General Flashcards
What is the clinical triad for carotid-cavernous fistula?
- Chemosis
- Pulsatile exophthalmos
- Ocular bruit
What is the most common cause of unilateral or bilateral proptosis in young and middle aged patients?
Thyroid eye disease (TED)
How is CCF treated?
Balloon embolization of the internal carotid
What systemic symptoms are associated with TED?
Heart palpitation
Weight loss
Heat intolerance
Hair loss
What are the classic signs/symptoms of orbital cellulitis?
Exophthalmos Lid edema Pain/restrictions on eye movement Fever Decreased VA Conj injection and chemosis
What 3 meds can cause pseudotumor?
Tetracyclines
Accutane
Contraceptives
In CCF, on MRI and angio, what would suggest CCF?
Asymmetrically enlarged cavernous sinus, or superior ophthalmic vein
What tests can be run to evaluate for TED?
Orbital CT (EOM enlargement w/o tendon involvement) T3 and TSH testing (High T3, low TSH)
What other types of pathology can TED cause?
SLK
Exposure K
Optic neuropathy
Restrictive myopathy
How is optic neuropathy from TED treated?
Immediate oral steroids (Pred 100mg QD 2-14 days)
OR
Orbital decompression
What risk factor significantly increases the likelihood of ophthalmic findings in TED?
Smoking
What is the Tx for orbital cellulitis?
Hospitalization
IV ABx (ceftiraxone or nafcillin)
Followed by oral ABx (augmentin, ceclor, bactrim)
Topical bacitracin or erythromycin if conjunctivitis or exposure are present.
What causes molluscum contagiosum?
DNA pox virus
What ocular reaction does molluscum contagiosum cause?
Follicular conjunctivitis
What is the typical presentation of molluscum?
Waxy, dome-shaped papules with central umbilication
What is the classic presentation of seborrheic keratosis?
Elevated, “stuck-on”, crusty, greasy, or plaque like lesion
What is the typical age range for seborrheic keratosis?
Elderly
What is the typical presentation of a keratoacanthoma?
Small, dome-shaped tumor on sun exposed skin, the progress to large lesions with central ulceration
What causes papillomas?
HPV
Follicals are associated with what 3 things?
Viral
Chlamydia
Toxic
What is the classic presentation of basal cell carcinoma?
Firm, pearly nodule with superficial telangiectasia.
May progress to central ulceration “rodent ulcer”
What is the most common type of skin cancer?
Basal cell carcinoma
What is the 2nd most common type of skin cancer?
Squamous cell carcinoma
Which is more likely to metastasize: Basal cell or squamous cell?
Squamous cell
What is the typical presentation of a sebaceous gland carcinoma?
Yellow, hard tumor on the upper eyelid that causes madarosis and thickened lid margins
What is the most lethal type of skin cancer?
Malignant melanoma
What is the typical presentation of malignant melanoma?
Irregular borders with rapid growth and color changes
What is the common precursor to squamous cell carcinoma?
Actinic keratosis (elevated scaly, pink/red lesion)
A Fleischer ring is an indicator of what condition?
Keratoconus
What is a Fleischer ring made of?
Iron deposits
What are the late stage signs of keratoconus?
Vogt striae
Munson’s sign
Hydrops
What are Vogt’s striae?
Vertical lines in deep stroma
V for Vertical lines
What is the classic presentation of staph marginal keratitis?
Stromal infiltrates in the periphery secondary to chronic bleph, without epi defect
RCE occurs most commonly in pts with a history of what?
Trauma (abrasions) Corneal dystrophies (ABMD)
What is a corneal ulcer?
Epi defect with associated stromal infiltrate
What are the UCRAP (HLA-B27) conditions?
Ulcerative colitis Crohn's Reactive arthritis Ankylosing spondylitis Psoriatic arthritis
What are the causes of granulomatous anterior uveitis?
Syphilis
Lyme
TB
Reactivated herp
What is the Tx for staph marginal keratitis?
ABx/roid combo Q4Hs
-Tobradex, zylet (lotepred, tobramy)
When using doxy for posterior bleph, what is the typical dosing?
100mg BID for 4 weeks, then QD for 3-6 months
What type of drug is natamycin?
Antifungal
What is the Tx for RCE?
Debridement Cyclo ABx Topical NSAID if needed BCL ATs
What Tx can be used to decrease recurrences of RCE?
Oral doxy 50mg BID x 2 months
Muro 128 ung QHS x 3 months
What is the classical presentation of fungal keratitis?
Gray-white corneal infiltrates with feathery edges and satellite infiltrates
What are 2 common topical antifungals?
Amphotericin B
Natacin
What are 2 systemic antifungals?
Ketoconazole
Itraconazole
What it the typical recall for staph marginal keratitis?
4 days
Then 3 weeks or so
What percent of newborns have congenital nasolacrimal duct obstruction?
5%
What is the typical presentation for dacryocystitis?
Epiphora
Edema over lac sac
Severe pain
What is the most common cause of an acquired nasolacrimal duct obstruction?
Idiopathic obstruction
What is the most common cause of congenital NLD obstruction?
Failure of the valve of Hasner to completely open by birth
What is the typical age of AKC?
Young to middle age
What are the common signs of AKC?
Corneal neo
Cataracts
Keratoconus
Milky edematous bulbar conj
VKC typically effects whom?
Young boys
What are the classic symptoms of VKC?
Intense itching Thick mucous Lacrimation Photophobia FBS Prominent papillae (cobble stone or Trantas dots)
Atopic dermatitis is what type of hypersensitivity reaction?
Type 1
What are the 2 cataracts associated with atopic dermatitis?
Shield cataract
PSC
What is the main cause of visual impairment in AKC?
SPK (interpalpebral)
What are the 3 mast cell stabilizers?
Alocril
Alomide
Alamast
When do mast cell stabilizers need to be used in order to be effective?
Prior to histamine release
What is the predominant area of ocular involvement in adult inclusion conjunctivitis?
Inferior
SLK is associated with what systemic condition?
Thyroid disease (50% of cases)
SLK can be cause secondary to what?
Contact lens wear
What is the typical presentation of SLK?
Thickened, red, sup bulbar conj
Velvety sup tarsal conj
Often bilateral, with adjacent SPK and filamentary keratitis
What is the most common cause of viral conjunctivitis?
Adenovirus
Viral conjunctivitis is more common in who, adults or kids?
Adults
Pharyngoconjunctival fever is cause by which serotypes of adenovirus?
3,4,5,7
What are the typical findings in pharyngoconjunctival fever?
Follicular conjunctivitis (occasionally hemorrhagic)
Low grade fever
Mild sore throat
What serotypes of adenovirus cause EKC?
8,19,37
What are the common findings of EKC?
+ PAN
SPK
SEKs in the 3rd week
Pseudomembranes
Are the majority of bacterial conjunctivitis cases cause by gram + or gram - bacteria?
Gram + (staph)
What gram - bacteria can cause bacterial conjunctivitis?
H. influenza
Moraxella catarrhalis
Which 2 bacteria are the most common causes of conjunctivitis in kids?
Strep pneumonia
H. influenzae
What are the common findings in gonococcal conjunctivitis?
Hyperacute discharge Conj chemosis w/pseudomembranes Papillary reaction Marked PAN Pain on urination Purulent urethral discharge
What is a possible severe consequence of conococcal conjunctivitis?
Corneal ulceration
What is another name for adult inclusion conjunctivitis?
Chlamydial conjunctivitis
What is the typical presentation of chlamydial conjunctivitis?
Unilateral giant follicals (limbal or palpebral), most concentrated in inferior fornices
Chronic red eye for weeks to months
What is the most common cause of preventable blindness worldwide?
Trachoma
What causes trachoma?
Chlamydia trachomatis serotypes A-C
What is the common presentation of trachoma?
Follicles in the form of Arlt lines (superior tarsal scarring) and Herbert’s pits
Follicular and papillary conjunctivitis of superior tarsal conj
Scaring of eyelids and ulceration from trichiasis
If you diagnose a non-CL wearer with SLK, what subsequent testing is warranted?
T3 and TSH
What is the frontline Tx for mild SLK?
ATs Q2Hrs
What is the additional Tx beyond ATs for mod/severe SLK?
Silver nitrate 0.5-1.0% applied to superior tarasal and bulbar conj, followed by irrigation and ABx ung
What is the Tx for filamentary keratitis?
Acetylcysteine 10% gtts, 3-5x/day
Mucomyst
What supportive measures can be taken for a pt with an adenovirus infection?
Cold compresses
Mild vasoconstrictors
ATs
IF SEVERE: mild steroid (lotemax) during first 1-2 weeks
What can be used to treat an adult with bacterial conjunctivitis?
5-7 days of QID of any of the following:
- Fluoroquinolones
- PolymyxinB/trimethoprim (polytrim)
- Tobramycin
What can be used to treat a child with bacterial conjunctivitis?
5-7 days QID of either:
- PolymyxinB/trimethoprim (polytrim)
- Bacitracin + polymyxin B (polysporin ung)
In cases of bacterial conjunctivitis with SPK, what medications are not recommended due to corneal toxicity?
Aminoglycosides (gentamicin, tobramycin)
What are the Tx options for chlamydial conjunctivitis?
1g azithromycin PO all at once
100mg doxycycline BID x 10 days
What is the Tx for a cornea involving gonococcal conjunctivitis?
Ceftriaxone IV (1g) 12-24hrs
What is the Tx for gonococcal conjunctivitis w/o corneal involvement?
1g ceftriaxone IM injection
What is the most common infectious cause of neonatal conjunctivitis?
Chlamydia
What is the Tx for Trachoma?
"SAFE" Surgery for trichiasis Antibiotics Facial hygiene Environmental hygiene
Patients with what 2 conditions present with pain out of proportion to findings?
SLK
Acanthamoeba
A lipid tear film deficiency results from what?
Blepharaitis
An aqueous layer deficiency is termed what?
Keratoconjunctivitis sicca
During what part of the day are KSC symptoms worse?
End of day
During what part of the day are MGD symptoms worse?
Morning
What 3 drug classes/types are associated with KCS?
Beta blockers
Oral antihistamines
Hormone replacement therapies
Name 3 collagen vascular diseases that are associated with KCS?
Rheumatoid arthritis
Sjogren’s
Lupus
A deficiency in what causes bitot spots?
Vitamin A
What is the typical demographic for KCS?
Women over 50
What is the typical demographic for Salzmann’s?
Female over 50
Salzmann’s is typically associated with what conditions?
Trachoma
Phlyctenulosis
KCS
What is the classic appearance of Salzmann’s?
Smooth, opaque, elevated, blue-gray stromal opacities
What ocular manifestation is associated with gout?
Band K
What is the common demographic for SLE?
Female, teens-20’s
What ocular findings may be seen in SLE?
Disc edema
Dry eye
Photophobia
Malar rash
What is the typical Tx for mild Salzmann’s?
ATs
What Tx can be utilized for acne rosacea?
Doxy 100mg BID with taper Omega-3's Metronidazole Warm compresses lid scrubs Topical abx
When does posterior polymorphous dystrophy typically get identified?
30’s-50’s
What is the most common symptom of posterior polymorphous dystrophy?
Decreased vision from edema
What occurs in the endothelium in posterior polymorphous dystrophy?
Metaplasia and overgrowth of endo cells
What is the classic presentation of posterior polymorphous dystrophy?
Bilateral, asymmetric patches of vesicles
Band-like lesions and geographic gray hazy areas at Descemet’s membrane
What is the inheritance pattern of Fuch’s endothelial dystrophy?
AD
Fuch’s endothelial dystrophy is most common in what demographic?
Post-menopausal women
An endo cell count of less than what will typically lead to edema?
<500 cells/mm^2
Disciform keratitis most commonly occurs in what condition?
Herpes simplex keratitis
What is the typical presentation of disciform keratitis?
Round area of central/paracentral edema with a clear demarcation between involved and uninvolved cornea
Scatterek KP may be present
What is the inheritance of macular dystrophy?
AR
“macul-AR”
When does macular dystrophy occur?
In the first decade of life
What is the typical presentation of macular dystrophy?
Child with diffuse corneal haze and irregular gray-white spots (mucopolysaccharide deposits
Decreased VA
Possible corneal erosions
What is interstitial keratitis?
Stromal inflammation without primary involvement of the epi or endo
90% of interstitial keratitis cases are aquired how?
Congenital syphilis
What is the clinical appearance of interstitial keratitis?
Salmon patch lesions (stromal neo) Stromal edema Conj injection AC reaction KPs
What is the clinical triad of congenital syphilis?
- Interstitial keratitis
- Hutchinson’s teeth
- Deafness
Papilledema and optic neuritis are found in which form of syphilis?
Tertiary
What are the Tx options for Fuch’s endothelial dystrophy?
NaCl 5% gtts QID or UNG
Glaucoma meds for IOP
What is the Tx for disciform keratitis?
Pred forte QID
Viroptic QID
What is the Tx for interstitial keratitis?
Topical steroieds
What medication can cause pigment deposition on the corneal endo?
Chlorpromazine
Malignant melanoma of the conj typically arise from what?
Primary acquired melanosis (PAM)
What is the most common conj malignancy in the US?
CIN
CIN gives rise to what malignant condition?
Squamous cell carcinoma
What is the typical presentation of CIN?
Elevated, gelatinous mass with neo
30% of primary acquired melanosis progresses to what?
Malignant melanoma
Primary acquired melanosis is caused by a proliferation of what?
Intraepithelial melanocytes
What is the typical presentation of a conj lymphoma?
Smooth, fleshy, subconj salmon-colored patch
What typically causes pyogenic granulomas?
Trauma
Surgery
What is the most important prognostic indicator of progression from PAM to malignant melanoma?
Thickness of the lesion
What 3 drugs can cause nystagmus?
Phenytoin (dilantin)
Phenobarbitol (luminal)
Salicylates
Which drug can cause blue/yellow color defects?
Digoxin
What type of cataracts can chlorpormazine cause?
Stellate cataracts
Amiodarone can cause deposits where?
Lens
What is the Tx for pyogenic granuloma?
ABx-steroid combo
tobradex, maxitrol
Pilocarpine can potentially cause what severe ocular side effect?
Retinal breaks
A history of cold sores and an increase in stress could lead to what ophthalmic condition?
Herpes simplex keratitis
Herpes simplex hides in which ganglion?
Trigeminal (gasserian)
What things may trigger recurrent HSK infections?
Stress Sun exposure Fever Trauma Immunosuppression
Which herpes simplex virus is most commonly responsible for HSK, type 1 or type 2?
Type 1
What is the early acanthamoeba presentation?
Epi defects ranging from SPK to whorl-like defects, to pseudodendritic lesions
Pain > signs
If left to grow, what is the more advanced presentation of acanthamoeba?
Patcy anterior stromal infiltrates that become confluent to form a ring ulcer
What are the Tx options for an HSK dendrite?
Viroptic
Zirgan
Why might Zirgan be preferred to treat an HSK dendrite over Viroptic?
Thimerosol toxicity of Viroptic
What is the typical presentation of Thygeson’s?
Small, bilateral, multiple, asymmetric, gray-white crumb-like clusters, central lesions
White, quiet eye
Look like SEIs, but more superficial
Stain minimally with NaFl
What are the 4 forms of ocular herpes simplex infection?
Epithelial keratitis
Disciform keratitis
Blepharoconjunctivitis
Keratouveitis
What is the Tx for HSK?
Viroptic Q2H for 5-7 days, then 5x/day for 7 days
NO STEROIDS on HSK (will work for stromal keratitis, though)
What is the Tx for herpes simplex stromal keratitis?
Pred forte QID
Viroptic QID
For recurrent HSK, what oral med can be prescribed?
Acyclovir 400mg BID
What is the Tx for herpes zoster ophthalmicus?
Acyclovir 800mg 5x/day OR
Valacyclovir 1000mg TID
What is the Tx for Thygeson’s?
ATs for mild severity
Severe:
Mild steroids (FML, loteprednol QID x 1 week)
Bandage SCL
What is the most common anterior corneal dystrophy?
ABMD (AKA EBMD, map-dot-fingerprint, Cogan’s dystrophy)
ABMD is slightly more common in which gender?
Female
What things characterize Von Hippel-Lindau disease?
Retinal capillary hemangioblastomas
What are the 5 drugs that can cause whorl keratopathy?
CHAI-T Chloroquine Hydroxychloroquine Amiodarone Indomethacin Tamoxifen
A cortical cataract can cause what type of refractive shift?
Hyperopic
A nuclear cataract can cause what type of refractive shift?
Myopic
PSC can be caused by what 2 things?
Steroids
X-rays
Which systemic condition may result in “Christmas tree cataracts”?
Myotonic dystrophy
What are the characteristics of myotonic dystrophy?
Miotic pupils External ophthalmoplegia Christmas tree cataracts Pigmentary retinopathy Muscle wasting and weakness
What is the inheritance of Wilson’s disease?
AR
Wilson’s disease results in an increased deposition of what?
Copper
In Wilson’s disease, where is copper most concentrated?
Liver
Brain
Cornea (Kayser-Fleisher Ring)
What signs/symptoms characterize Wilson’s disease?
Wrist tremor (asterixis) Basal ganglia degeneration Cirrhosis Corneal deposits Cataracts Carcinoma Dementia
What is the most common cause of pre-senile cataracts?
Diabetes
Severe atopic dermatitis can result in which 2 cataracts?
Shield cataracts
PSC
What type of cataract forms due to acutely high blood sugar?
Snowflake cataracts
What type of cataract is found in Wilson’s disease?
Sunflower cataract
What would differentials for glare or halos be?
Cataracts
Angle closure
Corneal edema
Corneal haze
Sildenafil carries a slight risk of developing what ocular condition?
NAION
What ocular side affect may occur from Digoxin use?
Blue-yellow defect
Entoptic phenomena
Retrobulbar optic neuritis
What is the average axial length of the eye?
24mm
A 1mm change in axial length of the eye results in what dioptric power?
3D
How thick must the remaining “bed” be for LASIK?
250microns
What is the formula for LASIK calculations?
Flap (120mu) + ablation (15mu per D) = >250mu (bed)
How much cornea is ablated per diopter for LASIK?
15microns per 1 diopter
What is the Tx for deep lamellar keratitis post LASIK?
Topical steroids (Pred 1%) If severe, flap needs to be lifted and irrigated
How long after LASIK does DLK usually appear?
Days right after surgery
How long after LASIK will epithelial ingrowth occur?
around 1 month post-op
What is the preferred time period to wait before re-treating LASIK or PRK?
6 months - earliest is 3 months
LASIK can cause a false high or low IOP?
False low
Positive Seidel’s sign after cataract surgery puts a patient at risk for what 5 complications?
Endophthalmitis Hypotony Iris prolapse Choroidal detachment Shallow A/C
What are the typical signs and symptoms of endophthalmitis?
Severe pain Loss of vision Corneal edema Injection Severe A/C reaction w/ possible hypopyon Vitreous cells Mucus discharge
What is the management for endophthalmitis?
Immediate referral to surgeon for aggressive ABx treatment
At what pressure does hypotony become a problem?
Under 6mmHg
Why does a choroidal detachment occur with low IOP?
Fluid accumulates in the suprachoroidal space
Why might diplopia occur after cataract surgery, and then resolve spontaneously?
Retrobulbar anesthesia
How can you manage cataract post op bullae?
Bandage CL if epi is intact
How long after cataract surgery does Irvine Gass typically set in?
3 months
What causes Irvine Gass?
Anterior seg inflammation migrating to the posterior seg, leading to breakdown of the blood-retinal barrier, causing vessel leakage
Where does fluid accumulate in Irvine Gass?
Outer plexiform layer
If topical steroids and NSAIDs are not effective for Irvine Gass, what may be indicated?
Periorbital steroid injection
ACIOLs have a higher risk of causing UGH syndrome. Why?
Haptic rubbing on iris causing hyphema and uveitis, clogging the TM
Is scleritis a granulomatous or non-granulomatous inflammation?
Granulomatous
50% of cases of scleritis are associated with what?
Underlying systemic disease - mostly collagen vascular disease (30%)
What is the most benign form of Scleritis?
Non-necrotizing diffuse scleritis
What is another name for necrotizing scleritis without inflammation?
Scleromalacia perforans
Scleromalacia perforans is typically a result of chronic what?
Rheumatoid arthritis
What is the worst form of scleritis?
Necrotizing with inflammation
What are the conditions that cause non-granulomatous uveitis?
UCRAP Ulcerative colitis Crohn's Reactive arthritis Ankylosing spondylitis Psoriatic arthritis
What lab will come back increased in Reiter’s syndrome?
Increased ESR
What are the typical signs/symptoms of Reiter’s syndrome?
Urethritis
Polyarthritis
Conjunctivitis (with iritis)
Increased ESR
What is the most common cause of uveitis in children?
Juvenile rheumatoid arthritis
What is the most common cause of posterior uveitis in adults?
Toxoplasmosis
What characterizes toxoplasmosis?
Unifocal yellow-white lesion obscured by overlying vitritis
“Headlights in the fog”
What characterizes histoplasmosis?
Multifocal punched-out yellow-white lesions
Peripapillary atrophy
Maculopathy
Ohio-Mississippi river valley
What are the typical signs of ocular sarcoidosis?
Granulomatous panuveitis
Retinal vasculitis
White, fluffy opacities of inverior vitreous
Posterior uveitis occurs in which stage of syphilis?
Secondary syphilis
What are the typical signs of secondary syphilis?
Acute multifocal chorioretinitis
Vitritis
Salt and pepper fundus
Flame hemes
Which condition results in “snow banking”?
Pars planitis - intermediate uveitis
Which test is used to see if a patient has ever had syphilis?
FTA-ABS
What is the typical Tx for uveitis?
Pred 1% Q1Hr with slow taper
Cycloplegic BID
What class of drug is brompheniramine?
Anti-histamine
What is the classical presentation of an iris cyst?
Globular, dark-brown structure that transilluminates
-don’t typically grow
What are Lisch nodules?
Small, round, lightly pigmented hamartomas of the iris
Typically bilateral and inferior
95% of the time Lisch nodules are found in what condition?
Neurofibromatosis
On what part of the iris are Koeppe nodules found?
Pupil margin
Where are Busaca nodules found?
Iris surface
In what condition might Koepe and Busaca nodules be found?
Granulomatous uveitis
What systemic conditions can cause granulomatous uveitis?
Sarcoidosis
TB
Syphilis
Episcleritis is usually idiopathic, but 40% of the time it is related to what?
Collagen vascular diseases
What is the classical presentation of episcleritis?
Younger pt with unilateral sectoral injection
No to mild irritation
Phlyctenular keratoconjunctivitis results from what type of hypersensitivity?
Type 4 - delayed
What is the most common cause of phlyctenular keratoconjunctivitis? What is the second most common cause?
Staph from blepharitis
TB
What simple test can be done to differentiate episcleritis from scleritis?
Phenylephrine 2.5% blanching
What is the purpose of amiodarone?
Anti-arrhythmic
At what dose of amiodarone is corneal verticillata inevitable?
400mg/day
What 3 ocular side affects may be caused by amiodarone?
Verticillata/whorl K
Anterior subcapsular cataract
NAION
What is the Tx for mild episcleritis?
ATs
Cold compresses
Topical decongestants if desired
What is the Tx for moderate to severe episcleritis?
Topical steroid (lotemax) or oral NSAID for 5-10 days
What is the Tx for pingueculitis?
Mild topical steroid (FML, lotemax, etc)
What is the Tx for phlyctenular keratoconjunctivitis?
Mild: topical decongestants
Mod-Severe:
Topical steroids, or steroid/abx combo
Addison’s disease is caused by what?
Too little corticosteroid in the system
What 3 things do you need to know about your patient before prescribing oral steroids?
Pregnancy
Peptic ulcer
Diabetes
What is the inheritance pattern of oculocutaneous albinism?
AR
What is the inheritance pattern of ocular albinism?
X-linked
Less commonly AR
What is ectropion uveae
Proliferation of iris posterior pigmented epithelium onto the surface of the iris
What is the cause of ocular albinism?
Decreased number of melanosomes
What typically causes the vision loss in ocular albinism?
Foveal hypopigmentation (hypoplasia)
What is the most significant threat to vision in a patient with ectropion uveae?
Secondary angle closure glaucoma due to iris ectropion and/or high iris insertion
Why should a patient with oculocutaneous albinism be referred to hmatology?
To rule out Chediak-Higashi and Hermansky-Pudlak syndromes, as they are potentially lethal
What are the 4 TB drugs?
RIPE Rifampin Isoniazid Pyrazinamide Ethambutol
What is a serious potential side effect of ethambutol?
Bilateral, retrobulbar optic neuritis
Minocycline and corticosteroids have what potential ocular side effect in common?
Blue sclera
What are the vision threatening complications of a retinal vein occlusion?
Macular ischemia and edema
Neovascularization - heme, glaucoma, RD
What is the leading cause of vision loss in CRVOs?
Macular edema
What is the clinical definition of an ischemic CRVO?
10DD or more of non-perfusion on FA
90% of cases of CRVO present with what reduced acuity?
20/200 or worse
What are the risk factors for CRVO?
Hypertension (61%)
Diabetes
CV disease
Open angle glaucoma
What is the most common vascular cause of vision loss?
Diabetic retinopathy
Which quadrant is most common for BRVOs?
Superior/temporal quad (60%)
What is the clinical appearance of a retinal vein occlusion?
Hemes
CWS
Mac edema
What are the risk factors for CRAO?
Hypertension (67%)
DM
Carotid disease
Cardiac valve disease
CRAO may be preceded by what?
TIAs/amaurosis fugax
90% of BRAOs are caused by what?
Emboli
What are the 4 types of emboli?
Cholesterol
Calcium
Fibrin
Plateles
What is the classic example of optic neuritis?
Young female Sudden vision loss APD Pain on EOM Vision loss worsenes for 2 weeks, then stabilizes and improves
What is the classical presentation of AAION?
Sudden, unilateral vision loss Disc edema Over 55 years old Temporal headache Scalp tenderness Jaw claudication Malaise
CRVOs and BRVOs result from what?
Compression of an artery on a vein leading to thrombus formation
What most commonly causes a CRAO?
Calcific emboli from heart valves
OR
Hollenhorst plaque from carotid
If a young patient presents with a CRVO, what might be the etiology?
Oral contraceptives Factor XII deficiency Collagen vascular disease AIDS (among others)
What is the most common cause of AAION?
GCA
What is GCA?
Systemic vasculitis of medium and large blood vessels
In AAION, what arteries become occluded?
SPCAs
What is the typical final acuity after a CRVO?
Similar to what the acuity was on initial presentation
When is PRP indicated after a CRVO?
Any of the following: Rubeosis is > 2 clock hours Angle neo Neo glaucoma Any posterior seg neo
How should mac edema after CRVO be treated?
Intravitreal steroids (according to SCORE study)
How often should patients be followed after a CRVO? What procedures should be done?
Every 6 months
Gonioscopy
BP
If neo arises after a BRVO, what is the Tx?
Sector laser of area of the occlusion
What is the Tx for persistent mac edema after BRVO?
Focal laser of the macula
How often should a patient be followed after BRVO?
1-2 months
Look for mac edema and neo
What test should be run in an older patient presenting with a CRAO to rule out GCA?
ESR
When should a PPV be considered after a non-clearing diabetic vit heme?
1 month
What is the Tx for demyleniating optic neuritis?
IV steroids for 3 days
Followed by oral pred for 11 days
What is the Tx for AAION?
High-dose steroid Tx
What are the typical findings in retinitis pigmentosa?
Waxy optic disc pallor Midperipheral pigment clumping Attenuated arterioles Hyaline bodies of the optic nerve PSC Keratoconus
Which type of photoreceptor suffers more damage in RP, rods or cones?
Rods (think night blindness)
What is the average age of diagnosis of RP?
9-19
What is choroideremia?
Diffuse, progressive atrophy of the choriocapillaris and RPE
What is the inheritance pattern of choroideremia?
X-linked recessive
Choroideremia has similar symptoms to what condition, but with a different fundus appearance?
RP
Fundus albipuncataus results in what symptoms?
Stationary night blindness
What is the characteristic appearance of fundus albipuncataus?
Numerous small, yellow-white dotlike lesions of the RPE in the midperiphery (spare the macula)
What macular changes may occur in RP that cause vision loss?
CME
ERMs
Atrophy
Pigmentary retinopathy is a side effect of what 2 antipsychotics?
Thioridazine
Chlorpromazine
Tamoxifen is known to have what ocular side effect?
Crystalline retinopathy
Roughly what percentage of patients with an acute, symptomatic PVD with have a retinal break?
10-15%
Where is the most common location for atrophic holes?
Temporal retina
sup>inf
What is the most likely area for a tractional retinal tear?
Superior temporal
What 2 things are defined as non-rhegmatogenous RDs?
Exudative RD Tractional RD (no retinal break)
Which is a bigger risk factor for RD, white without pressure or lattice degeneration?
Lattice
What is the most common cause of a tractional, non-rhegmatogenous RD?
Proliferative DM
What type of cells are proliferating in an ERM?
Glial cells in ILM
Who is the typical patient with CSR?
Male 20-50 with type A personality
Who is more at risk of developing wet AMD, myopes, or hyperopes?
Myopes
What is the end stage of dry AMD?
Geographic atrophy
What are the 4 risk factors that increase the likelihood of progression to wet AMD?
Multiple soft drusen
Focal hyperpigmentation
Hypertension
Smoking
What is a Lacquer crak?
Spontaneous, large linear break in Bruch’s membrane
What is the 5 year risk for developing wet AMD in the fellow eye?
40-85%
What is the change of CSR recurrence?
40%
At what VA should an ERM be treated?
20/50 or worse (>20/40)
What is the management for dry AMD?
Daily Amsler
High-dose antioxidants for cat 3-4 AMD
Low-dose antioxidants for cat 1-2 AMD
Smoking cessation
What are the Tx options for wet AMD?
Thermal laser photocoagulation
Photodynamic therapy (PDT)
Anti-vegF (mainstream managment)
What retinal findings are present in stage 3 HTN retinopathy?
CWS
Hard exudates
Where are CWS typically found in HTN?
within 3DD of the nerve
HTN retinopathy results from a breakdown of what?
Blood-retinal barrier
A/V nicking would be given what HTN retinopathy grade?
Grade 2
What retinal findings are seen in stage 4 HTN retinopathy?
CWS
Hard exudates
Nerve swelling
What are Elschnig spots?
Focal areas of choroidal atrophy (white spot with black center)
What causes Elschnig spots?
Past occurrences of acute HTN
What is the main difference between diabetic retinopathy and hypertensive retinopathy?
Hypertensive usually presents with a “dry retina” - few hemorrhages, rare edema, but more CWS and vessel attenuation
CMV retinitis is most common in patients with a CD4 count less that what?
50
What is the classical presentation of CMV retinitis?
Hemorrhagic retinitis
Thick, white-yellow patches of necrotic retina
Vascular sheathing
Hemes and CWS
In which retinal layer are flame hemes found?
NFL
In which layer of the retina are hard exudates found?
Outer plexiform layer
At what diastolic pressure should a pt be sent to the ER?
110-120
What 3 drugs have NAION as a potential side effect?
Sildenafil (Viagra)
Sumatriptan (Imatrex)
Amiodarone (Codarone
What are the common side effects of topical B-blockers?
Dry eye Depression Impotence Bradycardia Bronchoconstriction
What is the most common intraocular malignancy in children?
Retinoblastoma
What is the most common intraocular malignancy in all age groups?
Malignant melanoma
What is Coat’s disease and its presentation?
Idiopathic peripheral vascular disease Unilateral telangiectatic, dilated vessels (light-bulb appearance) Marked hard exudates Intraretinal hemes Exudative detachment Neovascular glaucoma
Retinoblastoma arises due to a mutation of what gene?
Rb - retinoblastoma tumor suppressor gene
What are the 3 most common presenting signs of retinoblastoma?
Leukocoria
Strab
Iris neo
What finding in retinoblastoma increase the mortality rate?
Optic nerve invasion
How are large retinoblastomas treated?
Chemotherapy and enucleation
How are small retinoblastomas treated?
External beam radiotherapy
Laser photocoagulation
Brachytherapy
Cryotherapy
Your patient presents with a focal, fluffy, yellow-white retinal lesion adjacent to an old scar with an overlying vitritis, what is the most likely Dx?
Toxoplasmosis
What type of organism is toxoplasmosis gondii?
Intestinal parasite
How is toxoplasmosis acquired?
Undercooked meet
Unpasteurized cheese
What is the triad for congenital toxoplasmosis?
Convulsions
Cerebral calcifications
Chorioretinitis
In Best’s disease, which test will be abnormal?
EOG
What is the typical presentation of dominant (familial) drusen?
Scattered drusen throughout the posterior pole
First 3 decades of life
Bilateral and symmetric
Appear at macula and around optic nerve head
Pt is asymptomatic
When is the typical onset of Stargardt’s?
Ages 6-10
What is the most common hereditary macular dystrophy?
Stargardt’s
What is the typical presentation of Stargardt’s?
Early stage: mild mottling and loss of FLR with VA decreased out of proportion to signs
Late stage: Fish tail shape of yellow flecks leading to beaten-bronze macular appearance (Bull’s eye maculopathy)
Possible salt and pepper in the periphery
Which test is abnormal in later stages of Stargardts?
ERG
What is the difference between fundus flavimaculaltus and Stargardt’s?
Fundus flavimaculatus doesn’t have the macular dystrophy, but the other signs are present
Patients are typically asymptomatic
What is the Tx for toxoplasmosis?
Oral pyrimethamine
Systemic steroieds
Folinic acid
Sulfadiazine OR Clindamycin OR azithromycin
Indomethacin is known for what ocular side effect?
Pigmentary retinopathy
What are the 3 typical symptoms of ocular ischemic syndrome?
Gradual vision loss
Dull periorbital pain/headache
Amaurosis fugax
What are the 4 typical signs of ocular ischemic syndrome?
Unilateral dot/bot hemes in midperiphery
Dilated, non-tortuous veins
Narrowed arteries
NVD and NVI
What is venous stasis retinopathy?
OIS without anterior segment findings (rubeosis)
What is the typical demographic for OIS?
Male, 50-70 years old
Total cholesterol should be less than how much?
200
What is the normal level of HDL?
40 or higher
What is the normal level of LDL?
<100
What is the normal triglyceride level?
<150
What are the high risk characteristics in diabetic retinopathy?
Neo of the disc > 1/4 DD
Any NVD or NVE with a vit heme
What is the leading cause of legal blindness in diabetes?
Macular edema
What is the ETDRS definition of CSME?
Retinal thickening within 500um of the foveal center
Hard exudates within 500um of the foveal center
Retinal thickening of at least 1DD
ETDRS recommends what Tx for CSME?
Focal argon laser
Patients with severe NPDR have a 10-50% chance of progression within the next __months.
12 months
What causes OIS?
Carotid or ophthalmic artery blockage >90%
What is the Tx for OIS?
PRP if any neo is present
Carotid Doppler and endarterectomy if needed
What is the prognosis for OIS?
Poor - Count fingers or worse after 1 year
What percent of eyes with CRVO’s develop rubeoisis? When is it most likely to occur?
50%
2-4 months
(think 90 day glaucoma)
What is Adie’s tonic pupil?
Acute, dilated pupil with possible ciliary body impairment
What is the typical demographic for Adie’s tonic pupil?
Female 20-40
Possible complaints of light sensitivity and near blur
Argyll Robertson and Horner’s pupils will demonstrate the most anisocoria in what lighting conditions?
Dark
A pre-ganglionic Horner’s will dilate with what drug?
Cocaine
IIH can present with what signs/symptoms?
Headache
CN 6 palsy
Transient visual obscurations
Enlarged blind spot
What 4 things may possibly cause IIH?
CANT Contraceptives Vitamin A Naladixic acid Tetracycline
What are Tx options for IIH?
Oral acetazolamide
weight loss
What is a potential serious side effect of oral acetazolamide?
Aplastic anemia
Oral acetazolamide can cause what type of refractive shift?
Transient myopic shift
What is the typical presentation of optic neuritis?
Young female
Sudden, unilateral vision loss (mild to severe)
APD
Pain on EOM (90%)
Visual field defect (usually central scotoma)
Uthoff’s sign
What conditions can cause optic neuritis?
MS Syphilis Cat-scratch disease Lyme Meningitis Sarcoidosis SLE Devic's disease
What is normal sed rate for a female?
(age + 10) / 2
What is normal sed rate for a male?
age / 2
What is the normal level of C-reactive protein?
0-1.0mg/dl
How is Leber’s optic neuropathy inherited?
Mitochondrial DNA
How does Grave’s disease cause vision loss?
Optic nerve compression from thickened EOMs
What is the Tx for optic neuritis?
IV steroids and Interferon beta
After an acute bout of optic neuritis, when does the vision generally return to normal?
2-3 months
While vision will return to normal after acute optic neuritis, what are the lasting effects?
Reduced contrast sensitivity
Optic nerve head pallor
What causes internuclear ophthalmoplegia?
Lesion of MLF
What is the presentation of INO?
Adduction deficiency on affected side
Abduction deficit on contralateral side
What is the typical demographic of Grave’s disease?
Middle aged to elderly female
What are the classical signs of Grave’s?
Dry, red eyes
Conj injection
Proptosis
Diplopia
What are the systemic symptoms of hyperthyroid?
Weight loss Nervousness Heat intolerance Heart palpitations Increased bowel movements Breathlessness
What testing should be done for Grave’s disease?
TSH, T3 and T4 levels Orbital CT or MRI, looking for inflamed EOMs Exophthalmometry VF, looking for optic nerve compression Forced ductions
Brown’s syndrome will cause diplopia in what gaze?
Upgaze, especially in adducted upgaze
In what order are the EOMs restricted in Grave’s?
IMSLO Inferior rectus Medial rectus Superior rectus Lateral rectus Obliques
What is Kocher’s sign?
The stare appearance in Grave’s
What is Gunn’s sign?
Retinal crossing changes, typically found in HTN retinopathy
What is the primary Tx for early Grave’s?
Ocular lubricants
What is the Tx for late stage Grave’s?
Orbital decompression, radiation, steroids (oral or IV)
What are the signs of Grave’s disease, in order as they occur?
NO SPECS No signs/symptoms Only signs of lid retraction/lag/stare Soft tissue signs/symptoms (lid edema, lag, chemosis) Proptosis EOM enlargement Corneal involvement Sight loss - optic nerve compression
What class of medication is Verapamil?
Ca channel blocker
What conditions is verapamil indicated?
HTN
Angina
Arrhythmia
What is the Tx for AAION?
IV or oral steroids long term, tapered over 3-6 months
What are the classic signs/symptoms of AAION?
Unilateral, profound vision loss Swollen optic nerve Jaw claudication Scalp tenderness Malaise Anorexia Temporal headache
What is the typical demographic for AAION?
Over 55
Which condition typically has a “disc at risk”, AAION or NAION?
NAION
Sed rate and CRP will be normal in which condition, AAION or NAION
NAION
What is the typical VF loss in NAION?
Altitudinal
If GCA is not treated, what sequelae is most common?
Progression of vision loss to the other eye
What are the potential side effects of oral steroids?
Poor BS control IOP spike Cataract Cushing's syndrome Poor wound healing Risk of secondary infections
What demographic does ocular myasthenia typically effect?
Young women
Old men
When are ocular MG symptoms the worst?
End of the day
What are the ocular signs/symptoms of MG?
Diplopia (EOM involvement)
Ptosis (levator involvement)
What are the potential systemic signs of MG?
Dysarthria (difficulty talking)
Dysphagia (difficulty eating)
Difficulty holding head upright
Respiratory failure
What class of medications can make MG worse?
Beta-blockers
Internuclear ophthalmoplegia is usually found in patients with what systemic condition?
MS
If a patient has a superior oblique palsy, which way will their head be tilted?
Away from the affected side
What test is done to confirm ocular MG?
Tensilon test
What medication is used in the Tensilon test?
Edrophonium
What is the antidote for the Tensilon test, should a patient have an adverse reaction?
IV atropine
Why should thyroid testing be done in a patient with MG?
Thyroid disease occurs in about 5% of MG patients
What class of medication is tamsulosin?
Alpha-1 blocker
What is the Tx for MG?
Pyridostigmine and/or immunosuppressants
A chiasmal lesion can result in what VF defect?
Bitemporal hemianopsia
can be inferior, superior, central, or complete
Why does a chiasmal lesion typically cause bitemporal involvement?
Compression of nasal fibers
What are the most common causes of chiasmal lesion?
Suprasellar meningiomas
Aneurysm of ICA
Craniopharyngioma
Glioma
Where would a lesion be located that is causing a homonymous inferior quadrantonopsia?
Parietal lobe
Where would a lesion be located that is causing homonymous superior quadrantanopsia?
Temporal lobe
What VF defect would be expected in toxic/nutritional optic neuropathy?
Central or centrocecal
If a patient has an occipital lobe lesion, what VF defect would you expect?
Homonymous and congruous
What VF defect may be present due to tilted disc syndrome?
Pseudo-bitemporal hemianopsia that does NOT respect the midline
What type of lesion will give a VF defect that respects the midline?
Chiasmal
What lesion would cause a macula only homonymous VF defect?
Lesion at tip of occipital lobe
What is the typical demographic for pigment dispersion syndrome?
20-45 year old myopic male
What is the typical presentation of Posner Schlossman syndrome?
Open angle
Few cells
IOP >40
What findings characterize Fuch’s heterochromic iridocyclitis?
Non-granulomatous, fine KPs
Low grade, asymptomatic chronic uveitis
What is the MOA for prostaglandin analogs?
Increased uveoscleral outflow
What is the MOA for Beta-blockers?
Decreased aqueous production
What is the MOA for Alpha-agonists?
Decreased aqueous production
Increased uveoscleral outflow
What is the MOA for Pilocarpine in glaucoma?
Increased TM outflow
What is the MOA for CAIs ?
Decreased aqueous production
Which glaucoma gtts should not be used in patients with a sulfa allergy?
CAIs
How should pigmentary glaucoma be treated?
IOP lowering gtts - but may be harder to control, as the amount of pigment being disbursed varies
ALT is very effective
What is the cause of glaucoma in pseudoexfoliation syndrome?
Deposits accumulating in the TM
A patient with lung problems and glaucoma should not be given which class of IOP meds?
Beta-blocker
What does a high PSD on VF indicate?
“lumpy” hill of vision with focal loss
What is the default spot size in VF testing?
III
After 5 years, what is the chance of progression from ocular hypertension to POAG?
9.6%
Which has a larger treatment spot size, ALT or SLT?
SLT
Drance hemes are typically associated with which type of glaucoma?
NTG
What steroid is found in Maxitrol?
Dexamethasone
Which cranial nerve is most susceptible to trauma?
CN 4
What is the initial Tx of an orbital blow-out fracture on day 1?
Nasal decongestants (don’t blow nose!)
What is absolute hyperopia?
The amount that can’t be overcome by accommodation
Which of the topical steroids is ester based?
Lotoprednol
How long does it typically take for a steroid response to occur?
30 days
NTG can be associated with what type of headaches?
Migraines
NTG is more common in persons of which decent?
Japanese
Which class of IOP lowering drop is contraindicated in a patient with a history of HSK, CME, or complicated cataract surgery?
Prostaglandin analogs