Ophthalmology Flashcards

1
Q

What changes to the lens can be seen with aging?

A

Yellows: May affect color discrimination
Opacifies: Cataract
Hardens: Nuclear sclerosis

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2
Q

What is presbyopia?

A

The ciliary body/lens loses accommodative ability with age meaning there is a loss of near vision

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3
Q

What eye diseases are the following conditions associated with?

HTN
Arthritis
Diabetes

A

HTN- retinal vein occlusion
Arthritis- dry eye
Diabetes- glaucoma, cataracts, diabetic neuropathy

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4
Q

What are the 4 leading causes of vision loss in the aging eye?

A
  1. Age-related macular degeneration (AMD)
  2. Glaucoma
  3. Cataract
  4. Diabetic retinopathy
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5
Q

__% of Americans over 65 have some cataract formation

A

50

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6
Q
For individuals 65 years of age or older,
asymptomatic, and without disease, the
American Academy of Ophthalmology
recommends a comprehensive eye
examination every ...
A

1 to 2 years.

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7
Q

chronic inflammation of
the eyelid; burning, itching,
tearing, and crusting of the eyelid

A

blepharitis

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8
Q

What is Entropion?

A

inward turning of the

eyelids and lashes,

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9
Q

What is ectropion?

A

outward turning of the

eyelids and lashes

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10
Q

What is dermatochalasis?

A

with time and age the layers of the skin over the eyelid can their elasticity and droop

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11
Q

What is the most common eyelid malignancy?

A

basal cell carcinoma- 90% of
eyelid tumors, affect the lower lids more
commonly than the upper.

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12
Q

What is the most common condition affecting the

cornea in the aging eye?

A

poor tear

production

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13
Q

Dry eye tx

A

several times a day, as needed for comfort,
and can refer patients with refractory
symptoms for ophthalmic treatment that may include
occlusion of the lacrimal puncta to
preserve the tear film and topical
cyclosporine drops (Restasis [Allergan])

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14
Q

Herpes Zoster Ophthalmicus tx

A

oral acyclovir
or its derivatives often can reduce
symptoms and shorten the course of the
disease.

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15
Q

What is the most common cause of visual loss in

the elderly?

A

age-related macular

degeneration, or AMD.

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16
Q

Risk factors for AMD

A

Advanced age
FH of AMD
Smoking
CV disease

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17
Q
People who have already
had vision loss in one eye from the
advanced stage of AMD have about a \_\_\_%
chance of developing vision loss from
advanced AMD in the second eye within 5
years
A

50

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18
Q

What defines the advanced stage of AMD?

A

when the changes of AMD are

associated with loss of vision.

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19
Q
What is the difference between  atrophic advanced stage
(sometimes called “dry” AMD), and a
neoneovascular
stage of advanced AMD(sometimes
called “wet” AMD)?
A

atrophic
advanced stage of AMD- associated with a gradual vision loss due to
atrophy of the photoreceptors overlying
retinal pigment epithelium and atrophy of
the underlying choriocapillaris, in the
central macular area.

neovascular
stage of advanced AMD- associated
with more sudden visual loss from the
ingrowth of new blood vessels, from the
underlying choriocapillaris through breaks
in Bruch’s membrane between the retina
and the choroid.; disc edema and disinform scar

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20
Q

What are the symptoms seen in intermediate vs advanced stage AMD?

A

Intermediate- no symptoms or slight difficulty reading, driving, etc due to atrophy not yet involving center of macula; straight lines may appear crooked

Advanced stage- central blind spot; peripheral vision usually remains intact

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21
Q

dx of advanced stage AMD

A
A fluorescein angiogram is performed to
confirm the diagnosis of the advanced
stage of AMD, especially the neovascular
form. The angiogram also can determine if an
individual with the neovascular form is a
candidate for laser photocoagulation,
photodynamic therapy, or other
pharmacologic treatments aimed at
inhibiting vascular endothelial growth
factor (VEGF).
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22
Q

In the Age-Related Eye Disease Study, a
multicenter prospective trial, the risk of
progression from intermediate to advanced
AMD was reduced when patients took a
daily dietary supplement containing …

A
vitamin C (500 mg), vitamin E (400 IU),
beta carotene (15 mg), and zinc oxide (80
mg).
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23
Q

tx for neovascular advanced stage AMD

A

laser
photocoagulation, photodynamic therapy
with verteporfin, and intraocular injection
therapy with anti-VEGF; all 3 can stabilize visual loss, and VEGF can

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24
Q

Risk factors for glaucoma

A

high
intraocular pressure (IOP), African racial
heritage, advanced age, and first-degree
relatives who have glaucoma.
Concurrent hypertension,
diabetes mellitus, and myopia may also be
associated with glaucoma risk.

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25
What is glaucoma?
optic neuropathy, a disease of the optic nerve head, that results in visual field changes.
26
What are the 2 types of glaucoma? Which is more common in older people?
``` primary open-angle glaucoma (POAG), and angle-closure glaucoma (ACG). The frequency of both types of glaucoma increases with age; POAG is the most common type in older people. Primary open-angle glaucoma accounts for 60% to 70% of all glaucoma cases in the U.S. ```
27
What causes POAG?
the normal drainage network of the eye has increased resistance, leading to elevated intraocular pressures.
28
What visual field changes are commonly seen in glaucoma?
Visual field changes in glaucoma are typically in the nasal, paracentral, or midperipheral portions of the field.
29
Visual fields should be assessed in all patients with glaucoma at _______ if possible. Visual field testing should be done more frequently on patients whose IOPs are not well controlled.
least once a year
30
What are predisposing factors for ACG?
people over the age 50, certain types of Asian ancestry and female gender with hyperopia.
31
What 2 conditions make a pt susceptible to ACG?
cataracts and farsightedness A cataractous lens tends to push the iris forward and block the drainage network
32
ACG Sx
severe ocular pain, blurred vision, halos around lights, headache, nausea, and vomiting.
33
External ocular signs of ACG
injected conjunctiva, hazy cornea, and pupil fixed and mid-dilated.
34
ACG tx
Angle-closure glaucoma can be definitively treated with a laser iridotomy, a hole in the iris
35
What exposures can cause damage to the lens and consequently cause a cataract?
chronic exposure to sunlight, age, diabetes, steroid use, smoking, trauma, and previous surgery
36
cataract sx
Disturbance of near or distance vision at first Progresses to diminution of vision Cataract severity and location determine impairment Glare is bothersome
37
Cataract tx
cataract surgery is indicated if visual impairment is significant, and patient’s ability to perform daily activities such as driving and reading is affected, regardless of cataract density. At present, there is no medical treatment for cataracts.
38
What is the prognosis following cataract surgery?
90% of pts achieve 20/40 vision or better. However, in about 15% of patients, the remaining lens capsule becomes opaque following cataract surgery and causes decreased vision The infrequent complications include infection, glaucoma, and retinal swelling or detachment.
39
What can be done if following a cataract surgery the remaining lens capsule becomes opacified?
``` vision in such patients can be improved by making an opening in this remaining capsule with a laser. The Nd:YAG laser (which stands for neodymium:yttrium-aluminum-garnet) is used in a procedure called a laser capsulotomy to cut out the opacified remnants. ```
40
What causes macular edema?
leakage from microaneurysms and other damaged vasculature.
41
When should diabetics get eye exams?
``` It is recommended that patients with type I diabetes have an annual eye exam beginning 5 years after diagnosis. Patients with type II diabetes should have an eye exam at the time of diagnosis and then annually thereafter. ```
42
What is usually the cause for central artery occlusion?
embolus
43
Central retinal artery occlusion appearance
On ophthalmoscopy, the inner layer of the retina is edematous except for the fovea, where only an outer layer of the retina is normally present. This difference in retinal swelling creates the so-called cherry-red spot, where the red spot is the normal red color of the retina surrounded by swollen inner layers of the retina.
44
What is the appearance of branch retinal artery occlusion?
``` Only the affected area appears edematous on ophthalmoscopy, corresponding to the inner layers of the retina normally perfused by the occluded branch retinal artery. ```
45
Branch retinal artery occlusion sx
patients have a sudden loss of a portion of | the visual field.d
46
Branch retinal artery occlusion tx
Treatment might be directed to moving the embolus further downstream by intermittent pressure on the eye while the retina is visualized so that less of the retina might be affected. Medical management should be directed toward finding and treating the source of the embolus to prevent additional emboli to the same or contralateral eye and other parts of the central nervous system.
47
Central retinal vein occlusion (CRVO) cause
result of a thrombus occluding the vein at the optic nerve draining the inner layers of the retina.
48
What is posterior vitreous detachment (PVD)?
With age, the vitreous may shrink and pull back from the retina. This separation is called posterior vitreous detachment (PVD) and is considered a physiologic process of aging
49
PVD sx
flashes of light or floaters, usually as one large floater.
50
In __%- ___% of patients, an acute posterior vitreous detachment leads to a retinal tear.
10% to 15
51
symptomatic retinal tear tx
laser photocoagulation or cryosurgery to prevent a retinal detachment.
52
Retinal detachment sx
Patients with a retinal detachment often notice a scotoma in the portion of their vision that is affected by the detachment. Retinal detachments are usually progressive—those that affect only a portion of vision will affect more over time. If the macula is detached, central visual acuity will be lost and there is an increased risk of permanent visual loss.
53
tx options for retinal detachments
(1) injecting an expansile gas bubble into the globe, (2) suturing a silicone band around the eye to support the retina (a scleral buckle), or (3) removing the vitreous (vitrectomy) with laser surgery or cryopexy applied to areas of retinal tears.
54
What systemic diseases can cause isolated CN palsies?
hypertension, diabetes, and generalized | atherosclerosis
55
CN III palsy S/Sx
``` ptosis and limitation of ocular movements in all fields of gaze except abduction; pupil may be involved (dilated with minimal to no reactivity) or not involved (normal size and reactivity); typically the patient will complain of double vision. ```
56
What are the most common causes of CN III palsy?
a compressive lesion, typically an aneurysm of the posterior communicating artery, and microvascular ischemia, commonly seen in diabetic patients.
57
If the pupil is not involved in third nerve palsy, and there are no other neurological signs, the cause is most likely...
ischemic and resolution usually occurs after several months
58
If CN III palsy is associated with pupil involvement what workup should be done?
urgent imaging with MRI/MRA is indicated to rule out an aneurysm.
59
ischemic | optic neuropathy cause
Ischemia from the closure of ciliary vessels that supply the optic nerve can lead to visual loss
60
Ischemic optic neuropathy S/Sx
slight blurring of the optic nerve margins. patients report some visual loss; it may be severe (a central scotoma) or may be demonstrated only on visual field testing. Color perception will be diminished in the affected eye
61
What is the difference between arteritic optic neuropathy and non-arteritic optic neuropathy?
arteritic (associated with temporal arteritis) or non-arteritic. When ischemic optic neuropathy is non- arteritic, the optic nerve usually is small.
62
patients older than 50 diagnosed with | ischemic optic neuropathy should have ...
sedimentation rate and C-reactive protein level checked urgently to rule out temporal arteritis.
63
Temporal arteritis sx
headaches, generalized malaise, night sweats, weight loss, and jaw claudication. There is also an association with polymyalgia rheumatica.
64
Temporal arteritis Tx
high doses of steroids tapered over many months, usually given orally, but if severe visual loss from ischemic optic neuropathy is present, intravenous steroid treatment should be considered. If ischemic optic neuropathy has already occurred in one eye, steroid treatment should be started to protect the fellow eye as soon as a temporal-arteritis diagnosis is suspected. Steroid treatment should not be delayed while awaiting temporal artery biopsy, as such treatment will not affect the biopsy results provided that the procedure is performed within about a week of the beginning treatment.
65
What is the definition of moderate low vision?
visual acuity of approximately 20/70 to 20/160 in the better-seeing eye.
66
What is the definition of severe low vision?
``` visual acuity of 20/200 (legal blindness) to 20/400 or worse (blindness according the World Health Organization) in the betterseeing eye. ```
67
What is the definition of amblyopia?
defined as a decrease in best- corrected visual acuity in one or both eyes, with no apparent ocular abnormality on physical examination. In practice, the term is used to include reduced visual function that results also from structural ocular abnormalities, such as cataracts, corneal opacities, or eyelid ptosis.
68
What is the most common cause of monocular visual impairment in children and young adults?
amblyopia
69
What are predisposing factors to amblyopia?
ocular media opacities such as cataract; significant refractive errors; and strabismus, or misaligned eyes.
70
Preferably, detection and treatment of amblyopia should occur by the age of __-__ years.
3 to 5
71
What is the cause of amblyopia?
Amblyopia develops if the visual image projected on the central retina is constantly unclear or obstructed during the critical period of early visual development.
72
What is the most common cause of amblyopia?
strabismus
73
What is a major difference in strabismus presentation in a child vs adult?
Adults typically report double vision but children rarely do. This is because the child's brain suppresses the image from the deviating eye, but in adults the mature visual system does not have this ability so the pt sees double.
74
What is leukocoria and what are some of the causes?
Leukocoria is an abnormal white retinal reflex; causes = retinoblastoma, retinal detachment, cataract
75
If a child has an enlarged cornea, there is concern of ...
congenital glaucoma
76
What are signs of poor vision in an infant with BL amblyopia?
failure to fix and follow an object, wandering eye movements, nystagmus, or unusual habits such as eye-poking or hand- waving.
77
T/F: Intermittent strabismus may occur in normal children up to 4 to 6 months of age.
T
78
T/F: In a child with myopia, amblyopia will not develop as long as a clear image is being focused on the retina for near objects.
T
79
What are hypertropia and hypotropia?
vertical deviation of the eye causes displacement of the corneal light reflex; if the reflex is below the retina in the deviating eye- hypertropia; if the reflex is above the pupil in the deviating eye- hypotropia
80
What are causes for immediate referral to ophthalmologist in children?
Poor red reflex in one or both eyes Concern about visual function by parent or physician Asymmetric or diminishing visual acuity Constant or acute onset strabismus When nystagmus is present or unusual habits such as hand waving or eye poking
81
An acuity of ____ or | worse in a child should be of concern
20/40
82
Amblyopia tx
``` Patching/Occlusion therapy- Patching the unaffected or better-seeing eye provides monocular stimulation to the amblyopic eye, promoting more normal visual development. ```
83
What complication must be monitored for with occlusion therapy?
occlusion amblyopia in the patched eye; visual acuity is monitored very closely
84
What is an alternative to occlusion therapy for amblyopia tx?
atropine drops in the non-amblyopic eye to prevent accommodation; this forces the child to fixate with the amblyopic eye when focusing on a near object Note: This therapy will fail if the child's amblyopic eye has poor near acuity
85
What is the leading cause of blindness in working-age Americans?
diabetic neuropathy
86
What is the effect of intensive glycemic control in type 1 diabetics with and without preexisting non proliferative diabetic retinopathy (NPDR)?
intensive glucose control reduces the rate of development and progression of diabetic retinopathy in type 1 patients with and without baseline retinopathy.
87
T/F: during the early stages of intensive glucose management, pre- existing retinopathy may worsen.
T
88
Diabetic nephropathy and proteinuria have | been associated with more advanced ___ and ___
retinopathy and macular edema
89
___ may benefit the diabetic kidney and retina even in normotensive pts
lisinopril
90
___ may be associated with increased macular exudates and vision loss
high cholesterol
91
Proliferative diabetic retinopathy (PDR) is a risk indicator for ....
MI, stroke, amputation
92
PDR elevates the risk of developing ___
nephropathy
93
What changes in the retinal vasculature are found in diabetic retinopathy?
Loss of pericytes early and endothelial cells lost later. Then followed by the formation of micro aneurysms,(1st clinically detectable change) Other sequelae include abnormal permeability, capillary nonperfusion, and neovascularization.
94
What are the clinical stages of diabetic retinopathy?
1. NPDR 2. Preproliferative diabetic retinopathy (PPDR)/ severe NPDR 3. PDR
95
Appearance of mild to moderate NPDR
microaneurysms, hard exudates, cottonwool spots, and intraretinal hemorrhages (dot blot or flame hemorrhages) Puts may be asymptomatic
96
What is diabetic macular edema?
Vascular leakage, fluid, and/or exudate in | the macula
97
What is the name for diabetic macular edema that | involves or threatens the fovea?
clinically significant macular edema | CSME
98
PPDR appearance
``` irregular dilations of retinal veins, called venous beading, intraretinal microvascular abnormalities or capillary shunt vessels, and extensive retinal hemorrhages. ```
99
Once the signs of PPDR appear, ___% of pts with develop PDR in 1 yr
50
100
PDR appearance
``` new retinal or optic disc blood vessels (neovascularization) that may be complicated by vitreous hemorrhage, traction retinal detachment, NPDR features ```
101
Explain the neovascularzation terms NVD and NVE.
``` Neovascularization originating around the optic nerve head is referred to as new vessels at the disc (NVD), shown on the left. If originating elsewhere on the retina, the neovascularization is called new vessels elsewhere (NVE) ```
102
Vitreous hemorrhage sx
Vitreous hemorrhage may be mild, perceived by the patient as dark spots or floaters. Alternatively, vitreous hemorrhage may be more severe and may fill the vitreous compartment with blood, decreasing the patient’s visual acuity to light perception only.
103
What is rubeosis iridis?
Iris neovascularization induced by retinal ischemia; may lead to peripheral iris adhesions blocking the normal drainage of aqueous fluid from the eye, potentially causing acute angleclosure glaucoma.
104
At which stage of diabetic retinopathy might laser photocoagulation therapy be of benefit?
PPDR- laser therapy at this stage may help prevent long-term visual loss
105
CSME tx
focal macular laser- uses a limited distribution of laser spots, delicately placed within the bed of retinal edema, and may include the direct treatment of associated leaking microaneurysms using yellow wavelength.
106
CME
cystoid macular edema
107
Diabetic retinopathy tx options
Panretinal photocoagulation (PRP) Virectomy-to evacuate vitreous hemorrhage, repair retinal detachment, and allow treatment with panretinal photocoagulation.; endophotocoagulation, may also be performed at the time of surgery to expedite regression of new retinal vessels.
108
ophthalmology screening guidelines in diabetics
Type 1 diabetes- annual exams beginning 5 years after diagnoses, but not before puberty type 2 diabetic puts need to be evaluated at time of diagnosis and every year afterward
109
Ophthalmic follow-up in a diabetic pregnant pt
Ideally, eye exam before conception Eye exam in the 1st trimester and then f/u schedule determined by the baseline retinopathy
110
What groups are at risk for glaucoma?
elderly African American Individuals with IOP, 1st degree relatives with glaucoma, and possibly those with high myopia or diabetes
111
What is the progression of the pathology of glaucoma?
ganglion cell death--> retinal nerve fiber layer change--> optic nerve head changes--> visual field changes
112
What are the optic nerve head changes seen in glaucoma?
``` increased size of the cup Thinning of the disc rim Progressive loss of neural rim tissue Disc hemorrhages Loss of nerve fibers ```
113
Visual field losses in glaucoma
loss of vision in the nasal field (a nasal scotoma, or nasal step), loss of vision near the central field (a paracentral scotoma), or loss of vision in the midperiphery (arcuate scotomas)
114
Up to __% of all patients with glaucoma may have pressures below 22 mm Hg at any given screening
50
115
tearing, photophobia, an enlarged eye, | and a hazy cornea in an infant
congenital glaucoma
116
What are some causes of secondary glaucoma?
``` trauma uveitis chronic steroid use diabetic retinopathy Ocular vascular occlusion ```
117
Blindness from glaucoma is ___-____ times more common in African-Americans than in Caucasians.
three to four
118
What is the definition of a glaucoma suspect?
an adult who has normal visual fields and anterior chamber angles that appear normal but also has (1) elevated intraocular pressure, or (2) optic disc and/or nerve fiber layer with an appearance that is consistent with glaucomatous optic nerve damage, or (3) both of these attributes.
119
f/u for glaucoma suspect
all glaucoma suspects should be reevaluated with an eye examination every 3 to 18 months
120
Glaucomatous optic nerve damage | involves the loss of axons. What nerve fibers are most susceptible?
The nerve fibers most susceptible in glaucoma are those entering the optic nerve in the superior and inferior poles.
121
What change in the cup-to-disc ratio is seen in glaucoma?
Because there is loss of nerve fibers (mostly at the superior and inferior poles of the optic nerve), the neuroretinal rim (consists of mostly nerve fibers) thins causing a vertical elongation of the cup, therefore, an increased cup-to-disc ratio.
122
What is one of the earliest signs of glaucoma?
defects in the nerve fiber layer- Damage may be diffuse or focal, resulting in a groove or wedge defect
123
What is the natural difference b/w the cup-to-disc ratio in African-Americans versus Caucasians?
African- Americans tend physiologically to have larger cup-to-disc ratios than Caucasians (based on a larger absolute disc size). This is important to keep in mind when using this ratio to determine glaucoma suspicion.
124
Cup-to-disc ratios greater than __ indicate a high level of glaucoma suspicion, while those of __-__ indicate a moderate level.
0. 9 | 0. 6 to 0.8
125
Glaucomatous changes of the optic nerve
increased cupping, further narrowing of the rim, increased pallor of the remaining neural tissue, heightened visibility of the pores of the lamina cribrosa, and displacement of the retinal vessels to the margin of the disc.
126
Glaucoma tx
topical beta-adrenergic antagonist (yellow top)- decrease aqueous production Topical adrenergic agonists (blue/purple top)- lower resistance to outflow and may decrease aqueous production Topical cholinergic agonists (green top)- increase aqueous outflow Carbonic anhydrase inhibitors (systemic or topical tx)- decrease aqueous production by inhibiting ion transport associated with aqueous humor secretion Prostaglandin F2alpha analogs (aqua top)- increase aqueous outflow
127
Prostaglandin F2alpha analogs should be used with caution in pts with ....
a history of uveitis or a history of or risk | factors for cystoid macular edema
128
Surgical tx options for glaucoma
laser trabeculoplasty, filtering surgery (trabeculectomy), drainage implant surgery, and cyclophotocoagulation
129
What groups are at high risk of angle closure glaucoma?
``` Elderly Hyperopic pts + FH Females Eskimos Asians ```
130
acute glaucoma tx
``` topical 2% pilocarpine drops in two doses, 15 minutes apart; timolol maleate 0.5% drops; apraclonidine 0.5% drops; and acetazolamide, 500 mg orally or parenterally. A 20% solution of IV mannitol, 1.5–2 g/kg/body weight infused over 30–60 minutes should be given if there are no medical contraindications. ```
131
In a pt with monocular ACG, what should be done in the unaffected eye?
The fellow eye should receive a prophylactic iridotomy if its chamber angle is narrow, because 58% to 75% of fellow eyes will suffer acute attacks.
132
3 categories of causes of red eye
Mechanical trauma Chemical trauma Inflammation/infection
133
List the 8 most common causes of red eye in order of urgency
``` (1) chemical injury, (2) angle-closure glaucoma, (3) ocular foreign body, (4)corneal abrasion, (5) uveitis, (6) conjunctivitis, (7) ocular surface disease, and (8) subconjunctival hemorrhage ```
134
What do each of these red eye symptoms tell you about the most likely cause of the red eye? ``` Itching Burning Foreign body sensation Localized lid tenderness Deep, intense pain Photophobia Halo vision ```
Itching- Allergy Burning- lid disorders, dry eye Foreign body sensation- foreign body, corneal abrasion Localized lid tenderness- hordeolum, chalazion Deep, intense pain- corneal abrasion, scleritis, iritis, acute glaucoma, sinusitis, etc Photophobia- corneal abrasion, iritis, acute glaucoma Halo vision- corneal edema (acute glaucoma, uveitis)
135
Red eye + decreased vision-->
referral to ophthalmologist
136
What is a hordeolum?
occurs due to obstruction of an oil gland at the base of the eyelashes. A hordeolum may look like a pimple and develops near the skin surface on the anterior margin of the lid, adjacent to the cilia.
137
What is a chalazion?
When a meibomian gland is obstructed, these glands may produce a tender, red swelling in the adjacent lid tissue
138
hordeolum or chiazzino tx
``` Hot compresses (warmer than lukewarm but not so hot that they burn) applied to the affected lid area externally for 10 minutes, 3 times daily, are highly effective for acute or subacute lesions. Compresses may have to be continued for several weeks until the condition is resolved. Because both conditions are usually sterile, topical antibiotics are usually unnecessary ```
139
burning, mattering of the lashes, and eyelids sticking together upon awakening inflammation of the eyelids, collarettes of dried skin and wax around the base of the eyelashes, associated local redness (Staph infection)
blepharitis
140
blepharitis tx
lid and face hygiene (warm compresses lid scrubs), artificial tears for dry eye, abx or abx-steroid ointment, oral doxycycline for refractory cases
141
What are the differences b/w preseptal and orbital cellulitis?
Preseptal cellulitis is anterior to the orbital septum; eyelids are often tender to the touch and can be swollen shut. The visual acuity, pupils and mobility are normal and there is no proptosis; tx with systemic abx and warm compresses Orbital cellulitis (EMERGENCY) - cellulitis extends posterior to the orbital septum; lids and conjunctiva are red and swollen, ocular mobility is impaired and there is pain with eye movement, proptosis, fever and leukocytosis ; tx requires hospitalization and ophthalmologist consult, IV abx
142
What are the most common causes of orbital cellulitis?
Staphylococcus aureus, Streptococcus species, and Haemophilus influenzae
143
What are the possible complications of orbital cellulitis?
cavernous sinus thromboses and meningitis
144
What is dacrocystitis?
swollen, inflamed lacrimal sac; if secondary to lacrimal duct obstruction tx with abx. Surgery after one episode
145
What are the most common causes of nasolacrimal obstruction in adults?
trauma | and recurrent infection of the lacrimal sac, causing stenosis and scarring
146
What does the discharge in conjunctivitis tell you about the likely cause?
purulent--> bacterial Clear--> viral watery, with stringy white mucus--> allergic
147
Most common causes of bacterial conjunctivitis
``` Staphylococcus species, usually harbored in the skin, are the most common cause of conjunctivitis. Streptococcus and Haemophilus species, harbored in the respiratory system, are the next most common. ```
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bacterial conjunctivitis tx
``` Topical ophthalmic antibiotic solutions, applied 4 times daily, should be prescribed for 7 days. Bacterial conjunctivitis is treated with a broad-spectrum topical antibiotic such as, erythromycin, sulfacetamide, trimethoprim-polymyxin, an aminoglycoside, or a fluoroquinolone. Warm compresses applied several times a day should be included in the treatment regiment. If there is no significant clinical improvement in 3 days, referral to an ophthalmologist is in order ```
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What is an important physical exam finding differentiating viral from bacterial conjunctivitis?
palpable preauricular lymph node
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What is the most common cause of viral conjunctivitis?
adenovirus
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What characteristics of a viral conjunctivitis warrant a referral to an ophthalmologist?
``` If the conjunctivitis or symptoms persist beyond 2 weeks or there is pain, photophobia, or decreased vision, the patient should be referred to an ophthalmologist. ```
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What are the causes of neonatal conjunctivitis (within the first 4 weeks of life) and the usual time seen after birth?
N. gonorrhoeae: 2-4 days Staph or Strep: 3-5 days Chlamydia: 5-12 days Viruses, e.g. herpes from mother
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Infant Gonococcal conjunctivitis presentation
swollen lids, heavy purulent exudate, “beefy-red” conjunctiva, and conjunctival edema.
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Dry eye tx
Artificial tears, cyclosporine drops/Restasis (improves tear production) Lubricating ointment at bedtime Punctal occlusion
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What is exposure keratitis and what are the causes?
``` Exposure keratitis comes from incomplete eyelid closure during blinking, deficient blinking, or eyes coming open during sleep; causes symptoms similar to dry eyes. ``` Exposure may also result from Bell’s palsy, scarred or malpositioned eyelids, or thyroid exophthalmos
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exposure keratitis management
lubricating solutions/ointments Tape lids shut at night Do NOT patch Refer severe cases
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What is a pinguecula?
a benign actinic change in the bulbar conjunctiva at the palpebral fissure due to sunlight exposure and drying; more common in people near the equator and those that spend time outdoors
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What is a pterygium?
When a pinguecula extends onto the cornea A pterygium is a thin sheet of fibrovascular material that grows most commonly on the nasal side of the cornea.
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What makes up the cornea?
Epithelium Bowman's layer Corneal stroma- made of collagen and comprises 95% of the corneal thickness Descemet's membrane- strongest layer of the cornea
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Corneal abrasion sx
foreign-body sensation, tearing, pain, and photophobia. If the abrasion persists, a deep, severe aching pain develops over time and is considerably worsened by exposure to light. Vision is usually blurred.
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Corneal abrasion tx
cycloplegic drop, such as 1% cyclopentolate, to relieve pain caused by ciliary body spasm; topical antibiotic drops (eg, fluoroquinolone, others) or ointment (erythromycin, bacitracin/polymyxin, or others). A pressure patch may be applied, although some physicians advocate no patching. One drop of topical anesthetic may be helpful, although topical anesthetics should never be prescribed for patient use because they are quite toxic to the corneal epithelium. Oral analgesic can be used for those in severe pain. If the abrasion is not healed in 24-48 hours refer to ophtho
162
Are acid or alkali burns to the eye typically more devastating?
alkali because the alkaline agent dissolves the corneal tissue and continues to cause damage long after the initial chemical contact
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bacterial keratitis s/sx
red, painful eye with purulent discharge, usually associated with decreased vision..Examination by penlight may reveal a discrete white or gray corneal opacity.
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red, tearing eye with foreign-body sensation, and small arborizing epithelial lesions in the shape of a twig or branch.
Corneal involvement by herpes simplex | virus
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What are the ocular side effects of topical steroids?
``` potentiate a latent herpes simplex infection of the cornea. Steroids can also facilitate penetration of the herpes infection to the deeper layers of the cornea, resulting in permanent corneal scarring or perforation. ``` Local use of steroids can elevate intraocular pressure in susceptible individuals over time can cause cataracts to progress faster than usual. misuse of steroids is capable of potentiating the development of fungal ulcers of the cornea.
166
Compare and contrast episcleritis and scleritis.
Episcleritis is an inflammation of the superficial episcleral vessels and usually causes relatively mild ocular discomfort. Although episcleritis can be associated with systemic autoimmune disorders, it is most commonly idiopathic. Scleritis is an inflammation of the sclera and deeper episcleral vessels and is often associated with more severe pain. An underlying autoimmune disorder can be found in up to 50% of patients with scleritis, most commonly rheumatoid arthritis.
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Episcleritis and scleritis tx
episcleritis often can be managed with topical steroids or nonsteroidal drops, ``` scleritis often requires additional systemic anti-inflammatory treatment with oral nonsteroidal anti- inflammatory drugs, oral steroids, or in some cases, other immunosuppressive ```
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Iritis s/sx
circumlimbal redness, pain, photophobia, decreased vision, miotic pupil
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List 9 s/sx of red eye disorders that may signify vision-threatening disorders
1. Decreased vision 2. Ocular pain 3. Photophobia 4. Circumlimbal redness 5. Corneal edema 6. Corneal ulcers, dendrites 7. Abnormal pupil 8. Proptosis 9. Elevated intraocular pressure
170
Define myopia, hyperopia and astigmatism.
myopia- near sightedness; image is focused in front of the retina hyperopia- far sightedness; image is focused behind the retina astigmatism- irregularly shaped cornea that results in blurred vision due to separate areas of image focus on the retina
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A healthy tear film is paramount to clear vision. The tear film is responsible for approximately __% of the refracting ability of the eye.
60
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What is keratoconus?
noninflammatory progressive ectasia of the cornea resulting in progressive thinning and steepening of the corneal surface. In advanced cases of keratoconus, the cornea becomes cone shaped
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What medicines are contraindicated in LASIK?
isotretinoin (Accutane), sumatriptan succinate (Imitrex), and amiodarone due to influences on the cornea
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Generally it is recommended that patients discontinue wearing soft lenses for ___ and hard lenses (RGPs) for ____ before refractive surgery, or until the refraction is stable.
2 weeks 3–6 weeks
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What testing (other than a complete ocular exam) is needed before refractive surgery?
Corneal topography determines the curvature and refractive power of the cornea. Pachymetry measures the corneal thickness. Wavefront analysis measures the properties of light entering and exiting the eye to map the patient’s individual refractive properties and aberrations. Ultrasound and interferometry are used in determining the needed refractive power of intraocular lenses.
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What are the procedures available for correcting refractive errors?
incisional corneal surgery (eg, radial or arcuate keratotomy—RK or AK); corneal inserts (eg, Intacs); photoablation (eg, LASIK, LASEK, and photorefractive keratectomy—PRK); conductive keratoplasty; ``` intraocular surgery (eg, intraocular lens implantation and natural lens replacement). ```
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Describe the LASIK procedure.
After administration of a topic ocular anesthetic, a suction ring stabilizes the globe while a microkeratome cuts a thin stromal flap. The flap is reflected back and the laser energy delivered, reshaping the cornea. The flap is reflected back into position and hydrostatic forces created by the pump mechanism seal the flap back down.
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What are the contraindications and cautions for LASIK?
LASIK is not recommended for patients with thin corneas, keratoconus, or other corneal diseases. The procedure is also not indicated for patients with excessive myopia, hyperopia, or astigmatism beyond the approved parameters of the laser. LASIK is not recommended for patients with significant systemic medical illnesses that may severely affect healing. Severe dry eye syndrome is an important contraindication to performing LASIK. In addition, patients in certain occupations may be restricted from undergoing LASIK.
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Describe the Photorefractive keratectomy (PRK) procedure.
Alcohol is placed on the eye to loosen the epithelium Central epithelium is debrided Laser ablation- changes the shape of the cornea Bandage contact lens is placed to aid in healing; epithelium regrows under contact
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What is the difference between conventional and wavefront-guided lasers?
Conventional lasers use a laser program that "imprints" standard refraction onto the cornea Wavefront-guided or custom laser imprints the pts custom refraction
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What is "mono vision"
When the dominant eye is set for distance and the other is set for intermediate or near vision during a refractive surgery
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What is conductive keratoplasty (CK)?
A fine conducting needle delivers radio frequency energy into the peripheral cornea in set patterns. This shrinks corneal collagen fibers, thereby reshaping the cornea.
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What is a phakic IOL?
an artificial lens that is surgically implanted in the eye while leaving the eye’s natural lens in place. This enables retention of natural focusing (accommodation) and helps to correct a refractive error. Phakic IOLs are used to treat nearsightedness and farsightedness.
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What is natural lens replacement?
an artificial lens is implanted in the eye, replacing the eye’s natural lens. The cornea is not reshaped. It is used to treat nearsightedness and farsightedness;
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What is the ocular manifestation of neurofibromatosis?
Melanocytic hamartomata of the iris (Lisch nodules) Ninety-five percent of individuals with NF1 will have Lisch nodules by the time they are 6 years old.
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What is the most common cause of emboli in the ophthalmic circulation in the elderly?
fibrin and cholesterol from ulcerated plaques in the wall of the carotid artery
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Central retinal artery occulsion (CRAO) tx
decreasing intraocular pressure and vasodilation in an attempt to allow the obstructing embolus to pass into less critical, smaller-caliber vessels.
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What is amaurosis fugax?
This is a transient ischemic attack involving the ocular circulation. The visual loss in amaurosis fugax typically consists of monocular dimming of vision or a sense of a “curtain coming down over the eye,” depending on what part of the retinal arterial tree is involved. Attacks usually lasts for 2–3 minutes, and then vision returns to normal as the embolus travels through the affected artery or the focal vasospasm resolves.
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What work up is needed for a pt with amaurosis fugax?
auscultation and imaging (Doppler and echocardiogram) of the carotid arteries and the heart as well as measurement of blood pressure in both arms.
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Central retinal vein occlusion (CRVO) fundoscopic appearance
retinal hemorrhages and cotton-wool spots
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What is acephalgic/occular migraine?
when all of the visual phenomena of a migraine occurs without a headache
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What ocular sx can be seen in pts with hyper viscosity syndromes?
amaurosis fugax and permanent visual loss
193
What are the fundoscopic findings in a pt with hyper viscosity syndrome?
dilated retinal veins, retinal hemorrhages and disc edema
194
Sickle cell anemia effect on the eye
Sickling can produce retinal arterial occlusions, especially in the retinal periphery. The retinal ischemia can lead to peripheral (“sea fan”) neovascularization vitreous hemorrhage, and tractional retinal detachment.
195
T/F: Ocular malignancies are most commonly | metastatic lesions.
T
196
The most common type of intraocular malignancy in adults is metastatic carcinoma, arising from ...
primaries in the breast or lung in | women and in the lung in men
197
What is the most common site for ocular metastasis?
the choroid
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prognosis for survival after detection of an intraocular metastasis is generally poor, with a mean length of survival of __-__ months.
6 to 9
199
What is the most common ocular manifestation of connective tissue disorders?
Dry eye
200
What is the ocular manifestation of ankylosing spondylitis?
Iritis- Photophobia, redness, and decreased vision Up to 25% of patients with ankylosing spondylitis have one or more attacks of iritis, which may precede the clinical arthritis.
201
What are the ocular manifestations of rheumatoid arthritis?
``` Dry eyes Episcleritis Scleritis Corneal ulcers Uveitis ```
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What is the characteristic triad of late ocular complications of juvenile rheumatoid arthritis?
iritis, cataract, and, band keratopathy (whitish deposits of calcium in the cornea)
203
What are the ocular manifestations of SLE?
Dry eyes Scleritis Peripheral corneal ulcers Retinopathy and optic neuropathy
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What are the ocular manifestations of polyarteritis nodosa?
``` Dry eyes Corneal ulcers Scleritis Hypertensive retinopathy Retinal vasculitis ```
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hypopyon | uveitis, arthritis and oral ulcers
classic triad of Behcet's disease
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What is the most common ocular presentation of sarcoidosis?
granulomatous uveitis characterized in part by large clumps of cellular deposits on the endothelial layer of the cornea, which are called keratic precipitates
207
Temporal arteritis ocular manifestations
Ischemic optic neuropathy, or infarction of the optic nerve head, is the most common presentation; it is associated with severe unilateral loss of vision, a relative afferent pupillary defect or Marcus Gunn pupil, and, a pale, swollen optic nerve head.
208
T/F: Thyroid ophthalmopathy can occur even in pts who are euthyroid
T
209
What can be included in thyroid ophtalmopathy?
``` Eyelid retraction Exophtalmos EOM dysfunction Corneal exposure Conjunctival erythema Optic nerve dysfunction ```
210
What eye muscle is most commonly affected by thyroid disease?
inferior rectus- causes restriction on attempted up gaze
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What are the 2 phases of thyroid ophthalmopathy? What is the tx for these phases?
congestive phase- lasts an average of 2 years; tx: tear subs, intermittent high dose steroids, if that fails--> orbital irradiation or surgical decompression cicatricial phase-changes in eyelids, EOM, or orbit; tx: surgical correction of muscle deviation, functional abnormalities or cosmetic issues
212
Within 5 years of an episode of optic neuritis, more than __% of women aged 20 to 40 will manifest signs and symptoms of multiple sclerosis.
40
213
What are the 3 most common ocular lesions seen in AIDS?
retinal cotton-wool spots, cytomegalovirus (CMV) retinitis, and Kaposi’s sarcoma of the eyelid or conjunctiva.
214
What medications can cause toxic retinopathy?
thioridazine, chloroquine, hydroxychloroquine, | and tamoxifen
215
What medications can cause toxic optic neuropathy?
amiodarone, ethambutol, isoniazid, and | fluoroquinolones
216
What is the initial tx for chemical burns to the eye?
Immediate irrigation | is the initial treatment.
217
What is the imaging study of choice for eye trauma?
CT
218
When should a ruptured globe be suspected?
If the patient reports history of severe blunt trauma, projectile injury, contact with a sharp object, or trauma resulting from hammering metal on metal. Bullous subconjunctival hemorrhage Uveal prolapse- A brown discoloration of the conjunctiva could represent uveal prolapse Irregular or pear-shaped pupil- mishaped pupil usually points to site of laceration or rupture Hyphema Vitreous hemorrhage Lens opacity Lowered IOP
219
What are the complications associated with hyphema?
rebleeding into the anterior chamber higher risk of glaucoma 25% of these pts with have other ocular injuries
220
What EOM limitation is typically seen with fracture of the orbital floor?
decrease in the | ability to elevate the eye
221
Ophthalmologic consultation should be sought in all cases of suspected blow-out fracture, because __% of these fractures are associated with occult ocular trauma.
25
222
What special consideration needs to be made for lacerations involving the medial 1/3 of the upper or lower lid?
The laceration could involve the tear drainage/cancalicular system. Repair must include reapproximation of the severed ends of the canaliculi to prevent persistent tearing.
223
What is Welder's keratitis?
corneal abrasions and epithelial | irregularities caused by ultraviolet light that appears hours after exposure
224
T/F: topical anesthetics should be prescribed to pts with symptomatic corneal abrasions
F - NEVER prescribe topical anesthetics for home use.
225
T/F: corneal abrasions due to soft contact lens should not be patched because the risk of corneal ulceration is significantly higher in these patients.
T