30. Ocular Injuries

Question 1

lateral geniculate body, eye misalignment results in lateral geniculate nucleus atrophy, usually unilateral, early detection important because vision develops early in life, with proper visual stimulation in the early months normal acuity develops at 3 years old, can be strabismic with slight misalignment but dense amblyopia, refractive **, presents with failed vision test, strabismus, **, detect by assesing red reflex ***, important to detect because decreased vision in children can also be due to retinoblastoma, can push into the visual axis, cancer cells can seed into the jelly of the eye

Answer 1

amblyopia,

Question 2

tropia which can manifest or be intermittent, direction of deviation can be eso or inward, exo or outward, hyper or upward, hypo or downward, diplopia is usually absent because the brain suppressed the image **, testing includes general inspection **

Answer 2

strabisumus

Question 3

fixes and follows an object of interest, head turns for extraocular motion testing, central & steady & and maintained, cover good eye, how does the child react? do they protest, cry, or evade, follow an interesting object for visual acuity and extraocular motion, if not moving the child’s head can demonstrate extraocular motion, photoscreen can determine if they are farsighted/nearsighed/astigmatic

Answer 3

infants

Question 4

3 year old may perform an E game, picture card, or HOTV chart, cover/uncover test, vision assessment

Answer 4

2-4 year olds

Question 5

usually snellen test, may perform E game, cover/uncover test, if less than 20/40 refer

Answer 5

child 5 and up

Question 6

optimize the retinal image, clera the visual pathway with cataract or ptosis surgery, correct the refractive error, glasses vs contacts 35% more likely to be bullied, intensity the neural image to the visual cortex, occulsion therapy full time vs part time, penalization (defocus) with cycloplegic to better eye

Answer 6

amblyopia therapy

Question 7

occulsion of the unaffected good eye, success of treatment is dependent on age, degree of amblyopia, compliance with patching, better tolerated in younger patients possible up to 18 years old, must be contnued through the patient’s first decade, does not eliminate strabismus, done with patch, occasionally can have allergy to the tape

Answer 7

occlusion therapy

Question 8

atropine 1% drop every morning in nonamblyopic eye, atropized eye cannot accomodate for near ision, child can still use better seeing eye for distance, child switches fixation at near to amblyopic eye

Answer 8

atropine penalization therapy

Question 9

glassess alone can correct, ***

Answer 9

strabismus

Question 10

either strengthen the muscle or weaken the muscle by recession or resection respectively. ***

Answer 10

strabsmus surgery

Question 11

poor red reflex in one or both eyes, concern about vision by parent or doctor, asymmetric or diminishing visual acuity

Answer 11

immediate referral

Answer 12

less emergent criteria for referral

Question 13

amblyopia must be detected early, visual acuity testing is cannot be overemphasized, amblyopia may present without strabismus, serious conditions may cause strabismus so refer,

Answer 13

important points

Question 14

shaken-baby syndrome

Answer 14

non-accidental trauma

Question 15

premature infants less than ***

Answer 15

retinopathy of prematurity

Question 16

looks ominous but is harmless, 🏥due to sneezing, coughing, valsalva, goes away

Answer 16

conjunctival hemorrhage

Question 17

Due to excessiveUV light, elevated lesion, ultraviolet light and sun exposure, gets inflamed, don’t let people touch them

Answer 17

Inflamed pinguecula & pytergium

Question 18

Inflammation of sclera, episcleritis more superficial, flat or usually benign, can be from environmental allergies, “underneath vessels”, scleritis, if untreated can thin sclera it can perforate leading to infection, key is to treat systemic disease

Answer 18

Episcleritis

Question 19

Inflammation of the colored part of the eye, anterior uveitis, redness circles the cornea, has photophobia, smaller pupil, cells and flare, hypopyon, and keratitic precipitates 💊cycloplegics, topical/periocular/systemic

Answer 19

Iritis

Question 20

Refer to ophthalmologist

Answer 20

Endopthalmitis

Question 21

Topical anesthetic should not be prescribed due to inhibition of growth and healing of the epithelium, loosens cornea which can be rubbed off, if visuals acuity is significantly reduced conjunctivitis is unlikely, check with flourescein for epithelium defects, pupil inequality is danger sign for ocular disease, medications applied in or around eye could be the source of the red eye

Answer 21

Therapeutic warning

Question 22

Reduced visual acuity in the absence of detectable organic disease, abnormal visual development-suppression, can be bilateral with effective blindness, may cause a lazy eye, eye misalignment results in lateral geniculate nucleus atrophy, commonly unilateral, 💊 before age 5 less likely to be effective if after 10, can be strabismic or refractive, form deprivation can result in cataracts, corneal scarring ptosis, and occlusion amblyopia, presents with failed vision test, one eye can be bigger than the other with congenital glaucoma, can cause a lazy eye, detect by red reflex, visual acuity, and evaluating ocular alignment, decrease vision can be due to retinoblastoma

Answer 22

Amblyopia

Question 23

Eso, exo, hyper, hypo, diplopia is absent in amblyopia, tested by cardinal positions with cover uncover test

Answer 23

Strabismus

Question 24

Pupil reflex is not very developed so sluggish, eye movement possibly uncoordinated, red reflex assessment, fundus exam is possible

Answer 24

Newborn exam

Question 25

Fixes and follows an object of interest, head turn for EOM testing, cover the good eye and see what happens, follow an interesting object

Answer 25

Infant exam

Question 26

Can start doing e game, cover/uncover test, photo-screener is good but not substitute for visual acuity, if vision is <20/40 refer, hundreds and thousands test

Answer 26

2-4 year olds

Question 27

Snellen test, may perform e game, cover/uncover, if less than 20/40 refer

Answer 27

5 and up

Question 28

Optimize retinal image, clear visual pathway, correct the refractive error, glasses vs contacts 35% to be blind, it e sift the neural image to the visual cortex, occlusion therapy full time vs part time, penalization defocus with the cycloplegic eye, occlusion therapy which is better up until 18 yo and doesn’t eliminate strabismus and also causes allergy to tape, atropine penalization therapy 1% drop every morning in the non amblyopia eye

Answer 28

Amblyopia therapy

Question 29

Glasses straighten them out, occasionally need to give bifocal, surgery by strengthening or weakening the muscle with recession or resection respectively

Answer 29

Strabismus therapy

Question 30

Poor reflex in one or both eyes, concern about vision by parent or doctor, asymmetric or diminishing visual acuity, constant or acute onset strabismus, less emergency intermittent strabismus on exam, persistent parental concern, associated syndromes or systemic disease

Answer 30

Immediate referral criteria

Question 31

amblyopia must be detected early, importance of visual acuity testing, amblyopia may present without strabismus, serious conditions may cause strabismus, if poor red reflex or poor vision or large eyes, refer to rule out cataracts, retinal disease, and glaucoma, vision training has no proven value in treatment of amblyopia or strabismus

Answer 31

amblyopia and strabismus important points

Question 32

shaken baby syndrome

Answer 32

non-accidental trauma

Question 33

CT

Answer 33

immediate response to trauma

Question 34

bony orbit, floor which results in vertical diplopia and hypoesthesia, medial wall which results in epistaxis and subcutaneous emphysema, optical canal fracture which results in traumatic optic neuropathy, eyelids which can affect lagopthalmos, lid margins, exposure keratopathy, lacrimal apparatus, conjunctiva and cornea and heals rapidly, anterior chamber can be flat due to loss of aqueous humor, iris & ciliary body which can affect plugs, iritis, hyphema, lens which can affect cataracts, subluxation which can result in partial dislocation, vitreous humor which involves hemorrhage and infections, retina which involves detachment, hemorrhage, edema, and macula

Answer 34

basic anatomy for orbital trauma

Question 35

place & time of injury, circumstances of occurrence, ocular history, drug allergies, tetanus immunization, if patient unable to respond, ask companion but may need to proceed with the physical exam, hammering on metal intraocular foreign body, grinding may cause corneal foreign body, welding may cause corneal UV burn, racquet sports cause hyphema, and fist fights cause hyphema, BOF, or ruptured globe

Answer 35

orbital trauma

Question 36

visual acuity, external exam, pupils, motility exam, anterior segment, opthalmopathy, radiologic studies CT is preferred initially because MRI can pull out metal, ultrasound is not first line

Answer 36

orbital trauma exam