Ophthalmology Flashcards
what sinuses are present at birth?
maxillary and ethmoid sinuses
at what age do we get frontal sinuses? sphenoid?
age 7 for frontal
adolescence for sphenoid
What cranial nerve controls Lateral rectus muscle and superior oblique?
LR6SO4
what is the most common wall of the orbit to break? 2nd most common?
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
what is the treatment for orbital cellulitis
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
what is the orbital septum
the divider between orbital cellulitis and preseptal cellulitis
what are the features of orbital cellulitis
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
what are the features of preseptal cellulitis
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
what does cranial nerve 7 do for the eye
closes the eye lid (shaped like a hook for it pulls the eyelid down)
what cranial nerve keeps the eye lid up
cranial nerve 3 (columns holding the eyelids up)
sympathetics- lift eye just a little
what is the differential for ptosis
- congenital - dystrophic levator palpebrae superioris muscle
- mechanical- hemangioma (tx= systemic beta blockers)
- traumatic
- myogenic- muscular dystrophy
- neuromyogenic- myasthenia gravis
- Neurogenic- cranial nerve 3 palsy
- idiopathic
what is the main eyelid elevation muscle?
levator palpebrae superioris
what is blepharitis? complications?
eyelid margin inflammation
anterior- crusting, microscopic dandruff like debris at eyelid margin
posterior- meibomian gland dysfunction, leads to blocked glands
complications- conjunctivitis, corneal ulcer
what is the differential for eyelid infection?
blepharitis- eyelid margin inflammation often associated with meibomian gland dysfunction
chalazion
hordeolum
orbital cellulitis/ preseptal cellulitis
what is the treatment for dacrocystocele
most resolve conservatively but have to keep a close eye on it
definitive management= surgical (probing or break open the sac)
what is the differential for conjunctivitis
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
where is the lens?
in the pupil
cannot see the lens
what is the triad of horners syndrome
SMALL upper lid ptosis
miosis (small pupil)- fails to dilate in dim light
anhydrosis- lack of sweating
in congenital Horner syndrome= iris heterochromia
what is anisocoria?
difference in pupil size
what is the differential for anisocoria?
physiologic pharmacologic mechanical (trauma, inflammation) horners CN III palsy adie (not common in peds)
where is the anterior chamber located?
in front of the iris behind the cornea
what examination must be done to look for uveitis
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
what are two causes of unequal red reflex
unequal refractive error
strabismus
who is at risk for retinopathy of prematurity
age <31 weeks (any weight)
birth weight less than 1250g
what are the main treatments for retinopathy of prematurity
anti-VEGF
laser ablation of avascular retina
what is the most common intraocular malignancy of childhood?
retinoblastoma
how does someone with glaucoma present?
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
what is papilledema
optic disc edema with raised intracranial pressure
normal visual acuity
bilateral (almost always)
what is the most likely visual field defect arising from a large pituitary macro adenoma?
bitemporal hemianopsia
Name 3 causes of amblyopia
- stimulus deprivation (ex: cataract, ptosis)
- strabismus
- unequal refractive error
name 2 treatment options for strabismus
patching
atropine drops
what is strabismus?
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
What is normal visual development >31 weeks <1 week 6-8 weeks 2-3 months 3-4 months
> 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
what are some red flags for vision at >3-4 months
visually disinterested +/- stares at bright lights forcefully rubs/pokes eyes strabismus nystagmus/searching eye movements disconjugate eye movements skew deviation sunsetting
what is white eyed blowout
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
how would a patient with a cranial nerve 7 (orbicularis) palsy present
unable to close eyelid
dry eye
if severe= corneal exposure leads to ulcer then blindness
what should you think of for major ptosis? minor ptosis?
Major ptosis- CN III (levator palpebrae superioris)
minor ptosis- mueller muscle- sympathetics
what is the most common cause of ptosis
congenital/infantile ptosis - congenital dystrophy of levator palpebrae superioris usually isolated unilateral or bilateral large or minimal
what is the most important pediatric cause of mechanical ptosis?
infantile hemangioma of upper eyelid
rapid growth within first few months of life= occlusion amblyopia
tx: beta blockers= po propranolol
what is a stye? how do they present? tx?
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
what is a chalazion? how do they present? tx?
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
what is orbital cellulitis
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
what is congenital nasolacrimal duct obstruction? what is the treatment? when does it usually resolve?
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
how does the eye look with a cranial nerve III palsy
down and out
upper lid ptosis, exotropia, hypotonia, pupil dilation
how does the eye look for a cranial nerve IV palsy
hypertrophic on affected side on cover test
how does the eye look for a cranial nerve VI palsy
esotropia with abduction deficit on affected side
What is hyphema?
- treatment?
- major possible long-term complication?
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
what is a congenital/infantile cataract?
opacification of the crystalline lens
tx= surgical + visual rehabilitation
what are the two treatment option for corneal abrasion
- Topical cycloplegic agent to relieve pain from ciliary spasm (not for home use) = ONLY for slit lamp exam
- 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
what infants do we screen for ROP?
<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
when do we stop screening for ROP?
when retinal vascular development completed
ROP regressed
no treatment needed by 45 weeks corrected gestational age
premature infants are at risk of what eye problems
amblyopia
strabismus
refractive error
what visual field defect is seem with suprasellar/pituitary mass?
bitemporal hemianopia
what visual field defect is seem with optic tract lesion?
homonymous hemianopia
what visual field defect is seem with parietal lobe lesion
inferior quadrantanopia
what visual field defect is seem with temporal lobe lesion
superior quandrantanopia
what visual field defect is seem with occipital cortex lesion
homonymous hemianopia with sparing of fovea
what test is used to differentiate between strabismus and pseudostrabismus
cover test
when should you refer a child with strabismus
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
What is the differential diagnosis for esotropia? (3)
infantile esotropia
accommodative esotropia
pseudo strabismus
CN VI palsy
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?
Congenital dystrophy of levator palpebrae superioris muscle = innervated by CN3 which is working normally but the muscle is not functioning
What is the most common source of infection for periorbital cellulitis? What about orbital cellulitis?
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!!!)
What are 2 complications of untreated anterior uveitis?
-treatment for anterior uveitis?
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
What is myopia? Heteropia?
Myopia = near sighted! (MN) image is focused in front of retina Heterotrpia = far sighted (HF) image focused behind the retina -letters closer together
at what age should you be able to fix and follow?
3 months
at what age should you react to bright light (blink, grimace)
6 weeks
what are some ways to assess vision
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)
what are some signs on physical exam of congenital blindness?
roving eye movements
no visual response
oculo-digital sign
paradoxical pupillary response
causes of congenital blindness?
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
what tests should you do to assess for strabismus
cover test
Bruckner red reflex
corneal light reflex (Hirschberg light reflex)
what is pseudoesotropia?
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
what is infantile esotropia?
onset before 6 months of age
large angle
needs strabismus surgery
what is the differential for exotropia
intermittent exotropia (most common)- present when tired or not paying attention, lose binocular vision when exotropia present cranial nerve III palsy
how might someone with superior oblique palsy present?
head tilt
tilt towards shoulder of unaffected side
what is anisometropia?
difference in refraction between the eyes
what is the most common cause of vision loss in children?
amblyopia
what are the treatment options for amblyopia
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
what are the treatment options for cataract?
intraocular lens implant
aphakic contact lenses
aphakic glasses
what are some causes of cataract?
idiopathic rubella trauma (accidental or non accidental) uveitis persistent fetal vasculature
if bilateral- steroids, radiation, galactosemia
what percentage of the population have anisocoria?
20%
what is the most common pediatric orbital malignancy? how do they present?
rhabdomyosarcoma
average age 5-7
rapid proptosis, but eye white/quiet
juvenile idiopathic arthritis is associated with what type of uveitis? who gets acute anterior uveitis?
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
what would you see with retinal examination for non-accidental trauma?
multiple bilateral diffuse multilayered hemorrhages
hemorrhages CANNOT be dated
need systemic workup to rule out other causes (leukaemia, hemophilia)
what is the gene mutation associated with retinoblastoma?
how does it present
RB1 gene mutation malignant tumor of developing retinal cells commonly presents as leukocoria decreased vision strabismus untreated leads to blindness and death
name one cause of optic disc edema besides increased ICP
acute autoimmune optic neuritis
severe acute unilateral visual acuity loss WITH afferent pupil defect and loss of colour vision
how do you properly assess refractive error?
cycloplegia refraction (eye exam with dilating drops)
what percentage of newborns have retinal hemorrhages?
25% SVD
40-50% forceps/vacuum
typically resolve in about 10 days
NO long term complications
newborn to 3 months of age what vision screening should be done?
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
6-12 months of age what vision screening should be done?
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
3-5 years of age what vision screening should be done?
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
6-18 years of age what vision screening should be done?
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
