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Pediatrics- Noelle > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

what sinuses are present at birth?

A

maxillary and ethmoid sinuses

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2
Q

at what age do we get frontal sinuses? sphenoid?

A

age 7 for frontal

adolescence for sphenoid

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3
Q

What cranial nerve controls Lateral rectus muscle and superior oblique?

A

LR6SO4

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4
Q

what is the most common wall of the orbit to break? 2nd most common?

A

the medial wall of the orbit is the thinnest and easiest to break with blunt injury
the 2nd most common fracture is the orbital floor- and can cause interior rectus entrapment

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5
Q

what is the treatment for orbital cellulitis

A

cefuroxime IV for 2-7 days
followed by amox-clav for a total of 14 days of antibiotics
tx underlying sinus condition- nasal decongestant
emergency referral to ophthalmologist
drainage of an orbital access is NOT usually needed
consider urgent drainage if vision threatened or superior subperiosteal abscess

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6
Q

what is the orbital septum

A

the divider between orbital cellulitis and preseptal cellulitis

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7
Q

what are the features of orbital cellulitis

A 
sick child
fever
white count
limited painful extra ocular movements
red eye
imaging: sinus opacification (usually caused by bacterial sinusitis), subperiosteal abscess, periorbital fat stranding
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8
Q

what are the features of preseptal cellulitis

A 
history of lid wound, bite
spread beyond the septum
well-looking patient
no fever
white eye
full eye movements with no pain (extra ocular muscles are not affected)
imaging- no sinus opacification
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9
Q

what does cranial nerve 7 do for the eye

A

closes the eye lid (shaped like a hook for it pulls the eyelid down)

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10
Q

what cranial nerve keeps the eye lid up

A

cranial nerve 3 (columns holding the eyelids up)

sympathetics- lift eye just a little

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11
Q

what is the differential for ptosis

A
  1. congenital - dystrophic levator palpebrae superioris muscle
  2. mechanical- hemangioma (tx= systemic beta blockers)
  3. traumatic
  4. myogenic- muscular dystrophy
  5. neuromyogenic- myasthenia gravis
  6. Neurogenic- cranial nerve 3 palsy
  7. idiopathic
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12
Q

what is the main eyelid elevation muscle?

A

levator palpebrae superioris

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13
Q

what is blepharitis? complications?

A

eyelid margin inflammation
anterior- crusting, microscopic dandruff like debris at eyelid margin
posterior- meibomian gland dysfunction, leads to blocked glands
complications- conjunctivitis, corneal ulcer

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14
Q

what is the differential for eyelid infection?

A

blepharitis- eyelid margin inflammation often associated with meibomian gland dysfunction
chalazion
hordeolum
orbital cellulitis/ preseptal cellulitis

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15
Q

what is the treatment for dacrocystocele

A

most resolve conservatively but have to keep a close eye on it
definitive management= surgical (probing or break open the sac)

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16
Q

what is the differential for conjunctivitis

A 
infection- viral (watery to mucoid), bacterial (purulent)- typically community-acquired is self limited (~70% improvement by 48 hours) therefore any topical antibiotic at appropriate dose x 7 days is effective
inflammation- minimal discharge
allergic- watery and itchy
keratitis- pain, white spot on cornea
iritis- red ring around the iris
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17
Q

where is the lens?

A

in the pupil

cannot see the lens

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18
Q

what is the triad of horners syndrome

A

SMALL upper lid ptosis
miosis (small pupil)- fails to dilate in dim light
anhydrosis- lack of sweating
in congenital Horner syndrome= iris heterochromia

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19
Q

what is anisocoria?

A

difference in pupil size

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20
Q

what is the differential for anisocoria?

A 
physiologic 
pharmacologic
mechanical (trauma, inflammation)
horners
CN III palsy
adie (not common in peds)
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21
Q

where is the anterior chamber located?

A

in front of the iris behind the cornea

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22
Q

what examination must be done to look for uveitis

A

need slit lamp examination (look for white blood cells in the anterior chamber)
uveitis is asymptomatic, no red eye, no pain
early systemic treatment is key to success
if left untreated= blindness

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23
Q

what are two causes of unequal red reflex

A

unequal refractive error

strabismus

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24
Q

who is at risk for retinopathy of prematurity

A

age <31 weeks (any weight)

birth weight less than 1250g

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25
Q

what are the main treatments for retinopathy of prematurity

A

anti-VEGF

laser ablation of avascular retina

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26
Q

what is the most common intraocular malignancy of childhood?

A

retinoblastoma

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27
Q

how does someone with glaucoma present?

A 
cloudy cornea, photophobia and tearing
do not want to open their eyes
tearing
- fluid in the anterior chamber and it can't escape
untreated leads to blindness
definitive tx= surgical
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28
Q

what is papilledema

A

optic disc edema with raised intracranial pressure
normal visual acuity
bilateral (almost always)

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29
Q

what is the most likely visual field defect arising from a large pituitary macro adenoma?

A

bitemporal hemianopsia

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30
Q

Name 3 causes of amblyopia

A
  1. stimulus deprivation (ex: cataract, ptosis)
  2. strabismus
  3. unequal refractive error
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31
Q

name 2 treatment options for strabismus

A

patching

atropine drops

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32
Q

what is strabismus?

A 
ocular misalignment of any kind
by definition it is BILATERAL
esotropia- eye turned in
exotropia- eye turned out
hypertrophic- abnormal eye higher
hypotropia- abnormal eye lower
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33
Q 
What is normal visual development
>31 weeks
<1 week
6-8 weeks
2-3 months
3-4 months
A

> 31 weeks: pupil response to light
<1 week: blink/aversion to bright light
6-8: eye contact and react to facial expressions
2-3 months: interest in bright objects
3-4 months: eyes properly aligned (no strabismus)
fix and follow toy

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34
Q

what are some red flags for vision at >3-4 months

A 
visually disinterested +/- stares at bright lights
forcefully rubs/pokes eyes
strabismus
nystagmus/searching eye movements
disconjugate eye movements
skew deviation
sunsetting
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35
Q

what is white eyed blowout

A

trapdoor orbital floor fracture in young child
globe and eyelid may appear fairly normal
entrapment leading to compartment syndrome of inferior rectus muscle
present with pain and nausea in attempted upgaze
requires emergency surgery

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36
Q

how would a patient with a cranial nerve 7 (orbicularis) palsy present

A

unable to close eyelid
dry eye
if severe= corneal exposure leads to ulcer then blindness

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37
Q

what should you think of for major ptosis? minor ptosis?

A

Major ptosis- CN III (levator palpebrae superioris)

minor ptosis- mueller muscle- sympathetics

38
Q

what is the most common cause of ptosis

A 
congenital/infantile ptosis
- congenital dystrophy of levator palpebrae superioris
usually isolated
unilateral or bilateral
large or minimal
39
Q

what is the most important pediatric cause of mechanical ptosis?

A

infantile hemangioma of upper eyelid
rapid growth within first few months of life= occlusion amblyopia
tx: beta blockers= po propranolol

40
Q

what is a stye? how do they present? tx?

A

acute infection of eyelid gland
red, swollen, tender eyelid mass
tx: ALWAYS warm compresses as much as possible
topical antibiotics are useless in the treatment of the current lesion, may help prevent new lesions by reducing blepharitis

41
Q

what is a chalazion? how do they present? tx?

A

chronic inflammation of meibomian gland
firm eyelid mass, non-tender when chronic
tx: ALWAYS warms compresses as much as possible
topical antibiotics are useless in the treatment of the current lesion, may help prevent new lesions by reducing blepharitis
Surgical incision and drainage prin if symptoms persist for months

42
Q

what is orbital cellulitis

A

inflammation of eyelid tissue POSTERIOR to the orbital septum
typically bacterial extension of sinusitis (Especially ethmoid) to orbit
often concurrent or following upper respiratory tract infection

43
Q

what is congenital nasolacrimal duct obstruction? what is the treatment? when does it usually resolve?

A

incomplete canalization of distal nasolacrimal duct
It is usually caused by persistence of a membrane at the distal valve of Hasner
unilateral or bilateral tearing with episodes of acute on chronic mucopurulent conjunctivitis
common but typically spontaneously resolves by 12 months
tx: nasolacrimal duct massage- crigler massage
surgical nasolacrimal duct probing +/- silicone stent after 9-12 months pro
no surgery if symptoms are intermittent

44
Q

how does the eye look with a cranial nerve III palsy

A

down and out

upper lid ptosis, exotropia, hypotonia, pupil dilation

45
Q

how does the eye look for a cranial nerve IV palsy

A

hypertrophic on affected side on cover test

46
Q

how does the eye look for a cranial nerve VI palsy

A

esotropia with abduction deficit on affected side

47
Q

What is hyphema?

  • treatment?
  • major possible long-term complication?
A 
microscopic (seen only on slit lamp) or gross blood in anterior chamber
almost always due to trauma
tx: restrict activity
shield to protect eye
topical cycloplegia and steroid drops

Blood in the anterior chamber of the eye from blunt or perforating trauma

  • treatment: rest, NO MOVEMENT AT ALL because might increase risk of rebleeding and increased intraocular pressure
    1. Bedrest
    2. HOB elevated
    3. May need hospitalization and sedation if kid is freaking out
    4. Can use topical steroids to decrease risk of rebleeding
    5. In rebleeding, may need to evacuate clot

Major complication: increased risk of glaucoma

48
Q

what is a congenital/infantile cataract?

A

opacification of the crystalline lens

tx= surgical + visual rehabilitation

49
Q

what are the two treatment option for corneal abrasion

A
  1. Topical cycloplegic agent to relieve pain from ciliary spasm (not for home use) = ONLY for slit lamp exam
  2. Topical antibiotic ointment until healed (do not use topical aminoglycosides or topical steroids as this increases risk of corneal ulceration)

**do not use semipressure patch since it can itself abrade the cornea and doesn’t help healing time

50
Q

what infants do we screen for ROP?

A

<31 weeks regardless of birth weight
BW<1250g
begin screening at 31 weeks if gestational age <27 weeks
4 weeks after birth if gestational age = or >27 weeks

51
Q

when do we stop screening for ROP?

A

when retinal vascular development completed
ROP regressed
no treatment needed by 45 weeks corrected gestational age

52
Q

premature infants are at risk of what eye problems

A

amblyopia
strabismus
refractive error

53
Q

what visual field defect is seem with suprasellar/pituitary mass?

A

bitemporal hemianopia

54
Q

what visual field defect is seem with optic tract lesion?

A

homonymous hemianopia

55
Q

what visual field defect is seem with parietal lobe lesion

A

inferior quadrantanopia

56
Q

what visual field defect is seem with temporal lobe lesion

A

superior quandrantanopia

57
Q

what visual field defect is seem with occipital cortex lesion

A

homonymous hemianopia with sparing of fovea

58
Q

what test is used to differentiate between strabismus and pseudostrabismus

A

cover test

59
Q

when should you refer a child with strabismus

A

it is normal to have intermittent strabismus during the first 3 months of life
refer if large angle, constant strabismus
if associated with leukocoria
acute cranial nerve palsy
other acute neurology symptoms/signs

60
Q

What is the differential diagnosis for esotropia? (3)

A

infantile esotropia
accommodative esotropia
pseudo strabismus
CN VI palsy

61
Q

A 5 mo baby presents to you with ptosis. Her mother says she has been this way since birth. Her extraocular movements and pupillary light reflexes are normal. What is your diagnosis?

A

Congenital dystrophy of levator palpebrae superioris muscle = innervated by CN3 which is working normally but the muscle is not functioning

62
Q

What is the most common source of infection for periorbital cellulitis? What about orbital cellulitis?

A

Periorbital cellulitis is USUALLY from an external infection (ie. scratch in the skin) whereas orbital cellulitis is USUALLY from an internal infection (ie. from sinusitis!!!)

63
Q

What are 2 complications of untreated anterior uveitis?

-treatment for anterior uveitis?

A

o Cataract
o Glaucoma
o Blindness
Treatment
o Systemic immunosuppression –initiate early
o Steroids - minimize topical/local steroid
therapy as much as possible to limit complications

64
Q

What is myopia? Heteropia?

A 
Myopia = near sighted! (MN)
image is focused in front of retina
Heterotrpia = far sighted (HF) 
image focused behind the retina
-letters closer together
65
Q

at what age should you be able to fix and follow?

A

3 months

66
Q

at what age should you react to bright light (blink, grimace)

A

6 weeks

67
Q

what are some ways to assess vision

A

teller acuity cards (3-4 months onwards)
Cardiff cards (Earliest= 18 months)
Preverbal- matching (Lea symbols, HOTV, tumbling E)
Age 4-5 (ETDRS, snellen chart)

68
Q

what are some signs on physical exam of congenital blindness?

A

roving eye movements
no visual response
oculo-digital sign
paradoxical pupillary response

69
Q

causes of congenital blindness?

A 
Little Albert Can't C
L- LCA (leber's congenital amaurosis)
A- albinism
C- CSNB congenital stationary night blindness
A- achromatopsia
N- nerve (optic nerve hypoplasia)
T- TORCH infections
C- cortical visual impairment
70
Q

what tests should you do to assess for strabismus

A

cover test
Bruckner red reflex
corneal light reflex (Hirschberg light reflex)

71
Q

what is pseudoesotropia?

A

the wide nasal bridge and EPICANTHAL FOLDS create the illusion of crossed eyes
the light reflex falls on the centre of the cornea in each eye
does NOT need any treatment

72
Q

what is infantile esotropia?

A

onset before 6 months of age
large angle
needs strabismus surgery

73
Q

what is the differential for exotropia

A 
intermittent exotropia (most common)- present when tired or not paying attention, lose binocular vision when exotropia present
cranial nerve III palsy
74
Q

how might someone with superior oblique palsy present?

A

head tilt

tilt towards shoulder of unaffected side

75
Q

what is anisometropia?

A

difference in refraction between the eyes

76
Q

what is the most common cause of vision loss in children?

A

amblyopia

77
Q

what are the treatment options for amblyopia

A

patching
atropine drops
safety glasses if vision in worse eye <20/50
treat underlying ethology (ie cataract)
refractive error correction- spectacles/ contact lenses
behavioural training

78
Q

what are the treatment options for cataract?

A

intraocular lens implant
aphakic contact lenses
aphakic glasses

79
Q

what are some causes of cataract?

A 
idiopathic
rubella
trauma (accidental or non accidental)
uveitis
persistent fetal vasculature

if bilateral- steroids, radiation, galactosemia

80
Q

what percentage of the population have anisocoria?

A

20%

81
Q

what is the most common pediatric orbital malignancy? how do they present?

A

rhabdomyosarcoma
average age 5-7
rapid proptosis, but eye white/quiet

82
Q

juvenile idiopathic arthritis is associated with what type of uveitis? who gets acute anterior uveitis?

A

chronic anterior uveitis
ASYMPTOMATIC SO SCREENING EXAMS ARE ESSENTIAL

acute anterior uveitis= iritis
pain, photophobia, decreased visual acuity
associated with >12, HLA B27, spondyloarthropathy associated

83
Q

what would you see with retinal examination for non-accidental trauma?

A

multiple bilateral diffuse multilayered hemorrhages
hemorrhages CANNOT be dated
need systemic workup to rule out other causes (leukaemia, hemophilia)

84
Q

what is the gene mutation associated with retinoblastoma?

how does it present

A 
RB1 gene mutation
malignant tumor of developing retinal cells
commonly presents as leukocoria
decreased vision
strabismus
untreated leads to blindness and death
85
Q

name one cause of optic disc edema besides increased ICP

A

acute autoimmune optic neuritis

severe acute unilateral visual acuity loss WITH afferent pupil defect and loss of colour vision

86
Q

how do you properly assess refractive error?

A

cycloplegia refraction (eye exam with dilating drops)

87
Q

what percentage of newborns have retinal hemorrhages?

A

25% SVD
40-50% forceps/vacuum
typically resolve in about 10 days
NO long term complications

88
Q

newborn to 3 months of age what vision screening should be done?

A

a complete examination of the skin and external eye structures
red reflex
failure of visualization or abnormal red reflex are indications for urgent referral to an ophthalmologist
high risk newborns (at risk of retinopathy or prematurity and family history of hereditary ocular diseases) should be examined by an ophthalmologist

89
Q

6-12 months of age what vision screening should be done?

A

a complete examination of the skin and external eye structures
red reflex
***assess for strabismus: corneal light reflex, cover test
fixation and following a target are observed

90
Q

3-5 years of age what vision screening should be done?

A

a complete examination of the skin and external eye structures
red reflex
assess for strabismus: corneal light reflex, cover test
fixation and following a target are observed
** visual acuity testing should be completed with an age-appropriate tool

91
Q

6-18 years of age what vision screening should be done?

A

screen as for 3-5 years whenever routine health examinations are conducted or whenever complaints occur

a complete examination of the skin and external eye structures
red reflex
assess for strabismus: corneal light reflex, cover test
fixation and following a target are observed
visual acuity testing should be completed with an age-appropriate tool

Pediatrics- Noelle (28 decks)

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