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SHELF Exams > Ophthalmology > Flashcards

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
Q

What is glaucoma?

A

optic neuropathy, a disease
of the optic nerve head, that results in
visual field changes.

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26
Q

What are the 2 types of glaucoma? Which is more common in older people?

A 
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.
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27
Q

What causes POAG?

A

the normal drainage network of
the eye has increased resistance, leading to
elevated intraocular pressures.

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28
Q

What visual field changes are commonly seen in glaucoma?

A

Visual
field changes in glaucoma are typically in
the nasal, paracentral, or midperipheral
portions of the field.

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29
Q

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.

A

least once a year

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30
Q

What are predisposing factors for ACG?

A

people over the
age 50,
certain types of Asian ancestry and female
gender with hyperopia.

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31
Q

What 2 conditions make a pt susceptible to ACG?

A

cataracts and farsightedness

A cataractous lens tends to push
the iris forward and block the drainage
network

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32
Q

ACG Sx

A

severe ocular pain, blurred
vision, halos around lights, headache,
nausea, and vomiting.

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33
Q

External ocular signs of ACG

A

injected
conjunctiva, hazy cornea, and pupil fixed
and mid-dilated.

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34
Q

ACG tx

A

Angle-closure glaucoma can be definitively treated with a laser iridotomy,
a hole in the iris

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35
Q

What exposures can cause damage to the lens and consequently cause a cataract?

A

chronic exposure to
sunlight, age, diabetes, steroid use,
smoking, trauma, and previous surgery

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36
Q

cataract sx

A

Disturbance of near or distance vision at first
Progresses to diminution of vision
Cataract severity and location determine impairment
Glare is bothersome

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37
Q

Cataract tx

A

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.

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38
Q

What is the prognosis following cataract surgery?

A

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.

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39
Q

What can be done if following a cataract surgery the remaining lens capsule becomes opacified?

A 
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.
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40
Q

What causes macular edema?

A

leakage from
microaneurysms and other damaged
vasculature.

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41
Q

When should diabetics get eye exams?

A 
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.
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42
Q

What is usually the cause for central artery occlusion?

A

embolus

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43
Q

Central retinal artery occlusion appearance

A

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.

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44
Q

What is the appearance of branch retinal artery occlusion?

A 
Only the affected area
appears edematous on ophthalmoscopy,
corresponding to the inner layers of the
retina normally perfused by the occluded
branch retinal artery.
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45
Q

Branch retinal artery occlusion sx

A

patients have a sudden loss of a portion of

the visual field.d

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46
Q

Branch retinal artery occlusion tx

A

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.

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47
Q

Central retinal vein occlusion (CRVO) cause

A

result of a thrombus occluding the vein at
the optic nerve draining the inner layers of
the retina.

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48
Q

What is posterior vitreous detachment (PVD)?

A

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

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49
Q

PVD sx

A

flashes of
light or floaters, usually as one large
floater.

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50
Q

In __%- ___% of patients, an
acute posterior vitreous detachment leads
to a retinal tear.

A

10% to 15

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51
Q

symptomatic retinal tear tx

A

laser
photocoagulation or cryosurgery to prevent
a retinal detachment.

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52
Q

Retinal detachment sx

A

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.

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53
Q

tx options for retinal detachments

A

(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.

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54
Q

What systemic diseases can cause isolated CN palsies?

A

hypertension, diabetes, and generalized

atherosclerosis

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55
Q

CN III palsy S/Sx

A 
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.
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56
Q

What are the most common causes of CN III palsy?

A

a compressive lesion, typically an
aneurysm of the posterior communicating
artery, and microvascular ischemia,
commonly seen in diabetic patients.

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57
Q

If the pupil is not involved in third nerve palsy, and there are no other neurological signs, the cause is most likely…

A

ischemic and resolution usually occurs after several months

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58
Q

If CN III palsy is associated with pupil involvement what workup should be done?

A

urgent imaging with
MRI/MRA is indicated to rule out an
aneurysm.

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59
Q

ischemic

optic neuropathy cause

A

Ischemia from the closure of ciliary vessels
that supply the optic nerve can lead to
visual loss

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60
Q

Ischemic optic neuropathy S/Sx

A

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

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61
Q

What is the difference between arteritic optic neuropathy and non-arteritic optic neuropathy?

A

arteritic (associated
with temporal arteritis) or non-arteritic.
When ischemic optic neuropathy is non-
arteritic, the optic nerve usually is small.

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62
Q

patients older than 50 diagnosed with

ischemic optic neuropathy should have …

A

sedimentation rate and C-reactive protein
level checked urgently to rule out temporal
arteritis.

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63
Q

Temporal arteritis sx

A

headaches, generalized
malaise, night sweats, weight loss, and jaw
claudication. There is also an association
with polymyalgia rheumatica.

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64
Q

Temporal arteritis Tx

A

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.

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65
Q

What is the definition of moderate low vision?

A

visual acuity of
approximately 20/70 to 20/160 in the
better-seeing eye.

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66
Q

What is the definition of severe low vision?

A 
visual
acuity of 20/200 (legal blindness) to
20/400 or worse (blindness according the
World Health Organization) in the betterseeing
eye.
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67
Q

What is the definition of amblyopia?

A

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.

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68
Q

What is the most common cause of monocular visual impairment in children and young adults?

A

amblyopia

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69
Q

What are predisposing factors to amblyopia?

A

ocular media opacities such as cataract;
significant refractive errors; and
strabismus, or misaligned eyes.

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70
Q

Preferably,
detection and treatment of amblyopia should occur by
the age of __-__ years.

A

3 to 5

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71
Q

What is the cause of amblyopia?

A

Amblyopia develops if the visual image
projected on the central retina is constantly
unclear or obstructed during the critical
period of early visual development.

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72
Q

What is the most common cause of amblyopia?

A

strabismus

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73
Q

What is a major difference in strabismus presentation in a child vs adult?

A

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.

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74
Q

What is leukocoria and what are some of the causes?

A

Leukocoria is an abnormal white retinal reflex; causes = retinoblastoma, retinal detachment, cataract

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75
Q

If a child has an enlarged cornea, there is concern of …

A

congenital glaucoma

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76
Q

What are signs of poor vision in an infant with BL amblyopia?

A

failure to fix and follow an object,
wandering eye movements, nystagmus, or
unusual habits such as eye-poking or hand-
waving.

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77
Q

T/F: Intermittent strabismus may
occur in normal children up to 4 to 6
months of age.

A

T

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78
Q

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.

A

T

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79
Q

What are hypertropia and hypotropia?

A

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

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80
Q

What are causes for immediate referral to ophthalmologist in children?

A

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

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81
Q

An acuity of ____ or

worse in a child should be of concern

A

20/40

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82
Q

Amblyopia tx

A 
Patching/Occlusion therapy- Patching
the unaffected or better-seeing eye
provides monocular stimulation to the
amblyopic eye, promoting more normal
visual development.
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83
Q

What complication must be monitored for with occlusion therapy?

A

occlusion amblyopia in the patched eye; visual acuity is monitored very closely

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84
Q

What is an alternative to occlusion therapy for amblyopia tx?

A

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

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85
Q

What is the leading cause of blindness in working-age Americans?

A

diabetic neuropathy

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86
Q

What is the effect of intensive glycemic control in type 1 diabetics with and without preexisting non proliferative diabetic retinopathy (NPDR)?

A

intensive glucose control reduces the
rate of development and progression of
diabetic retinopathy in type 1 patients with
and without baseline retinopathy.

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87
Q

T/F: during the
early stages of intensive glucose management, pre-
existing retinopathy may worsen.

A

T

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88
Q

Diabetic nephropathy and proteinuria have

been associated with more advanced ___ and ___

A

retinopathy and macular edema

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5
Perfectly
89
Q

___ may benefit the diabetic kidney and retina even in normotensive pts

A

lisinopril

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90
Q

___ may be associated with increased macular exudates and vision loss

A

high cholesterol

How well did you know this?
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91
Q

Proliferative diabetic retinopathy (PDR) is a risk indicator for ….

A

MI, stroke, amputation

92
Q

PDR elevates the risk of developing ___

A

nephropathy

93
Q

What changes in the retinal vasculature are found in diabetic retinopathy?

A

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
Q

What are the clinical stages of diabetic retinopathy?

A
  1. NPDR
  2. Preproliferative diabetic retinopathy (PPDR)/ severe NPDR
  3. PDR
95
Q

Appearance of mild to moderate NPDR

A

microaneurysms,
hard exudates, cottonwool
spots, and intraretinal hemorrhages (dot blot or flame hemorrhages)

Puts may be asymptomatic

96
Q

What is diabetic macular edema?

A

Vascular leakage, fluid, and/or exudate in

the macula

97
Q

What is the name for diabetic macular edema that

involves or threatens the fovea?

A

clinically significant macular edema

CSME

98
Q

PPDR appearance

A 
irregular dilations of
retinal veins, called venous beading, intraretinal
microvascular abnormalities or capillary
shunt vessels, and extensive retinal
hemorrhages.
99
Q

Once the signs of PPDR appear, ___% of pts with develop PDR in 1 yr

A

50

100
Q

PDR appearance

A 
new
retinal or optic disc blood vessels
(neovascularization) that may be
complicated by vitreous hemorrhage, 
traction retinal detachment, NPDR features
101
Q

Explain the neovascularzation terms NVD and NVE.

A 
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
Q

Vitreous hemorrhage sx

A

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
Q

What is rubeosis iridis?

A

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
Q

At which stage of diabetic retinopathy might laser photocoagulation therapy be of benefit?

A

PPDR- laser therapy at this stage may help prevent long-term visual loss

105
Q

CSME tx

A

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
Q

CME

A

cystoid macular edema

107
Q

Diabetic retinopathy tx options

A

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
Q

ophthalmology screening guidelines in diabetics

A

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
Q

Ophthalmic follow-up in a diabetic pregnant pt

A

Ideally, eye exam before conception

Eye exam in the 1st trimester and then f/u schedule determined by the baseline retinopathy

110
Q

What groups are at risk for glaucoma?

A

elderly
African American
Individuals with IOP, 1st degree relatives with glaucoma, and possibly those with high myopia or diabetes

111
Q

What is the progression of the pathology of glaucoma?

A

ganglion cell death–> retinal nerve fiber layer change–> optic nerve head changes–> visual field changes

112
Q

What are the optic nerve head changes seen in glaucoma?

A 
increased size of the cup
Thinning of the disc rim
Progressive loss of neural rim tissue
Disc hemorrhages
Loss of nerve fibers
113
Q

Visual field losses in glaucoma

A

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
Q

Up to __% of all patients
with glaucoma may have pressures below
22 mm Hg at any given screening

A

50

115
Q

tearing, photophobia, an enlarged eye,

and a hazy cornea in an infant

A

congenital glaucoma

116
Q

What are some causes of secondary glaucoma?

A 
trauma 
uveitis 
chronic steroid use
diabetic retinopathy
Ocular vascular occlusion
117
Q

Blindness
from glaucoma is ___-____ times more
common in African-Americans than in
Caucasians.

A

three to four

118
Q

What is the definition of a glaucoma suspect?

A

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
Q

f/u for glaucoma suspect

A

all
glaucoma suspects should be reevaluated
with an eye examination every 3 to 18
months

120
Q

Glaucomatous optic nerve damage

involves the loss of axons. What nerve fibers are most susceptible?

A

The
nerve fibers most susceptible in glaucoma are those entering the optic nerve in the
superior and inferior poles.

121
Q

What change in the cup-to-disc ratio is seen in glaucoma?

A

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
Q

What is one of the earliest signs of glaucoma?

A

defects in the nerve fiber layer- Damage may be diffuse or focal,
resulting in a groove or wedge defect

123
Q

What is the natural difference b/w the cup-to-disc ratio in African-Americans versus Caucasians?

A

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
Q

Cup-to-disc ratios greater than __ indicate
a high level of glaucoma suspicion, while
those of __-__ indicate a moderate
level.

A
  1. 9

0. 6 to 0.8

125
Q

Glaucomatous changes of the optic nerve

A

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
Q

Glaucoma tx

A

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
Q

Prostaglandin F2alpha analogs should be used with caution in pts with ….

A

a history of uveitis or a history of or risk

factors for cystoid macular edema

128
Q

Surgical tx options for glaucoma

A

laser
trabeculoplasty, filtering surgery
(trabeculectomy), drainage implant
surgery, and cyclophotocoagulation

129
Q

What groups are at high risk of angle closure glaucoma?

A 
Elderly
Hyperopic pts 
\+ FH
Females
Eskimos
Asians
130
Q

acute glaucoma tx

A 
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
Q

In a pt with monocular ACG, what should be done in the unaffected eye?

A

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
Q

3 categories of causes of red eye

A

Mechanical trauma
Chemical trauma
Inflammation/infection

133
Q

List the 8 most common causes of red eye in order of urgency

A 
(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
Q

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
A

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
Q

Red eye + decreased vision–>

A

referral to ophthalmologist

136
Q

What is a hordeolum?

A

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
Q

What is a chalazion?

A

When a meibomian gland is obstructed, these glands
may produce a tender, red swelling in the
adjacent lid tissue

138
Q

hordeolum or chiazzino tx

A 
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
Q

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)

A

blepharitis

140
Q

blepharitis tx

A

lid and face hygiene (warm compresses lid scrubs), artificial tears for dry eye, abx or abx-steroid ointment, oral doxycycline for refractory cases

141
Q

What are the differences b/w preseptal and orbital cellulitis?

A

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
Q

What are the most common causes of orbital cellulitis?

A

Staphylococcus aureus,
Streptococcus species, and Haemophilus
influenzae

143
Q

What are the possible complications of orbital cellulitis?

A

cavernous sinus thromboses and meningitis

144
Q

What is dacrocystitis?

A

swollen, inflamed lacrimal sac; if secondary to lacrimal duct obstruction tx with abx. Surgery after one episode

145
Q

What are the most common causes of nasolacrimal obstruction in adults?

A

trauma

and recurrent infection of the lacrimal sac, causing stenosis and scarring

146
Q

What does the discharge in conjunctivitis tell you about the likely cause?

A

purulent–> bacterial

Clear–> viral

watery, with stringy white mucus–> allergic

147
Q

Most common causes of bacterial conjunctivitis

A 
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.
148
Q

bacterial conjunctivitis tx

A 
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
149
Q

What is an important physical exam finding differentiating viral from bacterial conjunctivitis?

A

palpable preauricular lymph node

150
Q

What is the most common cause of viral conjunctivitis?

A

adenovirus

151
Q

What characteristics of a viral conjunctivitis warrant a referral to an ophthalmologist?

A 
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.
152
Q

What are the causes of neonatal conjunctivitis (within the first 4 weeks of life) and the usual time seen after birth?

A

N. gonorrhoeae: 2-4 days

Staph or Strep: 3-5 days

Chlamydia: 5-12 days

Viruses, e.g. herpes from mother

153
Q

Infant Gonococcal conjunctivitis presentation

A

swollen lids, heavy purulent
exudate, “beefy-red” conjunctiva, and
conjunctival edema.

154
Q

Dry eye tx

A

Artificial tears, cyclosporine drops/Restasis (improves tear production)
Lubricating ointment at bedtime
Punctal occlusion

155
Q

What is exposure keratitis and what are the causes?

A 
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

156
Q

exposure keratitis management

A

lubricating solutions/ointments

Tape lids shut at night

Do NOT patch

Refer severe cases

157
Q

What is a pinguecula?

A

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

158
Q

What is a pterygium?

A

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.

159
Q

What makes up the cornea?

A

Epithelium

Bowman’s layer

Corneal stroma- made of collagen and
comprises 95% of the corneal thickness

Descemet’s membrane- strongest layer of the cornea

160
Q

Corneal abrasion sx

A

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.

161
Q

Corneal abrasion tx

A

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
Q

Are acid or alkali burns to the eye typically more devastating?

A

alkali because the alkaline
agent dissolves the corneal tissue and
continues to cause damage long after the
initial chemical contact

163
Q

bacterial keratitis s/sx

A

red, painful eye with purulent
discharge, usually associated with
decreased vision..Examination by penlight
may reveal a discrete white or gray corneal
opacity.

164
Q

red, tearing eye with
foreign-body sensation, and small arborizing epithelial lesions in
the shape of a twig or branch.

A

Corneal involvement by herpes simplex

virus

165
Q

What are the ocular side effects of topical steroids?

A 
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
Q

Compare and contrast episcleritis and scleritis.

A

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.

167
Q

Episcleritis and scleritis tx

A

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
168
Q

Iritis s/sx

A

circumlimbal redness, pain, photophobia, decreased vision, miotic pupil

169
Q

List 9 s/sx of red eye disorders that may signify vision-threatening disorders

A
  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
Q

Define myopia, hyperopia and astigmatism.

A

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

171
Q

A healthy tear film is paramount to clear
vision. The tear film is responsible for
approximately __% of the refracting ability
of the eye.

A

60

172
Q

What is keratoconus?

A

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

173
Q

What medicines are contraindicated in LASIK?

A

isotretinoin (Accutane),
sumatriptan succinate (Imitrex), and
amiodarone due to influences on the cornea

174
Q

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.

A

2 weeks

3–6 weeks

175
Q

What testing (other than a complete ocular exam) is needed before refractive surgery?

A

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.

176
Q

What are the procedures available for correcting refractive errors?

A

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).
177
Q

Describe the LASIK procedure.

A

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.

178
Q

What are the contraindications and cautions for LASIK?

A

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.

179
Q

Describe the Photorefractive keratectomy (PRK) procedure.

A

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

180
Q

What is the difference between conventional and wavefront-guided lasers?

A

Conventional lasers use a laser program that “imprints” standard refraction onto the cornea

Wavefront-guided or custom laser imprints the pts custom refraction

181
Q

What is “mono vision”

A

When the dominant eye is set for distance and the other is set for intermediate or near vision during a refractive surgery

182
Q

What is conductive keratoplasty (CK)?

A

A fine conducting needle delivers radio frequency energy into the peripheral cornea in set patterns. This shrinks corneal collagen fibers,
thereby reshaping the cornea.

183
Q

What is a phakic IOL?

A

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.

184
Q

What is natural lens replacement?

A

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;

185
Q

What is the ocular manifestation of neurofibromatosis?

A

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.

186
Q

What is the most common cause of emboli in the ophthalmic circulation in the elderly?

A

fibrin and
cholesterol from ulcerated plaques in the wall of
the carotid artery

187
Q

Central retinal artery occulsion (CRAO) tx

A

decreasing intraocular pressure and
vasodilation in an attempt to allow the
obstructing embolus to pass into less critical,
smaller-caliber vessels.

188
Q

What is amaurosis fugax?

A

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.

189
Q

What work up is needed for a pt with amaurosis fugax?

A

auscultation and imaging
(Doppler and echocardiogram) of the carotid
arteries and the heart as well as measurement of
blood pressure in both arms.

190
Q

Central retinal vein occlusion (CRVO) fundoscopic appearance

A

retinal hemorrhages and cotton-wool spots

191
Q

What is acephalgic/occular migraine?

A

when all of the visual phenomena of a migraine occurs without a headache

192
Q

What ocular sx can be seen in pts with hyper viscosity syndromes?

A

amaurosis fugax and permanent visual loss

193
Q

What are the fundoscopic findings in a pt with hyper viscosity syndrome?

A

dilated retinal veins, retinal hemorrhages and disc edema

194
Q

Sickle cell anemia effect on the eye

A

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
Q

T/F: Ocular malignancies are most commonly

metastatic lesions.

A

T

196
Q

The most common type of intraocular
malignancy in adults is metastatic carcinoma,
arising from …

A

primaries in the breast or lung in

women and in the lung in men

197
Q

What is the most common site for ocular metastasis?

A

the choroid

198
Q

prognosis for survival after detection
of an intraocular metastasis is generally poor,
with a mean length of survival of __-__ months.

A

6 to 9

199
Q

What is the most common ocular manifestation of connective tissue disorders?

A

Dry eye

200
Q

What is the ocular manifestation of ankylosing spondylitis?

A

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
Q

What are the ocular manifestations of rheumatoid arthritis?

A 
Dry eyes
Episcleritis
Scleritis
Corneal ulcers
Uveitis
202
Q

What is the characteristic triad of late ocular complications of juvenile rheumatoid arthritis?

A

iritis, cataract, and, band keratopathy (whitish deposits of calcium in the cornea)

203
Q

What are the ocular manifestations of SLE?

A

Dry eyes
Scleritis
Peripheral corneal ulcers
Retinopathy and optic neuropathy

204
Q

What are the ocular manifestations of polyarteritis nodosa?

A 
Dry eyes
Corneal ulcers
Scleritis
Hypertensive retinopathy
Retinal vasculitis
205
Q

hypopyon

uveitis, arthritis and oral ulcers

A

classic triad of Behcet’s disease

206
Q

What is the most common ocular presentation of sarcoidosis?

A

granulomatous uveitis characterized in part by
large clumps of cellular deposits on the
endothelial layer of the cornea, which are called
keratic precipitates

207
Q

Temporal arteritis ocular manifestations

A

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
Q

T/F: Thyroid ophthalmopathy can occur even in pts who are euthyroid

A

T

209
Q

What can be included in thyroid ophtalmopathy?

A 
Eyelid retraction
Exophtalmos
EOM dysfunction
Corneal exposure
Conjunctival erythema 
Optic nerve dysfunction
210
Q

What eye muscle is most commonly affected by thyroid disease?

A

inferior rectus- causes restriction on attempted up gaze

211
Q

What are the 2 phases of thyroid ophthalmopathy? What is the tx for these phases?

A

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
Q

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.

A

40

213
Q

What are the 3 most common ocular lesions seen in AIDS?

A

retinal
cotton-wool spots, cytomegalovirus (CMV)
retinitis, and Kaposi’s sarcoma of the eyelid or
conjunctiva.

214
Q

What medications can cause toxic retinopathy?

A

thioridazine, chloroquine, hydroxychloroquine,

and tamoxifen

215
Q

What medications can cause toxic optic neuropathy?

A

amiodarone, ethambutol, isoniazid, and

fluoroquinolones

216
Q

What is the initial tx for chemical burns to the eye?

A

Immediate irrigation

is the initial treatment.

217
Q

What is the imaging study of choice for eye trauma?

A

CT

218
Q

When should a ruptured globe be suspected?

A

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
Q

What are the complications associated with hyphema?

A

rebleeding into the anterior chamber

higher risk of glaucoma

25% of these pts with have other ocular injuries

220
Q

What EOM limitation is typically seen with fracture of the orbital floor?

A

decrease in the

ability to elevate the eye

221
Q

Ophthalmologic consultation
should be sought in all cases of suspected
blow-out fracture, because __% of these
fractures are associated with occult ocular
trauma.

A

25

222
Q

What special consideration needs to be made for lacerations involving the medial 1/3 of the upper or lower lid?

A

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
Q

What is Welder’s keratitis?

A

corneal abrasions and epithelial

irregularities caused by ultraviolet light that appears hours after exposure

224
Q

T/F: topical anesthetics should be prescribed to pts with symptomatic corneal abrasions

A

F -
NEVER
prescribe topical anesthetics for home use.

225
Q

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.

A

T

SHELF Exams (4 decks)

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