Exam 2 Flashcards
1
Q
When does normal vision develop?
A
During infancy and childhood
2
Q
Focused visual stimuli are critical to:
A
Normal sight developmentEarly detection and correction of vision problems
3
Q
Visual Development-a) Newborns follow:b) By 2-3 months infants follow:c) By 4-6 months:
A
a) Facesb) Lights and high contrast objectsc) Visual system matures (20/40)
4
Q
Symptoms of Potential Eye Problems
A
Rubbing the eyesShutting or covering one eyeTilting or turning headSquintingInability to see distant objects clearlyBumping into walls or objectsHolding objects close to seeCrossing of eyes
5
Q
Red Reflex
A
Screen for posterior segment (RETINA) abnormalities or corneal opacities
6
Q
3 Categories of Visual Impairment
A
Neurological abnormalities that mimic vision impairmentVision impairment with NystagmusVision impairment without Nystagmus
7
Q
Neurological Abnormalities mimicking visual impairments
A
Developmental delay or autism - poor visual fixation
Poor occulomotor control - cerebral palsy or congenital motor apraxia
8
Q
define Nystagmus:
A
rhythmic oscillation of the eyes
usually horizontal, but can be vertical or rotatory
9
Q
Visual Impairment with Nystagmus
A
any disorder of the **bilateral anterior visual pathways (cornea to geniculate body) **that affects the visual acuity under the age of 2 almost always results in nystagmus
ex: Congeital cataracts, anterior segment anomalies, retinal degenertation/dystrophy, optic nerve anomalies
10
Q
Visual Impairment without Nystagmus is (almost always) caused by-
A
cortical visual impairment or delayed visual maturation
abnormality of the posterior visual pathways
- Hypoxia
- Hemorrhage
- Cerebral malformations
- Metabolic disorders
- Infections
11
Q
define Amblyopia:
A
lazy eye - loss of one eye’s ability to see details
in the absence of proper visual input from the visual pathway the brain “shuts down” the vision in the affected eye
12
Q
Amblyopia causes
A
prolonged abnormal visual experience
- distortion of normally clear retinal image (cataracts, refractive difference between eyes)
- abnormal binouclar interaction (Strabismus)
13
Q
Amblyopia treatment
A
address refractive errors
visual rehabilitation - patching eyes, fogging the good eye with chemicals or lenses
14
Q
define Strabismus:
A
misalignment of one eye relative to the other in one or more positions of gaze
15
Q
Manifest Strabismus (Tropia)
A
occurs spontaneously
may be constant or intermittent
examiner cannot induce it
16
Q
Latent Strabismus (Phoria)
A
apperent only when single binocular vision is disrupted (Cover Test)
can be induced by examiner
17
Q
Comitant Strabismus
A
misalignment is the same in all positions of gaze
18
Q
Incomitant Strabismus
A
misalignment is apperent in only certain positions of gaze
19
Q
Testing for Strabismus
A
corenal light reflexes
cover test
extraocular rotations
red reflex
20
Q
define: Esotropia
A
visual axes of the eyes are convergent
21
Q
Congential (Infantile) Esotropia
A
onset in first year of life
large, obvious deviation
treatment: surgery
22
Q
Accomodative Esotropia
A
cuased by excessive focusing due to normal accomodation in uncorrected hyperopia
intermittent intially and gradually becomes constant
age of onse ~2 years (6m -7y)
managment: glases, amblyopia treatment, surgery
23
Q
Nonaccomodative (Aquired Esotropia)
A
caused by unequal refractive errors, cataracts, corneal scarrring
treat underlying condition
24
Q
define: Exotropia
A
visual axes of the eyes are divergent
25
Exotropia
begin intermittently after age 2
child often closes one eye in bright sunlgiht
more noticeable when fatigued or ill
26
Color Blindness
80% of white-males have some red-green deficiency
familial
tested using Ishihara tests
27
Retinoblastoma
most common childhood occular tumor
can be hereditary (bilateral) or sporadic (unilateral)
28
Occular Tumors: Congenital Cataracts
can be secondary to trauma or inherited
can be unilateral or bilateral
29
Retinopathy of Prematurity
common in infants
incomplete retinal vascularization, can lead to retinal detachment
30
define: Emmetropia:
Visual condition in which an infinitely distant fixated object is imaged sharply on the retina (without an accommodative response)
31
What vision does this diagram represent?
Emmetropia
32
Refraction:
**Altering of the pathway of light** from its original direction, result of passing from one medium to another
33
Ametropia:
Refractive condition in which **parallel rays do not focus on the retina**; a deviation from emmetropia (abnormal vision)
34
define Myopia:
Refractive condition in which parallel rays of light entering the eye, _focus in front of the retina_; **nearsightedness**
Corrected using LASIK surgery
35
What vision does this diagram represent?
Myopia
36
Lenses for myopia
* Minus
* Concave
* Diverging
37
define Hyperopia:
Refractive condition in which parallel rays of light entering the eye f_ocus behind the retina_; **farsightedness**
38
What vision does this diagram represent?
Hyperopia
39
Lenses for hyperopia
* Plus
* Convex
* Converging
40
define: Astigmatism
Refractive condition in which **rays emanating from a single point are focused as two line images (blurry vision at all distances)**, generally at right angles to each other; due to unequal refraction of the incident light in different meridians
Eye becomes astigmatic when any of its refracting surfaces assumes a toroidal shape
**Eye is not perfectly round** (ex: football shaped not basketball shaped)
41
What type of asitgmatism is this?
compound myopic astigmatism
42
What type of astigmatism is this?
Compound hyperopic astigmatism
43
What type of astigmatism is this?
Mixed astigmatism
44
define Presbyopia:
**Reduction in accommodative ability** occurring normally with age and necessitating a plus lens addition for satisfactory seeing at near
Amplitude decreases from childhood to age 75
45
Presbyopia
affects 100% of people
treat with reading glasses
corrected surgically using: Conductive Keratoplast or Scleral Spacing Procedure (FDA trial)
46
define Accommodation:
_Ocular adjustment_ for vision at various distances, by _changes in shape (steepening) of the crystalline lens_
47
define Diplopia:
Condition in which a single object is perceived as two objects rather than as one; double vision
* usually results from EOM imbalance
* monocular: persists when fellow eye is covered
48
define: Anisometropia:
Condition of **unequal refractive state for the two eyes,** one eye requiring a different lens correction from the other
49
Six Elements or Major Categories of Eye History
1. chief complaint
2. medical history
3. medications/ hypersentitivities
4. visual and occular history
* last eye exam
* galsses or contacts
5. family eye and medical history
* cataracts, glaucoma, macular degneration
6. vocational and recreational demands
50
VISUAL Symptoms of Ocular Discomfor**t**
* Blurred vision
* Diplopia
* Distortion
* Vertigo
* Glare/light sensitivity
* Spots before eyes
* Light flashes
* Loss of vision
* Halos around lights
* Loss of visual field
* Night blindness
* Movement of field
51
OCULAR Symptoms of Ocular Discomfort
* Itching or burning
* Tenderness, soreness
* Pain, foreign body sensation
* Excessive lacrimation
* Change in blink rate
* Warm, hot, tired feeling
* Twitching of lids
* Mattering of eyelids
52
REFERRED Symptoms of Occular Discomfort
* Headache
* Fatigue
* Stress
53
Physical Exam
Visual Acutiy: Snellen
Pupils: size, shape, equality; reaction to light (PERRLA)
Extra-ocular muscles: movements of eyes into 6 cardinal positions (H test)
Visual field: confrontation testing
Anterior Segment Exam: slit lamp or pen light look at - lids, lashes, lacrimal gland, cornea, conjuntiva, iris, lens
Direct Ophthalmoscopy: media - cornea, lens, vitreous, disc, macula, vessels
54
Physical Exam: Visual Acuity
* Patients will usually get some letters correct and some incorrect as the letter size approaches their threshold
* Non-conventional methods: Near/Tumbling E/Pictures
* **Pg. 66 Mosby's Record line in which they miss NO letters**....(Evan)
55
Four Cardinal Eye Complaints
1. Changes in Vision
2. Changes in Appearance
3. Pain or Discomfort
4. Trauma
56
Cardinal Changes: Change in Vision
* Painless or Painful
* Extent of Vision Loss
* One or Both Eyes:
* Bilateral: neurologic etiology, not a primary problem
• Flashes or Floaters
* Multiple – retinal tear, vitreous hemorrhage
* Single – benign
• Rate of Onset
* Rapid deterioration: vascular cause
* Gradual loss: cataracts
57
Cardinal Changes: Pain or Discomfort
* Pain or no pain?
* Foreign body sensation
* Excessive tearing
* Itching or burning
* Light sensitivity
58
Cardinal Changes: Trauma
* Tetanus immunization state
* Fluid or chemical exposure
* Blunt or penetrating injury
59
Special Tests: Sit-Lamp Examination
Highly magnified views of: anterior segment and posterior segment
60
Special Tests: Intraocular Pressure
Analogous to systemic blood pressure
IOP – 8 to 21 mm Hg
Glaucoma screening
61
Emergent Conditions (immediate referral)
o Sudden Vision Loss
o Retinal Artery Occlusion
o Chemical Burns
o Acute Angle-Closure Gluacoma
62
Urgent Conditions
| (referal with 1 day or less)
o Acute glaucoma
o Orbital cellulitis
o Hyphema
o Corneal Ulcer
o Retinal Detachment
63
Implantable Collamer Lens (ICL)
used in patients who cannot have lasik (too nearsighted)
in surgery - cut the limbus, insert the ICL next to the patient's lens
64
Occular Maturity
often occurs at age 18
vision change of less than +or- 0.75 within 1 year
65
Cataract
natural **clouding** (or darkening) of lens
age dependent
typically affects older adults (60+), can occur in infants or children - rarely
**Leading cause of preventable blindness world wide**
66
Cataract Surgery
Entry Incision
Capsulorhexis (cutting the lens)
Phacoemuslification (use ultrasound to destroy lens)
Lens placement (standard, multifocal, accomodative lens types)
Corneal Arcuate Incisions (correct astigmatism if needed)
67
Keratoconus
**Cone-shaped cornea**
Progressive blinding disease
No good treatment - corneal transplant, Collagen Cross-Linking (Clinical Trial)
68
Identify this condition and describe the treatment:
pt reports - burning, gritty sensation that gets worse in the evenings
**Dry Eyes**
common with aging, F \>M, often worse when reading
exposure: Bell's palsy, Thyroid eye disease, scarred or malpositioned lids
may be associated with: rheumatological disorders, Stevens-Johnson, systemic meds
tx: artificial tears, lubricating ointment, punctal plug, Restasis, lid taping
69
Identify this condition and describe the treatment:
red, swollen lids and skin
normal: vision, pupils, occular motility, conjunctiva
**Anterior (preseptal) cellultis**
cause: trauma, URI, sinusitis, otitis
tx: cool compresses, systemic antibiotics
hospitalize if a child \< 3
70
Identify this condition and describe the treatment:
spontaneous blood red eye, with normal vision, no pain and no discharge
**Subconjunctival Hemorrhage**
tx: resolves in 2-3 weeks on own
71
Identify this condition and describe the treatment:
localized or diffuse redness, deep red, pain
pt: history of RA
**Episcleritis/Scleritis**
scleritis - deep red, pain, can be vision threatening
idiopathic may have rheumatologic/autoimmune associations
tx: refer to ophthalmologist
72
Identify this condition and describe the treatment:
red eye, watery discharge, foreign body sensation, dendrite branching
**Viral Keratitis**
cause: Herpes Simplex Virus (type 1)
refer: STAT
73
Identify this condition and describe the treatment:
thick, red lid margins with crusting, some loss of eye lashes
**Blepharitis**
staphylococcal, seborrheic (meibomian gland dysfunction)
tx: warm compress, lid hygiene, topical antibiotics ung (ointment), oral antibiotics
74
Identify this condition and describe the treatment:
watery discharge with stringy mucus, itching
pt is an asthmatic
**Allergic Conjunctivitis**
ITENSE ITCHING
hx: allergy, ashtma, atopic/allergic disease
tx: topical antihistamines, mast cell stablizers
75
Causes of this condition
hint: pt was born at 0730
Neonatal Conjunctivitis
Staph, strep, h.flu
N. gonorrhea - refer to ophthalmologist, systemic antibiotics and topical
Chlamydial - topical and oral erythromycin
76
Identify this condition and describe the treatment:
pain, tearing, foriegn body sensation, photophobia, blurred vision
fluroscein exam:
**Corneal Abrasion**
tx: cycloplegic drops, oral analgesics with codiene; topical antibiotics; pressure patch 24 hours
refer: if not healed in 24-48 hours
77
Identify this condition and describe the treatment:
red, painful decreased vision with purulent discharge
**Bacterial Keratitis**
refer STAT
78
Identify this condition and describe the treatment:
pt was at work in a lab and got something in his eye
**Chemical Injury**
tx: immediate irrigation for 15 minutes, further irrigate until pH is normal
Alkali causes more damage
refer: STAT
79
Identify this condition and describe treatment:
localized or diffuse lid cellulitis, tenderness
**Hordeola/chalazia**
inflammed lid glands due to obstructed orifces
tx: warm compress, topical antibiotic ung (ointment)
80
Identify this condition and describe the treatment:
severe eye pain, blurred vision, halos around lights, nausea and vomiting
exam: mid-dilated pupil, redness, cloudy cornea, hard eye
**Acute Glaucoma**
cause: dim lights, drugs, emotional stress
refer: STAT
81
Identify this condition and describe the treatment:
purulent discharge
**Bacterial Conjunctivitis**
cause: *Staph, Steph, Hemophilus Influenzae*
tx: warm compress, topical antibiotics, fluroquinolones
if *Neisseria gonorrhea* systemic antibiotics and hyperpurulent discharge
82
Identify this condition and describe the treatment:
circumcorneal redness, pain, photophobia, decreased vision, small pupil
**Iritis/Uveitis**
idiopathic, infectious, sarcoidosis, autoimmune disorders, trauma
refer
83
Identify this condition and describe the treatment:
watery, serous discharge, tender preauricular nodes
**Viral Conjunctivitis**
cause: Adenoviral, highly contagious
tx: no effective therapy (will clear in 1-2 weeks)
refer: pain, decreased vision, photophobia
84
Identify this condition and describe the treatment:
swollen, red lids and conjuncitva; proptosis; impaired occular motility and painful movement; decreased vision; afferent pupillary defect; optic disc edema
**Posterior (orbital) cellulitis**
tx: hospitalization, CT scan, blood cultures IV antibiotic
often a fungal infection in immunocompromised
can lead to cavernous sinus thrombosis, meningitis
85
**Vision Threatening Red Eye Disorders**
these need to be refered to ophthalmologist ASP!
orbital cellulitis
scleritis
chemical injuries
corneal infection
hyphema
iritis
acute glaucoma
86
Identify this condition and describe the treatment:
inflamamtion and irritation
pt has job exposure to sun, wind and dust
**Pinguecula** (top photo)**/Pterygium** (bottom photo)
tx: artifical tears, topical NSAIDs
refer: severe inflammation, or if pterygium is actively growing
87
Identify this condition and describe the treatment:
pt recieved a blow to the face, reports decreased vision and pain
**Hyphema**
blood in anterior chamber
refer STAT
88
Identify this condition and describe the treatment:
tearing and discharge
**Nasolacrimal Duct Obstruction**
infected tear sac (Dacryocystitis)
Congenital tx: daily massage, antibiotics if infected, refer if no resolution 6-8 months
Aquired tx: systemic antibiotics if infected, refer if chronic
89
Identify this condition and describe the treatment:
furuncle that points onto the conjunctival surface of the lid, examination shows involvement of the meibomian gland
**Stye (Internal Hordeolum)**
_meibomian gland_ involvement
can be on the upper or lower lid
can lead to generalized cellulitis
tx: warm compresses, topical antibiotics, may need I&D if conservative treatment fails
watch for cellultiis, may lead to a chronic inflammatory lesion
90
Identify this condition and describe the treatment:
pt reports foreign body sensation, burning sensation, lid crust, also has a problem with dandruff exam: no ulcerations
**Seborrheic Blepharitis**
associated with seborrheic dermatitis invovlement often of scalp, lashes, eyebrows and ears
tx: chronic condition, lid hygiene
91
Identify this condition and describe the treatment:
young infant, parents report excessive tearing
**Nasolacrimal Duct Obstruction and Dacryocystitis**
may devleop an infection
tx: massage over nasoalcrimal sac, cleanse the lids if infected use topical antibioitcs, may resolve on its own, or surgical treatement - probing of the duct
92
Exposure Keratitis
similar to dry eyes
cause: incomplete lid closure during blinking and sleep
may result from: Bell's palsy, malpositioned eyelids, thyroid exopthalmos
tx: lubricating solutions, mechanical measures to help close lid
93
define Blepharospasm:
eyes closed, lid spasms, may also have facial twitches
94
Identify this condition and describe the treatment:
hard, nontender swelling, conjunctiva - red and swollen, chronic granulomatous inflammation
**Chalazion**
_chronic granulomatous inflammation of a meibomian gland_
may follow an internal hordeolum
vision may or may not be blurred in addition to the other symptoms listed
tx: warm compresses refer: if persistent, ophthamologist may incise and curettage or corticosteroid injections
95
define Lid Retraction
eye bigger, appears to stare, upper lid pulled up, lower lid pulled down (Grave's Disease)
96
Identify this condition and describe the treatment:
localized, painful lid swelling, furuncle on the eyelid margin
**STYE** **(Acute Hordeloum- External)**
usually a _staphylocoocal_ infection
involves lash follicle and _gland Zies or Moll_
tx: warm moist compresses, topical (or oral) antibiotics, may spontaneously drain or resolve, I&D if conservative treatment fails
97
define Blepharoptosis:
upper lid droop, excess skin
98
Identify this condition and describe the treatment:
exam shows lids are hyperemic with telangiectasis, inflammation of the meibomian glands
**Posterior Blepharitis** -
inflammation of _meibomian glands_ can be bacterial (staphylococcal) or glandular dysfunction association with _acne rosacea_
99
define Entropion:
**eyelid flipped in**, lashes and skin against the eye
100
define Trichiasis:
normal lid position; **lashes directed posteriorly**
101
define Dermatochalasis
baggy eyelids
102
Identify this condition and describe the treatment:
pt reports foreign body and burning sensations and matting of the lashes exam: lid crusting, red-rims, discharge, some loss of lashes
**Staphylococcal Blepharitis**
can be intially asymptomatic, may also observe loss of lashes (ulceration) chronic condition
tx: lid hygiene, topical antibiotics for staph
103
define Ectropion:
**eyelid flipped out,** conjunctiva exposed
104
Identify this condition and describe the treatment: pt reports foreign body sensation, dryness, burning, exam shows lack of corneal and conjuctival luster, punctate erosions, stringy discharge
**Dry Eye **
**Keratitits Sicca**
**Keratoconjunctivitis Sicca**
deficiency in tear production, symptoms worsen as the condition progresses may be releated to autoimmune disorder, secondary to systemic drugs
tx: lubrication with artificial tears or ointment (Lacrilube)
105
What is the macula?
area of the retina responsible for detailed, fine central vision - made of rods and cones
106
What is the fovea?
the center of the macula
high density of CONES, NO rods
107
Describe Microaneurysms
saccular out pouching at the site of capillary degeneration
earliest ophthalmoscopic manifestation of diabetic retinopathy
108
Describe Macular Edema
breakdown of the inner blood-retinal barrier - allowing **leakage of fluid and plasma constituents into the surrounding retina**
can occur in non-proliferative and proliferative diabetic retinopathy
109
Macular Edema Treatment
**LASER**
* zaps leaking microaneurisms - no treatment of foveal avascular zone
* marked absorption of fluid and lipids
* lipids take longer to disappear by macrophages
**Intraocular Steroid Injections**
* stabilizes endothelial cells and blood-retinal barrier
* reduces immune and inflammatory response
**VEGF Inhibitiors**
* inhibits vascualar endothelial growth factor - reudcing neovascualrizaation
110
Changes in **NON-PROLIFERATIVE** diabetic retinopathy
* macular edema
* changes result due to **retinal ischemia** and **capillary obliteration**
* **_COTTON WOOL SPOTS_**
* acute swelling of axons
* intra-retinal microvascular abnormalities - dilation and duplication of the capillary bed
* venous beading (irregular diameter of retinal venules)
* capillary closure and dropout - increases Foveal Avascular Zone
111
Non-Surgical Means of Managing
Non-Proliferative Diabetic Retinopathy
Tight glycemic control
Rx hyperlipidemia
Control hypertension
112
Disease states in which vascular changes are seen:
CVO - central retinal vein occlusion
BVO - branching retinal vein occlusion
Sickle Retinopathy
Coats' Disease
Hypertension
Sarcoidosis
Radiation Retinopathy
Hyperviscosity Syndromes
Collagen Vascular Disorders
113
Pathogeneis of **Prolfierative Retinopathy**
114
Nevoascularization Elsewhere
occurs with
* severe venous beading
* intraretinal hemorrhages
* can occur anterior to the retina and into vitreous humor (which can apply traction to the NVE)
115
Nevoascularization of the Disc (NVD)
* pre retinal hemorrhage (anterior to retina and into the vitreous)
* larger fibrous component
* can cause traction of the retina
* can also be present with clinically signficant macular edema
116
Outcomes of Proliferative Retinopathy
traction retinal detachment
vitreous hemorrhage
neovascular glaucoma
117
Pathophysiology of traction retinal detachment and vitreous hemorrhage
1. neovascularization anterior to the retina
2. the posterior cortical vitreous contracts
this may induce hemorrhage - the blood will collect in the subvitreous space or vitreous cavity
118
Treatment of Proliferative Retinopathy
Viterectomy
Pantretinal Photocoagulation
VEGF Inhibitiors
119
Treatment of Proliferative Retinopathy:
**Viterectomy**
indications:
* tractional retinal detachment threatens the macula
* non-clearing vitreous hemorrhage
120
Treatment of Proliferative Retinopathy:
**Panretinal Photocoagulation**
may induce the regression of fibrovascular tissue - therefore decrease the likelihood of
* traction detachment
* vitreous hemorrhage
* neurovasuclar glaucoma
121
** Epidemiology **
as the duration of diabetes increases
* the rate of proliferative diabetic retinopathy \_\_\_\_\_\_\_\_
* the occurance of macular edema \_\_\_\_\_\_\_\_
increases
increases
122
Glycemic Control in Diabetic Retinopathy
* cannot completely prevent the occurance of retinopathy
* reduction in the rate of progression
* 35-45% reduction in risk of retinopathy progression for every 10% decrease in HbA1C
123
Other Risk factors for Diabetic Retinopathy (4)
Hypertension
Hyperlipidemia
Pregnancy
Anemia
124
Age-Related Macular Degeneration
* leading cause of severe central visual acuity loss
* chronic disease
* 2 types - Non-Exudative (Dry) and Exudative (Wet)
125
Risk Factors for AMD
age
hyperopia
smoking
low HDL and high LDL
familial history (parents \> sibling)
126
Features of Non-Exudative (dry) AMD
**drusen**
focal hyperpigmentation
retinal pigment epithelieum atrophy
127
Drusen
small or large, round, **yellow lesions - between the retinal pigment epithelium basement membrane and Bruch's membrane**
128
AERDS Supplementation in AMD
greatest reduction in conversion to advanced AMD
* lutein/zeaxanthine
* recommend AREDS 2 over AREDS 1
* anti-oxidants + zinc + copper
* zinc + copper alone
* anti-oxidatnts alone
129
Management of Non-Exduative (Dry) AMD
40-64: 2 year exam
\>65: 1-2 year exam
Daily Amsler Grid Monitoring
AREDS 2 Eye Vitamins - Vitamin C, E, Lutein/Zeaxanthine, Zinc, and Copper
Lifestyle modification - smoking cessation, optimize diet, exercise
130
What is being monitored for, using the Amsler Grid?
sudden decreased vision
**Metamorphosia**: distorted vision in which a grid of straight lines appears wavy
**Sctoma**: shadows of missing areas of vision
Blurring
131
Features of Exudative (wet) AMD
**chorodial neovascularization**
break in Bruch's membrane that allows new blood vessels to grow into the sub-RPE space
the vessels leak fluid, lipid, blood under the RPE and subretinally
can cause subretinal fibrotic scar formation
132
Management of Exudative (Wet) AMD
Anti-VEGF Drugs - Ranibizumab, Aflibercept (+PIGF)
Older therapies that have fallen out of favor: laser photocoagulation, photodynamic therapy
133
Anti-VEGF treatment
recombinant humanzied antibody fragments
one of the first therapies to stabilize and improve vision: can gain 6-9 letters instead of losing 23 letters
134
8 Point Occular Examination
1. Visual Acutiy
2. External adnexa (lids, brow, nodes)
3. Alignment and motility
4. Visual fields
5. Pupilary exam
6. Anterior Segment (conjunctiva, cornea, Anterior Chamber)
7. Posterior Segment (retina, choroid, optic nerve)
8. Intraocular Pressure
135
Identify this condition and describe the treatment and management:
patient is a cotton-headed-ninny-muggins and forgot to wear his lab goggles
**Chemical Injury**
**(pH is important determinate of extent of injury - alkali is worse)**
immediately: IRRIGATE!!!
topical anesthesia: proparacaine
cycloplegia (to prevent iris scarring)
prophylactic antibiotic
REFER STAT
136
Identify this condition and describe the treatment and management:
pt is a football player who was tackled on the turf, he is complaining of pain, increased tearing and foriegn body sensation - see photo
**Occular Surface Foreign Bodies**
Removal Techniques: flushing, cotton tipped applicator, needle, spud
tx: patching, topical antibiotic ointment, cycloplegia, oral anaglesics
refer: prolonged healing, infilitrate, increased pain, decreased vision
\*\*\*metal foreign bodies - toxic precipitate corenal breakdown, incites inflammatory response leads scarring and neovascualrization - refer because Burr required to remove rust ring
137
Signs of a Perforating Occular Injury
Corneal Scleral Laceration
Irregular Pupil
Subconjunctival Hemorrhage
Uveal Prolapse
Lens opacity or disolocation
Hyphema
138
Describe the treatment of a perforating occular injury
Shield Eye and Refer
no pressure applied - no patching
no topical meds
NPO
beware of narcotics for pain - can cause nausea and emesis - give an anti-emetic with narcotics
139
Identify this condition and describe the treatment and management:
pt was playing raquetball and got hit in the face
**Hyphema**
cycloplegia, rest, fox shield to prevent manipulation
shield eye and refer as a ruptured globe until proven otherwise
\*\*important to know vascular status - especially for sickle cell
140
Identify this condition and describe the treatment and management:
pt was hit in the face during a fight
physical exam shows: enophthalmos, restrictive diplopia, and hypothesia over the lower lid, ala of the nose, and the upper lip, teeth and gums
see CT scan:
**Orbital Fractures**
associated features: orbital hemorrhage, orbital emphysema, traumatic optic neuropathy, globe injury
tx: antibiotics, mucosal decongestents, corticosteroids, postural drainage, protection
abstience: aspirin, NSAIDs, noseblowing
surgical indications: enopthalmos (2mm or greater), restrictive diplopia, defect of \>50% of orbital wall
141
Identify this condition and describe other common clinical forms:
pt reports hitting his head and now has loss of visual acutiy and field, ipsilateral affarent pupillary defect, and dyschromatopsia (disorder of color vision)
**Traumatic Optic Neuropathy**
occurs in closed head injury patients and midfacial frature patients
clinical forms:
* indirect trauma optic neuropathy
* penetrating foreign body or fractures
* diffuse orbital hemmorrhage
* optic nerve avulsion/transection
* localized orbital hemorrhage (hematoma)
* optic nerve sheath hematoma
* tension (stage IV) orbital emphysema
142
Laceration Danger Zones of the Eyelid (3)
1. Eyelid Margin
2. Lacrimal System
3. Lid Retractors
143
describe the treatment and management:
**animal bites to the eyelid**
causative agents: cat (pasturella multocida), dogs (capnocytophaga)
tx: irrigate, debride nonviable tissue, early cloasure, antibiotics (amoxacillin, calvulnic acid)
144
Identify this condition and describe the treatment and management:
pt has proptosis, conjunctival edema (chemosis)
exam shows: reduced visual acuity, afferent pupillary defect, reduced occular motility
systemically toxic
**Orbital Cellulitis**
this is an emergency even with antibiotics mortality rate is 2% in the general population and 11% in newborns
start on systemic antibiotics
145
Identify this condition and describe the treatment and management:
pt reports ocular pain, headache located over the eyebrow, halos around lights and nausea
signs: steamy cornea, mid-dilated, fixed pupil and high IOP
**Acute Glaucoma**
tx: IV acetazolamide, topical pilocarpine, laser iridotomy
**emergent **
146
Identify this condition and describe the treatment and management:
pt reports painless vision loss, cherry red spot, chalky retina, attenuated vasculature
**Central Retinal Artery Occlusion**
emergency
lay patient flat, occular massage, high concentration of inhaled oxygen, IV acetazolamide and anterior chamber paracentsis
147
Identify this condition and describe the treatment and management:
pt reports pain less altitudinal visual field loss (loss of vision above or below the midline - see pic)
on opthalmascope exam: optic nerve swelling, **flame hemorrhages**
**Ischemic Optic Neuropathy**
can be arteritic AION (giant cell arteritis) or non-arteritic (NAION)
if caused bt giant cell arteritis - high dose systemic corticosteroid
admit and monitor closely
**refer emergently**
148
Identify this condition and describe the treatment and management:
painless sectoral vision loss
patient reports a "curtain-falling" of vision loss
**Retinal Detachment**
refer urgently
during transport postion pateint so retina will fall back into place with the assistance of gravity
photocoagulation surgery
149
Afferent Pupil
Releative Afferent Pupil Defect (RAPD) if defect in the "in" information
CN 2 (Optic Nerve)
150
Efferent Pupil
Anisocoria (unequal pupils) if defect is in the "out" signal
CN 3
Parasympathetic constricts
Sympathetic dilates
151
Near Triad
Miosis
Convergence
Accomodation
152
Pupillary Responses
Direct
Consensual
Accomodative
153
Relative Afferent Pupillary Defect (RAPD)
Marcus-Gun Pupil
**objective measure of the afferent light input of one eye compared to the other**
signifies **asymmetric pre-geniculate damage** - examples: retinal lesions, ispsilateral optic nerve, optic tract
tested by **Swinging Flashlight Test**
no anioscoria, not due to cataracts or corneal opacity
154
In an abnormally large pupil anisocoria is greatest in \_\_\_\_\_\_\_\_\_\_\_\_?
In an abnormally small pupil - anisocoria is greatest in \_\_\_\_\_\_\_\_\_\_\_\_?
abnormally large pupil - anisocoria greatest in light
abnormally small pupil - anisocoria greatest in dark
155
Identify this condition and describe the treatment and management:
**abnormally large pupil**, vermiform movement of iris, **sgemental/sector sphincter palsy**
**Adie's Pupil**
etiology: infection, inflammation, ischemia, local anesthesia, surgery, laser, trauma, autonomic
tonic pupil causes: diabetes, chronic alcoholism, encephalitis
treatment: increase biofocal strength, pilocarpine
156
Identify this condition and describe the treatment and management:
absent deep tendon reflexes, hyperthermia, syncopal episodes, dysgeusia, chronic GI motlity, tonic pupils
**Adie's Syndrome**
refer for a neurology consult
157
Pharmacologic Mydriasis
large dilated pupil
does not react to light or near
does not react well to miotics
exposure to :
* dilating drops
* parsympatholytic agents (Atropine, Asthma medicine)
* plants (Belladonna, Jimson Weed)
* pesticides
158
Cranial Nerve III Palsy
Associated with ptosis +/- EOM abnormality
Pupil involving a third nerve palsy - is an anerusym until proven otherwise
Causes: PCA aneurysm, trauma, brain tumor, microvascular ischemia
Isolated dilated pupil - not likely to be thrid nerve palsy
159
Pharmacologic Miosis
small pupil - poor reaction to light and near stimuli
exposure to:
* acetycholinesterases
* tick and flea collars
* pilocarpine and topical parasympathomimetics
160
Aberrent Reinnervation
third nerve palsy with smaller pupil
does NOT react well to light
light-near disocciation
clincial features: unilateral miosis which accompanies eye movement may also have lid elevation/retraction with eye movement
161
Horner's Syndrome Symptoms
Ptosis
Miosis
Anhydrosis
162
Etiology of Horner's Syndrome
Congenital - affected eye may be lighter, likely from birth trauma
Acquired - cartoid dissection, carotid aneurysm, apical lung tumor (Pancoast tumor), occult neuroblastoma
163
Pharmacologic Diagnosis of Horner's Syndrome
Cocaine Testing - confirms - nothing enstilled in eye before, Horner's pupil dilates less than normal one
Apraclonidine - little or no effect on a normal pupil
Localization of Horner's Syndrome - Hydroxyamphetamine Testing: done 48 hours after cocaine test
164
Glaucoma
chronic progressive ocular disease that to**leads to progressive damage to** **the optic nerve** and subsequent **loss of visual field**
major risk factor: increased IOP
165
Classification of Glaucoma
Based on Etiology
* Primary: open angle closure, congential
* Secondary: due to other ocular or systemic disease (inflammatory or lens induced glaucoma)
Based on Mechanism
* open angle glaucoma
* angle closure glaucoma
166
What is normal intraocular pressure?
10 to 21 mm Hg
167
Pathophysiology of IOP causing Optic Nerve damage
Mechanical Compression of Optic Nerve
Obstruction of blood supply and death of nerve fibers - causes hollowing of the optic nerve (cupping)
168
Eye Examination for Glaucoma
Check Vision
Refraction
Pupils (RAPD)
Measure IOP (Applanation, Tonopen, Schiotz, Pneumatonometer or palpation)
Gonioscopy
Examine Optic Nerve
Perimetry and Visual Fields - can do confrontation testing, or Humphrey Field Analyzer or Goldmen Perimetry
Imaging
169
ISNT Rule
"if it isn't ISNT then it isn't"
Rim width - distance between border of disc and position of blood vessel bending
Inferior \> Superior \> Nasal \> Temporal
170
Characteristic Field Defects
Arcuate Defects
Nasal Step
Paracentral Defect
Annular Scotomas
Temporal Wedge
Tunnel Vision with temporal Island
Enlargment of Blind Spot
171
ACUTE VISION LOSS - - - REFER IMMEDIATELY
Acute Glaucoma
Keratitis
Endophthalmitis
Vitreous or Retinal Hemorrhage
Retinal Detachment
Acute Maculopathy
Retinal Vessel Occlusions
Optic Neuritis
Ischemic Optic Neuropathy
Cortical Infart
172
CHRONIC VISION LOSS - - - REFER NON-URGENTLY
Refractive Error
Media Disturbances in the tear film, cornea, lens or vitreous
Lesions of the nueral visual pathway from the retina to the visual cortex
173
Open Angle Glaucoma
usually no symptoms
identified on routine eye exams
some patients compalin of decreased peripheral vision
prognosis: depends on stage at time of diagnosis and ability to reduce and manage IOP
174
Managment of Chronic Glaucoma
establish a baseline
set a reasonable goal for IOP
lower the pressure
continue to observe patient, modifiy if necessary
175
Prostoglandin Analogs for Glaucoma
**Xalatan, Travatan, Lumigan**
* increase uveo-scleral outflow, reducing IOP
* administered once a day
176
ß Adgrenergic Antagonists
**Timpotic, Betoptic S, Betagan**
* reduces the production of aqueous humor by inhibiting cAMP, reduces IOP
* adminstered 1-2x a day
* side effects: corneal anesthesis, ptosis, hypotony, burining, superficial punctate keratitis, dry eye
* systemic: psychosis, fatigue, BRADYCARDIA, syncope, alopecia, nausea, impotence, ASTHMA, altered response to hypoglycemia, heart failure, tinnitus, depression, anxiety, hallucinations, dysarthria, CVA
177
Sympathomimetics
**Epinephrine, Dipivefrin (Propine)**
* reduces aqueous humor production, increases outflow through trabecular meshwork
* twice a day
* side effects: local irritation, pigmentation, corenal damage, macular edema, HTN, cardiac failure
**Alpha Agonists: Iopidine, Alphagan**
* reduce production of aqueous humor, possibly increases outflow
* 3x a day
* side effects: local allergy, dry nose and mouth, fatigue, trachyphylaxis
178
Parasympathomimetrics
**Pilocarpine, Carbachol, Echothiophate**
* increases outflow facility, reduces IOP
* 2x a day for echo, 4x a day for pilo
* side effects: browache, headache, occular allergy, pupillary constriction, RD, ocular inflammation
* parasympathetic effects
179
Carbonic Anydrase Inhibitors
**Topical: Drozolamide (Trusopt), Brinzolamide (Azopt) - twice a day**
**Oral/Parenteral: Acetazolamide (Diamox), Methazolamide (Neptazane) - 2-4 x a day**
* reduces production of aqueous humor by inhibiting carbonic anydrase
* side effects: fatigue, parestheisas, metallic taste, electrolyte imbalance, acidosis, kidney stones, cardiovascualr and respiratory depressions, topical drops may cause local allergy
180
Hyperosmotic Agents
**Oral: Glyercol, Isosorbide**
**IV: Mannitol**
* reduce vitreous volume to lower IOP
* rapid effect to lower pressure within minutes
* side effects: nausea, vomiting, diuresis, cardiovascular overload, hyperglycemia in diabetics
181
Current Medical Treatments to Lower IOP
1. Prostaglandin
2. ß-Adrenergic Antagonists (ß-Blockers)
3. Adrenergic Agonists (Sympathomimetrics)
4. Carbonic Anhydrase Inhibitors
5. Cholinergic Agonists (miotics)
182
Surgical Treatments of Glaucoma
Laser - iridectomy
Trabeculectomy - guarded opening in the sclera
Glaucoma Drainage Device
183
Describe the presentation of congenital glaucoma:
* Epiphora – watering eyes
* Photophobia
* Blepharospasm
* Buphthalmos – enlargement of the eye
* Haab’s Striae - Horizontal breaks in Descemet's membrane
184
Describe Diabetic Retinopathy
leading cause of blindness in patients 20-64 years
prevelence increases with duration of diabetes and age of patient
185
Describe the retinal capillary changes in diabetic retinopathy (4)
1. microaneurysms
2. leakage of blood and fluid
3. poor blood supply/ischemia
4. growth of new abnormal blood vessels
186
Identifity the condition and describe the treatment:
pt is a type 2 diabetic of 10 years
opthalamoscopic examination shows: microaneurysms, nerve fiber layer infarcts (**cotton wool spots**) and macular edema hard exduates
**Non-Proliferative ****Diabetic Retinopathy**
Treatment:
* tight glycemic control
* Rx hyperlipidemia
* control hypertension
other microvascular changes are confined to the retina
* capillary non-perfusion
* IRMAs
* dot-and-blot intraretinal hemorrhages
* dialtion and bleeding of retinal veins
187
What is a microaneurysm?
pericyte loss - local structural weakness within the vessel wall
NO vision changes result
188
What are hard exudates?
Extracellular lipid which has leaked from abnormal retinal capillaries
fluid in the macula = blurry vision
189
Describe Macular Edema
most common cause of vision loss from diabetes
considered **clinically signifiican**t if close to the fovea or large area
diagnosis: exam, optical coherence tomography, fluroescein angiography
treatment: focal laser (zap microanuerysms), anti-VEGF, intra-ocular steroid
190
Severe Non-Proliferative Diabetic Retinopathy
4:2:1 Rule
**4 Quadrants** of diffuse intraretinal hemorrhages and **microaneurysms**
**2 Quadrants venous beading**
**1 Quadrant IRMAs**
15% chance of progessing to proliferative diabetic retinopathy within 1 year
191
Identify the condition and describe the pathophysiology and treatment
ophthalmoscopic exam shows neovascularization elswehere, decreased red reflex and vitreous hemorrhage;
pt reports increasing floaters, hx of type 1 DM
**Proliferative Diabetic Retinopathy**
retina is so ischemic that it responds by growing new blood vessels that break through the retina and bleed
* if growth off of the disc = NVD
* if growth off of the retina = NVE
this new growth can cause vitreous hemorrhage (floaters)
decreased red reflex
recurrent bleeding leads to fibrosis
treatment:
* virectomy
* panretinal photocoagulation
192
4 Common Diabetic Nerve Problems
1. Diabetic Retinopathy
2. Transient refractive errors
3. Higher incidence of cataract
4. Neovascular glaucoma
* neovascularization of iris and closure of the angle
193
Identify the condition and descirbe the treatment:
ophthalmoscopic examination shows: microaneurysms, arterial venous nicking, flamed shaped hemorrhages, and Elscnig Spots
**Hypertensive Retinopathy**
**clinical features:** microanerusysms, IRMA's, blot hemorrhages, hard exudates, venous beading, **Elschnig spots-** nonperfusion of choriocapillaries
**Acute**: associated with preeclampsia, eclampsia, pheochromocytoma or renal hypertension
**Severe**: flame-shaped hemorrhages, blurring of the disc marginas, exudates
aterial venous nicking - related to vascular sclerosis - see the image on the left
194
Identify this condition and describe the treatment:
ophthalmoscopic examination shows cotton-wool spots in a sector of the retina
patient reports vision loss, no pain
**Branch Retinal Vein Occlusion**
**superficial hemorrhages, retinal edema, cotton-wool sports** in a **_sector_** of the retina drained by the affected vein
if macula is affected - painless vision loss
occurs most commonly at arteriovenous crossing
**risk factors:** hx systemic hypertension, cardiovascular disease, increased BMI at age 20, hx of glaucoma
**tx:** anti-VEGF, sector photocoagulation
195
Identify this condition and describe the treatment:
ophthalmoscopic examination shows: retinal hemorrhages in all 4 quadrants
**Central Retinal Vein Occlusion**
retinal hemorrhages in all 4 quadrants
dilated, toruous retinal veins
can be ischemic which leads to neovascularization
tx: anti-VEGF, panretinal photocoagulation
196
Identify this condition and describe the treatment:
pt reports: sudden painless vision loss in his left eye
physical exam findings: RAPD, decreased visual acutiy
ophthalmoscopic examination: cherry red spot, retinal edema
**Central Retinal Artery Occlusion**
**\*\*\*\*irreversible vision loss within 90 minutes**
tx: ocular massage, reduce IOP via needle or drops, hyperbaric oxygen - none have great evidence
poor prognosis
central occlusion due to artherosclerotic disease, emboli, vascultitis, coagulopathy (branch - emobli)
**boxcarring of retinal vessels**
197
Identify this condition and describe the treatment:
pt reports - painless vision loss in her right eye, but vision has since returned
Carotid Stenosis Related Eye Diseases
**Amaurosis fugax - painless transient monocular vision loss**
descriptors: "curtain" coming down over the eye, blindness, dimming, fogging, or blurring
may see Hollenhorst plaque
\*\*can be an emboli from the heart; patient is at high risk for a stroke
198
Identify this condition and describe the treatment:
pt reports transient vision loss, scalp tenderness, arthralgia, and recent weight loss
exam shows: tenderness over temproal artery, thickened temproal artery, bruits
**Giant Cell Arteritis =**
**Temporal Arteritis**
**medium vessel vasculitis** in older people (\>65)
scalp tenderness, tender over temporal artery, jaw claudication, fever, weight loss, joint pain
transient vision loss, double vision, sudden marked vision loss from ischemic optic neuropathy
**tx: high dose steroids to save the other eye**
199
Other Causes of Retinal Vascular Disease/Ischemia
* Radiation
* Congenital AV malformations of the retina
* Lupus
* Bechet
* IBD
* Sarcoidosis
* Sickle Cell Disease
