EM Ophtha 7

Question 1

____ eyes have higher risk of acute angle-closure glaucoma

Answer 1

Hypermetropic (farsighted) eyes, having a shorter anterior to posterior length, a flatter cornea, and a narrower angle

Question 2

clinical features of acute angle-closure glaucoma

Answer 2

sudden painful vision loss
frontal or supraorbital headache
nausea and vomiting

fixed, midposition pupil
hazy cornea with conjunctival injection, most prominent at the LIMUS
rock hard eye

Question 3

triad PE for acute glaucoma

Answer 3

cloudy corniea
fixed midposition pupil
rock-hard globe

Question 4

carbonic anydrase inhibitors

Answer 4

ACETAZOLAMIDE 500 mg IV or PO, then 250 mg IV or PO 4 hours later,
max 1000 mg/day

BRINZOLAMIDE 0.5%, 1 drop, 3x daily

DORZOLAMIDE 2%, 1 drop, 3x daily

Question 5

topical beta blockers

Answer 5

TIMOLOL 0.5%, 1 drop, 2x daily

BETAXOLOL 0.5%, 1 droip, 3x daily

Question 6

topical a2-agonist

Answer 6

APRACLONIDINE, 1%, 1 drop 3x daily

BRIMONIDINE 0.2%, 1 droip, 3x daily

Question 7

hyperosmotic agent

Answer 7

MANNITOL, 15% or 20% solution, 1.5-2 g/kg IV over 30 minutes

GLYCERINE, 1-2 g/kg/dose orally, repeat every 5 hours

Question 8

remarks on pilocarpine

Answer 8

no longer recommended in the acute setting as cholinergic agents can paradoxically result in shallowing of the anterior chamber and further closure of chamber’s angle

Question 9

other treatment modalities in glaucoma

Answer 9

for pain and vomiting:
FENTANYL
- also lowers LOC [whereas ondansetron has no effect on IOP]

Question 10

Remarks on optic neuritis

Answer 10

visual loss is usally unilateral but can be bilateral

color vision is affected more commonly than visual acuity, and there may be visual field deficits

red desaturation test is helpful

can be idiopathic or an initial presentation of MULTIPLE SCLEROSIS

Question 11

List of eye diseses with acute visual loss WITHOUT PAIN

Answer 11

1. CRAO
2. CRVO
3. Retinal detachment
4. Temporal arteritis

Question 12

thinnest portion of the retina

Answer 12

macula

Question 13

remarks re ophthalmic artery

Answer 13

first branch off the internal carotid artery

supplies the central retinal artery

Question 14

CRAO: irreversible loss of visual function usually occurs after _______ of ischemia

Answer 14

4 hours

Question 15

clinical features of CRVO

Answer 15

Loss of vision is variable, ranging from vague blurring to rapid, painless, and monocular loss of vision

fundoscopy:
“blood-and-thunder fundus”:
optic disk edema and diffuse retinal hemorrhages in all quadrants

Question 16

CRVO vs papilledema vs optic neuritis

Answer 16

papilledema: bilateral optic disk edema (vs CRVO’s unilateral)

optic neuritis: peripheral retina is normal (vs CRVO’s diffuse retinall hemorrhages in all quadrants)

Question 17

remarks on flashing lights and floaters

Answer 17

binocular complaints are almost always intracranial (i.e., ophthalmic migraines)

mocular complaints are almost alway related to the symptomatic eye

Question 18

features of giantcell / temoral arteritis

Answer 18

headache
jaw claudication
fever, fatigue, myalgia, anorexia
temporal artery tenderness

ESR 70-100 mm/hour
CRP elevated

Question 19

treament of giant cell arteritis

Answer 19

HIGH-DOSE CORTICOSTEROIDS
if no visual complaints:
PREDNISONE 60 mg OD, until ff up with ophtha within 1 week

with visual loss:
admit
high-dose IV methylprenisolone
500-1000 mg per day for 3 days

“Steroids should not be delayed while waiting for a temporal artery biopsy to be performed; however, biopsies whould be performed within 1 week of starting steroid therapy”

Tocilizumab is recommended for those resistant to or unable to take corticosteroids

Question 20

acute cranial nerve III palsy with ipsilateral pupillary dilatation is ___________ until proven otherwise

Answer 20

posterior communicating artery aneurysm

Question 21

normal optic nerve sheath measurements

Answer 21

adult: 5.0 mm in diameter
children: 4.5 mm
infants: 4.0 mm

*measured 3 mm posterior to the globe (US contrast is greatest at this point)

**values above threshold of 5.7 to 6.0 mm predicts intracranial pressure >20 mm

Question 22

clinical features of CRAO

Answer 22

Sudden (occurring over seconds), profound, painless, monocular loss of vision - characteristic of CRAO
The event is often preceded by episodes of AMAUROSIS FUGAX (transient visual loss)

PE
afferent pupillary defect
pale retina
cherry red macula

Question 23

management of CRAO

Answer 23

more recent studies support IV tissue plasminogen activator within 4.5 hours of symptom onset, however, ophthalmologists have not yet reached consensus on optimal management

there is no evidence supporting or refuting the success of maneuvers such as

• digital massage or
• intraocular pressure-lowering drugs or
• breathing into a paper bag to increase partial pressure of arterial CO2

Question 24

management of CRVO

Answer 24

while no universally beneficial treatment exists, anti-vascular endothelial growth factor (anti-VEGF) and laser-induced chorioretinal anastomosis show promise

Question 25

anti-VEGF eye medications

Answer 25

intravitreal
bevacizumab
ranibizumab
aflibercept