Ophthalmology Flashcards
1
Q
Eye vitals
A
- Visual acuity
- Intraocular pressure (10-21)
- Pupils
2
Q
Red flags
A
- Decreased vision
- Haloes
- Pain
3
Q
Pin Hole occluder
A
Focuses light - this stops defects (errors of refraction)
USE = differentiate refractive errors vs other visual defects
IMPROVES = cornea or lens
NO IMPROVEMENT = retina or optic nerve
4
Q
PERRLA
RAPD
A
Pupils equal, round, reactive to light and accommodation
Relative afferent pupillary defect
5
Q
7 step approach to eye trauma
A
Mechanism of injury (blunt, sharp, foreign body, chemical - alkali worst than acid, because it goes right through vs. acid coagulates the tissue) Visual Acuity Pupils Cornea & Conjunctiva Fluorescein Anterior chamber Iris
6
Q
Visual acuity
A
Chart – fingers – movements – light perception
7
Q
Ocular trauma red flags
A
Loss of vision Loss of red reflex Flat anterior chamber* Tear shaped pupil* Uveal prolapse* **last 3 are clinical signs of globular rupture
8
Q
Cornea and Conjunctiva
A
Fluorescein stain
9
Q
Ciliary flush
A
= circular pattern
Causes:
Traumatic iritis
Hyphema
10
Q
Corneal laceration
A
Whitish lesion
“Tearing”
Requires glue or suturing
If underlying sclera normal
Not serious
No suturing
11
Q
Retrobulbar hemorrhage
A
- Acute proptosis**
- Lid Swelling
- Often limited EOMs
- Pain
- Loss of vision
- Loss of pupillary reaction
- Urgent treatment required to save optic nerve
- Topical and systemic IOP lowering meds
- Canthotomy and cantholysis
12
Q
Hyphema, Microhyphema
A
- *blunt trauma
- Limit activity
- HOB elevated allows RBCs to settle inferiorly and clot; prevents further clogging of trabecular meshwork
- No ASA or NSAIDs
- Shield
- Ophthalmologist to monitor IOP and control inflammation with steroids
13
Q
Ruptured globe
A
- Don’t push on the globe
- Do not take an IOP!!
- Shield
- NO patch
- Treat nausea and vomiting
- Limit activity
- Get patient to OR
- Remove non viable tissue
- Gently reposition prolapsed tissue
14
Q
Non-traumatic red eye
A
- Infectious
- Inflammatory
- Other
15
Q
Infectious red eye
A
Infectious:
- Conjunctivitis
- Viral
- Bacterial
- Keratitis (cornea)
- Contact lens related
- Bacterial
- Viral (Herpes Simplex)
- Cellulitis
- Orbital
- Periorbital
16
Q
Inflammatory red eye
A
Iritis
Episcleritis
Scleritis
Blepharitis
17
Q
Other red eye
A
Subconjunctival hemmorrhage
Allergic conjunctivitis
Acute glaucoma
Spontaneous erosion
18
Q
DO NOT MISS RED EYE
A
- infectious keratitis
- orbital cellulitis
- acute glaucoma
19
Q
Bacterial conjonctivitis
A
- Sx: tearing, foreign body sensation, stinging, photophobia, blurry vision
- S: discharge (purulent)
20
Q
Neonatal conjunctivitis
A
During first month of life *Gonococcus (within 24hrs); ceftriazone IV *Chlamydia (1-2w); erythromycin PO Erythromycin ointment as prophylaxis Culture and systemic therapy required
21
Q
Chlamydial Conjunctivitis
A
Sexually active adolescents/adults
Unilateral
Follicular reaction
Chronic (>3 weeks)
MicroTrak kit
Oral azythromycin (1g x1) or doxycycline (100mg BID)
*Chlamydia sensitive to tetracyclines and macrolides
22
Q
Bacterial Conjunctivitis: Organisms
A
- Children
- Hemophilus
- Strep Pneumoniae
- Staphylococcus
- Adults
- Strep Pneumoniae
- Staphylococcus
- Hemophilus
23
Q
Viral conjunctivitis
A
Very common, Adults and children
- Symptoms: Tearing, Foreign body sensation, Photophobia, Blurry Vision
- Signs: Discharge, Watery, Follicles, Pre-auricular node, Submandibular & cervical
Ask About: Red eye contact, URTI symptoms
Etiology: Adenovirus; hx of rhinorrhea, sore throat (pharyngitis); unilateral – bilateral
Investigations: None required
Therapy: No specific therapy, Cool compresses, Artificial tears
Very contagious, Hand washing, Stay away from work until asymptomatic
24
Q
Infectious Keratitis
A
Symptoms: Pain, Reduced Vision
Signs: White corneal infiltrate (ulcer), Flourescein uptake (epi defect), Discharge, Anterior Chamber Reaction
Ask About: Contact lens use
Etiology: Staphylococcus, Pseudomonas (Contact lens wearer), Strep. Pneumo
Associations: Lid or Conjunctival Disease, Sterile immunologic infiltrate
Large/Central Ulcer: Urgent referral (same day), Culture, Fortified Drops, Tobra / Vanco
Small/Peripheral Ulcer: Next day referral, Fluoroquinolone monotherapy, Moxifloxacin, No culture required
25
Cellulitis
Agents: staph and strep (hemophilus in non-immunized children)
When in doubt: CT to differentiate from orbital cellulitis
Normal: Vision, Position, Movement
26
Periorbital Cellulitis
```
Management
Oral antibiotics (mild): Amox/Clav
```
```
IV antibiotics (moderate-to-severe):
Pip-Tazo + Vanco
```
27
Orbital Cellulitis
Vision- and potentially life-threatening
Etiology: Sinusitis (MC), Trauma / surgery, Vascular extension (i.e. systemic bacteremia), local contiguous spread from periorbital cellulitis
Decreased vision, decreased ROM of the eye, afferent pupillary defect
*MAIN ETIOLOGY = SINUSITIS
28
Orbital Cellulitis (signs, mangement)
Signs: Blurred vision, Proptosis, Limited Ocular Mobility / Diplopia, Pain, Chemosis, Sinus congestion, toothache, Systemically unwell
Management: Admission Ophthalmology, ENT
IV Antibiotics: Pip-Tazo + Vanco (MRSA coverage)
29
PHENYLEPIPHERINE
SUPERFICIAL VESSELS INFLAMMAED + PHENYL = BLANCHED IN EPISCLERITIS
PHENYL AND NO BLANCHING = SCLERITIS
SCLERITIS 50% SYSTEMIC ETIOLOGY (RHEUMATOOID ARTHRITIS, LUPUS) ** MOST LIKELY HAVE SECONDARY ETIOLOGY
TB, SYPHILLIS, SARCOROID
30
Episcleritis
Symptoms: Asymptomatic or mild discomfort, Mild photophobia, Irritation
Signs: **Sectorial redness, Superficial episcleral injection, Localized tenderness
Etiology: Immune-mediated
Treatment: Oral/Topical NSAIDS
31
Scleritis **PAINFUL
Symptoms: Pain, Dull, Achy, Deep, Boring, Photophobia, Tearing
Signs: Bluish red injection, Deeper structures, Nodules, Necrosis
PAIN WAKE YOU UP AT NIGHT? YES = MORE LIKELY TO BE SCLERITIS
Etiology: Immune-mediated
Associated Diseases: 30-60% Collagen Vascular, Rheumatoid arthritis, Lupus
Wegener’s
Treatment: Topical steroids
± Oral/Topical NSAIDS
± Oral steroids
± Oral immunosuppressants
32
Acute Iritis
Symptoms: Pain, Redness, Photophobia
```
Signs: Tenderness, Miosis,
Keratic Precipitates
- WBC’s on corneal endothelium
Posterior Synechiae
- Iris-Lens adhesions
ANTERIOR CHAMBER CELLS/FLARE
```
Management
Cycloplegia
Referral for steroid therapy
*Think HLB-27 , SERO-NEGATIVE ARTHROPATHIES , ANKYLOSPONDYLAR, IBD
33
Acute glaucoma
```
Significant pain
Ocular
Headache
Nausea and Vomiting
Ocular pressure is transmitted centrally!
Decreased Vision
Colored haloes
```
Signs: Fixed mid-dilated Pupil, Steamy Cornea, Shallow anterior Chamber, ELEVATED IOP
Mechanism: Pupillary Block
Treatment: Pilocarpine 1%, Pressure Lowering Medications Topical- Oral -I.V.
Definitive Management: Laser Iridotomy
34
8 steps
1. Symptoms
2. Visual Acuity
3. Pupils
4. Conjunctiva
5. Discharge
6. Fluoroscein
7. Cornea
8. Anterior chamber
35
Vision (normal vs decreased)
```
*Normal Vision
Conjunctivitis
viral
bacterial
allergic
Subconj. Hemorrhage
Periorbital Cellulitis
```
```
*Decreased Vision
Keratitis
Acute Glaucoma
Orbital Cellulitis
(late stage)
Iritis – less marked
```
36
Pupils mid-dilated and poorly reactive
Acute glaucoma
37
Pupils constricted and poorly reactive
Iritis
38
Pupils constricted and poorly reactive
Iritis
| possible synechia - iris stuck to cornea or lens
39
Discharge (clear and purulent)
```
*Clear
Corneal Irritation
Keratitis
Erosion
Glaucoma
Allergy
Viral Infection
```
*Purulent
Bacterial Infection
40
Fluorescein Uptake
- Erosion
| - Herpetic Keratitis (dendritic)
41
Fluorescein Uptake
* GLOWS GREEN*
- Erosion
- Herpetic Keratitis (dendritic; tree branch pattern)
- infectious keratitis = has underlying opacity
42
Localized Opacity
| in corna
Cornea ulcer
Corneal infiltrate
*Consult
43
Anterior chamber
- cells and flare
- pus (hypopyon)
- shallow
Cells and flare: iritis
Pus (hypopyon): corneal ulcer
Shallow: acute glaucoma
44
Anti-glaucoma agents
1. Decrease production of aqueous: beta blocker (timolol), carbonic anhydrase inhibitors (dorzolamide)
2. increase outflow of aqueous: prostaglandin analogues (latanoprost), miotics (pilocarpine)
3. Both: alpha agonist (brimonidine)
45
globe rupture or prolapsed iris or intraocular foreign body
Tear shaped pupil
46
DO NOT MISS
1. Keratitis (corneal inflammation); contact lens, bacterial, viral (herpes simplex)
2. Orbital cellulitis; proptosis, vision changes, RAPD
3. Acute glaucoma
47
DO NOT MISS
1. Keratitis (corneal inflammation); contact lens, bacterial, viral (herpes simplex; tx: acyclovir)
2. Orbital cellulitis; proptosis, vision changes, RAPD
3. Acute glaucoma
48
Gono conjonctivitis
* *hyperpurulent + hyperacute
* *urgent referral
Mangament:
- Topical, IV Ceftriaxone, saline irrigation
- Oral Azithromycin or doxycline = if chlamydial co-infection
49
```
Pre-septal vs. orbital
Etiology
Systemic S&S
Ocular Mobility
Vision
Eye position
Pain w/eye movement
Conjunctival injection
Chemosis
RAPD
Lid Edema
```
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Preseptal
Etiology: trauma, conjunctivitis, dacryocystitis, chalazion
(vs. sinutis)
Systemic S&S: No* (vs. yes)
Ocular Mobility: Normal* (vs. abnormal)
Vision: Normal* (vs. decreased)
Eye position: Normal* (vs. proptosis)
Pain w/eye movement: NO* (vs. Yes)
Conjunctival injection: Absent (vs. present)
Chemosis: mild or absent (vs. marked)
RAPD: no (vs. maybe seen)
Lid Edema: mod-sev (vs. severe)
```
50
Uveitis
Iris, ciliary body (under iris), choroid (under retina)
Etiology
1. Autoimmune
- HLAB27: PAIR; psoriatic arthritis, ankylosing spondylitis, IBD, reactive arthriti
- NON-HLAB27: JIA
2. Infectious
- Syphilis, lyme, toxocoplasmosis, TB, HSV, Herpes zoster
3. Other
- sarcoid, trauma, large abraison
51
Signs of anterior uveitis
- tenderness of eye
- ciliary flush (conjunctival injection around LIMBUS - edge of iris)
- hypopyon (WBC collection ant chamber) - can affect visual acuity
- anterior chamber cells
- flare (smoke) in ant chamber
- keratic precipatic (cells) white dots on cornea (cells phagocytosed by endothelial cells)
- posterior synechia - iris stick to lens --> distorted pupil, can lead to acute glaucoma, treatment: cycloplegic - atropine
52
Glaucoma classification
Open angle - dysfunction of trabecular meshwork (water cannot leave); painless, chronic vision loss (peripheral)
RF primary: increased age, african, high IOP, family hx
RF secondary: trauma (hyphema), inflmmation, steroids (dammage meshwork), neovascularization (DB)
Angle-closure - iris and lens stop fluid from flowing; fluid keeps being made; pressure build behind iris
RF: older, female, Chinese or inuit, hyperope (far sighted)
Key features: color of cornea = hazy + glint = distorded
* *GLAUCOMA = OPTIC NEUROPATHY associated with HIGH INTRAOCULAR PRESSURE (not defined by high pressure)
- can have normal pressure with nerve damage can still be glaucoma = normal tension glaucoma
53
Ambylopia
Abnormal visual development → decreased visual acuity
| visual stimulation is highly important for maturation of the visual cortex
54
Ambylopia classfication
- strabismus (most common): leads to the generation of images that cannot be fused properly, image generated by one eye is suppressed by the visual cortex
- refractive error (second most common): leads to differences in image clarity
- visual deprivation : e.g., cataracts
55
strabismus direction
* direction of the eye that is NOT fixed on target
- esotropia: inwardly deviated "crossed eyes"
- exotropia: outwardly deviated "walled eyes"
- hyper; up
- hypo; down
56
Stye (hordeolum)
Definition: Acute, purulent inflammation of the glands or eyelash follicles of the eyelid.
most commonly Staphylococcus aureus, which gain access to meibomian glands (internal hordeolum) or eyelash follicles or glands of Zeis (external hordeolum, or stye), leading to an acute, purulent, painful inflammation of the eyelid.
57
Chalazion
Definition: Firm, nontender nodular lesion of the eyelid resulting from obstruction and subsequent chronic granulomatous inflammation of a Zeis or meibomian gland.
