ophthamology - anterior eye

Question 1

Describe what refractive errors are

Answer 1

Refractive errors including near-sightedness, far-sightedness, astigmatism, and presbyopia.

• Near-sightedness occurs when the optical power of the eye is too large and causes light to focus in front of the retina.
• Far-sightedness occurs when the optical power of the eye is too small and causes light to focus behind the retina.

Question 2

what are the elements of the basic eye exam?

Answer 2

Visual Acuity
Visual Fields
Ocular Motility
Pupils
External Exam (eyelids, conjunctiva, cornea)
Fundoscopic Exam (red reflex, disc, retina)

Question 3

what are you looking for in the basic eye exam with the pupils?

Answer 3

Round
Reactive to light
Equal
Afferent pupil defect

Question 4

what is the differential diagnosis for unilateral red eye?

Answer 4

Viral or Bacterial Conjunctivitis
Iritis
Corneal Abrasion
Corneal Ulcer
Herpes Simplex
Herpes Zoster Ophthalmicus
Subconjunctival Hemorrhage

Question 5

What is the differential for bilateral red eye?

Answer 5

Dry Eyes

Allergic conjunctivitis

Question 6

What is conjunctivitis?

Answer 6

“Pink Eye”
Inflammation of the conjunctiva caused by viral or bacterial infection.
Usually few days in duration.
Complain of eye pain, discharge, blurred vision, mattering of eyelids in the morning.

Question 7

what symptoms/signs indicate viral conjunctivitis?

Answer 7

More common than bacterial conjunctivitis.
Most commonly occurs after an upper respiratory tract infection.
Adenovirus most common organism.
Moderate inflammation of the conjunctiva (appears pink).
Associated with watery discharge.
May have a pre-auricular lymph node enlargement.

Question 8

what is the treatment regimen for viral conjunctivitis?

Answer 8

Treatment:
Hand hygiene is necessary as infection may spread to the contralateral eye.
No specific treatment but most are self-limiting within a week.
Cool compresses and artificial tears.
Severe cases require topical steroid eye drops with pronounced inflammation.

Question 9

what are the symptoms/signs that indicate bacterial conjunctivitis?

Answer 9

Most common organisms are Staphylococcus aureus and Streptococcus pneumoniae.
More inflammation of the conjunctiva than viral conjunctivitis (appears red).
Thick, purulent discharge (whitish-yellow or yellow in color).
Eyelid can appear more swollen and almost closed.

Question 10

What is the treatment for bacterial conjunctivitis?

Answer 10

Treatment:
Cultures are not routinely taken and empirical treatment is started.
Antibiotic eye drops usually for one week.
Preferably 3rd or 4th generation fluoroquinolone (Ciloxan, Ocuflox, Zymaxid or Vigamox), Sulfacetamide or Tobramycin.
Gentamicin drops can be toxic and cause irritation with prolonged use.

Question 11

What’s up with iritis?

Answer 11

Iritis is a form of uveitis with inflammation of the iris
8-12/100,000 per year most commonly in 20-40 years old.
May have an acute onset.
Symptoms include ocular or periorbital eye pain, photophobia, blurred or cloudy vision.
Redness (near the limbus).
May have an irregular shaped pupil.

Question 12

What is the treatment for iritis?

Answer 12

Treatment:
Topical Steroid Eye Drops (Pred-Forte)
Dilating Eye Drops (help prevent synechiae within the eye and with pain)
Occasionally Topical Glaucoma Drops

Question 13

What do you do if a patient has recurrent iritis?

Answer 13

First occurrence no systemic work up is necessary
Second recurrence then systemic workup is recommended:
HLA-B27, ACE level, CBC, ANA, RPR, VDRL, PPD, and chest X-ray
Ankylosing Spondylitis, Rheumatoid Arthritis, Behcet’s Disease, Crohn’s Disease, Ulcerative Colitis Lupus, Sarcoidosis, Syphilis, TB
If there is an underlying cause then patients may require steroid sparing agents such as methotrexate

Question 14

on examination, what indicates a corneal abrasion?

Answer 14

Examination may show irregular epithelium and slightly cloudy.
Fluorescein stain can be used with a blue light to highlight the epithelial defect.

Question 15

What’s the treatment of corneal abrasion?

Answer 15

Treatment:
Mild corneal abrasions can be treated with frequent artificial tears and topical antibiotic ointment.
Large corneal abrasions may require antibiotic ointment and patching of the eye or a contact lens can be placed on the eye. May require oral pain medication.
No topical anesthetic eye drops as they delay healing process.
Fortunately the abrasions heal quickly and should be checked on a daily basis to ensure no secondary infection develops.
Risk of future abrasions.

Question 16

what’s up with a corneal ulcer?

Answer 16

Corneal ulcer is an infection of the corneal stroma.
Causes include bacterial (Staph aureus, Pseudomonas), fungal (Fusarium) and protozoa (Acanthamoeba).
Caused by trauma with vegetative matter (fungal), contact lens wear (bacterial or protozoa) and risk 10 x higher for extended wear, dry eye, facial nerve paralysis.
Acute onset with severe pain, redness, decrease in vision, eyelid swelling.

*signs - White infiltrate is seen in the cornea.
May see thinning of the cornea where the infiltrate is present.
May also see a hypopyon inside the anterior chamber.

Question 17

what is the treatment for a corneal ulcer?

Answer 17

Treatment:

For small ulcers (

Question 18

What may cause dry eye?

Answer 18

Dry eye may occur if the body is not making enough tears.
Systemic Conditions: rheumatoid arthritis, lupus, Grave’s disease
Medications: anti-histamines, pain medication, anti-depressants

May also occur if there is enough tear production but the tears simply evaporate too quickly.
during situations of attention: computer work, reading
environmental conditions: ceiling fans, air conditioning

Question 19

what are the treatments for dry eye?

Answer 19

Common treatments include:
Artificial tears
Flax seed oil, Omega-3 vitamins
Medicated eye drops to help improve tear production (restasis)
Modification of oral medications, treatment of any underlying systemic disease
Punctal plugs

Question 20

what is the treatment for allergic conjunctivits?

Answer 20

Diagnosis can often be made based on symptoms.
Itchy eyes most important.
Treatment consists:
Avoidance of the offending allergen
Topical antihistamines (Zaditor, Naphcon-A)
Topical mast cell stabilizers/antihistamines (Patanol, Bepreve, Elestat)
Topical steroids (FML, Pred-Forte)

Question 21

what viral infection is quite worrisome in the eye?

Answer 21

Herpetic keratitis is a common viral infection that affects the corneal epithelium primarily the HSV1.
20,000 new cases/year.
28,000 reactivations/year.
One of the most frequent causes of permanent vision loss.

Question 22

what are the signs/symptoms of HSV1 infection in the eye?

Answer 22

Patients often present with unilateral eye redness (can be bilateral), pain, photophobia, decreased vision, and tearing.
Fluorescein on the ocular surface shows dendritic epithelial ulcer in branching pattern with terminal bulbs.

Question 23

what’s the treatment for ocular HSV1 infection?

Answer 23

Treatment:
Most cases will resolve spontaneously within three weeks. Medication can shorten the duration.
Topical trifluridine Q2H.
Oral acyclovir 400mg 5x/day or valacyclovir 1g TID.
Once healed patients may develop a corneal scar which can cause blurred vision.
Contact lens
Corneal transplant

Question 24

What signs make you think ocular manifestation of Hepes Zoster?

Answer 24

Herpes Zoster Ophthalmicus is a reactivation of VZV. Represents about 10-25% of all cases of Herpes Zoster and up to 65% may develop ocular manifestations.
Dermatological involvement of V1 distribution.
Symptoms include prodromal period of fatigue, low-grade fever, unilateral rash on forehead, upper eyelid and nose.

Ocular manifestations may occur and more likely if there is lesions affecting the tip of the nose “Hutchinson sign” as both innervated by the nasociliary nerve.
Symptoms include unilateral eye pain, redness, decreased vision, photophobia.
Fluorescein applied to corneal surface can reveal multiple swollen lesions with staining around them.

Question 25

What is the treatment for Herpes Zoster ophthalmicus?

Answer 25

Treatment:
Oral Acyclovir 800mg 5x/day for 10 days
Oral Valacyclovir 1g 3x/day for 10 days

Neurotrophic cornea may develop and patients are at risk for chronic dry eye and infections requiring chronic artificial tear supplements.

Question 26

What’s up with Pterygium?

Answer 26

Pterygium
Latin for “wing”
Benign fibrocascular tumor, UV induced
Often becomes inflammed
Treatment:  Artificial tears, Sunglasses, Vasoconstrictors (short-term). 
Conjunctival Autograft with Tissel glue.

Question 27

what’s up with angle closure glaucoma?

Answer 27

Risk factors include ethnicity (Asian population), age (6th-7th decade) and hyperopia.
Symptoms include unilateral severe eye pain, nausea, redness, blurred vision and halos around lights.
Examination may show sluggish, mid-dilated pupil, conjunctival injection, hazy cornea and shallow anterior chamber. When palpating the eye it may feel hard.

Question 28

what’s the treatment for angle closure glaucoma?

Answer 28

Definitive treatment is a laser peripheral iridotomy.

Allow the aqueous to gain access to the anterior chamber and opens of trabecular meshwork.

Question 29

what’s up with open angle glaucoma?

Answer 29

Open angle glaucoma is a progressive disease of the optic nerve that is often associated with elevated intraocular pressure.
Other risk factors include age, ethnicity, myopia and family history.
Patients usually do not experience any symptoms as it slowly causes damage to their peripheral vision.

With elevated intraocular eye pressure, stress is placed on the optic nerve leading to nerve cell damage and consequently enlargement of the optic nerve.

Question 30

what usually causes cataracts?

Answer 30

Patients may notice their vision is as they are looking through a dirty window, color de-saturation, night-time glare and halos.
Usually develop with age as lens proteins breakdown. Other causes in younger patients may include:
Diabetes (with with poorly controlled sugars)
Steroids (used to treat rheumatoid arthritis, emphysema)
Trauma
Radiation

Question 31

describe the surgical intervention in cataract surgery

Answer 31

When the cataracts develop to the point that a patient’s vision cannot be corrected with glasses and they are interfering with their daily activities surgical intervention is recommended.
Phacoemulsification involves lens removal using an ultrasound probe through a small incision.
Cataract is replaced with an artificial lens and is necessary to allow for functional vision post-operatively.