Ear and Eye Flashcards
What are the general functions of the ear? Nerve?
o Balance and hearing
o CN VIII vestibulocochlear
• What hx questions would you ask for an ear complaint?
o pain: LMNOPQRST o any hearing loss? o any vertigo (dizziness)? o any tinnitus (ringing)? o any hx of recent infection? o any discharge? If so, how much (quantitative), what color? (qualitative)
• how do you do an ear PE?
o Vitals
o EENT, Otoscopic, insufflation, hearing tests (whispered voice, tuning forks), neurological, CVS
What labs might be indicated after an ear PE? Imaging?
o CBC, chemistry screen (CMP), culture any discharge
o x-ray, CT or MRI to evaluate masses
• what additional ear tests are there? What referral may be needed?
o audiology, tympanometry o EENT (otologist), neurologist, audiologist, etc.
• What are some general complaints regarding the ear (not always directly related to inner, middle, external?
o Hearing loss o Tinnitus o Vertigo o Earache (otalgia) o Ear discharge (otorrhea)
• What are the 2 types of hearing loss?
o Conductive and sensorineural (SNHL)
o 3rd type: mixed hearing loss (of C and S)
• What is conductive hearing loss?
o from (physical/mechanical) problems that limit movement of the sound wave through the external and middle ear.
• What are some causes of conductive hearing loss?
o obstructed external ear canal – eg. cerumen impaction, foreign body, exostosis, psoriasis
o perforated tympanic membrane – eg direct trauma, otitis media, or explosion
o dislocated ossicle (malleus, incus, or stapes) - trauma to the ear
o Otitis media or serous otitis media
o Otitis externa - infection of the ear canal that causes it to swell
o Otosclerosis or ossicular chain fixation
o Congenital: eg external auditory canal atresia
o Cholesteatoma: growth of squamous epithelium in middle ear
• What is sensorineural hearing loss?
o damage to the hair cells or nerves that sense sound waves (sensory problem in inner ear)
• what are some causes or associated conditions of SNHL?
o acoustic trauma - prolonged exposure to loud noises
o barotrauma (pressure trauma) or ear squeeze - eg divers, climbers
o head trauma - eg fracture of the temporal bone
o ototoxic drugs - Bilateral loss, hx of use.
o Infection – mumps, measles, influenza, herpes, mono, syphilis, meningitis
o Aging—presbycusis: progressive bilateral hearing loss (high pitches), normal neuro exam
o Acoustic neuroma - tumor in the auditory nerve.
o Sudden SNHL (SSNHL): unilateral hearing loss over 72 hr. Associated with microvascular event, head trauma
o Ménière disease - hearing loss, vertigo and tinnitus. Gradual onset, often progresses to deafness and severe vertigo
o vascular diseases eg sickle cell disease, diabetes, polycythemia, and excessive clotting
o Multiple sclerosis
• What are some examples of ototoxic drugs as causes of SNHL?
o antibiotics including aminoglycosides (gentamicin, vancomycin), erythromycin, and minocycline, tetracycline
o diuretics including furosemide
o salicylates (aspirin) and nonsteroidal anti-inflammatories (NSAIDs) ibuprofen, naproxen
o antineoplastics (cancer drugs)
o antimalarial drugs (quinine, chloroquine)
o cocaine—intranasal or IV
• what is tinnitus?
o perception of sound (eg buzzing, ringing, roaring clicks) in absence of an acoustic stimulus may be intermittent, continuous, pulsatile; unilateral or bilateral
• what are the types of tinnitus?
o Subjective- audible only to pt, high frequency, due to damage of fine hair cells
o Objective- rare, can be heard by listening directly over the patients ear
o other
• What is etiology of subjective tinnitus?
o Acoustic trauma; Presbycusis; Barotrauma; CNS tumors; Eustacian tube dysfunction; Infections (OM, labryinthitis, meningitis); Meniere disease; Ear canal obstruction (wax, foreign body, tumor); Drugs (salicylates, loop diuretics, cisplatin, aminoglycosides)
o Can accompany SNHL
• What is etiology of objective tinnitus?
o A-V malformations; Monoclonus (palatal ms, tensor tympani, stapedius); Turbulent flow in carotid A or jugular V; Vascular middle ear tumor (esp if unilateral—R/O by ordering CT)
• What are other types/causes of tinnitus?
o hyperlipidemia, allergies, diabetes, hypertension, hypotension, syphilis, cardiovascular, endocrine, and metabolic disease, TMJ disorders, cervical injuries, stress, dietary deficiencies, and intake of stimulants (nicotine, caffeine).
• What is the workup for tinnitus?
o Hx: get good description of “sound” (episodic/constant, pitch, quality)
o Ask re: noise exposure, head trauma, hearing problems, dizziness, loss of balance, recent dental problems/work, bruxism, stress, ototoxic drug use, smoking, caffeine, HTN, anxiety, insomnia
o PE: Otoscopic exam, cranial N VIII function and hearing (whispered, tuning fork tests)
o Check for: carotid artery bruits, HTN, oral exam, neck and jaw hypertonicity, TMJ dysfunction
o audiology, angiography
• what is vertigo?
o a type of dizziness; nonspecific term describing a sensation of altered spatial orientation “illusory movement”
o most often caused by dysfunction of the vestibular, visual, or proprioceptive (posterior column) systems, or by diffuse impairment of blood flow to the brain
what are subjective/objective vertigo? Common in which population?
o subjective if patient has the impression they are “moving in space” (self-motion)
o objective if objects “moving around” the patient (motion of the environment)
o more common in aging, increased incidence of falling in those > 65 years.
• What are the 2 classifications of vertigo?
o True vertigo- sensation of movt; most common; Caused by asymmetry in the vestibular system (CN8, inner ear, cerebellum)
o Non-vertigo - syncope, fainting or sensation of impending fainting
What are ssx of true vertigo?
o either surroundings are moving or patient is moving within surroundings
o Postural instability, nausea and vomiting common, sweating
o Vertigo is worse when moving head
o Nystagmus is commonly seen on eye exam (involuntary movements of the eye)
• What are some further classifications of true vertigo?
o i. Peripheral vertigo: labyrinth or CN VIII
o Central vertigo: cerebullum, vestibular cortex in temporal lobe
• Peripheral vs central vertigo: nystagmus?
o Peripheral: Unidirectional with fast component towards normal ear, horizontal with rotation
o Central: Any direction, sometimes changes direction
• Peripheral vs central vertigo: other neuro signs?
o Peripheral: Absent
o Central: Often present (ataxic gait, diplopia, slurred speech, numbness)
• Peripheral vs central vertigo: postural instability?
o Peripheral: Unidirectional instability, walking
o Central: Severe instability, patient can fall while walking
• Peripheral vs central vertigo: hearing loss/tinnitus?
o Peripheral: may be present
o Central: abent
• What are the types of non-vertigo?
o Lightheadedness
o Disequilibrium
o Miscellaneous
• What happens in lightheadedness non-vertigo?
o “graying out” of vision, pallor, and a roaring sound in the ears suggests hypoperfusion of the brain (global hypoperfusion) from: hypotension, drugs, decreased cardiac output hypoglycemia, shock, dehydration, severe anemia, cardiac arrhythmias
• What happens in disequilibrium non-vertigo?
o occurs only while standing or walking (gait impairing), unsteady without any dizziness
o pt says that “dizziness is in feet, not in head”
o Source of problem may be: cerebellum; basal ganglia; cervical spondylosis; frontal lobe tumor; stroke; motor neuron diseases
• What may happen in miscellaneous cases of non-vertigo?
o chronic hyperventilation syndrome; often unaware to patient; frequent deep breaths while relaxed
o new eyewear & diplopia
o phobias- agoraphobia, acrophobia
o extra-ocular muscular palsy results in diplopia
• what info about vertigo and its cause can you get in hx?
o Onset: sudden or gradual?
o Sudden onset and vivid memory of episodes are often due to inner-ear disease
o Gradual and ill-defined vertigo most common in CNS, cardiac, and systemic diseases
o Duration:
o Episodic true vertigo that lasts for seconds, associated with head or body position changes likely benign paroxysmal positional vertigo (BPPV)
o Vertigo of sudden onset that lasts for minutes can be due to brain or vascular disease
o Vertigo that lasts for hours or days probably caused by Ménière disease or vestibular neuronitis
• What is general PE for vertigo? Otological exam?
o vital signs, supine and standing BP, orthostatic BP, CVS
o oto: examine ears for cerumen, discharge, foreign body; TM - perforation may result in sudden vertigo
• what extraocular movts can you do in PE for vertigo?
o “H in space”
o check for nystagmus (eye jerking movements)
o horizontal plane - most common form
o vertical plane - always abN, brain stem function disorder
o pendular - often congenital or after prolonged period of blindness
• what hearing tests can you do in PE for vertigo? Sensory?
o Gross hearing—whispered voice test
o Weber/ Rinne to assess conductive or sensorineural loss
o Sensory exam to assess proprioception: polyneuropathies can impair balance
• How do you test for vestibular imbalance in PE for vertigo?
o Past-pointing with eyes closed, repeat several times.
o Romberg test: tend to fall toward the vestibular lesion
• What are red flag concomintants for vertigo?
o head or neck pain, ataxia, loss of consciousness, focal neurological deficit
• what are some extra tests for (true?) vertigo?
o Dizziness simulation battery for *True vertigo
o Caloric testing: cold water into external canal produces tonic eye deviation to side of cold water and horizontal nystagmus to opposite side (Otoscopy done first!); Test is positive for vestibular dysfunction if asymmetry > 20% with affected ear producing less severe nystagmus; pt has transient vertigo identical to usual dizziness
o Nylen-Bárány maneuver: pt sits at the end of the examining table and is laid back quickly, while the head is supported and the neck is carefully hyperextended. The head is first turned toward one shoulder; then, the maneuver is repeated with the head turned toward the other shoulder; look for nystagmus (there may be a 10-20 sec. latency period)
• What are some non-vertigo extra tests
o Lightheadheadness: orthostatic hypotension- increase in pulse by 30 bpm, systolic BP drop of 15-20 mm Hg; carotid sinus massage; valsalva maneuver
o disequilibrium: drifts toward side of lesion; cerebellar (coordination) and proprioception testing; observe walking and turning; forward & backward walking
o miscellaneous: hyperventilation: sitting, breathe quickly and deeply (2 minutes while observing for nystagmus)
• what are some causes of earache/ear pain/otalgia?
o external ear –impacted cerumen or foreign body, local trauma, otitis externa
o middle ear – eustacian tube obstruction, OM, neoplasms
o referred pain from TMJ, wisdom teeth
o local infections: tonsillitis, enlarged adenoids, peritonsillar abscess
o atlas/axis subluxation
o tumor in pharynx, tonsils, tongue, larynx; thyroiditis
o neuralgia: trigeminal, sphenopalatine, glossopharyngeal, geniculate
o colds, allergies, cold wind blowing in ear
• what are red flag concomitants for earache?
o Diabetes or immunocompromised pt, redness/pain over mastoid,
o Severe swelling of canal meatus, chronic pain with head/neck symptoms
• What are some causes of acute ear discharge (otorrhea)?
o Acute OM with TM perforation
o Post-tympanostomy tube
o CSF leak from head trauma
o OE—infection or allergy
• What are some causes of chronic otorrhea?
o Cancer of ear canal; Cholesteatoma; Chronic purulent OM; Foreign body (usu kids); Mastoiditis
• What are red flag concomitants of otorrhea?
o head trauma, cranial nerve dysfunction, fever, erythema of the ear, diabetes or immune compromised
• what are the complaints of the external ear?
o Obstruction o AOE o COE o Perichondritis o Tumors
• what can cause obstruction of the external ear?
o cerumen may block & cause itching, pain, conductive hearing loss
o foreign body, esp. with children- beads, erasers, insects, just about anything!
• What are main causes of acute otitis externa?
o 1) Infection- e.g. strep, staph, E. coli, pseudomonas, aspergillus
o 2) “swimmers ear”
o 3) forceful cleaning of the ear
o 4) trauma
• What are sx of AOE?
o itching, pain, discharge possible, loss of hearing if canal becomes swollen or filled with purulent debris
• what are some things found on PE for AOE?
o pinna & tragus painful when pressed or tugged (different from OM)
o external canal appears red, swollen
o TM (may not be visualized) is normal pearly gray
o Pseudomonas infx produces purulent green/ yellow otorrhea
o Aspergillus looks like a fine white mat topped by black spheres
o fever, swollen lymph nodes possible
• what is etiology of COE? Ssx?
o often follows psoriasis, seborrheic dermatitis, eczema
o allergy or fungus
o pruritis, redness, discharge
• what is found on PE for COE?
o pinna & tragus less likely painful
o external canal appears irritated, perhaps dry, flaking tissue
o TM not usually affected
o May get secondarily infected, increased pain and swelling
• What is perichondritis?
o External ear: trauma, insect bites may lead dec blood supply to ear cartilage: avascular necrosis/deformity
• What are some types of tumors on external ear?
o sebaceous cysts, osteomas (bony growths) may occlude ear canal
o gouty deposits (tophi on outer ear)
o basal cell (BCC) and squamous cell carcinomas (SCC)- hx of sun exposure on external ear
• what are the compaints of the middle ear?
o AOM o COM (COME, CSOM) o Myringitis o Cholesteatoma o Acute mastoiditis o Otosclerosis o tympanosclerosis
• what is etiology of AOM?
o 2nd most common dz of childhood (URI # 1); ~ 20 million annual physician visits
o Cause: Organism, anatomic position of eustacian tube and immunologic factors
o Common: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
o Less common: Group A streptococcus (older kids), Staph aureus, Gram neg bacilli (newborns, immunocompromised), viruses, Mycoplasma pneumoniae
o Can also be sterile effusions (no organism found)
• What are risk factors for AOM?
o daycare exposure. (also source for URI)
o bottle-feeding
o smoker(s) in the household
o AOM in the first year of life is risk factor for recurrent acute otitis media.
• What are ssx of AOM?
o throbbing pain (or maybe NO pain), fever, dec hearing, n/v, moodiness, irritability
o child may tug on ear; sleep may be disrupted due to pain
• what is found on PE for AOM?
o bulging, red (or cloudy) TM, possible fluid line (yellow-gray if pus)
o decreased mobility on pneumatic otoscopy (insufflation)
• what are the most useful test in the dx of AOM?
o Bulging TM
o Cloudy TM
o Decreased Mobility
• What are some complications of AOM?
o Otitis media with effusion most common.
o If bilateral, hearing loss with resultant speech delay may occur in infants.
o Mastoiditis used to be a common complication, but now rare.
o Perforation (rupture) of the TM is frequent, but usually not serious (unless peripheral)
o IF TM perforates: discharge and sudden loss of pain
o If perforation is peripheral, check regularly for cholesteatoma
o May persist during Abx treatment, or relapse within 1 mo
• What are 2 types of COM
o Otitis media with Effusion (OME)- sometimes listed as Serous OM
o Chronic suppurative OM (CSOM)
• What is OME? Risk factors?
o Effusion (fluid) in the middle ear--incomplete resolution of acute OM or due to inflammation o Prior tympanostomy tube placement; Allergy (often food – dairy, oranges, apples; environmental); adenoid hypertrophy; Summer or Fall months
• Wha are ssx of COM?
o Hearing impairment – child’s behavior may be described as inattentive (ADD misdiagnosis?)
o Mild otalgia - intermittent ear pain tends to worsen at night; ear fullness or popping
o May also have overlapping sx of common cold: nasal d/s, sore throat
• What is found on PE for COM?
o Amber or gray TM, INTACT but typically retracted or in the neutral position
o Impaired mobility of the TM during pneumatic otoscopy
o Bubbles or air/fluid level may be seen
o Chronic cervical LA
• What is the course of COM?
o can persist: (COME) fluid behind intact TM; Risk of infection, recurrent AOM and/or perforation
• what is CSOM? Etiology? Ssx?
o chronic inflammation of middle ear that persists at least 6 wks with TM perforation and otorrhea
o acute OM resulting in perforation - central perforation leading to conductive hearing loss
o trauma to ear, head
o ssx: hearing loss, chronic purulent d/c, painless
• what is found on PE for CSOM?
o Perforation of the tympanic membrane (pars flaccida in patients with atticoantral disease and pars tensa in patients with tubotympanic disease)
o May see: retraction pocket in the posterosuperior quadrant, choleseatoma, granuloma, polyps
• What is the course of CSOM?
o May have a perforation without ever getting any symptoms, but sometimes a chronic bacterial infection develops.
o May flare up after an URI or after water enters the middle ear while bathing or swimming. Usually, flare-ups result in a painless discharge of malodorous pus from the ear. Persistent flare-ups may result in the formation of polyps, from the middle ear through the perforation and into ear canal.
o Persistent chronic infection can destroy parts of the ossicles leading to conductive hearing loss. In a child, this can lead to delayed intellectual development
• What is ddx for CSOM?
o Otitis externa, cholesteatoma (congenital or acquired), myringits, chronic mastoiditis, impacted cerumen, tympanosclerosis, Wegener granulomatosis
• What are the 5 types of OM?
o AOM, persistent AOM, OME, COME, CSOM
• What are dx criteria for AOM?
o Acute onset AND
o Middle ear effusion (bulging TM), limited or absent mobility air-fluid level behind membrane AND
o SSx of middle ear inflammation (red TM, otalgia)
• What are dx criteria for persistent AOM?
o Persistent features of middle ear infection during antibiotic treatment OR
o Relapse within one month of treatment completion
• What are dx criteria for OME, COME, CSOM?
o OME: Fluid behind intact TM in the absence of features of acute infx
o COME: Persistent fluid behind intact TM in the absence of acute infx
o CSOM: Persistent inflammation of the middle ear or mastoid cavity; Recurrent or persistent otorrhea through a perforated TM
• What is myringitis?
o Inflammation and/or infection of the TM. Primary or Secondary, Acute or Chronic forms
• What are primary causes of myringitis?
o can accompany Mycoplasma pneumonia URI
o TM trauma (foreign body, cleaning, explosion)
o Acute bullous Myringitis: vesicles on TM from infx (S pneumoniae, herpes)
o Acute hemorrhagic myringitis: bact or viral infx
o Fungal and eczematous forms
o Myringitis granulosa—unclear cause
• What are secondary causes of myringitis?
o Acute otitis media, acute otitis externa
o Chronic otitis media, chronic otitis externa
What are ssx for myringitis? What is found on PE?
o Serosanguinous otorrhea, otalgia, hearing impairment
o if acute: sudden onset of ear pain that lasts 24 to 48 hours, fever
o PE: Vesicles develop on the TM in bullous form, granulomatous tissue in granulosa form
What is cholesteatoma? Etiology?
o Growth of keratinizing squamous epithelium in middle ear and/pars tensa, can enlarge
o congenital, primary acquired, and secondary acquired. (prev perforation, retraction pocket)
• what are ssx of cholesteatoma?
o painless otorrhea, either unremitting or frequently recurrent.
o Conductive hearing loss initially, then can grow into inner ear causing SNHL
o dizziness is relatively uncommon
• what is found on PE for cholesteatoma?
o canal filled with muco-pus and granulation tissue
o TM perforation is present in >90% of cases.
o May require surgical removal
• What is acute mastoiditis? Etiology?
o Suppurative infection in the mastoid air cells
o Complication of severe AOM
o Streptococcus pneumoniae (most common), Streptococcus pyogenes, Staphylococcus spp, Haemophilus influenza, Pseudomonas aeruginosa
• What are ssx of mastoiditis?
o redness, swelling, tenderness behind ear, fever, hearing loss, profuse creamy ear d/c
- throbbing pain
what is foud on PE for mastoiditis?
o Bulging erythematous TM
o Tenderness (redness, swelling) over the mastoid area
o Postauricular fluctuance
o Protrusion of the auricle, downward displacement of auricle
What are complications of mastoiditis? Referral?
o subperiosteal abscess, CN 7 palsy, hearing loss, osteomyelitis, meningitis, venous sinus thrombosis
o MRI or CT. Treatment with drainage and antibiotics
• What is otosclerosis? Ssx?
o Genetic (autosomal dominant) metabolic bone disease affecting otic capsule and ossicles, leads to overgrowth of footplate in stapes/dysfunction
o F>M 2:1; much more common in whites, most commonly appears 15-35 yrs.
o Ssx: Progressive bilateral (conductive) hearing loss and tinnitus (occasionally, vertigo)
• What is tympanosclerosis?
o Sclerosis of TM: from chronic OM, post T-tube
o Leads to stiffening of the tympanic membrane and impaired conductive hearing
• What are ssx of tympanosclerosis? Found on PE?
o SSX: early asymptomatic, but hearing loss progresses
o PE: Whitish plaques on TM (areas of hyalinization with deposition of calcium and phosphate crystals)
• What are the 2 classes of inner ear disorder?
o Peripheral vestibular disorders
o Central vestibular disorders
• What are the types of peripheral vestibular disorders?
o Viral labyrinthitis
o Bacterial labyrinthitis
o Vestibular neuritis
o Benign paroxysmal positional vertigo (BPPV)
o Acoustic neuroma (vestibular schwannoma)
o Meniere’s dz
• What is viral labyrinthitis?
o URI precedes the onset of symptoms in up to 50% of cases
o sudden unilateral hearing loss and severe vertigo, frequently assoc nausea and vomiting
o patient is often bedridden while the symptoms gradually subside.
o vertigo eventually resolves after several days to wks; however, unsteadiness and positional vertigo; may persist for several mos
o Adults aged 30-60 years, rarely observed in children.
• What is found in PE for viral labyrinthitis?
o spontaneous nystagmus towards the normal side with diminished or absent caloric responses in the affected ear.
o hearing loss: mild to moderate, often higher frequencies (>2000 Hz)
• what is herpes zoster oticus?
o Aka: Ramsay-Hunt syndrome
o A unique form of viral labyrinthitis
o Caused by reactivation of a latent varicella-zoster virus infection, yrs after the primary infection.
• What are ssx of herpes zoster oticus?
o initial deep, burning, auricular pain followed a few days later by the eruption of a vesicular rash in the external auditory canal and concha. Vertigo, hearing loss, and facial weakness may follow
o Symptoms typically improve over a few weeks; however, patients often suffer permanent hearing loss and persistent reduction of caloric responses.
• What is bacterial laburinthitis?
o Caused by either direct bacterial invasion (suppurative labyrinthitis) or through the passage of bacterial toxins into the inner ear (serous labyrinthitis).
o meningitis typically affects both ears. Bacteria spread from the cerebrospinal fluid to the membranous labyrinth by way of the internal auditory canal or cochlear aqueduct.
o infections of the middle ear or mastoid most commonly spread to the labyrinth through a dehiscent horizontal semicircular canal. Usually, the dehiscence is the result of erosion by a cholesteatoma.
• What are ssx of bacterial labyrinthitis?
o profound hearing loss, severe vertigo, ataxia, and nausea and vomiting
o now rare in the post-antibiotic era
• what is vestibular neuritis?
o benign and temporary disorder of the vestibular nerve, vertigo NOT assoc with hearing loss
o more common in the fourth and fifth decades of life . M=F
o URI often precedes. More common in the spring and early summer, commonly viral
What are ssx of vestibular neuritis? Found on PE?
o sudden acute vertigo without hearing loss in an otherwise healthy patient.
o PE: horizontal nystagmus may be present, some gait instability, NO hearing loss
• What is BPPV?
o sudden vertigo elicited by provocative positions, triggering nystagmus. The character and direction of the nystagmus are specific to the part of the inner ear affected and the pathophysiology.
• What are the subclassifications of BPPV? Cause of BPPV?
o Location: semicircular canal (SCC) (ie, horizontal, posterior, or superior)
o Pathophysiology: canalithiasis and cupulolithiasis
o BPPV is due to posterior semicircular canal canalithiasis ~ 90% of the time.
• What is canalithiasis?
o (literally, “canal rocks”) particles residing in the canal portion of the SCCs. These densities are free floating and mobile, causing vertigo by exerting a force.
• What is cupulolithiasis?
o (literally, “cupula rocks”) refers to densities adhered to the cupula of the crista ampullaris. Cupulolith particles reside in the ampulla of the SCCs and are not free floating.
• What is etiology of BPPV? Risk factors?
o Idiopathic; head/ear traum; otitis media; vestibular neuritis; Ménière disease otosclerosis; SNHL; acoustic neuroma; vertebral basilar insufficiency
o Risks: inactivity, alcohol, caffeine, major surgery, and CNS disease.
• What are ssx of BPPV?
o Sudden onset: vertigo while trying to suddenly sit up, lying down, rolling over in bed, looking up.
o Symptoms start very violently and usually dissipate within 20 or 30 seconds
o Severe dizziness occurs as “attacks” some cases, even the slightest head movement causes N&V.
o Between episodes, patients usually have few or no symptoms. However, some patients complain of a continual sensation of a “foggy or cloudy” sensorium.
o In many, the symptoms periodically resolve and then recur.
• What is PE for BPPV?
o Generally unremarkable.
• What is the Dix-Hallpike maneuver?
o the standard clinical test for BPPV.
o Positive test: classic rotatory nystagmus with delay and limited duration is considered pathognomonic.
o Procedure: rapidly move the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side. Vertigo and nystagmus seen in posterior canal dysfunction
• What is acoustic neuroma?
o Aka vestibular schannoma
o benign, slow growing tumor derived from Schwann cells of CN VIII
• what are ssx of acoustic neuroma?
o unilateral, progressive SN hearing loss
o Vertigo, tinnitus, disequilibrium can be concomitant
o Headaches are present in 50-60% of patients
o Facial numbness occurs in about 25% of patients
• What should b considered acoustic neuroma until proven otherwise?
o Any unilateral sensorineural hearing loss
• What can cause other CN neuromas?
o A large tumor can compress the brainstem and affect other cranial nerves, inc intercranial pressure
• What is Meniere dz? Age? Etiology?
o lesion called “endolymphatic hydrops”
o increase in volume and pressure of the endolymph in the endolypmhatic spaces of inner ear.
o Age: typically occurs in early- to mid-adulthood; M=F
o Etiology: exact cause is unknown. Up to 50% of patients have a positive FH
• What are ssx of Meniere dz?
o Triad: waxing and waning SN hearing loss, tinnitus, vertigo
o Prodrome: fullness or blocked sensation in one ear (like listening to shell)
o Tinnitus followed by a decrease in hearing (esp low pitches); nausea, vomiting, diarrhea, pallor, and sweating common with an acute attack
o Vertigo is experienced concurrently with or follows shortly after the hearing symptoms; typically lasts min to hrs but may last several days.
o headache and gait unsteadiness may persist for several days
• what is the course of Meniere dz?
o following an acute episode, hearing may return to normal. Recurrence is common but unpredictable; hearing usually is decreased over time
o Rarely, patients may experience such severe vertigo that they will collapse to the ground.
• What are Tumarkin crises?
o Ménière-related drop/collapse attacks
o Bilateral Ménière disease occurs in as many as 1/3rd of these pts.
• What is found on PE of Meniere dz?
o complete neurological examination is necessary to R/O other conditions, esp. cranial nerve examination
o vestibular maneuvers (Nylen-Bárány, Dix Hallpike) may be helpful in diagnosing this syndrome.
• What are dx criteria for Meniere dz?
o i. isolated attacks of whirling, vertigo usu with n/v for at least 20 min, up to several hrs
o ii. tinnitus - multipitched, multisounds, roaring, whistling: severe, unilateral, constant or fluctuating
o iii. sensory hearing loss (progressive) [10-15% are bilateral]
• what is ddx of Meniere dz?
o migraine headache, hypothyroidism, labyrinthitis, multiple sclerosis, OM, ischemic stroke subarachnoid hemorrhage, TIA, vestibular neuritis, acoustic neuroma, salicylate toxicity
• what are the classes of central vestibular disorders?
o Toxic vestibulopathy
o Others: migrainous vertigo, brainstem ischemia, multiple sclerosis, cerebellar infarct
• What is toxic vestibulopathy? Agents?
o (hx of toxic agent ingestion)
o aminoglycoside antibiotics - creates bilateral vestibular damage, may have blurred vision while moving the head (eg streptomycin, gentamicin most vestibulotoxic; neomycin, kanamycin, tobramycin most auditory toxicity)
o aspirin can produce dose-related reversible tinnitus, hearing loss, dizziness
o alcohol produces reversible positional nystagmus
• What Qs should you ask about hx at an eye exam?
o ask about vision changes, eye pain, discharges, etc
• what does an eye exam include?
o Inspection – conjunctiva, discharges, eye and surrounding structures
o Visual acuity: Check near vision (Rosenbaum chart at 14”) and far vision (Snellen chart at 20’); Check color vision (can use Ishihara chart)
o Peripheral vision: visual fields by confrontation test
o PERRLA: check if Pupils are Equal Round and Reactive to Light and Accommodation
o Extra ocular movements: “H” and “X” in space; assess CN III, IV, VI; look for nystagmus
o Red reflex: absent or reduced red reflex indicates opacity of the cornea (infection or scar), lens (cataract), or vitreous hemorrhage.
o Fundoscopic exam
• How do you do a fundoscopic exam, and what can you find?
o Visualize the optic nerve for color (pale: compressive lesion, atrophy) and size/shape
o Enlarged optic cup or asymmetric optic nerve appearance between the two eyes (glaucoma)
o Swelling (edema) with blurred disc margins (ischemic optic neuropathy if unilateral; hypertensive optic neuropathy or increased intracranial pressure if bilateral).
o Check for spontaneous retinal venous pulsations (absence may indicate inc ICP)
o Examine the macula for hemorrhages (diabetic retinopathy or macular degeneration), scarring (macular degeneration), or yellow dots (exudates from diabetic retinopathy or Drusen from macular degeneration).
• What are some general sx/complaints at an eye exam?
o Vision loss; Errors of refraction; Conjunctival discharge; Eye strain; Photophobia; Scotoma; Floaters; HAs; Field defects; Dry eyes; Eye contusion; Red eye
• What should you ask about vision loss?
o Ask re rate of onset, pain or no, central or peripheral loss, uni- or bilateral
• What are errors of refraction?
o Hyperopia (far-sightedness) - most common; distant objects are clear, and close-up objects blurry. o Myopia (near-sightedness) - faraway objects will appear blurry o Astigmatism - refraction is unequal in different meridians of the eye; the cornea or the lens has a slightly different surface curvature. Often present at birth and may occur in combination with nearsightedness or farsightedness. o Presbyopia - a slow loss of ability to see close objects or small print. With age, the lens becomes less pliable and eventually cannot accommodate in response to the action of the ciliary muscles
• What is conjunctival discharge?
o From bacterial or viral conjunctivitis, allergic reaction
o Note: color, quality, quantity, irritating?
• What is eyestrain?
o COMMON: always looking within 20’ (prolonged reading or close work, computer screens)
o sensation of tired eyes, increasing difficulty focusing or seeing, eye dryness, headache
• what is photophobia? Causes?
o abnormal visual intolerance of light.
o eye infection; eye injury; conjunctivitis; Allergies; Acute glaucoma; Cataracts; Migraine headache; Eye inflammation (uveitis, iritis, keratitis); Corneal disorder (foreign body, abrasion, ulcer)
• what is scotoma?
o “blind spots”
o area of partial or complete blindness, usually within the central 30-degree area. From damage to nerve fiber layer in retina. Often seen by pt as “dark spot”
• what is “scintillating scotoma”?
o an irregular outline around a luminous patch in the visual field following mental or physical work, eyestrain or migraine prodrome (visual aura)
• what are floaters? Myodesopia?
o Myodesopia= perception of floaters
o Floaters= Deposits (various size, shape refractive index, and motility) within the eye’s vitreous humor Appear as “spots” or “threads” which slowly “float”
o Visible because of the shadows they cast on the retina or their refraction of the light that passes them
• What is etiology of floaters?
o Developmental, acquired (degenerative changes in vitreous humor or retina)
o May be associated with autoimmune uveitis; diabetic retinopathy; posterior vitreous detachment (PVD) with aging
• What types of HAs come with eye sxs?
o cluster, sinusitis, migraines
• what is the term for field defects?
o Hemianopsia: blindness or decreased vision in half of visual field of one or both eyes (All are concerning!
• What are the 3 types of hemianopsia?
o Homonymous hemianopsia: same side of both eyes, can be transient, lose pupillary reflexes; usu optic tract problem
o Crossed hemianopsia: opposite sides, often pituitary problem
o Quadrant hemianopsia: level of brain, pupil reflex present as optic tract not affected
• What is etiology of dry eyes?
o Aging (esp postmenopausal); Medications: antihistamines, nasal decongestants; Post-eye surgery; Mal-positioned eyelids; Chemical burn to eye; Dry climate; Vitamin A deficiency; Dry Eye Syndromes
• What is an example of a dry eye syndrome? Sxs?
o Keratoconjunctivivitis sicca
o bilateral dryness of eyes from lack of tears, more common in adult females
o eye redness, swelling, itching, burning and perhaps reduced vision
o Can be in conjunction with autoimmune dz. (RA, SLE or Sjogren’s)
• What is an eye contusion? Tx?
o often from blunt trauma; “black eye”
o use ice, for 24 hrs, then alternate with heat. HP arnica, ledum, symphytum
o suture minor lacerations around eye area; refer if more extensive damage
• what are causes of red eye?
o MANY
• what is red eye: hemorrhage of conjunctival vessels?
o sclera gets very red; due to minor trauma- straining, sneeze or cough
o not painful; no vision change, no pathological significance (unless blood dyscrasias), but alarming to pt.
• what is red eye: 2 types of injection (congestion of vessels)?
o Conjunctival (common) - peripheral, brick-red, tortuous superficial vessels; fade toward the iris; move with conjunctiva; blanch and refill with pressure (eg conjunctivitis) o Ciliary (less common) – (also known as ciliary flush or circumcorneal injection) violet or rose colored; fine, straight, deep vessels that radiate out from limbus (junction of conj. and cornea); fade toward periphery; doesn't blanch or move with conjunctiva. (eg iritis or acute glaucoma)
• What are the conditions of the conjunctiva?
o Acute conjunctivitis
o Pinguecula
o Pterygium
What is acute conjunctivitis? Etiology? Predisposing factors?
o Aka pink eye; very common
o Et: allergic (common), viral, bacterial
o factors: irritation from wind, dust, smoke, air pollution, common cold, corneal irritation from intense light, reflection from snow
how is vision affected by acute conjunctivitis? Ssx? PE?
o Vision: unchanged unless exudate clouds the eye
o Signs & Sxs: usually bilateral superficial dilated vessels (conjunctival injection); (unilateral disease suggests toxic, chemical, mechanical, or lacrimal origin).
o PE: normal intraocular pressure, PERRLA, normal vision
• What are the types of acute conjunctivitis?
o Allergic
o viral
o bacterial
• what are the types of allergic conjunctivitis?
o Acute
o Chronic
o Giant papillary
• Wat is acute allergic conjunctivitis?
o also called vernal (seasonal) conjunctivitis; recurs in spring and lasts through summer (with hay fever)
• what are ssx of allergic conjunctivitis?
o sudden, mild to moderate to bilateral severe swelling of conjunctiva & lids
o conjunctiva appears pale but easily visible blood vessels
o not painful, but pruritus is extremely common
o clear, watery discharge is typical
• What is found on PE of Allergic conjunctivitis?
o preauricular adenopathy is absent; chemosis (thickened, boggy conjunctiva) is common.
o discharge amount is usually sparse; discharge quality is clear, thin, stringy
o conjunctival injection is moderate
o Wright stain of discharge shows eosinophils
• What is chronic allergic conjunctivitis?
o non-seasonal, on/off throughout year
o little evidence of inflammation but itching, burning and photophobia may be present
o eyelid eversion may show velvety projections on palpebral conjunctiva
o may be misdiagnosed as dry eye syndrome
• what is giant papillary conjunctivitis? Et? Ssx?
o allergy to soft contact lenses; may be slow to develop
o Et: autoimmune response to pt’s own proteins or to the “trauma” of the lens wear
o Ssx: excessive pruritus, mucous production, increasing intolerance to contact use.
• What PE is found for giant papillary conjunctivitis?
o inflamed conjunctiva – red, itchy, and irritated
o may have a thick discharge, worse in morning
o eyelid eversion: see giant papillae usu on upper palpebral conjuctitva (cobblestone granulations)
• what is viral conjunctivitis? Ssx?
o adenovirus, common, lasts 1 – 2 wks
o SSX: pruritus, minimal pain; clear, thin, watery discharge is typical.
o occasionally severe photophobia and foreign-body sensation occurs, usually caused by adenovirus when associated with keratitis (inflammation of cornea) (epidemic keratoconjunctivitis [EKC])
• what PE is found for viral conjunctivitis?
o pre-auricular adenopathy is common in EKC and herpes; chemosis is variable.
o discharge: amount—moderate or sparse; quality—thin, seropurulent
o conjunctival injection is moderate to marked
o common concomitants: sore throat, nasal discharge (rhinitis)
• what is Herpes Simplex virus conjunctivitis?
o affects only 1 eye, most often occurs on the cornea which results in herpes keratitis o recurrences (in susceptible pts) usu take form of dendritic keratitis, with a characteristic raised lesion of the cornea “veins of a leaf”; nodules at terminal end of each “branch”
• what are early and late ssx of HSV conjunctivitis?
o early: foreign body sensation; lacrimation; photophobia; conjunctival injection
o late: anesthesia of cornea & dendritic keratitis lesion diagnostic; ulceration and permanent scarring of cornea may result (loss of vision)
• what are triggers for HSV conjunctivitis?
o fever, stress, sunlight, trauma
o associated with oral herpes, genital herpes
o immune compromised pts (HIV, DM)
o zoster (shingles) on the tip of the nose moving to cornea, resulting in uveitis and glaucoma
• what is etio and ssx of bacterial conjunctivitis?
o Etio: Staph and Strep are most common pathogens
o Ssx: acute onset, minimal pain, occasional pruritus
• What might be found on PE for bacterial conjunctivitis?
o preauricular adenopathy; chemosis is common.
o Discharge: copious; thick and purulent
o conjunctival injection is moderate to marked
o acute infx - gram stain or culture to identify
o chronic may produce little or no d/c except for crusting of eyelashes in AM, no itching
• what is Neisseria gonorrhea conjunctivitis (adults vs neonates)?
o adult - rare, 12-48 hr incubation period; severe, purulent discharge, usu unilateral, lids swollen; complications: corneal ulceration, abscess, blindness
o neonate- purulent discharge, 2-5 days after birth, may be severe lid edema
what is chlamydia tachomatis conjunctivitis (adults vs neonates)?
o adult inclusion conjunctivitis; “swimming pool conjunctivitis”- from exposure to infected genital secretions; other exposures from sharing eye make-up, etc; tends to be chronic with exacerbation and remission; pre-auricular adenopathy is occasional; discharge: scant; seropurulent; conjunctival injection is moderate
o neonatal inclusion conjunctivitis (inclusion blennorrhea—exposure from cervix); 5-14 day incubation, sx may be mild to severe; chemosis, mucopurulent d/c, often bilateral, no corneal damage occurs
what is trachoma?
o (Granular conjunctivitis) chronic infection of cornea and conj. caused by chlamydia
o Endemic in Africa, Asia, Middle East, Latin America, Pacific Islands, and aboriginal communities in Australia
o active disease most common in preschool children
• what are ssx of trachoma?
o Often asymptomatic
o incubation of 7 days, most contagious in early stages
o usu. bilateral mucopurulent keratoconjunctivitis
o conj. congestion, eyelid edema, photophobia, lacrimation, pain; in 7 - 10 d follicles develop in upper lid, gradually forming yellow-gray granules
o may cause corneal ulceration
• what PE is found with trachoma?
o conjunctival surface of the upper eyelid shows a follicular/ inflammatory response
o cornea may have limbal follicles, superior neovascularization (pannus), and punctate keratitis.
o infection with C trachomatis concurrently occurs in nasopharynx
• what is pinguecula?
o harmless slightly raised bumps, fatty deposits (yellow-white material) under conjunctiva (nasal side)
o no tendency to grow onto the cornea
o may become inflamed and red
• what is Pterygium?
o conjunctival thickening from chronic inflammation from wind, dust
o often distinct triangular lesion which may grow over cornea & affect vision
• what are the conditions of the cornea?
o Corneal trauma; corneal ulcer; band keratopathy; arcus senilis; UV keratitis
• What is etiology of a corneal trauma? Ssx?
o Etiology: foreign body and/or abrasion
o Ssx: pain, photophobia, blepharospasm (spasm of lid, treated with botulism toxin to paralyze lid), may be blurred vision
• What PE is found with a corneal trauma?
o evert lid to inspect for foreign body, Check cornea for foreign material or hemorrhage
o fluorescein stain picked up by blue lens
o Check PERRLA
o Ophthalmoscopic exam for retinal or vitreous hemorrhages or retinal detachment.
• What is etiology of a corneal ulcer?
o HSV most common cause; contact lenses (particularly soft lenses); traumatic corneal injury ; chronic topical steroid use; varicella-zoster virus (VZV)—shingles in ophthalmic branch of trigeminal N; Bacterial infections - staphylococcal spp, P aeruginosa, Streptococcus pneumoniae, and Moraxella spp
• What is Hutchinson’s sign?
o For a corneal ulcer
o The nasocilliary branch of CN V enervates tip of nose and cornea leads to loss of corneal sensation, may lead to blindness}
• What are ssx of a corneal ulcer?
o erythema of eyelid and conjunctiva; mucopurulent discharge; foreign body sensation; blurred vision; photophobia; pain
• what is band keratopathy?
o hard, white calcified plaques (bands) at 2, 5, 7, 10 o’clock of limbus
o may be hypercalcemia, secondary to kidney disease
• what is arcus senilis?
o Aka corneal arcus
o whitish deposits around limbus; usu in elderly
o may be related to hyperlipoproteinemia
• what is etiology of UV keratitis?
o exposure to UV lights, welding arcs, “snow blindness”
o Radiation damage to the corneal epithelium is cumulative
• What are ssx of UV keratitis? Found on PE?
o SSX: onset of foreign-body sensation, irritation, pain, photophobia, tearing, blepharospasm, and decreased visual acuity 6-12 hours after the exposure.
o PE: diffuse staining with fluorescein dye (loss of epithelium); lid edema, conjunctival hyperemia variable
• What is a condition of the uveal tract?
o Acute Uveitis (inflammation of uveal tract) (iris, ciliary body, choroids); most common in adults (age 20-50 yr); anatomically classified as:
o i) anterior (iritis), ciliary body (cyclitis), or both (iridocyclitis)
o ii) intermediate (peripheral uveitis)
o iii) posterior; rare, serious condition (choroiditis, chorioretinitis)
• what is etiology of acute uveitis?
o Etio: often is associated with an underlying systemic disease, or may be idiopathic
o i) ankylosing spondylitis - more common in men; pain, redness, photophobia in 1 or both eyes; HLA-B27 +, SI involvement, rib cage involved
o ii) Reactive arthritis- (triad of arthritis, urethritis, conjunctivitis); mainly men, HLA-B27 +, SI joint involved, prev STI or GI infection
o iii) infection- HSV, cytomegalovirus, VZV, toxoplasmosis, TB, histoplasmosis, syphilis
o iv) sarcoidosis—retina becomes inflamed, can lead to blindness
o v) auto-immune- collagen vasc. dz., juvenile rheumatoid arthritis (RA), Sjorgren’s
• what are ssx of diff types of uveitis?
o Anterior uveitis: acute - unilateral, painful ciliary flush, blurred vision, photophobia, and tearing
o Intermediate uveitis: painless; floaters and blurred vision
o Posterior uveitis: blurred vision, floaters, eye pain, photophobia
• What is found on PE for uveitis?
o 360° peri-limbal injection, which increases in intensity as it approaches the limbus.
o visual acuity may be decreased in the affected eye.
• What is a condition of the lens?
o Cataract: opacity of the lens with painless, progressive, gradual visual loss. May see with a light or ophthalmoscope (positive diopters).
• What is etiology of cataract?
o 1) developmental – “juvenile cataract” congenital or early life from poor diet, toxic inflammation or hereditary metabolic causes (important to check on child exams)
o 2) degenerative - senile degeneration, x-ray, UV light, trauma, diabetes; use of cortisone
• What are ssx of cataract?
o decreased visual acuity is the most common complaint
o increased glare (bright sunlight or at night the glare of headlights)
o progression of cataracts leads to mild-to-moderate myopia
o No red reflex
• What are 2 intraocular conditions?
o Glaucoma
o Hyphema
• What is glaucoma? 2 types?
o increased intraocular pressure
o acute closed angle glaucoma
o chronic open angle glaucoma
• what is acute closed angle glaucoma? Etiology?
o (WILL have red eye) EMERGENCY
o Etio: mechanical blockage of outflow channels in angle
o precipitating factors include drugs (ie, sympathomimetics, anticholinergics, antidepressants), and rapid correction of hyperglycemia.
• What are ssx of acute closed angle glaucoma?
o patients are elderly, hyperopic, and have no history of glaucoma
o most commonly, present with peri-orbital pain and visual deficits; pain is “boring”, concomitant
o ipsilateral headache.
o blurry vision, describes seeing “halos around objects.”
• What PE is found for acute closed angle glaucoma?
o blurred vision, can detect hand movements but can’t identify numbers or letters.
o corneal and scleral injection, ciliary flush. Edematous, cloudy cornea obscures fundoscopic exam
o increased IOP (normal limit, 10-20 mm Hg) and ischemia:
o Pain on eye movement, Dilated non-reactive pupil
o Medial crescent shadow seen
o Ophthalmoscopic exam: increased cup/disc ratio
• What is ddx for acute closed angle glaucoma? Tx?
o DDx: conjunctivitis, acute iritis
o Tx: REFER immediately, eyesight may be lost permanently from increased pressure on optic nerve.
• What is chronic open angle glaucoma? Etio?
o (NO red eye)
o 90% of all glaucoma; caused by a malfunction of the eye’s drainage system, often from organic changes associated with aging.
o Etio: decreased rate of aqueous outflow. Bilateral, genetic predisposition (autosomal recessive?)
• What are ssx of chronic open angle glaucoma? Prevention?
o SSX: gradual loss of peripheral vision. When uncontrolled, late loss of central vision and ultimate blindness
o Prevention: ocular tonometry every 3-5 years or with family hx yearly (10-21 mm Hg = normal) (abn. = 25-50 mm Hg., N pressure has diurnal variations of 3-4 mm Hg or more, so one normal does not R/O)
• What is Hyphema?
o hemorrhage into ant. chamber from trauma, see fluid line
o danger of recurrent bleeding which may cause glaucoma and visual loss
• what are some conditions of the orbit?
o Preseptal (periorbital) cellulitis
o Orbital cellulitis
o Exopthalomos
• What is preseptal (periorbital) cellulitis? Etio?
o inflammation/infection of eyelid and surrounding skin anterior to the orbital septum (common in kids)
o Etio: trauma, infection spread from nasal sinus or tooth, insect bite on face, seeding from bacteremia (S pneumoniae, S aureus, H flu), eyelid injury, conjunctivitis, chalazion
• What are ssx of preseptal cellulitis?
o tenderness, swelling warmth, redness of eyelid. Visual acuity not affected
o Typically mild condition, rarely leads to complications
o Thus, Less of an emergency, but sometimes difficult to distinguish from orbital cellulitis?
• What is orbital cellulitis?
o Emergency!
o infection of the orbital tissues (fat and muscles) posterior to the orbital septum. More common in kids
• what is etiology of orbital cellulitis?
o extension of infection from ethmoid sinus (~ 90% cases), local trauma, infx on face or teeth
o Same pathogens as above
o Progresses rapidly, can cause retinal artery or vein thrombosis, increased intraocular pressure - retinal damage, brain abscess, meningitis, cavernous sinus thrombosis
• What are ssx of orbital cellulitis?
o swelling and redness of eyelid and surrounding tissues, proptosis (down & lateral)
o extreme orbital pain (unilateral), and pain with eye movement, dec eye motility
o conjuctival hyperemia and chemosis
o decreased visual acuity
o depending on cause: nasal d/c, sinus bleeding, tooth abscess
o presence of fever, malaise, headache raise suspicion of meningitis (rash is late sign)
• what is ddx of orbital cellulitis? Tx?
o DDX other causes of eyelid swelling - allergy, insect bite, trauma, tumor
o Tx: refer to ophthalmologist or EENT for hospitalization. CT, IV antibiotics, possibly drainage
• What is exopthalomos? Etio?
o bulging of eyes, also known as “proptosis”
o Etiology: orbital inflammation, edema, injuries, hyperthyroid, leukemia, meningioma
• What are some conditions of the retina/macula?
o Retinal detachment o Posterior vitreous detachments o Macular degeneration o Retinopathies o Retinitis pigmentosa
• What is retinal detachment? Etiology?
o Emergency!
o Etiology: trauma, diabetes, inflammatory disorder; posterior vitreous detachment (most common), may be idiopathic
o usually occurs aged 40-70 years.
• What is ssx of retinal detachment?
o painless, dark or irregular floaters, flashes of light (photopsia), blurred vision which worsens progressively, curtain or veil in the field of vision, no redness; tears or retinal pieces hanging in vitreous humor
• what is posterior vitreous detachment? Ssx?
o With age, the vitrious gel can collapse and pull forward (may tear the retinal in the process)
o SSX: painless, floaters, flashes of light
• What is macular degeneration? On exam?
o leading cause of visual loss in the elderly (more common in whites than blacks)
o hemorrhagic disturbance in the macular region of the involved eye
o slow or sudden, painless loss of central visual acuity (wavy lines on Amsler grid)
o Ophthalmoscopic exam: drusen bodies
• What are 2 types of retinopathies?
o Diabetic; hypertensice
• What is diabetic retinopathy? Early and late signs?
o major cause of blindness in diabetics
o Early signs: venous dilation and small, red well demarcated lesions (microaneurisms), then macular edema develops which affects vision. Best seen with fluorescein angiography.
o Late signs: soft exudates (cotton-wool spots) (microinfarcts) caused by anoxia, or hard white-yellow (waxy) exudates caused by chronic edema from damaged capillaries
o Tortuous retinal neovascularization
• When would you make a referral with a case of diabetic retinopathy?
o if develop blurred vision (over 2 days) not assoc. with elevated glucose, sudden loss of vision in one or both eyes, black spots, cobwebs or flashing lights in the field of vision.
• What is hypertensive retinopathy? Signs?
o Vascular changes with extent and persistence of hypertension
o i) copper wire- brightening and widening of central strip on artery, moderate arteriosclerosis (yellow from lipids )
o ii) silver wire- central light reflex is entire width of arteriole from thickened walls
o iii) AV nicking- arteriole crossing a venule, thickened arteriole walls compress and obscure the vein
o iv) hemorrhages (often flame hemorrhages)
o v) soft exudates-“cotton wool” (retinal edema)- fuzzy, gray-white, irregular border (infarcts
o vi) hard exudates (macular star); well defined yellow-white deposits, may have serrated edges d/t deposits of serum, lipid and protein
o vii) Papilledema: optic disc swollen, margin blurred
• What is retinitis pigmentosa?
o inherited, slowly progressive, bilateral, retinal degeneration loss of photoreceptors and blindness
o night blindness and peripheral vision loss may become symptomatic in early childhood
o central island of vision gradually constricts over time
• what are some conditions of the eyelids?
o Blepharitis o Hordeolum- external and internal o Chalazion or meibomian cyst o Entropion o Ectropion
• What is blepharitis? Causes?
o (inflammation of lid margins causing irritation, itching, occasionally red eye)
o Causes: rosacea, seborrheic dermatitis, allergic or contact dermatitis, dry eye syndromes, chalazion, trichiasis, conjunctivitis, Sjogren’s syndrome, exposure to chemicals or irrantants
• What are ssx of blepharitis?
o eye irritation (burning, gritty sensation, watering) itching and erythema of the lids
o tearing, photophobia, blurred vision
o crusting and matting of the lashes and medial canthus, esp in morning
o Typically a chronic course with intermittent exacerbations and eruptions
• What is found on PE with blephitis?
o often findings of associated conditions
o loss of lashes (madarosis), whitening of the lashes (poliosis), scarring and misdirection of lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid margin ulcers, and lid irregularity (tylosis)
o corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal ulcers.
• What is external hordeolum?
o Aka “stye”
o Acute localized infection or inflammation of the eyelid margin involving sebaceous gland
o Staphylococcus aureus in 90-95% of cases, Common in kids
• What are ssx of external hordeolum?
o begins with pain, redness, tenderness of lid margin followed by small, round, tender induration
o lacrimation, photophobia, foreign body sensation
o pustule on lid margin, ruptures and heals spontaneously.
• What is internal hordeolum?
o acute inflammation of meibomian gland, usu more severe
o pain, redness, edema more localized, abscess can form
o spontaneous rupture rare, recurrence is common
• what is chalazion/meibomian cyst?
o chronic enlargement of meibomian gland from infection & occlusion of its duct, often following inflammation of the gland
o at onset, looks like a stye but painless; chronic stage may appear like BCC or SCC
o after few days, infection resolves leaving a painless, slowly growing, firm mass in the lid
o evert lid to see hyperemia and localized cyst
• what is entropion?
o lid inversion
o lid area atrophic (elderly) or scarred, then lashes grow inward, causing irritation, blepharospasm, may lead to corneal ulceration and scarring
• what is ectropion?
o lid turns outward
o tissue relaxation with aging, edema
o Leads to poor drainage of tears, excess tearing, redness, irritation
• What are conditions of the lacrimal apparatus?
o Dacryoadenitis: enlarged lacrimal gland on upper lateral aspect of eye; tender, red if acute; painless if chronic. Can abscess
o Dacryocystitis: inflammation of lacrimal sac (seen in infants); usu secondary to obstruction of nasolacrimal duct; tenderness, swelling, redness; may express pus from sac
o Dacryostenosis: congenital narrowed lacrimal duct in neonate; excess tearing, may be pus expressed, usu resolves in 6 mos
• What are some eye conditions requiring urgent referral?
o Problems causing a painful eye, often red, with reduced vision: acute angle-closure glaucoma, corneal ulcer, traumatized eye, intraocular infection after eye surgery
o Problems causing sudden and profound visual loss with or without pain: retinal artery occlusion, retinal detachment
o Eye trauma: foreign bodies, corneal abrasions, blunt trauma, lacerations
o Infection spreading to eye: Orbital cellulitis
o Field defects
