ENT and Ophtho - 2019 Updated! Flashcards
Give a condition that corresponds to the following eye conditions:
a. Coloboma
b. Dislocated Lens
c. Aniridia- absent iris
d. Glaucoma
a. Coloboma- defect in iris- CHARGE
b. Dislocated Lens- Marfan’s
c. Aniridia- absent iris- WAGR (Wilms Tumour-aniridia syndrome)
d. Glaucoma- NF1, SWS (Sturge Weber)
What underlying diagnosis would you suspect in a child with tearing, photophobia and blepharospasm?
Glaucoma
blepharospasm is twitching/contraction of eyelid
21 m with crusty yellow discharge from Left eye and conjunctivitis. Normal visual acuity, no propotosis, no periorbital swelling, normal EOM. You prescribe cipro topical drops. At 36 h exam, unchanged. What is your next step?
a. Refer to ophto
b. Prescribe IV antibiotic
c. Continue and return in 48 h
d. Prescribe fucidic acid drops
a. Refer to ophto - should see response in 1-2 days - if no response then refer to ophtho
* note - fucidic acid is a steroid antibiotic drop - only ophthalmologists should put steroids in eyes!
What is the management of bacterial conjunctivitis?
warm compresses; topical antibiotics (gent/tobra or cipro)
What type of bacteria would you suspect are causing this eye infection and how should it be treated? - significant conjunctival injection, edema (chemoses), gritty sensation, purulence, tenderness on palpation.
Neisseria gonorrhea or meningitidis
Needs treatment with systemic antibiotics (not topical)
Child 3 y/o referred for behaviour problems. Mom concerned because child refuses to wear patch for
amblyopia for the past 8 months. What do you do?
1. Refer to social work
2. Immediate referral to ophthalmology for other treatment modalities
3. Refer to ophthalmology once child has started to wear patch again
4. Refer to parenting class through public health to learn skills to make child wear patch
- Immediate referral to ophthalmology for other treatment modalities
Can do chemical patching with atropine drops
When would your refer a child with esotropia or exotropia to an ophthalmologist (2 lines)?
o Refer if: (goal- normal sight, straight looking eyes, binocular vision)
- Constant strabismus at any age
- Intermittent manifest strabismus after 4-6 mos
- Persistent esodeviation after 4 mos
- Positive corneal light reflex test or cover-uncover tests
- Asymmetry of pupil
- Deviation that changes depending upon position of gaze (incomitant strabismus)
- Torticollis not explained on MSK basis
- Complaints of diplopia or eye fatigue
- Parental concern about ocular alignment
- Decreased visual acuity
Picture of child. Apparent right esoptropia but normal corneal reflex. What is the diagnosis?
pseudostrabismus
3 mo Baby with crusty yellow eye discharge, no conjunctivitis, on and off for past 3 months. What is your management? a. Refer to ophto b. Massage tear duct c. Topical abx daily d. Dacryrhinostomy
b. Massage tear duct
blocked tear duct (nasolacrimal duct obstruction; dacryostenosis)
Tx: massage 2-3 times daily; cleanse any discharged liquids with warm water; can use topical antibiotics for mucopurulent drainage but IF red/hot/swollen/tender/febrile needs systemic abx
Refer at 9-12 mos if not resolving
A baby has congenital nasolacrimal duct obstruction (dacrostenosis). What statement is true about this condition?
a) it is present at birth
b) baby may develop dacrocystitis
c) it should be treated with topical antibiotics
d) it is always symptomatic at birth
b) baby may develop dacrocystitis
a is also true
3mos with Nasolacrimal duct obstruction, what to do:
a) observe
b) refer to ophtho
c) topical abx
d) systemic abx
a) observe
96% resolve by one year of age
Treatment for nasolacrimal duct obstruction?
a . Nasolacrimal massage 2 – 3 times per day with cleaning lids with warm water
b. 96% resolve by 1 year of age
c. Ophthalmology referral during the first 6 months is not necessary unless there are multiple cases of acute dacryocystitis or large congenital mucocele
d. Most Ophthalmologist advise referral between 6 – 13 months because during this period simple probing of the duct is curative in 95%
e. After 13 months the cure rate with probing alone falls to 75% and silicone intubation of the duct is necessary
a . Nasolacrimal massage 2 – 3 times per day with cleaning lids with warm water
This is the right “treatment” option, but everything else here is true as well
3 causes of leukocoria
Leukocoria = white pupillary reflex (white instead of red)
- cataract
- retinoblastoma
- chronic retinal detachment
- advanced ROP (cictricial)
A child is found to have different sized pupils. The physical exam is otherwise normal. Which statement is true:
a. unequal pupils are seen in 25% of normal children - seems most correct
b. it is an autosomal recessive trait - autosomal dominant per OMIM
c. the larger pupil is abnormal - no could be the larger or the smaller
d. the larger pupil will have an abnormal shape - not necessarily, though maybe if associated
with coloboma
CORRECT: a. unequal pupils are seen in 25% of normal children (anisocoria)
b. it is an autosomal recessive trait - autosomal dominant per OMIM
c. the larger pupil is abnormal - no could be the larger or the smaller
d. the larger pupil will have an abnormal shape - not necessarily, though maybe if associated with coloboma
Physiologic anisocoria (also known as simple or essential anisocoria) is the most common cause of a difference in pupil size of 0.4 mm or more
What are pathologic causes of anisocoria? (name 2)
Horner syndrome (can be caused by underlying neuroblastoma)
congenital iris defects (coloboma, aniridia)
medications (topical)
- err on the side of referring to ophtho
What are features of physiologic/simple anisocoria?
less than 0.4mm difference between the sides usually persistent (look back through old photos and see if it has always been there)
Which sport is the most common cause of eye injury in Canada:
a. baseball
b. hockey
c. soccer
d. golf
e. javelin
f. basketball
basketball
The sports that most commonly cause eye injuries, in order of decreasing frequency, are basketball, water sports, baseball, and racquet sports.
Child with hyphema, when is rebleeding most likely to occur
a) 24 h
b) 4 days
c) 1 week
d) 2 week
b) 4 days
Mgmt: head of bed to 30 degrees, bed rest, shield without underlying patch on affected eye, consult ophtho (they will prescribe topical steroids and cycloplegia agent)
If there is a hyphema, list 2 steps in your immediate management. What is 1 complication if not treated properly?
Urgent optho evaluation Bed rest - HOB at 30 degrees Eye shield Pain control Treat nausea
Complication: loss of vision due to: rebleeding, glaucoma, corneal blood staining
Picture of a stye. What is this? How do you treat it?
Stye AKA hordeolum - inflammation and infection (staph) of sebaceous glands in the eyelid
- treat with warm compresses and consider topical antibiotics
- Optho referral in 2 weeks if no improvement
What is a chalazion and how do you treat it?
chronic inflammation of sebaceous glands (it is a lipogranuloma)
- tx: referral to ophtho for surgical excision
Description of an infant with a hemangioma on the eye lid. List 2 thing you would do for immediate management
- assess visual acuity
- evaluation by ophthalmologist
- consider initiation of oral propanolol
- assess for other hemangiomas on face, especially in beard distribution
5year old boy, with serous and mucoid discharge from left eye (exact words). No periorbital edema or erythema. Mom and brother had a similar episode a week ago. How do you manage? a. reassure b. start antibiotics drops c. po keflex d. CT orbits
a. reassure
Contact lens kid on cipro drops. Exam unchanged after 48 hours. Mgt?
a) ref to ophtho - with contact lenses should always err on side of sending to ophtho
5 yo girl holding 2 month old baby sister who accidentally pokes her eye (corneal abrasion on fluorescein)?
List 2 steps in managing.
- topical antibiotic ointment (e.g. erythromycin) 4x/day for 3-5 days
- ibuprofen or Tylenol for pain
- plan follow-up to ensure resolved in 24-48 hours
symptoms of corneal abrasion: pain, tearing, photophobia, decreased vision
Which is true regarding retinal hemorrhages:
a. needed to diagnose shaken baby syndrome
b. can occur in a vaginal delivery
c. do not occur after a C-section
d. always associated with trauma
e. can occur with CPR
b. can occur in a vaginal delivery - yes, 25%, higher if vacuum assisted - 100% will be resolved by 6-8 weeks
Can occur with C/S but less likely; CPR is a rare if at all true cause of retinal hemorrhage; can be atraumatic
Picture of large confluent round red lesion centrally on fundus with central targetoid pale lesion
overlying it, normal optic disc can be seen) Which of the following diagnoses is this fundi consistent with:
a. Toxoplasmosis
b. Shaken baby syndrome
c. Late finding in ROP
d. Tay-sachs disease
ANSWER: d. Tay-sachs disease - cherry red spots
- cherry red spots bright red with lighter halo
- T-S is a sphingolipidosis
a. Toxoplasmosis - chorioretinitis - darker red with central light spot
b. Shaken baby syndrome - retinal hemorrhage
c. Late finding in ROP - tortuous vessels
You are seeing a 3 year old girl in your Emergency department. Her parents noticed that her right upper eyelid was mildly reddened and swollen before going to bed last night. This morning, she awoke with significant swelling and redness of the right upper and lower eyelids,
to the point of being unable to open the eye. She is febrile at 38.6 degrees, but appears otherwise well.
Name 4 signs on physical examination that would make you suspect an orbital cellulitis vs. a periorbital cellulitis.
Orbital cellulitis
- change in visual acuity
- pain with EOM
- proptosis
- ophthalmoplegia - weak eye muscle leads to restricted EOM +/- diplopia
In a 1 year old child, which sinus would be developed
a. Ethmoid
b. frontal
c. sphenoid
a. Ethmoid
EMSF
- ethmoidal and maxillary sinuses are present at birth but only ethmoidal sinuses are pneumatized
- maxillary sinuses pneumatize at age 4 years
- sphenoidal sinuses present at 5 years
- frontal sinuses begin development at 7-8 years and are not fully developed until adolescence
Which is the last sinus to develop:
a) frontal
b) maxillary
c) sphenoidal
d) anterior ethmoid
e) posterior ethmoid
a) frontal
EMSF
- ethmoidal and maxillary sinuses are present at birth but only ethmoidal sinuses are pneumatized
- maxillary sinuses pneumatize at age 4 years
- sphenoidal sinuses present at 5 years
- frontal sinuses begin development at 7-8 years and are not fully developed until adolescence
What is most likely to be associated with hearing loss?
a) prematurity
b) congenital CMV
c) APGARs of 2 at 1 minute
d) Sibling with language delay
b) congenital CMV
most common infectious cause of congenital sensorineural hearing loss (1/100 newborns have
congenital CMV and 75% of these have SNHL)
- the others are all also risk factors for hearing loss
Daycare worker worried about child’s hearing. What would be suggestive on history?
a) maternal lasix
b) congenital CMV
c) history of delayed language in a sibling
b) congenital CMV
16 month boy has episodes (once weekly) of falling down suddenly and refusing to get up. Remains conscious. Recovers in a few minutes. Sometimes vomits. Eyes are noted to move during the episode. What is his diagnosis (1)? What is one associated condition (1)?
- benign paroxysmal vertigo of childhood(age of onset 2-12 years)
- associated condition is migraine (it’s a migraine variant)
Name 4 perinatal risk factors for the development of sensorineural hearing loss. (may be asked to name 4 non-infectious risk factors in newborn period)
- TORCH infection (CMV, rubella, syphilis, HSV, toxoplasmosis)
- low birth weight (<1500g)
- Hyperbili
- Apgars 0-4 at 1 minute
- Ototoxic medications (ahminoglycosides, loop diuretics)
- ventilation more than 5 days
Which is the most objective test to detect a middle ear effusion:
a) otoscopy
b) audiometry
c) tympanometry
d) auditory evoked potentials
e) Weber and Rhine tests
c) tympanometry
- gives info about TM compliance (if the middle ear is filled with fluid the TM will be non compliant)
A boy has an acute onset of right ear pain and progressive right facial weakness. On examination his TM is normal, but there is pain with movement of the pinna and vesicles visible in the ear canal. He is afebrile and his cranial nerve examination is normal apart from an inability to wrinkle his forehead, close his eye or smile on the right side. What is your treatment:
a. IV cloxacillin
b. PO prednisone and PO acyclovir
c. Physiotherapy for nerve stimulation
d. Tympanocentesis
b. PO prednisone and PO acyclovir
- remember ocular lubricant to protect cornea, esp at night since eye cannot close
- facial nerve travels through middle in ear in up to 50% of people (so any infection or inflammation there causes facial nerve paralysis)
- this kid has Ramsay-Hunt syndrome (vesicles in external ear canal and ipsilateral facial nerve palsy)
