Approach to Eye Complaint

Question 1

What are the possible associated sx of eye complaint?

Answer 1

• pain
• drainage
• itching/burning
• vision change
• blurry vision
• flashing lights

(bolded terms are emergent)

Question 2

What are the conditions of PMHx that would be relevant within an eye complaint?

Answer 2

• glaucoma
• diabetes
• thyroid dz
• ASCD
• collagen vascular dz
• HIV
• IBD

Question 3

What external areas of the eye should you inspect during the exam?

Answer 3

• eyebrows
• periorbital area
• lashes
• lacrimal apparatus
• conjunctiva
• cornea

Question 4

What should you look for when inspecting eyebrows?

Answer 4

• symmetry
• plucking or falling out
• scaly skin (seborrheic dermatits)
• scars

Question 5

What should you look for when inspecting periorbital area?

Answer 5

• edema, bruising, injury
• allergic shiners (top photo)
• xanthelasma (cholesterol level, 2nd photo)
• proptosis/exophthalmos (bulging eyes, usually a/w hyperthyroidism, 3rd photo)
• dacrocytosis
• rash (to hairline consider shingles, pustules consider acne or insect bites; bottom photo)

Question 6

What should you look for when inspecting eyelids/eyelashes?

Answer 6

• incomplete eyelid closure (possibly proptosis (top photo) or perioribital edema)
• flakiness/crustiness (blepharitis)
• erythema (contact derm, allergies, ifxn)
• swelling
• scabs/new lesions (BCC (2nd photo) or SCC)
• eyelid inversion (entropion, 3rd photo) or eversion (ectropion, last photo), ectropion seen in elderly, prior surgeries, previous ifxns, or genetic disorders
• ptosis
• chalazion or hordeolum

(palpation of eyelid may reveal chalazion, hard sensation/pain may represent hyperthyroidism, glaucoma, or retrobulbar tumor)

Question 7

What are the different underlying causes of ptosis?

Answer 7

(ptosis: drooping of upper eyelid due to muscle abnormality)

• congenital: absent levator (won’t be tested on other causes)
• mechanical: inflammation, eyelid tumors, dermoid cysts
• aponeurotic: dehiscence of aponeurosis connecting levator muscle to eyelid
• neurologic: CN III palsy (ptosis, diplopia, ophthalmoplegia, down and out gaze), Horner’s syndrome (won’t be tested on this), other causes (botulinum toxin or myasthenia gravis)
• myogenic: won’t be tested on causes

Question 8

What is the difference between a chalazion and a hordeolum (stye)?

Answer 8

• chalazion: blocked meibomian gland, usually nontender unless inflamed, in the lid, not an infection (left photo)
• hordeolum (stye): bacterial infection of meibomian gland, tender/painful, along the lashline (right photo)

Question 9

What are the possible causes, symptoms, and tx for blepharitis?

Answer 9

• causes: bacterial (s. aureus) most common, inflammatory skin conditions (psoriasis, seborrheic derm, rosacea, eczema), or allergens (cosmetics, contacts)
• symptoms: red swollen itchy eyes, gritty/burning sensation, excessive tearing, blurred vision improves w/ blinking, flaking/scaling eyelids (in photo)
• treatment: warm compress, eyelid washing w/ dilute baby shampoo, artifical tears, topical abx (if patient doesn’t respond to other tx)

Question 10

What are the possible conditions a/w lacrimal apparatus?

Answer 10

• clogged tear duct: transient, common in infants (most outgrow), keep eye clean and warm compresses
• dacrostenosis: narrowing of nasolacrimal duct, “milk” the duct for tx, may require probing duct
• dacrocystitis (photo): infection of lacrimal duct, common in newborns and elders, requires systemic abx and occasional probing duct

Question 11

What are the 3 common abnormal findings of conjunctiva?

Answer 11

• erythema (subconjunctival hemorrhage)
• purulence (pink eye, conjunctivitis)
• pterygium (tissue growth)

(normal conjunctiva should be clear)

Question 12

What are the 3 possible causes of conjunctivitis?

Answer 12

• allergic: mild, bilat sx; gritty, pruritic, irritated eyes w/ clear discharge
• viral: mild-mod bilat sx; gritty, burning, irritated eyes w/ clear discharge; eyes matted shut in morn
• bacterial (photo): usually unit w/ copious amnts of purulent drainage throughout entire day; drainage reaccumulates minutes after cleaning

(tx not included b/c we will not be tested on this)

Question 13

What should you look for when inspecting cornea?

Answer 13

(test corneal sensitivity (CN V sensory and CN VII motor) w/ cotton ball)

• cornea should be clear
• brown tint: blood from trauma in anterior chamber
• white scar: previous abrasion/ulcer
• corneal abrasion
• white line encircling iris (arcus senilis)

Question 14

How do you look for a corneal abrasion and what are possible causes?

Answer 14

• visualization via fluorescein stain and blue light (look for/remove foreign body)
• possible causes: foreign body or herpes simplex keratitis (pathognomonic dendritic lesion, leading cause of blindness worldwide)

Question 15

• whitish linear (lipid deposition) encircling the colored iris
• common over 60 y/o
• if < 40 y/o, check cholesterol levels

Answer 15

arcus senilis

Question 16

How should the lens appear with the red light reflex?

Answer 16

• lens should be clear, red color is from the retina
• yellow or gray lens: possibly cataract, can be nml in persons w/ increased melanin, but should be symmetric
• brown speckles: possibly cataract

Question 17

• sudden increase in intraocular pressure, considered a medical emergency
• underlying cause of increased pressure: failure of aqueous flow from ciliary body into irido-corneal junction
• acute, severe pain; decreased vision
• pupil will be dilated and fixed
• tx: ophthalmologist referral

Answer 17

acute angle closure glaucoma

Question 18

How should the sclera appear on exam?

Answer 18

• normal sclera is white
• brown: can be birthmarks (increased melanin), can be a/w increased risk for glaucoma
• blue: inherited, brittle bone dz
• yellow: icterus, neonatal, liver dz, pancreatic cancer, GB dz

Question 19

What is the purpose of the eye cover/uncover test?

Answer 19

• have patient cover 1 eye while staring straight at a fixed point
• movement in uncovered eye means tropia is present (eye moves opposite direction of tropia, either esotropia (eye turned in) or exotropia (eye turned out))

Question 20

How do you treat esotropia/exotropia (aka lazy eyes) and what can happen if left untreated?

Answer 20

• tx: eye patching over unaffected eye in young children, if this fails then surgery
• if not treated: brain chooses to focus w/ unaffected eye and affected eyes loses vision (amblyopia)

Question 21

How do you use an ophthalmoscope?

Answer 21

• use the same eye and hand as the eye of the patient you are examining
• have patient look at fixed point behind your shoulder
• start 15 inches away from patient and move closer until you are almost cheek to cheek

Question 22

What will you see in a normal ophthalmoscopic exam?

Answer 22

• veins and arteries (veins more defined/darker/larger, arteries brighter/smaller)
• optic disc (yellowish orange oval, color can vary w/ ethnicity)
• macula (darkened area)
• margins should be sharp

Question 23

• increased intracranial pressure that results in intra-axonal edema along optic nerve, leading to swelling and engorgement of optic disc
• possible causes: intracranial hemorrhage, meningitis, trauma, mass lesion

Answer 23

papilledema

Question 24

• increased intraocular pressure within eye leads to backward depression of the disc and atrophy
• base of the backward depression of disc will be pale in appearance
• normal cup to disc ratio is 0.4, ratio of 0.7 suggests glaucoma

Answer 24

glaucomatous cupping

Question 25

- white or grayish ovoid lesions w/ irregular soft borders - moderate in size, smaller than the disc - result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of retinal nerve fiber layer - possible causes: hypertension, **diabetes**, HIV, and others

Answer 25

cotton wool spots \*high yield\*

Question 26

- yellowish, round spots that vary from tiny to small, edges can be soft or hard - haphazardly distributed but may conc at posterior pole between optic disc and macula - consist of dead pigment epithelial cells - possible causes: nml aging, age related **macular degeneration**

Answer 26

drusen bodies

Question 27

- painless vision loss, considered a medical emerg - initial warning signs of this condition is a posterior vitreous detachment (transient floaters/flashes of light) - persistent sx of vision loss of black dots are more concerning - curtain over portion of visual field is classic sign of this condition - tx: referral to ophthalmology (small: photocoagulation; large: surgical tx)

Answer 27

retinal detachment \*high yield\*

Question 28

acute vision loss graph, won't be tested on this but nice study tool

Answer 28