Ophthalmology Flashcards
Trauma: When to consult an ophthalmologist?
Any sight-threatening injury
Trauma: What to inspect for ophtho
Orbit (edema, hematoma, ecchymosis); Lids (laceration, hematoma, edema, foreign bodies); Pupils (irregularity - may be benign or indication of neurologic pathology like brain mass lesion affecting CN 3); EOM (unequal, limited, or decreased movement which may indicate laceration or entrapment); Anterior chamber (hyphema - indicates intraocular trauma); Interior eye with fundoscope (ruptured retinal vessels, which may indicate physical abuse)
Things to measure after eye trauma
- Visual acuity (1st! to establish baseline)
- Pupillary reactions
- Intraocular pressure (after using topical anesthesia)
- Cornea (using fluorescein dye and blue-light filter)
Penetrating trauma of the eye
- Don’t try to remove
- Shield eye
- Refer to ER with ophtho consult
- Alleviate pain with systemic analgesic
- Avoid eye drops
- Prophylactic antibiotics
Foreign body in the eye
Pain, irritation, foreign body sensation
- Evert lids
- Stain with fluorescein and examine with Wood’s lamp
- Remove with cotton swab or blunt edge/needle tip after anesthetic applied
- Patching if large corneal abrasions (limit patching to 24h)
What does a rust ring on cornea indicate and wha to do?
Metallic foreign body; must be removed by rotating burr (refer to ophthalmology)
Chemical burn of the eye
- Irrigate with saline for at least 30 min
- Eye shield
- Transport to ER, refer to ophthalmologist
Base worse than acid
Orbital floor fracture: What bones are involved and what are sxs
- Maxillary, palatine, zygomatic
- Structures get trapped inferiorly
- Swelling and misalignment, movement restricted (inability to look up usually)
- Double vision is common
- Prompt ophthalmology referral!
Most likely dx: Pain, sensation of foreign body in eye + photophobia, tearing, injection, and blepharospasm?
Corneal abrasion
Tx of corneal abrasion
topic anesthetic helps to confirm dx; then saline irrigation, abx ointment (Gentamicin), APAP for pain
patching recommended only for LARGE abrasions and only 24h
daily follow up, failure to heal should prompt referral to ophthalmologist
Risk factors for corneal ulcer
- inflammation/infection
2. trauma, contact lens use, poor lid apposition
Most likely dx: Pain, photophobia, tearing, circumcorneal injection and watery to purulent discharge?
Corneal ulcer
Dendritic lesion for corneal ulcer indicates what etiology?
Herpes keratitis
Tx for corneal ulcer?
Refer to ophthalmology, stain and culture lesion, avoid topical steroids because increase risk of perforation
Reasons for retinal detachment?
- Spontaneous
- 2/2 Trauma
- Extreme myopia
- Inflammatory changes in vitreous, retina, or choroid
Acute onset of painless blurred or blackened vision that occurs over several minutes to hours and progresses to partial monocular blindness. Classically described as curtain being drawn over eye from top to bottom. May see floaters or flashing lights.
Retinal detachment
Tx for retinal detachment?
Emergency ophthalmology consult. Keep patient supine with head turned to the side of retinal detachment. Good prognosis (80% recover without reoccurrence)
What are causes of macular degeneration?
- Age (prevalence increases after 50yo)
2. 2/2 toxic effects of drugs like chloroquine or phenothiazine
What is the leading cause of irreversible central vision loss?
Macular degeneration
Treatment for central retinal artery occlusion?
Emergency ophthalmology consult
What are reasons to do an emergent ophthalmology consult?
- Retinal detachment
- Central retinal artery occlusion
- Orbital floor fracture
- Acute-closure glaucoma
Sudden, painless and marked unilateral loss of vision. Pallor of retina, arteriolar narrowing, separation of arterial flow (box-carring), retinal edema, perifoveal atrophy (cherry red spot) - most likely dx?
Central retinal artery occlusion sxs (bad prognosis)
Sudden, unilateral, painless blurred vision or complete visual loss. Also afferent pupillary defect, optic disc swelling, and “blood and thunder” retina (dilated veins, hemorrhages, edema, and exudates)
Central retinal vein occlusion sxs (vision typically resolves with time)
Signs of hypertensive retinopathy?
arteriolar narrowing, copper or silver wiring, and AV nicking (atherosclerosis)
First signs of diabetic retinopathy? and what’s the first stage called
First stage = non-proliferative
- Microaneuryisms
- Retinal hemorrhages, retinal edema, hard exudates (cotton wool spots)
Second stage of diabetic retinopathy?
Second stage = proliferative
- Neovascularization
- Viterous hemorrhage
Tx of diabetic retinopathy and prognosis?
Treat by optimizing glucose control, regulating blood pressure, laser photocoagulation, and vitrectomy. Severe disease is permanent.
Most common type of cataract?
Senile, part of natural aging process
Causes of cataracts?
- Aging
- Trauma
- Congenital causes
- Systemic disease (diabetes)
- Certain medications (steroids, statins)
- Exposure to sun predisposes cataract development
Gradual decrease in vision; may have double vision, excess glare, fixed spots, reduced color perception; insidious onset. Translucent, yellow discoloration of lens
cataract
Condition defined by increased intraocular pressure with optic nerve damage and loss of peripheral vision fields
open-angle glaucoma
Painful eye with loss of vision, injection, steamy cornea, fixed mid-dilated pupil, decreased visual acuity, and tearing - what to do?
Dx: Acute-closure glaucoma
Emergency ophtho consult
Treatment of acute-closure glaucoma
Emergency ophtho consult
Decrease IOP with beta-blockers and carbonic anhydrase inhibitors and/or increasing outflow (prostaglandin-like meds, cholinergic agents, epinephrine components). A-Agonists (brimonidine) do both mechanisms.
What is a possible complication of sinusitis, dental infections, facial infections, infection around globe or eyelids, and infections of lacrimal system?
Orbital cellulitis
Patient presents with ptosis, eyelid edema, exophthalmos, purulent discharge, and conjuctivitis. Also fever, restricted range of motion of eye muscles, sluggish pupillary response. What should you do?
Dx: Orbital cellulitis
- Emergency requiring hospitalization and broad spectrum (until causative agent found) IV antibiotics, surgical drainage possibly
- Inadequate tx can lead to meningeal or cerebral infection
- IV til fever subsides, then oral 2-3 weeks
Nafcillin and metronidazole or clindamycin, second- or third-generation cephalosporins, and FQs
Chronic inflammation of lid margins, red rims, eyelashes adhere, dandruff-like deposits and fibrous scales; conjunctiva is clear or slightly erythematous; thick, cloudy discharge possible if glands obstructed - dx and tx?
Blepharitis
Tx: Lid scrubs using diluted baby shampoo; massage to express meibomian glands; topic abx if infection is suspected
Acute onset, small, mildly painful nodule or pustule within a gland in the upper or lower eyelid. Palpable, indurated area in the involved eyelid with central area of purulence with surrounding erythema - dx, usual pathogen, and tx?
Hordeolum (stye)
Pathogen: staph aureus
Tx: warm compresses several times a day for 48h; topical abx if secondary infection develops; incision and drainage may be indicated if it does not resolve
Relatively painless, indurated lesion, deep from the palpebral margin; insidious onset with minimal irrigation, may appear white to grayish; can become pruritic and cause erythema - dx, tx
Chalazion
Can be 2/2 chronic inflammation of internal hordeolum
Tx: warm compresses and referral to ophthalmologist for elective excision if not resolved
Most conjunctivitis is viral or bacterial? (and which strand/bacteria?)
Viral - Adenovirus
VERY contagious
Acute onset of unilateral or bilateral erythema of the conjunctiva, copious watery discharge, and ipsilateral tender pre auricular lymphadenopathy - dx and tx?
Dx: Viral conjuctivitis - adenovirus
Tx:
1. Eye lavage with normal saline bid x 7-14 days; vasoconstrictor-antihistamine drops may also have beneficial effects
2. Warm to cool compress reduce discomfort
3. Ophthalmic sulfonamide drops my prevent secondary infection but not routinely prescribed
Acute onset of copious purulent discharge from both eyes, may have mild decrease in visual acuity and mild discomfort. Eyes may be “glued” shut on awakening. Dx and tx?
Dx: Bacterial conjuctivitis - s. pneumo, staph aureus, moraxella, heomophilus aegyptius
Tx: Attention to hygiene, including hand washing and avoidance of contamination.
Topical antibiotics - sulfonamides, FQs, and ahminoglycosides are common. Drops are more effective than ointment.
Rare pathogens: chlamydia and gonorrhea (non-chlorinated swimming pool, sexual contact or to neonate during delivery). These cause severe conjunctivitis and keratitis with permanent visual impairment.
Some rare pathogens may need systemic abx.
Elevated, yellowish fleshy conjunctival mass found on sclera adjacent to cornea (typically on nasal side). Painless inflammation possible. - Dx and tx?
Dx: Pinguecula
Tx: No treatment necessary; can be resected if cosmetically undesirable
Slow growing thickening of bulbar conjunctiva. Can be unilateral or bilateral. Looks like highly vascular triangular mass growing from nasal side toward cornea. Dx/tx?
Dx: Pterygium.
Important to differentiate from pinguecula because this eventually encroaches on cornea and interferes with vision.
tx: Excision if interfering with vision
Condition defined as an increase in intracranial pressure?
Papilledema
What are causes of papilledema?
Malignant hypertension, hemorrhagic stroke, acute subdural hematoma, pseudotumor cerebri among others
What are clinical signs of papilledema?
Disc appears swollen, margins are blurred, obliteration of vessels. Patients may be asymptomatic or have transient visual alterations for a few seconds.
Blurred vision and decreased acuity
Location of the lesion determines the effect on vision.
- Anterior to optic chiasm: one eye
- At the chasm: affect both eyes partially
- Posterior to chiasm: corresponding defects in both visual fields
Causes of transient vision loss
- Secondary to TIA
- Emboli (amaurosis fugax)
- Giant cell (temporal) arteritis
Sxs and tx of giant cell arteritis?
Tender temporal artery, fever, malaise, and very high ESR
Prompt tx with systemic corticosteroids to prevent blindness
Causes of sudden vision loss?
Central retinal artery occlusion, central retinal vein or branch vein occlusion, optic neuropathy, papillitis (optic disc inflammation) and retrobulbar neuritis among others
Causes of gradual vision loss?
- Macular degeneration (Central)
- Tumors
- Cataracts
- Glaucoma (peripheral)
If a corneal light reflex test is positive, what does that indicate? What other tests support the dx?
Misalignment - strabismus
Cover-uncover test my reveal latent strabismus which might not be readily apparent otherwise
Tx of strabismus
Eye exercises, patchy therapy, surgery in severe cases. If left untreated after age of 2 then amblyopia will result
Reduced visual acuity not correctable by refractive means (i.e. can’t just correct with glasses)
Amblyopia
loss or lack of development of optic nerve, brain favors one eye
Causes of amblyopia
Strabismus (most commonly), uremia or toxins like alcohol, tobacco, lead, and other toxic substances
Yellowing of sclera indicates
Jaundice/icterus, retention of bilirubin
Blue or cyanotic sclera may be seen in infants with what condition?
Osteogenesis imperfecta
