Ophthalmology Flashcards
At what ages should infants be able to
1. Show visual fixation
2. Track across midline/to 180 deg
3. Conjugate gaze
4. Develop binocular vision
5. Accommodation
- 6-8 weeks
- 2 months - tracking 180 by 10 weeks
- 4 months
- between 3 and 7 months
- 2-3 months
Are infants nearsighted or farsighted at birth?
Farsighted
Due to the size and shape of the eye they are hyperoptic, but this decreases with growth
Premature or LBW infants are typically less hyperoptic or even myopic
When should you refer to Ophtho if an infant cannot fix?
3-4 months
When should I child first get visual acuity testing?
3-4 years
What can cause an abnormal red reflex? What is your first step?
Strabismus
Cataracts
Glaucoma
Retinoblastoma
High refractory error
Immediate referrral to ophtho
What is the most common cause for unilateral cataract?
Sporadic
Causes of bilateral cataracts
Autosomal dominant inheritance
Trisomies 13, 18, 21
Galactosemia and other metabolic abnormalities
TORCH infections
Risk factors for ROP
Prematurity
Low BW
Prolonged exposiure to high supplemental oxygen
Assisted ventilation for > 7 days
Surfactant therapy
Hyperglycemia
Insulin therapy
Cumulative illness severity
Dacryostenosis treatment and when to refer to ophtho
Treatment is lacrimal sac massage
Refer for possible probing if it persists after 6-7 months
Treatment for stye (hordeolum)
Usually self limiting and resolves in 5-7 days
Warm compresses to help with secretions and blood flow to gland
Topical antibiotic can be used if there is blepharitis (eyelid inflammation)
Systemic antibiotics only if associated cellulitis
Difference between stye (hordeolum) and chalazion
Stye is infectious - lesion of the eyelid from follicle gland or meibomian gland
Chalazion is non-infectious - lesion of the eyelid from obstruction of meibomian gland with granulomatous inflammation
Treatment for chalazion
Typically resolves on own in few months
NO ANTIBIOTICS
Protracted cases, increasing pain, or obstructing vision = refer to ophtho
2 physical exam maneuvers to detect strabismus
Corneal light reflex test
Cover/uncover test
Meaning of
1. Protanopia
2. Deuteranopia
- Loss of L cones (red), results in blue-green vision
- Loss of M cones (green), results in red-blue vision
Both more common in boys
Where in the nervous system does
1. Upbeating jerk nystagmus
2. Downbeating jerk nystagmus
suggest an injury?
- Pons, can be medulla or cerebellum
- Cervicomedullar junction
Most common causes of optic atrophy in children
Intracranial tumors
Hydrocephalus
Examples of midline facial defects
Optic nerve hypoplasia
Neural tube defects
Single central incision
Cleft lip/palate
TEF
Conotruncal heart defects
Diaphragmatic hernia
Omphalocele
Imperforate anus
Microphallus or undescended teste
Causes of secondary glaucoma in children
Trauma
Intraocular hemorrhage
Surgical complications (after cataract removal)
Chronic steroid use
Sturge-Weber syndrome
Red flags in a painful red eye which should prompt referral to ophtho
Vision abnormalities
Distorted pupil
Corneal involvement
Red, watery eye with gritty sensation
Adenovirus most common
No treatment, may get relief from lubricating drops
Common causes of bacterial conjunctivitis
Strep pneumo
H flu
Moraxella catarrhalis
Treatment for bacterial conjunctivitis
Erythromycin ointment or Septra drops for 5-7 days
Use fluoroquinolone drops for contact wearers due to risk of Pseudomonas
24 hours of therapy before going to school
Should corneal abrasions be reassessed?
Yes
Recheck in 24-48 hours for resolution
How to distinguish between preseptal and orbital cellulitis
Both have eye pain and red, swollen eyelid
Orbital –> pain with eye movements, ophthalmoplegia, chemosis, and/or proptosis
Treatment of orbital cellulitis
IV antibiotics (vanco, ceftriaxone, +/- metronidazole) for 3-5 days
Then oral therapy for total 2-3 weeks
Surgery may be required if not responding as expected
Complications of orbital cellulitis
Orbital abscess
Subperiosteal abscess
Intracranial extension
Causes of papilledema
Mass
Brain abscess
Cerebral edema
Noncommunicating hydrocephalus
Idiopathic intracranial hypertension
Treatment for hyphema
Refer to ophtho
Protect eye with a rigid shield
Steroids and cytoplegic drops
Alleviate vomiting and pain as they can increase intraocular pressure
Prevent secondary bleeding with antifibrinolytic therapy
When is the highest rebleeding risk with hyphema
In the first week after injury
Increases risk for long term complications like glaucoma
Symptoms of orbital floor fracture
Vertical diplopia
Limited vertical gaze (entrapment of inferior rectus muscle)
Circumferential ecchymosis
Subconjunctival hemorrhage
Hypema
Enophthalmos
Retinal findings in Tay Sach’s disease
Pale optic disc
Cherry red spot in the macula
When to screen for ROP
31 weeks corrected OR 4 weeks of life
Whichever is LATER
What genetic syndromes are associated with a coloboma
CHARGE syndrome
Cat-eye syndrome
Trisomy 13 and 18
Kabuki syndrome
Walker-Warburg syndrome
MIDAS syndrome
DiGeorge syndrome
+++ others
Unique ocular finding of Williams syndrome
Stellate iris
Most common cause of unilateral cataracts
Idiopathic
Bilateral more concerning for underlying pathology
Concerning complication post cataract removal surgery
Secondary glaucoma
How to tell between
1. Bacterial
2. Viral
3. Allergic
conjunctivitis
- Purulent, usually one eye but can be both
- Watery discharge, often starts in one eye then spreads to other in 24-48 hours
- Watery, stringy discharge, ITCHY
Causes of acquired 6th nerve palsy
Increased ICP
Meningitis
Mass
Vascular anomalies
Trauma
Idiopathic
Post viral
- When to screen for ROP
- Who to screen
- 31 weeks or 4 weeks of life, whichever is later
- < 31 weeks, < 1250g
Symptoms of optic neuritis
Reduced visual acuity
RAPD
Periocular pain
May have changes to colour vision
Visual field defects
Hyperemic/swollen disc on fundoscopy
Anterior uveitis
Inflammation of the iris and ciliary body
Complications of uveitis
Band keratopathy
Posterior synechiae
Cataracts
Intraocular hypertension
Treatment for anterior and posterior uveitis
Anterior = topical steroids
Posterior = systemic steroids
Patients will often need systemic immunosuppresion for long term therapy (MTX, cyclosporine, TNF a inhibitors)
Role of cycloplegic agents (atropine) in uveitis
Prevent adhesion of the iris to lens
Indications to refer bacterial conjunctivitis to ophtho
Vision loss
Severe purulent discharge
Corneal involvement
Conjunctival scarring
Recurring symptoms
Severe pain
HSV infection
Severe photophobia
Involvement with contact lens
Chorioretinitis causes and findings
Scars on retina
Ex: toxo, CMV, syphilis, sarcoidosis
Intracranial complications from mastoiditis
Meningitis
Temporal lobe or cerebellar abscess
Epidural or subdural abscess
Venous sinus thrombosis
Extracranial complications of mastoiditis
Subperiosteal abscess
Facial nerve palsy
Hearing loss
Labrynthitis
Osteomyelitis
Benzold abscess (in SCM)
Classic triad of glaucoma
Tearing
Photophobia
Blepharospasm
Ocular findings of vitamin A deficiency
Night or complete blindness
Dry eyes (xerophthalmia)
Corneal scarring
Symptoms of retinal detachment
Acute vision loss (peripheral and/or central)
Flashing lights and floaters
Shade over one eye
May see an RAPD
Symptoms of vitreous hemorrhage
Decreased or hazy vision, black spots, cob webs
May have absent red reflex with large hemorrhage
CT for trauma
Treatment of corneal abrasions
Topical antibiotic ointment
Oral analgesia
Do NOT prescribe topical anesthetics
What nerves innervate the muscles of the eye?
LR6 = CN 6 for lateral rectus
SO4 = CN 4 for superior oblique
CN 3 for rest = superior, medial and inferior rectus, inferior oblique
CN 3 also controls levator palpebrae that raises eyelid, as well as pupil constriction
Movements of the eye muscles
Rectus muscles = in the name (medial, lateral, superior, inferior)
Superior oblique = internal rotation, depression
Inferior oblique = external rotation, elevation, abduction
Decreased visual acuity, eye pain worse with movements, headache, decreased colour vision, visual field defects
If unilateral, RAPD
Optic neuritis
Who to screen for ROP
Infants < 31 weeks
Infants < 1250 g
When to screen for ROP
31 weeks corrected OR 4 weeks of life, whichever is LATER
Treatment for ROP
Laser ablation of the avascular portion of the retina
Nyctalopia
Night blindness
Often from Vit A deficiency
Dacryoadenitis
1. symptoms
2. Causes
Inflammation of the lacrimal gland
1. pain, redness, swelling over lacrimal gland, increased tearing or drainage, periauricular lymphadenopathy
2. Mumps, flu, EBV, herpes, sarcoid, TB, syphilis
Gene involved in retinoblastoma
RB1 on long arm of chromosome 13
Need mutation in both members of a gene pair
Retinoblastoma clinical findings
Leukocoria
Strabismus
Periorbital erythema
Ocular proptosis
Vision loss
What is the prognosis for retinoblastoma
Good, but high risk of other cancers later on in life
Osteosarcoma, pineal tumor, soft tissue sarcomas, melanomas
Anisometropia
Vision in one eye is worse than the other due to high refractive error
Horner syndrome triad
Damage to sympathetic supply
Partial ptosis
Facial anhidriosis
Miosis
