Eyes III and IV

Question 1

Cataracts

• Etiology
• Risk factors
• Symptoms
• PEx
• Tx

Answer 1

Cataracts

• Leading cause of blindness in the world
• Opacity to natural lens of the eye
• Often bilateral
• Degree of opacification and extension to which lens is affected is variable

Etiology

• Age related (senile cataracts)
• Congenital
• Traumatic
• Medication related (steroids)

Risk factors

• Sun exposure
• Smoking

Symptoms

• Gradual, chronic, painless loss of VA
• Complain of glare, especially at night

PEx

• Dec VA
• Dec color VA
• Opalescent changes to lens
• Abnormal / absent red reflex
• As cataracts mature, the retina is blurred or obscured until a normal red reflex cannot be obtained

Tx

• Refer to ophtho
• Rx glasses
• CE w/ IOL
• Prognosis is excellent

Question 2

Strabismus

• What is it
• Types
• Risk factors
• Complications
  
  • Amblyopia
  • What is it
  • Types
• PEx
• Tx

Answer 2

Strabismus

• Any anomly in the alignment of the eyes
• May be intermittent or constant
• Types:
  
  • Esotropia (crossing)
  • Exotropia (wandering)
  • Vertical misalignments (hypertropia)
  • Less common
    
    • Oblique muscle palsies
    • Duane’s syndrome (abducent nerve palsy)
    • Brown syndrome

Risk factors

• Affects 4% of the population
• Family hx
• Low birth weight
• Neurologic complications (cerebral palsy)
• Low vision (i.e. born with optic nerve atrophy)

Complications

• Amblyopia
  
  • Reduction in VA caused by disuse / misuse during the critical period of visual development
  • Visual development occurs up until the age of 6-8 years old
  • Types:
    
    • Strabismic
    • Anisometropic or refractive
    • Deprivational
      
      • Congenital cataracts
      • Ptosis
      • Blocked visual axis

PEx

• Vision
• EOMs
• Corneal light reflex (Hirschberg’s test)
  
  • Tropia: always deviated
  • Phoria: sometimes deviated
• Cover/uncover test
• Alternative cover test

Tx

• Refer to ophtho
• Rx glasses
• Therapeutic eye patching
• Eye muscle sx

Question 3

Nystagmus

• What is it
• Movement patterns
• Etiology
• Signs and symptoms
• Tx

Answer 3

Nystagmus

• Rhythmic regular oscillation of the eyes
• Movement patterns
  
  • Jerk nystagmus (MC)
    
    • Consists of alternating phases of a slow drift in one direction with a quick “jerk” in the opposite direction
  • Pendular nystagmus
    
    • Consists of slow, “pendular” oscillations to and from
• May be variable depending on eye movements

Etiology

• Congenital
• Intoxication
• Metabolic derangements
• Infections
• Tumors

Signs and symptoms

• Possible dec VA
• Notice eye shimmering or shaking

Tx

• Depends on underlying cause and may be managed by ophtho or neuro
  
  • Meds (baclofen, gabapentin)
  • Botulinum injections (Botox)
  • Prism lenses
  • Sx (Kestenbaum muscle sx)
• Sometimes no tx is required

Question 4

Optic neuritis

• What is it
• Associated with
• Clinical presentation
• PEx
• Dx
• Tx

Answer 4

Optic neuritis

• Inflammatory demyelinating condition that results in acute vision loss in one eye
• Strongly associated with MS and is the presenting factor in 20% of patients
• Also associated with viral infections, such as measles, mumps, and influenza
• Most cases occur in women between ages 20-40 (this lines up with MS)

Clinical presentation

• Acute onset (hours to days)
• Monocular vision loss
• Eye pain, worse with EOMs
• VF defects, usually central scotoma

PEx

• Loss of color vision
• Dec VA
• Relative afferent pupillar defect (APD) - PERRL
• Possible optic nerve changes
• Most cases (2/3) are retrobulbar (behind the eye) so there may be no changes on fundus, however in some cases (1/3) the optic nerve is swollen with pallow and occasionally has flame shaped peri papillary hemorrhages

Dx

• MRI of brain and orbit (with gadolinium contrast)
• Also assesses risk for MS

Tx

• Refer urgently to ophtho
• IV methylprednisolone x 3 days, then oral taper to accelerate vision recovery
• VA returns in 2-3 weeks
• Optic atrophy may be seen if sufficient nerve fibers have been destroyed
• If VA does not return, must r/o compressive lesion or tumor

Question 5

Papilledema

• What is it
• Clinical presentation
• Ddx

Answer 5

Papilledema

• Swelling of the optic nerve head, usually in association with elevated intracranial pressure
• Optic disk is swollen, with blurred margins, cup may be obscured due to swelling
• The venules are dilated and tortuous
• There may be flame hemorrhages and infarctions (white, indistinct “cotton-wool spots”) in the nerve fiber layer, and edema in the surrounding retina

Clinical presentation

• Patients often present first with other signs & symptoms of increased intracranial pressure before papilledema is noted
• HA (especially first thing in the morning)
• Often with N/V
• Transient vision changes (sometimes VA is normal in acute phase)

DDx

• Intracranial mass lesion (tumor)
• Cerebral edema (encephalopathy, TBI)
• Disorders of the CSF
• Obstructive hydrocephalus
• Idiopathic intracranial hypertension (aka pseudotumor cerebri)

Tx

• Urgent ophtho referral
• MRI
• Possible lumbar puncture
• VF, OCT

Question 6

Age related macular degeneration

• What is it
• Risk factors
• Symptoms
• Dry AMD
• Wet AMD
• PEx
• Dx
• Tx

Answer 6

Age related macular degeneration

• Leading cause of adult blindness in industrialized countries
• Degenerative dz of the macula that causes central vision loss
• Incidence increases with each decade over 50 years old
• Risk factors: age, female, smoking, family hx, possible genetic component

Symptoms

• Gradual or acute painless vision loss in one or both eyes
• Metamorphopsia (wavy/distorted vision) is one of the earliest signs of wet AMD
• Central scotoma

​Dry AMD

• Retinal drusen appear as discrete yellow deposits
• Retinal pigment epithelium atrophies decreasing central vision
• Dry AMD has better prognosis than Wet

Wet AMD

• May be acute onset
• Characterized by growth of abnormal vessel into the subretinal space
• New vessels leak
• Wet AMD accounts for 80-90 % of cases of blindness due to AMD

PEx

• Possible dec VA
• Amsler grid distortion
• Dry AMD
  
  • Drusen, pigmented mottling
  • Geographic atrophy
• Wet AMD
  
  • Subretinal fluid or blood
  • Subretinal neovascular membrane

Dx

• Dry or wet: fundus exam with ophtho
• Wet may require
  
  • Fluoresceine dye retinal angiography
  • OCT

Tx

• Ophthalmology referral
• Vitamins (antioxidants/zinc)
• Smoking cessation
• Daily Amsler Grid
• Intravitreal anti-angiogenic injections (VEGF inhibitor)
• Photodynamic therapy
• Low vision aids

Question 7

Retinal detachment

• What is it
• Risk factors
• Symptoms
• PEx
• Tx

Answer 7

Retinal detachment

• MC is tear in the retina - vitreous fluid can work its way under the retina causing detachment
• Superior temporal retinal area is the most common site of detachment
• Other causes include traction on the retina by vitreous detachment or processes such as DM
• Can be spontaneously or secondary to trauma
• Risk factors: age over 50 y/o, extreme myopia, previous ocular sx, or family hx

Symptoms

• Patients often complain of an acute onset of monocular, decreased vision and may describe a “curtain coming down” over their eye
• Other complaints include cloudy or smoky vision, “floaters”, or “flashes of light”
• No pain or redness (no inc in IOP)

PEx

• Afferent Pupillary Defect
• Fundoscopic exam may reveal a billowing or tent-like elevation of the rugose retina
• The elevated retina often appears out-of-focus and gray
• May also notice vitreous hemorrhage

Tx

• Urgent referral to ophtho
• During transport patient should remain supine and with head turned to ipsilateral side to help the retina fall back into place with the aid of gravity
• Treatment is directed at closing the tears utilizing cryosurgery or laser surgery

Question 8

Amaurosis fugax

• What is it
• Dx
• Tx

Answer 8

Amaurosis fugax

• Amaurosis fugax (“fleeting blindness”) is usually caused by retinal emboli from ipsilateral carotid disease
• The visual loss is usually described as a curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes, and a similar curtain effect as the episode passes
• Workup warranted to determine cause of embolus

Dx

• Noninvasive evaluation of the carotids can be accomplished using duplex ultrasonography and magnetic resonance angiography (MRA)
• Emboli from cardiac sources (such as atrial fibrillation) may also be responsible, therefore EKG and echocardiography may be indicated

Tx

• Depends on the cause

Question 9

Central retinal artery occulsion

• What is it
• Symptoms
• Signs
• PEx
• Tx

Answer 9

Central retinal artery occulsion

• When amaurosis fugax lasts longer than a few minutes
• Occlusion of retinal arteries by emboli results in decreased blood flow and hypoxia to retina
• May have repeated transient episodes before complete loss (amaurosis fugax)

Symptoms

• Sudden painless, total monocular vision loss
• No eye redness

PEx

• Often no light perception
• Afferent pupillary defect
• Pale retina with cherry red spot at the fovea (there is backup blood flow at the fovea)

Tx

• Emergent referral to ophtho
• Tx not effective unless started within a few hours of onset
• Goal is to evaluate cause and prevent further emboli
  
  • Carotid plaques
  • Cardiac emboli
  • R/o temporal arteritis is pt is over than 55 y/o
• Prognosis is poor

Question 10

Central retinal vein occulsion

• Symptoms
• PEx
• Tx

Answer 10

Central retinal vein occulsion

• Occulsion of veins due to thrombi
• In patients with hypercoagulable states

Symptoms

• Symptoms often noticed first thing upon waking
• Acute painless unilateral vision loss
• No eye redness

PEx—

• Signs
• Variable visual acuity
• +/- APD
• Multiple hemorrhages
• Venous dilation and tortuosity
• “Blood and Thunder” fundus

Tx

• Urgent referral to ophtho
• ASA (if underlying coagulopathy)
• Observation in most cases
• Tx if there is macular edema
• Evaluate cause if pt is young
  
  • Severe HTN
  • Hypercoagulable states
• Prognosis: variable

Question 11

Diabetic retinopathy

• What is it
• When are exams recommended
• Symptoms
• 2 changes to the retinal vasculature
• Classification
• PEx
• Tx

Answer 11

Diabetic retinopathy

• Leading cause of blindness in the Western world in patients less than 50 y/o
• DM patients should have yearly dilated exam
• Exam is recommended:
  
  • Type I DM within 5 years of dx
  • At first dx in Type II
  • If ocular sxs develop or if there are suspicious findings of retinopathy
• Present in 40% of DM patients
• Typically asymptomatic until later stages
• Patients may complain of blurred vision due to acute increases in serum glucose, causing lens swelling and a refractive shift even in the absence of retinopathy

Many factors lead to development of clinical diabetic retinopathy which cause two basic changes to the retinal vasculature, namely:

• Abnormal permeability of the vessels
• Vascular occlusion leading to ischemia and subsequent neovascularization

Classification

• Non-proliferative Diabetic Retinopathy
• Proliferative Diabetic Retinopathy
• Diabetic Macular Edema (can occur at any stage, with either one above)

PEx

• Non-proliferative
  
  • Microaneurysms (earliest sign)
  • Dot-blot hemorrhages
  • Cotton-wool spots (ischemia)
• Proliferative
  
  • All features of non-proliferative
  • Neovascularization
  • Vitreous hemorrhage
  • Traction RD
  • Prognosis worse in proliferative
• Macular Edema
  
  • Can occur at any stage
  • Fundoscopic findings
    
    • Retinal thickening
    • Microaneurysms
    • Hard exudates

Tx

• Control blood sugar
  
  • Glucose < 120
  • A1C < 7
• Reduce comorbity
• Ophtho referral
  
  • Laser photocoagulation
  • Anti angiogenic injection
  • Vitrectomy

Question 12

Hypertensive retinopathy

• Symptoms
• PEx
• Classification
• Tx

Answer 12

Hypertensive retinopathy

• Retinal vascular changes due to systemic HTN

Symptoms

• Asymptomatic
• No vision complaints

PEx

• Systemic HTN
• Characteristic fundoscopic findings

Classificiation

• Mild
  
  • Arteriolar Narrowing (“Copper wiring”)
  • Arteriolar Sclerosis (“Silver wiring”)
  • A:V crossing changes (“A:V nicking”) - artery becomes hard and stops flow of veins, blood backs up, because they cross tightly to each other
• Moderate
  
  • Cotton-wool spots
  • Retinal hemorrhages
  • Retinal edema/exudates (macular star)
• Severe (some or all of the above, plus)
  
  • Disc edema (papilledema)

Tx

• Control BP
• Refer to ophtho