Ophtho Flashcards
Most common signs of retinoblastoma
Leukocoria
Esotropia
Corneal light reflex in strabismus
No response in affected eye
Red reflex in strabismus
Red reflection is MORE intense from deviated eye
Amblyopia
Eye fails to achieve normal visual acuity even with prescription glasses or contact lenses
Occurs in up to 1/2 of younger children with strabismus
Myopia
Nearsightedness
Hyperopia
Farsightedness
Internuclear ophthalmoplegia
Caused by lesion of MLF in mid-pons
Disorder of horizontal eye movements: affected eye unable to ADduct, contralateral eye able to ABduct but with nystagmus
Unilateral (commonly caused by stroke)
Bilateral (commonly caused by demyelning disorder ie. MS)
Ex. Right MLF lesion causes Right INO (unable to adduct right eye when looking left)
Giant cell arteritis presentation
Unilateral vision loss (often) Headache Jaw claudication Scalp tenderness Constitutional symptoms High ESR/CRP RF: age, female, smoking, low BMI, PMR
GCA tx
1st step: high dose pred for months-years (usually switched to immunosuppression)
- Temporal artery biopsy
- Urgent referral to ophtho and rheum
- If left untreated, will involve other eye within 2 weeks
Optic neuritis presentation, etiology
Young females Reduced colour vision Pain with EOM Visual field defect Often due to MS May be idiopathic
Optic neuritis tx
Refer to ophtho and neuro
MRI MS protocol
High dose IV steroids
Retinal vascular occlusion: Arterial occlusion etiology, fundoscopy
May be caused by embolism (stroke workup), inflammation (GCA, vasculitis)
Fundoscopy: retinal pallor due to ischemia, cherry red spots (fovea appears red compared to surrounding retina)
Retinal vascular occlusion: Venous occlusion etiology, fundoscopy
Older pt with microvascular dz, atherosclerosis (arteries squish the veins)
Younger pt with hyperviscosity due to polycythemia, myeloma, etc.
Fundoscopy: cotton wool spots (areas of ischemia, hemorrhage)
Retinal detachment
Black curtain, flashes of light (photopsia), floaters
Macula on –> emergency, needs to be fixed before macula comes off; pinhole correction means NO fovea involvement
Macula off –> not an emergency anymore; no pinhole corection means fovea involved, will not be able to regain vision
Vitreous detachment
Normal part of aging
Floaters and flashes
All need dilated retinal exam to rule out retinal tear/detachment within a few days
No good tx for floaters
Lesion of optic nerve
Ipsilateral monocular vision loss
Lesion of optic chiasm
Bitemporal hemianopsia
Lesion at optic tract
Contralateral homonymous hemianopsia
Cataracts symptoms
Blurred vision Glare Difficulty seeing in low light Loss of contrast sensitivity Loss of ability to discern colours Change in refractive status
Cataracts surgical guidelines
Visual acuity 20/50 or worse WITH glasses
Visual acuity 20/40 or better but with significant visual impairment
Always up to the patient, except
Driving (must be 20/50 or better)
Angle closure glaucoma
Macular degeneration: dry type
More common
slow progressive atrophy of RPE and photoreceptors
Characterized by Drusens in macula
Tx: Smoking cessation, vitamins
Macular degeneration: wet type
RPE detachment and choroidal neovascularization
Leaky vessels
Tx: Anti-VEGF injections
Symptoms of macular degeneration
Progressive and bilaterall loss of central vision, metamorphopsia, distortion of vision, scotoma or blind spot
Open angle glaucoma
Chronic decreased outflow or increased production of aqueous fluid
Increased cup-to-disc ratio
Slow loss of peripheral vision, asymptomatic
Tx: Lower IOP with drops (prostaglandins ie. latanoprost better than beta blockers ie. timolol), laser or surgery as last line
Cataract
Opacity of lens
Closed angle glaucoma
Mechanical blockage of fluid flow to anterior chamber, closing angle between lens and cornea
N/V, headache, acute changes in vision, pupil fixed in mid-dilation
IOP up to 40-60
Normal IOP
10-22mmHg
Closed angle glaucoma tx
Emergency Eye drops (ie. timolol) IV diamox (carbonic anhydrase inhibitor to decrease fluid production) IV mannitol Check kidneys! Laser peripheral iridotomy
Diabetic retinopathy on fundoscopy
Nonproliferative: Microaneurysms Retinal hemorrhage Cotton wool spots Proliferative (worse): ischemia of retina with neovascularization Any stage: Macular edema
Diabetic retinopathy tx
Control diabetes
Non-proliferative - no tx
Macular edema - anti-VEGF
Proliferative - laser photocoagulation, anti-VEGF injection, vitrectomy
Emmetropia
No refractive error
Astigmatism
Light rays not refracted uniformly due to non-spherical surface of cornea or non-spherical lens
May cause blurry vision, squinting, headaches
Anisometropia
Difference in refractive errors btwn eyes
2nd most common cause of amblyopia in children
Preseptal cellulitis tx
Systemic abx to cover S. aureus, Strep, H. influenza if child
Ie. Amox clav
Septal cellulitis tx
Admit
Blood cultures x2
Orbital CT
IV abx (CTX + Vanco x 1wk)
Hordeolum
Stye
Acute inflammation of eyelid gland (Meibomian, glands of Zeis or Moll)
Infectious agent typically S. aureus
Tx: Warm compresses, lid care, gental massage)
Chalazion
Chronic granulomatous inflammation of Meibomian gland often preceded by internal hordeolum
NOT infectious case
Blepharitis
Inflammation of lid margins
S. aureus, seborrheic, meibomian gland dysfunction
Warm compresses, lid massage, lid washing, topical/systemic abx as needed
Viral conjunctivitis common culprit
Adenovirus
Bacterial conjunctivitis common causes
S. aureus S. pneumo H. influenza M. catarrhalis N. gonorrhoeae, C. trachomatis in neonates
Most common cause of bacterial conjunctivitis in neonates
C. trachomatis
Leading infectious cause of blindness in world
Trachoma
Trachoma tx
Oral azithro and topical tetracycline
Episcleritis vs scleritis
Phenylephrine drop –> reexamine 10-15min later
Episcleritis = episcleral vessles blanch with phenylephrine
Corneal abrasion tx
Topical abx
Topical NSAIDs
Cycloplegic
Patch
Corneal ulcer
Corneal opacity stains with fluorescein
Seidel test: Fluorescein under cobalt blue filter –> leaking penetrating lesions
Tx: URGENT referral to ophtho, culture prior to tx, topical abx q1h
Herpes simplex keratitis
Usually HSV1
Dendritic lesion with terminal end bulbs in epithelium that stains with fluorescein
Tx: Topical or systemic antiviral, NO STEROIDS initially (only done by ophtho)
Herpes zoster ophthalmicus
CNV1
Tx: Oral antiviral immediately, topical steroids/cycloplegia as indicated, erythromycin ointment if conjunctiva involved
Hutchinson’s sign
If tip of nose is involved, globe will be involved in 75% Of cases
Most common cause of reversible blindness worldwide
Cataracts
Most common surgical technique for cataracts
Phacoemulsification
New or markedly increase in floaters or flashes of light require dilated fundus exam to R/O
Posterior vitreous detachment/retinal detachment
Retinal artery occlusion hallmark on exam
Cherry red spot atcentre of macula
also retinal pallor, cotton wool spots, cholesterol emboli
Retinal artery occlusion presentation
Sudden, painless, severe monocular loss of vision
Retinal artery occlusion tx
OCULAR EMERGENCY
Needs to attempt to restore blood flow within 2h
Ocular massage and high flow O2
Decrease IOP (topical BB, IV acetazolamide, IV mannitol)
Central retinal vein occlusion hallmark on exam
Blood and thunder:
Diffuse retinal hemorrhages, cotton wool spots, venous engorgement, swollen optic disc, macular edema
Leading cause of irreversible blindness in western world
Age related macular degeneration
Most common cause of age related macular degeneration
Dry/Non-exudative/non-neovascular
Characteristic finding of dry AMD
Drusen - yellow/white deposits btwn RPE and BRuch’s membrane
Characteristic finding of wet AMD
Chorionic neovascularization
Classic clinical feature of AMD
Variable degree of progressive central vision loss
Metamorphsia
Wet AMD tx
Intraveitreal injection of anti-VEGF
Pressures > ___ increase risk of developing glaucoma
21mmHg
Primary open angle glaucoma
Resistance from trabecular meshwork
Earliest signs are optic disc changes (Increased C:D ratio)
Slow progressive irreversible loss of peripheral vision
Primary open angle glaucoma tx
Increase aqueous outflow (topical cholinergics, topical prostaglandins, topical alpha adrenergics)
Decrease aqueous production (topical beta blockers, topical and oral carbonic anhydrase inhibitors, topical alpha adrenergics)
Surgery
Acute angle-closure glaucoma
Fixed mid-dilated pupil RF: hyperopia, pupil dilation, asian female, >70yo, mature cataract RED PAINFUL EYE Unilateral >40mmHg IOP
Acute angle closure glaucoma tx
Beta-blockers (timolol)/miotics (pilocarpine - increases outflow)
Diamox (Carbonic anhydrase inhibitor to decrease aqueous production)
Hyperosmotic agents (oral glycerine, IV mannitol)
Laser iridotomy is definitive
Highly specific sign of neurosyphillis
Argyll-Robertson pupil (bilateral small pupils that constrict with accommodation but NOT to light reflex)
CN III palsy
Eye deviated down and out with ptosis
Pupillary dilation
Most common cause of relative afferent pupillary defect
Optic neuritis
Relative afferent pupillary defect
Impairment of direct pupillary response to light caused by lesion in visual afferent (sensory) pathway anterior to optic chiasm
Pupils DILATE in response to rapid swinging of light from unaffected to affected eye
Cannot have RAPD in both eyes
Most common malignancy on eyelid
BCC
Most common primary intraocular malignancy in adults
Uveal melanoma
Most common intraocular malignancy in adults
Metastases
Kaposi’s sarcoma secondary to
Human Herpes Virus 8
Diabetic retinopathy
Most common cause of blindness in young people in NA
Non-proliferative –> Proliferative
Tx: DM/HTN control, anti-VEGF injections, vitrectomy if non-clearing vitreous hemorrhage and tractional RD
Optic neuritis tx
IV steroids with taper to oral form
Can’t start oral form in isolation as this increases likelihood of eventually development of MS
Heterotropia vs heterophoria
Deviation NOT corrected by fusion mechanism in heterotropia
Deviation IS corrected by fusion mechanism in heterophoria (ie. not seen when pt is focusing with both eyes)
Most common primary intraocular malignancy in children
Retinoblastoma
Strabismus tx
Glasses
Occlusion therapy
Sx
Botox
Suspected globe rupture initial management
CANT CT orbits Ancef +/- Aminoglycoside IV NPO Tetanus status
Alkali or acid burns worse for eyes?
Alkali
Managing chemical burn
Irrigate immediately DO NOT attempt to neutralize Cycloplegic drops to decrease iris spasm and prevent secodnaey glaucoma Topical abx and patching Ophtho may rx topical steroids
Common mydriatics
Dilate pupils
2 classes:
1. Cholinergic blocking (tropicamide) - dilation plus cycloplegia (loss of accomodation)
2. Adrenergic stimulating (ie. phenylephrine) - stimulate pupillary dilatory muscles, no effect on accomodation
CMV retinitis
Full thickness retinal inflammation causing edema and scarring –> blurred vision, floaters, photopsia –> scarring and possible retinal detachment
Think about in immunocomprised pt ie. HIV (reactivation of latent dz)
Fundoscopy: Yellow-white fluffy hemorrhagic lesions along vasculature
Tx: oral antivirals
Hallmark signs of trachoma
Follicular conjunctivitis and pannus formation (neovascularization) in cornea
