Ophthalmology Flashcards
What is a hordeolum?
localized infection or inflammation of the eyelid margin involving hair follicles of the eyelashes
What is an internal hordeolum compared to an external hordeolum?
An internal hordeolum is a meibomiam gland abscess that points towards the conjunctiival surface/presents on the inside of the eyelid. An external hordeolum or sty is a smaller abscess on the margin of the eyelid.
What is the pathophysiology/ most common cause of hordeola?
Hordeolum’s are common staphylococcal abscesses. Most commonly Staph aureus.
Which age group does hordeola most commonly affect?
Children and teens
What are common symptoms of Hordeola?
eyelid redness tearing swelling pain photophobia foreign body sensation vision acuity is normal
If left untreated, or does not respond to treatment, what general illness can hordeola lead to?
general cellulitis of the lid
In what situation are hordeola diagnosed, and what might it be hard to distinguish from?
Hordeola are diagnosed in the clinic, but can be difficult to distinguish from chalazion.
How is a hordeolum treated?
warm compresses are helpful (5-10 minutes, 3-4 times a day)
incision, if a resolution does not begin within 48 hours
applying antibiotic ointment may be beneficial every 3 hours in the acute stage
What is a chalazion?
a noninfectious obstruction of the meibomiam gland; a common granulomatous inflammation of a Meibomian gland that may follow an internal hordeolum
What are granulomas?
a collection of immune cells that form when the immune system attemps to wall off substances it perceives to be foreign, but cannot eliminate
What is the cause of Chalazia?
The meibomian gland becomes blocked by accumulation of secretion, often in a patient with blepharitis; blocked meibomian gland’s duct releases gland contents into soft tissue of the eyelid, causing a build-up under the eyelid
What other lid disorders can contribute to Chalazia?
hordeola and blepharitis
Chalazia are common among patients with what other type of conditions?
Chalazia are commonly found in patients with other skin conditions
What are common symptoms of Chalazion?
eyelid redness
nontender swelling on the lid
swelling of the adjacent conjunctiva
may distort vision, if the swelling is large enough to impress the cornea
How would you treat Chalazion?
warm compresses are helpful (5-10 minutes, 3-4 times a day)
incision and curettage, if chalazion persists past several weeks
corticosteroid injection may also be effective (reduces inflammation)
How do you distinguish between chalazion and hordeolum?
After a few days, chalazion will be nontender, and localization will occur away from the lid margin. Whereas, hordeolum will remain painful and present on the lid margin near the eyelashes. Hordeolum are also infectious, whereas chalazion are not.
What is Blepharitis?
inflammation of the eyelid margins that may be acute or chronic
List 5 ways that Blepharitis can be characterized.
- Acute Ulcerative
- Acute Non-Ulcerative
- Chronic
- Anterior
- Posterior
What is the cause of Acute Ulcerative Blepharitis?
caused by a bacterial infection; usually staphylococcal
may also be caused by a virus (herpes simplex, varicella zoster)
What is the cause of Acute Nonulcerative Blepharitis?
caused by an allergic reaction
What area of the eye does Acute Blepharitis affect?
the eyelid margin at origins of the eyelashes
What is the difference between eye discharge caused by a bacterial infection and discharge caused by a viral infection?
Bacterial infections cause crusty looking, pussy discharge. Viral infections cause watery, wet discharge.
What is the cause of Chronic Blepharitis?
we don’t know; chronic blepharitis is ideopathic noninfectious
inflammation
What does seborrheic mean?
common red, itchy skin rash
What other conditions do patients with Chronic Blepharitis commonly have?
acne rosacea
recurrent hordeola or chalazia
seborrheic dermatitis of face and scalp
increased tear evaporation and secondary keratoconjunctivities (especially those with meibomian gland dysfunction or seborrheic blepharitis)
What are common symptoms of Acute Ulcerative Blepharitis?
small pustules may develop on the eyelash follicles
may form shallow marginal ulcers
eyelids can become glued together by dried secretions
red eyelid margins
What are common symptoms of Acute Non-ulcerative Blepharitis?
eyelid margins have excess fluid eyelid redness eyelashes can become crusted itching rubbing and rash contact sensitivity
What are common symptoms of Chronic Blepharitis?
itching and burning of the eyelid margins
conjunctival irritation
tearing
photosensitivity
foreign body sensation
greasy and scales in seborrheic blepharitis
What exam technique is used to diagnose blepharitis?
Slit-Lamp Exam
What are common supportive treatment measures for blepharitis?
treatment of keratoconjunctivitis sicca (dry eyes)
warm compresses
cleansing of the eyelids with eyelid cleanser or baby shampoo
What is a form of treatment used for Acute Nonulcerative Blepharitis?
if persistent, topical corticosteroids for inflammation
What is a form of treatment for bacterial-caused Acute Ulcerative Blepharitis?
antimicrobials
Is Blepharitis commonly bilateral or unilateral?
bilateral
What area of the lid does Anterior Blepharitis affect?
involves eyelid skin, eyelashes, and associated glands
What area does Posterior Blepharitis affect
meibomiam glands
What conditions are associated with Anterior Blepharities?
staphylocci infection
seborrheic dermatitis
seborrhea of scalp, brows, and ears
What condition is Posterior Blepharitis strongly associated with?
acne rosacea
What are common symptoms of Anterior Blepharitis?
irritation burning itching red-rimmed scales or granulations clinging to the lashes
How is Anterior Blepharitis treated?
cleanliness of the lid margins
daily removal of scales or ganulations on eyelashes
antibiotic ointments may be applied to lid margins
What are symptoms of Posterior Blepharitis?
irritation burning itching lid margins are hyperemic (red, excess of blood) with telangiectasias (spider veins) meibomiam glands are inflamed
What are telangiectasisas?
spider veins
How is Posterior Blepharitis commonly treated?
gland expression may be sufficient
If Posterior Blepharitis causes inflammation of the conjunctiva, what are more active treatments that can be used?
long-term low-dose oral antibiotic therapy (kills staphylococci)
short-term topical corticosteroids (reduce inflammation)
What is Entropian?
the inward turning of the lower lid
What causes Entropian?
age-related tissue relaxation (due to weakness of the muscle surrounding the eye or as a result of degeneration of the fascia)
may follow scarring of the conjunctiva
post infectious or post traumatic changes
blepharospasm
What are symptoms of Entropian?
occurs gradually over time foreign body sensation tearing red eye may cause redness, light sensitivity, dryness, or scratching of the cornea by the lashes and subsequent irritation
In what population does entropian primarily occur?
elderly
How is entropian diagnosed?
in clinical examination
How is Entropian treated?
surgery if the lashes rub on the cornea
botulinum toxin (temporary)
epilation of the eyelashes
cool compresses to reduce swelling
What is Ectropian?
the outward turning of the lower lid
What can cause Ectropian?
age-related tissue relaxation
cranial nerve VII palsy
post-traumatic or post-surgical changes
What are symptoms of Ectropian?
excessive tearing dry eyes exposure keratitis redness light sensitivity foreign body sensation
In what setting is Ectropian diagnosed?
in clinical examination
How is Ectropian treated?
symptomatic relief includes tear supplements and lubricants
surgery if there is excessive tearing, exposure keratitis, or a cosmetic problem
What is Dacryocystitis?
an infection of the lacrimal sac usually due to congenital or acquired obstruction of the nasolacrimal system
What are the two types of Dacryocystitis, and what causes them?
Dacryocystitis can be acute or chronic. Acute Dacryocystitis is usually caused by straph aureus or streptococci. Chronic Dacryocystitis can by caused by Staph epidermis, streptococci, or gram-negative bacilli
What age groups most often have Dacryocystitis?
infants
adults over 40
Is Dacryocystitis usually bilateral or unilateral?
unilateral
What are common symptoms of Acute Dacryocystitis?
pain swelling tenderness redness purulent, pussy material may be expressed all in the tear sac area
What are common symptoms of Chronic Dacryocystitis?
tearing and discharge
mucus or pus may be expressed
How is Acute Dacryocytitis treated?
warm compresses
systemic antibiotic therapy
surgery of the underlying obstruction may be done electively, but is sometimes performed urgently in acute cases
How is Chronic Dacryocystitis treated?
antibiotics may give temporary relief, but surgical correction is needed
common and often resolves spontaneously; sometimes duct massage is helpful with large swellings
What is Conjunctivitis?
inflammation of the conjunctiva
What is the most common eye disease?
conjunctivitis
What are most cases of Conjunctivitis caused by?
Viruses or bacterial infections, including gonoccal and chlamydial
What are causes of Conjuntivitis?
viral and bacterial infection keratoconjunctivitis sicca *dry eye allergy chemical irritants self-harm contact with a contaminated object or surface
How can conjunctivitis be transmitted?
Conjunctivitis is very contagious. IT can be transmitted directly by contact with contaminated fingers, towels, hankerchiefs, etc. Even contaminated eyedrops
How is Viral Conjunctivitis transmitted?
adenovirus is the most common cause of viral conjunctivitis
What are symptoms of Viral Conjunctivitis?
cold symptoms (malaise, fever, pharyngitis, preauricular adenopathy)
burning or gritty sensation
eyelashes may stick together
copious watery discharge (common with viruses!)
foreign body sensation
follicular conjunctivitis
How is Viral Conjunctivitis treated?
There is no specific treatment for viral conjunctivitis. It usually lasts two weeks and goes away on its own. Cold compresses can be sued to reduce discomfort. Topical sulfonamides (oral antibiotics) can be used to prevent a secondary bacterial infection.
Is Viral Conjunctivitis usually bilateral or unilateral?
Bilateral; if unilateral, it is typically caused by the Herpes Simplex Virus and is associated with lid vesicles. HSV conjunctivitis is typically treated with topical and/ or systemic antivirals.
What are common causes of Bacterial Conjunctivitis?
Chlamydiae, gonococci, S. aureus, Streptococci pneumoniae, Pseudomonas, Haemophilus species, Moraxella
What are common symptoms of Bacterial Conjunctivitis?
pussy discharge (common with bacterial infections!)
mild discomfort
eyelashes stick together
What important symptom does Conjunctivitis NOT cause?
Bacterial conjunctivitis does NOT cause blurred vision
How is Bacterial Conjunctivitis diagnosed?
in clinical examination
What studies might be ordered in the diagnosis of Bacterial Conjunctivitis?
scrapings and cultures in severe cases
other STD testing in the chlamydia and gonorrhea cases
How is Bacterial Conjunctivitis treated?
with a topical sulfonamide or oral antibiotic
When should you refer Bacterial Conjunctivitis to an ophthalmologist?
If symptoms do not relieve after 48-72 hours after treatment
If Gonococcal Conjunctivitis is present
When there is corneal involvement
How is Gonococcal Conjunctivitis typically acquired?
through contact with infected genital secretions (TEST FOR OTHER STDs)
What is the trademark symptom for Gonococcal Conjunctivitis?
copious purulent discharge
also redness, lid edema, and tenderness upon palpation
How can you test for Gonococcal Conjunctivitis?
scraping or culture of discharge
When should you refer Gonococcal Conjunctivitis?
ALWAYS, EMERGENTLY
Gonococcal Conjunctivitis may lead to perforation of the cornea
How is Gonococcal Conjunctivitis treated?
1-g dose of intramuscular ceftriaxone
topical antibiotics may be added
What else is recommended upon suspicion of Gonococcal Conjunctivitis?
screening for other sexually transmitted diseases
routine treatment for chlamydial infection
Chlamydial Keratoconjunctivitis is the most common cause of what?
blindness worldwide
What is another name for Chlamydial Keratoconjunctivitis?
Trachoma
How is Chlamydial Keratoconjunctivitis diagnosed?
immunologic tests or polymerase chain reaction on conjunctival samples, but do not wait to treat
What might Chlamydial Keratoconjunctivitis lead to?
scarring of the tarsal conjunctiva leads to entropion adn trichiasis, inversion of the eyelashes, in adulthood
How is Chlamydial Keratoconjunctivitis treated?
1-g dose of azithromycin
improvements in hygiene can assist with prevention
What is Allergic Conjunctivitis?
acute, intermittent, or chronic conjunctival inflammation usually caused by airborne allergens (pollens, molds, dust mites, animal dander)
What are symptoms of Allergic Conjunctivitis?
redness stringy, watery discharge/tearing intense itching conjunctival edema and/or hyperemia eyelashes stick together burning sensation
What is Vernal Keratoconjunctivitis?
severe type of conjunctivitis common among males aged 5-20 with eczema, asthma, or season allergies; treated with topical corticosteroids
What is Atopic Keratoconjunctivitis?
more chronic disorder of adulthood that results in forniceal shortening and entropion with trichiasis; upper and lower tarsal conjunctivitis have papillary conjunctivitis; treated with corticosteroids
How is Allergic Conjunctivitis typically treated?
topical anthihistamines, NSAIDs, mast cell stabilizers, or a combination
topical corticosteroids
avoidance of allergic triggers
antigen desensitization
What is Keratoconjunctivitis Sicca?
Dry Eyes
What is conjunctival injection?
the dilation of conjunctival vessels
What are causes of Keratoconjunctivitis sicca?
age-related
part of Sjorgren’s Syndrome, RA, or SLE
result of conditions that scare tear ducts, such as Steven-Johnson syndrome or trachoma
What are symptoms of Keratoconjunctivitis sicca?
dryness
redness
foreign body sensation ('gritty or sandy' feeling)
in severe cases:
photosensitivity
eye strain
blurry vision
discomfortWhat are you likely to see when you examine an eye with Keratoconjunctivitis sicca?
conjunctival injection
scattered, fine, punctate loss of cornea epithelium and conjunctival epithelium
How might Keratoconjunctivitis sicca be diagnosed? What tests are done?
not typically diagnosed in an office
Schirmer test - measures the rate of production of the aqueous component of tears
Tear Break-up Test (TBUT)
slit-lamp - may see abnormalities in tear film stability and tear film meniscus
in severe cases: damaged corneal and conjunctival cells can be seen using 1% rose Bengal stain
How is Keratoconjunctivitis treated?
artificial tears
cyclosporine opthalmic emulsion (restasis)
lacrimal punctal occlusion by canicular plugs or cautery in sever cases
Are tumors of the eye usually benign or malignant?
benign, but the most common malignant tumor is basal cell carcinoma
Is Pinguecula and Pterygium usually bilateral or unilateral?
bilateral
What is Pinguecula?
a raised yellowish mass within the bulbar conjunctiva, adjacent to the cornea
In what age group is Pinguecula commonly seen?
adults over the age of 35
What is the prognosis of Pinguecula?
usually does not grow, but can become inflamed
What is Pterygium?
a thickening of conjunctiva in the shape of a triangle usually on the nasal side growing inward toward the cornea
What are common symptoms of Pterygium?
decreased vision (especially if it grows to cover the cornea), red eye, irritation, and foreign body sensation
In what circumstances does Pterygium most commonly occur?
tropical climates
tend to be found in males
genetic factors may be involved
What can cause Pterygium?
prolonged exposure to wind, sun, sand, and dust
What is the prognosis of Pterygium?
can become inflamed and grow
How is Pinguecula and Pterygium treated?
no treatment is required for inflammation, but short period treatment with topical NSAIDs or weak corticosteroid drops may help
artificial tears
surgical removal
What is a Corneal Ulcer?
an open sore on the cornea
What are common causes of corneal ulcers?
commonly associated with contact lens use, eye trauma (foreign body), and eyelid abnormalities
Infectious - bacterial, viral, fungal, and amoebas
Non-infectious - neurotrophic keratitis, exposure keratitis, dry eye, allergic eye disease, or other inflammatory disorders
What are symptoms of Corneal Ulcers?
pain photophobia tearing reduced vision/decreased visual acuity may be accompanied by hyperemia and hypopyon (layering of white blood cells in the anterior chamber) purulent or watery discharge
How are Corneal Ulcers diagnosed?
slit-lamp examination
all but the smallest ulcers are cultured
fluorescein staining - defect will appear bright green under blue light
What tests might you order to diagnose Corneal Ulcers?
check visual acuity and visual fields
check for foreign bodies that might be causing the ulcer
possible gram stain and culture
How are Corneal Ulcers Treated?
initially empiric topical broad-spectrum antibiotic therapy around the clock
When should Corneal Ulcers be referred?
any patient with an acute painful red eye and corneal abnormality should be referred emergently to an ophthalmologist
What is Infectious Keratitis?
an inflammation of the cornea caused by bacteria, virus, fungus, or parasites (Acanthamoeba)
What causes Bacterial Keratitis?
Pseudomonas aeruginosa, Moraxella species, and other gram-negative bacilli; staphylococci (MRSA), and streptococci
What are risk factors for Bacterial Keratitis?
wearing contact lenses
corneal trauma
What are common symptoms of Bacterial Keratitis?
eye redness eye pain excess tears or other drainage blurred vision photophobia foreign body sensation
What presentations might you see when examining Bacterial Keratitis?
cornea is hazy
ulcer and adjacent stromal abscess
hypopyon
How might Bacterial Keratitis be diagnosed?
gram stain and culture
How is Bacterial Keratitis treated?
high-concentration topical antibiotic drops applied hourly for 48 hours
When should you refer Bacterial Keratitis?
any patient with suspected Bacterial Keratitis must be referred emergently to an ophthalmologist
Why is diagnosis of Herpes Simplex Keratitis important?
It is an important cause of ocular morbidity
How does Herpes Simplex reach the eyes, and what contributes to its recurrence?
Herpes Simplex colonizes the trigeminal ganglion, leading to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency
What does Herpes Simplex usually cause or manifest as in the eyes?
manifests as eyelid, conjunctival, and corneal ulceration
What is a hallmark symptom of Herpes Simplex Keratitis?
dendritic branching
corneal ulcer
How is Herpes Simplex Keratitis diagnosed?
clinical exam
fluorescein stain with blue light
viral culture if diagnosis is in doubt
How is Herpes Simplex Keratitis treated?
debridement and patching
topical antivirals
occasionally systemic antivirals
What treatment should NOT be used for Herpes Simplex Keratitis and why?
topical corticosteroids may lead to corneal ulcers if used to treat Herpes Simplex Keratitis
When should Herpes Simplex Keratitis be referred?
any patient with a history of herpes simplex eye infection and an acute red eye should be referred urgently to an ophthalmologist
How does Herpes Zoster Ophthalmicus affect the eye?
involves the ophthalmic division of the trigeminal nerve
What is an important risk factor for Herpes Zoster Ophthalmicus?
HIV
What are common symptoms of Herpes Zoster Ophthalmicus?
malaise
fever
headache
preorbital burning or itching (for day or longer)
rash is initially vesicular, becoming pustular, and then crusting
involvement with the tip of the nose or lid margins predicts involvement with the eye
How might Herpes Zoster Ophthalmicus present upon examination?
ocular signs include: conjunctivitis, keratitis, episcleritis, and anterior uveitis
high intraocular pressure
How is Herpes Zoster Ophthalmicus treated?
oral antivirals
topical antivirals
anterior uveitis is treated with topical corticosteroids and cycloplegics
When should Herpes Zoster Ophthalmicus be treated?
• any patient with herpes zoster ophthalmicus and ocular symptoms or signs should be referred urgently to an ophthalmologist
How might a patient contract Fungal Keratitis?
a corneal injury involving a plant material or in an agricultural setting
Who is most at risk for Fungal Keratitis?
contact lens wearers
What might one see when examining Fungal Keratitis?
multiple stromal abscesses
little epithelial loss (indolent/lazy progression)
How is Fungal Keratitis diagnosed?
corneal scraping culture
What is the treatment for Fungal Keratitis and what might impede treatment?
topical or systemic antifungals
grafting is required
diagnosis tends to be delayed and treatment is difficult
What is Acanthamoeba Keratitis?
keratitis caused by amoeba
Who is most at risk for Acanthamoeba Keratitis?
contact lens wearers
What are common symptoms of Acanthamoeba Keratitis?
severe pain
perineural and ring infiltrates in cornaeal stroma is characteristic but not specific
How is Acanthamoeba diagnosed?
culture requres special media
confocal microscopy
How is Acanthamoeba treated?
long-term intensive topical biguanide and diamidine (long-term is required because of the organism’s ability to encyst within corneal stroma)
corneal grafting may be required
What treatment should NOT be used for Acanthamoeba Keratitis?
corticosteroids may adversely affect visual outcome
What is Acute Angle-Closure Glaucoma?
involves a physically obstructed anterior chamber angle
What can cause Acute-Angle Closure Glaucoma?
primarily results form the forward ballooning of the iris so that it reaches the back of the cornea, obstructing the anterior chamber filtration angle and reducing the outflow of aqueous humor; a pre-exisiting narrow angle closed by pupillary action (dark room, stress)
What are essential factors in the diagnosis of Acute Angle-Closure Glaucoma?
older age group, particularly in farsighted individuals rapid onset with severe pain visual loss with "halos around lights" hard eye palpation high IOP
How does the causation vary for Primary Acute Angle-Closure Glaucoma, and Secondary Acute Angle-Closure Glaucoma?
Primary - involves pre-existing narrow angle
Secondary- NO pre-existing narrow angle; caused by anterior uveitis, dislocation of the lens, or due to certain drugs
What are risk factors for Acute Angle-Closure Glaucoma?
family history farsightedness or short stature more common in Asians and Inuits hypertension diabetes cardiovascular disease
What are common symptoms of Acute Angle-Closure Glaucoma?
rapid onset extreme pain blurred vision - usually with "halos around lights" nausea abdominal pain headache possible blindness reduced visual acuity
How might Acute Angle-Closure Glaucoma appear under examination?
red eye cloudy cornea pupil dilation is non-reactive intraocular pressure greater than 50 (normal is 10-20) hard eye palpation
How might Acute Angle-Closure Glaucoma be treated?
agents that decrease the production or secretion of aqueous humor
laser iridotomy (punctures hole in iris to allow drainage)
oral diuretics will draw fluid from the eyes
treatment is aimed at preventing further damage
When should you refer Acute Angle-Closure Glaucoma?
emergently!
If a patient comes to you with ____ ____, ___, and ___; examine the eyes!
sudden headache
nausea
vomiting
What is Chronic Open-Angle Glaucoma?
multifactorial optical neuropathy that is chronic, progressive, and irreversible with characteristic loss of optic nerve fibers
What causes Chronic Open-Angle Glaucoma?
decreased permeability through the trabeculae inot the canal of Schlemm leads to increased intraoccular pressure
What percentage of Glaucoma cases are Chronic Open-Angle?
90%
What are essential components to Chronic Open-Angle Glaucoma?
no symptoms in early stages
insidious bilateral loss of peripheral vision, resulting in tunnel vision
preserved visual acuity until advanced disease
pathologic cupping of the optic disks
intraocular pressure is elevated
In what group does Chronic Open-Angle Glaucoma most often occur?
African Americans and Hispanics - occurs at earlier age and results in more severe optic nerve damage
What are symptoms of Chronic Open-Angle Glaucoma?
early disease - asymptomatic
loss of peripheral vision - may progress to tunnel vision
bumping into objects
Is Chronic Open-Angle Glaucoma usually bilateral or unilateral?
bilateral
How is Chronic Open-Angle Glaucoma usually diagnosed, and what criteria must be met?
usually diagnosed upon eye-screen exam
consistent and reproducible abnormalities in at least two: optic disk swelling or retinal nerve fiber layer, visual field, intraocular pressure
How is Chronic Open-Angle Glaucoma generally treated?
prostaglandin drops (increase outflow of aqueous humor)
beta-adrenergic blockers
laser therapy and surgery
What is Uveitis?
nonspecific term for intraocular inflammation
What makes up the anterior uvea?
iris and/or ciliary body
What makes up the intermediate uvea?
structures just posterior to the lens
What makes up the posterior uvea?
choroid, retina, vitreous
How is Uveitis categorized?
By area in the uvea: anterior, intermediate, or posterior; also by Acute Non-granulomatous Anterior Uveitis, Granulomatous Anterior Uveitis, and Posterior Uveitis
What causes Uveitis?
usually immunologic, but can be infective or neoplastic idiopathic isolated eye disease medications toxins trauma
What symptoms differentiate the different sub-categories of Uveitis?
Acute Non-granulomatous Anterior Uveitis: deep eye pain, redness, photophobia, and visual loss
Granulomatous Anterior Uveitis: blurred vision, mildly inflammed
Posterior Uveitis: gradual loss of vision in quiet eye, un-resolving floaters, commonly bilateral
Where is Uveitis more common?
the developing world
What are common symptoms of Uveitis?
decreased visual acuity
pain
photophobia
blurry vision
How might Anterior Uveitis look under examination?
inflammatory cells and flare within the aqueous
conjunctival vessel dilation
ciliary flush (redness)
small pupil size of affected eye (usually only one)
hypopyon and fibrin in sever cases
KP precipitates (keratic) and iris nodules
How might Intermediate Uveitis look under examination?
aggregates and condensations of inflammatory cells forming “snowballs”
How might Posterior Uveitis appear under examination?
bilateral cells in the vitreous humor white or yellow lesions in the retina (retinitis) choroiditis exudative retinal detachments retinal vasculitis optic disk edema slit-lamp exam -look for inflamed cells
How is Anterior Uveitis treated?
topical steroids
injected or systemic steroids
pupil dilation
How are Intermediate and Posterior Uveitis treated?
systemic, periocular, or intravitreal corticosteroids
occasionally systemic immunosuppression
When should Uveitis be referred?
Urgently for both, but particularly Acute
Is Uveitis typically bilateral or unilateral?
Anterior Uveitis is usually unilateral, while Posterior Uveitis is usually bilateral
What is a Cataract?
opacity or discoloration of the lens
Why is the Cataract so important to know about?
Leading cause of world blindness
What are essential components to Cataract diagnosis?
gradually progressive blurred vision
No pain or redness
lens opacities
What types of Cataracts are there?
age-related (90%) metabolic congenital (lens opacity within 3 months of age) systemic disease association secondary eye disease traumatic inhalation of corticosteroids
How are age-related cataracts caused?
continual addition of lens fibers, causing denser lens, which is hard to see through
What can cause congential Cataract?
idiopathic drugs taken by mother in the first trimester metabolic disease of the mother intrauterine infection maternal malnutrition
What are risk factors for Cataracts?
aging smoking UV sun exposure diabetes prolonged steroid exposure alcohol
What is the predominant symptom of Cataracts?
progressive blurring vision
Are Cataracts usually bilateral or unilateral?
usually bilateral, but asymmetric; can be unilateral, but watch for development in the other eye
What are symptoms of age-related Cataracts?
decreased visual acuity blurry vision distorted or "ghosting" images glare, especially while driving falls loss of color vision double vision
What are symptoms of Congenital cataract?
none; asymptomatic
under exam: leukocoria - white pupil when exposed to red light (red light test)
nystagmus
RULE OUT TUMOR
How are cataracts usually treated?
surgery - most commonly performed surgical procedure; improves visual acuity in 95% of cases
When should you refer cataracts?
when visual impairment adversely affects the patient’s lifestyle
What are essential components to diagnosing Retinal Detachment?
loss of vision in one eye that is usually rapid, possibly with curtain spreading across field of vision
no pain or redness
detachment seen in opthalmoscopy
How does Retinal Detachment occur?
most cases are due to one or more retinal tears or holes
may be caused by penetrating or blunt ocular trauma
traction from posterior vitreous detachment
fluid build-up and resulting detachemnt
What are the two most common predisposing factors for Retinal Detachment? In what age group does it most commonly occur?
nearsightedness and cataract extraction; people over 50
What are common symptoms of Retinal Detachment?
showers of floaters; moving spots or streaks
photopsias
visual vield loss; “curtain coming across vision”
central vision loss if macula is involved
visual acuity of 20/200 or worse
How is Retinal Detachment diagnosed?
slit-lamp exam
dilated fundus with ophthalmoscope
may find one or more retinal holes or tears
What is the treatment for Retinal Detachment?
not all tears are treated, but many are closed, sometimes wiht a laser
intraocular gases to hold retina in place
surgical reattachment
prognosis correlates with duration of symptoms and size of holes
When will you refer Retinal Detachment?
all cases urgently
emergently when central vision is intact
position had back during transportation, so retina stays in place
What is a Vitreous Hemorrhage?
leakage of blood into the areas in and around the vitreous humor of the eye
How is a Vitreous Hemorrhage caused?
retinal tear diabetic or sickle-cell retinopathy retinal vein occlusion retinal vasculitis neovascular age-related degeneration blood dyscrasia therapeutic anticoagulation trauma subarachnoid hemorrhage severe straining
What are symptoms of a Vitreous Hemorrhage?
sudden visual loss
abrupt onset of floaters that may progress in severity
report of “bleeding in the eye”
vision ranges from 20/20 to light perception
What symptom will you not see with a Vitreious Hemorrhage?
no inflammation
What symptoms will you not see with Retinal Detachment?
no pain or redness
What will you see upon a Vitreous Hemorrhage examination?
inability to see fundus details becuase of blood
localized collection of blood in front of the retina
What exams might you order to diagnose a Vitreous Hemorrhage?
eye exam with pupil dilation
ultrasound of the eye
labs for underlying causes
CT for underlying injury
How is a vitreous hemorrhage treated?
patches over eyes for limited movement head at 30-45* avoid blood thinners retinal tears are closed with a laser detached retinas are reattached surgically
When do you refer a Vitreoius Hemorrhage?
Anytime one is suspected
What are essential components to Age-Related Macular Degeneration?
older age group
acute or chronic deterioration of central vision in both eyes
distortion or abnormal size of images
no pain or redness
macular abnormalities seen in ophthalmoscopy
What is Age-Related Macular Degeneration?
deterioration of the central portion of the retina called the macula, which is responsible for focusing central vision
Why is Age-Related Macular Degeneration so awful?
it is the leading cause of blindness in patients 65 years of age or older in developed countries?
What two types of Age-Related Macular Degeneration are there?
Dry and Wet; all cases of macular degeneration begin with the dry stage
What are other names for Dry Age-Related Macular Degeneration?
atrophic and geographic
What are other names for Wet Age-Related Macular Degeneration?
neovascular and exudative
What are common causes or contributors to Age-Related Macular Degeneration?
older age group (especially those over 50) family history smoking regular aspirin users cardiovascular disease hypertension sun exposure lack of exercise/obesity
In what groups are Age-Related Macular Degeneration most common?
caucasian
female
red or blond hair
Is Age-Related Macular Degeneration usually bilateral or unilateral?
Unilateral
What is a primary precursor for Age-Related Macular Degeneration?
drusen; discrete yellow deposits
What is the primary symptom of Age-Related Macular Degeneration?
loss of central vision only
What symptoms will not be present in Age-Related Macular Degeneration?
pain or redness
How common is Dry Age-Related Macular Degeneration?
85% of cases
What causes Dry Age-Related Macular Degeneration?
due to atrophy and degeneration of the outer retina and retinal pigment epithelium
What are the symptoms for Dry Age-Related Macular Degeneration?
gradually progressive bilateral central vision
painless
What might you see in a Dry Age-Related Macular Degeneration exam?
changes in retinal pigment epithelium
drusen
areas of chorioretinal atrophy
How is Dry Age-Related Macular Degeneration treated?
daily supplements to reduce risk of Wet ARMD: zinc copper vitamin C vitamin E low-vision aids may help
What is the occurrence of Wet Age-Related Macular Degeneration?
15% of cases, but accounts for 90% of blindness caused by ARMD
What causes Wet Age-Related Macular Degeneration?
choroidal new vessels grow between the retinal pigment epithelium and Bruch membrane; new vessels are “leaky,” leading to accumulation of serous fluid, hemorrhage, and fibrosis
What are symptoms of Wet Age-Related Macular Degeneration?
rapid onset of visual loss
visual distortion (central blind spot)
straight lines appear crooked
central vision gets darker until its gone
What might you see in a Wet Age-Related Macular Degeneration Exam?
subretinal fluid
retinal edema
gray-green discoloration
exudates in or around macula
detachment of retinal pigment epithelium
subretinal hemorrhage in or around macula
soft drusen (larger and paler than hard drusen
How is Wet Age-Related Macular Degeneration treated?
oral treatment of zinc, copper, antioxidants, and carotenoids
inhibitors of vascular growth factors
macular surgery
supportive measures (magnifiers, high-power reading glasses, large computer monitors, telescopic lenses, etc.)
corticosteroids
laser removal of neovascularizatoin
How might you diagnose Age-Related Macular Degeneration?
funduscopic examination
color of fundus photography (wet is grey green)
fluorescein angiography
optical coherence tomography
What is the prognosis for Age-Related Macular Degeneration?
damage is irreversible
treatment is aimed at limiting progression
When would you refer Age-Related Macular Degeneration?
urgently in older patients who develop sudden vision loss
What are essential components of Central and Branch Retinal Vein Occlusions?
sudden monocular loss of vision
no pain or redness
widespread or sectoral retinal hemorrhages
Central and Branch Retinal Vein Occlusions are common causes of what?
acute vision loss (branch is 4 times as common)
What are risk factors for Central and Branch Retinal Vein Occlusions?
hypertension age (over 50) glaucoma diabetes increased blood viscosity arrhythmia cardiac vulvar disease
What are common symptoms of Central and Branch Retinal Vein Occlusions?
commonly first noticed upon waking painless vision loss can be sudden, but may be over days or weeks no pain or redness widespread sectoral retinal hemorrhages
How would you examine for Central and Branch Retinal Vein Occlusions?
fundoscopy: widespread retinal hemorrhages retinal venous dilation and tortuosity retinal cotton-wool spots optic disk swelling
What is a common sign of Central Retinal Vein Occlusion?
visual loss first noticed upon waking
What is the presentation of Central Retinal Vein Occlusions?
widespread retinal hemorrhages retinal venous dilation tortuosity rental cotton-wool spots optic disk swelling
What are symptoms of Branch Retinal Vein Occlusion?
may be present in a variety of ways
sudden loss of vision at the time of occlusion if fovea is involved or some time later if it is not
gradual vision loss with development of macular edema
How is Branch Retinal Vein Occlusion diagnosed?
fundoscopy
color fundus photography
fluorescein angiography
optical coherence tomography
How are Central and Branch Retinal Vein Occlusions treated?
generally treat symptoms
anti-vascular endothelial growth factor
focal laser photocoagulation
panretinal laser photocoagulation if neovascularization develops
When should you refer Central and Branch Retinal Vein Occlusions?
urgently
What are essential components in diagnosing Central and Branch Artery Occlusions?
suddon monolcular loss of vision
no pain or redness
widespread or sectoral retinal pallid swelling
What are causes of Central and Branch Artery Occlusions?
embolus, thrombosis, diabetes mellitis, hyperlipidemia, hypertension, migraines, oral contraceptives
What are symptoms of Central and Branch Artery Occlusions?
sudden
painless
profound vision loss
visual acuity is usually reduced to counting fingers or worse
visual field is restricted to an island of vision in temporal field
What are key findings that might help diagnose Central and Branch Artery Occlusions?
pupil responds poorly to direct light, but constricts briskly when the other eye is illuminated
fundoscopy shows pale, opaque fundus with red fovea (cherry-red spot)
retinal arteries are attenuated, and “box-car” segmentation of blood in the veins may be seen
What are symptoms of Central Artery Occlusion?
sudden profound monocular loss
visual acuity is usually reduced to counting or worse
visual field is reduced to an island of vision in the temporal field
pallid swelling of the retina
cherry-red spot at the fovea
retinal arteries are attenuated
box-car segmentation of blood in veins may be seen
emboli are seen in artery or its branches on occasion
In patients over 50 that are diagnosed with Central Artery Occlusion, what else must be considered?
giant cell arteritis
What are common symptoms of Branch Retinal Artery Occlusions?
sudden loss of vision if fovea is involved
sudded loss of visual field is the presenting complaint
fundal signs of retinal swelling and cotton-wool spots are limited to area of retina supplied by the occluded artery
How are Central and Branch Artery Occlusions diagnosed?
clinical evaluation
color fundus photography
fluorescein angiography
How are Central and Branch Artery Occlusions treated?
sometimes reduction of intraocular pressure
immediate treatment if within 24 hours of presentation: lower IOP, digital massage, anterior chamber paracentesis may dislodge
removal of material inside artery or angioplasty with stenting within two weeks
If suspected Central and Branch Artery Occlusions, what else should be considered?
screen for corotid and cardiac sources of emboli to prevent possible stroke
screen for diabetes mellitus and hypertension
When should Central and Branch Artery Occlusions be referred?
emergently, especially if caught soon after onset
If suspicious of Central or Branch Artery Occlusion, what tests should be ordered?
identify carotid and cardiac sources of emboli
doppler ultrasonography and echocardiography to find underlying embolic source
if giant cell arteritis is suspected, platelet count should be done immediately
When should you refer Central or Branch Artery Occlusion?
central - emergently
branch - urgently
giant cell arteritis - ADMIT!
What is Transient Moncular Visual Loss?
monocular loss of vision usually lasting a few minutes with complete recover; ocular transient ischemic attack
What is another name for Transient Moncular Visual Loss?
Amaurosis fugax (fleeting blindness)
What causes Transient Moncular Visual Loss?
a retinal embolus from ipsilateral carotid disease or the heart
What are symptoms of Transient Moncular Visual Loss?
A curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes and a similar curtain effect as the episode passes
What might you see in a Transient Moncular Visual Loss exam?
nothing, an embolus is rarely seen
What do you want to screen for if Transient Moncular Visual Loss is suspected?
the source of the embolus; it could lead to stroke
How would you treat Transient Moncular Visual Loss?
oral apsirin or other anti-platelet drug, until cause has been determined
70-99% should be considered for urgent carotid endarterectomy or possibly angioplasty with stenting (prevent stroke)
anticoagulation
surgical treatment
When should you refer Transient Moncular Visual Loss?
refer all cases of episodic visual loss; admit embolic transient visual loss if there were two or more episodes in the preceding week
What is Diabetic Retinopathy?
noninflammatory retinal disorder characterized by retinal capillary closure and microaneurysms
In what percentage of diabetic patients is Diabetic Retinopathy found?
35% of all cases, 20% of Type II
What age group does Diabetic Retinopathy cause blindness in?
all, but it is the leading cause of blindness in adults 20-65 years of age
How does Non-proliferative Diabetic Retinopathy present?
before proliferative increased capillary permeability micro-aneurysms dot and blot hemorrhages exudates macular ischemia macular edema venous bleeding cotton-wool spots (soft-exudates) venous dilation and intraretinal microvascular abnormalities
What is generally the first sign of Non-proliferative Diabetic Retinopathy?
micro-aneurysms
Compared to Non-proliferative, Proliferative Diabetic Retinopathy is more or less common?
less common, but more severe visual loss; develops after non-proliferative Diabetic Retinopathy
What might Proliferative Diabetic Retinopathy lead to?
vitreous hemorrhage and traction retinal detachment
What is Proliferative Diabetic Retinopathy characterized by?
abnormal new vessel formation occurring on the inner retinal surface
What are symptoms of Proliferative Diabetic Retinopathy?
blurred vision
floaters (black spots)
flashing lights in the field of vision
sudden, severe, painless vision loss
What might you see while examining Proliferative Diabetic Retinopathy?
neovascularization arising from either the optic disk or the major vascular arcades
vitreous hemorrhage
traction retinal detachment
How might you treat Diabetic Retinopathy?
optimize blood glucose, blood pressure, kidney function, and serum lipids
annual exams
macular edema - anti-vascular endothelial growth factor
When should you refer Diabetic Retinopathy?
all diabetic patients with sudden loss of vision or retinal detachment should be referred emergently to an ophthalmologist
proliferative urgently
nonproliferative referral
What is Hypertensive Retinopathy?
Hypertensive Retinopathy is retinal or choroidal vascular damage due to hypertension.
In what age group are the most florid ocular changes seen when diagnosing Hypertensive Retinopathy?
Young patients with abrupt blood pressure elevation.
What are some common causes of Hypertensive Retinopathy, and what trademark presentations do they accompany?
Acute Elevation in Blood Pressure causes reversible vascular constriction.
A Hypertensive Crisis causes optic disk Edema.
Chronic or Severe Blood Pressure Elevation will cause exudative (leaky fluid) vascular changes, arteriole wall thickening, and arteriovenous nicking.
What are primary risk factors related to Hypertensive Retinopathy?
smoking
diabeties
What are common symptoms of Hypertensive Retinopathy?
blurry vision
visual field defects
- vision issues do not usually develop until late in the disease
What can you expect to find when examining a patient with Hypertensive Retinopathy?
superficial flame-shaped hemorrhages
small, white, superficial foci of retinal ischemia (cotton-wool spots)
yellow hard exudates
optic disk edema
How would you diagnose Hypertensive Retinopathy?
slit-lamp exam
fundoscopy
history - duration/severity of hypertension
What would you see when examining a patient with Chronic Hypertensive Retinopathy?
arterial narrowing
tortuous retinal arteries
arteriovenous crossing abnormalities - “arteriovenous nicking”
arteriovenous with moderate vascular wall changes - “copper-wiring”
more sever vascular wall changes - “silver wiring”
How would you treat Hypertensive Retinopathy?
Main Objective - Treat Hypertension!
You can treat the retinal edema with laser therapy or with intravitreal injection of corticosteroids or anti-vascular endotheleal growth factor.
What is Blood Dyscrasias?
Blood Dyscrasias is a pathologic condition of the blood and usually refers to a disorder of the cellular elements of the blood.
What general blood conditions may lead to retinal or choroidal hemorrhages?
Severe thrombocytopenia (low blood platelet count) or anemia (low red blood cell count)
What is Sickle Cell Retinopathy?
Sickle Cell Retinopathy is a form of Blood Dyscrasias. It is common in hemoglobin SC disease, but may also occur in other hemoglobin S variants.
What are symptoms of Blood Dyscrasias?
white centered retinal hemorrhages
involvement with the macula may result in permanent vision loss
What are symptoms of Sickle Cell Retinopathy?
“salmon-patch” preretinal/intraretinal hemorrhages
“black sunbursts” resulting from intraretinal hemorrhage
new vessels
severe visual loss is rare, but more common in patients with pulmonary hypertension
How would you treat Sickle Cell Retinopathy?
retinal laser photocoagulation reduces the frequency of vitreous hemorrhage from new vessels
surgery is occasionally needed for persistent vitreous hemorrhage or tractional retinal detachement
What are signs of an HIV infection/AIDS in the eyes?
manifests clinically as cotton-wool spots
retinal hemorrhages
micro-aneurysms
may lead to reduced contrast sensitivity, retinal nerve fiber layer, and outer retinal damage
What is CMV Retinitis?
a sight-threatening complication of HIV/AIDS, chemotherapy, and bone marrow transplants
What are symptoms of HIV Infection/AIDS in the eyes?
progressively enlarging yellowish-white patches of retinal opacification
retinal hemorrhages
retinal vascular arcades
patients are often asymptomatic until there is involvement of the fovea or optic nerve, or until retinal detachment develops
List three initial treatments for HIV/AIDs in the eyes.
valganciclovir 900 mg orally twice daily for 3 weeks
ganciclovir 5 mg/kg, forscarnet 60 mg/kg, or cidofovir 5 mg/kg intravenously
local administration of gancicloviror foscarnet, or sustained-release ganciclovir intravitreal implant
What is Ischemic Optic Neuropathy?
Ischemic Optic Neuropathy is sudden visual loss due to obstructed blood flow to the optic nerve.
What are essential diagnoses of Ischemic Optic Neuropathy?
Sudden painless visual loss with signs of optic nerve dysfunction, and optic disk swelling in anterior ischemic optic neuropathy.
What causes Ischemic Optic Neuropathy?
Inadequate perfusion of the posterior ciliary arteries that supply the anterior portion of the optic nerve.
What causes Ischemic Optic Neuropathy?
may be caused by giant cell arteritis hypertension diabetes mellitus hyperlipidemia thrombophilia (blood clot disorder) sleep apnea
What are common symptoms of Ischemic Optic Neuropathy?
sudden visual loss
altitudinal field defect
optic swelling
How is Ischemic Optic Neuropathy diagnosed?
Fundoscopy
How is Ischemic Optic Neuropathy treated?
Emergency high-dose systemic corticosteroid treatment to prevent visual loss in the other eye
When would you refer Ischemic Optic Neuropathy?
Urgently to an ophthalmologist; admit patients with giant cell arteritis
What is Optic Neuritis?
Optic Neuritis is inflammation of the optic nerve that is strongly associated with demyelinating disease, particularly multiple sclerosis.
What are essentials of diagnosis for Optic Neuritis?
subacute unilateral visual loss with signs of optic nerve dysfunciton
pain exacerbated by eye movements
optic disk usually normal in acute stage but subsequently develops pallor
What group of people are diagnosed with Optic Neuritis most often?
Patients with a demyelinating disease, especially multiple sclerosis. It arises in people ages 20-40 (prime subjects for multiple sclerosis).
What are common causes of Optic Neuritis?
demyelinating diseases infectious diseases (especially in cases involving children) tumor mestastases to optic nerve chemicals, drugs neuromyelitis optica
What are common symptoms of Optic Neuritis?
abrupt, unilateral vision loss (hours to days) visual acuity ranges form 20/30 to no perception of light field loss is usually central periorbital pain with eye movement brow ache, globe tenderness dimness in light intensity loss of color vision afferent pupillary affect
What will Optic Neuritis look like in an exam?
papilitis: swollen optic disk
flame-shaped hemorrhage
temporal disk pallor (4-6 weeks after swelling)
RAPD (Marcus-Gun Pupil)
2/3 patients will have normal disk inflammation
What is RAPD or Marcus-Gunn pupil?
The pupil of the affected eye dilates during the swinging light test. It will not constrict when the light is shining on it.
What is Optic Neuritis often a presenting manifestation of?
Multiple Sclerosis
How is Optic Neuritis treated?
Intravenous Methylprednisolone corticosteroids low-vision aids will help improve some of vision, but de-myeletaion disease will progress optic neuritis visual acuity improves in 2-3 weeks
When should Optic Neuritis be referred?
Refer Urgently
What causes Optic Disk Swelling?
intraocular disease: central retinal vein occlusion, posterior uveitis, posterior scleritis
orbital and optic nerve lesions
severe hypertensive retinochoroidapathy
raised intra-cranial pressure
What is Papilledema?
Optic disk swelling due to raised intra-cranial pressure.
Is Papilledema usually unilateral or bilateral?
bilateral
What symptom usually occurs with Optic Disk swelling?
Optic disk swelling usually produces visual field loss without loss of acuity
What symptoms are associated with Chronic Optic Disk Swelling?
visual field loss and occasionally profound loss of acuity
What tests need to be ordered when Optic Disk swelling is found and why?
Urgent imaging is needed to exclude an intracranial mass or cerebral venous sinus occlusion as the cause.
What vision impairment are Optic Disk Drusen associated with?
farsightedness
What might Optic Disk Drusen be mistaken for and why?
Optic disk swelling because Optic Disk Drusen cause disk elevation
How can you identify Optic Disk Drusen?
Drusen are yellowish-white spots that may be obvious clinically or can be demonstrated by their autofluorescence. Buried drusen are best detected by orbital ultrasound or CT scanning.
What cranial nerves cause Ocular Motor Palsies?
Cranial nerves III, IV, and VI, which innervate the extraocular muscles.
What can cause Ocular Motor Palsies?
multiple sclerosis Guillian-Barre syndrome diabetes mellitus infections giant cell arteritis hypertension trauma to the eye lesions
What are symptoms of Ocular Motor Palsies?
double vision pain on movement pain around the eyes headache nausea
What Ocular Motor Palsy causes one eye to look down and to the side?
3rd Nerve Palsy - the III ocular nerve controls all ocular muscles except the lateral rectus (moves eye laterally) and the superior oblique (allows for clockwise downward rotation). All movement is restricted except laterally.
What Ocular Motor Palsy causes the eye to turn inward?
4th nerve palsy - the IV ocular nerve controls the superior oblique. Palsy prevents downward rotation. All movement is restricted except inward rotation.
What palsy restricts lateral movement of the eye?
6th Nerve Palsy. VI Ocular Nerve controls the lateral oblique function. All movement is restricted except medially.
What is Stabismus?
misalignment of the eyes; cross-eyes; one of the most common eye problems in children
What are causes of Stabismus?
usually an eye muscular issue refractive error muscle imbalance rare: retinoblastoma, cranial nerve palsy could be infantile or acquired
What are risk factors for Stabismus?
family history genetic disorder (Down Syndrome) prenatal drug exposure prematurity/ low birth weight cerebral palsy congenital eye defects
How is Stabismus usually diagnosed?
physical and neurologic examinations at well-child check-ups
tests: corneal light reflex, alternate cover, cover-uncover
prisms
How is Stabismus treated?
patching or atropine drops for attendant amblyopia
contact lenses or eyeglasses for refractive error
eye exercises for convergence insufficiency
surgical alignment
Tropia
Strabismus that manifests with both eyes open
Phoria
latent Strabismus, observed when one eye is covered
Pseudostrabismus
eye position that appears to look like strabismus, but is a result of a broad bridge of the nose. It is not actually Strabismus.
Esotropia
One or both eyes turning upward
Exotropia
One or both eyes turning outward
What is Nystagmus?
involuntary eye movement; also called dancing eyes
What is a symptom of Nystagmus?
Nystagmus causes reduced or limited vision
What causes Horizontal Nystagmus?
may be due to inner ear problems or lesions
What is Congential Nystagmus?
Nystagmus that develops in infants between 6 weeks to 3 months of age. It is usually bilateral, may be inherited, and causes blurry vision.
What is Acquired Nystagmus?
Nystagmus associated with serious medical conditions or drug and alcohol use. Patients report that things around them look shaky.
What are causes of Nystagmus?
family history albinism Meniere's Disease Multiple Sclerosis Stroke Head Injury Eye Problems (Cataracts, Strabismus) Medications Alcohol and Drug Abuse
What are symptoms of Nystagmus?
rapid eye movements sensitivity to light dizziness difficulty seeing in the dark vision problems holding the head in a turned or tilted position the feeling that the world is shaking
How is Nystagmus diagnosed?
physical exam
CT or MRI (may be looking for underlying abnormalities)
How is Nystagmus treated?
glasses
surgery
treatment of underlying disorder
What is Thyroid Eye Disease?
a syndrome in which the orbital tissues are infiltrated by chronic inflammatory cells and mucopolysaccharides; particularly the extraocular muscles; results in abnormal clinical and orbital imaging; • an autoimmune disease that leads to overactivity of the thyroid gland; the back of the eyes are attacked by the immune system, resulting in inflammation and swelling; may push the eyes forward
What are common symptoms of Thyroid Eye Disease?
surface irritation diplopia proptosis lid retraction and lid lag conjuctival chemosis episcleral inflammation extraocular dysfunction
How is Thyroid Eye Disease diagnosed?
clinical findings
CT - enlargement of the extraocular muscles, usually affecting both orbitals
How is Thyroid Eye Disease treated?
systemic corticosteroids
radiotherapy
peribulbar corticosteroid injections
surgical decompression with marked proptosis
lateral tarsarrhaphy (surgically joining of the eyelids)
What is chemosis?
swelling of the conjunctiva
What is Orbital Cellulitis?
infection of the orbital tissues
What causes Orbital Cellulitis?
most often - extension of infection from adjacent sinuses
less common - direct infection
What are symptoms of Orbital Cellulitis?
swelling and redness of the eyelid and surrounding tissues conjunctival hyperemia and chemosis decreased ocular motility pain with eye movements decreased visual acuity proptosis fever
How is Orbital Cellulitis treated?
hospitalization and treatment with meningitis-dose antibiotics
surgery indicated for: compromised vision, abscess or foreign body
What is Periorbital Cellulitis?
infection f the eyelid and surrounding tissues
What causes Periorbital Cellulitis?
contiguous spread form local facial or eyelid injuries, insect or animal bites, conjunctivitis, chalazion, or sinusitis
What are symptoms of Periorbital Cellulitis?
tenderness swelling warmth redness and discoloration sometimes fever
How is Periorbital Cellulitis treated?
antibiotics against sinusitis pathogens
How is Periorbital Cellulitis and Orbital Cellulitis diagnosed? What other tests are ordered?
clinical
CT or MRI for orbtial cellulitis (see how far infection has spread
blood cultures for orbital cellulitis
How might you differentiate between orbital cellulitis and blepharitis?
Blepharitis is localized, while orbital cellulitis will spread to the entire eye
What are some symptoms of Conjunctival and Corneal Foreign Bodies?
foreign body sensation
tearing
redness
occasionally discharge
How are foreign bodies diagnosed?
Patient says that there is something in their eye and gives a consistent history. Foreign bodies can be verified under a slit-lamp examination, usually with fluorescein staining.
How foreign bodies in the eye treated?
irrigation or removal with a damp, cotton-tipped swab or small needle
bacitracin-polymyxin ophthalmic ointment
rust rings from iron must be excised by scraping or with a low-speed rotary burr
intraocular foreign body - EMERGENCY treatment from an ophthalmologist
How are Corneal Abrasions diagnosed?
history of trauma to the eye - tends to involve a fingernail, piece of paper, or contact lens
examination with a light
fluorescein stainging if needed
What are symptoms of a Corneal Abrasion?
severe pain
photophobia
tearing
foreign body sensation
How are Corneal Abrasions treated?
bacitracin-polymyxin ophthalmic ointment
mydriatic
analgesics either topical or oral nonsteroidal anti-inflammatory agents
What are typical symptoms of Contusions-Closed Globe Injuries?
Eyelid Ecchymosis Minor Lid Lacerations Conjuctival, anterior chamber, or vitreous hemorrhage retinal hemorrhage, edema, or detachment laceration of the iris cataract dislocated lens glaucoma globe rupture (laceration)
What is Eyelid Ecchymosis?
a black eye
What are minor lid lacerations?
lacerations that do not involve the lid margin or tarsal plate - may be repaired with nylon sutures;
lacerations involveing the lid margin should be repaired by an ophthalmologist
When and how would you examine Contusions/ Closed Globe Injuries?
Evaluation can be difficult when massive lid edema or laceration is present. Unless immediate need for eye surgery, attempt to evaluate: visual acuity pupil shape and pupillary responses extraocular movements anterior chamber depth or hemorrhage presence of red reflex
When would you suspect a Globe Laceration?
corneal or scleral laceration visible
aqueous humor is leaking (positive Seidel sign)
anterior chamber is very shallow (eg, making the cornea appear to have folds) or very deep (due to rupture posterior to the lens)
pupil is irregular
How would you treat a Contusion/Closed Globe Injury?
apply a protective shield
systemic antimicrobials as for intraocular foreign bodies
if vomiting, give antiemetics
tetanus prophylaxis
When would you refer a Contusion/ Closed Globe Injury?
Always refer immediately to an ophthalmologist
What is Hyphema?
an anterior chamber hemorrhage; pooling or collection of blood inside the anterior chamber
What can also occur with Hyphema?
Any injury causing hyphema involves the danger of secondary hemorrhage, which may cause glaucoma with permanent visual loss. Intraocular pressure can rise and should be monitored every day for a few days and regularly for weeks to months.
How is Hyphema treated?
bed rest with head elevated 30-40*
eye shield to protect eye from further trauma
aspirin and any drugs inhibiting coagulation should be avoided
What disease can adversely affect the outcome of Hyphema?
Sickle Cell Anemia
What is Subconjunctival Hemorrhage?
bleeding under the conjunctiva
What causes Subconjunctival Hemorrhages?
sudden or severe sneeze, cough, heavy lifting, straining, vomiting, or even rubbing one’s eyes too roughly
can be a side effect of eye surgery or blood thinners
What are symptoms of Subconjunctival Hemorrhages?
bright red patch in the eye that may spread and become green or yellow (disappears within two weeks)
How are Subconjunctival Hemorrhages treated?
They are not. They go away on their own in about two weeks
What is a Lens Dislocation?
a lens that has moved out of position because some or all of the supporting ligaments have broken
What causes Lens Dislocation?
trauma
some hereditary conditions predispose patients to weak ligaments (Marfans)
What are symptoms of Lens Dislocation?
blurry vision
iris may quiver
How are Lens Dislocations diagnosed?
lens appears off center on eye exam or dilation
How are Lens Dislocations treated?
condition is permanent
vision corrected with glasses
What is an Orbital Fracture or “Blow Out” Fracture?
a blunt trauma forces the orbital contents through one of the most fragile portions of the orbital wall, typically the floor
What are symptoms of Blow Out Fracture?
diplopia - double vision
enophthalmos - posterior displacement of the eyeball
inferiorly displaced globe
hypesthesia (diminished capacity for physcial sensation) of the cheek and upper lip
subcutaneous emphysema (gas or air in a layer of the skin)
epistaxis, led edema, and ecchymosis
How is a Blow Out Fracture diagnosed?
CT scan
How is a Blow Out Fracture Treated?
Surgical repair if more than two weeks of diplopia or unacceptable enophthalmos
Emmetropia
the normal refractive condition of the eye in which, with accommodation relaxed, parallel rays of light are brought accurately to a focus upon the retina
Accommodation
the process of increasing the curvature of the lens
Hyperopia
farsightedness; the eyeball is shorter than normal and the parallel rays of light are brought to focus behind the retina; objects at infinity are not seen clearly unless accommodation is used; objects closer to infinity may not be seen because accommodation is finite
What are symptoms of Hyperopia?
may cause headaches and blurring of vision
How is Hyperopia treated?
Can be corrected with convex lenses, which aid the refractive power of the eye in shortening the focal distance
Myopia
nearsightedness; the anteroposterior diameter of the eyeball is too long; unaccommodated eye focuses on objects closer than infinity
objects beyond a close distance cannot be seen without biconcave lenses
What are causes of myopia?
genetic
can be caused by sleeping in a lighted room before the age of two, or accelerated by extensive close work activities, such as studying
How is myopia treated?
bioconcave lenses
Astigmatism
the curvature of the cornea is not uniform; causes light rays to be refracted to a different focus, blurring the retinal image
How is an Astigmatism treated?
cylindric lenses
Presbyopia
natural loss of accomodative capacity with age; inability to focus on objects at normal reading distance; usually occurs after 45
What are treatments of Refractive Errors?
glasses contacts surgery topical atropine and pirenzepine for nearsightedness rigid contact lenses at night
What is Ultraviolet Keratitis?
ultraviolet burns of the cornea
What causes Ultraviolet Keratitis?
use of sunlamp without eye protection
What are symptoms of Ultraviolet Keratitis?
asymptomatic initially
after 6-12 hours - pain and severe photophobia
How do you diagnose Ultraviolet Keratitis?
slit-lamp examination with fluorescein - shows diffuse punctate staining of both corneas
How is Ultraviolet Keratitis treated?
binocular patching
instillation of 1-2 drops of 1% cyclopentolate (relieves discomfort)
recovers in 24-48 hours without complications
What should NOT be prescribed with Ultraviolet Keratitis?
local anesthetics - delay corneal healing
What is Chemical Conjunctivitis and Keratitis?
pain in the eyes after exposure to a chemical
How is Chemical Conjunctivitis and Keratitis diagnosed?
slit-lamp - it can be difficult to assess severity of chemical burns
How is Chemical Conjunctivitis treated?
copius irrigation with water, saline solution, or buffering solution
do NOT neutralize
