Ophthalmology Flashcards
1
Q
what sinuses are present at birth?
A
maxillary and ethmoid sinuses
2
Q
at what age do we get frontal sinuses? sphenoid?
A
age 7 for frontal
adolescence for sphenoid
3
Q
What cranial nerve controls Lateral rectus muscle and superior oblique?
A
LR6SO4
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
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
6
Q
what is the orbital septum
A
the divider between orbital cellulitis and preseptal cellulitis
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
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
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)
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
11
Q
what is the differential for ptosis
A
- 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
12
Q
what is the main eyelid elevation muscle?
A
levator palpebrae superioris
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
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
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)
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
17
Q
where is the lens?
A
in the pupil
cannot see the lens
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
19
Q
what is anisocoria?
A
difference in pupil size
20
Q
what is the differential for anisocoria?
A
physiologic pharmacologic mechanical (trauma, inflammation) horners CN III palsy adie (not common in peds)
21
Q
where is the anterior chamber located?
A
in front of the iris behind the cornea
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
23
Q
what are two causes of unequal red reflex
A
unequal refractive error
strabismus
24
Q
who is at risk for retinopathy of prematurity
A
age <31 weeks (any weight)
birth weight less than 1250g
25
what are the main treatments for retinopathy of prematurity
anti-VEGF
| laser ablation of avascular retina
26
what is the most common intraocular malignancy of childhood?
retinoblastoma
27
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
```
28
what is papilledema
optic disc edema with raised intracranial pressure
normal visual acuity
bilateral (almost always)
29
what is the most likely visual field defect arising from a large pituitary macro adenoma?
bitemporal hemianopsia
30
Name 3 causes of amblyopia
1. stimulus deprivation (ex: cataract, ptosis)
2. strabismus
3. unequal refractive error
31
name 2 treatment options for strabismus
patching
| atropine drops
32
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
```
33
```
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
34
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
```
35
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
36
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
37
what should you think of for major ptosis? minor ptosis?
Major ptosis- CN III (levator palpebrae superioris)
| minor ptosis- mueller muscle- sympathetics
38
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
```
39
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
40
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
41
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
42
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
43
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
44
how does the eye look with a cranial nerve III palsy
down and out
| upper lid ptosis, exotropia, hypotonia, pupil dilation
45
how does the eye look for a cranial nerve IV palsy
hypertrophic on affected side on cover test
46
how does the eye look for a cranial nerve VI palsy
esotropia with abduction deficit on affected side
47
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
48
what is a congenital/infantile cataract?
opacification of the crystalline lens
| tx= surgical + visual rehabilitation
49
what are the two treatment option for corneal abrasion
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
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
51
when do we stop screening for ROP?
when retinal vascular development completed
ROP regressed
no treatment needed by 45 weeks corrected gestational age
52
premature infants are at risk of what eye problems
amblyopia
strabismus
refractive error
53
what visual field defect is seem with suprasellar/pituitary mass?
bitemporal hemianopia
54
what visual field defect is seem with optic tract lesion?
homonymous hemianopia
55
what visual field defect is seem with parietal lobe lesion
inferior quadrantanopia
56
what visual field defect is seem with temporal lobe lesion
superior quandrantanopia
57
what visual field defect is seem with occipital cortex lesion
homonymous hemianopia with sparing of fovea
58
what test is used to differentiate between strabismus and pseudostrabismus
cover test
59
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
60
What is the differential diagnosis for esotropia? (3)
infantile esotropia
accommodative esotropia
pseudo strabismus
CN VI palsy
61
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
62
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!!!)
63
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
64
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
```
65
at what age should you be able to fix and follow?
3 months
66
at what age should you react to bright light (blink, grimace)
6 weeks
67
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)
68
what are some signs on physical exam of congenital blindness?
roving eye movements
no visual response
oculo-digital sign
paradoxical pupillary response
69
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
```
70
what tests should you do to assess for strabismus
cover test
Bruckner red reflex
corneal light reflex (Hirschberg light reflex)
71
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
72
what is infantile esotropia?
onset before 6 months of age
large angle
needs strabismus surgery
73
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
```
74
how might someone with superior oblique palsy present?
head tilt
| tilt towards shoulder of unaffected side
75
what is anisometropia?
difference in refraction between the eyes
76
what is the most common cause of vision loss in children?
amblyopia
77
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
78
what are the treatment options for cataract?
intraocular lens implant
aphakic contact lenses
aphakic glasses
79
what are some causes of cataract?
```
idiopathic
rubella
trauma (accidental or non accidental)
uveitis
persistent fetal vasculature
```
if bilateral- steroids, radiation, galactosemia
80
what percentage of the population have anisocoria?
20%
81
what is the most common pediatric orbital malignancy? how do they present?
rhabdomyosarcoma
average age 5-7
rapid proptosis, but eye white/quiet
82
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
83
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)
84
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
```
85
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
86
how do you properly assess refractive error?
cycloplegia refraction (eye exam with dilating drops)
87
what percentage of newborns have retinal hemorrhages?
25% SVD
40-50% forceps/vacuum
typically resolve in about 10 days
NO long term complications
88
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
89
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
90
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
91
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
