Eye conditions and evaluation Flashcards
A confluence of blood vessels
arcade
What type of fluid is in the posterior chamber of the eye?
Vitreous Humor
fluid in the eye, found between the cornea and the lens
Aqueous Humor
progressive, drain is clogged and slowed but still flowing
Open Angle Glaucoma
What is the flow of aqueous humor
Ciliary body=> posterior chamber=> pupil=> anterior chamber=> trabeculae=> scleral venous sinus (canal of Schlemm)=> vein
there is a structural failure of the iris. The iris is collapsed forward and stops the flow. what is this?
closed angle glaucoma
Visual input from rods and cones, contrast (acuity), accommodation, light reflex
CN II Optic nerve (S)
Innervation for: Superior, inferior and medial rectus, and inferior oblique, levator palpebrae superioris, constrictor (sphincter) pupilae, ciliary m. (for accommodation)
CN III Oculomotor (M)
Provides sensory from cornea, conjunctiva, sclera, lacrimal gland, eye lids, iris (dilation)
CN V Trigeminal V1, V2 (B)
Innervates Lateral rectus Mm
CN VI Abducens (M)
Orbicularis oculi innervation
CN VII Facial (M)
This provides the fine tuning for light to hit the right spot
Lens
Broad refraction of light to direct to the lens
Cornea
Name the 4 most common vision problems
Myopia
Hyperopia
Presbyopia
Astigmatism
Inflammation of the eyelid, and lid margin
Occurs at Meibomian gland (eyelashes)
Most often occurs in people with allergies, rosacea, seborrheic dermatitis, oily skin, dandruff, or dry eyes
Blepharitis
Blepharitis can lead to what 4 things
Excess tears, flaking, crusting, redness
If untreated can lead to an erosion of the eye lashes.
Eye lashes contribute to the overall health of the eye which leads to issues spreading tear film and other dryness issues of your eye
Complications of Blepharitis
Blepharitis treatment options are?
Gently clean lids & lashes with warm water & baby shampoo
Antibiotics when needing to clear up infection
Corticosteroid eyedrops with severe inflammation
Lower eyelid turns outward, and doesn’t completely touch/cover the eye
* mostly in elderly, due to lax lid muscles * can also occur secondary to scars on or near lid, or due to facial nerve palsy
Ectropion
Ectropion Treatment?
If mild, artificial tears or lubricating ointment will work
If worse, surgery to reposition lower eyelid
Eyelid (usually the lower eyelid) and eyelashes turn inward towards eye, causing the lashes to rub against cornea and conjunctiva
Entropion
Entropion treatment is?
Soothing eyedrops/artificial tears
Tape applied to lid to pull it down towards cheek underneath
Surgery to tighten up the lid
-Painful, tender, red, pus‐filled infection of the glands
(Zeis, Moll, meibomian) at the base of the eyelashes
-Often secondary to blepharitis
-Looks like a pimple or boil pointing on lid margin
-Only ever at the eye lid margins because they are from meiboian glands that makes oil for your eye lash.
Stye (Acute Hordeolum*)
Stye Treatment?
Don’t squeeze the stye
As soon as a stye begins to form, apply clean, warm washcloth compress several times a day until stye comes to a head and opens
Once the stye opens, wash eyelid thoroughly to prevent bacteria from spreading
Recurrence may require antibiotic tablets or ointment
Swellings in the eyelid caused by blockage of one of the glands (e.g., meibomian gland) that lubricate the eye
Chalazion
Chalazion treatment?
Small ones often go away on their own
Can speed up process by applying warm water
compress 2‐4x/day for 5‐20 minutes
If large, or it fails to go away or it becomes infected, MD may prescribe antibiotics or corticosteroid eyedrops
Surgical drainage is done as last resort
Slightly raised, yellowish, well‐circumscribed plaques on the nasal portion of one or both eyelids
May accompany lipid disorders (hyperlipidemia, hypercholesterolemia, and others), as well as diabetes and obesity
Xanthelasmas
xanthelasma treatment?
None required unless, for cosmetic reasons, the patient would like them removed surgically
Slow‐growing,fleshy, non‐cancerous bumps that are pink or skin‐ colored
* Can be removed surgically if unsightly
Papillomas
Fluid‐filled
* Many variations (inclusion cysts, sweat gland cysts, etc.)
* Almost always non‐cancerous
*Should be removed if they grow, disturb vision, or are located where they are subject to recurring injury, bleeding or irritation
*Often indistinguishable from chalazion or stye
Cysts
Drooping of the upper eyelid‐ unilateral or bilateral
* May partially block vision
* Causes: weakness of the levator palpebrae superioris muscle due to: congenital (familial), normal aging, stroke, diabetes mellitus, injury, damage to the oculomotor nerve, sympathetics to eye (Horner’s), myasthenia gravis
* Treatment depends on cause
Caused by ACH receptors
Ptosis
inward growth of eye lashes; can produce chronic lid edema
Trichiasis
Roundworm infection that can cause chronic lid edema (Not usually seen in early or “light” infection)
Trichinosis
Forward bulging of the eyeball(s)
* Most common cause is hyperthyroidism (Grave’s
disease)
* Other causes: inflammation of tissue behind eyeball due to infection, orbital cellulitis, tumor behind eyeball, aneurysm
* Eye feels dry, gritty due to air exposure
* Lid lag sign: when patient looks down after looking up, lid is slow to move down
Exophthalmos
Inflammation of the conjunctiva – the transparent membrane that covers the white of the eye and lines the inside of the eyelids
‐ A.K.A. “pinkeye”
‐ Causes redness, irritation, gritty feeling in eye, and discharge
conjunctivitis
Most commonly due to bacterial infection ‐ highly contagious, transmitted hand‐to‐eye, or by washcloth,
towel
‐ produces yellow or green discharge that can cause eyelids to stick together
‐ Can also be caused by viral infection ‐ also highly contagious, producing watery discharge ‐ often with sore throat, tonsillar lymphadenopathy
-Can also be caused by allergies
conjunctivitis causes
Conjunctivitis treatments?
clean eyelids, face with warm water
* use washcloth soaked in warm water as a compress to relieve
discomfort
* antibiotic eyedrops or ointment
* launder washcloths, towels pillowcase each day; don’t share these items with others; keep hands away from eyes
Leakage of blood into space between conjunctiva and sclera
* Alarming bright red patch in eye – like a “puddle of blood”
* Rarely serious
* Very common
-See opthamoligist if there is pain with it
subconjunctival hemorrhage
Causes pain, redness, sensitivity to light
* Can blur vision
* May not see it without special dye (fluorescein) and slit lamp magnification (ophthalmologist)
* Can become infected
Corneal Abrasions, Cuts, and Ulcers
Can be difficult to see without fluorescein dye and slit‐lamp
magnification with blue light
Removal by irrigation is attempted first
Careful removal by sterile swab or hypodermic needle is attempted
next
Antibiotics are given to prevent infection
as a chiropractor you do not touch it. Do not remove it, if it is a small fleck of something they can attempt to wash their eye out themselves or send them out. Cover it and send them if it is large enough.
foreign body in cornea
Central, diseased part of cornea is cut out & replaced with a cornea from a donor (a person who has recently died)
* Usually takes several months to a year for new cornea to completely heal and for vision to be clear
corneal transplant
inflammation of the sclera
* Uncommon. Most commonly affects people 30‐60 years of age
* Sometimes occurs with autoimmune disorders (such as rheumatoid arthritis) or with inflammatory bowel disease
Scleritis
a mild inflammation of the episclera, a transparent layer that sits between the conjunctiva and the sclera
* Usually affects young adults
Episcleritis
what is different between the symptoms of scleritis and episcleritis?
Scleritis may cause aching pain, blurred vision
Episcleritis is rarely harmful
Blocked nasolacrimal duct
Can be congenital or acquired following infection, deviated septum, nasal polyps and swelling, fracture of facial or nose bones
dacryostenosis
Infection of the lacrimal sac
* Usually secondary to dacryostenosis
* Causes pain, redness, swelling, tearing, conjunctivitis, blepharitis, fever
* Treatment: frequent application of hot compresses and antibiotics
dacryocystitis
what are the 3 layers that lubricate the eye aka the “disgusting sandwich”
Outer oil layer (meibomian glands) * Middle water layer (lacrimal glands) * Inner mucus layer ‐ helps spread tears evenly
keratoconjunctivitis sicca is also known as?
Dry Eye
result when the tear film breaks down, and parts of cornea dry out
* Symptoms:
* Burning, scratching, stinging, irritated eyes, often with redness * Eye fatigue
* Discomfort while wearing contact lenses * Mucus in or around eyes
Dry Eye
What are dry eye treatments?
Tear replacement * Artificial tears–eye drops that mimic the natural tear film, or as an ointment (ask the pharmacist for recommendations)
* Tear conservation= Tiny punctal plugs inserted into the tear drainage ducts Avoid: smoke, direct wind, AC
* Use a humidifier during winter
* Try to blink more often, and rest the eyes
* Lubricating eye ointment at bedtime
* Anti‐inflammatory medications
Both of these are benign neoplasms of the conjunctiva
Pinguecula
Pterygium
A raised yellowish white mass on the bulbar conjunctiva
‐ Adjacent to the cornea at 3‐ and/or 9‐o’clock position
‐ Risk factors are ultraviolet light exposure, dry eyes, and dust
exposure
Pinguecula
Fleshy, triangular growth of bulbar conjunctiva onto cornea at 3 &/or 9‐o’clock
* Found more in hot, dry climates‐ has the same risk factors as pinguecula
* Some evidence suggests that this is a pinguecula that has progressed
* May spread across and distort cornea, causing astigmatism and blurring
* surgical removal is necessary in these circumstances
Pterygium
perfect vision depends on what?
- Perfect eyeball length ‐ cornea to retina
- Cornea bends the light coming into eye
- Lens adjusts the focus of the light
-eyeball being too long from front to back
-nearsightedness
-Objects in the distance are blurred, but near objects are seen clearly
-Starts during elementary school years, progressively worsens until late 20’s
myopia
Eyeball is shorter than normal
farsightedness
Hyperopia
age related condition often referred to as farsightedness, but different from hyperopia
presbyopia
Treatments of myopia?
Corrective lenses (don’t cure, reverse, or slow progression of refractive errors, but they improve vision)
* Bates exercises
* Orthokeratology (“Ortho‐K”)
* Refractive surgery
- Uses eye focusing exercises to attempt correction * Minimal correction of .25 ‐.75 diopters at most
what is this?
Bates Method
Short‐term corneal re‐shaping using contacts worn at night
Especially helpful for sports, and when dusty conditions make normal contacts difficult to wear
Wear contacts each night; effects last for a day or two
Ortho-K aka
Orthokeratology
-A tiny knife makes multiple cuts into cornea, radiating like spokes of a wheel
-The worse the nearsightedness, the more cuts are needed
Radial Keratotomy
Potential complications of Radial Keratotomy treatment?
Fluctuating vision for first few months
* Unpredictable healing
*Weakened cornea more prone to rupture if hit directly * Difficulty fitting and wearing contact lenses if needed * Glare or haze around lights
Cornea is sliced from the side; laser beam then reshapes the tissue of the inner layer of the cornea
Complications include infection, loss of sharpness of vision
Cannot be used in patients with thin corneas
LASIK
What eye shape has a greater risk of closed angle glaucoma?
Hyperopia
Blurred or distorted vision due to irregularities in shape of cornea or lens
* may see lines (vertical, horizontal or diagonal) out of focus
May occur with nearsightedness or farsightedness
* Tends to remain stable throughout life
astigmatism
Greek for “old sight”
* Caused by age‐related stiffening of the lens → loss of lens’s ability to change shape through accommodation
-starts in 40’s, usually affects everyone
-Earliest sign is need to hold reading material at arm’s length
Presbyopia
Treatment for presbyopia?
For people who had perfect vision or were far‐sighted when they were younger:
* Reading glasses
For nearsighted people:
* Bifocals or trifocals (or progressive lenses) Take glasses off when reading or doing close‐up work * Can’t read very well when wearing contacts
an bigger cup in the cup to disc ratio can be an early sign of?
possible sign of increased pressure aka glaucoma
This appears to be a mole or darkened spot on the retina and is a normal variant
Crescent
Gradual clouding of the normally transparent lens, usually due to aging
* Proteins in the lens begin to clump together
cataracts
What are these?
Certain medications(especially corticosteroids)
* DiabetesMellitus
* Alcoholism
* Smoking
* Long‐term exposuretosun
* Deficiency of anti‐oxidants in the diet
Factors that can facilitate or precipitate cataracts
What are the symptoms of cataracts?
- Decreased vision, blurred vision, dimmed vision
- Decreased night vision
- Glare, especially facing headlights at night
- Decreased color vision
What will cataracts look like during an ophthalmoscopic exam?
decreased red reflex, or gaps in it
direct inspection, you see a cloudy whiteness when you look through the pupil
What steps would you perform to evaluate cataracts?
-Evaluate visual acuity with Snellen Eye Chart
* Use ophthalmoscope to check for whiteness in pupil area and/or interrupted red reflex
* Eye doctor will make final diagnosis
What is the treatment for cataracts?
Surgical extraction is only effective cure: lens is removed, replaced with a plastic lens implant
Doctor may recommend cataract removal earlier if patient has diabetes mellitus or retinal detachment (because cataract interferes with exam of fundus)
high frequency ultrasound waves are used to emulsify lens so it can be vacuumed out
Phacoemulsification
Deterioration of the blood vessels of the retina in people with diabetes mellitus.
Can progress to advanced stage without symptoms
diabetic retinopathy
How can chiropractors screen for diabetic retinopathy?
Check visual acuity and central visual fields
What are the two forms of diabetic retinopathy? Which is better to have?
Non-proliferative (less serious)
Proliferative
-Blood vessels are narrow, blocked, deteriorating, sometimes
hemorrhaging
* Blood flow and oxygen to retina is reduced
* Tiny yellow exudates form on retina
non-proliferative diabetic retinopathy
-Fragile new vessels form and grow over retina
* Blood leaks into vitreous humor
* Scar tissue may be generated pulling on retina, increasing risk of retinal detachment
Proliferative diabetic retinopathy
What hormone increases vascularization in the eye?
VEGF
Vascular Endothelal Growth Factor
How do you treat diabetic retinopathy
Focus on controlling diabetes
* Control blood pressure if elevated
* Laser surgery (photocoagulation)
* Secure retina to back of eye
* Cryotherapy (freezing)
-Anti-VEGF shots
-Partial or complete loss of vision in one eye caused by conditions that affect normal visual development
-most common cause of monocular blindness (impaired vision in one eye)
Amblyopia
What are the two causes of amblyopia?
Strabismus
Anisometropia
-(crossed eyes or wall‐eye) due to weaker muscles in one eye ‐ AKA lazy eye
Strabismus
occurs when the eyes have an unequal refractive power (for example, one eye is 20/20, the other is 20/40)
Anisometropia
What is the difference in amblyopia and ansiometropia?
Amblyopia- what the brain does with the info, turns the signal down
Ansiometropia- the eye has an issue
How do you evaluate for strabismus?
- Check for asymmetry of visual acuity
(Left eye vs. Right eye)
= anisometropia - Check eye alignment- pen light & pupil refraction
- Do the Cover/Uncover Test
How do you treat strabismus?
- Eyeglasses
- Patching
- Surgical correction
_______________ eye is what you see when you look at the patient
___________ is the loss of vision caused by untreated strabismus or
anisometropia ‐ and refers to what the patient sees
Strabismus/lazy eye;
Amblyopia
Increased INTRACRANIAL pressure can push optic disc out, blur margins
* Almost always bilateral
* Refer for MRI or CT to start determining cause
*Can lead to vision loss if
left untreated
Papilledema
-A light‐colored ring seen at the periphery of the cornea due to lipid
infiltration
* A normal finding in older patients, but should be evaluated in young people
Corneal Arcus
A.K.A. Arcus Senilis
unequal pupil size
anisocoria
what makes up Horner’s syndrome?
Horner’s= ptosis, anhidrosis, miosis
Continuously produced by the ciliary body
* Circulates between posterior and anterior chambers
* Nourishes the lens and cornea
* Maintains appropriate pressure within the eyeball
* Drains into angle in front of iris, through a trabecular meshwork (reticulum) and then through Canal of Schlemm
aqueous humor
60‐90% of cases of glaucoma
* Angle in anterior chamber is open, *drainage of aqueous humor through
trabecular meshwork is obstructed
Gets worse over time, but with few or no symptoms * may notice blind spots, ↓ peripheral vision, ↓ night vision
open angle glaucoma
How do you evaluate for open angle glaucoma?
gentle palpation of closed eye may reveal rigidity
* Eye doctor conducts routine eye exam and checks pressure
* Measures eye pressure (normal pressure: < 20 mm Hg)
* Ophthalmoscopy reveals cup:disc ratio > .5
*Exam reveals loss of peripheral vision
Treatment options for open angle glaucoma?
-Topical medications
* Oral medications
* Surgery: laser trabeculoplasty
* Trabeculectomy may be required
Acute, or Narrow‐Angle glaucoma
* Develops quickly, as drainage angle suddenly becomes blocked
* Eyeball quickly hardens
* Pressure causes eye pain, blurred vision, rainbow halos around lights, headache, nausea, vomiting
* An emergency! Refer to opthalmologist
Closed angle glaucoma
How do you treat closed angle galucoma?
Iridectomy- laser used to remove the blockage of aqueous humor flow
Leading cause of vision loss in people > 60
* Gradual development of blurred central vision, difficulty reading, and blind spots in the central area of vision (peripheral vision is retained)
Macular degeneration
what are the two types of macular degeneration?
Dry
Wet
The most common type of macular degeneration
* Tissues of retina thin and cells decay, especially in macula area
* Yellow deposits (Drusen bodies) form on retina
* May affect only one eye at first
* Symptoms:
* Gradual blurring of central vision
* Difficulty reading and recognizing faces
Dry Macular Degeneration
Less common macular degeneration but more severe
* Progresses faster
* Begins the same way as dry macular degeneration
* Abnormal new blood vessels grow into macula area from the choroid layer
* They leak blood and fluids, which injure the photoreceptor cells
* Distorted vision is one of the early signs * Straight lines appear wavy
* Shapes look deformed
Wet Macular Degeneration
How do you diagnose macular degeneration?
Decreased visual acuity (Snellen chart)
* Use Amsler Grid: Blurred or wavy lines (grid lined paper)
* Color testing: Decreased color vision
* Fundoscopic exam: Drusen bodies, hemorrhage in the macula area
* Visual field exam: Central field defects
* Refer to Ophthalmologist
What is the treatment for Dry Macular Degeneration?
No currently proven treatment will prevent vision loss
* Proper nutrition can slow progression
All macular degeneration patients: stop smoking; eat right; manage BP; reduce exposure to sunlight; monitor progress with regular eye exams
What is the treatment for Wet Macular Degeneration?
Laser surgery
photodynamic therapy
Injections into the eye to stop vessel growth
*All macular degeneration patients: stop smoking; eat right; manage BP; reduce exposure to sunlight; monitor progress with regular eye exams
Symptoms and Signs:
* Sensation of flashing lights
* Many “floaters” (dark or light spots, specks or lines) in field of vision
* Blurred vision
* Shadow or part of field of vision
Retinal Detachment
Most cases start with a tear or hole caused by:
* Aging changes in the vitreous fluid
* Weak patches in the retina itself
* Tear allows vitreous to
leak behind retina and
further separate it from
the choroid layer
retinal detachment
Primary type of RD is called :
Rhegmatogenous
Most common type of RD is?
Rhegmatogenous
Exudates/fluid accumulates behind retina without tear or hole, due to:
* Inflammatory disease in the posterior eye * Tumor in posterior eye
* Traction on retina due to diabetic retinopathy
-just cant find the mechanical failure causing fluid seeping
Secondary retinal detachment
Vitreous cavity shrinks, causing traction on retina, producing “flashing lights”
* If traction is strong enough to create small holes or tears in retina, vitreous humor seeps under the retina, producing blurring, floaters, spots, flecks, or lines in field of vision
-Will not heal on its own, needs surgery
retinal detachment
laser beam is directed at area around defect, forming a scar that holds the retina to the choroid
photocoagulation
uses intense cold to freeze the area around the defect, causing a scar that holds the retina to the choroid
cryopexy
For uncomplicated detachment in upper retina
1. After freezing the defect with cryopexy, surgeon injects a bubble of gas into the vitreous cavity
Pneumatic Retinopexy
Most common surgery for repairing retinal detachment
Scleral Buckling
Bloody or cloudy vitreous is removed
* Scleral buckle is usually inserted
* In difficult cases:
* Air, silicone or oil injected into vitreous cavity
Vitrectomy
