cornea on topography. Late signs include Vogt’s striae (VERTICAL folds in the cornea), Munson’s sign (cone appearance of the cornea when patient viewed from above), and hydrops (tears in Descemet’s membrane). Horizontal folds are called Haab striae and are related to glaucoma.

E. Disciform keratitis is described as secondary stromal edema in the presence of endotheliitis. The remaining options all impact Bowman’s layer directly. Recall that Bowman’s layer does NOT regenerate.

A. Macular dystrophy is the only corneal dystrophy that is autosomal recessive. The rest of the options are autosomal dominant.

D. The fine yellow-white rings of crystals in Schnyder’s are composed of cholesterol. Macular Dystrophy presents with multiple gray-white opacities composed of mucopolysaccharides. Granular Dystrophy presents with snowflake granules composed of hyaline. Lattice Dystrophy presents with lattice-like branches of amyloid. Calcium is associated with Band K, which affects Bowman’s layer.

B. The minimum number is 400-700 cells/mm². This range is seen in older patients or those diagnosed with Fuchs’ endothelial dystrophy. From birth, the average range is 3,000-4,000. After 80, that number drops to about 1,000-2,00 cells. Recall that endothelial cells do not regenerate.

C. Diabetes is only considered a RELATIVE contraindication. Absolute contraindications include young age, unstable refractive error, unrealistic expectations, k-cone, active herpes, contact lens warpage, connective tissue disease and/or immunocompromised state (including chronic steroid use. Relative contraindications include ocular surface disease (anything related to lid hygiene), fluctuating blood sugar levels, POAG, pregnancy, and/or retinal thinning.

E. Cortical cataracts have been associated with hyperopic shifts in vision. Cerulean cataracts are congenital and present as small, blue-green opacities that rarely affect vision. Nuclear sclerosis is the most common aging cataract and most often leads to a myopic shift as the lens swells. Rosette cataracts are caused by trauma. PSC cataracts lead to reduced vision at distance and near, worse while reading with constricted pupils.

C. 1 mm of axial length corresponds to about 3 diopters. This emphasizes the importance of accurate A scan measurements prior to surgery.

B. Brinzolamide is a carbonic anhydrase inhibitor that is not associated with follicular conjunctivitis. Recall that chlamydia presents with both follicles AND papillae. Herpes and adenovirus can cause viral conjunctivitis of which follicles are a classic finding. Alphagan, CL solution, and molluscum can all lead to toxic conjunctivitis which presents with follicles.

C. Peak incidence of CME post-cataract surgery is 6-10 weeks. The most common cause of CME is post-cataract surgery and is known as Irvine-Gass syndrome. Most cases are resolved with NSAIDs within 6 months. On FA, HYPERfluorescence appears in a petaloid pattern.

B. Most tears, holes, and detachments occur in the superior temporal region of the retina.

B,C,E: RP, Gyrate atrophy, and choroideremia lead to complaints of poor night vision (nyctalopia). Night blindness is a consequence of damage to the rod photoreceptors in the retina. It is important to note that nyctalopia is not limited to these three conditions.

C. Presence of a halo is a positive sign and will steer diagnosis towards benign. To recall, remember the phrase “To Find Small Ocular Melanomas, Use Helpful Hints Daily”: Thickness (elevation >2mm), Fluid (subretinal), Symptoms, Orange pigment (lipofuscin), Margins are irregular, Ultrasound Hollowness, Halo absence, Drusen present.

D. NVE with associated preretinal or vitreous hemorrhage is a high risk characteristic. Other high risk characteristics include NVD > ¼ DD within 1 DD of the optic nerve and any NVD or NVE with associated preretinal or vitreous hemorrhage. The other options refer to non-proliferative diabetic retinopathy. Severe NPDR follows the 4-2-1 rule: 4 quadrants with severe hemorrhaging, 2 quadrants of venous beading, and 1 quadrant of IRMA.

B,C,D: CSME, macular edema in the presence of diabetic retinopathy, needs to meet at least one of the three main criteria. The three criteria include: retinal thickening within 1/3DD of the foveal center, hard exudates within ⅓ DD of the foveal center with adjacent retinal thickening, or retinal thickening of at least 1 DD within 1 DD of the foveal center.

C. Hollenhorst plaques (an example of an emboli) is the most common cause of BRAO. Other causes include GCA, elevated IOP, and other diseases that affect the retina. Calcific emboli are most associated with CRAO. Thrombi are the main cause of BRVOs.

D. Osteogenesis imperfecta is not correlated with angioid streaks. Recall PEPSI as the most common causes of angioid streaks. Pseudoxanthoma elasticum, Ehlers-Danlos syndrome, Paget’s Disease, Sickle-cell disease, and idiopathic.

B. The greatest threat to the patient’s vision is a CRAO. Elevated IOP leads to reversal of blood flow due to the change in perfusion pressure. Ischemic damage from CRAO is irreversible.

A. The most common cause of NVG is a central vein occlusion. Other causes include proliferative diabetic retinopathy, retinal detachments, and ocular ischemic syndrome. All of these conditions cause a release of VEGF. Release of growth factors leads to development of new blood vessels. In NVG, new vessels grow into the drainage angle leading to poor outflow. This change to the angle leads to elevated IOP and development of NVG, aka 90 day glaucoma.

A,C,D: The classic triad of signs in RP include bone spicules in the periphery, waxy optic disc pallor, and arterial attenuation. Late stage signs include PSC cataracts, optic disc drusen, macular changes, and progressive loss on visual fields. These are not considered classic findings but rather associated. PSC is responsible for central vision loss in patients with RP.

A. Trauma is the number 1 cause of unilateral glaucoma. This is due to damage to the TM when the iris root is affected.