ANATOMY

Question 1

What are the differences between somatic and visceral senses?

Answer 1

Somatic senses include tactile, thermal, pain, and proprioceptive sensations.
Visceral senses provide sensations from internal organs.

Question 2

How does a sensation occur?

Answer 2

(a) There must be a stimulus.
(b) A sensory receptor must convert the stimulus to an electrical signal.
(c) A nerve pathway conducts the information to the brain.
(d) A region of the brain translates or integrates the nerve impulse into a sensation.

Question 3

Give an example of adaptation

Answer 3

(b) Adaptation is the decrease in the strength of a sensation during prolonged exposure
to a stimulus. This causes the perception of a sensation to fade or disappear even
though the stimulus is still present.

like smell

Question 4

List the different types of receptors and functions.

Answer 4

1) Mechanoreceptors - detect mechanical deformation of adjacent cells
2) Thermoreceptors - detect changes in temperature
3) Nociceptors - detect pain
4) Photoreceptors - detect light
5) Chemoreceptors - detect the presence of chemicals in solution
6) Osmoreceptors - detect the osmotic pressure of fluids

Question 5

Thermoreceptor ranges of sensation?

Answer 5

1. 50 - 105ºF=activates cold receptors, (located in the epidermis.)
2. 90 - 118ºF=activates warm receptors, (located in the dermis)
3. Temperatures below 10ºC (50ºF) and above 48ºC (118ºF) —> stimulates nociceptors,
   instead of thermoreceptors, thus eliciting painful stimulations

Question 6

Nociceptors location?

Answer 6

found in virtually all tissues of the body (except the brain)
Nociceptors do not adapt to pain.

Question 7

What is the difference in presentation between acute pain and chronic pain?

Answer 7

(4) Fast pain is known as acute, sharp, or pricking pain, for example, from a needle
puncture. This pain is precisely localized.
(5) Slow pain tends to be chronic, aching, burning, or throbbing, and is more diffuse.

Question 8

Olfactory pathway
 Stimulus?
 Sensory receptor?
 Conduction path?
 Integration?

Answer 8

(1) In order to be smelled, substances (odorants) must be dissolved. Mucus secreted by olfactory glands serves as a solvent for the inhaled odorants.
(2) The interaction of the olfactory receptor cells and the odorant molecules leads to nerve impulses

(1) Olfactory receptors cells are neurons with olfactory cilia in the olfactory epithelium that detect chemicals called odorants.
(2) Their axons form olfactory nerves (cranial nerve I) and extend through cribriform plate to olfactory bulb via holes in the cribiform plate.
(3) At the olfactory bulb, they synapse with olfactory bulb neurons forming the olfactorytract.
(4) The olfactory tract will project to cerebral cortex (frontal and temporal lobe) for awareness of smell and to limbic system for emotional response to odors.

Question 9

List the different types of proprioceptive receptors and locations.

Answer 9

(2) Proprioceptors provide information concerning movement. These receptors are located
in the skeletal muscles, tendons, in and around synovial joints, and in the inner ear.
(a) Muscles spindles (in the muscles) inform which muscle are contracting.
(b) Tendons organs (in the tendons) inform the amount of tension in our tendons.
(c) Joint kinesthetic (in and around synovial joints) inform the position of our joints
while doing work.
(d) Hairs cells in the middle ear monitors the orientation of the head relative to the
ground and positioning during movements.

Question 10

Gustatory pathway
 Stimulus?
 Sensory receptor? 
 Conduction path?
 Integration?

Answer 10

(1) To be tasted, substances (tastants) must be dissolved in saliva.
(2) Once dissolved, tastants enter taste pores and make contact with the gustatory hairs.
(3) The results is an electrical signal that stimulates the gustatory receptor cell to transmit a nerve impulse.
(4) Adaptation to taste occurs quickly and the threshold for taste varies for each of the primary tastes.
(1) Taste buds convey their impulses to the facial CN VII (carries taste information from the anterior 2/3 of the tongue), glossopharyngeal CN IX (carries taste information from the posterior 1/3 of the tongue), and vagus CN X (carries taste information from taste buds on the epiglottis and in the throat).
(2) From the taste buds, impulses propagate along these cranial nerves to the midbrain.
(3) From the midbrain, the axons go to the final destination of primary gustatory area (parietal lobe of cerebral cortex) for the conscious perception of taste.
(4) Some axons go to the limbic system and the hypothalamus for emotions related to food.

Question 11

What cranial nerves are associated with taste?

Answer 11

1. the facial CN VII (carries taste information from
   the anterior 2/3 of the tongue)
2. glossopharyngeal CN IX (carries taste information from the posterior 1/3 of the tongue),
3. vagus CN X (carries taste information from taste buds on the epiglottis and in the throat).

Question 12

How many muscles are there in the eye?

Answer 12

Six extrinsic muscles work together to move the eyeball from left to right and up and
down:
(a) Superior rectus, inferior rectus, lateral rectus, medial rectus, superior oblique, and
inferior oblique.

Question 13

Where are the Lacrimal glands?

Answer 13

Located in the temporal region of the superior eyelid.

Question 14

What are Meibomian glands?

Answer 14

Meibomian glands are oil glands along the edge of the eyelids where the
eyelashes are found.

Question 15

Layers of the eye
 Fibrous tunic?
 Vascular tunic?
 Retina?

Answer 15

(1) The fibrous tunic is divided into two regions: the posterior sclera and the anterior cornea.
(a) The cornea is a nonvascular, transparent, fibrous coat that covers the iris. The cornea bends light rays to help focus them on the retina.
(b) The sclera is also known as the white of the eye and is comprised of dense
connective tissue.
1) It covers the entire eye except for the cornea.
2) It provides shape and affords protection to the inner parts.
3) Its posterior aspect is pierced by the optic nerve (cranial nerve II).
(2) The vascular tunic, or middle layer, is composed of three portions: the choroid, ciliary body, and iris.
(a) The choroid is a thin membrane that lines most of the internal surface of the sclera. It contains blood vessels that nourishes the retina, and contains pigment melanin (causes dark brown in color) that absorbs stray light rays.
(b) The ciliary body consists of the ciliary processes and the ciliary muscle.
1) The ciliary processes consist of folds on the internal surface of the ciliary body whose capillaries secrete aqueous humor.
2) The ciliary muscle is a smooth muscle that alters the shape of the lens for near and far vision (accommodation).
(c) The iris is the circular colored portion seen through the cornea. It consists of circular and radial smooth muscle fibers.
1) The black hole in the center of the iris is the pupil; it is the area through which light enters the eyeball.
2) The iris functions to regulate the amount of light that passes through the lens into the posterior cavity of the eye.
3) The lens focuses light rays onto the retina.
(3) The retina, or inner layer, lies in the posterior three-quarters of the eye and functions in image formation.
(a) The neural layer of the retina contains three zones of neurons which are named in the order they conduct nerve impulses. These are the photoreceptor layer, bipolar cell layer, and ganglion cell layer.
1) The photoreceptors are called rods and cones based on their shape.
2) The rods allow us to see shades of gray in dim light.
3) The cones are instrumental in color vision and in visual acuity (color vision in
bright light).
4) The cones are densely concentrated in a small depression in the posterior portion of the eye called the fovea centralis. The fovea centralis is located in the macula lutea, which is the exact center of retina. The fovea centralis is the area of the sharpest vision because of the high concentration of cones.
(b) The pigmented layer of the retina is a sheet of melanin located between the choroid and the neural part of the retina. The melanin in the pigmented layer of the retina, like in the choroid, also helps to absorb stray light rays.
(c) From photoreceptors, information flows through the outer synaptic layer, to bipolar cells, through the inner synaptic layer, to ganglion cells and exit as the optic (II) nerve.

Question 16

How are images formed on the retina?

Answer 16

(2) Retinal image formation involves the refraction of light, the change in shape of the lens (accommodation), constriction of the pupil, and convergence of the eyeballs.
(a) Refraction is the bending of light rays where two different substances meet. The
refraction media are the cornea, aqueous humor, lens, and vitreous body.
1) The cornea carries out 75% of refraction.
2) Images are focused on the retina upside down and undergo a mirror image
reversal. These images are then rearranged by the brain to produce an image
perceived in the actual orientation.
3) Refraction abnormalities can result in myopia, hyperopia, and astigmatism.

Question 17

What is the functions of:
 Accommodation?
 Constriction?
 Convergence?

Answer 17

(b) Accommodation is the ability of the lens to instantly change its curvature for near or
far vision. The ciliary muscle contracts for viewing near objects and relaxes for far
objects.
(c) Constriction of the pupil occurs simultaneously with lens accommodation and inhibits stray light rays from entering the eye through the periphery of the lens.
(d) Convergence is the medial movement of both eyeballs so that they are directed on
the object being viewed. This allows for binocular vision, which allows the
perception of depth and an appreciation of the three dimensional nature of objects.

Question 18

State the 2 different types of photoreceptors and the functions.

Answer 18

(2) Rods (dark, shades of gray) contain a photopigment called rhodopsin that undergoes
structural changes and starts the process leading to initiation of a nerve impulse.
(a) Non-functional during daylight, as they split faster than they can reform.
(b) Vitamin A deficiency decreases rhodopsin production and leads to night blindness.
(3) Cones (bright, color) contain three different opsins that play roles in the eventual
initiation of a nerve impulse.

Question 19

Visual pathway:
 Stimulus?
 Sensory receptor?
 Conduction pathway?
 Integration?

Answer 19

a. Rods and cones convey impulses on to bipolar cells of the retina. The ganglion cells initiate
the nerve impulse.
b. Impulses from ganglion cells are conveyed along axons through the retina to the optic nerve
(cranial nerve II), the optic chiasm, optic tract, and the cerebral cortex. About 50% of
neurons in this pathway cross within the optic chiasm to reach the opposite side of the
brain.
c. Sight is perceived in the primary visual areas of the occipital lobe of the brain. The right
side of the brain receives images of the left side of objects seen by each eye; the left side of
the brain receives images of the left side of objects seen by each eye.

Question 20

What are the structures of the outer ear?

Answer 20

(a) Auricle - the external aspect of the ear that collects sound waves and directs them
toward the auditory canal.
(b) External auditory canal - A curved tube that extends from the outside and directs
sound waves towards the eardrum. It contains a few hairs and glands which secrete
cerumen (earwax).
(c) Tympanic membrane - The thin, semi- transparent partition between the external
auditory canal and middle ear. Sound waves cause the eardrum to vibrate.

Question 21

. What are the structures of the middle ear?

Answer 21

(a) The middle ear is connected with the upper part of the throat by way of the auditory tube (Eustachian tubes). When the auditory tube is open, air pressure can equalize on both sides of the eardrum drum. This protects it from rupturing.
(b) Three tiny bones called auditory ossicles extend across the middle ear.
1) malleus
2) incus
3) stapes

Question 22

What are the structures of the inner ear?

Answer 22

(4) The internal ear is where all the receptors for hearing and equilibrium are housed. It is divided into two general regions: the outer bony labyrinth and the inner membranous labyrinth.
(a) The bony labyrinth is part of the temporal bone and is divided into the cochlea,
vestibule, and semicircular canals and contains a fluid called perilymph, which
surrounds the membranous labyrinth.
(b) The membranous labyrinth is a series of sacs and tubes in the same general shape as the bony labyrinth and contains a fluid called endolymph.
(c) The vestibule constitutes the oval portion of the bony labyrinth. The membranous labyrinth in the vestibule consists of two sacs called the utricle and saccule.
(d) Posterior to the vestibule are three bony semicircular canals arranged at right angles

Question 23

Structures needed for vestibular senses?

Answer 23

(c) The vestibule constitutes the oval portion of the bony labyrinth. The membranous
labyrinth in the vestibule consists of two sacs called the utricle and saccule.
(d) Posterior to the vestibule are three bony semicircular canals arranged at right angles to one another; two vertical and one horizontal. All enlarges at one end into a
swelling called the ampulla. The semicircular ducts lie inside of the semicircular
canals, connecting the utricle to the vestibule.
(e) Lying anterior to the vestibule is the cochlea, a spiral bony canal which has the
principal organ of hearing, the spiral organ. It rests on the basilar membrane within
the cochlear duct.
(f) Projecting over and in contact with the spiral organ are hair cells, which are covered
by the tectorial membrane. Hair cells synapse with sensory neurons in the cochlear
branch of the vestibulocochlear nerve

Question 24

Structures needed for hearing?

Answer 24

(1) Sound waves enter the ear through the external auditory canal, strike the tympanic
membrane, and are conducted through the ossicles (the malleus, incus and stapes).
(2) The stapes repeatedly strikes the oval window, which sets up waves in the perilymph of
the cochlea.
(3) Pressure wave changes in the cochlea (spiral organ) move the (4) Pressure wave
changes in the cochlea (spiral organ) move the tectorial membrane which moves hair
cells that fires action potentials that travel up via the cochlear branch of the
vestibulocochlear nerve (CN VIII).

Question 25

Auditory pathway:
 Stimulus?
 Sensory receptor?
 Conduction path?
 Integration?

Answer 25

a. Nerve impulses from the cochlear branch of the vestibulocochlear nerve (VIII) pass to the
midbrain and thalamus and ultimately go to the primary auditory area in the temporal lobe.
b. Because auditory axons cross from both sides, the left and right auditory areas receive
impulses from both ears.

Question 26

Equilibrium pathway:
 Stimulus?
 Sensory receptor?
 Conduction path?
 Integration?

Answer 26

(1) There are two kinds of equilibrium (balance) - static and dynamic.
(a) Static equilibrium refers to the maintenance of the position of the body relative to
the force of gravity, for example when the head is tilted or a car is speeding up or
slowing down (linear acceleration or deceleration)
(b) Dynamic equilibrium is the maintenance of the body position in response to sudden
movements such as rotational acceleration or deceleration.
(c) The receptor organs for equilibrium are in the internal ear. They are the saccule,
utricle, and the semicircular ducts.
1) Saccule and utricle contain macula with hair cells and supporting cells.
2) Otolithic membrane sits on macula and contains otolithic crystals.
(2) Static equilibrium
(a) The walls of the utricle and saccule contain small, flat regions called the maculae.
(b) The maculae contain the hair cells and supporting cells that are the receptors for
static equilibrium.
(c) The hair cells contain long extensions of the cell membrane and are the sensory
receptors.
(d) Floating over the hair cells is a thick, gelatinous material called the otolithic
membrane. It is embedded with calcium carbonate crystals known as otoliths.
(e) The otolithic membrane sits on top of the macula and slides as the head is moved.
(f) Movement pulls on the hair cells and makes them bend. This initiates a nerve
impulse that is then transmitted to the vestibular branch of the vestibulocochlear
(VIII) nerve.
(3) Dynamic equilibrium
(a) The three semicircular ducts within semicircular canals maintain dynamic
equilibrium.
(b) The ducts are positioned at right angles to one another in three planes. This
positioning permits detection of an imbalance in three planes.
(c) In the ampulla, the dilated portion of each duct, there is a small elevation called the
cristae.
(d) Each cristae is composed of a group of hair cells and supporting cells covered by a
jellylike material called the cupula.
(e) When the head moves, the endolymph in the semicircular ducts flows over the hair
cells and bends them.
(f) Movement of the hair cells stimulates sensory neurons and transmits impulses to the
vestibular branch of the vestibulocochlear (VIII) nerve.
b. The Equilibrium Pathway to the Brain
(1) The equilibrium pathway to the brain includes the vestibular branch axons of the
vestibulocochlear (VIII) nerve which, enters the medulla or the cerebellum. From here,
the vestibulocochlear nerve synapses with the next neurons in the equilibrium pathway.
(2) From the medulla, some axons conduct nerve impulses along the cranial nerves that
control eye movement and head and neck movement.
(3) Other axons from the spinal cord tract transmit impulses for regulation of muscle tone in
response to head movements.
(4) Various linkage between the medulla cerebellum and cerebrum enable the cerebellum to
play the role in maintaining equilibrium.
(5) The information that comes into the cerebellum is continuously being integrated and it
works in coordination with the cerebrum to make continuous adjustments to coordinate
movement

Question 27

Physical examination
1. Head
 Visual
 Palpation

Answer 27

(1) Inspection
(a) Head position
1) Should be upright and still
2) Note any jerking or bobbing motion (tremor), nodding synchronized with pulse
(aortic insufficiency), head tilted or favoring one side (unilateral hearing/vision
loss or torticollis)
(b) Facial features
1) Eyelids, eyebrows, palpebral fissures, nasolabial folds, and mouth for shape and
symmetry (slight asymmetry is common).
(c) Facies
1) Defined as an expression or appearance of the face and features of the head and
neck that, when considered together, is characteristic of a clinical condition or
syndrome (Cushing syndrome, Lupus Erythematosus, Acromegaly, Bell Palsy,
Down syndrome).
(d) Size, shape, and symmetry
1) Note changes in size and shape, or unusual features (edema, bruising, coarsened
features, exophthalmos, hirsutism, lack of expression, excessive perspiration,
pallor, or pigmentation variations), as they are suggestive of a developing facies.
2) For asymmetric findings, compare with other side of face
a) if the entire side of the face is affected, may indicate facial nerve paralysis.
b) if only the mouth is involved, may indicate trigeminal nerve problem.
3) Tics (facial spasms) may be associated with facial nerves problems, Tourette
syndrome, or psychogenic in origin.
(e) Skull
1) for size, shape, and symmetry.
(f) Scalp
1) Part the hair from the frontal to occipital region, noting any lesions, scabs,
tenderness, nits, or scaliness.
(g) Hair
1) Note any hair loss (alopecia) pattern (more common in men than in women), or
hair loss associated with tight braiding.
(2) Palpation
(a) Skull (gently, systematically, front to back)
1) should be symmetric and smooth
(b) Scalp
1) should move freely over the skull
a) no tenderness, swelling, or depressions
b) indentation or depression may indicate skull fracture
(c) Hair (texture, color, and distribution)
1) should be smooth and symmetrically distributed
a) Coarse, dry, and brittle may indicate hypothyroidism
b) Fine, silky may indicate hyperthyroidism
(d) Temporomandibular joint space (bilaterally)
1) Note any pain, crepitus, locking, or popping.
(e) Salivary glands
1) Palpate any asymmetry or enlargement.
a) Should be movable, soft and non-tender.
b) If enlarged, express material as you press on the glands.
1 Parotid duct (Stensen duct) – maxillary, second molar tooth
2 Submandibular duct (Wharton duct) - small papilla at the sides of the
frenulum
a enlarged, tender gland → viral, bacterial infection, ductal stone.
b discrete nodule → cyst or tumor

Question 28

Physical examination
2. Face
 Different types of facies (eg. Cushing syndrome, myxedema, hyperthyroid, etc.)

Answer 28

Defined as an expression or appearance of the face and features of the head and
neck that, when considered together, is characteristic of a clinical condition or
syndrome (Cushing syndrome, Lupus Erythematosus, Acromegaly, Bell Palsy,
Down syndrome). 
(1) Cushing syndrome:
(a) Rounded, “moon-shaped” face
(b) Thin erythematous skin
(c) +/- Hirsutism
(2) Myxedema:
(a) Puffy, dulled yellowed skin.
(b) Coarse, sparse hair.
(c) Temporal loss of eyebrows.
(d) Periorbital edema.
(e) Prominent tongue.
(3) Hyperthyroidism:
(a) Fine, moist skin.
(b) Fine hair.
(c) Prominent eyes.
(d) Lid retraction.
(e) Staring/startled expression.
(4) Acromegaly:
(a) Coarsened features.
(b) Broadened nasal alae.
(c) Prominence of zygomatic arches.
(5) Hippocratic Facies:
(a) Sunken eyes, cheeks, temporal areas
(b) Sharp nose
(c) Dry, rough skin
(d) Terminal stages of illness
(6) Facial Palsy:
(a) Asymmetry of 1 side of face
(b) Eyelid not closing completely
(c) Drooping lower lid
(d) Drooping corner of mouth
(e) Loss of nasolabial fold
(7) Hydrocephalus:
(a) Enlarged head 
(b) Bulging fontanel
(c) Dilated scalp veins
(d) Bossing of skull
(8) Sclera visible above iris
(9) Down Syndrome:
(a) Depressed nasal bridge
(b) Epicanthal folds
(c) Mongoloid slant of eyes
(d) Low-set ears
(e) Large tongue
(10) Lupus (SLE):
(a) Butterfly rash
(b) Malar surfaces and bridge of nose
(c) Blush with swelling
(d) Scaly, red maculopapular lesions
(11) Thyroglossal duct cyst:
(a) Freely movable cystic mass
(b) High in neck
(c) Midline
(d) Duct at base of tongue
(e) Remnant of fetal development

Question 29

Physical examination
3. Neck
 Thyroid
Location?
Physical exam findings and possible etiologies (nodular, painfully enlarged, non-painful,
etc)
 Hyoid bone and cricoid cartilage.
 Know what makes up the borders for anterior and posterior triangles of the neck.
 Lymph nodes locations (ex. clavicular, cervical, auricular, etc.)
 Know the different salivary glands and locations.
 RECALL examinations for meningitis.

Answer 29

(1) Inspection
(a) Use an anterior or posterior technique and with the next slightly extended (do not
hyperextend).
(b) Note glands size, symmetry, and contour as it moves with swallowing (may be
visible only when observing from the lateral aspect).
(2) Palpation
(a) Use an anterior or posterior technique and with neck slightly flexed forward, slightly
rotated, and relaxed sternocleidomastoid.
(b) Note size, shape, configuration, consistency, tenderness, and the presence of any
nodules while swalowing.
1) Thyroid lobes (if felt) should be small, smooth, and free of nodules.
a) The thyroid is approximately 4 cm, and the right lobe is often 25% larger
than the left.
1 Coarse tissue or a gritty sensation suggests an inflammatory process.
2 Hard or irregular nodules suggest malignancy.
3 Enlarged and tender thyroid may indicate thyroiditis
2) Identify the hyoid bone and thyroid/cricoid cartilages.
a) Should be smooth, non-tender and move under your finger when the patient
swallows.
(a) Occipital, posterior auricular (mastoid), preauricular, parotid, retropharyngeal
(tonsillar), submandibular, submental. anterior cervical chain, two posterior cervical
chains and supraclavicular chain.
Nuchal rigidity (resistance to flexion) may be associated with meningeal
irritation.

Question 30

Physical examination
4. Eyes
 Visual inspection of external eye (e.g. Periorbital, Eyelid, Conjunctiva, Pupil/Iris).
 Where is the lacrimal gland?
 Where are the Meibomian glands and know function.

Answer 30

(1) Surrounding Structures
(a) Eyebrows
1) Hair size, extension, and texture
a) Note whether the eyebrows extend beyond the eye itself (or end short of it).
b) If eyebrows are coarse (or do not extend beyond the temporal canthus).
1 May have hypothyroidism
c) If appear unusually thin
1 Ask if the patient waxes or plucks them.
(b) Orbital and periorbital area
1) Inspect for edema, puffiness, sagging tissue below orbit.
a) Loss of elastic tissue that occurs with aging.
b) Periorbital edema is always abnormal.
1 May represent thyroid eye disease.
2 Allergies.
3 Renal disease (nephrotic syndrome).
4 Xanthelasma lesion (irregularly shaped, yellow-tinted lesions suggestive
of abnormality of lipid metabolism).
(2) Eyelid Inspection:
(a) Inspect closed lid
1) Fasciculations and tremors (hyperthyroidism).
(b) Ability to close completely/open widely
1) Lids do not completely close (lagophthalmos) - cornea may become dried and be
at increased risk of infection.
a) Common causes are Thyroid eye disease, Bell palsy, overaggressive ptosis or
blepharoplasty surgical repair.
(c) Observe for flakiness, redness, or swelling on the eyelid margin.
1) Eyelashes should be present on both lids and should curve away from the globe.
(d) Normal (when open) - superior eyelid should cover a portion of the iris but not the
pupil itself.
1) Ptosis - if one superior eyelid covers more of the iris than the other, or extends
over the pupil.
a) Indicates weakness of the levator muscle (congenital or acquired) or a paresis
of a branch of CN III.
(e) Note if lids evert or invert.
1) Ectropion - lid is turned away from the eye (may result in excessive tearing)
2) Entropion - lid is turned inward toward the globe (may cause irritation,
increasing the risk of infection)
3) Hordeolum (stye) - acute supportive inflammation (staphylococcal) of the
follicle of an eyelash that forms an erythematous or yellow lump.
4) Blepharitis - crusting along the eyelashes caused by bacterial infection
(seborrhea, psoriasis, rosacea, or allergic response).
(3) Eyelid Palpation:
(a) Palpate the eyelids for nodules.
(b) Digital palpation tonometry - gentle palpation through closed lids to assess
intraocular pressure (hardening).
1) Normal - orbit can be gently pushed into the orbit without discomfort.
2) Pain - consistent with scleritis, orbital cellulitis, and cavernous sinus thrombosis
3) Firm and resists palpation - may indicate severe glaucoma or tumor.
(4) Conjunctiva:
(a) Inspect for translucency and vascular pattern
(b) Palpebral conjunctiva
1) Pull lower eyelid down while patient looks up.
(c) Upper tarsal conjunctiva (only when there is a suggestion that a foreign body may be
present).
1) Evert the lid on a small cottoncovered applicator by pulling the eyelashes gently
downward and forward.
(d) Normal - translucent and free of erythema.
(e) Erythematous or cobblestone appearance - allergic or infectious conjunctivitis.
(f) Bright red blood in a sharply defined area surrounded by healthy-appearing
conjunctiva - subconjunctival hemorrhage.
1) Occurs with violent coughing, sneezing, straining (bowel movement), vomiting,
pregnancy labor, trauma, foreign objects, and aggressive rubbing of the eye.
Hemorrhages resolve spontaneously.
(g) Pterygium - abnormal growth of conjunctiva that extends over the cornea from the
limbus.
1) Common with heavily exposure to ultraviolet light
(5) Cornea:
(a) Inspect for clarity by shining a light tangentially (from the side) on it.
1) Normal - clear/transparent.
(b) Corneal sensitivity (CN V)
1) Touch the cornea with wisp of cotton.
a) Normal - response is a blink (intact sensory fibers of CN V and motor fibers
of CN VII (facial nerve)..
b) Decreased sensation - associated with diabetes, viral infections (herpes
simplex or zoster), neuralgia or ocular surgery.
(c) Corneal arcus (arcus senilis) - lipids deposited in the periphery of the cornea.
Complete circle is circus senilis.
(6) Iris and Pupil:
(a) Iris - pattern should be clearly visible (generally irides are same color).
(b) Pupil - expect to be round, regular, and equal in size.
1) Size - estimate the pupillary sizes and compare them for equality.
a) Miosis - pupillary constriction to less than 2 mm.
1 Miotic (pupil fails to dilate in the dark) is commonly caused by ingestion
of narcotics (morphine) or drugs that control glaucoma.
b) Myadriasis - pupillary dilation of more than 6 mm and failure of the pupils to
constrict with light.
1 May indicate coma (due to diabetes, alcohol, uremia, epilepsy, or brain
trauma)
2 May be caused the use of eye drops (glaucoma medications, atropine, or
strabismus management)
c) Anisocoria - inequality of pupillary size.
2) Response to light (directly and consensually)
a) Direct - Dim the lights in the room so that the pupils dilate. Shine a penlight
directly into one eye and note if pupil constricts.
b) Consensual - Note also the consensual response of the opposite pupil
constricting simultaneously with the tested pupil. Repeat the test by shining
the light in the other eye.
3) Swinging flashlight test - evaluate the health of the optic nerve and looks for an
afferent pupillary defect.
a) Shine the light in one eye and then rapidly swing to the other. There will be a slight dilation in the second eye while the light is crossing the bridge of the
nose, but it should constrict equally to the first eye as the light enters the
pupil.
b) Repeat going in the other direction.
1 If the second pupil continues to dilate rather than constrict, an afferent
pupillary defect (an optic nerve disease) is present.
a May be cause by optic neuritis, glaucoma and optic nerve tumor, and
multiple sclerosis.
4) Accommodation
a) Ask the patient to look at a distant object and then at a test object (either a
pencil or your finger) held 10 cm from the bridge of the nose. (Can test from
far to near, or from near to far).
1 Normal - pupils to constrict when the eyes focus on the near object (or
dialate when eyes focus on the far object).
2 A failure to respond to direct light but retaining constriction during
accommodation is sometimes seen in patients with diabetes or syphilis.
The eyelid margin describes the portion located at the edge of the eyelid. It is the
juncture of the conjunctiva and the skin, known as the mucocutaneous margin. It is
the site of the eyelashes as well as the orifice (opening) of the Meibomian glands.

Question 31

Physical examination
 Eye movement
What are the extraocular eye muscles?
What cranial nerves are involved?
What is nystagmus and how do you test for it?
 Visual acuity testing with Snellen chart and visual field testing.
 Pupil testing
What is miosis vs. mydriasis?
Direct vs. Consensual pupillary reaction to light?
What is the swinging flashlight test?
What is pupillary accommodation?
 What is jaundice?
 What is the corneal light reflex? What is the cover-uncover test?
 What does the corneal light reflex test and cover-uncover test for?
What is esotropia vs. exotropia?
 Know the steps to do a proper ophthalmoscopic examination.

Answer 31

Extraocular Muscles - movement of the eyes is controlled by the integrated function of the
CNs III (oculomotor), IV (trochlear), and VI (abducens) and the six extraocular muscles.
(1) Ask patient to look at your finger as it moves through the six cardinal fields of gaze.
Full movements indicate integrity of muscle strength and cranial nerves.
(2) Have the patient follow your finger in a horizontal plane from extreme lateral (temporal)
positions.
(a) Note any Nystagmus (involuntary rhythmic movements of the eye).
1) Sustained nystagmus (horizontal, vertical, rotary, or mixed pattern) could be
congenital or acquired.
a) Acquired forms include: trauma, CNS disorders (stroke or tumor), toxic or
metabolic (alcohol or medications).
(3) Have the patient follow your finger in the vertical plane, going from ceiling to floor.
(a) Normal - smooth movement without exposure of the sclera.
(b) Lid lag (exposure of the sclera above the iris) - may indicate thyroid eye disease.
(4) Corneal light reflex - test the balance of the extraocular muscles.
(a) Direct a light source at the nasal bridge from a distance of about 30 cm.
(b) The light should be reflected symmetrically from both eyes (centered, slightly
medial).
1) If not symmetrical (imbalance), perform the cover-uncover test to evaluate.
(5) Cover-uncover test - identifies strabismic eye (crossed eye).
(a) Ask the patient to stare straight ahead at a near fixed point.
(b) Cover one eye and observe the uncovered eye for movement as it focuses on the designated point.
(c) Remove the cover and watch for movement of the newly uncovered eye as it fixes
on the object.
(d) Repeat the process, covering the other eye.
1) If the “straight” eye is being tested, there will be no movement because it is
already fixated.
2) If the “strabismic” eye is being tested, then it will fixate on the object by moving
after the “straight” eye is covered.
a) Exotropic - is outward (away from the midline).
b) Esotropic - is inward (toward the nose).

Question 32

Physical examination
 Fundus vs. Macula
Where is the macula in relation to the optic disc?
 What might we see upon ophthalmoscopic examination in a person with IOP?
What disease processes are associated with IOP?
 Abnormal fundoscopic exam findings 
Papilledema
Glaucomatous cupping
Drusen bodies
Cotton wool spots
Dot hemorrhages
 Abnormal external eye exam findings:
Exophthalmos
Episcleritis
Corneal ulcer
Strabismus
Cataracts
Lipidemia retinalis
Xanthelasma palpebrum
Corneal Arcus

Answer 32

a

Question 33

Physical examination
5. Ears
 Know the external anatomy of the ear.
 What are the components of:
External ear
Middle ear
Inner ear 
 What organs are responsible for vestibular senses?
 What organ is responsible for hearing and what CN is it associated with?
 Diagnostic tests to know and understand:
Whisper test
Weber
Rinne

Answer 33

(1) Includes the auricle (or pinna) and external auditory canal, and is cartilage-covered skin.
(a) Auricle – extends slightly outward from the skull and is positioned on a nearly
vertical plane.
1) Helix – is the prominent outer rim
2) Antihelix – is the area parallel and anterior to the helix.
3) Concha – is the deep cavity containing the auditory canal meatus.
4) Tragus – is the protuberance lying anterior to the auditory canal meatus.
5) Antitragus – is the protuberance on the antihelix opposite the tragus.
6) Lobule – is the soft lobe on the bottom of the auricle.
(b) External auditory canal – S-shaped pathway, approximately 1 inch long, composed
of bone and cartilage covered with thin, sensitive skin.
1) Cerumen - protects and lubricates the canal lining.
a) Secreted by the apocrine glands.
b) Provides an acidic pH environment (inhibits growth of microorganisms).
(2) Middle ear – is an air-filled cavity in the temporal bone.
(a) Ossicles – three small connected bones (malleus, incus, and stapes) that transmit
sound from the tympanic membrane to the oval window (inner ear).
(b) Tympanic membrane – separates the external ear from the middle ear.
1) Concave, connected at the center (umbo) by the malleus.
2) Translucent, permitting the middle ear cavity and malleus to be visualized.
3) Mostly tense (pars tensa), but the superior portion (pars flaccida) is more flaccid.
(c) Eustachian tube – cartilaginous, fibrous, and bony passageway between the
nasopharynx and the middle ear.
1) Drains mucus into back of the nose turbinate by ciliary action.
2) Muscles briefly open this passage (during swallowing, yawning, or sneezing) to
clear secretions and to equalize ear pressure with atmospheric pressure (permits
the tympanic membrane to vibrate freely).
(3) Inner ear – is a membranous, curved cavity inside a bony labyrinth consisting of the
vestibule, semicircular canals, and cochlea.
(a) Cochlea – coiled structure containing the organ of Corti, transmits sound impulses to
the CN VIII.
(b) Semicircular canals and vestibule – contain the end organs for vestibular function.
1) Equilibrium receptors here respond to movement and send signals to the
cerebellum to maintain balance.
3) Weber test (helps assess unilateral hearing loss).
a) Place the base of the vibrating tuning fork on the midline of the patient’s
head.
b) Ask the patient whether the sound is heard equally in both ears or is better in
one ear (lateralization of sound).
1 1 Should hear the sound equally in both ears.
4) Rinne test (helps distinguish whether the patient hears better by air or bone
conduction).
a) Place the base of the vibrating tuning fork against the patient’s mastoid bone.
1 Ask the patient to tell you when the sound is no longer heard.
a Time this interval of bone conduction, noting the number of seconds.
2 Quickly position the still-vibrating tines 1 to 2 cm (0.5 to 1 in) from the
auditory canal.
3 Again ask the patient to tell you when the sound is no longer heard.
a Continue timing the interval of sound due to air conduction heard by
the patient.
b) Compare the number of seconds sound is heard by bone conduction versus
air conduction.
1 Air-conducted sound should be heard twice as long as bone-conducted
sound (if bone-conducted sound is heard for 15 seconds, air-conducted
sound should be heard for 30 seconds).

Question 34

Physical examination
6. Nose
 Structure of external nose.
 Structure of internal nose.
 What structures in the internal nose are key components for olfaction?
 What is Kiesselbach plexus?
 What are turbinates and what is the function?
 Know the paranasal sinuses and their locations

Answer 34

(1) External nose – is formed by skin-covered bone and cartilage.
(a) Nares – openings of the nose, surrounded by the cartilaginous ala nasi and
columella.
(b) Bridge – formed by the frontal and maxillary bones.
(2) Internal nose
(a) Nasal floor – is formed by the hard and soft palate.
(b) Nasal roof – formed by the frontal and sphenoid bone.
(c) Mucous membrane lined with small hairs – vascular membrane that covers the
internal nose.
1) Collect and carry debris and bacteria from the inspired air to the nasopharynx for
swallowing or expectoration.
2) Contains immunoglobulins and enzymes that serve as a defense against
infection.
(d) Olfactory epithelium – location of the receptors for smell.
(e) Septum – divides the internal nose into two anterior cavities (vestibules).
(f) Cribriform plate – lies on the roof of the nose and houses the sensory endings of the
olfactory nerve.
(g) Kiesselbach plexus – convergence of small fragile arteries and veins, located on the
anterior-superior portion of the septum.
(h) Adenoids – Lymphatic nodules that lie on the posterior wall of the nasopharynx.
(i) Turbinates – parallel, curved bony structures covered by vascular mucous
membrane.
1) Form the lateral walls of the nose and protrude into the nasal cavity.
2) Increase the nasal surface area to warm, humidify, and filter inspired air.
a) A meatus below each turbinate is named for the turbinate above it.
1 Inferior meatus drains the nasolacrimal duct.
2 Middle meatus drains the paranasal sinuses.
3 Superior meatus drains the posterior ethmoid sinus.
(j) Paranasal sinuses – are air-filled, paired extensions of the nasal cavities within the
bones of the skull.
1) Lined with mucous membranes and cilia that move secretions along excretory
pathways (easily obstructed).
2) Only the maxillary and frontal sinuses are accessible for physical examination.
a) Maxillary sinuses lie along the lateral wall of the nasal cavity in the
maxillary bone.
b) Frontal sinuses are in the frontal bone superior to the nasal cavities.
c) Ethmoid sinuses lie behind the frontal sinuses and near the superior portion
of the nasal cavity.
d) Sphenoid sinuses are deep in the skull behind the ethmoid sinuses.

Question 35

Physical examination
7. Throat
 Know components in throat seen upon visual inspection.
 Know the salivary glands and locations.
 What landmarks demarcate the oropharynx?

Answer 35

(1) Mouth – houses the tongue, teeth, and gums, is the anterior opening of the oropharynx
(a) Roof of the mouth – formed by the hard palate (bony arch) and the soft palate
(fibrous component).
(b) Uvula – hangs from the posterior margin of the soft palate.
(c) Floor of the mouth – formed by loose, mobile tissue covering the mandibular bone.
(d) Tongue – is anchored to the back of the oral cavity at its base and to the floor of the
mouth by the frenulum.
1) Dorsal surface – covered with thick mucous membrane supporting the filiform
papillae.
a) Fungiform papillae (taste receptors) are scattered throughout the filiform
papillae of the tongue, and specific areas are sensitive to the five basic taste
sensations of sour, sweet, salty, bitter, and umami (savory).
2) Ventral surface – has visible veins and fimbriated folds (fringe-like projections
of thin mucous membrane)
(e) Salivary glands (parotid, submandibular, and sublingual) – located in tissues
surrounding the oral cavity.
1) Saliva – initiates digestion and moistens the mucosa.
2) Stensen ducts are parotid gland outlets that open on the buccal mucosa opposite
the second molar on each side of the upper jaw.
3) Wharton ducts open on each side of the frenulum under the tongue.
a) They drain saliva from the submandibular and sublingual glands to the
sublingual caruncle at the base of the tongue.
4) The sublingual glands have many ducts opening along the sublingual fold.
(f) The gingivae (fibrous tissue covered by mucous membrane) are attached directly to
the teeth and the maxilla and mandible.
1) The roots of the teeth are anchored to the alveolar ridges (alveolar process) of
the maxilla and mandible.
2) The enamel-covered crown is visible to examination (Adults generally have 32
permanent teeth).
(2) The oropharynx, continuous with but inferior to the nasopharynx, is separated from the
mouth by bilateral anterior and posterior tonsillar pillars.
(a) The tonsils, lying in the cavity between these pillars, have crypts that collect cell
debris and food particles.
(b) Swallowing is initiated when food is forced by the tongue toward the pharynx.
1) Muscles in the pharynx contract and prevent movement of the food into the
nasopharynx, and respiration is inhibited as the epiglottis closes.
2) Food is then propelled into the esophagus

Question 36

Clinical Care of the Eyes
1. Vision loss
 What is the definition of transient vision loss?

Answer 36

a. Transient visual loss (vision returns to normal within 24 hours, usually within 1 hour).
(1) More Common.
(a) Few seconds (usually bilateral): acute change in BP or disc drusen.
(b) Few minutes: Amaurosis fugax (transient ischemic attack; unilateral),
vertebrobasilar artery insufficiency (bilateral).
(c) Ten to 60 minutes: Migraine (with or without a subsequent headache).

Question 37

Clinical Care of the Eyes
2. Blepharitis
 What is blepharitis and what parts of the eye are affected?
 How does blepharitis present?
 What is the initial treatment for blepharitis?

Answer 37

(2) Common chronic bilateral inflammatory condition of the lid margins
(1) Anterior blepharitis involves the lid skin, eyelashes, and associated glands.
(2) Posterior blepharitis results from inflammation of the Meibomian glands.
(1) Scrub the eyelid margins twice a day with a commercial eyelid scrub (Ocusoft) or
baby shampoo on a washcloth.
(2) Warm compresses for 10 to 15 minutes 1-2x/day.
(3) Lid massage
(4) Artificial tears
(5) Omega-3 supplement (fish oil/flaxseed oil)
(6) Antistaphylococcal antibiotic eye ointment applied daily to the lid margins.
(a) Bacitracin ointment
1) Dose: apply one application twice daily (BID)
(7) Long-term, low-dose oral antibiotic therapy
(a) Tetracycline - a Tetracycline antibiotic
1) Dose: 250mg BID (a Tetracycline is the most effective antibiotic with the
fewest side effects)
(b) Doxycycline - is in the Tetracycline family of antibiotics
1) Dose: 100mg BID for 7 days

Question 38

Clinical Care of the Eyes 
3. Conjunctival hemorrhage
 What vessels and what space is affected by conjunctival hemorrhages?
 What are some etiologies?
 What are the signs/symptoms?
 What is the treatment?

Answer 38

(1) The fragile conjunctival vessels can rupture from trauma, sudden increased
venous pressure. The hemorrhage results from rupture of small vessels in the
space between the episclera and the conjunctiva.
(a) Valsalva (e.g., coughing, sneezing, vomiting, bearing down with constipation,
or other forms of straining).
(b) Traumatic: Can be isolated or associated with a retrobulbar hemorrhage or
ruptured globe.
(c) Hypertension and diabetes.
(d) Bleeding disorder.
(e) Antiplatelet or anticoagulant medications (aspirin, warfarin).
(f) Topical steroid therapy.
(g) Hemorrhage due to orbital mass (rare).
(h) Idiopathic.
(1) Symptoms
(a) Red eye, foreign body sensation, usually asymptomatic unless there is
associated chemosis.
(2) Signs
(a) Blood underneath the conjunctiva, often in one sector of the eye. The entire
view of the sclera can be obstructed by blood
. Treatment:
(1) None required (usually clears spontaneously within 2 to 3 weeks)
(2) Artificial tear drops QID (for irritation

Question 39

Clinical Care of the Eyes
4. Conjunctivitis
 What is the most common cause of conjunctivitis?
 How does a viral conjunctivitis present vs. bacterial conjunctivitis?
 What is seen on gram stain of gonococcal conjunctivitis?
 What are the treatments for the different etiologies of conjunctivitis?

Answer 39

(a) Adenovirus is the most common cause of viral conjunctivitis.
viral:(a) Symptoms: Itching, burning, tearing, gritty or foreign body sensation; history
of recent upper respiratory tract infection or contact with someone with viral
conjunctivitis.
(b) Signs: Watery discharge, red and edematous eyelids, pinpoint subconjunctival
hemorrhages, punctate keratopathy (epithelial erosion in severe cases),
membrane/pseudomembrane (severe cases).
1) Critical signs: Inferior palpebral conjunctival follicles, tender palpable
preauricular lymph node.
bacterial:(a) Symptoms: Redness, foreign body sensation, discharge; itching is much less
prominent.
(b) Often complain of having to wipe purulent exudate in morning.
(c) Signs:
1) Critical: Purulent white-yellow discharge of mild-to-moderate degree.
2) Other: Conjunctival papillae, chemosis, preauricular node typically absent
(unlike gonococcal).
(b) Gram stain: gram-negative intracellular diplococci
(1) Viral conjunctivitis
(a) Mild: Artificial tears or tear ointment (four to eight times per day for 1 to 3 weeks)
(b) Moderate: Antihistamine drops
1) Epinastine (Elestat) - Ophthalmic antihistamine
2) Dose: 0.05% solution 1 drop to affected eye BID
(c) Severe viral conjunctivitis
1) Consult ophthalmology BEFORE giving steroids
2) If a membrane/pseudomembrane is present, gently peel with a cotton-tip
applicator.
3) Severe (significant photophobia): add topical steroids (may relieve symptoms,
but prolong infectious period)
a) Ophthalmic Corticosteroids
(2) Allergic conjunctivitis
(a) Mild: Artificial tears four to eight times per day.
(b) Moderate: Antihistamine (e.g., Patanol (Olopatadine) 0.1% BID or Epinastine
(Elestat) 0.05% QID).
(3) Bacterial conjunctivitis for non-contact lens wearers (non-gonococcal)
(a) Erythromycin ophthalmic ointment
1) 0.5 inch ointment inside lower lid QID for 5-7 days
(4) Bacterial conjunctivitis for contact lens wearers (nongonococcal)
(a) Ciprofloxacin (Ciloxan) or Ofloxacin (Ocuflox) - Fluoroquinolone antibiotic class.
1) Dose: 0.3% Solution, use 12 drops in affected eye QID for 5-7 days
(5) Bacterial conjunctivitis (nongonococcal)
(a) Topical antibiotic therapy
1) Trimethoprim/polymyxin B (Polytrim)
a) Dose: 1 drop in affected eye Q 3 hours for 7-10 days.
(b) Associated dacryocystitis: systemic antibiotics are necessary.
1) Amoxicillin/Clavulanate (Augmentin)
a) Dose: 875/125 mg BID or 500/125 mg TID
(6) Gonococcal conjunctivitis
(a) Ceftriaxone 1 g IM, PLUS azithromycin 1 g PO both in a single dose. Ceftriaxone
(Rocephin) - is a 3rd generation Cephalosporin antibiotic.
1) Dose: 2 grams IV every 12 hours.
(b) Azithromycin (Zithromax) - Macrolide antibiotic
1) Dose: Azithromycin 500 mg PO on day one and then 250 mg daily for the next 4 dys
(c) Patients with penicillin/cephalosporin allergy:
1) Gentamicin 240mg IM x 1 dose PLUS Azithromycin 2mg PO x 1 dose

Question 40

Clinical Care of the Eyes
5. Ocular foreign body
 What are the steps to attempt foreign body removal?
 What antibiotics are prescribed?
 What is the treatment for metallic foreign body?

Answer 40

(b) Remove foreign body (with saline irrigation or swab)
(c) Topical antibiotics
1) Non-contact lens wearers
a) Erythromycin ointment TID – QID applied to lower lid
2) Contact lens wearers
a) Ciprofloxacin ointment
1. 0.5inch in lower lid Q 1-2 hours for first 2 days then QID for up
to 12 days until re-epithelialization has occurred.
b) Ciprofloxacin 0.3% ophthalmic solution
1. 2 drops Q15 minutes for first 6 hours, then 2 drops Q30 for the
remainder of first day then 2 drops hourly on day 2 and 2 drops
QID on days 3-14.

Question 41

Clinical Care of the Eyes
6. Corneal ulcer
 What is the treatment?
 When can a contact lens wearer be cleared to start wearing contact lens after corneal ulcer?

Answer 41

2) Contact lens wearers
a) Ciprofloxacin ointment
1. 0.5inch in lower lid Q 1-2 hours for first 2 days then QID for up
to 12 days until re-epithelialization has occurred.
b) Ciprofloxacin 0.3% ophthalmic solution
1. 2 drops Q15 minutes for first 6 hours, then 2 drops Q30 for the
remainder of first day then 2 drops hourly on day 2 and 2 drops
QID on days 3-14.
(3) No patching
(a) NOTE: Do not patch the eye because of the risk of Pseudomonas infection,
which can cause rapid, aggressive ulceration with corneal melting and
perforation.
(2) Instruction to stop wearing contact until cleared by optometry or ophthalmology.

Question 42

Clinical Care of the Eyes
7. Hordeolum and Chalazion
 What anatomical structures are involved?
 How does a hordeolum vs. chalazion present?
 What is the initial treatment?

Answer 42

(1) Hordeolum
(a) Acute infection that usually involves Staphylococcus species.
1) External (abscess of gland of Zeis on lid margin, classic “stye”)
a) usually is smaller and on the margin
2) Internal (abscess of meibomian gland)
a) abscess that usually points onto the conjunctival surface of the lid.
(2) Chalazion
(a) Chronic focal granulomatous inflammation within the eyelid secondary to the
obstruction of a meibomian gland or gland of Zeis (hordeolum).
1) If the outflow of these sebaceous secretions is obstructed, the oily secretions are
retained and may leak into the adjacent tissue, which will in turn induce chronic
granulomatous inflammatory response leading to formation of lipogranuloma.
(1) Hordeolum
(a) Localized eyelid tenderness, swelling and erythema
(b) May have foreign body sensation depending on location
(c) Visible, or palpable, well-defined subcutaneous nodule in the eyelid
(d) May also note “pointing” of mucopurulent material
(e) Associated blepharitis or acne rosacea.
(2) Chalazion
(a) Hard and nontender nodule on the eyelid
1) usually develops farther back on the eyelid than a hordeolum
(b) Edema on the upper or lower lid
(c) Erythema and edema of the adjacent conjunctiva.
(1) Warm compresses, which are placed on the face for about 15 minutes four times a day.
(2) Massage and gentle wiping of the infected eyelid after the warm compress can
also aid in drainage.
(3) Patient should discontinue eye makeup.
(4) Do NOT squeeze or pop a Hordeolum/Chalazion.
(5) Role of antibiotics are controversial
(a) If there is concern of patient developing periorbial cellulitis then antibiotic treatment
warranted
(b) Bactrim BID for 5-7 days

Question 43

Clinical Care of the Eyes
8. Hyphema
 Where does the blood in a hyphema accumulate?
 What is the initial management for someone with a traumatic hyphema?

Answer 43

A hyphema is an accumulation of red blood cells within the anterior chamber.
(2) This happens between the cornea and the iris (the colored part of the eye).
(1) Immediate ophthalmology or optometry consult.
(2) Bed rest with elevation of the head (to allow blood to settle) or limited
activity (No strenuous activity, bending, or heavy lifting).
(3) Place a rigid shield (metal or clear plastic) over the involved eye at all times.
(4) Avoid antiplatelet/anticoagulant medications (i.e., aspirin-containing
products and NSAIDs) unless otherwise medically necessary.
(5) Mild analgesics only (e.g., acetaminophen).
g. Initial Care of the Disease and Follow Up:
(1) Follow up daily after initial trauma (check visual acuity, IOP, and slit lamp
examination).
(2) After initial follow up period, patient may be maintained on a long-acting
cycloplegic agent (e.g., atropine 1% daily to b.i.d.)
(3) Glasses or eye shield during the day and eye shield at night.

Question 44

Clinical Care of the Eyes
Uveitis/Iritis
 What anatomical structures are involved?
 What is commonly seen in slit lamp examination of anterior non-granulomatous uveitis?
 What are the different etiologies of granulomatous vs. nongranulomatous uveitis?
 How does granulomatous vs. nongranulomatous uveitis present?
 What is the initial treatment and management of uveitis?

Answer 44

(1) Iritis is inflammation of the anterior segment of the uveal tract. Usually
immunologic but possibly infective or neoplastic.
(2) Classified as acute or chronic and as nongranulomatous or granulomatous,
according to the clinical signs, and by its involvement of the anterior, intermediate,
posterior, or all (panuveitis) segments of the eye. The common types are acute
nongranulomatous anterior, granulomatous anterior, and posterior.
(a) Inflammatory cells and flare within the aqueous (WBC released from vessels appear
as snowflakes)
(b) Blurred vision in a mildly painful and mildly inflamed eye
(c) Hypopyon (WBC pool) and fibrin within the anterior chamber.
(d) Keratic precipitates (KPs) (cells seen on the corneal endothelium)
(a) Acute nongranulomatous anterior uveitis: pain, redness, photophobia, and visual
loss.
(b) Granulomatous anterior uveitis: blurred vision in a mildly inflamed eye.
(1) Only to be initiated by or under the direction of Ophthalmologist.
(a) Cycloplegic (for pain and inflammation)
1) Mild to moderate: Cyclopentolate 1% t.i.d.
2) Severe: atropine 1% b.i.d. to q.i.d.
(b) Topical steroid
1) Prednisolone acetate 1% q1-6h

Question 45

Clinical Care of the Eyes
10. Oribal cellulitis
 How is periorbital cellulitis different than orbital cellulitis?
 How does periorbital cellulitis vs. orbital cellulitis present?
 What is the treatment of periorbital cellulitis?
 What is the treatment of orbital cellulitis?

Answer 45

(1) Cellulitis is an infection that can affect the skin and/or the eyes.
(2) Periorbital (Preseptal) cellulitis
(a) Involves soft tissues anterior to the orbital septum
(b) Infections arise from external sockets
(3) Orbital cellulitis affects the eye socket (called the orbit). This form of cellulitis
can cause the eye or eyelid to swell, keeping the eye from moving properly.
(a) Infections typically arise from paranasal sinuses
(2) Signs
(a) Critical
1) Eyelid edema, erythema, warmth, and tenderness. Conjunctival chemosis
and injection, proptosis, and restricted extraocular motility with pain on
attempted eye movement are usually present. Signs of optic neuropathy
(e.g., afferent pupillary defect, dyschromatopsia) may be present in severe
cases.
(b) Other
1) Decreased vision, retinal venous congestion, optic disc edema, purulent
discharge, decreased periorbital sensation, fever. CT scan usually shows an
adjacent sinusitis (typically at least an ethmoid sinusitis), possibly a
subperiosteal orbital collection.
(1) The specific antibiotic agents vary.
(a) In patients from the community with no recent history of hospitalization,
nursing home stay, or institutional stay, we currently recommend:
1) IV antibiotics (beyond the discussion of this topic)
(b) IF on a ship start either Amoxicillin/Clavulanate (Augmentin) 875 mg PO BID
or Ceftriaxone (Rocephin) 2 gram IM
f. Treatment:
(1) Admit hospital and consult neurosurgery, otorhinolaryngology, infectious
disease, maxillofacial surgery (dental) as necessary.
(2) Broad-spectrum intravenous antibiotics to cover gram-positive, gram-negative, and
anaerobic organisms are recommended for 48 to 72 hours, followed by oral
medication for at least 1 week. The specific antibiotic agents vary.
(3) Surgery may be required to drain the paranasal sinuses or orbital abscess.
(a) If the orbit is tight, an optic neuropathy is present, or the IOP is severely
elevated, immediate canthotomy/cantholysis may be needed.

Question 46

Clinical Care of the Eyes
11. Orbital fracture
 Compare anatomical differences between orbital zygomatic fracture, nasoethmoid fracture,
orbital floor fracture
 What are the critical signs of orbital fracture?
 What is the initial management and treatment of orbital fractures?

Answer 46

(a) Orbital rim fracture - affects the bony outer edges of the orbit.
1) Because the rim is made up of very thick bone, an injury to this area has to
carry a lot of force for a fracture to occur (car accidents).
(b) Blowout fracture - affects the floor or inner wall of the orbit.
1) A crack in the very thin bone that makes up these walls can pinch muscles
and other structures (Getting hit with a baseball or a fist).
(c) Orbital floor fracture - trauma to the orbital rim pushes the bones back,
causing the bones of the eye socket floor buckle to downward.
(a) Critical
1) Restricted eye movement (especially in upward gaze, lateral gaze, or both).
2) Subcutaneous or conjunctival emphysema (air pockets).
3) Hypoesthesia (decreased sensation) in the distribution of the
infraorbital nerve (ipsilateral cheek and upper lip).
4) Point tenderness
5) Enophthalmos and hypoglobus (posterior displacement - may initially be
masked by orbital edema and hemorrhage).
f. Treatment:
(1) Prophylactic oral antibiotics to cover sinus pathogens
(a) Amoxicillin/Clavulanate (500/125 mg TID or 875/125 mg PO BID.)
(b) Azithromycin
(c) If patient has penicillin allergy
1) Doxycycline 100mg BID
(2) Instruct the patient not to blow their nose.
(3) Nasal decongestants
(a) Oxymetazoline (Afrin) nasal spray BID for 3 days.
(4) Apply ice packs to the eyelids for 20 minutes every 1 to 2 hours for the first 24 to
48 hours and attempt a 30-degree incline when at rest.
(5) Consider oral corticosteroids.
(a) Prednisone - is an oral systemic corticosteroid.
1) Dose: 40 mg PO daily for 5-10 days (there are many different doses and
ways to taper longer courses of Prednisone).
(6) Neurosurgical, otolaryngology or oral maxillofacial surgery consultation.
(7) Surgical repair should be considered based on the following criteria:
(a) Immediate Repair (Within 24 to 48 hours).
1) Muscle entrapment with nonresolving bradycardia, heart block, nausea,
vomiting, or syncope.
(b) Repair in 1 to 2 weeks.
1) Persistent, symptomatic diplopia in primary or downgaze.

Question 47

Clinical Care of the Eyes 
12. Pterygium
 What is the usual cause of pterygium?
 What physical exam findings?
 What is the management and when should surgery be done?

Answer 47

(2) Related to sunlight exposure, chronic inflammation and oxidative stress.
1) Wing-shaped fold of fibrovascular tissue arising from the interpalpebral
conjunctiva and extending onto the cornea. Usually nasal in location.
Initial Care of the Disease and Follow Up:
(1) Protect eyes from sun, dust, and wind (UV-blocking sunglasses or goggles).
(2) Lubrication with artificial tears four to eight times per day (for irritation).
(3) For an inflamed pterygium:
(c) Mild
1) Artificial tears QID
(d) Moderate to severe
1) Ophthalmic Corticosteroids
2) NSAID drop
a) Ketorolac (Acular) - Ophthalmic NSAID (Should only be started by
MO or Ophthalmologist)
1. Dose: 0.5% solution, use 1 drop in affected eye QID
2. MOA: Inhibits cyclooxygenase, reducing prostaglandin and
(1) Asymptomatic patients may be checked every 1 to 2 years.
(2) Pterygia should be measured periodically (every 3 to 12 months, initially) to
determine the rate at which they are growing toward the visual axis.
(3) If treating with a topical steroid, check after a few weeks to monitor inflammation and
IOP.