Ophthalmology: Review Slides Flashcards
What are the eight components to a basic eye exam?
Confrontational visual fields Ophthalmoscopy Ocular motility Pressure, intraocular Pupil reaction Anterior chamber depth Acuity Ancillary- Color Amsler Upper lid eversion
Eyelids are AKA ?
What are the two function
Palpebrae
Protection
Aid lacrimal system- spread new, pump old
What glands are contained w/in the eye lids and what do they make?
What is the space between the upper/lower lid called
What is the name of the union between the upper and lower lids?
Meibomian- oil part of tears
Palpebral fissure
Canthus
What are the three eyelid muscles, their function, and what are they innervated by ?
Orbicularis oculi- closes, CN7
Levator palpebrae superioris- opens upper, CN3
Mueller’s Muscle- assists opening lids; Symp ANS
Define LR6SO4REST3 movement and CN innervation
SR: elevation, 3
LR: abduct, 6
IR: depression, 3
MR: adduction, 3
IO: extortion/elevation, 3
SO: intorsion/depression, 4
Eye muscles work in ?
What type of response has to occur for movement to occur?
Tandem, yoked
Ipsilateral opposing muscle relaxation
Define Emmetropia
Define Myopia
Normal vision
Nearsighted, axial length too long, image falls in front of retina
Define Hyperopia
Define Astigmatism
Farsighted, axial length too short so image falls behind retina
Elliptical shape, refracting power is different between cornea and lens
Define Strabismus
Define Phoria
Define Tropia
Misalignment of eye
Deviation only apparent when eye is covered
Deviation is evident w/ both eyes open
What are the four prefixes for eye deviations
Eso: in
Exo: out
Hyper: up
Hypo: down
Dec red reflex indicates?
Strabismus is revealed w/ ? test
Eye pointing in wrong direction
Poor in amblyopia
Cover/uncover or Hirschberg
Acquired strabismus’ can cause ? and associated w/ ? underlying issue
If congenital (<6mon), what is the PT at risk for developing?
Diplopia, primary or off-axis
CN palsy, mass
Amblyopia
What type of strabismus is present w/ CN3, CN4 or CN6 palsy?
Define Nystagmus
3: R norm, S down, left; aneurysm
4: both to R; congenital trauma
6: R normal, L to R; cranial pressure
Repetitive/rhythmic oscillations of eyes
What are the different types of nystagmus?
Most congential nystagmus’ are ? and require ?
Physiologic: normally evoked
Pathologic: congenital, acquired
Jerk: slow drift w/ fast recovery
Pendular: equal paced drift/recovery
Idiopathic
Complete exam
Define Neuro-Significant Nystagmus
Define Amblyopia
Vertical/see-saw motions due to brain stem lesion
Abnormal development of visual system w/out anatomical damage
Amblyopia is AKA ? and results in ?
What are the 3 etiologies
Lazy eye, not necessarily misaligment
Bi/Lateral reduced vision
Refractive
Strabismus
Occlusion
How are amblyopias Tx?
When is the visual potential the greatest?
Glasses
Patch/atropine
Surgery
<8y/o, neuroplasticity
What are the 3 layers of tears and where are they made?
Outer: oil, meibomian gland
Mid: water, accessory/lacrimal
In: mucin, goblet
Define Extropion
How does it present
What is it caused by
How is it Tx
Outward turning of lower lid
Tearing/irritation
Scarring from skin d/o
Inc lid laxity
CN7 palsy
Lubrication until surg correction
Define Entropion
How does it present
What is it caused by
How is it Tx
Inward turning of lower lid
Foreign body sensation Irritation Tearing
Involution from age
Conjuctival scarring
Lube until surgical correction
Define Blepharitis
How does it present
How is it Tx
Inflammation of eyelid
Burning Foreign sensation Epiphora worse in AM
Concomitant ocular rosacea
Eyelid scrub/warm compress
Mod/Sev: Erythro ointment (ung) every bedtime (uhs) or,
Doxy 100mg PO QD x 2wks
Define Chalazion
How does it present
How is it Tx
Nodule inside of meibomian gland
Mild discomfort
Warm compress/massage
Steroid injection/excision >4wks
Define Hordeolum
How does it present?
How is it Tx
Staph infected nodule causing pain
Red/painful nodule
Warm compress/massage Doxy 100mg BID Erythromycin 250mg BID Surgery if recalcitrant UnTx= preseptal
Define Dacryoadenitis
How does it present
What can cause this?
Inflammation/infected lacrimal gland
Unilateral temporal lid tenderness in kids/young adults
Mumps/EBV
Idiopathic
Bacteria
What image is ordered for dacryoadenitis
If condition is bilateral, what DDxs need to be considered?
How is this Tx?
Orbital CT
Sarcoid
Sjogrens
Mild: COLD compress, NSAID
Acute/purulent: ABX/Anti-viral
Idiopathic/Resistant: PO steroid, responds <48hrs
Define Dacryocystitis
How does this present
What can cause it?
Inflammation of lacrimal sac and/or canaliculus
Tearing, pain w/ erythema, purulent drainage
Preseptal cellulitis
Bacterial infection
Nasolacrimal duct obstruction
How is Dacryocystitis Tx
Define Conjunctiva
Warm compress/massage
Amox/Clavu 500mg TID
InD if large abscess
Febrile= admit w/ IV ABX
Thin mucous membrane on inner surface of eye lid and outer surface of eye
What are the two conjunctiva
Define Fornix
Palpebral- inner eye lid
Bulbar- over sclera
Point that bulbar/palpebral conjunctiva meet
What is the causes, S/Sxs and Tx for viral conjunctivitis
Adenovirus
Watery d/c
Diffuse injection
Pre-auricular adenopathy
Infiltrates
Self limiting but highly contagious
What is the causes, S/Sxs and Tx for allergic conjunctivitis
Pollen, mold, pets
Stringy d/c, Itching, Chemosis
Topical antihistamine
What is the causes, S/Sxs and Tx for bacterial conjunctivitis
Staph A
Strep pneumo
C trachomatis
N ghonorrea
Mucopurulent d/c
Topical ABX
Define Pinguecula
How does it present
How are they Tx
Yellow bumpy growth on conjunctiva at 3/9 o’clock w/out invading cornea
ASx, no vision changes
Artificial tears
Topical steroids if severe
Define Pterygium
How does it present
How is it Tx
Yellow bumpy growth on conjunctiva at 3/9 o’clock that invades cornea, irritation and vision loss
Tears/sunglasses
Surgery- interference w/ sight/close to visual axis, excessive irritation
Define Thyroid Eye Dz
This is the MC cause of ?
Graves Ophthalmopathy or any thyroid state- hyper, hypo, eu
Unilateral proptosis in adults
How does early/late thyroid eye dz present
What is done for work up and how is the Dx confirmed?
Early:
Burning Photophobia Red Tearing
Late:
Pressure Chemosis Swelling
Complete thyroid tests
If normal- careful monitor
Confirmed w/ CT scan
How is Thyroid Eye Dz Tx
Mild:
Tears
Elevated head at night/taping
Mod/Sev: PO Prednisone Orbital decompression/radiation Lid retraction repair Strabismus surgery
What is used to stain the eye to assess for corneal abrasion?
What sign may be seen?
NaFl (flourescein)
Seidel’s- penetrating trauma
How are corneal abrasions Tx
How does bacterial kertitis present?
Topical fluroquinolone (prophylactic)
Cycloplegic
No patches/touching/contacts
Infected cornea w/ white opacity and epithelial defect due to colonization of corneal stroma
Bacterial keratitis MC occurs after ?
This can also occur from
This condition causes ? to the eye
Contact lens wearing
Anterior segment dz
Stromal thinning (ulcer)
What are the S/Sxs of bacterial keratitis
What microbes can cause it?
How is it Tx?
Pain Edema Photophobia
Hyperemia
Staph Strep Serratia
Pseudomonas Moraxella
Fluoroquinolone and Cycloplegic drops w/ daily f/us
Wears contacts- add Polymyxin B/Trimeth or Tobramycin
Pseudomonas keratitis is especially high risk in ? PTs
Fungal Keratitis will present w/ and is due to ?
Contact wearers
Can perf cornea <48hrs
Asymmetric feathery edges after trauma w/ vegetative matter
What is the inner and outer layer of the sclera?
What is it made of?
Where is the thickest point?
In: stroma
Out: episclera
Collagen
Elastic fibers
Posterior aspect
Two functions of sclera?
Episclera is made of ?
Episclera is joined to ? by CT strands
Protection
Attachment point for EOMs
Vascularized CT
Tenon’s Capsule- CT that encases globe as sleeve like sheath that covers tendons at EOM insertions
Episcleritis
What associated d/os can cause this
MC idiopathic
More prevalent in younger PTs
Herpes Thyroid dz
Collagen vascular dz (RA, Lupus)
Rosacea
How does Episcleritis present
What tests are done during work up?
How is it Tx
Acute w/ mild pain
Normal acuity
Engorged vessels w/out d/c
Slit lamp w/ anesthesia (phenylephrine) cause blanching
Mild: Cold compress/tears
Mod/Sev: topical Fluorometholone or Loteprednol
Ibuprofen
Scleritis
What tests are done to differentiate from episcleritis
Severe boring pain across jaw/forehead
Inflammation
Photophobia
Phenylephrine does not blanch
Slit lamp green light- avascular indicates necrosis
How is scleritis Tx
Necrotizing scleritis is Tx the same way but w/ ? referral?
NSAIDs
H2 blocker
Prednisone
ImmSuppressor- Clophosphamide
Rheumatology
How is posterior scleritis tx?
Cyclophosphamide
Rituximab
Glucocorticoids
Major differentiator for scleritis
Major differentiator for conjunctivitis
Severe pain
D/c
What are the 3 parts of the uveal tract and their funtion?
Iris- only visible portion
Ciliary body- produces aqueous humor; contains ciliary muscle for accommodation
Choroid- between sclera and retina; supplies blood to retina
Anterior uveitis may be AKA ?
This is associated w/ ? d/os?
Iritis
Iridocyclitis
\+HLA-B27- Anklyosing, Reiters Sarcoidosis Syphilis/TB Lymphoma Trauma
How does anterior uveitis present?
How is this Tx
Ciliary flush
Keratic precipitates:
fine/white= non-granulas
Mutton fat= granulomatus
Mild/Mod: scopolamine
Sev: Atropine
Prednisolone
What is the prognosis for anterior uveitis?
Posterior uveitis is AKA ?
First- excellent
Repeat- poor
Vitreitis
Choroiditis
Retinitis
What d/os are associated w/ posterior uveitis?
How does this present?
Toxoplasmosis- MC
AIDS- CMV
TB/Syphilis
Dec vision w/ floaters
Hazy vitreous
Optic disc swelling
How is posterior uveitits Tx
What is the MC severe infection of the eye?
What happens if this MC is left unTx?
Topical cycloplegic/steroid
CMV when CD4 <100
Blind <6mon
CMV retinitis is seen in ? PT populations?
How does this present in clinic?
AIDs
Transplant
Lymphoma
Leukemia
Floaters
Blurred vision
Blind spots- scotomata
Flashes if retinal detachment
What two Sxs are rare w/ CMV retinitis?
What is the most common sign finding?
Pain
Photophobia
Cotton wool spots
MC Sx of late onset strabismus from stroke/trauma/tumor?
Lateral lid pain, swelling, tenderness is ? Dx
Diplopia
Dacryoadenitis
Contact wearer w/ red/painful eye. Upon fluorescein exam, green burst is seen meaning ? Dx
What part of the body has the highest protein concentration of any body tissue?
HSV keratitis
Lens
What are the 3 parts of the lens?
MC RF for cataracts?
Capsule Cortex Nucleus
Age
Define Nuclear Cataract
Define Posterior Subcapsular Cataract and it’s MC Sxs
Yellow/brown discoloration of central view
Distance vision more blurry than near
Opacities near posterior aspect of lens
MC Sxs- glare, difficulty reading
Define Cortical Cataracts and their presentation
What issues develop as cataracts develop?
What is one benefit of developing nuclear cataracts?
Radial/spoke like opacities
ASx until central field invaded
Glare w/ headlights- common Monocular diplopia Foxed spots in visual fields Dec color perception Progressive visual loss
Thickening lens= second sight, improved near vision
Near vision dec w/ posterior subcapsular cataracts
How are cataracts Tx by stage of development
What are 3 reasons to perform cataract surgery
Early: spectacle prescription
Small central: pupil dilation
Late: removal; corrective refractive error
Manage Dzs (glaucoma diabetes) Improve visual function Prevent deprivational amblyopia in infants
MC cause of congenital cataracts
What are the 3 types of congenital cataracts
Idiopathic
Polar: opacity of lens pole
Nuclear: opacity of fetal nucleus
Lenticonus: opacified protrusion of lens capsule
What are the S/Sxs of congenital cataracts
This condition worked up focusing on?
How is it Tx
Mild-Sev decreased vision
Infant squints/keeps eyes closed
Absent/decreased red reflex
Hx of maternal illness
Medical emergency, surgical Tx in first 3-4mon
Why do congenital cataracts in infants have to be tx so quickly?
Define subluxation lens anomaly
Prevent amblyopia
Partial disruption of the zonular fibers
Decentered lens but partiall in aperture
Define dislocated lens abnormality
What is the MC and other associated RFs for lens position anomalys
Complete disruption of the zolular fibers
Lens is displaced out of posterior chamber
MC- trauma Marfans- superotemporal Homocystinuria- inferonasal Acquired syphilis High myopia
How do lens position anomalys present
Define Floaters
Dec vision w/ monocular diplopia Iridodenses Phacodonesis Irregular astigmatism Angle closure glaucoma
Small aggregates of vitreous from normal aging
What is the causes of acute onset floaters?
Define Flashers
Posterior vitreous detachment
Retinal tear
Uveitis
DM/Sickle associated bleeding
Suggests vitreal traction on peripheral retina
from posterior vitreous detachment/retinal tear
What does flashers w/ floaters indicate?
If flashes occur w/ migraines what may be seen?
Blood/pigment in vitreous
Scintillations
Zig-zag lights
What are the RFs for vitreous detachments
How does this present
How is it Tx
Diabetic retinopathy
Ophthalmic surgery
Trauma
Sudden appearance of black spots/flashing lights
Refer
Photocoagulation/cryotherapy for retinal detachment
When viewing PTs retina, where is the optic disc?
What supplies blood to the different areas of the retina?
Nasal portion
Inner retina- central retinal artery
Outter retina- choroid
What do retinal arteries and veins look differently on exam?
How are peripheral retinal structures viewed
Art: orange/red
Vein: larger, crimson
Indirect ophthalmoscopic techniques
What provides retinal pigment epithelium?
What are the RFs for retinal artery occlusion
Metabolic support system
GCA Embolus Thrombosis Collage vascular dz Hypercoagulation d/o
What are the S/Sxs of a retinal artery occlusion
What will be seen on exam?
What is the only vascular structure spared?
Unilateral painless acute vision loss
Whitening of retina
Cherry red macula
Box car segmentation arterioles
Cilioretinal artery
What type of retinal occlusion occurs if clot comes from central retinal artery?
What type of occlusion occurs if clot comes from branch of retinal artery and what type of loss will be seen
CRAO
BRAO
Horizontal hemifield vision loss
What structure of the eye may be spared during a retinal artery occlusion?
What is the first lab ordered when PT presents w/ suspected retinal artery occlusion?
Macula due to choidal supply
ESR, r/o GCA
How is retinal artery occlusion Tx
What will be seen on exam during retinal vein occlusion?
Occular massage
Anterior chamber paracentesis
Acetaolamide
Timolol topicals
Blood and Thunder fundus
Dilated veins
Flame shaped hemorrhage
Cotton wool spots/exudates
If BRVO is present, what part of vision is lsot?
What are the two types of retinal vein occlusions and what will be seen?
Horizontal hemifield loss w/ respect to horizontal line
Ischemic CRVO- multiple cotton wool spots w/ extensive hemorrhage
Non-ischemic CRVO- mild fundus changes
How is retinal vein occlusion Tx
What is the leading cause of blindness in the US for ages 20-64?
Mandatory ophthalmic eval <72hrs
D/c OCPs
PRP neorevascularization (iris/angle)
ASA 325 once a day
DM
After DM Dx, optical baseline needs to be established w/in ?
What type of DM rarely has retinopathy?
6mon
DMT-1 but will develop proliferative dz after 30yrs
What hormones can influence acceleration of diabetic retinopathy?
What are the 4 levels of severity for non-proliferative diabetic retinopathy?
Puberty
Pregnancy
VMild- microaneurysms Mild- microaneurysm, exudate, wool spots Mod: severe retinal hemorrhage, mild IRMA Sev: 4-2-1 4 quads severe retinal hemorrhage 2 quads venous beading 1 quad IRMA
