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Physical Exam 2 Didactic Midterm > Ophthalmic Exam > Flashcards

Ophthalmic Exam Flashcards

1
Q

define triage timelines

A
  • Emergent – Requires care within 1 hour
  • Urgent – Requires care within 4 to 6 hours
  • Semi-urgent – Requires care within 24 hours
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2
Q

give examples of emergent eye conditions

A

Chemical Splash/ Burn

Painless Unilateral Vision Loss:

  • Central Retinal Artery Occlusion
  • Arteritic Anterior Ischemic Optic Neuropathy secondary to GCA

Acute Ocular Trauma

  • blow out fx
  • Enophthalmos and/or vertical displacement of eye

Penetrating Injury

Severe Unilat Pain w/Vision Loss

  • Acute Angle Closure Glaucoma

Cellulitis: periorbital

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3
Q

give examples of urgent eye conditions

A

FB

Corneal Abrasion

Sudden Onset Diplopia:

  • oculomotor palsy III
  • Trochlear palsy IV
  • abudcens palsy VI

Acute Onset Flashes and Floaters

  • Posterior Vitreal Detachment (PVD)
  • Retinal Detachment (RD)

Sudden Onset Red Eye

  • Subconjunctival Hemorrhage
  • Conjunctivitis - viral, bacterial, Epidemic Keratoconjunctivitis, allergic
  • Keratitis – Microbial Keratitis aka Corneal Ulcer, Herpes Simplex
  • Uveitis (Iritis) - Acute Anterior Uveitis
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4
Q

give examples of semi-urgent eye conditions

A

Chalazion

Hordeolum (stye)

Cellulitis –

  • Preseptal Cellulitis:
  • Orbital Cellulitis: EMERGENCY STAT opth consult, hospitalzation
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5
Q

Tx of chemical burns/ splashes

A

IRRIGATE min 30 mins - normal saline is best, use tap water if thats all you have

determine ofending chemical and pH - normal 7.0-7.3

STAT ophthal consult through ED once pH is normalized

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6
Q

when dealing w/ a Penetrating Injury is it important to ALWAYS -

A

Cover eye with shield and send for STAT ophthalmology consult through ED

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7
Q

emergent causes of Painless Unilateral Vision Loss

diagnostic characteristic?

A

Central Retinal Artery Occlusion

  • VA in range of counts fingers to NLP
  • Usually patient with Hx of HTN, carotid occlusive disease, cardiac valve disease – typically secondary to arterial embolus to eye via Ophthalmic Artery
  • Will see diffuse whitening of retina with “cherry red spot” in macula
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8
Q

Nonarteritic Anterior Ischemic Optic Neuropathy si/sx

A

EMERGENT Painless Unilateral Vision Loss

If loss reported upon awakening

note inferior hemisphere field loss +/- good to fair VA

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9
Q

Secondary to transient non/hypo-perfusion of Short Posterior Ciliary Arteries surrounding/nourishing the optic nerve

Will see optic nerve head edema +/- splinter hemorrhages

A

Nonarteritic Anterior Ischemic Optic Neuropathy

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10
Q

In patient presenting w/ Painless Unilateral Vision Loss

Consider Arteritic Anterior Ischemic Optic Neuropathy secondary to Giant Cell Arteritis if:

A
  • Patient >55yo
  • Temporal scalp tenderness +/- jaw claudication
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11
Q

emergent Severe Unilat Pain w/Vision Loss is likely ??

A

Acute Angle Closure Glaucoma

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12
Q

Si/Sx Acute Angle Closure Glaucoma

A

Severe Unilat Pain w/Vision Loss

nausea/vomiting,

reporting rainbow or halos around lights

Vision reduced secondary to hazy, edematous cornea

IOP >45mmHg

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13
Q

Tx Acute Angle Closure Glaucoma

A

RAPIDLY ↓IOP

  • topical BB - (timolol)
  • CAI (dorzolamide, brinzolamide)
  • alpha agonist (apraclonidine)
  • PO acetazolamide or methazolamide

Requires STAT referral to ophthalmology for LPI once edema clears

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14
Q

Tx FB

A

Superficial - irrigate out

Cotton tipped swab, sponge spear or 25G or smaller needle - oblique approach with bevel up tangent to surface

Rx broad-spectrum antibiotic QID – tobramycin

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15
Q

NEVER Rx anesthetic bc??

A

melt the cornea

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16
Q

Tx corneal abrasion

A

topical broad-spectrum AB QID – tobramycin

Possibly bandage CL for comfort if defect extensive

Homatropine cycloplegia to relax Ciliary Body and decrease pain

PO analgesics as required

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17
Q

proper technique to remove corneal abrasion

A
  • Remove gently from edge of defect in toward center of defect with spud or other fine instrument
  • Attempting to remove in opposite direction may result in healthy tissue being removed
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18
Q

Sudden Onset Diplopia is caused by?

A

nerve palsy

III – Oculomotor:

IV – Trochlear

VI – Abducens -

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19
Q

CN III Palsy – Oculomotor is an emergency IF??

A

•aneurysm -> pupil fixed and dilated or minimally reactive

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20
Q

muscle innervation

III – Oculomotor:

IV – Trochlear

VI – Abducens

A

III – Oculomotor: Superior, Inferior, Medial Rectus, Inferior Oblique, Levator Palpebrae

  • Anyueisms
  • Microvascular

IV – Trochlear –> Superior Oblique

VI – Abducens –> Lateral Rectus

  • In adults, due to:
  • Microvascular disease
  • Lesion in Cavernous Sinus
  • Trauma
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21
Q

Etiology & Si/Sx of CN III Palsy

A

CN III Palsy – Oculomotor

Si/Sx

Eye is down and out

upper lid ptosis

pupil dilated (microvasc vs aneurysm)

  • aneurysm - pupil fixed and dilated or minimally reactive
  • Microvascular - pupil normally reactive secondary to DM or other systemic disease
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22
Q

differentiating b/w causes of CN III palsy

  • Aneurisms
  • Microvascular
A

look at pupil!!

aneurysm - pupil fixed and dilated or minimally reactive

•Microvascular - _pupil normally reactiv_e secondary to DM or other systemic disease

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23
Q

Si/Sx of CN IV palsy

A

trochlear

Vertical/tilted diplopia with compensatory head tilt to opposite side,

•Diplopia worse in downgaze (SO - non-emergent)

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24
Q

Si/sx CN VI palsy

causes in adults?

A

abducens

Horizontal diplopia with affected eye turned in (LR)

•In adults, due to:

  • Microvascular disease
  • Lesion in Cavernous Sinus
  • Trauma
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25
Q

dx?

A

CN III palsy oculomotor

Eye is down and out

upper lid ptosis

pupil dilated (microvasc vs aneurysm)

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26
Q

dx?

A

VI – Abducens

•Horizontal diplopia with affected eye turned in (LR)

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27
Q

Acute Onset Flashes and Floaters

dx?

causes?

A

Posterior Vitreal Detachment (PVD) - >50yo

Retinal Detachment (RD) - younger pt

  • trauma
  • high myopia
  • recent ophthalmic surgery
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28
Q

si/sx of

Posterior Vitreal Detachment (PVD) vs

Retinal Detachment (RD)

A

Flashes that were followed by floaters

PVD - no loss/decrease vision and no peripheral field loss

RD - sense of a veil or shade being pulled over visual field

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29
Q

Most common reason patient presents for emergent eye care

A

Sudden Onset Red Eye

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30
Q

Sudden Onset Red Eye is likely caused by

A

Subconjunctival Hemorrhage

Conjunctivitis

Keratitis – serious

Uveitis (Iritis)

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31
Q

Sudden Onset Red Eye that is typically noticed by someone else

A

Subconjunctival Hemorrhage

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32
Q

QuickVue (Quidel) point-of-care test help dx?

A

Viral Conjunctivitis - test for adenovirus

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33
Q

Pseudomembrane is seen w/ what type of conjunctivitis

A

Epidemic Keratoconjunctivitis

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34
Q

what is the “Rule of 8’s”

condition?

A

Epidemic Keratoconjunctivitis

1st 8 days: red eye with fine corneal staining

  • 2nd 8 days: focal epithelial lesions/pseudomembrane
  • 3rd 8 days: subepithelial infiltrates
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35
Q

type of conjuctivitis in patient who:

often recent URTI self/family member

A

Viral

36
Q

si/ sxBacterial Conjunctivitis

tx

A

purulent discharge

mattering of lashes

Tx: broad spectrum antibiotic 7-10 days

  • Fluoroquinolone TID/QID
  • Tobramycin QID (avoid gentamycin)
  • Polytrim (trimethoprim/polymyxin B) QID (kids)

AzaSite (azithromycin) BIDx2d then QHSx10d (kids

37
Q

tx of allergic conjunctivitis

A

topical antihistamines/mast cell stabilizers

  • Rx vs OTC ketotifen fumarate or olopatadine
  • Avoid vasoconstrictors
38
Q

dz that is aggressive in CL wearers

si/sx

tx

A

Microbial Keratitis aka Corneal Ulcer - Pseudomonas can penetrate cornea in <72hrs

Si/sx

pain, photophobia, tearing, +/- mucopurulent discharge

Decreased vision if on/near visual axis

Whitish infiltrate underlying (+) staining epithelial defect

Tx:

fluoroquinolone - Loading dose in-office then hourly

  • Possible fortified tobramycin or vancomycin
  • STAT referral for eye consult if near visual axis
39
Q

dendritic lesions with terminal endbulbs ”Great masquerader”

dx?

A

Herpes Simplex Keratitis

40
Q

unilateral, deep pain with significant photophobia

No discharge

Redness maximal at the edge of cornea

“Circumlimbal Flush”

Dx and Tx??

A

Acute Anterior Uveitis

_Primary etiolog_y - Idiopathic, Traumatic, Autoimmune , Facial Herpes Zoster

Recurrence or bilateral presentation -> systemic

Tx:

Topical corticosteroids – inflammation

cycloplegia for pain relief and to prevent posterior synechiae

Refer for eye consult within 24 hours

41
Q

less concerning diagnosis of Painful Eyelid

Tx?

A

Chalazion - hot compress

Hordeolum (stye) - same as above,

  • may drain if pointing at lid margin
  • Rx topical antibiotic ointment after draining

Preseptal Cellulitis: antibiotics appropriate for sinusitis – z-pack

42
Q

differentiate

Chalazion

Hordeolum (stye)

A

Chalazion: non-infectious inflammation of Meibomian Gland within the eyelid

Hordeolum (stye): infection of lash follicle and associated Glands of Zeis and Moll

43
Q

Resolving _____may leave small, painless lump in lid

  • Dead PMN cells
  • May be referred for excision if cosmetic problem
A

chalazion

Hordeolum (stye) - nothing left behind

44
Q

differentiate

Preseptal Cellulitis:

Orbital Cellulitis

A

Preseptal Cellulitis: Infection of tissue anterior to orbital septum

Tx: antibiotics appropriate for sinusitis – z-pack

Orbital Cellulitis: Infection of tissues anterior to and/or posterior to the orbital septum

Tx: meningitis-dose abx

45
Q

Si/Sx

Preseptal Cellulitis:

Orbital Cellulitis:

A

Preseptal Cellulitis:

  • Tenderness
  • Warmth
  • swelling and redness of lid area
  • VA not affected, EOM function normal, no proptosis

Orbital Cellulitis:

  • preseptal-like signs and symptoms +
  • high fever
  • proptosis
  • malaise
46
Q

painful and very concerning eye conditions

A

Orbital Cellulitis: Infection of tissues anterior to and/or posterior to the orbital septum

Si/Sx

  • Tenderness, Warmth. swelling, redness of lid
  • VA not affected
  • EOM function normal
  • high fever, malaise
  • proptosis

Tx: antibiotics appropriate for sinusitis – z-pack

  • Monitor closely for worsening
  • Refer for opth consult w/in 24 hrs
47
Q

Proptosis is seen in ??

Preseptal Cellulitis:

Orbital Cellulitis:

A

Orbital

48
Q

Yellow or whitish-yellow deposits in or around macula - Drusen

dx?

A

macular degeneration

49
Q

Tortuosity: twisted, winding vessels (“nicking”)

A

HTN retinopathy

50
Q

copper wiring?

A

Attenuation: narrowing of arterioles

51
Q

“whitish” optic nerve head

A

optic nerve atrophy

52
Q

blurred optic disc margins

A

optic nerve head edema

53
Q

define

hyphema

hypopyon

A

hyphema - blood in anterior chamber

hypopyon - WBC in anterior chamber

54
Q

red reflex of ocular macula are abnormal in a child if?

what dz?

A

white glow in a child = retinoblastoma

55
Q

glaucoma is characterisitic of what on slit lamp exam?

A

opacities (“dark spots”)

56
Q

Fundus Exam consists of

A
  • Optic nerve head (nasal to the macula)
  • Peripapillary area (area immediately around optic nerve head)
  • Vasculature (retinal arteries and veins; exit optic nerve head and branch throughout the retina)
  • Macula (temporal to optic nerve head) – evaluate last since uncomfortable for the patient
57
Q

optic nerve head exam is

normal:

abnormal:

A

normal: slightly orange-pink hue; white inside the cup

abnormal: whitish, - indicator that there has been some form of optic nerve atrophy

58
Q

Disc Margin Evaluation

normal

abnormal

A

normal margins should appear flat, clear, and distinct

abnormal: Large C/D - glaucoma

•increasing C/D ratio over time can indicate loss of nerve fibers resulting in a thinning neuroretinal rim

59
Q

Retinal Vasculature Evaluation differentiate

Arterioles:

Venules:

A

Arterioles:

  • narrower
  • brighter red
  • •2/3 size of venules

Venules:

  • wider
  • darker, deeper red
60
Q

•Irregularity at A/V crossing may be diagnostic??

A

hypertensive retinopathy)

61
Q

Presence of hemorrhages or cotton wool spots diagnostic –

A

BAD, diabetic

62
Q

Evaluation of the Macula:

when should it be done?

normal vs abnormal

A

Save for last and reduce illumination

Normal

  • Retinal sheen around macula in children
  • •Macula should appear flat

abnormal

  • Yellow or whitish-yellow deposits in or around macula - Drusen = macular degeneration
  • Hard: small, well-defined
  • Soft: “fluffy,” poorly defined
63
Q

Tonometry is a measure of??

normal values??

A
  • IOP
  • Normal” range between 8 and 20mmHg
64
Q

conditions associated w/

elevated IOP

decreased IOP

A

•Elevated IOP can result in damage to the Optic Nerve = Glaucoma (angle- closure)

  • Results from inefficient drainage from or over-production of aqueous

•Decreased IOP - uveitis

65
Q

appalation tonometry vs tonopen

A

appalation:

“Gold Standard” is Goldmann applanation tonometry

Requires slit lamp and judgement aligning mires

tonopen

Does not require a slit lamp

Gives a digital readout

66
Q

Steps to using tonopen

A
  1. Instill 1 drop proparacaine in each eye
  2. Place OcuFilm cover on instrument
  3. Press button to turn on (XL-Black, AviaBlue)
  4. Gently tap center of cornea - NOT too hard!
  5. Will hear click with each successful measure and beep when all readings acquired
  6. Averaged IOP will show in window with confidence value
67
Q

findings that woukd make you susoect intraocular FB

A
  • Seidel Sign
  • Iris tear
  • Corneal laceration
68
Q

If insult has penetrated Anterior Limiting Lamina (Bowman’s Membrane),

fluorescence??

A

•will see fluorescence in the corneal stroma and possibly anterior chamber

69
Q

Fluorescein will not stain conjunctiva

dx??

A

•laceration

70
Q

Fluorescein Staining Technique

A
  1. Wet the strip with a drop of sterile saline or eyewash NOT contact lens solution or water
  2. Wait at least 30 seconds to view the eye with cobalt blue light
  3. The longer you wait, the more you might see as permeates into epithelium through weakened tight junctions between cells
  4. Stains epithelium by diffusing between cells or pooling in areas where epithelium is disrupted or missing
71
Q

General steps to fully utilize Direct Ophthalmoscopy:

A

Inspect the ocular media

Examine the anterior segment

Examine the retina

72
Q
A
73
Q

Anterior Segment Examination includes

A
  1. Optic Nerve Head Examination
  2. Disc Margin Evaluation
  3. Optic Nerve Head Evaluation
  4. Retinal Vasculature Evaluation
  5. Evaluation of the Macula
74
Q

seidels sign

A

assesses for the presence of aqueous humor leakage from the anterior chamber.

Fluorescein - is an orange to red color.

  • When diluted, turns green under cobalt blue light

positive when the fluorescein dilutes in the aqueous humor –> will fluoresce bright green

75
Q

Microbial Keratitis aka Corneal Ulcer will need a STAT referral for eye consult if ???

A

near visual axis

76
Q

tx of Microbial Keratitis aka Corneal Ulcer

A

fluoroquinolone - Loading dose in-office then hourly

• Possible fortified tobramycin or vancomycin

eye consult within 4-6hrs after starting antibiotics

77
Q

what triage & presenting symptom

Central Retinal Artery Occlusion

Arteritic Anterior Ischemic Optic Neuropathy secondary to Giant Cell Arteritis if:

A

emergent

Painless Unilateral Vision Loss

78
Q

what presenting si/sx and triage?

Acute Angle Closure Glaucoma

A

emergent

Severe Unilat Pain w/Vision Loss

79
Q

presenting si/sx and triage

Nerve palsy: III – Oculomotor, IV – Trochlear , VI – Abducens

A

Sudden Onset Diplopia

urgent

80
Q

presenting si/sx and triage

Posterior Vitreal Detachment (PVD)

Retinal Detachment (RD)

A

Acute Onset Flashes and Floaters

urgent

81
Q

presenting si/sx & triage

Subconjunctival Hemorrhage

Conjunctivitis – Viral vs Bacterial vs Allergic

Keratitis – Microbial vs Herpetic

Uveitis

A

Sudden Onset Red Eye

urgent

82
Q

presenting si/sx and triage

Chalazion

Hordeolum (stye)

Cellulitis – Preseptal Cellulitis & Orbital Cellulitis:

A

painful eye & semi-urgent

Chalazion

Hordeolum (stye)

Cellulitis – Preseptal Cellulitis

painful eye & emergent

Orbital Cellulitis:

83
Q

Acute Anterior Uveitis si/sx

A

unilateral, deep pain with significant photophobia

No discharge

Redness maximal at the edge of cornea

“Circumlimbal Flush”

Anterior chamber cells and flare

84
Q

•Peak fluorescence at “normal” pH of __?

A

7.6

85
Q

NaFl requires ____ ____ illumination to fluoresce

A

Colbalt Blue

Physical Exam 2 Didactic Midterm (4 decks)

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