EENT #4 Flashcards
What is papilledema?
Optic nerve swelling secondary to increased intracranial pressure (usually bilateral)
Symptoms of papilledema
- Vision often preserved
- Headache
- Nausea
- Vomiting
Diagnostics for papilledema
- Funduscopy: swollen optic disc with blurred margins
- MRI or CT scan of the head to rule out mass
- Then Lumbar Puncture (increased CSF pressure)
How do you manage papilledema?
Acetazolamide: decreases production of aqueous humor
Treat underlying cause
True or False, in papilledema, there is no Marcus-Gunn pupil present?
True
What is optic neuritis?
CN II Inflammation
Acute inflammatory demyelination of the optic nerve
Optic Neuritis is MC in ______ and young patients ______
Women
Aged 20-40 years old
Etiologies of optic neuritis
- Multiple Sclerosis
- Autoimmune
- Ethambutol, Chloramphenicol
Symptoms of optic neuritis
- Painful loss of vision
- Decrease in color vision (desaturation)
- Visual field defects: central scotoma (blind spot)
- Usually unilateral
What is seen on physical exam in a patient with optic neuritis?
- Ocular pain worse with movement
- Marcus-Gunn Pupil: relative affarent pupillary defect
- Optic disc swelling, blurring
What is a Marcus-Gunn Pupil?
During swinging flashing test from unaffected eye to affected eye, pupils appear to dilate
What confirms the diagnosis of optic neuritis when MS is suspected?
MRI
Management of optic neuritis
- IV Methylprednisolone initially followed by oral corticosteroids
- Vision usually returns to normal without treatment
MCC of Marcus-Gunn Pupil
Optic neuritis
-Other causes: CRVO, CRAO, retinal detachment
What is an Argyll-Robertson Pupil?
Near-light dissociation
Pupil constricts on accommodation but does not react to bright light
MCC of Argyll-Robertson Pupil
Neurosyphilis
-Other causes: Diabetic neuropathy, Midbrain lesions
What kind of visual field defect would be present if there is lesion in the midline optic chiasm (pituitary adenoma)?
Bitemporal Heteronymous Hemianopsia
What is the leading cause of preventable blindness in the US?
Acute narrow angle closure glaucoma
Risk factors for an acute angle closure glaucoma attack?
- Narrow angle or large lens
- Age > 60
- Hyperopes (farsightedness)
- Females
- Asians
What is the pathophysiology of acute narrow angle closure glaucoma?
-Decreased drainage of aqueous humor via trabecular meshwork and canal of Schlemm
What are precipitants of angle closure attacks?
- Mydriasis (pupillary dilation) closes the angle further
- -Dim lights
- -Sympathomimetics
- -Anticholinergics
Symptoms of an acute angle closure glaucoma attack
- Sudden onset of severe, unilateral ocular pain
- Halos around lights and loss of peripheral vision
- Nausea
- Vomiting
- Headache
What is seen on exam of a patient with an angle closure glaucoma attack?
-Conjunctival erythema
-Cloudy, steamy cornea
-Mid-dilated fixed pupil (reacts poorly to light)
Eye hard on palpation
How do you diagnose a patient with an angle closure glaucoma attack?
- Tonometry: increased IOP > 21
- Funduscopy: optic disc blurring or cupping (thin outer rim)
How do you manage a patient with angle closure glaucoma?
Combination of topical agents (Timolol, Apraclonidine, Pilocarpine) with systemic agent to lower pressure (PO or IV Acetazolamide or IV Mannitol)
What is the definitive treatment for angle closure glaucoma?
Iridotomy (laser)
What type of drug is Timolol and does it affect visual acuity?
Topical BB
No, it does not affect visual acuity
Risk factors for chronic (open angle) glaucoma
- African Americans
- Age > 40
- Family History
- Diabetes Mellitus
Pathophysiology of open angle glaucoma
-The increased IOP is due to reduced aqueous drainage through trabeculum which eventually damages the optic nerve
Symptoms of chronic open angle glaucoma
- Usually asymptomatic until later in disease
- Slow progressive painless bilateral peripheral vision loss progressing to central loss
What is seen on physical exam in chronic open angle glaucoma?
Cupping of the optic disc
Increased cup to disc ration
Notching of the disc rim
Management of chronic open angle glaucoma
- Reduce IOP: Latanoprost (Prostaglandin) is first-line
- Laser therapy (trabeculoplasty) if medical therapy fails
- Surgery is last-line treatment
What is Amaurosis Fugax?
Transient monocular vision loss (lasting minutes) with complete recovery
What are some causes of Amaurosis Fugax?
- Retinal emboli or ischemia
- GCA
- CRAO
- Migraine (visual aura)
- SLE
Symptoms of Amaurosis Fugax
- Vision loss descending over visual field
- Temporary curtain or shade comes down and lifts up within 1 hour
What is common in the history of patient with a central retinal artery occlusion (CRAO)
50-80 years old
History of atherosclerotic disease
MC etiology of a CRAO
- Emboli from carotid artery atherosclerosis MC
- Cardiogenic emboli 2nd MC, but MC in young patients
Symptoms of CRAO
- Acute, sudden painless monocular vision loss (may be preceded by Amaurosis Fugax)
- May have insulated carotid bruit (same side)
What is seen on funduscopy of patient with a CRAO?
- Pale retina with cherry-red macula
- Boxcar appearance of retinal vessels (segmentation of retinal flow)
- Emboli may be seen
How do you manage a patient with a CRAO?
- Co2 rebreathing
- 100% oxygen
- Ocular massage to dilate vessels and dislodge clot
- Acetazolamide
- Ophthalmology consult
What is a CRVO?
Thrombus in the central retinal vein that leads to fluid backup in the retina
Risk factors for CRVO?
DM HTN Glaucoma Hypercoagulable states (polycythemia vera) Multiple Myeloma Smoking
Symptoms of a CRVO
Sudden painless monocular vision loss
What is seen on a funduscopy in a CRVO?
Extensive retinal hemorrhages (blood and thunder appearance)
-Retinal vein dilation, macular edema, optic disc swelling may be seen
True or False: There is no definitive treatment for a CRVO?
True
Review Eye muscles and movements they make
