HEENT - Vision Loss - Exam 2 Flashcards by Kelsey Peiser

What is photopsias?

Perceived flashes of light in the field of vision

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What are hard exudates?

Yellowish-white deposits of lipids in outer layers of retina (mostly macular area) from leakage due to damaged capillaries

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What is drusen?

Yellow, fatty, protein and lipid deposits under retina (occur naturally with age)

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What is a scotoma?

An area of partial alteration in field of vision with surrounding areas of normal visual acuity

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What is metamorphopsia?

Visual defect in which linear objects look curved or rounded

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What are cotton wool spots also known as?

Soft exudates

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What are cotton wool spots?

Pale, grayish white areas with ill-defined edges

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What is the Amsler grid used for?

Monitor central vision loss

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What is considered an abnormal finding on the Amsler grid test?

Wavy pattern when looking at the grid

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What should pupils be evaluated for?

PERRLA- pupils equal, round, reactive to light and accommodation

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What CN’s does the pupillary light reflex require? Which one is afferent/ efferent?

CN II = afferent

CN III = efferent

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What is considered a normal pupillary reflex?

Shine light in unaffected eye, bilateral pupils constrict

*abnormal = no reflex bilaterally = afferent pupillary defect

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If there is a lesion in CN II, what will be present upon exam?

Afferent

Sine light in affected eye, no pupillary reflex bilaterally

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What type of relative afferent pupillary defect (RAPD) will be seen upon performing the “swinging flashlight test”?

Marcus Gunn pupil

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What are the 3 primary components of glaucoma?

Intraocular pressure increase (urgent if >30mmHg)
Optic nerve damage
Visual field loss

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What is angle-closure glaucoma?

Acute rise of intraocular pressure (IOP) due to outflow obstruction

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How is angle-closure glaucoma identified on exam?

Shine light from lateral (temporal) aspect of eye towards the nose > if shadow projects on nasal iris, the chamber is narrow

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What is the presentation of angle-closure glaucoma?

Acutely decreased vision
Halos around lights
Ciliary flush
Steamy, cloudy cornea
Mid-dilated pupil 4-6mm, reacts poorly to light
Firm globe
Severe eye pain

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What is the gold standard for diagnosis of angle-closure glaucoma?

Gonioscopy (can measure angle)

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What should NOT be used in the management of angle-closure glaucoma?

Cycloplegics (dilating drops)

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What is included in the management of angle-closure glaucoma?

Ophthalmologic emergency!
Topical ocular anti-hypertensive meds (beta blockers, alpha-2 agonists)
Oral/ IV osmotic agents (mannitol)
Laser peripheral iridotomy 
Surgical trabeculectomy

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What are the causes of open-angle glaucoma?

Optic neuropathy
Increased aqueous production/ decreased outflow > IOP
(Pathogens not clear)

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What is the presentation of open-angle glaucoma?

Increased IOP (usually)
Increased cup/ disc ratio
Afferent pupillary defect

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What are early vs late symptoms of open-angle glaucoma?

Early- asymptomatic

Late- chronic painless visual field loss (peripheral first)

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What is included in the management of open-angle glaucoma?

Ophthalmologic referral Topical ocular anti-hypertensive medications Laser trabeculoplasty Surgical trabeculectomy Goal is to reduce risk of progression

What is a cataract?

Opacity secondary to breakdown and clumping of proteins within the lens

Do cataracts usually present with unilateral or bilateral symptoms?

Bilateral

How do cataracts present clinically?

Gradual, chronic, painless vision loss Difficulty with night driving Decreased visual acuity

What would be seen on an exam of a patient with cataracts?

Yellowing/ opalescent changes to the lens

When should management of cataracts be considered?

If a patient struggles with ADL due to vision changes > possible prescription glasses

What are surgical options for cataracts?

Extracapsular cataract extraction | Intraocular lens implant

What is the prognosis for a patient with cataracts?

Excellent (with no ocular comorbidity)

What are the 2 categories of macular degeneration?

Dry- strophic | Wet- neovascularization or exudative

What is the general presentation of macular degeneration?

Blurred vision Metamorphopsia (Amsler grid distortion) Central scotoma

What presentation of ARMD is unique to the dry subtype?

Drusen deposits Pigment mottling (loss of retinal pigment) Geographic atrophy (thinning/ loss of tissue in macula) Vision loss slow/ gradual

What presentation of ARMD is unique to the wet subtype?

Subsequent degeneration = “leaky vessels” Fibrosis/ scarring Rapid vision distortion

What is included in the management of both dry and wet ARMD?

``` Referral Vitamins/ omega 3 fatty acids Stop smoking Daily Amsler grid Low vision aids ```

What is included in the management of only wet ARMD?

Photocoagulation Photodynamic therapy Intravitreal steroid/ monoclonal antibodies

What does retinal detachment result in?

Ischemia and rapid degeneration of photoreceptors

What is the main risk factor for retinal detachment?

History of myopia (near sightedness)

What are the 3 types of RD?

Rhegmatogenous, nonrhegmatogenous and exudative (rare)

What are the most common causes of a rhegmatogenous RD?

Full-thickness tear Posterior vitreous detachment (PVD) Traumatic RD

What is posterior vitreous detachment (PVD)?

PVD normally adhered to retina but shrinks/ liquifies with age > pulls away from retina resulting in tears

What is the cause of nonrhegmatogenous RD?

Vitreous traction pulling on retina and tearing it | Associated with diabetes

How does diabetes related to nonrhegmatogenous RD?

Fibrosis from neovascularization adherent between retina and vitreous

How does RD present?

``` Painless Floaters/ photopsias Loss of vision (curtain-like) Raised, whitish retina May have afferent pupillary defect ```

What is the management for a RD?

If sudden onset of symptoms: Urgent referral Laser photocoagulation (small tear) Surgery (frank RD)

What is included in the surgical treatment of a RD?

Scleral buckle | Vitrectomy- replaced with gas, silicone oil

What is hypertensive retinopathy?

Retinal vascular changes due to chronic, systemic hypertension

Is hypertensive typically symptomatic or asymptomatic?

Asymptomatic (95%)

What are the characteristic ophthalmic changes seen with hypertensive retinopathy?

``` Arteriolar narrowing - copper wiring Arteriolar sclerosis - silver wiring A:V crossing changes - nicking Cotton wool spots Retinal hemorrhages ```

What is included in the management of hypertensive retinopathy?

Systemic BP control Referral Laser photocoagulation if retinal hemorrhage

What are the 2 classifications of DR?

Non-proliferative and proliferative

What are the characteristics of non-proliferative DR?

``` Blurred vision Retinal hemorrhage Cotton wool spots Venous dilation Hard exudates ```

What are the characteristics of proliferative DR?

Neovascularization Preretinal and vitreous hemorrhage Traction RD Retinal thickening

What is involved in the management of DR?

Blood sugar control Referral Laser photocoagulation Vitrectomy

What are the 2 types of vascular occlusion and how is each classified?

Central Retinal Artery Occultion (CRAO) = embolic | Central Retinal Vein Occlution (CRVO) = thrombotic

What is included in the presentation that is unique to CRAO?

``` Acute, TOTAL, painless loss of vision Often "no light perception" - "black as night" Afferent pupillary defect Ischemic retinal whitening "Cherry red spot" ```

What is included in the presentation that is unique to CRVO?

Acute, VARIABLE, painless loss of vision Scotoma with blurred vision (possible visual field loss) +/- afferent pupillary defect "Blood and thunder" retinal appearance

What is involved with the management of vascular occlusion that is unique to CRAO?

Ocular emergency No effective treatment/ poor prognosis Evaluate etiology - carotid plaques

What is involved with the management of vascular occlusion that is unique to CRVO?

Aspirin Observation Treatment for retinal edema/ ischemia Evaluate etiology if young- hypercoagulable state

What is optic neuritis?

Acute inflammatory demyelination of the optic nerve

Does optic neuritis typically in one or both eyes?

One - mononuclear vision loss = 90%

How does vision loss associated with optic neuritis present?

Vision loss over hours to days, peaks at 1-2 weeks

What disease is associated with optic neuritis?

``` Multiple sclerosis (MS) 30% at 5 years, 50% at 15 years ```

How does optic neuritis present?

Central scotoma Painful (worse with EOM) Abnormal color vision Photopsias

What is involved in the management of optic neuritis?

MRI brain and orbits with contrast | IV methylprednisone

When is IV methylprednisone used specifically for treatment of optic neuritis?

Severe vision loss or 2+ white matter brain lesions on MRI (more rapid but short term treatment, may delay onset of MS short term)