Ophtho Flashcards
Dacryocystitis
Infection of lacrimal sac
Usually in infants and adults > 40 yo
Sudden onset pain and redness in medial canthal region.
Sometimes have purulent d/c from punctum
Staph aureus and b-hemolytic Strep usual organisms
Episcleritis
infection of episcleral tissue b/n conj and sclera
Mild-moderate discomfort, photophobia, watery discharge
Hordeolum
abscess over upper or lower eyelid
- of ciliary follicle and glands along lid margin
usually due to staph aureus
red, tender swelling
Tx:
- warm compress
- topical abx
Chalazion
Lid discomfort
chronic granulomatous inflmmation of meibomian gland
Hard, painless lid nodule
Tx:
- usually regress spontaneously
- may require excision
Orbital cellulitus
Infection posterior to orbital septum
Unilateral
Kids more
Fever, proptosis, restriction of EOM, swollen and red eyelids
Allergic conjunctivitis
Acute hypersensitivity caused by environmental allergens
PMH of atopic dermatitis, asthma, eta, usually
Sx: intense itching, hyperemia, tearing, conj edema, eyelid edema
Tx: topical antihistamines, artificial tears, cool compresses
Atopic keratoconjunctivitis
Severe form of ocular allergy
Itching, tearing, thick mucous discharge, photophobia, blurred vision
Painful retinitis / retinal necrosis + keratitis + conjunctivitis + rapid visual loss
HSV retinitis
Fundoscopy - widespread, pale, peripheral lesions and central necrosis of the retina
Painless retinitis
CMV retinitis
Fundoscopy - fluffy/granular retinal lesions near retinal vessels + associated hemorrhages
Endophthalmitis
1 form is postoperative - usually within 6 weeks of surgery
Change in vision is common
Candida can also cause
Amaurosis fugax
Warning that there is a stroke coming!
Can be other etiologies like retinal detachment, optic neuritis
Usually caused by retinal emboli from ipsilateral carotid artery
Transient monocular blindness lasting only a few minutes - “curtain falling down”
Whitened, edematous retina following distribution of retinal arterioles
Vascular in origin usually
Usually in people w/ atherosclerosis, CAD or HTN
Do a duplex US of neck
Central retinal artery occlusions
- sx
- cause
- what it looks like
Sx: Sudden painless loss of vision in 1 eye
Cause:
atheromatous particles
emboli
local retinal A compression
Result:
Usually irreversible vision loss
Pallor of optic disc (ischemic retinal whitening)
cherry red fovea
boxcar segmentation of blood in retinal arteries and veins
Central retinal vein occlusion
- sx
- causes
Sx: Sudden painless unilateral loss of vision
Cause: Usually in HTN pts
Result:
Visual loss variable (vs irreversible in CRAO)
Disk swelling
venous dilation + tortuosity
streaky linear retinal hemorrhages
cotton wool spots
Best diagnostic for acute glaucoma
Tonometry
Tx central retinal artery occlusions
Ophthalmologic emergency
Ocular massage –> dislodges embolus to help perfuse
Can use anterior chamber paracentesis to lower IOP
Carbogen therapy (5% CO2, 95% O2)
Dx corneal abrasions or herpes keratitis
Fluorescein stain of eye
Macular degeneration
Early findings - distortion of straight lines such as they appear wavy
Driving and reading one of first activities affected
Episcleritis
Inflammation of tissue b/n conj and sclera
Strongly assoc w/ rheumatoid arthritis and IBD
Cause of blindness via Giant Cell Arteritis
Ischemic optic neuropathy because involve ophthalmic artery
Will cause permanent blindness
Anterior uveitis
Red eye w/ leukocytes in anterior chamber
Inflammation of ciliary body and iris
Uveitis associations
Sarcoidosis
Ankylosing spondylitis
External hordeolum
THis is a stye!
Common staph abscess of eyelid
Tx w/ warm compresses
Sympathetic ophthalmia
Spared eye injury
Immune-mediated inflammation of 1 eye after penetrating injury to the other eye
- due to uncovering of hidden antigens
- break open eye, expose immune sys to these antigens in immune-privileged cite
Usually p/w anterior uveitis
Acute angle closure glaucoma - characteristics- consequences
Severe painvision losshalos around lightspupils dilatedInjected appearing scleraTearing, N/VPermanent vision loss 2-5 hrs after onset
Optic neuritis
Painful loss of vision
Central visual field defect
Fundoscopy normal
Tx diabetic retinopathy
Laser photocoagulation
Tonometry
Measures IOP
Tx OA glaucoma
Beta blocker
Alpha agonist
Carbonic anhydrase inhibitor
Prostaglandin analog
Tx AAC glaucoma
Pilocarpine drops
IV acetazolamide
Oral glycerin
Tx AAC glaucoma
Pilocarpine drops
IV acetazolamide
Oral glycerin
Pale optic nerve a sign of
Prior infarction (ischemic optic neuropathy)
Prior inflammation (MS, optic neuritis)
Ddx retinitis pigmentosa
Abetalipoproteinemia Mt disease Bardet-Biedl syndrome Laurence Moon syndrome Freidreich ataxia Refsum disease
Retinitis pigmentosa
- mutation
- what happens
Chr 3 mutation
Degeneration of retinal receptors + adjacent pigment cells
Degeneration progresses: small accumulations of pigment appear around periphery of retina
Optic disc palor later evident in disease
Retinal phakomas
Gliomatous tumors
No tx needed
Principal components need for makign diagnosis of tuberous sclerosis
Red glass test
Get 2 images if eyes not moving together
Red image appears to L indicating eye covered by red glass not moving to left as much as other eye
REMEMBER:
- assume that eye is not moving where red image appears to be
Congenital cataracts infections
Rubella
CMV
Ddx leukocoria in infant
Can be opacification of lens (cataract) or retina is white
Cataract:
- rubella
- CMV
Retina:
- scar from retinopathy of prematurity
- retinoblastoma
Glaucoma can develop in 1/3 of children with what disease?
Sturge weber
B12 deficiency scotoma
Blind spot enlarges and extends temporally to involve macula
Similar to blind spot w/EtOH and tobacco excess = tobacco-alcohol amblyopia (B1 deficiency)
Acute large central scotoma
- ddx?
Methyl alcohol intoxication
Papillitis vs/ papilledema
Papillitis (inflamm optic N head)
- visual loss
- pain w/ eye mvmts
- sensitivity to light
- pressure on globe
- early sign of MS usually
Papilledema:
- no visual loss
Tunnel vision vs. Concentric constriction
Concentric constriction
- area perceived enlarges as test screen moved farther away from patient
- overall visual field always smaller than normal vis field
- if assoc w/ optic atrophy, can happen from neurosyphilis
Tunnel vision
- same size field even if test screen moved farther away
- not physiologic pattern of visual loss
- should suggest conversion d/o or malingering
Marcus Gunn (afferent pupillary) defect
Dx w/ swinging flashlight test
Often in ppl w/ MS as sequela of optic neuritis
Damage to optic N –> reduce light perception in affected eye
Pupil constrict bilaterally if shine in unaffected eye
Pupil dilate if shone in affected eye
Nyctalopia
Night blindness
Happens w/
retinitis pigmentosa
vit A deficiency
color blindness
Scintillating scotomas
classic for migraine aura
Long standing HTN –> retina changes?
Segmental narrowing of arterioles
- can get nicking as arterioles cross over veins
Most common eye muscle nerve palsy
6th nerve (abducens) > 3rd N > 4th N
Causes of abducens dysfunction w/ LR palsy in:
- kid
- adult
Kid
- increased ICP
- direct damage to brainstem (brainstem glioma)
Adults:
- nasopharynx mets to N
- vascular disease
Gradenigo syndrome
Facial sensation + LR palsy
Happens w/ osteomyelitis of petrous pyramid
Abducens and trigeminal N affected as pass close to tip of petrous bone
Chronic ear infections can extend to petrous and produce syndrome
1 eye muscle N damaged w/ trauma to face
4th cranial nerve = trochlear
SO muscle extends far anterior into orbit –> high risk of injury w/ trauma to orbit or full face
Get head tilt w/ injured muscle
Most common eye muscle N involved w/ herpes zoster ophthalmicus
4th nerve
- it shares nerve sheath w/ ophthalmic division of trigeminal
What type of CN 3 palsy do you get w/ diabetics?
Vessel affected is usually deep in 3rd nerve
- not superficial so pupillary constriction usually ok
Can get pain in and about eye w/ damaged 3rd N
Oculomotor fiber aberrant regeneration - what should you suspect?
Usually due to lesions that chronically compress 3rd nerve
Suspect:
Aneurysms
Cholesteatomas
Neoplasms
Internuclear ophthalmoplegia
MLF syndrome
On attempted conjugate lateral gaze AWAY from side of lesion, get nystagmus
- nystagmus (Fast component) is directed temporally to lesion side
1 1/2 syndrome
L MLF and L abducens nucleus damaged
Left gaze, both eyes still in center Right gaze (away from lesion), get nystagmus to L
Ocular bobbing
Rapid down deviation of both eyes followed by SLOW upward conjugate eye mvmts
Involuntary mvmt usually develops w/ pontine damage (eg pontine glioma)
Damage to cerebellum also gets this
Optokinetic nystagmus
Should be elicitable in normal pts
If nystagmus is less obvious on rotating drum in given direction, pt may have PARIETAL lesion responsible for asymm. response
Does orbital cellulitis cause vision loss?
NO! Not usually
Will c/o orbital pain, proptosis, pain with eye mvmts
CT to see extent of cellulitis
Cavernous sinus thrombosis
Proptosis
Pain
Retina changes
VA affected b/c venous drainage not ok
Adie tonic pupil
Tonically dilated pupil
Usually seen in healthy young women
Can occur alone or w/ absent tendon reflexes
If unilateral –> suspect local trauma to eye
If bilateral –> suspect drug use
Probably due to degen of ciliary ganglia
Usually benign phenoenon
Usher syndrome
Hearing loss + visual impairment
Retinitis pigmentosa
Defective inner ear
Most common cause of acute monocular blindness
Ischemic optic neuropathy
- usually due to occlusion of posterior ciliary A (branch of ophthalmic artery)
- not assoc w/ carotid disease
Sudden painless loss of vision in 1 eye
VF have inferior altitudinal defect w/ involvement of central vision –> loss of acuity
- opposite eye can get affected soon after
RIsk factors:
HTN
DM
Need to exclude GCA
How can you tell when you have increased ICP on funduscopy?
Veins normally pulsate
Will not pulsate with increased ICP
What is best sensory test for afferent pupillary defect?
Swinging flashlight
What can give you blurry vision?
Papillitis Diplopia Cataracts Papilledema/Optic nerve stuff Macular degeneration Homonymous hemianopia
For person w/ Horner’s, do you see a bigger difference in pupil reflex in dark or light?
Dark
How do you monitor retina during electonystagmography studies?
Retina is negatively charged in comparison with cornea – creates a dipole to monitor
Painful Horner’s after vigorous activity?
Carotid dissection
PIgmentary degeneration of retina
can occur with infections (congenital toxo, CMV)
Part of hereditary metabolic disorder (RP)
opsoclonus
irregular jerking of eyes in all directions
Sudden loss of vision
Onset of floaters
Fundus is difficult to visualize
1 cause of vitreous hemorrhage is diabetic retinopathy
Vitreous hemorrhage
Afferent pupillary defect is very specific for…
Optic nerve problem
What aneurysm gives you CN 3 palsy?
Posterior communicating cerebral artery
Most common cause of 4th nerve palsy
Head trauma
1 cause of cherry red spot of fovea?
Central retinal artery occlusion
There is ischemia of retina - becomes pale - and now can see choroid clearly underneath macula
Circulation of eye
Chroidal circulation
Retinal arteries
Most common cause of viral conjunctivitis is
Adenovirus.
Infection often has systemic sx
Ocular migraine sx
Binocular!
A 3-year-old female is brought to your office for a health maintenance examination, and her father expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling E visual acuity chart. With both eyes uncovered during a cover/uncover test, the corneal light reflex in the right eye is medial to the pupil when focused on a fixed point, but the light reflex in the left eye is almost centered in the pupil. When the left eye is covered, the right eye moves quickly inward to focus on the fixed point, and the corneal light reflex is centered in the pupil. When the left eye is uncovered, the right eye returns to its original position. When you cover the right eye, no left eye movement is noted. Which one of the following is the most likely diagnosis? (check one) A. Strabismus B. Amblyopia C. Cataract D. Esotropia E. Heterophoria
Strabismus is an ocular misalignment that can be diagnosed on a cover/uncover test when the corneal light reflex is deviated from its normal position slightly nasal to mid-pupil. The misaligned eye then moves to fixate on a held object when the opposite eye is covered. The eye drifts back to its original position when the opposite eye is uncovered. Amblyopia is cortical visual impairment from abnormal eye development-most often as a result of strabismus. Cataract is a less frequent cause of amblyopia. Esotropia is a type of strabismus with an inward or nasal deviation of the eye that would be evidenced by a corneal light reflex lateral to its normal position. (The outward eye deviation seen in this patient is exotropia.) Heterophoria, or latent strabismus, does not cause eye deviation when both eyes are uncovered.
Age related macular degneration
- predisposition
- risk factors
occurs more frequently in light-skinned individuals than in dark-skinned individuals.
Risk factors include smoking and hypertension
Ophthalmopathy of Grave’s may get worse when treated w/ what?
Radioactive iodine
Ophtho side effect of sildenafil
Non-arteritic anterior ischemic optic neuropathy (NAION) is a very rare but serious condition which may occur in men taking sildenafil.
It causes restriction of blood flow to the optic nerve and can result in permanent blindness.
Bitot spots
Dry silver-gray plaques on bulbar conj
Seen in vit A deficiency
Tx bacterial conjunctivitis
Sulfonamide drops
Binocular fixation present at what age in kids?
3-4 months
NOrmal acuity in newborn is…
20/200 - 20/400
Coloboma
Defect of lid that can range from small indentation to large cleft
Can lead to ulceration from excessive drying
Epicanthal folds
Folds of skins on nasal side of eye
Usually more prominent at birth and recede with time
Responsible for pseudostrabismsus by making eyes appear closer together
Blepharitis
Inflammation of lid margins
Most common causes of neonatal conjunctivits
Chlamydia
Gonorrhea
Conjunctivitis
Tearing
COnjunctival injection
Lid edema
Discharge
Dacryostenosis
Caused by congenital lacrimal duct obstruction
Usually unilateral
CLear d/c
Spontaneous resolution by age 1
Strabismus
Misalignment of eyes
Deviations can be:
- convergent (esotropia)
- divergent (exotropia)
- results from abnormal innervatino of muscles from supranuclear nerve
Dx strabismus
Hirschberg test - looking for corneal reflex
Cover test
Amblyopia
decrease in acuity 2/2 unclear image falling on retina
Usually 2/2 strabismus or by opacity in visual axis
Dx corneal abrasions
Slit lamp of eye under blue filtered light after instillation of fluorescein
Tx - topical abx
Periorbital cellulitis
No true orbital involvement
ONly eyelids and surrounding tissues involved
Eye mvmts normal
Follicles + inflammatory changes in conjunctiva of eye
Neovascularization in cornea
Immigrant
Trachoma 2/2 C. trachomatis serotype A-C
Can also cause nasal discharge as it moves
Tx: Topical tetracycline or oral azithromycin
