Ophthalmology

Question 1

What is the hallmark of conjunctivitis?

Answer 1

Hyperemia of the conjunctival vessels.

Question 2

What are the signs, symptoms, and treatment of ALLERGIC conjunctivitis?

Answer 2

Itching, bilateral, seasonal, long duration

Tx: vasoconstrictors or topical antihistamines/mast cell stabilizers

Question 3

What are the signs, symptoms, and treatment of VIRAL conjunctivitis?

Answer 3

Preauricular adenopathy, highly contagious (look for affected contacts); clear, watery discharge
Tx: supportive, hand washing to prevent spread

Question 4

What are the signs, symptoms, and treatment of BACTERIAL conjunctivitis?

Answer 4

Purulent discharge, classic in neonates

Tx: topical abx +/- systemic abx

Question 5

What are the 3 common causes of neonatal conjunctivitis?

Answer 5

Chemical, Neisseria gonorrhoeae, and Chlamydia trachomatis

Question 6

What causes chemical conjunctivitis? How do you recognize it?

Answer 6

Caused by silver nitrate (or erythromycin) drops that are given to all newborns to prevent gonorrhea conjunctivitis. The chemical conjunctivitis (with NO purulent discharge) appears within 12 hrs of instilling the drops and resolves within 48 hrs. It is always the best guess if the conjunctivitis happens in the first 24 hrs of life.

Question 7

How can you distinguish gonorrheal from chlamydial conjunctivitis?

Answer 7

Gonorrheal (look for sxs of gonorrhea in mother) - extremely purulent discharge starting between 2 and 5 days after birth; tx = systemic ceftriaxone or cefotaxime
Chlamydial/inclusion (mother often w/o sxs) - mild-to-severe conjunctivitis beginning between 5 and 14 days after birth; tx = oral erythromycin for conjunctivitis or pneumonia

Question 8

True or false: Conjunctivitis frequently causes loss of vision.

Answer 8

False. Other than transient blurriness (due to tear film debris) that resolves with blinking, conjunctivitis should NOT affect vision.

Question 9

Define glaucoma. What are the risk factors for developing it? What are the two general types?

Answer 9

Ocular HTN (or elevated intraocular pressure, measured with a tonometer); effects include visual field defects and blindness.
Risk factors: age >40, black race, positive family history
2 types: open-angle and closed-angle

Question 10

Describe the physical findings of open-angle glaucoma. How common is it? How is it treated?

Answer 10

Painless and does not have acute attacks. Only signs are elevated intraocular pressure (usually 20-30 mmHg), a gradually progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on fundoscopic exam)
90% of glaucoma cases
Tx: beta blockers, prostaglandins, alpha-AdR agonists, carbonic anhydrase inhibitors, cholinergic agonists, laser therapy, surgery

Question 11

How does closed-angle glaucoma present? What should you do if you recognize it?

Answer 11

Sudden ocular pain, seeing halos around lights, red eye, high intraocular pressure (>30 mmHg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil. OPTHALMOLOGIC EMERGENCY! Tx pt immediately with pilocarpine, oral glycerin +/- acetazolamide to breatk the attack. Definitive surgery (peripheral iridectomy) is used to prevent further attacks. *In rare cases, anticholingeric meds can trigger an attack in a susceptible, previously untreated pt.

Question 12

How do steroids affect the eye?

Answer 12

Whether topical or systemic, steroids can cause cataracts and glaucoma. Topical ocular steroids can worsen ocular herpes and fungal infections. DO NOT give topical ocular steroids to a pt with a dendritic corneal ulcer that stains green by fluorescein (HERPES)!

Question 13

Define ultraviolet keratitis. How is it treated?

Answer 13

Exposure to UV light can cause keratitis (corneal inflammation) with pain, foreign body sensation, red eye, tearing, and decreased vision. Pts have a history of welding, using a tanning bed or sunlamp, or snow-skiing (“snow-blindness”). Tx with an eye patch (for 24 hrs) and topical antibiotic. You can reduce pain with an anticholinergic eye drop that causes paralysis of the ciliary muscle (cycloplegia).

Question 14

What pediatric rheumatologic condition is commonly associated with uveitis?

Answer 14

Common in juvenile rheumatoid arthritis (esp. pauciarticular form)

Question 15

What is the most common cause of painless, slowly progressive loss of vision?

Answer 15

Cataracts, esp. in the elderly. Tx is surgical removal of the affected lens(es) and replacement with an artificial lens.

Question 16

What should cataracts in a neonate suggest?

Answer 16

TORCH (toxoplasmosis, other, rubella, CMV, and HSV) infection or inherited metabolic disorder (classic is galactosemia)

Question 17

What changes in the retina and fundus are seen in diabetes?

Answer 17

Dot-blot hemorrhages, microaneurysms, neovascularization of retina

Question 18

What changes in the retina and fundus are seen in HTN?

Answer 18

Arteriolar narrowing, copper/silver wiring, cotton-wool spots
Papilledema may be seen with severe HTN and should alert you to the presence of a HTN emergency.

Question 19

What is the most common cause of blindness in patients under and over the age of 55?

Answer 19

Under 55 - diabetes

Over 55 - senile macular degeneration (look for macular drusen)

Question 20

What is the most common cause of blindness in black patients?

Answer 20

Glaucoma (#3 overall cause of blindness in the U.S.)

Question 21

Define proliferative diabetic retinopathy. How is it treated?

Answer 21

After many years of established DM, defined as development of neovascularization (new, abnormal growth of vessels in the retina).
Tx: application of laser beam to periphery of entire retina (panretinal photocoagulation), surgical or medical vitrectomy in some cases, promising new medical therapies (e.g. VEGF inhibitors - bevacizumab, ranibizumab, pregaptanib)

Question 22

How is nonproliferative diabetic retinopathy treated?

Answer 22

Focal laser tx when macular edema is present - laser is applied only to affected area. In severe cases, panretinal photocoagulation is used. Otherwise, tx is supportive (tight control of blood glucose, follow-up eye exams).

Question 23

Distinguish between preorbital (preseptal) and orbital cellulitis.

Answer 23

Both may present with swollen lids, fever, history of facial laceration, trauma, inset bite, or sinusitis, and chemosis (edema of conjunctiva).
If ophthalmoplegia, proptosis, severe eye pain, or decreased visual acuity is present = orbital cellulitis. This is an emergency because it may extend into the skull causing meningitis, venous thromboses, and/or blindness.

Question 24

What are the common bacterial causes of preorbital and orbital cellulitis? How are they treated?

Answer 24

Strep. pneumo, H. influenzae type B, and Staph. aureus or other strep species (in pts with history of trauma). Treat with blood cx and broad-spectrum abx until culture results are known. Orbital cellulitis requires hospital admission and IV abx.

Question 25

What is the key to managing chemical burns to the eye? Which is worse - acid or alkaline burns?

Answer 25

Key is copious irrigation with the closest source of water. The longer you wait, the worse the prognosis. Do NOT wait to get additional history.
Alkali burns have a worse prognosis b/c they tend to penetrate more deeply into the eye.

Question 26

Distinguish between a hordeolum (stye) and a chalazion. How are they treated?

Answer 26

Hordeolum - painful red lump near the lid margin
Chalazion - painless lump away from the lid margin
Treat both with warm compresses. For chalazions, use intralesional steroid injection or incision and drainage if warm compresses don’t work.

Question 27

How do you recognize and treat HSV keratitis?

Answer 27

Usually begins with conjunctivitis and vesicular lid eruption, then progresses to classic dendritic keratitis (seen with fluorescein stain). Tx with topical antivirals (e.g. idoxuridine, trifluridine). Corticosteroids are generally contraindicated with dendritic keratitis, because they may make the condition worse.

Question 28

What findings suggest an ophthalmic herpes zoster infection?

Answer 28

Pts with involvement of the tip of the nose (Hutchinson sign) and/or medial eyelid, typical zoster dermatomal skin rash, and eye complaints. Treat with oral acyclovir. Complications include uveitis, keratitis, and glaucoma.

Question 29

How do you recognize a central retinal artery occlusion? What causes it?

Answer 29

Sudden (within a few min), painless, unilateral loss of vision. Classic fundoscopic appearance: pale, opaque fundus with a cherry red spot in fovea (center) of macula. No satisfactory tx is available. Most common cause is emboli (from carotid plaque or heart) but watch for temporal arteritis.

Question 30

Describe the symptoms of temporal arteritis. What should you do if you suspect it?

Answer 30

Jaw claudication, loss of vision (due to central retinal artery occlusion), tortuous temporal artery (as seen or palpated on exam), markedly elevated ESR, and coexisting polymyalgia rheumatica (in 50% of cases, causes proximal muscle pain and stiffness). If suspected, administer corticosteroids immediately before confirming diagnosis with temporal artery biopsy.

Question 31

How do you recognize central retinal vein occlusion? Describe the cause and treatment.

Answer 31

Sudden (within a few hrs), painless, unilateral loss of vision. Classic fundoscopic appearance: distended, tortuous retinal veins, reintal hemorrhages and a congested, edematous fundus. No satisfactory tx is available. Most common causes are HTN, DM, glaucoma, and increased blood viscosity (e.g. leukemia). Complications are related to neovascularization, leading to vision loss and glaucoma.

Question 32

Describe the classic history of a patient with retinal detachment.

Answer 32

Sudden (instant), painless, unilateral loss of vision with “floaters” (little black spots that are seen no matter where the pt looks), and flashes of light. Sometimes described as “curtain or veil coming down in front of my eye.” Surgery may save pt’s vision by reattaching the retina.

Question 33

True or false: Cataracts and macular degeneration are common causes of bilateral, painless loss of vision in the elderly.

Answer 33

True. Although one side may be worse than the other, bilateral complaints are not uncommon. Red reflex typically becomes black with a significant cataracts. Those with macular degeneration typically have yellow-white deposits called drusen in and around the macula. Treat cataracts with surgery; most cases (90%) of macular degeneration are “dry” or nonexudative subtype, which is treated supportively (e.g. magnification aids).

Question 34

How do optic neuritis and papillitis present? What are the common causes?

Answer 34

Present with fairly quick (over hours to days), painful, unilateral or bilateral loss of vision. Optic disc margins may appear blurred on fundoscopic exam with papillitis, just as in papilledema.
Multiple sclerosis (which can also cause internuclear ophthalmoplegia) is a very common cause of optic neuritis, esp. in 20-40 year-old women. Lyme disease, malignancy, and syphilis are other causes.

Question 35

What causes bitemporal hemianopsia until proven otherwise?

Answer 35

Pituitary tumor (or other neoplasm) pressing on optic chiasm

Question 36

Where is the location of the lesion with right anopsia (monocular blindness)?

Answer 36

Right optic nerve

Question 37

Where is the location of the lesion with bitemporal hemianopsia?

Answer 37

Optic chiasm

Question 38

Where is the location of the lesion with left homonymous hemianopsia?

Answer 38

Right optic tract

Question 39

Where is the location of the lesion with left upper quadrant anopsia?

Answer 39

Right optic radiations in right temporal lobe

Question 40

Where is the location of the lesion with left lower quadrant anopsia?

Answer 40

Right optic radiations in the right parietal lobe

Question 41

Where is the location of the lesion with left homonymous hemianopsia with macular sparing?

Answer 41

Right occipital lobe (from posterior cerebral artery occlusion)

Question 42

What two disease commonly cause isolated palsies of CN III, IV, and VI? How do you recognize them?

Answer 42

Usually due to vascular complications from DM and HTN. Symptoms generally resolve on their own within 2 months.
In pts >40 y/o with a history of DM or HTN and no other neurologic deficits or pain, observation is generally all that’s required. If resolution does not occur within 8 weeks, if pt is <40 y/o, if neither HTN nor DM is present, or if pt develops pain or other neurologic deficits, order MRI of head to rule out tumor or aneurysm (i.e. benign cause is less likely).

Question 43

What are the physical exam findings of a CN III palsy? What should you remember when trying to determine the cause?

Answer 43

Eye is down and out, and pt can move the eye only laterally! If it’s due to benign vascular causes (i.e. HTN or DM), pupil is normal and close observation is all that’s needed. A “blown” (dilated, nonreactive) pupil is a medical emergency - most likely cause is aneurysm or tumor. Order an MRI scan and/or cerebral angiogram.

Question 44

What are the physical findings in palsies of CN IV (trochlear)?

Answer 44

Affected eye cannot look down when the gaze is medial because of superior oblique muscle paralysis

Question 45

What are the physical findings in palsies of CN VI (abducens)?

Answer 45

Pt cannot look laterally with affected eye because of lateral rectus muscle paralysis

Question 46

How do lesions of CN V and VII affect the eye?

Answer 46

CN V (afferent, sensory limb) and VII (efferent, motor limb) are involved in the corneal blink reflex. Lesions can produce corneal drying, which can be treated with saline eye drops.

Question 47

What is strabismus? Beyond what age is it abnormal in children?

Answer 47

“Lazy eye” - affected eye deviates, most commonly inward. Normal only if intermittent and during the first 3 months of life; when constant or persistent it required ophthalmologic referral to prevent blindness (known as amblyopia) in the affected eye.

Question 48

Why does blindness develop in patients with strabismus?

Answer 48

Visual system is still developing until age of 7 or 8 years. If one eye does not see well or is turned outward, the brain cannot fuse the two different images that it sees. Thus, it suppresses the “bad” eye, which does not develop the proper neural connections. This eye will never see well and cannot be corrected with glasses. This problem is treatable with special glasses or surgery if it is caught in time.

Question 49

What is presbyopia? When does it occur?

Answer 49

Between ages of 40 and 50 years, when the lens loses its ability to accommodate. Pts then need bifocals or reading glasses for near vision. It is a normal part of aging.