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Pediatrics > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

What are the vision screening principles? (I-ARM)

A
  • Inspection - Evaluation for pupil and eyelid symmetry, face or head tilt, conjunctival redness, and squinting
  • Acuity assessment
    • Neonates and infants: evaluation of eye fixation and pupillary responses
    • Children: use of eye charts or cards
  • Red reflex assessment - single best screening examination for infants and children
  • Motility assessment of each eye and assessment of alignment (Hirschberg test)
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2
Q

Why is visual accuity poor at birth?

When does it improve?

A

Immaturity of the visual centers in the brain responsible for vision processing

Rapidly improves during the first 3-4 months of life

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3
Q

What is the meaning of the following findings on red reflex examination?

  • Dark, dull, or white reflex:
  • Dark, dull reflex:
  • Yellow or white reflex:
  • Unequal red reflex:
  • Brighter red reflex in a deviated eye:
  • Dull reflex:
A
  • Dark, dull, or white reflex: Cataract
  • Dark, dull reflex: Vitreous hemorrhage
  • Yellow or white reflex: Retinoblastoma
  • Unequal red reflex: Anisometropia
  • Brighter red reflex in a deviated eye: Strabismus
  • Dull reflex: Glaucoma
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4
Q

Normal visual development is dependent on…(2)

A
  • Proper eye alignment
  • Equal visual stimulation of each retina
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5
Q

Visual development is most critical during the first __-__ months of life

A

3-4

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6
Q

What is binocular fusion? What is required for binocular vision to develop?

A

The integration of retinal images from both eyes into a single, three dimensional perception

Binocular cortical connections are present at birth but apropriate visual input from each eye is necessary to refine and maintain these neural connections

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7
Q

What is the most common cause of decreased vision during childhood?

A

Amblyopia

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8
Q

What can lead to impairment in stereopsis (depth perception)?

A
  • Improper eye alignment
  • Any pathologic condition that unilaterally blurs the retinal image (congenital cataracts)
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9
Q

What is amblyopia?

A

Poor vision caused by abnormal visual stimulation that results in abnormal visual development

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10
Q

What is the most comomn cause of red watery eyes in the first 24 hours of life?

A

Chemical conjunctivitis (lasts less than 24 hours)

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11
Q

What factors can lead to more severe vision loss with amblyopia?

When are children most susceptible to amblyopia?

A

The earlier the onset, the longer the duration of the abnormal stimulus, and the more blurry the image, the more severe the vision loss

The first 3-4 months of life

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12
Q

What is the best screening test for amblyopia in infants and preverbal children?

In older children?

A
  • Infants: bilateral red reflex test
  • older children: Formal acuity testing
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13
Q

What are the management steps in treating amblyopia?

A
  • Ensure that there is a clear retinal image by correcting any refractive errors with eyeglases or surgically removing opacities
  • Patching the normal eye forces the use of the amblyopic eye
  • The earlier the intervention, the better the prognosis
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14
Q

What are some causes of neonatal conjunctivitis (during 1st month of life)?

A
  • Infection acquired from the vaginal canal or from hand-to-eye contamination (Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex)
  • Chemical conjunctivitis results from drops or ointment that are typically instilled into a newborn’s eyes as prophylaxis against Neisseria gonorrhoeae (1% silver nitrate)
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15
Q

How do you distinguish conjunctivitis due to Neisseria vs. Chlamydia vs. herpes simplex?

A
  • N. Gonorrhoeae: 2-4 days of life; purulent discharge, eyelid swelling and can lead to corneal ulcer
  • C. Trachomatis: 4-10 days of life; serous or purulent discharge, variable lid swelling
  • Herpes simplex: 6 days - 2 weeks of life; usually unilateral serous discharge
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16
Q

How is conjunctivitis treated when due to…

  • N. Gonorrhoeae
  • C. Trachomatis
  • Herpes Simplex
A
  • N. Gonorrhoeae: IV cefotaxime and topical erythromycin; treat parents
  • C. Trachomatis: Oral erythromycin; treat parents
  • Herpes simplex: IV acyclovir and topical trifluorothymidine
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17
Q

Define the following differential diagnoses for conjunctivitis

  • Congenital glaucoma:
  • Dacrocystitis:
  • Endophthalmitis:
A
  • Congenital glaucoma: Glaucoma characterized by clear tears, enlarged cornea, and corneal edema
  • Dacrocystitis: Infection of nasolacrimal sac
  • Endophthalmitis: Infection within the eye - rare and often results in blindness
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18
Q

What are the most common causes of red eyes in older infants and children?

A
  • Viral
  • Bacterial
  • Allergic conjunctivitis
  • Blepharitis (eyelid inflammation)
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19
Q

What diagnoses should be considered if history includes unilateral conjunctivitis?

A
  • Foreign body
  • Corneal ulcer
  • Herpes simplex keratitis
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20
Q

What are the steps in evaluaiton of red eye in children?

A
  • History
  • Occular examination (I-ARM)
  • Fluorescein staining of corneal epithelium to evaluate for abrasion of the corneal tissue
    • Positive staining associated with trauma, ulcer, or hepes simplex keratitis
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21
Q

If there are eosinophils on conjunctival scraping or severe itching of the eye, the cause of conjunctivitis is most likely…

A

Allergy

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22
Q

What are the differences between features of bacterial and viral conjunctivitis?

A

Bacterial: Purulent, no preauricular lymphadenopathy and bacteria and PMNs on gram stain

Viral: Watery, preauricular lymphadenopathy common, no bacteria on gram stain

Both have minimal itching

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23
Q

What are the most comomn causes of bacterial conjunctivitis?

A
  • nontypeable Haemophilus influenzae
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
  • Staphylococcus aureus
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24
Q

What are some clinical features of bacterial conjunctivitis?

A

Purulent discharge, conjunctival erythema, lid swelling; bilateral involvement is common

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25
Q

What is the management for bacterial conjunctvitis?

A

Topical antibiotics are effective and include sulfacetamide, polymyxin B and trimethoprim sulfate, gentamicin, tobramyicin, and erythromycin

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26
Q

What indications are there for referral to an opthalmologist with a child who has bacterial conjunctivitis?

A

Severe eye involvement, conjunctivitis associated with contact lenses, suspected corneal ulcer, or lack of improvement with topical antibiotics

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27
Q

Describe pharyngoconjunctival fever

A

An upper respiratory infection that includes pharyngitis and fever and bilateral conjunctivitis

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28
Q

What are the clinical features of viral conjunctivitis?

A

Severe watery conjunctival discharge, hyperemic conjunctiva, preauricular lymphadenopathy, and foreign body sensation cause by corneal involvement

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29
Q

Viral conjunctivitis is highly contagious and lasts for…

A

2-3 weeks

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30
Q

What is the management of viral conjunctivitis?

A

Cool compresses and topical nonsteroidal anti-inflammatory drug drops; abx if bacterial superinfection occurs

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31
Q

What virus leads to epidemic keratoconjunctivitis? (similar to pharyngoconjunctival fever but confined to the eyes)

A

Adenovirus

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32
Q

What are the clinical features of Epidemic keratoconjunctivitis?

A
  • Petechial conjnctival hemorrhage
  • Pseudomembrane along conjunctiva
  • Photophobia from corneal inflammation (in 1/3 of patients)
  • Lack of fever or pharyngitis
  • Highly contagious
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33
Q

What is the management of epidemic keratoconjunctivitis? When should the child be referred to an opthalmologist?

A

Treatment is supportive, including cool compresses and topical NSAID drops

Children with corneal involvement should be referred to an opthalmologist

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34
Q

Which type of herpes causes ocular herpes simplex infection?

A

HSV-1 (initial exposure)

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35
Q

What are the clinical features of ocular herpes simplex virus?

A

Skin eruption with multiple vesicular lesions

Corneal ulcer (rare)

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36
Q

What is the management of ocular herpes simplex?

A
  • Systemic or topical acyclovir may speed recovery if administered within 1-2 days of onset
  • Topical antibiotics applied to the skin may prevent secondary bacterial infection
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37
Q

What type of hypersensitivity reaction leads to allergic conjunctivitis?

A

Type 1 hypersensitivity reaction

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38
Q

How is allergic conjunctivitis managed?

A
  • Removal of environmental allergen
  • Topical mast cell stabilizing drops, such as cromolyn
  • Topical antihistamines
39
Q

What is Hemorrhagic conjunctivitis?

What causes it?

A

Hemorrhagic conjunctivitis is a dramatic presentation of pediatric red eye in which the child presents with both conjunctivitis and subconjunctival hemorrhage

Causes include infection with Haemophilus influenzae, adenovirus, and picornavirus

40
Q

What causes blepharitis?

A

Staphylococcus aureus infection

41
Q

How is blepharitis treated?

A

Treatment includes eyelid hygiene, in which the eyelids are scrubbed twice daily with baby shampoo

Topical erythromycin ointment is also applied

42
Q

What is nasolacrimal duct obstruction (NLD)?

A

Failure of complete canalization of the lacrimal system that results in obstruction to tear outflow

43
Q

Where does obstruction occur in nasolacrimal duct obstruction?

A

Obstruction typically occurs distally at Hasner’s valve

44
Q

What are the clinical features of NLD?

A
  • Watery eye
  • Matted eyelashes
  • Mucus in the medial canthal area
  • Bilateral involvement (1/3 of patients)
45
Q

What is usually the only management needed for NLD?

What are secondary management options?

A
  • Observation only is needed for most children
  • Nasolacrimal massage may help open the distal obstruction
  • Topical antibiotics are administered if infection is present
46
Q

Describe NLD probing

A

A small steel wire is passed through the nasolacrimal system through Hasner’s valve into the nose - cures NLD obstruction in most cases

Typically performed between 6 and 12 months of age

47
Q

What is amniotocele and what causes it?

A

Amniotecele is swelling of the nasolacrimal sac caused by accumulatin of fluid as a result of NLD obstruction

48
Q

What are the clinical features of amniotocele?

A

Bluish swelling in the medial canthal area - represents fluid in the distended nasolacrimal sac

Infection may occur, manifesting as warmth, erythema, tenderness, and increased induration

49
Q

What is the management for amniotocele?

A
  • Local massage (if no infection)
  • Intravenous antibiotics
  • Urgent NLD probing (if infection)
50
Q

Retinal hemorrhages are highly suggestive of…

A

Child abuse

51
Q

What are some nonabuse causes of retinal hemorrhages?

A

Birth trauma, leukemia, increased ICP, malignant htn, bacterial endocarditis, ITP, and rarely cardiopulmonary resuscitation

52
Q

How long does corneal abrasion take to heal?

A

24-48 hours

53
Q

What are clinical features of corneal abrasion?

A
  • Severe pain, tearing and photophobia
  • Foreign body sensation
54
Q

How is corneal abraison diagnosed?

A

Corneal abrasion is identified on fluorescein staining of the cornea

55
Q

What are the managment options for corneal abrasion? When is an opthalmologist consulted?

A
  • Placement of a protective shield or patch for 24-48 hours in severe cases
  • Instillation of a topical antibiotic prevents bacterial superinfection
  • Opthalmologic consultation to evaluate for a bacterial corneal ulcer if abrasion is associated with contac lens
56
Q

What is hyphema?

A

Blood in the anterior chamber

57
Q

What causes hyphema?

A
  • Blunt trauma is the most frequent cause (tearing of iris vasculature)
  • Iris neovascularization (diabetes, tumors, vascular diseases)
  • Iris tumors (juvenile xanthogranuloma)
58
Q

What are the clinical features of hyphema?

What are the complications?

A
  • Impaired vision (blood aqueous fluid level may be seen)
  • Complications
    • Rebleeding 3-5 days after initial injury
    • Glaucoma
    • Staining of the cornea with blood
    • Optic nerve damage (in kids with sickle cell)
59
Q

What is the management for hyphema?

A

Opthalmologic consultation and bed rest for at least 5 days

60
Q

What is the usual cause of orbital floor fracture?

A

Blunt trauma

61
Q

In an orbital floor fracture, the _____ _____ and the ______ ______ ______ can become entrapped within the fracture

A

Orbital fat; Inferior rectus muscle

62
Q

What are some possible negative outcomes of entrapment of tissues due to orbital floor fracture?

A
  • Diplopia as a result of restricted vertical eye movement
  • Strabismus
  • Enophthalmos (backwards displacement of the globe into the orbit)
63
Q

Numbness of the cheek and upper teeth below an orbital fracture may occur as a result of _______ ______ injury

A

infraorbital nerve

64
Q

What is the management of an orbital floor fracture?

A
  • Empiric oral antibiotics (prevent infectious contamination from the maxillary sinus)
  • Surgical repair is indicated if diplopia persists 2-4 weeks after injury or if enophthalmos is significant
65
Q

What is normal intraocular pressure in infants?

How high is the ocular pressure in infants with congenital glaucoma?

A

Normal pressure: 10-15 mm Hg

Congenital glaucoma: exceeding 30 mm Hg

66
Q

What is the difference between congenital glaucoma and adult glaucoma?

A

Adult glaucoma - increased intraocular pressure that damages the optic nerve but does not change the size of the eye

Congenital glaucoma - not only restricts optic nerve injury but also expands the size of the eye because the eye wall is much more elastic during infancy

67
Q

What anatomic abnormality leads to congenital glaucoma?

A

Outflow of aqueous humor is reduced because of maldevelopment of the trabecular meshwork

68
Q

What is the inheritance of congenital glaucoma?

A

Autosomal dominant

69
Q

What are the clinical features of congenital glaucoma? How often is it bilateral?

A

Tearing, photophobia, enlarged cornea, corneal clouding, and a dull red reflex

Bilateral involvement is present in 70% of patients

70
Q

What is the management of congenital glaucoma?

A

Surgery to open outflow channels is almost always required

Topical or systemic medications such as ß-adrenergic and carbonic anhydrase inhibitors

71
Q

What is retinopathy of prematurity (ROP)?

A

Proliferation of vessels seen in premature infants exposed to oxygen

72
Q

What are some risk factors for ROP (besides high concentration oxygen exposure)?

A
  • Low birth weight
  • Young gestational age
  • Blood transfusions
  • Hyalin membrane disease
  • Intracranial hemorrhage
73
Q

What are some possible late complications of ROP?

A

Myopia, astigmatism, amblyopia, strabismus, and blindness

74
Q

Opthalmologic examinations are performed every _-_ weeks in patients with ROP to monitor for progression

A

1-2 weeks

75
Q

What is the management for severe ROP?

A

Retinal cryopathy and laser therapy

76
Q

What are the two most important factors for prevention of ROP?

A
  1. Minimizing the amount of oxygen delivered
  2. Effective treatment of hyaline membrane disease
77
Q

What is leukoria?

A

A white pupil - refers to an opacity at or behind the pupil that can be caused by a cataract, an opacity within the vitreous, or by retinal disease (retinoblastoma)

78
Q

What are some general causes of congenital cataracts?

A
  • Genetic syndromes
  • Nonsyndromic genetic inheritance
  • Metabolic derangements
  • Intrauterine infections
  • Trauma
79
Q

What is the management of congenital cataracts?

A

Treatment includes evaluation for underlying disease and early surgery to prevent amblyopia

80
Q

Surgery for congenital cataracts perfromed after _______ of age is associated with poor visual outcome

A

2-3 months

81
Q

What is retinoblastoma?

A

A malignant tumor of the sensory retina

82
Q

What is the average age at presentation for retinoblastoma?

A

13-18 months

83
Q

What genetic abnormality is associated with retinoblastoma?

A

Mutation or deletion of a growth suppressor gene on both alleles on the long arm of chromosome 13 (requires 2 hits)

84
Q

How is retinoblastoma inherited?

A

Autosomal recessive

85
Q

What are the two most common presenting signs of retinoblastoma?

A

Leukocoria and strabismus

86
Q

What is the hallmark finding for retinoblastoma on imaging?

A

Calcification within the tumor

87
Q

How is retinoblastoma diagnosed?

A

Visual inspection with an opthalmoscope

88
Q

How do you manage retinoblastoma when the tumor is…

  • Large:
  • Small:
  • Very small and peripheral:
A
  • Large: generally treated by removal of the entire eye
  • Small: External beam radiation; however, radiation may induce formation of secondary tumors
  • Very small and peripheral: Cryotherapy or laser photocoagulation
89
Q

The cure rate for retinoblastoma is ___% if the tumor does not extend beyond the sclera or into the orbit

A

90%

90
Q

What is strabismus?

A

Misalignment of the eyes

91
Q

Describre the following terms (strabismus):

  • Esotropia
  • Exotropia
  • Vertical
  • Pseudostrabismus
A
  • Esotropia: eye turned nasally
  • Exotropia: eye turned laterally
  • Vertical: eye turned up or down
  • Pseudostrabismus: prominence of the epicanthal folds that results in the false appearance of strabismus even though the eyes are actually appropriately aligned
92
Q

If strabismus occurs before 5-7 years of age, how is vision affected?

A

The child suppresses the image in the deviated eye. If this suppression is prolonged, amblyopia may result

93
Q

How is vision affected if strabismus occurs later than 5-7 years of age?

A

The mature visual system is unable to suppress the image in the deviated eye, and diplopia results

94
Q

How is strabismus managed?

How is it managed if it is associated with farsightedness?

A
  • Occular patching to prevent amblyopia is important
  • Surgery is often required to correct any misalignment that does not respond to patching or glasses
  • Strabismus associated with farsightedness is intially treated with corrective lenses

Pediatrics (24 decks)

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