Ophthalmology Flashcards
T or F
The Physiological cup in the eye sits inside of the Optic Disk ?
- True
Hypertensive Retinopathy is caused by ?
- Hypertension
- Due to
1) Vascular changes
2) Damage to retina
3) Choroid
4) Optic nerve
Hypertensive Retinopathy depends on the degree/type of damage, what are the two types?
1) Acute hypertension: can cause Vasospasm
2) Chronic hypertension: leads to Arteriosclerosis
Hypertensive Retinopathy risk factors include?
- Lipid levels
- Smoking
- Weight
What are the three visual signs of Hypertensive Retinopathy ?
- AV Nicking
- Copper Wiring
- Silver Wiring
Mild retinopathy includes (1 or more) ?
- Gen Arteriolar narrowing
- Focal arteriolar narrowing
- Arteriovenous nicking
- Arteriolar wall opacity (silver wiring)
Moderate retinopathy includes (1 or more) ?
- Microaneurysm
- Cotton wool spot
- Hard exudates
Malignant retinopathy includes?
- Moderate retinopathy
plus
- Optic disc swelling
Retinal Venous Occlusive Disease symptoms?
- Acute
- Painless loss of vision in one eye
- Only part of vision decreased (Superior/inferior)
- Branch retinal vein occlusion (BRVO)
or
- Central retinal vein occlusion (CRVO)
Retinal Venous Occlusive Disease Fundus exam reveals?
- Dilated, tortuous vein with retinal hemorrhages
- Cotton wool spots and retinal edema
Treatment of Retinal Venous Occlusive Disease ?
- ASAP referral
- Anti-VEGF injections (Bevacizumab)
1) Decreases macular edema
2) Improves long term prognosis
- Younger patients without above risk factors: workup for hypercoagulable state = Systemic disease
Retinal Artery Occlusions ?
- Branch retinal artery occlusion or Central artery occlusions (Cherry Spot)
- Caused from an Emboli
- Cholesterol
- Calcific
- Atherosclerotic plaque
- Hollenhorst plaque
Retinal Artery Occlusions symptoms include?
- Sudden painless vision loss in area affected
- Edematous opacification of the inner retina in distribution of affected vessel
Central artery occlusion will show ?
– Appearance of cherry red spot
- Will show dull red color due to ischemia
If Retinal Artery Occlusions pt presents to ophtho within 4 hrs of vision loss what can you attempt?
- Attempt measures to try to dislodge emboli
- Typically vision loss is permanent due to irreversible ischemia
Diabetic Retinopathy is the leading cause of vision loss for what ages?
- 20 thru 74
- Risk factors
DM onset and Age
Pathogenesis of diabetic retinopathy ?
- Hyperglycemia over time leads to
- Microvascular endothelial cell damage
- Capillary occlusion/retinal ischemia
- Dysfunction of endothelial barrier
- Leakage of serum and retinal edema
What causes the vision loss in Diabetic Retinopathy?
- Macular edema (capillary leakage)
- Macular ischemia (capillary occlusion)
- Sequlae from ischemia-induced neovascularization
Two forms of Diabetic Retinopathy?
1) Non Proliferative
2) Proliferative
Non Proliferative diabetic retinopathy includes what signs during a visual exam?
- Retinal microvascular changes
- Microaneurysms
- Cotton wool spots
- Intraretinal hemorrhages
- Hard exudate
- Retinal edema
- Arteriolar and venous abnormalities
Proliferative Diabetic Retinopathy has ?
- Extraretinal neovascularization
Proliferative Diabetic Retinopathy Extraretinal neovascularization includes ?
- Retinal ischemia
- Neovascularization
Vascular Endothelial Growth Factor (VEGF)
Complications of proliferative diabetic retinal neovascularization includes ?
1) Vitreous hemorrhage
2) Retinal detachment
Treatment of Diabetic proliferative retiopathy includes?
- Panretinal photocoagulation to peripheral ischemic retina
- Anti-VEGF intravitreal injections
- Surgery
What is the major cause of vision loss in both Proliferative and Non proliferative Diabetic Retinopathy vision loss?
- Vascular permeability (Macular Edema)
- Cystic pockets of fluid build up in the central part of the Retina
- Retinal detachment
Treatment for macular edema in both Proliferative and Non proliferative Diabetic Retinopathy ?
- Anti-VEGF intravitreal injections
- Laser therapy on leaking microaneurysms
Goal in treatment of diabetic retinopathy?
- Delay & Prevention of complications
T or F
Pregnancy associated with worsening or Diabetic Retinopathy ?
- True
- Speeds up progression
Schedule for diabetic pts to have eye exams?
- DM I
Within 5 years of Dx
Annual check ups after - DM II
Upon Dx
Annual check ups after - Pregnancy
Before conception / or Early 1st trimester
Check ups 1 to 3 months during
Age-Related Macular Degeneration (ARMD) is the leading cause of what blindness? What age group?
- Severe central visual acuity loss
- > 50 y/o
What are the two categories of Age-Related Macular Degeneration (ARMD)?
1) Dry ARMD
or
2) Wet ARMD
Risk factors for ARMD ?
1) Age & Cigarette MC
2) Caucasian
4) Family history
5) Female
6) Hyperopia
7) Light colored eyes
Dry Age-Related Macular Degeneration (ARMD) causes ?
- Slow
- Progressive central vision loss
Dry Age-Related Macular Degeneration (ARMD) findings?
- Drusen
- large density of macular drusen increase risk of ARMD
- Retinal atrophy
- Retinal hyperpigmentation
T or F
Small hard amount of Drusen may be associated with normal aging
- True
Treatment of Dry Age-Related Macular Degeneration (ARMD)?
- AREDS2 eye vitamins
Vitamin E, C & Zinc - Decrease progression to late stage ARMD
Wet Age-Related Macular Degeneration (ARMD)
- Choridal neovascularization
- Subretinal fluid or hemorrhage
- Eventual fibrosis/scarring
Wet Age-Related Macular Degeneration (ARMD) causes ?
- Quick decrease in central acuity
plus
- Metamorphopsia Distorted vision in which a grid of straight lines appears wavy
and/or
- Central scotoma
Grey, black or blind spot in the middle of one’s vision
Wet Age-Related Macular Degeneration (ARMD) treatment includes?
- Anti-VEGF therapy can be effective if initiated BEFORE fibrotic changes
Age Related Macular Degeneration (AMD)
- Breakdown of light-sensitive cells of the macula
- Progressive loss of central vision
- Spares peripheral vision
Retinal Detachments classified as ?
1) Rhegmatogenous
(most common)
2) Tractional
(associated with neovascularization)
3) Exudative
(associated with neoplasia or inflammation)
Rhegmatogenous Retinal Detachment causes?
- Full thickness retinal break
- Secondary to posterior vitreous detachment (PVD)
- Vitreoretinal traction can lead to retinal tears Horseshoe tears
Rhegmatogenous Retinal Detachment (MOST COMMON) symptoms?
- Sudden floater
- Flashes
- “curtain” across vision
Rhegmatogenous Retinal Detachment prognosis ?
- Depends if Macula was detached
- Emergency
- Catastrophic vision loss
Age related Cataract ?
- Pogressive clouding/opacification of crystalline lens
- Due to proteins and lipids
- Leading to decrease in vision
Age related Cataract symptoms ?
- Decrease in visual acuity
- Decrease in contrast sensitivity
- Glare (may have trouble driving at night)
- Change in glasses prescription (myopic shift)
Age related Cataract can be caused by excessive steroid use ?
T of F
- True
Age related Cataract treatment ?
- If interfering with ADLs = Surgery
- Phacoemulsification
Congenital Cataract
- @ birth or develop within first year
- 33% associated with systemic syndrome
- 33% inherited
- 33% undetermined
Congenital Cataract may be unilateral or bilateral, but almost always bilateral in ?
- Systemic disease
or
- Familial
Congenital Cataract must be corrected within the first 3 months after birth?
T or F
- True
Congenital Cataract workup includes?
Bilateral
- If YES FH =
No workup
- If NO FH = Systemic workup for TORCH infections - Toxoplasmosis - Other (syphilis, varicella-zoster, parvovirus B19) - Rubella - Cytomegalovirus (CMV) - Herpes infections
Unilateral
- Typically not warranted
Congenital Cataract timing of surgery important because if Cataracts present prior to development of the fixation reflex (at 2-3 months) it increases the chances of more impact on child’s visual development ?
T or F
- True
- Bilateral cataracts
sensory deprivation nystagmus develops at age 2-3 months, at which point visual potential decreases markedly
Congenital Cataract surgery timing?
- Between months 1-3
- With 1 week interval if bilateral
Glaucoma
- Group of diseases with a characteristic optic neuropathy
- IOP a risk factor BUT not a requirement
- Progressing “Cupping” of the optic nerve, cup gets larger
- Peripheral vision loss
Two types of glaucoma include?
- Open angle
- Closed (Narrow) angle
Acute or Chronic
Eye Aqueous is produced in the ciliary body and then drains where?
- Trabecular meshwork
What is the second leading causes of blindness?
- Glaucoma
Open angle glaucoma risk factors include?
- Most common
- Age
- Vision loss is irreversible
- First periphery and progresses
- Most patients do not appreciate vision loss until central vision is affected
- Family history
- Myopia (nearsightedness)
- Race (African Caribbean)
Acute closed angle glaucoma risk factors include?
- Age
- Female
- Hyperopia (farsightedness)
- Certain medications
- Race (Asian)
Open angle glaucoma is associated with decreased ?
- Efficiency of the trabecular meshwork
- Clogged drain
Closed angle glaucoma is associated with decreased ?
- Access to the trabecular meshwork
- Closed drain
- Chronic form
Acute angle closure glaucoma ?
- Sudden extreme elevation of IOP
- Acute blockage of trabecular meshwork by
iris (anatomically predisposed eye) - Precipitated by dilation/low light conditions
Acute angle closure glaucoma symptoms include?
- Emergency !!!
- Intense pain
- Headache
- Nausea/vomiting
- Decreased vision
- Halos
- Emergent IOP lowering required to prevent
permanent vision loss.
Acute angle closure glaucoma PE findings?
- Red Eye
- Dilated Pupil
- Cloudy cornea
Clinical Presentation of Acute Angle Closure Glaucoma includes?
- Rapidity and Degree of IOP determine the onset and severity of symptoms
- Eye pain
- Decreased vision
- Nausea / vomiting
- Halo around lights
- Headache
Symptoms that suggest a rapid rise in IOP causing acute angle closure ?
- Conjunctiva redness
- Corneal edema or Corneal cloudiness
- Mild dilated pupil that reacts poorly to light
Why is the pupillary sidebar test important?
- Differentiates whether a patient is complaining of
1) Decreased vision from an ocular problem (Cataract)
or
2) Defect of the optic nerve
The ‘swinging light test’ is used to detect ?
- Relative Afferent Pupil Defect (RAPD)
- A means of detecting differences between the two eyes in how they respond to a light shone in one eye at a time.
- The test can be very useful for detecting unilateral or asymmetrical disease of the retina or optic nerve
How do you evaluate for glaucoma ?
- Visual Acuity
- Evaluation of the pupils
- Measure IOP
- Slit lamp examination
of the anterior segments - Visual field testing
How do you evaluate for Specifically Angle-closure Glaucoma if you don’t have a tonometer ?
- Test anterior chamber depth
- By shining a light from the side of the eye
- Darkness on the nasal side = decreased anterior chamber
Management for acute angle closure glaucoma < 1 hour from symptoms?
- Ophthalmologist referral if availability is within 1 hour
Management for acute angle closure glaucoma > 1 hour from symptoms?
- Emperic treatment if availability is greater than 1 hour
- Laser or Surgical iridotomy (GOLD STANDARD)
- IV acetazolamide (carbonic anhydrase inhibitor)
- Topical B blocker
- Mannitol for diuresis
Ultimately
What is the only modifiable risk factor in glaucoma?
- Managing IOP
- lowered via
1) Laser
2) Surgery
3) Medications
Papilledema
- (bilateral) optic disc swelling
- Results from increased intracranial pressure (ICP)
Papilledema causes?
- Tumors / Lesions in CNS
- Idiopathic intracranial hypertension
(aka pseudotumor cerebri) - Decreased CSF resorption
(Venous sinus thrombosis, inflammatory processes, meningitis, subarachnoid hemorrhage) - Increased CSF production (tumors)
- Cerebral edema/encephalitis
- Medications
1) Tetracycline
2) Minocycline
3) Lithium
4) Accutane
5) Nalidixic acid
6) Corticosteroids (both use and withdrawal)
Papilledema symptoms include?
- Transient visual obscurations: “Grayouts” of vision (Orthostatic changes)
- Pulsatile tinnitus
- Diplopia from 6th nerve palsy
- Decreased vision
- Headache
- Nausea, vomiting
Papilledema treatment includes?
- Treat underlining cause
- Neuro and Ophtho consults
- MRI/MRV brain/orbits
- Visual acuity
- Visual fields
- Color vision
- Possible LP with opening pressure
Amblyopia
- Diminished vision occurring during the years of cortical visual development (8 - 10y/o)
- Secondary to abnormal visual stimulation
- Unilateral MC
Amblyopia classifications?
1) Refractive
2) Deprivation
3) Strabismus
Amblyopia Dx can be difficult in children?
T or F
- True
- Children do not complain about baseline vision
Amblyopia screening ?
- PreK visual acuity screening
- Red reflex
- Cover testing
Amblyopia management ?
- Prompt referral and treatment are critical
- If not identified prior to completion of cortical visual development (8 to 10)
- Vision will not improve with any treatment
Amblyopia treatment ?
1) Address underlying cause of amblyopia
2) Force fixation with amblyopic eye via
- Patching
or
- Pharmacologic therapy
Strabismus
- Ocular misalignment
- Due to eye muscle issues
- Children or Adults
Strabismus causes?
- Trauma
- Inflammation
- Infection
- Thyroid/Graves eye disease
Autoimmune / Inflammation
Hypertrophy - Myasthenia Gravis
(Eye muscle neuromuscular junction)
- Dysfunction of cranial nerve 3, 4, or 6 Ischemic Compressive (tumor/aneurysm) Inflammatory Demyelinating (MS)
Strabismus Dx test ?
- Abnormal corneal light reflex
- Cover and Uncover test
Horizontal Strabismus include?
1) Esotropia (ET)
“crossed inward eyes”
2) Exotropia (XT)
“wandering/drifting outward eye”
Vertical strabismus include?
1) Left hypertropia (LHT)
Describe the hypertropic eye
2) Right hypotropia
Child Strabismus treatment?
- Before the ages of 8 - 10
- Eye exercises with patch therapy or surgery
- Patch good eye
Adult Strabismus
- Emergency
- > 50
- F > M
- 3rd nerve palsy
- Giant cell arteritis (temporal arteritis)
Adult Strabismus presentation ?
- Limitation of Supraduction
Infraduction and Adduction
As well as
1) Ptosis and Pupillary dysfunction
&
2) Dilated pupil (10% of pts)
Adult Strabismus can be partial or complete ?
- True
Complete adult strabismus presents?
- Upper Eye lid down
- Eye down and out
Causes of Adult strabismus ?
- Aneurysm MC
- Microvascular disease
- Infarct
- Tumor
- Inflammation
- Infection
- Infiltration
- Trauma
T or F
Adult strabismus - 3rd nerve palsy can be the first sign of expanding or rupturing aneurysm located at junction of posterior communicating artery and internal carotid artery?
- True
- Therefore, emergent consultation and imaging (MRA or CTA) are warranted
Giant cell arteritis (temporal arteritis) can be a cause of adult strabismus?
T or F
- True
- Transient or Constant binocular strabismus
- Tender temporal artery = Bx
Adult Strabismus - Giant cell arteritis (temporal arteritis S&S?
- Emergency
- Tender temporal artery
- Malaise
- Fever
- Jaw claudication
- HA
- Anorexia
- Wt loss
- Joint/muscle pain
Adult Strabismus - Giant cell arteritis (temporal arteritis work up includes?
- ESR (elevated)
- CRP (elevated)
- CBC (thrombocytosis, normaochromic normocytic anemia)
+/- temporal artery biopsy
Adult Strabismus - Giant cell arteritis (temporal arteritis treatment includes?
- High dose steroids
- Slow taper x 1-2 years
Adult Strabismus Dx includes?
- Abnormal corneal light reflex (Red Reflex) Test
- Cover and uncover test
