Ophthalmology Flashcards
Eyelids are AKA ?
What is the two functions?
Palpebrae
Protect eye
Aid lacrimal- spread new/drain old tears
What type of glands do the eyelids hold?
What is the name of the space between the upper and lower lid?
Meibomian
Palpebral fissure
Upper and lower eye lids meet on each side of the eye at the ?
What muscle closes the eye and what nerve innervates it?
Canthus
Orbicularis oculi; CN7
What muscle opens the upper eyelid and what nerve innervates it?
What does Mueller’s muscle do and what nerve innervates it?
Levator palpebrae superioris: CN3
Inserts on tarsus plate to
assist opening BOTH lids during fear/surprise; Sympathetic ANS
What are the 3 tunics of the globe?
? is the front window of the eye and what is its major role?
Fibrous- Sclera Cornea
Vascular- Iris Ciliary Choroid
Nervous- Retina
Cornea
Major refractive surface
Define Limbus
What type of cells provide color to the iris and what is the function?
Sclera/Cornea junction
Melanin
Light regulation into eye
Define Pupil and what innervates it?
Define Conjunctiva and what are the two parts
What is the name of the junction where the two conjunctiva meet?
Circular opening in iris
Sphincter: P-ANS
Dilator: S-ANS
Clear membrane
Palpebra: inside of eyelid
Bulbar: covers sclera
Fornix
People w/ blue eyes have all of the melanin w/in the iris located ?
People w/ brown eyes have all of the melanin located ?
Behind pupil
Back and front of pupil
What is the function of the ciliary body?
What is the function of the ciliary muscle?
What type of ciliary movements allow for near/far vision?
Produce aqueous humor
Change zonular tension, control lens
Contraction= less tension, fatter lens (accomodation) Tension= taught, thinner lens (distance vision)
Define Choroid
What is its function?
Vascular pigmented layer between sclera/retina
Supplies blood to outer retina
Where is the anterior chamber and what does it contain?
Where is the posterior chamber and what is it filled with
Between cornea/iris
Contains aqueous humor and drainage system
Behind iris/front of vitreous
Filled by aqueous humor
Lens has ? shape and suspended by ?
What ‘responsibility’ does it have?
Biconvex
Zonules
1/3 of refractive power
What are the four components of the vitreous humor?
Retina is AKA and is the ? of the eye
Collagen
Soluble proteins
Hyaluronic acid
Water
Fundus
Neural lining
How thick is the retina?
What is contained within it and how many per eye?
10 layers, 9 are transparent
Photoreceptor- send signals to brain
Cones: color/acuity, 6M
Rods: black/white, night, 120M
Where is the macula located?
What is its function?
What structures does it contain?
Posterior pole of retina
Central fovea depression
Fine/central vision
Mostly cones
1/3 of all nerve fibers
Define Optic disc
This structure lacks rods and cones so is AKA the ?
Nerve fiber convergence to leave eye; visible portion of optic nerve in eye
Physiologic blind spot, 15* temporally
What are the four rectus muscles of the eye?
What are the two oblique muscles of the eye?
Eye muscles work in ? meaning that ? process have to work for movement
Superior Lateral Inferior Medial
Inferior Superior
Tandem, yoked
Ipsilateral opposing relax for movement to occur
Define LR6SO4REST3, movement and CN innervation
SR: elevate, 3 LR: abduct, 6 IR: depress, 3 MR: adduct, 3 IO: extort/elevate, 3 SO: intorsion/depress, 4
What are the 3 layers of tears and where are they produced?
What is the sequence of drainage out of the eye?
Outer- oil, meibomian gland
Mid- lacrimal, accessory
Inner- mucin, goblet cells
Punctum
Canaliculus
Lacrimal sac
Nasolacrimal duct
Optic pathway is ? pathway while the oculomotor and Parasymp are ? pathways
Define the Double Decussation
Afferent (eye to brain)
Efferent (brain to iris)
Direct and consensual response of crossing at:
Chiasm
Pretectal/EW nuclei
When needs to be done at minimum during an eye exam?
Acuity- glasses preferred Direct ophthalmoscopy- undilated Pupils Intraocular pressure EOMs
How is distance visual acuity assessed?
Visual distance acuity charts are calibrated for ? distance
What eye is done first?
Ratio: standard/patient performance
TD/LS (test distant/letter size)
20ft
R (OD)
What is the conversion if PT can read 20/20 at ten feet?
What are the f/u tests if PT can’t read chart?
20/40
Count fingers
Hand motion
Light perception
Typically near vision acuity is only done ?
This form of acuity is best for ? PT populations?
Near vision complaint
>40y/o
Bed ridden
How far from the face is the near visual acuity test conducted?
When dealing w/ PT ocular compliant, visual acuity becomes a ? and is abbreviated as ?
14-16”
VS
OD OS OU
cc: w/ correction
sc: w/out correction
? is done on ALL PTs w/ occular complaints and prior to ? procedure?
Define Visual Impairment
Define Visual Disability
Visual acuity
Prior to putting anything in eye (exception: chemical splash)
Condition of the eye
Condition of PT
What is a near normal, mod/low, sev/low and legally blind score?
Pinhole acuity test is done when vision is worse than ? and is AKA ?
20/25-20/70: near norm
20/80-20/160: mod low
20/200cc-20/400: sev low/legally blind
20/40
Visual potential
What is the difference between AF and Army flight physical cardinal movements?
What is the purpose of cardinal movements?
AF: 6
Army: 8, add up/down
Symmetrically tests each muscle for: Paralysis Entrapment Weakness
Why are eyes w/ shallow anterior chamber depths not dilated?
What meds are used for dilation?
Triggers angle closure glaucoma crisis
Undergoing pupil observation
Mydriatics:
Adrenergic- dilation
Cholinergic- paralyzes sphincter
What is the adrenergic stimulating medication?
What are the five cholinergic blocking agents?
If PT gets one of these drugs, how is their vision changed and why
Pheylephrine
Cycopentaolate x 24hrs Homatropine x 72hrs Atropine x 2wks Tropicamide x 6hrs Scopolamine x 1wk
No accommodation= blurry near vision due to ciliary body involved
What items are looked for when doing ophthalmoscopy exam?
Why is intraocular pressure measured and what is a normal range?
Red reflex
Optic disc (physiologic cup)
Retinal circulation/back ground
Macula
Glaucoma screening by measuring aqueous outflow
10-21mmHg
What are the two methods of measuring intraocular pressure?
What is the gold standard for testing IOP?
What is the name of the eye exam used to evaluate the macula?
Tono-pen- ask about latex allergy and anesthetize first
Non-contact tonometry- air puff test
Goldmann tonometry
Amsler grid test
What are the components of a basic eye exam?
Confrontational fields Ocular motility Ophthalmoscopy Pupillary reaction Pressure, intraocular Acuity Anterior chamber depth Ancillary- Amsler Color Eversion
Define Emmetropia
Define Hyperpropia
Normal state, objects at infinity seen clearly w/ unaccommodated eye
Far sighted, axial length is short, image falls behind retina
Define Myopia
Define Astigmatism
Define Presbyopia
Near sighted, axial length is long, image falls in front of retina
Elliptical shape, different refracting power between cornea/lens
No accommodation due to lens hardening
Typical manifestation= no ability to focus on near objects
How does the curvature of glasses change for the different type of vision?
What are the other parts possibly seen in glasses prescriptions?
+ sphere: hyperopia
- sphere: myopia
Cylinder: astigmatism correction
Axis: astigmatism orientation for the eye
Prism- amount and direction
Bifocal- if needed for reading, always a +
How are lens prescriptions written?
What are the three types of eye deviations?
(Sphere) - (Cylinder) x (Axis)
Orthophoria- no deviation during cover/Hirshberg
Heterophoria- normal deviation, discovered with alternating cover test
Heterotropia- deviated when using both eyes, seen on alternating cover test
Heterotropia is AKA ?
When is this condition is congenital, what happens?
What eye tends to have the worse vision?
Tropia
One eye suppressed to eliminate double vision
Most deviated has worse vision (amblyopia)
Define Strabismus
Define Phoria
Define Tropia
Misaligned eyes
Deviation only seen when one eye is covered
Deviation seen when both eyes are open/uncovered
Define Concomitant Strabismus
This type of deviation leads to ?
Non-paralytic strabismus
Misalignment equal in all directions of gaze w/ early onset
Bad vision acuity
Define Incomitant Strabismus
Define third, fourth and sixth vasculopathic tropias
Misalignment varies w/ direction of gaze due to nerve dysfunction or mechanical restriction
3: aneurysm
4: congenital trauma
6: cranial pressure
Define Nystagmus
What do most of the PTs with this condition suffer from?
Involuntary movement of eyes
Partial sightedness
Legally blind
What are the two classifications of nystagmus?
What are the two classifications based on eye movement patterns?
Physiological- evoked, eyes far to one side, tracking object
Pathologic- abnormal, congenital (<6mon), acquired (>6mon)
Pendular- eye movements equally paced in each direction
Jerk- slow drift in one direction, rapid movement back
What are the four parts to a Hx when working up a nystagmus?
How are alternating nystagmus Tx
How are severe/disabling cases Tx
Infancy occular Hx
Drug/alcohol use
Vertigo
TBI
Baclofen- not for Peds
Retrobulbar botulinum injection
Define Amblyopia
These are AKA ?
Defected vision w/out detectable anatomic damage
Lazy eye
What are the four etiologies of amblyopia
Refractive: large uncorrected error (anisometropia)
Strabismus: deviated eye becomes amblyopic
Occlusion: ptosis/patching or media opacities
Organic: toxin, nutrition
How are amblyopias tested for at different ages?
What type of results are of low concern
<2: visual function
2-5: acuity picture cards
20/40 and equal eyes
How is strabismus testing done in PTs w/ amblyopia
What DDx may be considered?
What normal PE finding is poorly seen in these PTs?
Corneal light reflex test
Cover test
Epicanthus
Red reflex
What type of refractive error is more common in amblyopia
How are strabismus’ Tx in amblyopia PTs
Hyperopia
Patch better eye 2-6hrs/day
>11y/o- usually unsuccessful, polycarbonate lens
Surgical correction of strabismus’ are delayed until ?
Define Ec/Entropion
What are the Sxs of Ect/Entropion can include tearing d/t?
Vision is stabilized
Ec: lower lid turns out
En: lower lid turns in
Ec: punctal malposition
En: lashes abrading globe
What are the 4 etiologies of ectropion?
Paralytic: CN7 palsy
Involutional: lower lid laxity
Cicatricial: scarring
Mechanical: mass on lid/cheek
What are the two etiologies of entropion?
How are both Ect/Entroption Tx?
Involutional: lid laxity w/ age
Cicatricial: conjunctival scarring
Surgery
Define Lagophthalmos
What Sxs does this present w?
What will be seen on PE?
Inability to close eyes
Foreign sensation
Irritation
Tearing- failed lacrimal pump
Inability to close eyes
Exposed keratopathy
What are the 5 etiologies of lagophthalmos?
Lower lid laxity w/ age CN7 palsy Proptosis Over corrected ptosis/blepharoplasty from sugery Lid trauma causing scars
How is lagophthalmos Tx
Mild: tears/gels/ointment
Tape eye close at bed
Mod/Sev: tarsorrhaphy, suture lids together, gold weight inserted under lid for permanent Tx
Define Ptosis
What are the presenting Sxs?
Drooping of upper lid
Obstructed upper vision Difficulty reading Secondary amblopyia (peds)
What are the etiologies of Ptosis
How are congenital/acquired cases Tx
Congenital: abnormal levator Acquired: thin/detached levator aponeurosis Horners CN3 Palsy w/ ophthalmoplegia M Gravis
Surgery:
Tighten levator aponeurosis Resect levator muscle
Define Blepharitis
How does this present
Scaling of lid margin proximal to lashes
Photophobia Itching Burning
Epiphoria- excess tears
What are the MC causes of blepharitis
How is this Tx
Demodex
Meibomian dysfunction (chalazia)
Seborrhea
Staph infection (hordeola)
Margin shampoo/scrub
Warm compress w/ massage
Staph: Erythromycin ung
Gland: Doxy 100mg PO QD
Erythromycin 200mg PO BID
Define Hordeolum
How are these caused?
AKA stye
Acute painful nodule
Staph infection
Sebaceous gland
How are hordeolums Tx
When are these referred to surgery?
What are the two adverse outcomes?
Warm compress/massage
Erythmycin ointment
PO Doxy if + blepharitis
Compress/ABX fail after 4wks
Need for rapid relief
En/Ectropion
Define Chalazion
What do PTs complain of at presentation
Lipogranulomatous inflammation from meibomian gland obstruction
Mildly tender
How are Chalazions Tx
When are these PTs referred to surgery?
Warm compress
Triamcinolone injection- c/i in dark complexion PTs
No resolution after 1mon
Incision and curettage of meibomian gland
Define Dacryocystitis
What are the presenting Sxs
What will be seen on PE?
Inflammation of lacrimal sac at nasal end of gland
Tearing Pain D/c
Erythema Preseptal cellulitis
What is the etiological cause of Dacryocystitis
How is this Tx
Bacterial infection
Nasolacrimal duct obstruction
Amox/Clavu 500mg PO q8hrs
Warm compress/massage
InD
Febrile= admit/IV ABX
When are dacryocystitis referred for surgical correction?
What is the name of the procedure?
Chronic
Once acute episode has resolved
Caryocystorhinostomy
Define Dacryoadenitis
What presenting Sxs will PTs have
What will be seen?
Inflammation of lacrimal gland
Swelling Pain Tearing
Swollen tender and erythematous gland
What three autoimmune issues can lead to dacryoadenitis
What two viral agents can rarely cause this?
Sarcoidosis Sjogrens Vasculitis
Mono Mumps
What is done during work up for dacryoadenitis
If unclear etiology, how is this Tx?
If infectious etiology, how is it Tx?
CT scan of orbit
Biopsy lacrimal gland
Systemic ABX, f/u q24hrs
Amox/Clavu: 500mg q8hrs
Cephalexin: 500mg q6hrs
What are the more common skin Cas that can affect the lid?
What is the surgical procedure for removing one of these?
How are PTs Tx if unable/unwilling to have surgery?
Basal cell
Squamous
Mohs removal (basal)
Radiation
Define the conjunctiva
What are the two
Define Fornix
Thin mucous membrane
Palpebral- inner eye lid
Bulbar- over sclera
Location where the two meet
What is the MC cause of viral conjunctivitis
How does this present?
Adenovirus
Preauricular adenopathy
Pink hue that usually spreads to unaffected eye
Watery d/c
How is viral conjunctivititis Tx
What PT education goes w/ this Dx
Cold compress/tears
Topical steroids if infiltrate/membrane present
ABX only if secondary infection
Highly contagious mid-7 days
What are the MC causes of bacterial conjunctiviits
What 3 DDxs need to always be considered?
Staph A
Strep pneumo
H Influenzae
N gonorrhea
N meningitidis
C trachomatis
If PT presents w/ the 3 DDx for bacterial conjunctivitis, what is the next step and why?
What are the Sxs of bacterial conjunctivitis?
Ophthalmology ASAP
Gonococcal ulcer perfs quickly
Lid adhesions
Beefy red/irritation
More likely unilateral
How are bacterial conjunctivitis cases worked up?
How is this Tx?
Gram stain/culture if Neisseria Dx suspected
Trimeth/Polymyxin QID x 7d
Besi/Moxifloxacin QID x 7d
Ceftriaxone 1g IM
Azith 1g PO x 1 dose
Doxy 100mg PO x 7d
PCN c/i: Cipro 500mg PO x 5d
How is bacterial conjunctivitis Tx if Neirsseria has invaded cornea?
What can cause allergic conjunctivitis?
What type of hypersensitivity are these reactions?
Admit for IV ABX:
Ceftriaxone 1g IV q12hrs
Animal Molds Pollen
Type 1
How does allergic conjunctivitis present?
How are these cases Tx
What PO antihistamines can be tried?
Intense itch w/ watery d/c
Bilateral erythema w/ stringy mucoid d/c
Mild: tears
Mod: topical mast stabilizers: Olopatadine, Ketotifen
Sev: topical steroid: Loteprednol
Cetirizine Fexofenadine
Diphenhydramine
How does subconjunctival hemorrhage present?
What medications can cause this?
ASx blood in one sector under conjunctiva
ASA
Warfarin
Subconjunctival hemorrhage presenting w/ ? Sxs needs an orbital CT?
How are these cases Tx
Proptosis
EOM restrictions
Elevated IOP
Tears
D/c elective ASA
Define Pinguecula and Pterygium
How are they similar?
How are they different?
White/yellow bump on conjunctiva at 3 or 9 o’clock position
Highly vascularized PTs at equitorial regions w/ chronic sun exposure
Ptery- invades cornea
Ping- no cornea invasion
How are Pingueculas/Pterygiums Tx
Define Phylctenule and what causes it
Tears/topical steroid (sev)
Surgery- ptery interferes w/ sight/visual axis
Nodular growth at limbus from bacterial protein (Staph) hypersensitivity
If unable to refer/evac PT w/ phylctenule, how are they Tx?
Define Conjunctival Nevus
These cases can but rarely develop into ?
Steroid/ABX combo: Tobra/Dexameth
Tobra/Lotaprednol
Benign/ASx pigmented lesion over sclera
Malignant melanoma; vascular network seen through conjunctiva
How are conjunctival nevus Dx
What is the major concern in PTs presenting w/ conjunctival lacerations?
Biopsy necessary
Resected if suspicious
Ruptured globe
Retained foreign bodies
How are conjunctival lacerations Tx
Define Thyroid Eye Dz
<1cm: Erythromycin oint TID
>1cm: surgical closure
Graves Ophthalmopathy but can be seen in hyper/po/euthyroid PTs too
What is the MC cause of bilateral and unilateral ptosis in adults?
What work up is done and how is the Dx confirmed
Thyroid Eye Dz
Complete thyroid work up
Normal= careful monitoring
CT to confirm
What phase of Thyroid Eye Dz does the upper eye lid retraction begin?
How are mild, mod and severe cases Tx
Early
Mild: tears, elevate head, tape lids at night Mod/Sev: PO Prednisone Decompression/radiation Lid repair Strabismus surgery
What are the buzz word differentiators for the different types of conjunctivitis?
Any damage to cornea results in ?
Viral: preauricular adenopathy
Bacterial: mucopurulent d/c
Allergic: intense itches
Visual impairment
Define Keratitis
What are the 5 layers of the cornea from out to in?
Inflammation of cornea
Epithelium Bowman membrane Stroma Descemet's membrane Endothelium
How is erosion damage to the corneal epithelium seen on PE?
Corneal ulcer implies damage to ? layer
Sodium Fluorescein stain
Stromal damage from infiltrate
What is the difference in presentation between bacterial/fungal and sterile infiltrates in corneal ulcers?
B/F: Extremely painful, aggressive
Blindness <48hrs
St: Minimal pain, most on peripheral cornea
Secondary to contact wear
What are the S/Sxs of a HSV Keratitis ulcer?
What will be seen if it’s an advanced dz?
Epithelial dendrites
Photobphobia
Almost all- unilateral
Stromal scarring vascularization
How is HSV Keratitis Tx
What is NOT given to these PTs?
Referral
Antivirals
Topical ulcers can cause ocular perforation/tissue loss
Define Bacterial Keratitis
What are the MC microbes causing bacterial keratitis?
Bacterial colonization on cornea, interrupts intact corneal epithelium
Staph Strep Pseudo Morax Serratia
What PT population is bacterial keratitis MC in ?
How is this Tx
Contact wearers w/ over night wear
Fluoroquinolone q1-2hrs
Tobra/Cipro if contact wearer
Daily monitoring
Vision threatened: fortified AB q30min
What type of Hx highly suspects fungal keratitis?
What other Hx may suggest this?
Outdoor eye trauma w/ vegetative matter
Topical CCS use
Contacts
Recent surgery
What is the MC presentation of fungal keratitis?
How are these cases Tx
What meds can be used for Tx
Feathery white opacity
Initial, same as bacterial
Refer to Ophth for culture
Surgical debrisment
Topical Natamycin/Amph B
Fluconazole
Voriconazole
What med is c/i for Tx of fungal keratitis?
What drugs can cause corneal pigmentation?
What is the benefit of getting this issue?
Topical steroids
Hydroxy/Chloroquine- deposits
Amiodarone- whorl shaped
Phenothiazines
Indomethacin
Rarely causes vision loss
Most resolve w/ drug d/c
What is the MC cause of recurrent corneal erosion?
How does this case present?
Dog claw
Mid-morning/late night onset of sudden/severe pain
“Sharp pain w/ eye open”
“Eyelid stuck to front of eye”
How are recurrent corneal erosion Tx
When are these PTs referred to surgery?
Muro-128 ointment to dehydrate cornea at night
Tears during day
PO analgesic
Dilate to ease accommodation spasm
Severe, 90% success
Define Keratoconus
If this becomes severe, it can lead to ?
Dz of unknown etiology causing thinning of central cornea
Leads to increased myopia, irregular astigmatism
Blindness
Corenal transplant
Define Munson Sign
What other unique findings may be seen on PE?
Keratoconus- bulging lower lids from thinning central cornea bulge on inferior cornea
Fleischer RIng at base of cone
Vogt’s Striae
Define Arcus Senilis
When does this condition go from normal aging process to abnormal finding?
What finding on PE confirms this Dx?
Gray/white deposits on peripheral cornea
Under 40, hyperlipoproteinemia
Clear area between deposit and limbus w/out vision changes
What are the two functions of the sclera
What is it made of?
Where is the thickest point?
Protection
EOM attachment points
Collagen
Elastic fibers
Posterior aspect
Episclera is connected to ?
What is the function of this attachment structure
Tenon’s capsule
Dense CT encasing globe
Sheath covering tendons at EOM insertions
Episcleritis is more prevalent in ? but is MC ?
What d/os are associated w/ this eye issue?
Young adults
Idiopathic
HZoster RA/Lupus Rosacea Thyroid dz Syphilis
How does episcleritis present
What is done during work up?
Acute sectorial presentation w/out d/c
Slit-lamp w/ anesthesia- Mobile vessel w/ CTA
Phenylephrine lets vessel blanch
How is episcleritis Tx
Mild:
Cold compress/tears
Mod/Sev:
Fluorometholone
Ibuprofen
Loteprednol
What CT Dzs can cause scleritis
What infections can cause it?
What is different about scleritis and what is the prominent feature?
Wegeners RA Ankylosing P nodosa Lupus
Herpes zoster
Syphilis
Older PTs
Severe/boring eye pain radiating to jaw/brow
How is this condition classified?
Diffuse- wide inflammation
Nodular- immovable inflamed nodule
Necrotizing w/ inflammation- extreme pain from systemic dz and blue appearance
Necrotizing w/out inflammation- no Sxs but long standing dz (RA)
Posterior- unrelated to systemic Dz
Posterior scleritis can cause ? injury to occur
How is scleritis different on PE?
What two examinations need to be done?
Exudative retinal detachment
Phenylephrine doesn’t allow blanching
Slit lamp w/ green light- r/o avascular areas
Fundus exam- r/o posterior scleritis
How is diffuse/nodular scleritis PTs Tx
What meds are used if there is no improvement?
All referred to Ophth and:
NSAIDs
Ranitidine
Prednisone
Clophosphamide
How is necrotizing sclertitis Tx
How is posterior scleritis Tx
Refer NSAIDs Rantidine and,
Clophosphamide
Perf= scleral patch graft
Controversial use of:
Cyclophosphamide
Rituximab
Glucocorticoids
What are the three pats of the uveal tract?
When this tract becomes inflamed, what is the Dx w/ ? area of involvement?
Iris- only visible portion
Ciliary body
Choroid
Uveitis Ant: iris, ciliary body Inter: between ciliary body and early retina Post: retina Pan- all areas
Anterior uveitis is AKA ?
What are the associated RFs for this Dz?
Iritis
Iridocyclitis
HLA-B27 (AS, Reiters)
JA
TB/Syphilis
Lymphoma
What are the S/Sxs of anterior uveitis?
What might be seen on PE?
Ciliary flush/injection
Keratic precipitates:
fine/white- non-granulomatous
mutton fat- granulomatous
Floaters/Flares
Hypopyon- cells at bottom of anterior chamber
Irregular pupil
Koeppe/Busacca nodules
How is anterior uveitis Tx
What is the prognosis difference for PTs w/ this Dx?
Clycloplegics:
Scopolamine- mild/mod
Atropine- severe
Topical steroid:
Prednisolone
First: non-granulous excellent
Repeat granulomatous- poor
Posterior uveitis is a combo Dx of what 3 things
What is the MC cause?
Vitreitis
Choroiditis
Retinitis
Toxoplasmosis
What is the MC severe infection affecting the eye?
What PT population does this occur in?
What happens if this is left untreated?
CMV retinitis
CD4<100
Blind <6mon
What is the MC finding of CMV retinitis
What else may be seen on PE?
Cotton wool spots
Scotomata
Flashes w/ retinal detachment
Stellate shaped KPs
How is CMV retinitis Tx
How is posterior uveitis Tx
HAART
PO Valganciclovir
Refer
Topical cycloplegic/steroid w/ anterior involvement
How is non-necrotizing/posterior uveitis due to RA Tx
How is the necrotizing form Tx?
Tears
PO NSAIDs/steroids
No topical steroids
Scleral patch graft if high risk for perf
What part of the body has the highest concentration of protein concentration?
What strctures are lacking here?
What are the 3 layers?
Lens
Blood vessels
Nerves
Capsule Cortex Nucleus
What are the functions of the capsule?
What are the functions of the cortex?
Semipermeable membrane that envelopes/molds lens during accommodation
Produce lens cells, fibers for life
Older cells are deeper, lose organelles to become transparent
What is the MC RF for developing cataracts?
What does the cataract have another MC with
Age
Cataract surgery- MC done in US
What is the MC form of age related cataracts?
What type of vision issue does the PT present w/?
What is a benefit w/ a saying?
Nuclear sclerosis- yellow/brown discoloration
Blurry distance vision
Second sight of the aged, more myopic
Define Posterior Subcapsular
What do PTs present complaining of?
What is the MC cause?
Opacities near posterior aspect of lens
Glare and difficulty reading
> 50y/o
Define Cortical cataract
How does this present?
Why is this usually not seen in routine clinic?
Radial/spoke like opacities
ASx until central progressino, causes glare as MC Sx
Reqs pupil dilation
What is the MC complaining Sx of cataracts?
What other Sxs/issues may be seen?
Progressive vision loss w/ glare from oncoming headlights
Monocular diplopia
Fixed spots in visual field
Dec color perception- blue hair dye
How are catarcts Tx
Cataract surgery is done for ? reasons?
Early: spectacle prescription
Small central: pupil dilation
Late: surgical removal
Temporary benefit w/ Scopolamine
Glaucoma
Improve visual function
ARMD
Diabetic retinopathy
Congenital cataracts are MC ?
This condition can potentially have ? sole presenting issue?
Idiopathic
Galactosemia
What are the different types of congenital cataracts?
How can these present?
Posterior polar Coronary Lenticonus Sutural Lamellar
Anterior polar Blue dot
Dec vision
Infant squinting/eyes closed
Absent/abnormal red reflex
When working up congenital cataracts, whose Hx is important?
What PT population is this a medical emergency, why?
These PTs need to be referred to prevent ?
Maternal
Infant w/ cataracts- brain learns to see w/ macula during first 3-4mon
Deprivational amblyopia
Define subluxation lens position anomaly
Define dislocation lens position displacement?
Partial zonular disruption, lens de-centered but partially visible in pupillary aperture
Complete disruption of zonular fibers
Lens is displaced out of natural position in posterior chamber
What are the two MC causes of lens position anomalys?
What types occur and what is retained by the PT
Trauma- subluxation
Marfans Syndrome- superotemporal subluxation w/ retained accommodation
What type of subluxation occurs w/ homocystinuria?
What is lost in this type of lens anomaly?
Inferonasal subluxation/dislocation
Accommodation lost
Define Phacodonesis
Define Iridodonesis
Where are these issues seen?
Quivering lens
Quivering of iris
Lens position anomaly
How is lens dislocation into anterior chamber Tx
How are lens subluxations Tx?
Replaced w/ head manipulation or surgery
ASx- observe
Significant Sxs- surgery
Surgery, only if PT has Sxs
What is the MC cause of floaters?
What can cause an acute onset?
Age
DM/Sickle induced bleeding Retinal tear Int/Post uveitis Posterior vitreous detachment Foreign body
If PT complains of flashes, what does this suggest?
What two things must be r/o?
Traction of vitreous on paripheral retina
Retinal detachment
Posterior vitreous detachment
PTs w/ flashes and floaters mean ?
If PT presents w/ flashes and migraine, what can be seen?
Blood/pigment in vitreous
Scintillations
Zig-zag lights
Define Weiss ring
How do PTs w/ vitreous opacities present?
Vitreous opacity seen by PT after vitreous detachment
Floaters
Blurry to severe vision loss
Where is the fovea
Where does macula get blood supply from?
4mm temporal
0.8mm inferior to optic nerve
Yellow dot/vasculatur is medial to black dot (temporal)
Optic nerve is nasal portion of retina
Choroid
How do arteries/veins differ in the retina on exam?
How do they cross each other in the eye?
Arteries- thinner, orange/red
Vein- larger, crimson
Arteries/veins cross each other
No V/V or A/A crossing
What is the only place in the body vessels are visible w/out doing surgery
What structures supply blood to the retina
Retina
Central artery- inner retina
Choroid- outer retina and photo receptors d/t high O2 demand
What physical feature can tell if PTs fundus is light or dark?
What are the two parts of the inner retina?
Where does this structure extend through?
Skin tone
Nerve fiber layer (to midbrain w/ pupillary response)
Ganglion cell layer
Optic chiasm to geniculate nucleus
Retinal vascular ischemia issues manifest in ? layer
What will be seen on PE?
Nerve fiber layer
Opacification of inner retina - cotton wool spots in DM
Retinal artery occlusion involving the branch of the retinal artery will present w/ ?
What part of the eye may be spared and why?
Horizontal hemifield vision loss
Macula- cilioretinal arteries from choroidal supply
What are the RFs for retinal artery occlusion?
How does central retinal artery occlusion present?
What other RFs/Hx may be present
Lupus OCPs GCA
Unilateral painless acute vision loss
Light perception or worse
Afferent pupil defect
Hx of amoaurosis fugax
What will be seen upon fundoscopic exam during central retinal artery occlusions?
How does branch retinal artery occlusions present?
Opacification/white retina
Cherry red spot in center
Box-car/segmented arterioles
Unilateral painless acute altitudinal/sectoral field loss
What is different about the prognosis in BRAOs?
What is the first labs ordered for suspected CRAO/BRAOs?**
Permanent visual field defects
Rare neovascularization
Platelets ESR CRP**
PT >55y/o, r/o GCA
How are CRAO/BRAOs Tx?
How are retinal vein occlusions going to present?
Ocular massage
Anterior paracentesis
Acetazolamide
Ophthalmic Timolol
Horizontal hemifield loss w/ respect to horizontal midline
What causes retinal vein occlusions?
What is the biggest risk factor?
Thickened arterioles compressing veins causing stagnant outward flow
> 65y/o
What will be seen on funcdoscopic exam of central retinal vein occlusions?
What are the two different types of occlusions?
Blood and Thunder fundus
Dilated veins
Swollen disc
Ischemic- cotton wool spots w/ extensive hemorrhage
Non-ischemic- mild fundus changes
What is the prognosis of BRAO?
What can cause prognosis to be complicated?
Good, half develop collateral vessels
Chronic macula edema
Noevascularization
How are retinal vein occlusions Tx
How are these PTs Tx if there is neovascularization or macular edema present?**
Ophtho eval <72hrs
D/c OCPs
Dec IOP
Intravitreal anti-VEGF** injection
PRP
ASA one x/day
What is the leading cause of blindness in PTs < and >64y/o?
After PTs are Dx w/ this an ocular baseline must be established w/in ?
<64- DM
>64- macular degeneration
6mon
What type of DM rarely has retinopathy?
This benefit wears off though and is prevalent after how long?
Type 1
30yrs
What are the RFs for diabetic neuropathy?
What hormonal influences can accelerate the retinopathy?
Duration Control Pregnancy HTN Nephropathy
Pregnancy
Puberty
What are the two types of diabetic neuropathy?**
What will be seen in each type?
Non-proliferatve:
Mild/Mod/Sev
Cotton wool Hemorrhage
IRMA Miroaneurysm Exudates
Proliferative**:
Late, new vessels grow at disc
What may be seen during the 4 phases of non-proliferative diabetic neuropathy?
Very mild: microaneurysms
Mild: Microaneurysms Exudate Cotton wool spots
Mod: Retinal hemorrhage in 1-3 quadrants or mild IMRA
Sev: 4-2-1 rule
4 quad- retinal hemorrhage
2 or more: venous beading
1 or more: moderate IMRA
What is the MC factor indicating a PT has progressed from non-proliferative to proliferative diabetic retinopathy?**
What constant sequelae will be seen in these PTs?
Neovascularization
Fragile vessels= recurrent hemorrhages
What are the Sxs of proliferative diabetic retinopathy
What signs may be seen
Slow dec of vision
Floaters, 2/2 hemorrhage
Scotomas
Lacy vessel- Nerve Retina Iris
Boat shaped pre-retinal hemorrhages, anterior to retinal vessels
Cotton wool spots
Absent red reflex
How is diabetic retinopathy Tx
NPDR- tight glucose control
+ Neovascular changes-
Anti-VEGF
PRP
How does macular edema present?
What causes retinitis pigmentosa?
Gray/opacified retina
Micro-aneurysms
Dot/blot hemorrhage
Exudates
Loss of viable photoreceptors, initially rods
Retinal pigment changes
How does Retinitis Pigmentosa present?
What signs may be seen on PE?
How is it Tx
Lost color/peripheral vision
Night blindness
Photopsia
Scotoma
Bone spicules
Golden-ring sign
Vit ADEK
Low vision aids
What are the 3 types of retinal detachments
Rhegmatogenous- break in myopic eyes (higher Rx= higher risk)
Exudative- leakage w/out a break d/t something below retinal layer
Tractional- contraction of fibers pulling on retina, diabetic/retinopathy or prematurity
What are the presenting S/Sxs of a rhegmatogenous retinal detachment?
How are retinal detachments worked up?
What can be done in clinic to aid w/ Dx?
Flashes and floaters
Referral for complete dilated ocular exam
Red reflex from distance, detachment eye will be lighter
How are rhegmatogenous retinal detachments Tx?
How are tractional detachments Tx?
Pneumatic retinopexy- intravitreal gas bubble w/ laster
Scleral buckle- silicone belt around globe
Pars plana vitrectomy
What are the two different types of macular degeneration
What is the MC abnormality
Non-exudative, dry
Exudative, wet
Drusen- yellow deposits on retina, limits nutrition to photoreceptors
What are the RFs for macular degeneration?
What are the S/Sxs of Dry AMD?
What will be seen on exam
Older female w/ light pigmentation who smokes and FamHx
Gradual loss of central vision
Macular drusen
Pigment clumps on outer retina
What are the S/Sxs of Wet AMD
What will be seen on fundoscopic exam?
Distortion of straight lines- metamorphopsia
Rapid loss of central vision
Drusen
Neovascularization
Hemorrhages
What are the RFs for progressing from Dry to Wet AMD?
Age Hyperopia Blue eyes FamHx Larger drusens Focal clumping HTN Smoking
How is AMD Tx
Dry: Vit C E Beta-carotene Zinc
No Beta-carotene for smokers
Wet: Anti-VEGF
Laser photocoagulation
What is the hallmark of hypertensive retinopathy
What else may be seen
Diffuse arteriolar narrowing
Copper wire vessel- arteriol narrowing
Silver wire- sclerosis
A:V ratios 1:3 or 1:4
What are the Sxs of hypertensive retinopathy
What are the signs?
Scotomas
Double vision
Cotton wool spots
AV nicking
How to tell hypertensive retinopathy from diabetic retinopathy
What are the S/Sxs of chloroquine toxicity
HTN- dry, more white than hemorrhage
Abnormal color vision
Difficulty adjusting to dark
Bulls-eye maculopathy
How often do PTs on chloroquine need eye exams
When examining PT eyes, presence of hemorrhage indicates ? type of ARMD
Baseline w/in first year
Annually after 5yrs of use
Wet- needs anti-VGF
PT complains of loss of vision w/ description of ‘curtain pulled down’ is indicative of ?
If curtain sensation was accompanied by flashes and floaters would indicate?
Retinal detachment
Rhegmatogenous
Cherry red spot on macular means ?
What part of the eye has the highest resistance for the flow of aqueous humor?
This point of high resistance is AKA ?
CRAO
Trabecular meshwork at junction of cornea/iris
Anterior chamber angle
Where does aqueous humor exit the eye?
Define glaucoma
Schlemm’s canal
Progressive optic nerve damage and visual field loss
What are the two categories of glaucoma
What measurement is used to assess the progression of glaucoma
Open angle- MC, normal outflow pathway
Angle closure- blockage of outflow
Cup to disc ratio
Smaller= less visible cup
Larger= more concern
Define Ocular HTN
How is this Tx
Normal nerve
Normal anterior chamber
No visual field loss
IOP >21
Monitor annually
Define Primary Open Angle Glaucoma
What two mechanisms can lead to this?
Loss of retinal fiver layer and reduction of vision
Vascular- optic nerve ischemia
Mechanical- cribiform plate compression
What is the only modifiable RF against primary open angle glaucoma?
This condition may AKA ?
IOP >28
Thief in the night-
What is the sequence of progressive vision loss seen in Primary Open Angle Glaucoma
What are the RFs for this condition
Parts of pages are missing
Tunnel vision- late
Central fixation- preserved until late
Temporal island- remaining visual field
Age >50
AfAm/hispanic
FamHx
DM
What is not a RF for primary open angle glaucoma
What part of the day is IOP the highest
Systemic HTN
Morning
Normal tension glaucoma is AKA ? and is a variant of ?
What will be seen?
Low tension glaucoma
POAG
IOP 21 or less
Open anterior chamber
Visual field/optic nerve damage
What is a unique RF for normal tension glaucoma
What are the two mechanisms causing acute angle closure glaucoma
Obstructive sleep apnea
Relative pupil block- iris pushed forward
Non-pupil block- iris pulled/positioned anteriorly (inflammatory conditions)
PT presents w/ intense ocular pain, photobia, N/V, what is the Dx
What precipitating event is seen?
Acute Angle Closure Glaucoma
Leaving movie theater
How are AACG attacks stopped
What med is used if their IOP is <50?
What is the Tx of choice?
1 drop q5min of :
Timolol
Apraclonidine
Prednisolone/Dexameth
Acetazolamide 500mg IV
Laser iridotomy
What causes Chronic ACGlaucoma?
How is this Tx
Anterior angle closed by peripheral anterior synechiae
(front of iris binds to corneal endothelium)
Trabeculectomy/tube shunt`
PT presents w/ Port-Wine stain, what eye issue may be present?
What may be seen on the cornea during PE?
Sturge Weber syndrome presents w/ congenital glaucoma
Linear tears- Descenemet membrane
Haab striae- horizontal
How is congenital glaucoma Tx
PO Acetazolamide
Topical Levobunolol/Timolol
Surgery-
Goniotomy
Trabeculotomy/ectomy/shunt
Mother brings baby to clinic w/ complaint of squinting, blinking hard and IOP is 32. Dx?
What causes secondary glaucoma?
Congenital glaucoma
Males playing sports, has blunt trauma and experiences glaucoma at 10yrs
What causes neovascular secondary glaucoma?
What will be seen on exam?
How is it Tx
Fibrovascular membrane grows into meshwork, slows drainage
Vessels growing into iris
Timolol, PRP
Where/why wold steroid response glaucoma be seen?
Dx of glaucoma requires ? two things, otherwise its ? Dx
Refractive surgery
Reqs: optic nerve damage, progressive vision field loss
Ocular HTN
Define Hemianopia
Define Homonymous
Loss of half of visual field
Visual field loss on same side of both eyes
Define Scotoma
Define Anisocoria
Red/absent vision w/in intact visual field
Unequal size of pupils >1mm
? and ? make up the photoreceptors in the retina
Where does initial visual processing and interpretation take place?
Nerve fiber layer
Optic nerve
Process: Retina
Interpret: visual cortex
Where does the optic tract stop
This location is AKA ?
Lateral geniculate body
Neural way station, axons leave as optic radiations
What type of vision occurs w/ lesion in chiasm?
Afferent pathway is CN ?
Efferent pathway is CN ?
Bitemporal heminopsia
A2
E3
Double decussation is responsible for ? response
Marcus Gunn pupil is a ? defect and what occurs
Direct/consensual
Afferent
Light in good eye, normal constriction response
Shine light in bad eye, both pupils dilate
What causes Adie’s Tonic pupil
What is seen on PE
Else would be seen on neuro PE
Denervatin of PNS supply to sphincter and ciliary muscle
Irregularly dilated, poor reaction to light
Slow accommodation
Dec/absent knee/ankle DTRs
How is an Adie’s Tonic pupil Dx confirmed
Pilocarpine
Adies constriction
Normal pupils- no constriction
