EENT #1 (Eyes)

Question 1

Ectropion
-Muscle involved
-What is it?
-Risk Factors
-Symptoms
-Treatment

Answer 1

-Relaxation of orbicularis oculi muscle
-Eyelid and lashes turned outward (Everted)
-RF: Elderly, congenital, infectious
-Irritation, dryness, tearing, sagging eyelid
-Artificial tears, surgical correction

Question 2

Entropion
-Muscle involved
-What is it?
-Risk Factors
-Symptoms
-Treatment

Answer 2

-Spasms of orbicularis oculi muscle
-Eyelid and lashes turned inward (inverted)
-RF: Elderly
-Corneal abrasion, erythema, tearing, irritation
-AT and surgical correction

Question 3

Dacryocystitis
-What is it?
-Etiologies
-Symptoms (acute vs chronic)
-Management (acute vs chronic)

Answer 3

-Infection of the lacrimal sac due to obstruction of nasolacrimal duct
-Staph epidermis, Staph A, GABHS
-Acute: tearing, signs of infection (tender, warmth to medial canthal (nasal) side of lower lid, edema, erythema). Purulent discharge maybe.
-Chronic: mucopurulent discharge without other signs of infection.
-Treatment (Acute): warm compresses + ABX (Clinda, Vanco + Ceftriaxone)
-Treatment (Chronic): dacryocystorhinostomy.

Question 4

Blepharitis
-What is it?
-Risk Factors
-Posterior vs Anterior etiologies
-Symptoms
-Treatment

Answer 4

-Inflammation of the eyelid margin
-RF: Down syndrome, Atopic dermatitis, Rosacea, Seborrheic dermatitis
-Posterior (MC): MGD
-Anterior: Infectious (Staph A) or Seborrheic
-Crusting, scaling, red-rimming of eyelid, flaking of lashes
-Eyelid hygiene: warm compresses, lid scrubs

Question 5

Hordeolum (Stye)
-What is it?
-Etiologies (MCC)
-Symptoms
-Treatment

Answer 5

-Localized abscess of eyelid margin
-Staph Aureus MCC
-Erythematous, painful, warm, nodule or pustule on eyelid
-Warm compresses mainstay
–I&D if no drainage after 48 hours

Question 6

Chalazion
-What is it?
-Pathophysiology
-Symptoms
-Management

Answer 6

-Painless, indurated granuloma of internal meibomian gland
-Obstruction of Zeis or Mebomian glands
-Non-tender, localized eyelid swelling
-Eyelid hygiene and warm compresses, resolves on it’s own most times

Question 7

Pinguecula
-What is it?
-Symptoms
-Risk Factors
-Management

Answer 7

-Slow growing thickening of bulbar conjunctiva
-Yellow, slightly elevated nodule on nasal side of sclera. Does NOT grow onto cornea.
-RF: Irritation (windy, sunny, ocular trauma)
-No treatment needed

Question 8

Pterygium
-What is it?
-Risk Factors
-Symptoms
-Treatment

Answer 8

-Slow growing thickening of the bulbar conjunctiva
-RF: UV exposure in sunny climates, sand/wind/dust
-Elevated, superficial, fleshy triangular-shaped growing fibrovascular mass that starts medially and extends laterally
-Observation, AT, removal if it affects vision

Question 9

Retinoblastoma
-MC primary intraocular malignancy in childhood
-Most diagnosed before age _____
-Associated with what gene?
-Symptoms
-What diagnostic to diagnose it?
-Management

Answer 9

-Age 3
-RB1 gene
-Leukocoria (abnormal white reflex instead of red), strabismus or nystagmus
-Ocular US (intraocular calcified mass)
-Radiation, chemo
–Can be associated with bone neoplasms, fatal if untreated

Question 10

Macular Degeneration
-MCC of permanent blindness in older adults
-Two Types
-Symptoms
-Fundus Exam of Both Types
-Treatment for Dry
-Treatment for Wet

Answer 10

-Dry (atrophic) MC type, Wet (exudative/neovascular)
-Bilateral, progressive central vision loss (including detailed and color vision). Central scotomas, metamorphopsia, micropsia
-Fundus (Dry): Drusen bodies (small, round, yellow/white spots on outer retina).
-Fundus (Wet): new, abnormal vessels that can cause retinal hemorrhaging and scarring
-Treatment (Dry): Zinc, Vitamins C and E, Amsler grid
-Treatment (Wet): VEGF Inhibitors (Bevacizumab, Aflibercept). Laser photocoagulation.

Question 11

Strabismus
-What is it?
-Referral needed for strabismus if persists > _____ what age?
-Two Types
-Symptoms and Exam Findings
-Diagnostics
-Management

Answer 11

-Misalignment of one or both eyes
-Refer if persists > 4-6 months of age
-Exotropia: divergent, deviated outward (temporally)
-Esotropia: convergent, deviated inward (nasally)
-Diplopia, scotomas, amblyopia, asymmetric corneal reflex
-Hirschberg corneal light reflex testing (initial), cover-uncover test (deviates inward or outward)
-Patch therapy over normal eye to strengthen weak eye

Question 12

Viral Conjunctivitis
-MCC
-Transmission
-Symptoms
-Management

Answer 12

-Adenovirus
-Direct contact, highly contagious, swimming pools are common source during outbreaks
-FBS, ocular erythema, itching, normal vision.
-Starts unilateral and progresses to bilateral in 1-2 days
-Ipsilateral preauricular LAD, copious watery tearing, punctate staining on slit lamp
-Supportive treatment: warm/cool compresses, ATs, Antihistamines (Olopatadine)

Question 13

Allergic Conjunctivitis
-Symptoms
-Physical Exam Findings
-Management

Answer 13

-Conjunctival erythema, normal vision
-Allergic symptoms, marked pruritus, often bilateral
-Atopic history
-Cobblestone mucosa, erythema, watery or mucoid discharge, chemosis, no visual deficits
-Symptomatic treatment: Topical antihistamines (Olopatadine), Pheniramine-Naphazoline, Topical NSAIDs (Ketorolac)

Question 14

Bacterial Conjunctivitis
-MC due to
-Symptoms
-Diagnostics
-Treatment (Non-Contacts, Contacts)

Answer 14

-MC due to Staph Aureus
-Purulent discharge, lid crusting, eye stuck shut in morning, conjunctival erythema, no vision changes
-Clinical, Culture/Gram Stain of discharge
-Non-Contacts: Topical ABX (Erythromycin ointment, Trimethoprim-Polymyxin B, Moxifloxacin, Ofloxacin)
-Contacts (cover Pseudomonas): Topical Ciprofloxacin, Ofloxacin

Question 15

Ocular Chemical Burns
-Alkali burns (worse than acids): causes liquefactive necrosis, denatures proteins and collagens
-Acid burns: causes coagulative necrosis: cleaners, batteries
-Symptoms
-Treatment

Answer 15

-Symptoms: ocular pain, decreased vision, blepharospasm (can’t open eye), photophobia
-Immediate irrigation until pH neutral (7.0-7.4) with LR or normal saline. Then, examine eye.
-Topical ABX: Poly-Trim, E-mycin ointment, or Moxifloxacin

Question 16

Retinal Detachment
-Risk Factors
-MC type
-Symptoms
-Diagnostics
-Treatment

Answer 16

-RF: Myopia (nearsighted), previous cataract surgery, older age, trauma
-Rhegmatogenous: full-thickness tear from choroid plexus
-Photopsia (flashes), floaters, progressive unilateral peripheral vision loss or shadow/curtain coming down. No ocular pain or redness.
-Funduscopy: Positive Shafer’s Sign (clumping of brown-colored pigment vitreous cells in AC resembling tobacco dust)
-Emergency!! Keep patient supine with head turned toward side of detachment. Laser, cryotherapy, ocular surgery.

Question 17

Orbital (Septal) Cellulitis
-Infection of orbit posterior to orbital septum
-MC in ______
-MC secondary to _______
-Symptoms
-Diagnostics (what is best)
-Management

Answer 17

-MC in kids 7-12 years of age
-MC secondary to sinus infection (ethmoid)
-Ocular pain with EOM, ophthalmoplegia (EOM weakness), diplopia, proptosis, vision changes, eyelid erythema and edema
-High resolution CT scan
-Admission + IV ABX (Vanco + ONE OF THE FOLLOWING: Ceftriaxone/Cefotaxime, Amp-Sulbactam, Piper-Tazo, Clindamycin)

Question 18

Preseptal (Periorbital) Cellulitis
-Infection of the eyelid and periocular tissue anterior to orbital septum
-MCC include…
-Symptoms
-Diagnostics (what is best)
-Management

Answer 18

-MCC include Staph A (including MRSA), Strep, anaerobes
-Unilateral ocular pain, eyelid edema and erythema, NO proptosis, ophthalmoplegia, ocular pain with EOM**
-High resolution CT scan
-Outpatient management if > 1 year of age
–MRSA coverage: Oral Clindamycin

Question 19

Globe Rupture
-Immediate consult, emergency!
-Symptoms
-What test/exam finding is positive?
-Management?

Answer 19

-Diplopia, VA decreased, enophthalmos/exophthalmos, 360 degree conj hemorrhage. Teardrop/irregularly shaped pupil.
-Positive Seidel’s Test: parting of fluoro dye by clear stream of aqueous humor from AC.
-Rigid eye shield. Impaled objects left undisturbed. Emergent ophthalmology consult.

Question 20

Orbital Floor (Blowout) Fractures
-MC Type
-Symptoms
-Diagnostics
-Management

Answer 20

-Inferior MC Type: Orbit fat and inferior rectus may prolapse into the maxillary sinus.
-Diplopa with upward gaze (inferior rectus muscle entrapment), orbital emphysema (eyelid swelling after blowing nose), anesthesia to anteromedial cheek (stretching of infraorbital nerve)
-CT scan: Teardrop sign
-Nasal decongestants, avoid blowing nose or sneezing, ABX (Amp-Sulbactam or Clindamycin)

Question 21

Diabetic Retinopathy
-MC type of new permanent vision loss in 20-74 years old
-Types
-Symptoms of both
-Management for each type

Answer 21

-Nonproliferative: micro aneurysms, cotton wool spots, hard exudates (yellow spots that circinate), blot and dot hemorrhages, flame-shaped hemorrhages.
-Proliferative: neovascularization, vitreous hemorrhage.
-Maculopathy: macular edema or exudates, blurred or loss of central vision. Can occur at any stage.
-Treatment
–Nonproliferative: strict glucose control, laser.
–Proliferative: VEGF Inhibitors, laser photo treatment, strict glucose control.
–Prevention: annual eye exams in diabetics.

Question 22

Hypertensive Retinopathy
-Mild
-Moderate
-Severe

Answer 22

Mild: Abnormal light reflexes on dilated tortuous arteriole. AV nicking. Copper wiring = moderate narrowing. Silver wiring = severe narrowing.

Moderate: Hemorrhages (flame or dot shaped), cotton wool spots, hard exudates, and micro aneurysms.

Severe: All of the above + papilledema (blurring of optic disc). This is an ophthalmic emergency!

Question 23

Ophthalmia Neonatorum (Neonatal Conjunctivitis)
-Day 1 MCC
–Treatment
-Day 2-5 MCC
–Treatment
–Prevention
-Days 5-7 MCC
–Treatment
–Prevention

Answer 23

Day 1: Chemical conjunctivitis due to silver nitrate. ATs once it occurs.

Days 2-5: Gonoccocal MCC.
-Treatment: IM or IV Ceftriaxone.
-Prophylaxis: Topical E-mycin

Days 5-7: Chlamydia Trachomatis MCC.
-Treatment: Oral E-mycin.
-May occur up to 23 days after birth.
-Prevention: None successful.

Question 24

Ocular Foreign Body and Corneal Abrasion
-Symptoms
-Diagnostics

-Management
–Non contact lens wearer
–Contact lens wearer
–FB removal
–Corneal abrasions
–Rust ring
–When should you NOT patch?

Answer 24

-FBS, tearing, red/painful eye, photophobia, blepharospasms.
-Check VA first. Fluoro staining: corneal abrasion = ice rink/linear abrasions.

-Non contacts: E-mycin ointment, Poly-Trim B.
-Contacts: Topical Cipro or Ofloxacin.
-FB removal: sterile irrigation and cotton swab.
-Abrasions: Patch if > 5mm but not longer than 24 hours. 24 hour ophthalmology follow up.
-Rust ring: remove with burr at 24 hours.
-Do not patch if you suspect Pseudomonas**

Question 25

Bacterial Keratitis
-What is it?
-Etiology if non-contact wearer
-Etiology if contact lens wearer
-Risk Factors (biggest?)
-Symptoms and Exam Findings
-Management

Answer 25

-Corneal ulceration and inflammation
-S. Aureus
-Pseudomonas Aeruginosa
-Improper contact lens wear MC, dry ocular surface
-ocular pain, photophobia, red eye, vision changes, tearing, FBS, difficulty opening eye, ciliary injection (limbal flush), hazy cornea, corneal opacification, increased fluoroscein uptake on slit lamp
-Fluoroquinolone topical (Moxifloxacin, Gatifloxacin). Do not patch the eye.

Question 26

Herpes Keratitis
-What is it?
-Symptoms
-Physical Exam Findings
-Diagnostics (on slit lamp)
-Management

Answer 26

-Corneal infection due to reactivation of herpes simplex virus in trigeminal ganglion. Major cause of blindness in US.
-Acute onset of ocular pain, photophobia, eye redness, watering, blurry. Limbic injection (ciliary flush), hazy cornea, preauricular LAD.
-Slit lamp: dendritic branching corneal ulceration with fluoroscein staining.
-Topical antivirals: Trifluridine, Ganciclovir. PO Acyclovir.

Question 27

Cataract
-What is it?
-MCC of blindness in the world.
-Risk Factors
-Symptoms and Exam Findings
-Management

Answer 27

-Lens opacification (thickening). Usually bilateral.
-RF: Aging, Smoking, Glucocorticoid use, DM, UV light, Trauma
-Painless, slow, progressive blurred vision over months to years. Difficulty with night driving.
-Absent red reflex, opaque lens.
-Observation if mild, surgical correction.

Question 28

Uveitis (Iritis)
-Anterior vs Posterior (What is it)
-Etiologies
-Symptoms
–Anterior
–Posterior
-Exam Findings
-Diagnostics
-Management
–Anterior
–Posterior

Answer 28

-Anterior: Inflammation of iris or ciliary body
-Posterior: choroid inflammation

-Etiologies: SLE or autoimmune diseases: IBD, Sarcoidosis, HLA-B27, Infectious (CMV, Toxo, TB), Trauma.

-Symptoms of Anterior: unilateral severe ocular pain and photophobia, eye redness, tearing, blurred vision or decreased vision.

-Symptoms of Posterior: blurry vision, floaters. May not be painful.

-Ciliary injection, consensual photophobia, constricted pupil (miosis).

-Diagnostics: Inflammatory “cells and flare” (WBCs and proteins) on slit lamp.

-Anterior Treatment: Topical glucocorticoids.
-Posterior Treatment: Systemic glucocorticoids.

Question 29

Papilledema
-What is it?
-Etiologies
-Symptoms
-Diagnostics (what is seen on funduscopy)
-Management

Answer 29

-Optic nerve (disc) swelling secondary to increased intracranial pressure (usually bilateral).
-Etiologies: ICH, cerebral tumor, increased CSF, severe hypertension.
-headache, nausea, vomiting, vision preserved.
-Funduscopy: swollen optic disc with blurred margins. MRI or CT scan of the head to rule out mass effect.
-Acetazolamide (decreases aqueous humor and CSF production)

Question 30

Optic Neuritis (CN II Inflammation)
-What is it?
-Risk Factors
-Etiologies
-Symptoms
-Exam Findings (specific ones)
-Management

Answer 30

-Acute inflammatory demyelination of the optic nerve.
-RF: Young women (20-40 years old)
-MS, Ethambutol, Autoimmune (Etiologies)
-Painful loss of vision, desaturation (loss of color vision), central scotoma. Unilateral.
-Exam Findings: Marcus-Gunn Pupil (pupils dilate with light, relative affarent pupillary defect).
-Diagnostics: Funduscopy = papillitis (optic disc swelling/blurring)
-Management: IV Methylprednisolone then oral corticosteroids.

Question 31

Marcus Gunn Pupil
-What is it?
-MCC
-Another phrase for it?

Answer 31

-During swinging flashlight test from unaffected eye to the affected eye, the pupils appear to dilate.
-MCC is Optic Neuritis
-Relative Affarent Pupillary Defect

Question 32

Argyll-Robertson Pupil
-What is it?
-MCC

Answer 32

-Pupil constricts on accommodation, but does not react to bright light.
-Neurosyphilis is the MCC

Question 33

Where would a lesion on the optic nerve be (exact location) if there is a bitemporal heteronymous hemianopsia?

Answer 33

-Midline optic chiasm lesion (such as a pituitary adenoma)

–This means both temporal peripheral fields are blind.

Question 34

Acute Narrow Angle-Closure Glaucoma
-Leading cause of preventable blindness in the US
-Risk Factors
-Pathophyisology
-Precipitates
-Symptoms
-Exam Findings
-Diagnostics
-Management
–Medical
–Definitive

Answer 34

-RF: Age > 60, Hyperopia (far-sighted), females, Asians.
-Decreased drainage of aqueous humor via TM and canal of Schlemm.
-Precipitates: mydriasis (dilation), dim lights, anticholinergics, sympathomimetics.
-Sudden onset of severe, unilateral ocular pain. Halos around lights, loss of peripheral vision. Nausea, vomiting, headache.
-Exam: Conjunctival erythema, cloudy, steamy cornea. Mid-dilated fixed pupil. Eye hard on palpation.
-Tonometry (increased IOP > 21)
-Funduscopy: optic disc blurring or cupping.
-Gonioscopy is GOLD
-Treatment
–Combination of topical agents (Timolol, Pilocarpine) with systemic agent (PO or IV Acetazolamide or IV Mannitol). Latanoprost, Brimonidine, etc.
–Iridotomy is definitive.

Question 35

Chronic (Open Angle) Glaucoma
-What is it?
-Risk Factors
-Symptoms
-Exam Findings
-Management

Answer 35

-Slow, progressive, painless bilateral peripheral vision loss.
-RF: AA, age > 40, family history, DM
-Asymptomatic until late in disease, slow painless bilateral peripheral vision loss (tunnel vision).
-Cupping of optic discs, increased CD ration, notching of disc rim.
-Prostaglandin analogs first line (Latanoprost)
-Laser therapy if medical fails.

Question 36

Amaurosis Fugax
-What is it?
-Etiologies
-Symptoms
-Diagnostics

-In most cases, the emboli is from what location?
-Where does the optic nerve enter the skull?

Answer 36

-Transient monocular vision loss (lasting minutes) with complete recovery
-Etiologies: Retinal embolic or ischemia. Can be seen with TIA, GCA, CRAO, Migraine, SLE
-Vision loss descending over visual field, temporary curtain/shade that comes down and resolves within 1 hour.
-Diagnostics: Carotid duplex US, Eye exam, MRI, etc.

-MC from carotid artery bifurcation.
-Optic foramen. Travels within the optic canal to reach the middle cranial fossa.

Question 37

Central Retinal Artery Occlusion (CRAO)
-Ophthalmic emergency!
-Risk Factors
-Etiologies
-Symptoms
-Diagnostics (what is seen on Fundus exam)
-Management
-Prognosis

Answer 37

-RF: 50-80 years old, history of atherosclerotic disease
-Etiologies: Emboli from carotid artery atherosclerosis MC, Cardiogenic emboli (2nd MCC overall)
-Symptoms: Acute, sudden painless monocular vision loss. May have ipsilateral carotid bruit.
-Fundus exam: retinal ischemia, pale retinal with cherry red macula. Boxcar appearance of retinal vessels.
-Management: CO2 rebreathing, 100% oxygen, ocular massage, ophthalmology consult.
-Poor prognosis even with treatment

Question 38

Central Retinal Vein Occlusion (CRVO)
-Risk Factors
-Symptoms
-Diagnostics (what is seen on Fundus exam)
-Management

Answer 38

-RF: HTN, DM, Glaucoma, Hypercoagulable states (Polycythemia Vera, etc.), Smoking
-Symptoms: Sudden onset of painless monocular vision loss.
-Fundus: Extensive retinal hemorrhages (blood and thunder appearance). Retinal vein dilation, macular edema, optic disc swelling. May have Marcus-Gunn Pupil.
-Management: no definitive treatment