Eye Flashcards
A 61-year-old female presents to your office with a sudden painless loss of vision in her right eye. Her past medical history includes both hypertension and type 2 diabetes mellitus.
Which one of the following would make you suspect retinal vein occlusion as the cause of her sudden visual loss? (check one)
An afferent pupillary defect in the contralateral eye
Right eye redness
Tortuous retinal veins on funduscopic examination
Macular drusen on funduscopic examination
Tortuous retinal veins on funduscopic examination
The signs of retinal vein occlusion typically include sudden painless loss of vision or distortion of vision. Redness is not typical and should cause the clinician to suspect an alternate diagnosis. Tortuous and dilated retinal veins are the most common finding on funduscopic examination. Patients also often have multiple cotton-wool spots, although these are not specific to retinal vein occlusion. An afferent pupillary defect often occurs on the affected side. Diabetes mellitus and hypertension are both risk factors for retinal vein occlusion, increasing the likelihood in this patient.
A 24-year-old male presents with a 1-week history of right eye redness. He says his eye hurts, especially with light exposure. He reports no history of trauma, but recalls his 2-year-old daughter having “pink eye” about a month ago. He has a previous history of ankylosing spondylitis.
On examination his conjunctiva appears injected and he has a sluggishly reacting pupil. No discharge is noted. Reduced anterior spine flexion is noted on examination of the back. Fluoroscein staining of the cornea is negative.
Which one of the following is the most appropriate next step to manage this patient’s eye condition? (check one)
Artificial tears
Ocular antibiotics
Ocular corticosteroids
Oral acetazolamide
Ophthalmic olopatadine (Patanol)
Ocular corticosteroids
Uveitis is inflammation of the uveal tract and can affect any or all of its components, including the iris. It is the most common extra-articular manifestation of ankylosing spondylitis (AS), seen in up to 60% of patients with AS. Iritis presents with a painful red eye with conjunctival injection, photophobia, and a sluggishly reacting pupil. A hazy-appearing anterior chamber results from the iris producing an inflammatory exudate. Treatment includes topical corticosteroids, but oral or parenteral corticosteroids and NSAIDs are also effective. Reduced anterior spine flexion (a positive modified Schober test) results from the skeletal manifestations of AS. A “bamboo spine” is classically seen on lumbar radiographs. Oral or ocular antibiotics, artificial tears, ophthalmic olopatadine, and oral acetazolamide are ineffective. Ophthalmology referral is recommended (SOR B).
A 4-year-old male sees you for pre-kindergarten screening. On corneal light reflex testing, the light reflex in the patient’s right eye is in the center of the pupil. In the left eye it is located below the pupil, over the inferior-lateral portion of the iris.
This clinical finding is associated with a congenital palsy of which one of the following cranial nerves? (check one)
Third
Fourth
Fifth
Sixth
Seventh
Fourth
In a corneal light reflex test, the patient’s attention is attracted to a target while a light is directed at the eyes. In normally aligned eyes the light reflex will be located in the center of each pupil. In patients with esotropia the reflex will be over the lateral portion of the iris in the affected eye. In exotropia the light reflex is over the medial iris, in hypertropia it is over the inferior iris, and in hypotropia it is over the superior iris. The finding observed in this child, hypertropia, will occur with a congenital palsy involving the superior oblique muscle, which is innervated by the fourth cranial nerve.
A 52-year-old mechanic complains of an irritation in his right eye lasting for 2 days. On direct visualization you see a small, dark foreign body on the periphery of the cornea and are able to remove it with no complications. However, there is a patch of reddish-brown discoloration extending several millimeters around the area where the foreign body had been.
Which one of the following is most appropriate for this patient? (check one)
Watchful waiting
Irrigation with 0.9% saline solution under pressure
An antibiotic ointment to be used every 2–4 hours
Gentle debridement with a #11-blade scalpel
Prompt ophthalmologic evaluation
Prompt ophthalmologic evaluation
If a metal foreign body is present on the cornea for more than 24 hours a rust ring will often be present in the superficial layer of the cornea. This material is toxic to the cornea and should be removed as soon as possible, but it is not an emergency. The proper removal of a rust ring requires the use of a slit lamp and specialized ophthalmic equipment. Referral to an eye specialist within 24–48 hours is the best management in this case.
Which one of the following is the hallmark of proliferative diabetic retinopathy? (check one)
Blot hemorrhages
Cotton-wool spots
Drusen
Macular edema
Neovascularization
Neovascularization
Diabetic retinopathy is caused by chronic hyperglycemia and is the leading cause of blindness in adults in the United States. Routine screening with a dilated eye examination or retinal imaging performed and interpreted by a skilled clinician shortly after the diagnosis of diabetes mellitus is recommended. Diabetic retinopathy is classified in two stages. Nonproliferative diabetic retinopathy may occur within the first decade following hyperglycemia and is characterized by blot hemorrhages, cotton-wool spots, and retinal vascular microaneurysms. As the number of hemorrhages and microaneurysms increases, normal blood flow is interrupted. Proliferative diabetic retinopathy is the second stage and is characterized by neovascularization, which occurs in response to poor blood flow and retinal ischemia. These new blood vessels are fragile and rupture easily leading to vitreous hemorrhage, fibrosis, and retinal detachment. Drusen are extracellular deposits that accumulate within the macula in macular degeneration, which is unrelated to diabetic retinopathy. Macular edema can occur in both stages of diabetic retinopathy.
A 7-year-old African-American male is brought to your office with a 1-day history of purulent, crusted eyelashes in the morning, and red eye. There is no history of visual change, foreign body, or injury. The child is otherwise in good health and has normal developmental milestones. No fever or respiratory distress is noted. A clinical diagnosis of bacterial conjunctivitis is made. The mother is anxious to keep the child in school. Which one of the following would be the most appropriate time for the child to return to school? (check one)
Once treatment is started
When there is no crusting or drainage in the morning
After 1 week of treatment
When the absence of fever for 24 hours is documented
Once treatment is started
Once therapy is initiated, children with bacterial conjunctivitis should be allowed to remain in school. Careful hand hygiene is important, however, and behavior must be appropriate to maintain adequate hygiene. No specific length of treatment or evidence of clinical response is required before returning to school.
A 34-year-old white mechanic felt a slight impact on his left eye while hammering on an axle 2 days ago. He has experienced some discomfort since that time, and complains of blurring of vision. Physical examination discloses no local erythema or other evidence of injury to the eye. Fluorescein staining is negative. His visual acuity is 20/40 in the affected eye. The most likely diagnosis is: (check one)
Traumatic iritis
Corneal abrasion
Intraocular foreign body
Bacterial corneal ulcer
Retinal detachment
Intraocular foreign body
Complaints of discomfort in the eye with blurred vision and a history of striking steel should arouse strong suspicion of an intraocular foreign body.
A 3-year-old female is brought to your office for a health maintenance examination, and her father expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling E visual acuity chart. With both eyes uncovered during a cover/uncover test, the corneal light reflex in the right eye is medial to the pupil when focused on a fixed point, but the light reflex in the left eye is almost centered in the pupil. When the left eye is covered, the right eye moves quickly inward to focus on the fixed point, and the corneal light reflex is centered in the pupil. When the left eye is uncovered, the right eye returns to its original position. When you cover the right eye, no left eye movement is noted. Which one of the following is the most likely diagnosis? (check one)
Strabismus
Amblyopia
Cataract
Esotropia
Heterophoria
Strabismus
Strabismus is an ocular misalignment that can be diagnosed on a cover/uncover test when the corneal light reflex is deviated from its normal position slightly nasal to mid-pupil. The misaligned eye then moves to fixate on a held object when the opposite eye is covered. The eye drifts back to its original position when the opposite eye is uncovered. Amblyopia is cortical visual impairment from abnormal eye development-most often as a result of strabismus. Cataract is a less frequent cause of amblyopia. Esotropia is a type of strabismus with an inward or nasal deviation of the eye that would be evidenced by a corneal light reflex lateral to its normal position. (The outward eye deviation seen in this patient is exotropia.) Heterophoria, or latent strabismus, does not cause eye deviation when both eyes are uncovered.
A 62-year-old Asian female presents to your office with pain and redness in her left eye that started last night. She does not wear contact lenses. The pain has become more severe and she now has a headache, light sensitivity, and mild nausea. Examination of the eyes reveals diffuse conjunctival injection on the left. Her pupils are 4 mm bilaterally but the left one reacts poorly to light. Her visual acuity is 20/30 on the right and 20/100 on the left.
Which one of the following would be most appropriate at this time? (check one)
Polymyxin B/trimethoprim ophthalmic drops (Polytrim)
Prednisolone ophthalmic drops (Omnipred)
An erythrocyte sedimentation rate and C-reactive protein level
MRI of the brain with contrast
Emergent evaluation by an ophthalmologist
Emergent evaluation by an ophthalmologist
This patient has symptoms and examination findings that are concerning for acute angle-closure glaucoma. Her risk factors include her age, sex, and Asian ancestry. The examination findings include conjunctival redness, corneal edema, a poorly reactive mid-dilated pupil, decreased vision, severe eye pain, headache, and nausea. This condition needs to be evaluated and treated emergently to preserve vision. The examination is not consistent with infectious conjunctivitis, which generally does not cause severe pain, headache, or decreased pupillary response. Conditions such as scleritis or episcleritis may present with similar features, but the pupillary response may help differentiate them from glaucoma. Referral to an ophthalmologist would still be most prudent. This patient’s presentation is not consistent with a vasculitis or multiple sclerosis.
The mother of a newborn infant is concerned because her baby’s eyes are sometimes crossed. Assuming the intermittent eye crossing persists, which one of the following is the most appropriate age for ophthalmologic referral? (check one)
10–14 days
6 months
12 months
24 months
6 months
In many normally developing infants there may be imperfect coordination of eye movements and alignment during the early days and weeks of life, but proper coordination should be achieved by age 4–6 months. Persistent deviation of an eye in an infant requires evaluation.
A 30-year-old male presents to your office after sustaining a scratch to the eye while playing with his 2-year-old nephew. A penlight examination reveals sensitivity to light and mild conjunctival irritation with no foreign body. Pupillary response, extraocular movements, and visual acuity are all normal. Fluorescein staining reveals a 3-mm corneal abrasion.
Which one of the following would be the most appropriate management? (check one)
Patching the affected eye
Patching the unaffected eye
Prednisolone ophthalmic drops
Tetracaine ophthalmic drops
Oral naproxen
Oral naproxen
Corneal abrasions are a common cause of acute eye pain and are often evaluated in primary care settings. Small (4 mm), uncomplicated abrasions typically heal within 1–2 days and usually respond to oral analgesics such as acetaminophen or NSAIDs. A 2013 review reported effective pain relief and earlier return to work with use of topical NSAIDs, although a 2017 Cochrane review subsequently found that evidence may be lacking to support their use, especially considering the higher cost when compared to oral options.
Patching has been proven ineffective for pain relief and can delay healing, although ophthalmologists sometimes use patching to treat large abrasions or to provide a protective barrier for patients who may have difficulty avoiding rubbing their eyes, such as children or people with cognitive impairment. Patching of the unaffected eye is done to treat amblyopia but is not appropriate for managing corneal abrasions. Topical corticosteroids such as prednisolone are not appropriate for treatment of corneal abrasions due to increased susceptibility to infection and the risk of delayed healing and should only be used under the guidance of an ophthalmologist. While point-of-care use of topical anesthetics such as tetracaine may be considered, repeated administration is not recommended as continued use may cause damage to the corneal epithelium, delay healing, and mask symptoms. While topical antibiotics are often prescribed in the setting of corneal abrasion to prevent bacterial superinfection, evidence to support this practice in general is lacking. However, contact lens wearers are at increased risk of infection due to Pseudomonas aeruginosa and should be prescribed an antibiotic with antipseudomonal activity.
A 78-year-old male presents for a routine health maintenance examination and is concerned about a gradual loss in his vision during the past year. He has smoked 1 pack of cigarettes per day for the past 60 years. He has no other medical problems. On Amsler grid testing he notes distorted grid lines.
Which one of the following would you recommend for this patient? (check one)
Watchful waiting
Avoiding all vitamin supplements
Treatment to reverse his visual changes
Smoking cessation to prevent further vision loss
Smoking cessation to prevent further vision loss
This patient presents with signs and symptoms that suggest age-related macular degeneration. Smoking is a modifiable risk factor and smokers should be counseled to quit (SOR C). The patient should be referred to an ophthalmologist for further evaluation and management. Watchful waiting would not be appropriate. Vitamin supplements with Age-Related Eye Disease (AREDS) and AREDS2 formulations have been shown to delay visual loss in patients with age-related macular degeneration (SOR A). Age-related macular degeneration is not reversible but treatment can delay progression or stabilize the changes (SOR A).
A patient sees you because of eye pain and swelling that have been present for a few days. A physical examination reveals a small, pink, tender area of the upper eyelid with an adjacent, slightly inflamed gland opening at the eyelid margin.
Which one of the following would be the most appropriate initial treatment? (check one)
Warm compresses and gentle massage of the eyelid
Topical moxifloxacin ophthalmic solution 0.5% (Vigamox)
Topical tobramycin/dexamethasone ophthalmic solution 0.3%/0.1% (Tobradex)
Oral cephalexin (Keflex)
Incision and drainage
Warm compresses and gentle massage of the eyelid
This patient has a hordeolum (stye). Typical first-line treatment is to apply warm compresses and perform gentle massage of the area to promote drainage of the occluded gland. Antibiotics and incision and drainage are not necessary unless surrounding cellulitis is present or there is failure to improve with initial therapy.
A 30-year-old female sees you for a routine health maintenance visit. She has myopia and says she is considering LASIK eye surgery and wants your advice.
You tell her that LASIK is associated with (check one)
a moderate reduction in problems with glare
a moderate reduction in problems with dry eyes
satisfactory improvement of vision in almost all patients
prevention of presbyopia
satisfactory improvement of vision in almost all patients
LASIK corrective vision surgery has become increasingly common over the last 20 years. A laser is used
to cut a flap the size of a contact lens consisting of corneal epithelium and stroma. This flap is repositioned
and heals without sutures.
It is important to counsel patients on realistic expectations. Vision following the procedure may not be as
clear as with glasses or contact lenses and some individuals still require external correction. Up to 40%
of patients experience dry eyes following the surgery (SOR B). These symptoms may be worse in patients
with chronic pain syndromes such as fibromyalgia, migraine, and irritable bowel syndrome (SOR C).
Glares, halos, and starbursts may affect up to 20% of patients following LASIK. This may be especially
bothersome at night (SOR B).
LASIK does not correct age-related presbyopia (SOR C). Reading glasses may be necessary if this
develops in certain patients. Overall, however, most patients are satisfied with their results and only 3%
are unhappy with their vision following surgery (SOR C).
A 67-year-old male presents to your office for evaluation of chronic redness, flaking, and discomfort of his eyelids. Additionally, his eyes feel irritated, dry, and sandpapery at times. He has had difficulties with these symptoms on and off throughout his life but they have worsened lately. He has not had any vision changes and does not wear contact lenses.
On examination his eyelids appear red and mildly swollen with yellow crusting at the bases of the eyelashes. You note bilateral mild conjunctival injection. Visual acuity is intact, as are pupil reactions and extraocular movements.
Which one of the following treatments is appropriate first-line therapy for this condition? (check one)
Warm compresses and gentle cleansing with a mild shampoo
Sodium sulfacetamide eye drops
Topical betamethasone
Oral acyclovir (Zovirax)
Oral cephalexin (Keflex)
Warm compresses and gentle cleansing with a mild shampoo
This patient has blepharitis, a chronic inflammation of the eyelids. Seborrhea is a common cause in older
adults. In younger patients including children, colonization with Staphylococcus may be a contributing
factor. Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of
tear films, which leads to dry eyes and irritation. Other diagnoses to consider in this patient include
conjunctivitis, preseptal cellulitis, and Sjögren’s syndrome. Conjunctivitis typically involves the
conjunctiva and an eye discharge but less involvement of the eyelids is present. Cellulitis is an acute rather
than chronic condition and involves more pain and swelling. Sjögren’s syndrome causes dry eye but not
inflammatory changes of the lid.
The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried
secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization
load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral
antibiotics can be considered for more severe cases.
