exam 3 vision Flashcards
A 50-year-old woman went to an ophthalmologist because of several months of worsening vision that had begun to interfere with her driving. Past history is notable for long-standing menstrual irregularity and infertility.
attached vision field test
What kind of vision loss is this? What could be causing this?
Bitemporal hemianopia
Optic chiasm lesion
A 67-year-old man awoke one morning with a dark purplish-brown spot in the upper part of his vision that disappeared when he covered his right eye. This did not improve over the following week, so he went to see an ophthalmologist. Careful testing of his visual fields revealed the following vision loss:
what is this?
Monocular Scrotoma (blindspot)
Branched retinal artery occlusion
Name a lesion that could occur at each labeled position
A)Right branch of retinal artery blockage
B)Optic neuritis, ophthalmic artery occlusion, Traumatic optic neuropathy, glaucoma, injury, cataracts, amblyopia.
C)Pituitary adenoma – at the chiasm
D)Optic tract lesion – stroke, meningioma
E)Meyers loop lesion – pie in the sky – temporal lobectomy for epilepsy, tumors
F)“Internal” optic radiations –ie not the Meyer’s loop radiations. Could also be due to damage just to upper bank of cortex on one side
A 29-year-old man was referred to a neuro-ophthalmologist because of worsening vision in his left visual fields. Past history is notable for complex partial seizures for 5 or 6 years, and an oligoastrocytoma in the left temporal lobe. He had been treated with chemotherapy and radiation with an initially good response.
Visual field test attached, what does it show?
What type of artery occulsion could cause this? What else could cause this?
left homonymous hemianopia
PCA occlusion, occipital stroke
Left field represented on right post-chiasmatically. So a lesion in right optic tract, right LGN or right cortex could cause same pattern of loss.
Where is the lesion? What changes would you see?
Right optic tract lesion and right side of optic chiasm, would cause left homonymous hemianopia (loss of left visual field in each eye)
A 57-year-old right-handed man visited the emergency room several times because of headaches that had begun 4 months previously. He had intermittent throbbing bilateral or right occipital pain, and zigzagging lines in his field of vision. He had no personal or family history of migraines. Recently he noticed vision problems that caused him to bump into objects on his left side.
Attached visual field test. What kind of vision loss is this?
Meyer’s loop, pie in the sky
from optic radiation or superior calcurian Lesion
What is this and what symptoms would arise?
- occipital, superior calcarine cortex AVM
- vision changes (inferior quadrant loss)
- 52 year old Caucasian male presents to ER with sudden onset of blurred vision, painless in the left eye one day ago.
- PMHx: Diabetes, Myocardial Infarction
- PSHx: No prior ocular surgeries
- Social: Smokes 2 packs per day.
Diagnosis?
Central Retinal artery occlusion
cherry red spot
Possible etiologies of Central retinal artery occlusion
- Embolic: Artheroscelrotic plaque thrombosis, Hollenhorst plaque
- Giant Cell arteritis: elevate ESR, CRP, and thrombocytosis
What is this?
•Hollenhorst plaque, happens often at bifircations
What is this?
Branch retinal artery occlusion, whitening in specific vessel distribution
What is this?
Blood and thunder
Central retinal artery occlusion
- 42 year old Asian myopic male with 1 week history of floaters and flashes presents to ER with sudden onset of blurred vision in the left eye.
- PMHx: None
- PSHx: No prior ocular surgeries
- Social: Does not drink or smoke
Retinal detachment
3 things that can cause retinal detachment?
- Rhegmatogenous: most common type. Most commonly related to posterior vitreous detachment
- Exudative: due to inflammatory conditions
- Tractional: due to scarring and fibrovascular proliferations
What is this and what caused it?
retinal detachment- Rhegmatogenous (due to tear in retina)
- 26 yo M with 2-day history of significant right eye pain, redness, and photophobia
- Associated with mildly blurry vision
PE: mild decrease in acuity in the right eye, lower intraocular pressure right eye
Slit lamp exam attached, what is the diagnosis? Patient had normal fundoscopic exam.
- WBC in anterior chamber secondary to inflammation or infection (White dots floating)
- Flare: proteins from increased vascular permiability
- Iritis/anterior uveitis-inflammation of anterior uveal tract: iris and ciliary body
- Tx: systemic treatment (if autoimmune related cause), dilating drops (relieve discomfort from inflammation)
- 6 month old boy noted by mother to have leukocoria (yellow/white pupil) x 2 months
- No vision concerns, no eye pain, No history trauma or infection, No FH eye problems
- Child otherwise healthy, growing well
Diagnosis
Retinoblastoma
•RB1 gene on q14 band of chromosome 13, codes for protein pRB, which suppresses tumor formation
Healthy 5 yo girl for well child check
•Vision screen: Right eye 20/20; Left eye 20/100. Eyes are straight and move together. No notable abnormality of ocular surface or media opacity.
Cycloplegic refraction (the eyes are dilated to prevent accommodation): Right eye: +0.50 +0.25 x 90; Left eye: +3.50 +1.50 x 90
What is this and what caused it?
- Amblyopia
- Caused by: Anisometropia (difference in refractive error between two eyes)
- Tx: Patching or penalization good eye to treat the amblyopia
A 25 year old male present to the ED with a 2 day history of red and swollen eye on the left side. He has pain with eye movement and sees double when looking down. There have been no vision changes but it is difficult to open the lids.
Examination:
Pupils: 4mm-2mm bilaterally, no APD, EOM: Restricted OS, IOP: 15 OD 18 OS, Visual Acuity: 20/25 OU, Color Vision: 24/24 OU
Sinusitis 1 year ago.
Diagnosis?
Orbital Cellutitis
Tx: IV antibiotics
50 y/o female c/o sudden onset left eye pain when going to see a movie with her kids
Vision is blurred, like looking through a “steamy” glass and there are rainbow haloes around the lights
Pain around eye is severe (10/10), aching, throbbing pain, associated with headache and nausea. Patient notes has had similar intermittent eye pain in the past couple months but always resolved
PE: Check pupils: Right eye round and reactive; Left eye mid-dilated, unreactive
Check intraocular pressure: Right eye feels soft; Left eye feels firm – intraocular pressure is high
- Acute angle closure glaucoma
- rapid increase in IOP leading to pain, decreased vision, corneal edema, injection due to occlusion of aqueous drainage from the eye by the iris
- (open angle glaucoma is chronic and painless, so steady progression vision loss)
82 year old woman presents with painless loss of vision in the right eye.
PMH: hypertension, hypercholesterolemia. Reports recent weight loss, achiness. Notes some jaw pain – maybe due to poor dentition
Diagnosis?
Giant Cell Arteritits
Dx: >2cm temoral artery biopsey
Tx: High dose Sterioids
55 year old man, sudden onset of right sided headache, Tender to touch and not relieved with ibuprofen.
PE: Vision a little blurry, Noticed right lid a little droopy, one pupil smaller than other and is worser in dim light
•Past medical history: no hypertension/DM/hyperlipidemia, Never smoked, No recent head/neck trauma
What is the diagnosis? What needs to be done?
- Right eye constricted more than the left (anisocoria) and mild ptosis (droopy right eye lid), mitosis (constricted pupil), anhydrosis (loss sweating)
- Horner’s Syndrome: ipsilateral loss sympathetic tone
- test with cocaine (should dilate eyes)
- Painful Horner syndrome is an emergency =Risk of stroke with carotid dissection
- Painful Horner’s: ER for stat CTA (carotid dissection)
- Horner plus neurologic symptoms: ER for brain MRI (lateral medullary syndrome)
32 year old woman presents with constant headaches for past 6 weeks. Reports pain behind right eye. Notes vision greys out when she strains.
Attached fundoscope for both eyes.
High LP pressure and normal CSF
Diagnosis and treatment?
papilledema
Idiopathic intracranial HTN
Tx: lower ICP: meds (acetazolamide, topiramate),
29 year old man presents with loss of vision in the right eye. Reports progressive vision loss over 1-2 days. Past medical history: unremarkable.Reports recent back pain.
- Pupils: rAPD
- unable to identify color plate in OD
- pain with extraocular movements, OD
•PE: Vision 20/300 OD, 20/20 OS; Slit lamp exam and fundus exam normal
Optic Neuritis (maybe MS)
- Pupils: rAPD = likely an optic nerve problem
- unable to identify color plate in OD (Another sensitive marker for optic nerve dysfunction)
Myopia
- excess optical power
- the cornea is too strongly curved for the length of the eye
- images anterior to retina
- eye is too long
hyperopia
- insufficient optical power
- the cornea’s curvature is too flat for the length of the eye
- images posterior to retina
- eye is too short
- custom glasses or contact lens
Astigmatism
- corneal curvature is not perfectly spherical, but is elliptical or distorted.
- custom glasses fix
post-chiasmatic lesion results in…
contralateral field loss, and each eye will show some loss of vision when tested individually
Nonproliferative Diabetic neuropathy results in vision loss from?
macular edema, macular ischemia.
Proliferative diabetic neuropathy results in vision loss as a consequence to?
neovascularization through vitreous hemorrhage, tractional retinal detachment and neovascular glaucoma.
A patient presenting with photopsias (flashes of light) and floaters should be seen urgently to evaluate for possible
- Retinal tear
- Treatment: mainly surgical by closing retinal breaks by laser, cryopexy in addition to vitrectomy and/or placement of a scleral buckle.
