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Medicine & Surgery > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

What is normal IOP pressure?

A

10-21 mm Hg
Ocular hypertension 22-25 mmHg
Concern for glaucoma >30 mmHg
*most people >40 mmHg have some degree of eye pain

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2
Q

How to organize an approach to the red eye?

A

Extra vs. intra-ocular

Painless vs. painful

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3
Q

What are extra-ocular causes of red eye?

A 
blepharitis
chalazion, hordeolum
dacrocystitis
periorbital cellulitis
orbital cellulitis
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4
Q

What are intra-ocular causes of red eye?

A 
conjunctivitis - viral, bacterial, fungal, irritant
corneal abrasions
corneal ulcers/erosions
keratitis - infectious, chemical, inflammatory
iritis/uveitis, radiation
episcleritis
scleritis
subconjunctival hemorrhage
hyphema 
endophthalmitis
acute angle closure glaucoma
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5
Q

Where is aqueous humour produced

A

ciliary body

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6
Q

What is the path of aqueous humour in the eye

A

ciliary body - posterior chamber - pupillary aperture - anterior chamber - canal of schlemm - absorbed into episcleral vein

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7
Q

What are 6 causes of floaters

A 
o	Retinal break or detachment
o	Posterior vitreous detachment
o	Vitreous haemorrhage
o	Vitreous debris 
o	Posterior uveitis
o	Corneal opacity / FB
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8
Q

What are causes of flashes

A 
o	Retinal break or detachment
o	Retinitis
o	Posterior vitreous detachment
o	Migraine
o	CNS disorder → occipital lobe pathology
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9
Q

What type of bacterial conjunctivitis requires IV antibiotics instead of topical?

A

Gonoccocal conjunctivitis

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10
Q

What are 5 historical points to ask on review of systems?

A 
floaters/flashers
vision loss
blurry vision
redness
pain
headache
tearing
itching
scalp tenderness
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11
Q

What are 10 points on ocular physican exam to include?

A 
visual acuity
pupillary response
RAPD
extra-ocular movements
other cranial nerves 
color/red desaturation
ocular pressure
lid/lacrimation/external exam
lymphadenopathy *pre-auricular
conjunctiva/sclera
cornea
anterior chamber
iris
lens
vitreous
fundus
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12
Q

What are 10 points on ocular physican exam to include?

A 
visual acuity
pupillary response
RAPD
extra-ocular movements
other cranial nerves 
color/red desaturation
ocular pressure
lid/lacrimation/external exam
lymphadenopathy *pre-auricular
conjunctiva/sclera
cornea
anterior chamber
iris
lens
vitreous
fundus
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13
Q

What 2 muscles innervate the eyelids? What nerves innervate these muscles?

A

orbicularis oculi - CN VII

levator palpebra - CN III

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14
Q

What are the 3 chambers of the eye?

A

anterior chamber - cornea to iris
posterior chamber - iris to lens
vitreous chamber - lens to retina

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15
Q

What are the 5 layers of the cornea? (superficial to deep)

A
  1. epithelium
  2. bowman’s layer
  3. stroma
  4. descemet’s membrane
  5. endothelium
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16
Q

What innervates the sensation in the cornea?

A

CN V - trigeminal nerve

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17
Q

What are 5 ocular causes of red eye that need urgent ophthalmology referral?

A 
acute angle closure glaucoma
infectious keratitis
hyphema
hypopion
iritis/uveitis
corneal ulcer
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18
Q

What are 5 ocular causes of red eye that need urgent ophthalmology referral?

A 
acute angle closure glaucoma
infectious keratitis
hyphema
hypopion
iritis/uveitis
corneal ulcer
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19
Q

What is the physiology behind hyperopia? myopia?

A

hyperopia: visual axis length too short
myopia: visual axis length too long

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20
Q

What are 2 classes of mydriatic drugs?

A
  1. Anticholinergic (dilation by paralyzing iris sphincter)
    - tropicamide, cyclopentolate, homatropine
    * also cycloplegic, paralyze ciliary body, will affect accommodation
  2. Adrenergic (dilation by stimulating pupillary dilator)
    - phenylephrine
    * not a cycloplegic
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21
Q

What are 2 classes of mydriatic drugs?

A
  1. Anticholinergic (dilation by paralyzing iris sphincter)
    - tropicamide, cyclopentolate, homatropine
    * also cycloplegic, paralyze ciliary body, will affect accommodation
  2. Adrenergic (dilation by stimulating pupillary dilator)
    - phenylephrine
    * not a cycloplegic
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22
Q

What are 4 types of glaucoma topical medications?

A
  1. Beta blockers
    - timolol, levobunolol
  2. Cholinergic agonists
    - pilocarpine
  3. Alpha 2 agonists
    - brimonidine, apraclonidine
  4. adrenergic stimulating
    - epinephrine
  5. carbonic anhydrase inhibitors
    - acetazolamide, brinzaolamide, etc.
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23
Q

What is the mechanism of action of the different anti-glaucoma medications? (lower IOP)

A
  1. Beta blockers
    reduce formation of aqueous humour by ciliary body
  2. Cholinergic agonists
    increase aqueous outflow through trabecular network
  3. alpha 2 agonists
    decrease aqueous production, increased uveoscleral (non trabecular meshwork) aqueous outflow
  4. carbonic anhydrase inhibitors
    aqueous humor suppression
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24
Q

What are 3 common causes of bacterial conjunctivitis?

A

non typeable H. influenza
S. aureus
S. pneumonia

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25
Q

What is EKC?

A

Epidemic keratoconjuncitvitis
caused by adenovirus, highly contagious
spectrum of conjunctivitis to keratitis, can have prolonged course

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26
Q

What are clinical features of EKC?

A 
preauricular lymphadenopathy (ipsilateral)
follicular conjunctivitis
watery discharge
hyperemia/chemosis
corneal opacities
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27
Q

What is a chalazion and where is it located?

A

Granulomatous inflammation of the meibomion glands
occur when the meibomion pores get clogged, undernear the tarsal plate
seen best when eyelid everted

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28
Q

What is the difference between a corneal abrasion and corneal ulcer?

A

Corneal ulcer has associated inflammatory infiltrate/opacity - appears white on plain exam

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29
Q

What are differentiating features between preseptal and septal (orbital cellulitis)

A 
Orbital cellulitis is associated with:
painful extraocular movements
limited extraocular movements
RAPD 
Proptosis
Chemosis
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30
Q

What is the most common opportunistic ocular infection with HIV/AIDS?

A

CMV retinitis

associated with CD4 counts

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31
Q

What are 3 predictors of vision loss in hyphema?

A

large hyphema
sickle cell disease or trait
bleeding diatheses

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32
Q

What are 5 etiologies of spontaneous hyphema?

A

Diabetes mellitus
Iris melanoma, retinoblastoma, and other eye tumors
Juvenile xanthogranuloma
Clotting disorders (eg, thrombocytopenia, hemophilia, Von Willebrand disease)
Medications that inhibit platelet function (ASA, warfarin)

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33
Q

What 3 diagnoses should you consider in traumatic hyphema?

A

globe rupture
posterior segment injury
intraocular foreign body

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34
Q

What are 5 physical exam findings associated with hyphema?

A 
Photophobia
Decreased visual acuity
Aniscoria
Elevated IOP
Corneal blood staining
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35
Q

What are 8 findings of globe rupture?

A

Markedly decreased visual acuity
Eccentric pupil
Increased anterior chamber depth
Low intraocular pressure
Extrusion of vitreous
External prolapse of the uvea or other internal ocular structures
Tenting of the cornea or sclera at the site of globe puncture
Seidel’s sign, fluorescein streaming in a tear drop pattern away from the puncture site

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36
Q

What are 3 types of retinal detachment?

A

rhegmatogenous (from PVD or trauma)
exudative (from infection)
traction

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37
Q

What are risk factors for retinal detachment

A

posterior vitreous detachment
myopia
cataract surgery
fluroquinolone use (rare)

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38
Q

What are symptoms of retinal detachment

A

floaters/cobwebs (PVD)
photopsia (flasher’s, from mechanical tug on retina stimulating photoreceptors)
shower of black spots (vitreous hemorrhage)
curtain vision loss

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39
Q

What should you instruct your patients with orbital floor fractures to avoid?

A

blowing nose
valsalva
=> reduce chance of ocular emphysema

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40
Q

What are 8 major diagnostic considerations in ocular trauma?

A 
ruptured globe
retinal detachment
hyphema
traumatic iritis
traumatic mydriasis/miosis
iridodialysis
corneal abrasion/foreign bodies
intraocular foreign body
orbital fractures (blowout, entrapment)
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41
Q

What are 4 complications of hyphema

A 
increased IOP
corneal blood staining
chronic glaucoma
anterior/posterior synechia formation 
*rebleed
42
Q

Where do ocular ruptures usually occur? (2)

A

insertion of intraocular muscles
limbus
(sclera is thinnest)

43
Q

What features of blunt globe injuries are associated with poor prognosis and higher rates of enucleation? (4)

A

afferent pupillary defect
retinal detachment
poor initial visual acuity
absent red reflex

44
Q

What is the sensitivity/specificity of CT for open globe injuries?

A

sens 75%

spec 93%

45
Q

What are 4 causes of vitreous hemorrhage?

A

diabetic retinopathy
posterior vitreous detachment
retinal vein occlusion
trauma (shaken baby syndrome)

46
Q

Which lid lacerations should be referred to oculoplastics? (5)

A
  1. involving lid margin
  2. involving canalicular system (medial)
  3. involving the levator or canthal tendons
  4. through the orbital septum (orbital fat confirms diagnosis)
  5. with significant tissue loss
47
Q

What are causes of conjunctivitis?

A 
viral
bacterial
mechanical
allergic
toxic
radiation
48
Q

What is a pterygium?

A

Wedge shaped area of conjunctival fibrovascular tissue that grows from nasal side of sclera and extends ONTO cornea
*associated with increased exposure to UV light

49
Q

What is a pingecula?

A

Raised yellow or white tissue on the conjunctiva, raised but NOT on cornea
*also associated with UV light exposure or dryness

50
Q

What is the difference between a corneal ulcer vs. infiltrate?

A

Ulcer is associated with an overlying corneal epithelial defect (fluroscein uptake), infiltrate has an intact corneal epithelium

51
Q

What are 8 causes of transient monocular vision loss?

A 
amaurosis fugax - embolic ischemia to retinal artery (usually from carotids)
giant cell arteritis
nonarteritic anterior ischemic optic neuropathy
retinal vein occlusion
retinal migraine/vasospasm
optic neuropathy
papilledema
optic nerve compression
angle closure glaucoma
spontaneous hyphema
vitreous floaters
52
Q

Where is the lesion in monocular vision loss?

A

anterior to the optic chiasm

anterior chamber, lens, vitreous, retina, ocular arteries/veins, optic nerve

53
Q

Where is the lesion in binocular vision loss

A

posterior to the optic chiasm (chiasm, optic radiations, temporal/parietal lobes, occipital lobes)

54
Q

What are 3 causes of transient binocular vision loss?

A

migraine
seizure
vertebrobasilar ischemia

55
Q

What are 5 causes of retinal artery occlusion in children?

A 
sickle cell disease
vasculitis (HSP, SLE)
hypercoagulable/thrombotic states
IVDU
pregnancy
congenital heart disease with R->L shunt
ocular trauma
56
Q

What are 3 physical exam findings in CRAO?

A

pale retina (white)
cherry red macula
RAPD
(decreased VA, somtimes can see retinal emboli)

57
Q

What are 4 physical exam findings in CRVO?

A 
retinal hemorrhages
cotton wool spots
retinal edema
dilated retinal veins 
\+/- RAPD if complete
58
Q

What are 3 causes of unilateral proptosis?

A

retro-orbital tumor
retro-orbital abscess
retro-orbital hematoma

59
Q

What part of the visual field does a lesion in the temporal radiations affect? (Meyer Loop)

A

superior quadrantanopsia

60
Q

What part of the visual field does a lesion in the parietal radiations affect?

A

inferior quadrantnopsia

61
Q

What systemic disease is CRVO associated with?

A

Hypertension

62
Q

What are 4 critical causes of diplopia?

A

basilar artery thrombosis (posterior CVA)
botulism
basilar meningitis
intracranial aneurysm with CN III palsy

63
Q

What are 4 emergent causes of diplopia?

A

myasthenia gravis
verterbral artery dissection
Wernicke’s encephalopathy
orbital apex syndrome (cavernous sinus disease)

64
Q

How do you distinguish diplopia from orbital myositis vs. cranial nerve abnormality?

A

Ocular myositis can be distinguished from a neuro- genic palsy in that it abruptly restricts eye movement away from the muscle, whereas a CN palsy smoothly and progressively impairs movement toward the weakened muscle

65
Q

How do vascular vs. compressive CN III palsies classically present?

A

Vascular - pupillary sparing
Compressive - pupillary involvement
Parasympathetic fibres run superficially on the external portion of the nerve, affected sooner in compressive neuropathies

66
Q

Where is the lesion in internuclear opthalmoplegia (INO)?

A

medial longitudinal fasciculus

67
Q

What are the basic elements of an ocular exam

A 
VA
IOP
Slit lamp
fundoscopy
pupils/CN exam
68
Q

Describe the Snellen chart and interpretation

A

Measured at 6 m or 20 feet, 10 feet
20/20 = what one sees at 20 feet, what a normal eye sees at 20 feet
vs. 20/50, what one sees at 20 feet a normal eye sees at 50 feet
*use pinhole for best corrected VA

69
Q

What medication should you avoid for pupillary dilation in the ED?

A

Atropine

lasts 2 weeks

70
Q

Which eyelid lacerations require ophtho referral?

A

involving lid margin
deep to tarsal plate
involving cannalicular system

71
Q

What sutures and technique to repair non margin involving eyelid laceration?

A

6-0 prolene (or gut)

vertical simple interrupted

72
Q

What options to remove crazy glue to eyelids

A

Very rare to have true EYE involvement
Warm water compresses, tea tree oil safe
Pry apart lashes, usually just need time

73
Q

Which orbital floor fractures require repair?

A

Enophthalmos
Diplopia >2 weeks
Large (2x2cm)

74
Q

How does conjunctiva heal?

A

Similar to mucous membrane

Sliding and proliferatio of epithelial cells, 1-2 days to heal

75
Q

What layers of corneal contribute to healing?

A

epithelium - normal turnover 5-7 days
stroma
endothelium
*heal from limbus inward

76
Q

Management of UV radiation corneal injury?

A

Usually only invades to epithelium/stroma

Analgesia, sunglasses, protective glasses, lubrication

77
Q

Why are alkali injuries worse than acid injuries to cornea?

A

Alkali - saponification of tissues, liquifaction necrosis

Can penetrate to anterior chamber causing diffuse inflammation

78
Q

Worst cornea chemical injuries?

A

extensive limbal epithelial damage - limits ability to heal

white limbus = dead limbus

79
Q

What happens with acid injuries to cornea?

A

denatures and precipitates proteins
coagulation necrosis
limits depth of damage

80
Q

What does ophtho use to treat chemical corneal injuries?

A

Abx drops (tetracyclines)
Topical steroids
lubricants
+/- Vitamin C

81
Q

What can cause toxic corneal injuries?

A 
topical anesthetic
topical preservatives (benzalkonium chloride)
82
Q

What are 5 causes of subconjunctival hemorrhage

A 
spontaneous
valsalva
anticoagulants 
trauma
bleeding diatheses
83
Q

How does traumatic iritis present

A

anterior cells, photophobia, pain, decreased VA, ciliary flush

84
Q

What are traumatic hyphemas often associated with?

A

traumatic iris tear

other anterior chamber injuries, open globe, retinal damage, vitreous

85
Q

When do rebleeds occur with hyphema?

A

typically days 2-5

86
Q

Suggestions for antibiotics in corneal abrasions

A

Moxifloxacin - contact lens wearer, organic material

Polysporin - non-contact lens, most material

87
Q

definition of penetrating and perforating

A

penetration: wound passes into structure
perforating: wound passes through structure

88
Q

What is the immediate management of ruptured globe?

A 
Call ophtho
Shield eye
IV Ancef
Tetanus 
Analgesia 
NPO
89
Q

What is commotio retinae?

A

intracellular edema secondary to shock waves from trauma and disruption of photoreceptor layer
Examines as retinal whitening
(appears like CRVO)
self resolving

90
Q

What is chorioretinitis sclopetaria?

A

high velocity missle in orbit without globe disruption (often GSW)
diffuse chorioretinal injury

91
Q

What retinal injury is classically associated with CPR?

A

Purtscher retinopathy

Optic nerve edema, cotton wool spots, retinal hemorrhages (like diabetic retinopathy)

92
Q

How does traumatic optic neuropathy typically present?

A

RAPD with relatively normal eye exam otherwise

93
Q

What are typical symptoms of blepharitis

A

dry eye symptoms, morning crusting

94
Q

What are 4 classic symptoms of orbital cellulitis

A

EOM restriction/pain
red eye
poor pupil reaction
decreased VA

95
Q

What are 5 common bacterial causes of conjunctivitis?

A 
S. aureus
S. epidermidis
S. pneumoniae
H. influenza
Gonoccocal
96
Q

What SLE findings are associated with HSV, HZV?

A

HSV: dendrites
HZV: pseudodendrites (often “sloppy” looking)

97
Q

How to differentiate epislceritis vs. scleritis? (other than phenylephrine test)

A

Episcleritis more superficial, not painful to touch

Scleritis usually has a rheumatologic undertone, tender on palpation

98
Q

What are 4 causes of iritis? (major categories)

A

Rheumatologic
Infectious - TB, syphilis, HSV, HZV, adenovirus
Traumatic
Postop

99
Q

What are 4 key symptoms of optic neuritis?

A

decreased VA
decreased color vision
RAPD
pain on EOM

100
Q

What is the definitive treatment for angle closure glaucoma?

A

laser peripheral iridotomy

101
Q

what options to dilate the eyes in ED?

A

mydriacyl or phenylephrine

Medicine & Surgery (10 decks)

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