Ophth Flashcards
What are the components of the basic eye exam?
C ROAD MAP Confrontation Reaction Ophthalmoscopy Acuity Depth Motility Ancillary- Amsler Color Eversion Pressure
Eyelids are called ?
What are their two functions
Palpebrae
Protection
Spread new/drain old tears
What are the three muscles of the eyelid, their function and nerve innervation/
Orbicularis oculi- closes, CN7
Levator palpebrae- opens, CN3
Muellers- opens both, S-ANS
What movements to the rectus and oblique muscles of the eye do?
SR: elevate
LR: abduct
IR: depress
MR: adduct
IS: intor/depress
SO: extro/elevate
Eyes work in ?, “ ? “
What type of response has to happen for movement to occur?
Tandem, yoked
Ipsilateral opposing relaxation
Define Emmetropia
Define Hyperopia
Define Myopia
Normal, clearly seen w/ unaccommodated eyes
Farsighted, short axial length causes images to fall behind
Near sighted, long axial length causes images to fall in front
Define Astigmatism
Define Presbyopia
Eliptical shape, different refracting power between cornea/lens (difference on horizontal/vertical axis)
Loss of accommodation; progressive hardening of lens and loss of ability to change shape
Define Strabismus
Define Phoria
Define Tropia
Misalignment of eye
Misalignment evident w/ eye covered
Misalignment w/ eyes open and uncovered
What are the three types of eye deviations
Orthophoria- no deviation
Heterophoria- normal deviation, not present on cover-uncover test
Heterotropia- deviation when using both eyes
Noticed on cover-uncover test
What happens during Heterophoria deviation
How is this type of deviation noticed?
Both eyes point in same direction until one eye is covered- fusion broken
When cover applied, covered eye moves away from open eye
Discovered w/ alternating cover test
What happens during a Heterotopia deviation?
What happens if this is congenital?
What type of visual issue occurs due to this deviation?
Both eyes don’t point in same direction when both are open
One eye is suppressed to eliminate diplopia
Deviated eye has amblyopia
How is an ocular misalignment Dx confirmed?
If an acquired cause, what vision issue develops and usually do to ? etiology?
Cover-uncover
Hirschberg
Diplopia (primary/off-axis)
CN palsy/mass
Congenital ocular misalignment puts PT at risk for ?
Define ‘Third Strabismus’ and the cause
Amblyopia
R eye- normal
L eye- down/left
Aneurysm
Define ‘Fourth Strabismus’ and the cause
Define ‘Sixth Strabismus’ and the cause
Both eyes to R
Congenital trauma
R eye normal
L eye- right deviation
Cranial pressure
Define Nystagmus
Most of these are congenital cases due to ? and require ?
Repetitive rhythmic oscillations of the eye
Idiopathic, no eye exam required
Define Neuro-significant Nystagmus
Define Amblyopia
These are AKA ?
Vertical/see-saw movements from brain stem lesion
Abnormal development of visual system w/out anatomical damage
Lazy eyes
How are amblyopias Tx
Tx methods are best before ? age due to ?
Glasses
Patch/Atropine of better eye
Surgery
<8y/o, neuroplascticity
What are the three layers of tears and where are they made?
What are the three parts of the drainage system?
Outer- oil, meibomian
Middle- water, accessory
Inner- mucin, goblet
Punctum
Canaliculus
Sac
Duct
Define Ectropion
What causes this and how does it present
How is it Tx
Outward turning of lower lid
Inc lid laxity
Tearing, Irritation
Lubrication until surgery
Define Entropion
What causes this and how does it present?
How is it Tx?
Inward turning of eyelid
Involutional- age
Tearing Irritation
Lubricate until surgery
Define Blepharitis
How does it present
How is it Tx?
Inflammation of eyelid
Epiphoria worse in morning
Burning Foreign sensation
Shampoo/Compress
Staph etiology- Erythromycin ointment
Meibomian dysfunction- Doxy/Erythromycin
Define Chalazion
How does it present
How is it Tx
Inflammation due to blocked meibomian gland
Mild discomfort, well demarcated
Warm compress/massage
>4wks- Triamcinolone or escision
Define Hordeolum
How does it present
How is it Tx
Staph infected/sebaceous gland nodule
Painful
Compress/massage
Doxy/Erythromycin
Resistant- surgical drainage
Hordeolums are AKA ?
What Tx combo is used for hordeolums if blepharitis is also present?
When are these referred to surgery?
Styes
Erythromycin and Doxy
> 4wks ABX failure
When are Triamcinolone injections for chalazions c/i?
Define Dacryoadenitis
How does it present
Dark complexion PTs
Inflammation of lacrimal gland
Acute temporal lid tenderness
How is Dacryoadenitis Dx confirmed
If condition is bilateral, consider ? systemic Dzs
if infectious etiology, consider ?
Orbital CT
Sarcoid/Sjogrens
Mumps Mono
How is Dacryoadenitis Tx
Define Dacryocystitis
Mild- cold compress, NSAIDs
Acute/Purulent- systemic ABX
Infection- Augment/Cephalexin
Inflammation of lacrimal sac/canaliculus from bacterial infection/duct obstruction
How is Dacrycystitis Tx
Define the conjuctiva and the two types and where they meet
Augmentin/InD
Febrile PTs- admit, IV ABX
Thin membrane on eyelid/eye
Palpebra: inner eye lid
Bulbar: sclera
Both meet at fornix
MC cause of viral conjunctivitis
How does it present
How is it Tx
Adenovirus
Preauricular adenopathy
Self limiting
Highly contagious Week 2
ABX only if secondary bacterial infection present
What causes allergic conjunctivitis
How does it present
How is it Tx
Pollen Mold Pets
Severe itching
Stringy d/c
Topical antihistamines
What causes bacterial conjunctivitis
How does it present
How is it Tx
Staph A
Strep pneumo
C trachomatis
N ghonorrea
Thick d/c
Non-gonoccocal:
Tirmeth/Polymyxin B
Besi/Moxifloxacin
Neisseria/Chlaymida:
Ceftriaxone (Cipro if PCN c/i)
Topical fluroquinolones- if cornea involved
Azith or Doxy
What 3 DDx microbes must be considered when Dxing bacterial conjucntivitis
Why do these need to be considered?
N gonorrhoeae/meningitidis
C trachomatis
Gonoccocal infections can cause corneal ulcer and perf quickly
What antihistamines/cell stabilizers can be used for alelrgic conjunctivitis
What can be used for severe cases?
What PO antihistamines can be used?
Olopatadine Ketotifen
Loteprednol
Cetirizine Fexofenadine Diphenhydramine
Define Pinguecula
How does it present
How is it Tx
Bumpy “growth” on the exposed conjunctiva at 3/9 o’clock region
ASx w/ no vision loss
Tears/steroid
Define Pterygium
How does it present
How is it Tx
Bumpy “growth” on the exposed conjunctiva at 3/9 o’clock region
Invasive growth into cornea affects vision
Surgical removal
Define Thyroid Eye Dz
This condition is the MC cause of ?
Graves Ophthalmopathy, but can be any thyroid state
Bi/unilateral proptosis in adults
How are Thyroid Eye Dz cases worked up?
How is it Tx
Complete thyroid test
Normal- careful monitoring
CT confirms opthalmic Dx
Mild- tears, elevate, tape
Mod/Sec- Prednisone
Surgical interventions
What is used to stain corneal abrasions?
If penetrating trauma is present, what will be seen?
How are these Tx?
Sodium fluorescein
Seidels sign
Topical ABX
Cycloplegic
Do not patch
Define Bacterial Keratitis
This MC occurs in ? population but can be seen in ?
Bacteria infection of cornea affecting the stroma
Contact lens wearers
Anterior segment dz
How is bacterial keratitis Tx
If PT wears contacts, what ABX are added?
Daily f/u w/:
Fluoroquinolones and Cycloplegic drops
Polymyxin B/Trimeth
Trobramycin
What population is at high risk for pseudomonas keratitis?
Contact wearers
Perf <48hrs
How does fungal keratitis present
How does this type of infection begin?
What needs to be avoided during Tx
Asymmetric w/ feathery edge
Traumatic vegetative matter
Topical steroids
? military population is at high risk for fungal keratitis
What are the two functions of the sclera
Recent ocular surgery
Topical CCS
Protection
Attachment points for EOMs
What materials make the sclera
Where is the sclera thickest
Collagen
Elastic fibers
Posterior aspect
Episclera is joined to ? structure
What is the function of this structure
Tenon’s capsule
CT around globe
Covers tendons at EOM insertions
How does Episcleritis present
How is it Tx
More common younger adult w/ red/dull pain
Sectorial, engorged vessels
No d/c
Midl: cold compress, tears
Mod/Sev:Fluorometholone
Loteprenol
NSAID
What are the two causes of scleritis?
How does it present
What PE test confirms Dx
Idiopathic of systemic CT Dz
Severe boring pain*
Phenylephrine doesn’t show blanching (test in episcleritis will blanch)
How is scleritis Tx
What meds are added if case is resistant to Tx?
NSAIDs
H2 blocker- Rantidine
Prednisone, Clophosphamide
What are the 3 parts of the uveal tract
What are the S/Sxs of Anterior Uveitis
Iris- only visible part
Ciliary body
Choroid
Conjunctival ciliary injection/flush
Keratic precipitates:
Fine/white= non-granulous
Mutton fat= granulous
What are the associated d/s w/ Anterior Uveritis
Labs are needed if this condition has ? presentation/
Reiter/Ankylosing HLA-B27 JA Infection (Syph/TB) Lymphoma Sarcoidosis
Bilateral Granulomatous Recurrent
How is Anterior Uveitis Tx
What is the PTs prognosis?
Referral
Atropine/Scopalamine
Prednisolone
First time non-granule: good
Recurrent granule: poor
What is the MC cause of Posterior Uveitis
What other etiologies can cause it?
Toxoplasmosis
CMV Autoimmune Syph/TB/Toxocarisis Idiopathic Malignant
How does posterior uveitis present on PE?
How is it Tx
Inflammatory cells in vitreous- hazy exam
Disc swelling w/ edema
Retinal/choroid hemorrhage- exudate/infiltrates
Refer
Cycloplegic/steroid if anterior involved
What is the MC severe infection affecting the eye?
This MC usually isn’t seen until ? lab result is present?
CMV Retinitis
CD4 <100
What is the MC finding on exam of CMV retinitis
How quickly can PT go blind
Cotton-wool spots
2-6mon
Visual chart of eye muscles used for looking in different locations
PT R:
SR IO
LR MR
IR SO
PT L:
IO SR
MR LR
SO IR
What is the MC Sx of late onset strabismus cause by trauma, stroke or tumor
What part of the body has the highest concentration of protein than any other tissue
Diplopia
Lens
What are the 3 layers of the lens
What is the biggest RF for cataracts?
What is a common and other presenting complaints?
Capsule
Cortex
Nucleus
Age
Glare w/ headlights- Common
Monocular diplopia
Dec color perception
What is a benefit of developing nuclear cataracts?
What is the opposite of this benefit?
Second sight- thickening of lens improves near vision
Near vision dec w/ posterior subcapuslar
How are cataracts Tx
What are the reasons to perform surgery on cataracts?
Early- spactacles
Small central- dilation
Large- surgery/corrective refractive
Prevention of deprivational amblyopia in infants
Improve visual function
Management of ocular dz (Glaucoma Diabetic retinopathy)
MC cause of congenital cataracts
When do these become medical emergencies
Idiopathic
Congenital cataracts in infant- surgery w/in first 3-4mon to prevent permanent amblyopis
What is the difference berween subluxation and dislocation of lens?
What is the MC cause of subluxation lens anomalys?
Sub: decentered
Dis: displaced
Trauma
What are the S/Sxs of a lens position anomaly?
If PT w/ Marfans has lens position anaomaly, where is it usually displaced to?
If PT has homocystinuria, where is the lens usually displaced?
Iridodonesis Phacodonesis Angle closure glaucoma Irregular astigmatism Dec vision w/ monocular diplopia
Superotemporal
Inferonasal
Define Floaters
Define flashes
Small aggregates of vitreous from normal aging process
Vitreal traction on peripheral retina
What would be seen if PT presents w/ flashes and migraines?
If PT presents w/ flashes and floaters, ? is suspected
Scintillations
Zig-zag lights
Blood/pigment in vitreous
S/Sxs of vitreous detachment
How are these Tx
Sudden appearance of black spots/flashing lights
Floaters
Photocoagulation
Cryotherapy
Refer
What vessel supplies the inner and outer retina?
What is a normal vascular branching pattern?
How do arteries and vessels appear different?
In: central retinal artery
Out: choroid
2:3 A:V ratio
Art: thin, orange/red
Vess: larger, crimson
S/Sxs of retinal artery occlusion
What will be seen on PE?
What vascular structure will be spared?
Painless unilateral acute vision loss
Cherry red macula
Box car segmentation of arterioles
Cilioretinal
Why is the macula spared during retinal artery occlusions
If PT has BRAO, what type of vision loss will they present w/?
Choidal supply
Horizontal hemifield vision loss
What is the first set of orders placed for suspected retinal artery occlusion?
What controversial Txs may be done?
ESR CRP Platelets
Timilol
Acetazolamide
Massage
Paracentesis, anterior
How do retinal vein occlusions present
What could be seen on PE?
What type of vision loss do they present w/?
Unilateral painless loss of visoin w/ possible RAPD
Blood and Thunder fundus
Flame shaped hemorrhage
Horizontal hemifield loss w/ respect to horizontal line
How are retinal vein occlusion Tx
What is the leading cause of blindness in the US for PTs between 20-64?
D/c OCPs
Ophth eval <72hrs
ASA
Diabets
After Dx of DM, how long do PTs have to have visual baseline established?
What type of DM rarely has retinopathy
<6mon
Type 1, but most will develop w/in 30yrs
What is seen at the different levels of severity in non-proliferative diabetic retinopathy
VMild- microaneurysms Mild- CW spots Exudates Microaneurysms Mod: retinal hemorrhages, mild IRMA Sev: 4-2-1 rule 4 quadrants of severe retinal hemorrhage 2 or more quadrants of venous beading 1 quadrant or more of moderate IMRA
What is the hallmark finding of proliferative diabetic retinopathy
Where does the MC tend to be found
Neovascularization
Mascular arcades
What will be seen on PE of proliferative diabetic retinoapthy
How is this form of retinopathy Tx
Pre-retinal hemorrhage (board shaped)
CW spots
Loss of red reflex w/ floaters
PRP
Anti-VEGF injection
Tight glycemic control
What is the criteris for clinically significant macular edema
Edema <500um (1/3 disc diameter) to center of fovea
Hard exudate <500um from center of fovea
Retinal edema >1disc area/diameter of focea
What causes retinitis pigmentosa
How do these PTs present
What is seen on PE?
Loss of photoreceptors
Changes in retinal pigmentation
Night blindness
Bone spicule pigmentary retinopathy
How is retinitis pigmentosa managed?
What are the 3 different types of retinal detachments?
Vit ADEK supplements
Rhegmatogenous- break/tear
Exudative- leak w/out break (mass)
Traction- proliferative diabetic retinopathy
How does a retinal detachment present?
If VA is significantly affected what may be seen?
Flashers and Floaters
Curtain pulled down
Metamorphopsia
Ripples in a pond0 retinal hydration lines
RAPD
How can a retinal detachment be identified on PE?
How are these Tx
Eye w/ detachment= lighter reflex
Bed rest w/ head back
Refer, surgery
