Ophthalmology

Question 1

What is the eye disorder in each of the following: Marfan syndrome, CHARGE, Congenital CMV, JIA?

Answer 1

• Marfan → ectopic lentis
• CHARGE → coloboma
• Congenital CMV → chorioretinitis
• JIA → anterior uveitis

Question 2

What are 3 causes of leukocoria?

Answer 2

1. Retinoblastoma
2. Cataract
3. Vitreous hemorrhage (AHT)
4. Coloboma
5. Coat’s disease (subretinal lipid)
6. Persistent fetal vasculature
7. Ocular toxocariasis (after exposure to cat or dog feces)
8. Retinal detachment

Question 3

What are tests that can be done to assess for amblyopia or strabismus?

Answer 3

• Hirschberg light reflex
  
  • Look at the light reflex on the corneas
  • If the eyes are straight, light reflexes should fall in the same place in each eye
• Cover test
  
  • Require a child’s attention/cooperation, good eye movement capability, reasonably good vision in each eye
  • Comprised of 1) cover-uncover test 2) alternate cover test
• By age:
  
  • HOTV chart (four-letter shapes), tumbling E chart or Lea symbols (shapes) from 36mo of age
  • Logarithm of the minimum angle of resolution, Lea Hyvärin (LogMAR LH) chart (standardized validated identifiable shapes) from 42 months of age.
  • LogMAR Snellen chart (letters of the alphabet or numbers) after six years of age.
  • The Allen chart (pictograms), previously widely used, is now thought to be too culturally specific to be helpful

Question 4

What is the management of a hyphema?

Answer 4

• Urgent ophtho consult
• Minimize vision-threatening sequelae (rebleeding, glaucoma, corneal blood staining).
• Bedrest, head of bed to 30degrees, monitor intraocular pressure
• Limit activity for at least 1 week
• Eye shield without patch over affected eye until hyphema resolved or at least 1 week
• Cycloplegic agent to immobilize the iris
• Topical/systemic steroids to minimize intraocular inflammation
• Avoid all NSAIDs
• Topical/systemic pressure lowering agents if pressure is raised

Question 5

When is the highest risk of re-bleeding in hyphema cases?

Answer 5

4-5 days after injury

Question 6

What are possible complications of hyphemas?

Answer 6

• Glaucoma
• Permanent vision loss

Question 7

What is the management for a corneal abrasion?

Answer 7

1. Topical antibiotics (ointment)
2. Cycloplegic if having photophobia
3. NSAIDs for pain
4. Remove FB if present

Question 8

What is the management of orbital cellulitis?

Answer 8

• IV antibiotics → Ceftriaxone (if CNS symptoms) or Cefuroxime IV, total 14-21 day course with step-down
  
  • HR: Cefuroxime IV 150 mg/kg/d divided q8h for 2-7 days followed by Amoxicillin clavulanic acid PO tid (amoxicillin component 45-60mg/kg/d, max 4 g/d) for a total IV +PO antibiotic treatment time of 14 days
  • Note: usually don’t need to for cover S. aureus and anaerobes unless chronic sinusitis
• Treat underlying condition - nasal steroid spray/decongestant
• Urgent referral to ophthalmology → follow-up at least Q24h in sever cases
• CT/MRI imaging of orbits/sinuses to detect complications
• Possible surgical drainage of abscess → wide variation in threshold for surgery, consider if:
  
  • VIsion threatened
  • Superior → subperiosteal abscess (risk of frontal sinus spread to brain)
  • Severe disease (drainage may shorten LOS and ABx duration)

Question 9

What are the visual field findings for the following:

• Suprasellar/pituitary mass
• Optic tract lesion
• Parietal lobe lesion
• Temporal lobe lesion
• Occipital cortex lesion

Answer 9

• Suprasellar/pituitary mass compresses chiasm
  
  • Classic visual field defect = bitemporal hemianopia
• Optic tract lesion
  
  • Visual field defect = homonymous hemianopia
• Parietal lobe lesion
  
  • Visual field defect = inferior quadrantanopia
• Temporal lobe lesion
  
  • Visual field defect = superior quadrantanopia
• Occipital cortex lesion
  
  • Visual field defect = homonymous hemianopia with sparing of fovea

Question 10

What are red flags at > 3-4mo for poor vision?

Answer 10

• Visually disinterested +/- stares at bright lights
• Forcefully rubs/pokes eyes
• Strabismus
• Nystagmus/searching eye movements
• Disconjugate eye movements
• Skew deviation
• Sunsetting

Question 11

A child with a right cranial nerve seven palsy (CN VII) may suffer from:

1. Inability to open the affected eye
2. Inability to close the affected eye
3. Poor corneal sensation
4. Corneal ulcer and poor visual acuity
5. B and D

Answer 11

5 – CN III is the columns that hold the eye open, CN VII is the hook that closes the lids, for CN V1 remember that that Five is for Feelings (sensation). Inadequate eyelid closure, reduced blinking, or reduced sensation may lead to corneal epithelial defects/ulcer and associated visual loss.

Question 12

After being struck by a baseball to the right maxilla, a 6-year-old girl with eyelid swelling has pain, nausea and vomiting when she tries to look up. The most appropriate management is

1. Urgent MRI brain
2. Orbital floor fracture repair if symptoms persist >2 weeks
3. Emergent CT orbits followed by surgery to free an entrapped inferior rectus muscle
4. Consult ophthalmology to rule out papilledema and consult neurosurgery
5. MRI brain within 2 weeks

Answer 12

3 - “White-eyed blowout” fracture (inferior rectus muscle entrapment) requires emergency management

Question 13

A 2-year-old boy presents to the emergency department with the right eyelid inflammation. MRI demonstrates ethmoidal sinusitis with an obvious subperiosteal abcess of the medial orbital wall. The most important next step is

1. Urgent drainage of the abcess
2. Metronidazole IV
3. Moxifloxacin PO and nasal decongestants
4. Cefuroxime IV
5. Saline nasal rinses

Answer 13

4/D – admission with IV antibiotic therapy and close follow up is recommended. Coverage for anaerobes is generally not required, but may be considered in the setting of chronic sinusitis.

Question 14

A child with new onset eyelid ptosis, pupil dilation, exotropia and hypotropia most likely has

1. CN III palsy
2. CN VI palsy
3. Cerebral aneurysm
4. Horner syndrome
5. Papilledema

Answer 14

Answer: A / 1

Question 15

A 3-year-old child with recurrent chalazia and photophobia has a white ‘dot’ on the right cornea for the past few weeks. The most appropriate management is

1. Incision and drainage of the chalazia
2. Patch to treat the corneal abrasion
3. Warm compresses and eyelid care
4. Tetracycline PO
5. Urgent ophthalmology consultation

Answer 15

5 / E – A white spot on the cornea is never normal. Cornea abrasions do not cloud the cornea, they cannot be easily seen without fluorescein staining.

Question 16

An effective topical antibiotic for community bacterial conjunctivitis is

• a. Fusidic acid bid
  b. Moxifloxacin tid
  c. Polymyxin B sulfate/gramicidin qid
  d. Gatifloxacin tid
  e. Any topical antibiotic is effective for this self-limited condition

Answer 16

E – Relative to systemic antibiotics, topical antibiotics on the ocular surface provide extremely high antibiotic concentrations to the conjunctiva. This negates the need for culture and sensitivity testing for uncomplicated cases of community-acquired conjunctivitis: essentially all antibiotics (if used as prescribed) are effective in this scenario.

Question 17

A 5 year old is struck in the eye by a foam projectile from a toy “Nerf” gun. On examination, the visual acuity is 20/80. The conjunctiva appears injected. The affected pupil is large and slightly oval. A red reflex is present. Which of the following diagnoses is MOST likely?

1. Vitreous hemorrhage
2. Microhyphema
3. Traumatic optic neuropathy
4. CN III palsy
5. Ruptured globe

Answer 17

2 / B – Microhyphema.

• Hyphema is a common complication of blunt injury to the eye. The lack of any visible blood in the anterior chamber does not rule out a microhyphema (versus a ‘macro’, or ‘gross’ hyphema). A slit lamp exam is required to microscopically identify red blood cells in the anterior chamber.
• Significant blunt ocular trauma is often associated with a traumatic mydriasis with a slightly irregular pupil, indicating a significant injury to the iris sphincter muscle.
• This should be distinguished from a “peaked” (tear drop shaped) pupil that would suggest a corneoscleral laceration.
• CN III palsy involves more than pupil dilation and would not occur with this mechanism of injury.
• Traumatic optic neuropathy is characterized by an afferent pupil defect and is typically associated with profound vision loss at time of diagnosis. It is unlikely with this mechanism of injury in the absence of other eye findings.
• The presence of a red reflex suggests that there is no significant vitreous hemorrhage.

Question 18

In your brightly-illuminated exam room, a 3-month-old boy’s right pupil is slightly smaller than the left. Which of the following findings would suggest Horner syndrome of the right eye?

1. A severe right upper eyelid ptosis.
2. The right iris appears lighter in colour than the left.
3. A mild right proptosis.
4. Optic disc edema in the right eye.
5. Limited abduction in the right eye.

Answer 18

2 / B – Horner syndrome is characterized by a pupil that fails to dilate (miosis), along with mild ipsilateral ptosis (loss of Muller muscle function) and anhydrosis of the ipsilateral face. In its congenital form, interruption of the sympathetic tracts also results in asymmetric iris colour, usually in the form of inadequate pigmentation of the ipsilateral iris (iris heterochromia).

Question 19

A 2-year-old girl has a new onset swollen, erythematous left knee. You consider a diagnosis of juvenile idiopathic arthritis (JIA). Which of the following will be most helpful in confirming this diagnosis?

a. Bilateral episcleral injection near the limbus (“ciliary flush”) b. Bilateral photophobia
c. Prominent blepharitis in both eyes
d. Mild enlargement of the globes

e. White blood cells in the anterior chamber of both eyes

Answer 19

E – Slit lamp examination by a trained examiner is the ONLY way to detect the chronic “silent” uveitis that gradually leads to irreversible vision loss in patients with JIA.

Question 20

Which diagnosis could be suspected in a 5-month-old with exotropia and an abnormal red reflex?

1. Bilateral retinoblastoma
2. Monocular congenital cataract
3. Myopia resulting from congenital glaucoma
4. Infantile exotropia
5. All of the above

Answer 20

E – Any media opacity within the eye can block light from entering and leaving the eye (including corneal lesion, hyphema, cataract, vitreous hemorrhage, retinoblastoma). Refractive error and strabismus do not produce an absent red reflex, but can produce asymmetric red reflexes.

Question 21

A 2-month-old has “big, beautiful eyes”. It is hard to get her to open her eyes. You note tearing in the right eye. Red reflexes are present. What is the most likely diagnosis?

1. Neurofibromatosis type 1
2. Congenital glaucoma
3. Nasolacrimal duct obstruction
4. Persistent fetal vasculature
5. Stickler’s syndrome (COL2A1 mutation)

Answer 21

2

Question 22

An obese 16-year-old girl with headaches and blurry vision presents with new onset diplopia. She takes isotretinoin for acne. You detect an esotropia on cover testing. The diagnosis is:

1. Right lateral rectus muscle dysfunction
2. Right cranial nerve VI palsy
3. Raised intracranial pressure
4. Isotretinoin-induced intracranial hypertension
5. All of the above

Answer 22

E – Raised intracranial pressure induces CN VI palsy, preventing the lateral rectus from abducting the eye(s) fully. In its most subtle form, this manifests as an esotropia that can only be detected with cover test while the patient fixates in side gaze on a distance target. Idiopathic and medication-induced intracranial hypertension is a common diagnosis that demands timely diagnosis to prevent permanent visual loss.

Question 23

What is the most likely visual field defect arising from a large pituitary macroadenoma?

1. Monocular visual loss
2. Bitemporal hemianopsia
3. Homonymous hemianopsia
4. Superior quadrantanopsia
5. Bilateral macular scotomata

Answer 23

2 / B - Lesions anterior to the optic chiasm produce monocular, ipsilateral visual field loss. Posterior to the optic chiasm, lesions produce bilateral homonymous field defects in the visual field opposite to the lesion. Chiasmal lesions classically impinge on the fibres from the nasal retina of both eyes, producing bitemporal visual field loss.

Question 24

13. Which scenario best describes amblyopia?
14. Visual acuity improves to normal IMMEDIATELY when a myopic 6-year-old puts on her spectacles for the first time
15. A 3-year-old with a congenital cortical arteriovenous malformation has a complete right homonymous hemianopia
16. An 8-year-old has an obvious exotropia for 30 minutes before bedtime every night
17. A baby’s congenital cataract is successfully in early infancy. After surgery, she wears a contact lens but still has poor visual acuity in the affected eye.
18. A 5-year-old with optic nerve glioma has an afferent pupillary defect

Answer 24

• D – Amblyopia is a failure of normal visual development… the brain has not learned to see normally. Clinically, the visual acuity remains subnormal even when all causes of decreased acuity have been corrected. Instantaneous improvement in visual acuity with spectacle wear indicates refractive error, whereas a gradual improvement with weeks or months of continuous spectacle wear indicates amblyopia.
• Most cortical brain lesions spare visual acuity, but even if acuity were affected, this would represent a structural cause of vision loss rather than simply amblyopia. Intermittent strabismus that is only present for a small portion of waking hours tend not to develop amblyopia, as they are functioning binocularly most of the time.
• Even with “perfect” surgical treatment and aggressive visual rehabilitation, outcomes for congenital cataracts remain suboptimal, as deprivational congenital amblyopia has such a strong effect on visual development.
• An optic nerve lesion with an afferent pupillary defect is a structural cause of visual acuity loss, one does not need to postulate amblyopia as a cause for the poor vision.

Question 25

14. A mother is concerned that her 6-month-old infant has an esotropia. What will be MOST helpful in confirming this diagnosis?
15. Corneal light reflex test
16. Observation of the child’s wide nasal bridge and prominent epicanthal folds.
17. Red reflex.
18. Direct ophthalmoscopy.
19. “Cover” or “cover-uncover” test.

Answer 25

5 / E – While all these tests provide some information, the cover test is the most reliable method of detecting strabismus, particularly when the angle of strabismus is small. A successful cover test depends on good fixation on a visual target, which is typically achievable with a near target in a 6-month-old infant.

Question 26

15. Which is true regarding the VAST MAJORITY of cases of childhood-onset strabismus?
16. Strabismus results primarily from weak or “unbalanced” extraocular muscles
17. Strabismus results from congenital cranial nerve abnormalities
18. Despite normal muscles and nerves, the brain is unable to keep the eyes properly aligned either some or all of the time
19. Strabismus is associated with dyslexia
20. Poor eye tracking causes reading difficulties; this is best treated with “eye exercises” or “vision therapy”

Answer 26

3 / C – The vast majority of cases of childhood onset strabismus are the result of a failure of a brain to maintain normal binocularity. Most have nothing to do directly with the extraocular muscles or the cranial nerves.

In some cases, correction of refractive errors (especially high hyperopia in patients with esotropia) corrects or partially corrects the problem. In other cases, surgery is required to re-establish or improve binocularity. While home-based convergence exercises can be prescribed for the patient with a specific subtype of exotropia (convergence insufficiency type of intermittent exotropia), there is no demonstrable benefit for other types strabismus to be treated with “vision therapy”.

Poor eye tracking is not the cause of reading problems. In fact, the reverse is true: as children become increasingly skilled at reading, eye tracking efficiency progressively improves. Thus no “eye tracking exercises” are required for children diagnosed with “poor tracking” when reading – they just need help and practice learning to read!

Dyslexia is a CNS “processing” disorder - it has nothing to do with the eyes or with strabismus.

“Vision therapies” have no demonstrable benefit for dyslexia.

Question 27

A 4-year-old boy is noted to have reduced visual acuity in his right eye on routine office screening. Which of the following is true?

1. Given the child’s age, any treatment for amblyopia must be performed urgently to have any hope of success.
2. The most likely cause for his reduced acuity is an undiagnosed congenital cataract.
3. Refractive error is not in the differential diagnosis because refractive errors affect both eyes.
4. The most appropriate management in this case is referral to an eye care professional.
5. It is likely that this child will have an absent red reflex in the affected eye.

Answer 27

4 / D – The purpose of visual acuity screening is to identify children who need a more thorough assessment by an eye care professional, so referral is appropriate. Unilateral amblyopia is more common than bilateral amblyopia. The most common causes of unilateral amblyopia are refractive error and strabismus. Deprivational amblyopia (such as that caused by cataract) is far less common. Broadly speaking, while treatment for amblyopia can be attempted at any age, outcomes are generally more favourable the younger the patient. Thus timely (but not emergency) referral is warranted to maximize the chance of success.

Question 28

An 8-year-old girl presents with a 3-day history of worsening bilateral eyelid edema. There is copious discharge from both eyes. She has a rhinorrhea and a sore throat. with ocular irritation. All family members have recently had an upper respiratory tract infection. The most likely diagnosis is:

1. Periorbital cellulitis
2. Orbital cellulitis
3. Bacterial conjunctivitis
4. Viral conjunctivitis
5. Blepharitis

Answer 28

4 / D – Bilateral periorbital or orbital cellulitis is rare. Bacterial conjunctivitis typically presents with purulent discharge. Copious [watery] discharge suggests a viral etiology, as does the history of an associated upper respiratory tract infection

Question 29

Which

1. Bacterial sphenoidal sinusitis is the most common etiology
2. Fever and leukocytosis in an unwell child is typical
3. Painful eye movements should raise suspicion of the wrong diagnosis
4. A mild afferent pupillary defect can be observed
5. Eyelid inflammation is limited to the confines of the orbital rim is most true of preseptal/periorbital cellulitis?

Answer 29

3 / C – Bacterial sinusitis is the most common etiology of orbital cellulitis, and is characterized by fever and leukocytosis. In preseptal cellulitis, inflammation is primarily anterior to the orbital septum, and it is free to extend beyond the confines of the orbital rim. Inflammation in preseptal cellulitis should not lead to significant orbital symptoms such as painful and/or limited eye movements. An afferent pupillary defect represents a compromise of the afferent visual pathway (such as the ipsilateral optic nerve). It is never a normal finding. In the context of cellulitis, an afferent pupillary defect suggests orbital involvement and demands emergency investigation and management.

Question 30

Blepharitis:

1. May be characterized by photophobia and corneal ulcer/scarring
2. May cause chalazia, a common cause of amblyopia
3. May be eradicated with a short course of topical antibiotics
4. Is a benign condition in children
5. Causes “dry eye”, which can be cured with over-the-counter artificial tears

Answer 30

1 / A – Chronic inflammation of the eyelid margin, or blepharitis, is not always benign. Itcan produce significant corneal complications in paediatric patients, including photophobia and corneal ulcer/scarring. Chalazia are associated with blepharitis, but they are not a common cause of amblyopia (even when large, chalazia are most commonly transient). This chronic condition may be temporarily improved but is not eradicated with a short course of topical antibiotics. “Dry eye” symptoms may be improved using lubrication with artificial tears, but this does not cure the underlying tear film imbalance.

Question 31

Congenital nasolacrimal duct obstruction (NLDO):

1. Typically resolves with conservative treatment
2. Requires conjunctival culture, if complicated by two or more episodes of bacterial conjunctivitis
3. Demands early referral to maximize surgical success
4. Can be treated by Crigler massage, a homeopathic treatment that just gives the parents something to do while waiting for spontaneous resolution
5. Is characterized by the “classic triad” or epiphora (tearing), photophobia, and an enlarged eye are the “classic triad” of NLDO

Answer 31

1 / A – Most cases of NLDO (>80%) resolve spontaneously (or with conservative management) by age 9 months of age. Consequently, most ophthalmologists do not offer nasolacrimal duct probing +/- stent under general anaesthesia until age 9-12 months. There is evidence for the effectiveness of Crigler massage in mechanically encouraging opening of the congenital membranous obstruction at the distal nasolacrimal duct, and regular Crigler massage also empties the nasolacrimal sac, reducing the bacterial load that may lead to recurrent conjunctivitis in infants with NLDO. An infant with tearing, photophobia, and buphthalmos should be referred emergently for suspicion of congenital glaucoma

Question 32

A six-month-old child is brought to the emergency department with unexplained rib fractures and a skull fracture. Red reflex examination is normal. Choose the most correct statement.

1. An urgent ophthalmology consultation is warranted within one week after presentation
2. Examination with the direct ophthalmoscope is usually sufficient to detect retinal hemorrhages
3. There is no pathognomonic finding for abusive head trauma, but multiple bilateral retinal hemorrhages raise concern
4. Retinal hemorrhages can be dated within +/- 1 week of onset
5. Infants with multiple retinal hemorrhages typically demonstrate signs of reduced vision at the initial assessment

Answer 32

3 / C – Ophthalmologic consultation should be sought as quickly as possible if abusive head trauma is suspected. Practically, consultations should be performed within 24 hours, as some hemorrhages may resolve within a day or two. Direct ophthalmoscopy and/or red reflex assessment is wholly inadequate; binocular indirect ophthalmoscopy should be performed with the pupils dilated. Ideally fundus photography is also obtained to supplement documentation. The effect of abusive head trauma and retinal hemorrhages on the infant visual system is typically not readily apparent in the acute setting, as neurologic compromise and other factors may limit the assessment of the afferent visual system. Retinal hemorrhages cannot be dated and are not pathognomonic for abusive head trauma. However, multiple, bilateral multi-layered, extensive retinal hemorrhages should raise suspicion in the absence of any other causes for retinal haemorrhage, particularly if macular schisis is also present.

Question 33

You have just taken over care of a newborn with trisomy 21. Which statement is most correct?

1. Urgent ophthalmic consultation is required
2. The normal red reflex test should be performed, as for any other infant
3. Cataracts in trisomy 21 are present at birth
4. Nystagmus is typically associated with a benign intracranial lesion
5. Strabismus in trisomy 21 patients can be corrected with spectacle wear

Answer 33

B – While ophthalmologic consultation is recommended for infants with trisomy 21, consultation can be performed electively in the absence of any concerns. As such, a normal primary care visual assessment should be performed as for any other infant (including red reflex testing). While some infants with trisomy 21 will have visually significant congenital or early-onset cataracts, adult cataracts are far more common. While most nystagmus in children with trisomy 21 has a benign etiology, all patients with nystagmus must be referred for ophthalmologic assessment. As for strabismus in general, some cases are corrected with spectacles, while others require surgery.

Question 34

24. Billy is a 3-year-old boy who was poked with a stick while “playing swords”. When you apply fluorescein to the eye and look with cobalt blue light at the slit lamp, you observe bright green fluorescein over the entire cornea. Choose the most correct statement.
25. Diagnosis = Complete corneal abrasion
26. A CT scan of the orbits would be useful to rule out an occult foreign body
27. Visual acuity would be affected if this were a penetrating injury
28. You probably put too much fluorescein in the eye
29. Topical anaesthetic drops should be prescribed for analgesia

Answer 34

4 / D – While the mechanism of injury should strongly raise suspicion for corneal abrasion or even penetrating ocular trauma, it is highly unusual for the entire corneal epithelium to be removed via trauma. This suggests that too much fluorescein was used. Wait 15 minutes and then reassess the patient – you may now be able to see a distinct area where fluorescein remains bound to the abraded cornea. It is possible to have normal visual acuity despite a penetrating injury. Topical anaesthetic drops are toxic to the cornea when used chronically and thus should not be prescribed for analgesia. Assuming the possibility of a ferromagnetic foreign body has been ruled out, MRI may be advantageous over CT scan in the paediatric population.

Question 35

Which statement is TRUE?

1. Any eye suspected of globe rupture should be protected with a patch
2. A large, slightly irregular pupil strongly suggests corneal laceration
3. Simple eyelid lacerations should be sutured in the emergency department
4. Diagnosis of microhyphema requires a slit lamp
5. Uveitis is best characterized by diffuse conjunctival injection statement is TRUE?

Answer 35

4 / D – Shield (do not patch) an injured eye. A “peaked” pupil suggests a cornea laceration; an enlarged slightly irregular pupil is more suggestive of traumatic mydriasis with injury to the iris sphincter muscle. Do not suture eyelid lacerations – the anatomy is complex and injuries are frequently more severe than they appear on cursory examination. A proper slit lamp is needed to see cells in the anterior chamber (a portable slit lamp is not sufficient). Uveitis is characterized by ciliary flush.

Question 36

What are the indications for referral to ophthalmology for conjunctivitis?

Answer 36

• Vision loss
• Severe purulent discharge
• Corneal involvement (e.g. ciliary flush, photophobia, severe foreign body sensation)
• Conjunctival scarring
• Cutaneous-conjunctival involvement (Stevens Johnson)
• Recurrent symptoms, severe pain, severe photophobia
• HSV infection
• Involvement of contact lens
• PCH: also says if no prompt response to therapy

Question 37

What is the differential diagnosis for retinal hemorrhages?

Answer 37

Non-accidental trauma (especially if bilateral diffuse & multilayered)

Others: birth, major trauma, Glut-1 deficiency, bleeding disorder, HTN, sepsis, malignancies (e.g. leukemia)

Question 38

What are the different types of glaucoma?

Answer 38

• Primary → isolated anomaly of the drainage apparatus of the eye (trabecular meshwork)
  
  • Congenital open-angle glaucoma
  • Systemic abnormalities: Sturge-Weber, NF-1, Stickler syndrome, Lowe syndrome, Marfan syndrome, T13
• Secondary → associated with other ocular or systemic abnormalities
  
  • Traumatic glaucoma: hyphema, angle concussion, ghost cell glaucoma
  • Intraocular neoplasm: retinoblastoma, leukemia, melanoma, iris rhabdomyosarcoma
  • Secondary to surgery for congenital cataract
  • Steroid-induced glaucoma

Question 39

What is the treatment for the following conditions:

Viral conjunctivitis, Bacterial conjunctivitis, Corneal abrasion/ulcer, Episcleritis/scleritis, Iritis/uveitis, Herpetic keratitis

Answer 39

1. Viral conjunctivitis - Hand washing, supportive (artificial tears, cold compresses), isolate for 48h
2. Bacterial conjunctivitis - topical antibiotics (moxifloxacin), oral amox-clav for H flu, IV Ceftriaxone for gonorrhea + azithro for chlamydia
3. Corneal abrasion/ulcer - frequent topical antibiotics, topical cycloplegic drops if anterior segment inflammation, daily FU with ophtho
4. Episcleritis/scleritis - artificial tears, topical steroid +/- NSAIDs; Scleritis: oral NSAIDs +/- oral steroids
5. Iritis/uveitis - topical steroids and cycloplegic drops, +/- oral steroids
6. Herpetic keratitis - oral antiviral (e.g. acyclovir), topical antibiotics for epithelial defects, +/- topical steroids for intraocular inflammation