Ophtho

Question 1

What is acute angle closure glaucoma?

Answer 1

Due to meds (anticholinergics such as tolterodine, sympathomimetics, and decongestions) or other stimuli (eg dim light)
Presentation: PAINFUL, sudden-onset eye pain, blurred vision, headache, and nausea; conjunctival erythema, corneal opacification, fixed mid-dilated pupil, n/v
Halos around lights
Dx: gonioscopy (gold standard); ocular tonometry (measures IOP) helpful if urgent ophtho consulation is unavailable

Question 2

Visual acuity testing.

Answer 2

Performed routinely at age 4, but can be performed as early as age 3 in cooperative children.

Question 3

What is amaurosis fugax?

Answer 3

Presentation: PAINLESS, rapid, transient (<10min) monocular vision loss; “curtain” descending over visual field
Etiology: retinal ischemia due to atherosclerotic emboli originating from ipsilateral carotid artery
Dx: duplex u/s of the neck

Question 4

What is anterior uveitis?

Answer 4

Presentation: PAINFUL, red eye assoc. w/ photophobia, tearing, diminished visual acuity
Exam: hazy “flare” in aqueous humor, layering of white cells in the anterior chamber (hypopyon)
Idiopathic or traumaict, assoc. w/ chron’s disease, spondyloarthritis

Question 5

What is vitreous hemorrhage?

Answer 5

Commonly caused by proliferative diabetic retinopathy.
Presentation: sudden loss of vision and onset of floaters; fundus is difficult to visualize
Tx: conservative - upright position during sleep, which enhances settling of hemorrhage

Question 6

What is sympathethic ophthalmia/”spared eye injury”?

Answer 6

Characterized by an immune-mediate inflammation of one eye (the sympathetic eye) after a penetrating injury to the other eye.
Etiology: uncovering of “hidden” antigens when natural barrier is defective; immune response against antigens can involve autoantibodies as well as a cell-mediated reaction
Presentation: anterior uveitis, but panuveitis, papillary edema, and blindness may develop

Question 7

Central retinal artery occlusion.

Answer 7

Acute painless monocular vision loss
Due to embolized plaque from ipsilateral carotid artery; cardioembolic source
Central fovea appears red from underlying choroid (“cherry red spot”)
Transient
Dx: noninvasive imaging of carotids to evaluate for stenosis
Tx: ocular massage and high flow O2 administration

Thombolytics may be useful if initiated w/in 4-6h of visual loss but they are administerd intraarterially. Their efficacy has not been systematically studied.

Question 8

Detached retina

Answer 8

Light flashes, floaters, “curtain” across visual field starting from the periphery; not transient

Question 9

Central retinal vein occlusion

Answer 9

Painless, sudden vision loss (or haze) due to venous thrombosis
Can progress to ischemic form that can be painful
Fundoscopy: dilated and tortuous veins leading to scattered and diffuse hemorrhages (“blood and thunder”), disk swelling, and/or cotton wool spots

Question 10

What is dacryocystitis?

Answer 10

Infection of the lacrimal sac. Occurs in infants and adults over 40yo.
Acute: sudden onset of opain and redness in medial canthal region; sometimes purulent discharge is noted from the punctum.
Some pts present w/ fever, prostration, and elevated WBC
S. aureus and beta-hemollytic strep are the usual infecting organisms
Tx: systemic abx tx

Question 11

What is episcleritis?

Answer 11

Inflammation or infection of the episclera tissue between the conjunctiva and sclera.
Presentation: acute onset of mild to moderate discomfort, photophobia, watery discharge
Diffuse or localized bulbar conjunctival injection

Question 12

What is hordeolum?

Answer 12

Abscess located over the upper or lower eyelid.
Usually caused by s. aureus.
Appears as a localized, red, tender swelling over the eyelid

Question 13

What is chalazion?

Answer 13

Presents as lid discomfort
Chronic, granulomatous inflammation of the meibomian gland.
Appears as a hard, painless lid nodule

Question 14

What is orbital cellulitis?

Answer 14

Infection POSTERIOR to the orbital septum.
Unilateral and more common in children
Manifested by an abrupt onset of fever, proptosis, restriction of extraocular movements and swoolen, red eyelids.

Question 15

What is presbyopia?

Answer 15

Common age-related disorder that results from loss of elasticity in the lens which prohibits accommodation (required to focus on near objects)
Classic - tendency of pts to hold reading material at a further distance
Tx: reading glasses

Question 16

What is macular degeneration?

Answer 16

Leading cause of blindness in industrialized countries
Early finding: distortion of straight lines such that they appear wavy (grid test)
RF: increasing age, smoking
Fundoscopy: drusen deposits in macula

Question 17

Papilledema

Answer 17

May enlarge blind spot

Question 18

Viral conjunctivitis.

Answer 18

Pink eye
Most commonly due to adenovirus, causes acute conjunctival injection and water or mucoid discharge.
Usually preceded by viral prodrome (eg fever, pharyngitis)
Sxs typically improve w/in 5 d
Tx: warm or cold compress
+/- antihistamine/decongestant drops

Question 19

What is strabismus?

Answer 19

Intermittent or constant ocular misalignment usually due to nasal deviation (esotropa) or less commonly temporal deviation (exotropia)
Exam: asymmetric red reflexes or corneal ligh reflexes or a deviation during cover eye test
Cover eye test: performed by askign child to fix gaze on target as examiner covers one eye whil observing movement of the other - normal eye keeps the same position and does not move; misaligned eye shifts to re-fixate on object when normal eye is covered
Esotropria beyond early infancy must be treated to prevent amblyopia (vision loss from disuse of deviated eye)
Tx: patching normal eye (occlusion therapy) to strengthen deviated eye or
blurring the vision of normal eye w/ cycloplegic drops (penalization therapy)

Question 20

What is age related macular degeneration?

Answer 20

Usually seen in pt age >50.
Presents w/ progressive and bilateral loss of central vision.
Navigation vision (allowing pts to navigate around obstacles in their surroundings and maintain socal independence) is preserved.
Results from degeneration and atrophy of the central retina (macula), retinal pigment epithelium, Bruch’s membrane, and choriocapillaries.

Question 21

Retinal detachement

Answer 21

40-70yo
Photopsia (flashes of light), floaters (spots in visual field)
“curtain coming down over eyes”
Laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina, retinal pigment epithelium, and choroid.

Question 22

What is proliferative diabetic retinopathy?

Answer 22

In the initial states it is asx.
Pts may later complain of decreased visual acuity.
Neovascularization is the hallmark of proliferative diabetic retinopathy.
Other findings: vitreous hemorrhage and macular edema. These changes may lead to retinal detachment.

Question 23

What is exudative macular degeneration?

Answer 23

Typically presents as painless, progressive blurring of central vision, which can be acute or insidious.
It occurs bilaterally.
Testing reveals central scotoma.
Growth of abnormal vessels in retinal space on exam.
Sudeen visual loss ma occur if it is complicated by retinal detachment.

Question 24

What is allergic conjunctivitis?

Answer 24

An acute hypersensitvity reaction caused by environmental exposure to allergens (pollen, animal dander, dust, mold spores)
Presentation: episode intense itching, hyperemia, tearing, and edema of the conjunctiva and eyelids; pts complain of mild photophobia or a dry-eye sensation
Gritty sensation in eye
Hx of atopic disorder such as asthma or seasonal allergies
Condition usually subsides in 24h w/o treatment
Tx: topical agents (antihistamines, vasoconstrictors, mast cell stabilizers, articial tears)

Question 25

What is anterior uveitis?

Answer 25

Inflammation of the anterior uveal tract, especially the iris.
Discharge is NOT common and if present is not profuse
Usually causes significant pain, miosis, and photophobia, visual loss may be present
No gritty sensation and itching

Question 26

What is atopic keratoconjunctivitis?

Answer 26

A severe form of ocular allergy.
Presentation: itching, tearing, thick mucus discharge, photophobia, and blurred vision
Different from allergic conjunctivitis due to more severe symptoms w/ a prolonged course, potential visual impairment due to corneal involvement, and thickening of eyelids and surrounding skin

Question 27

What is viral keratitis?

Answer 27

Infection of the cornea related to HSV or varicella zoster.

Pt typically have corneal vesicles, opacification, and/or dendritic ulcers.

Question 28

HSV infection

Answer 28

In HIV pts, both HSV and VZV can cause severe, acute retinal necrosis assoc. w/ pain, keratitis, conjunctivititis, uveitis, and fundoscopic findings of widespread peripheral pale lesions and central retinal necrosis.
Tx: oral acyclovir/valcyclovir

Question 29

CMV retinitis

Answer 29

Painless
Not usually assoc. w/ keratitis or conjunctivitis
Fundoscopic findings: hemorrhages and fluffy or granular lesions around the retinal vessels

Question 30

What is open angle glaucoma?

Answer 30

More common in African Americans.
Generally asymptomatic in the intiatial stages, followed by gradual loss of peripheral vision over a period of years, and eventual tunnel vision.
Exam: high IOP, cupping of the optic disc w/ loss of peripheral vision
Beta blockers such as timolol effective in initial managment
Laser trabeculoplasty used as adjunctive measure
If there is continuous increase in IOP, surgical trabeculotomy is done.

Question 31

What is non-proliferative diabetic neuropathy?

Answer 31

Characterized by the dilatioin of veins, microaneursyms, retinal hemorrhages, edema, and hard exudates.

Question 32

Herpes simplex keratitis

Answer 32

Frequent cause of corneal blindess in the US
Pain, photophobia, blurred vision, tearing, redness
Hx of prior episodes may be present
Usually, the recurrences are precipitated by excessive sun exposure, outdoor occupation, fever, or immunodeficiency
Corneal vesicles and dendritic ulcers are characteristic.
Dendritic ulcer are the most common presentation
Primary dx clinically, although epithelial scrapings show multinucleated giant cells
Tx: oral or topical antiviral therapy

Question 33

What is herpes zoster opthlamicus?

Answer 33

An infection caused by VZV.
Most episodes occur in the elderly.
Presents w/ fever malaise and a burning itching sensation in the periorbital region.
Exam: vesicular rash in distribution of the cutaneous branch of the 1st division of the trigeminal never.
Conjunctivities and dendrifrom corneal ulcers characterize they eye involvement.

Question 34

Fungal keratitis

Answer 34

Occurs after injury in agricultural workers or immunocomprised patients.
The cornea shows multiple stromal abscesses.

Question 35

Ocular rosaceas

Answer 35

Ocular rosacea can involve the cornea, conjunctiva, and lids and causes burning or foreign body sensation, blepharitis, keratitis, conjunctivitis, corneal ulcers, and recurrent chalazia.
Sxs may not be concurrent w/ skin findings.
Mild sxs are treated w/ lid scrubs, topical abx (metronidazole, erythromycin), and ocular lubricants.

Question 36

What is trachoma?

Answer 36

Due to infection w/ chlamydia trachomatis serotypes A, B, and C.
Acute trachoma presents w/ follicular conjunctivitis and inflammation; plae follicles; pannus (neovascularization) formation in the cornea
Repeated or chronic infection causes inversion of the eyelashes (trichiasis) and scarring of the cornea.
There is often concomitant nasopharyngeal infection (eg rhinohear, pharyngitis)
Dx: clinically be examination of tarsal conjunctiva
C trachomatis may be visible by Giemsa stain exam of conjunctival scraping
Tx: oral azithromycin
If there is trichiasis, eyelid surgery is needed to perserve vision