Ophthalmology Flashcards
What changes to the lens can be seen with aging?
Yellows: May affect color discrimination
Opacifies: Cataract
Hardens: Nuclear sclerosis
What is presbyopia?
The ciliary body/lens loses accommodative ability with age meaning there is a loss of near vision
What eye diseases are the following conditions associated with?
HTN
Arthritis
Diabetes
HTN- retinal vein occlusion
Arthritis- dry eye
Diabetes- glaucoma, cataracts, diabetic neuropathy
What are the 4 leading causes of vision loss in the aging eye?
- Age-related macular degeneration (AMD)
- Glaucoma
- Cataract
- Diabetic retinopathy
__% of Americans over 65 have some cataract formation
50
For individuals 65 years of age or older, asymptomatic, and without disease, the American Academy of Ophthalmology recommends a comprehensive eye examination every ...
1 to 2 years.
chronic inflammation of
the eyelid; burning, itching,
tearing, and crusting of the eyelid
blepharitis
What is Entropion?
inward turning of the
eyelids and lashes,
What is ectropion?
outward turning of the
eyelids and lashes
What is dermatochalasis?
with time and age the layers of the skin over the eyelid can their elasticity and droop
What is the most common eyelid malignancy?
basal cell carcinoma- 90% of
eyelid tumors, affect the lower lids more
commonly than the upper.
What is the most common condition affecting the
cornea in the aging eye?
poor tear
production
Dry eye tx
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])
Herpes Zoster Ophthalmicus tx
oral acyclovir
or its derivatives often can reduce
symptoms and shorten the course of the
disease.
What is the most common cause of visual loss in
the elderly?
age-related macular
degeneration, or AMD.
Risk factors for AMD
Advanced age
FH of AMD
Smoking
CV disease
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
50
What defines the advanced stage of AMD?
when the changes of AMD are
associated with loss of vision.
What is the difference between atrophic advanced stage (sometimes called “dry” AMD), and a neoneovascular stage of advanced AMD(sometimes called “wet” AMD)?
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
What are the symptoms seen in intermediate vs advanced stage AMD?
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
dx of advanced stage AMD
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).
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 …
vitamin C (500 mg), vitamin E (400 IU), beta carotene (15 mg), and zinc oxide (80 mg).
tx for neovascular advanced stage AMD
laser
photocoagulation, photodynamic therapy
with verteporfin, and intraocular injection
therapy with anti-VEGF; all 3 can stabilize visual loss, and VEGF can
Risk factors for glaucoma
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.
What is glaucoma?
optic neuropathy, a disease
of the optic nerve head, that results in
visual field changes.
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.
What causes POAG?
the normal drainage network of
the eye has increased resistance, leading to
elevated intraocular pressures.
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.
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
What are predisposing factors for ACG?
people over the
age 50,
certain types of Asian ancestry and female
gender with hyperopia.
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
ACG Sx
severe ocular pain, blurred
vision, halos around lights, headache,
nausea, and vomiting.
External ocular signs of ACG
injected
conjunctiva, hazy cornea, and pupil fixed
and mid-dilated.
ACG tx
Angle-closure glaucoma can be definitively treated with a laser iridotomy,
a hole in the iris
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
cataract sx
Disturbance of near or distance vision at first
Progresses to diminution of vision
Cataract severity and location determine impairment
Glare is bothersome
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.
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.
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.
What causes macular edema?
leakage from
microaneurysms and other damaged
vasculature.
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.
What is usually the cause for central artery occlusion?
embolus
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.
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.
Branch retinal artery occlusion sx
patients have a sudden loss of a portion of
the visual field.d
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.
Central retinal vein occlusion (CRVO) cause
result of a thrombus occluding the vein at
the optic nerve draining the inner layers of
the retina.
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
PVD sx
flashes of
light or floaters, usually as one large
floater.
In __%- ___% of patients, an
acute posterior vitreous detachment leads
to a retinal tear.
10% to 15
symptomatic retinal tear tx
laser
photocoagulation or cryosurgery to prevent
a retinal detachment.
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.
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.
What systemic diseases can cause isolated CN palsies?
hypertension, diabetes, and generalized
atherosclerosis
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.
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.
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
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.
ischemic
optic neuropathy cause
Ischemia from the closure of ciliary vessels
that supply the optic nerve can lead to
visual loss
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
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.
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.
Temporal arteritis sx
headaches, generalized
malaise, night sweats, weight loss, and jaw
claudication. There is also an association
with polymyalgia rheumatica.
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.
What is the definition of moderate low vision?
visual acuity of
approximately 20/70 to 20/160 in the
better-seeing eye.
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.
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.
What is the most common cause of monocular visual impairment in children and young adults?
amblyopia
What are predisposing factors to amblyopia?
ocular media opacities such as cataract;
significant refractive errors; and
strabismus, or misaligned eyes.
Preferably,
detection and treatment of amblyopia should occur by
the age of __-__ years.
3 to 5
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.
What is the most common cause of amblyopia?
strabismus
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.
What is leukocoria and what are some of the causes?
Leukocoria is an abnormal white retinal reflex; causes = retinoblastoma, retinal detachment, cataract
If a child has an enlarged cornea, there is concern of …
congenital glaucoma
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.
T/F: Intermittent strabismus may
occur in normal children up to 4 to 6
months of age.
T
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
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
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
An acuity of ____ or
worse in a child should be of concern
20/40
Amblyopia tx
Patching/Occlusion therapy- Patching the unaffected or better-seeing eye provides monocular stimulation to the amblyopic eye, promoting more normal visual development.
What complication must be monitored for with occlusion therapy?
occlusion amblyopia in the patched eye; visual acuity is monitored very closely
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
What is the leading cause of blindness in working-age Americans?
diabetic neuropathy
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.
T/F: during the
early stages of intensive glucose management, pre-
existing retinopathy may worsen.
T
Diabetic nephropathy and proteinuria have
been associated with more advanced ___ and ___
retinopathy and macular edema
___ may benefit the diabetic kidney and retina even in normotensive pts
lisinopril
___ may be associated with increased macular exudates and vision loss
high cholesterol
Proliferative diabetic retinopathy (PDR) is a risk indicator for ….
MI, stroke, amputation
PDR elevates the risk of developing ___
nephropathy
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.
What are the clinical stages of diabetic retinopathy?
- NPDR
- Preproliferative diabetic retinopathy (PPDR)/ severe NPDR
- PDR
Appearance of mild to moderate NPDR
microaneurysms,
hard exudates, cottonwool
spots, and intraretinal hemorrhages (dot blot or flame hemorrhages)
Puts may be asymptomatic
What is diabetic macular edema?
Vascular leakage, fluid, and/or exudate in
the macula
What is the name for diabetic macular edema that
involves or threatens the fovea?
clinically significant macular edema
CSME
PPDR appearance
irregular dilations of retinal veins, called venous beading, intraretinal microvascular abnormalities or capillary shunt vessels, and extensive retinal hemorrhages.
Once the signs of PPDR appear, ___% of pts with develop PDR in 1 yr
50
PDR appearance
new retinal or optic disc blood vessels (neovascularization) that may be complicated by vitreous hemorrhage, traction retinal detachment, NPDR features
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)
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.
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.
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
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.
CME
cystoid macular edema
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.
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
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
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
What is the progression of the pathology of glaucoma?
ganglion cell death–> retinal nerve fiber layer change–> optic nerve head changes–> visual field changes
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
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)
Up to __% of all patients
with glaucoma may have pressures below
22 mm Hg at any given screening
50
tearing, photophobia, an enlarged eye,
and a hazy cornea in an infant
congenital glaucoma
What are some causes of secondary glaucoma?
trauma uveitis chronic steroid use diabetic retinopathy Ocular vascular occlusion
Blindness
from glaucoma is ___-____ times more
common in African-Americans than in
Caucasians.
three to four
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.
f/u for glaucoma suspect
all
glaucoma suspects should be reevaluated
with an eye examination every 3 to 18
months
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.
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.
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
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.
Cup-to-disc ratios greater than __ indicate
a high level of glaucoma suspicion, while
those of __-__ indicate a moderate
level.
- 9
0. 6 to 0.8
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.
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
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
Surgical tx options for glaucoma
laser
trabeculoplasty, filtering surgery
(trabeculectomy), drainage implant
surgery, and cyclophotocoagulation
What groups are at high risk of angle closure glaucoma?
Elderly Hyperopic pts \+ FH Females Eskimos Asians
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.
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.
3 categories of causes of red eye
Mechanical trauma
Chemical trauma
Inflammation/infection
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
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)
Red eye + decreased vision–>
referral to ophthalmologist
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.
What is a chalazion?
When a meibomian gland is obstructed, these glands
may produce a tender, red swelling in the
adjacent lid tissue
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
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
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
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
What are the most common causes of orbital cellulitis?
Staphylococcus aureus,
Streptococcus species, and Haemophilus
influenzae
What are the possible complications of orbital cellulitis?
cavernous sinus thromboses and meningitis
What is dacrocystitis?
swollen, inflamed lacrimal sac; if secondary to lacrimal duct obstruction tx with abx. Surgery after one episode
What are the most common causes of nasolacrimal obstruction in adults?
trauma
and recurrent infection of the lacrimal sac, causing stenosis and scarring
What does the discharge in conjunctivitis tell you about the likely cause?
purulent–> bacterial
Clear–> viral
watery, with stringy white mucus–> allergic
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.
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
What is an important physical exam finding differentiating viral from bacterial conjunctivitis?
palpable preauricular lymph node
What is the most common cause of viral conjunctivitis?
adenovirus
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.
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
Infant Gonococcal conjunctivitis presentation
swollen lids, heavy purulent
exudate, “beefy-red” conjunctiva, and
conjunctival edema.
Dry eye tx
Artificial tears, cyclosporine drops/Restasis (improves tear production)
Lubricating ointment at bedtime
Punctal occlusion
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
exposure keratitis management
lubricating solutions/ointments
Tape lids shut at night
Do NOT patch
Refer severe cases
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
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.
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
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.
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
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
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.
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
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.
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.
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
Iritis s/sx
circumlimbal redness, pain, photophobia, decreased vision, miotic pupil
List 9 s/sx of red eye disorders that may signify vision-threatening disorders
- Decreased vision
- Ocular pain
- Photophobia
- Circumlimbal redness
- Corneal edema
- Corneal ulcers, dendrites
- Abnormal pupil
- Proptosis
- Elevated intraocular pressure
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
A healthy tear film is paramount to clear
vision. The tear film is responsible for
approximately __% of the refracting ability
of the eye.
60
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
What medicines are contraindicated in LASIK?
isotretinoin (Accutane),
sumatriptan succinate (Imitrex), and
amiodarone due to influences on the cornea
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
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.
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).
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.
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.
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
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
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
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.
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.
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;
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.
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
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.
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.
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.
Central retinal vein occlusion (CRVO) fundoscopic appearance
retinal hemorrhages and cotton-wool spots
What is acephalgic/occular migraine?
when all of the visual phenomena of a migraine occurs without a headache
What ocular sx can be seen in pts with hyper viscosity syndromes?
amaurosis fugax and permanent visual loss
What are the fundoscopic findings in a pt with hyper viscosity syndrome?
dilated retinal veins, retinal hemorrhages and disc edema
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.
T/F: Ocular malignancies are most commonly
metastatic lesions.
T
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
What is the most common site for ocular metastasis?
the choroid
prognosis for survival after detection
of an intraocular metastasis is generally poor,
with a mean length of survival of __-__ months.
6 to 9
What is the most common ocular manifestation of connective tissue disorders?
Dry eye
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.
What are the ocular manifestations of rheumatoid arthritis?
Dry eyes Episcleritis Scleritis Corneal ulcers Uveitis
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)
What are the ocular manifestations of SLE?
Dry eyes
Scleritis
Peripheral corneal ulcers
Retinopathy and optic neuropathy
What are the ocular manifestations of polyarteritis nodosa?
Dry eyes Corneal ulcers Scleritis Hypertensive retinopathy Retinal vasculitis
hypopyon
uveitis, arthritis and oral ulcers
classic triad of Behcet’s disease
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
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.
T/F: Thyroid ophthalmopathy can occur even in pts who are euthyroid
T
What can be included in thyroid ophtalmopathy?
Eyelid retraction Exophtalmos EOM dysfunction Corneal exposure Conjunctival erythema Optic nerve dysfunction
What eye muscle is most commonly affected by thyroid disease?
inferior rectus- causes restriction on attempted up gaze
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
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
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.
What medications can cause toxic retinopathy?
thioridazine, chloroquine, hydroxychloroquine,
and tamoxifen
What medications can cause toxic optic neuropathy?
amiodarone, ethambutol, isoniazid, and
fluoroquinolones
What is the initial tx for chemical burns to the eye?
Immediate irrigation
is the initial treatment.
What is the imaging study of choice for eye trauma?
CT
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
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
What EOM limitation is typically seen with fracture of the orbital floor?
decrease in the
ability to elevate the eye
Ophthalmologic consultation
should be sought in all cases of suspected
blow-out fracture, because __% of these
fractures are associated with occult ocular
trauma.
25
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.
What is Welder’s keratitis?
corneal abrasions and epithelial
irregularities caused by ultraviolet light that appears hours after exposure
T/F: topical anesthetics should be prescribed to pts with symptomatic corneal abrasions
F -
NEVER
prescribe topical anesthetics for home use.
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
