OPTH Lec02 Flashcards
When assessing for history, what are things you should focus on?
Is the visual loss transient or persistent? Monocular or binocular? Did the visual loss occur abruptly, or over hours, days, or weeks? Age, race and any medical conditions? Was there pain associated with the loss?
When performing an examination, what things do you look at?
1) Visual acuity 2) Confrontational visual fields (because homonymous hemianopia can still have normal VA) 3) Pupils - Marcus Gunn pupil (positive for APD) 4) Corneal assessment 5) Ophthalmoscopy (look for media opacities and fundus)
What are media opacities?
Irregularities of the clear, refractive media. Look at the cornea, anterior chamber, lens and vitreous. These do not cause afferent pupillary (sensory) defects but may physically alter the pupil
What is this?
Iris Synechia - when the iris adheres to the cornea and mis-shapes the pupil
What is corneal edema?
Dulling of the reflection of incident light off the cornea. Ground glass appearance.
What causes corneal edema?
increased IOP, acute infections, corneal inflammation, damage to the corneal tissue by dystrophies, trauma or surgery. Can also be due to glaucoma *acute angle closure).
How will a patient with acute angle glaucoma present?
With INTENSE PAIN, fixed pupil, very very red eye, corneal damage, high IOP
How do you treat a patient with acute angle glaucoma?
laser iridotomy
What is this?
Corneal edema - ground glass appearance
What is this?
Acute angle closure
What is hyphema?
Blood in the anterior chamber due to trauma. This can be spontaneous in rubeosis (neovascularization of the iris caused by diabetes, tumors, surgery or chronic inflammation)
What is this?
hypema
What is hypopion?
WBCs forming pus in the anterior chamber usually because of an infection
What is this?
hypopion
What are lenticular changes?
Changes in lens edema, or shift in refractive error.
What can cause lenticular changes?
1) Cataracts usually develop slowly and everyone will eventually get cataracts. Patient may say that they have sudden vision loss if they never close one of their eyes. If cataracts is advanced it may cause inflammation or glaucoma. 2) Sudden changes in blood sugar or electrolytes
What is a vitreous hemorrhage? How can you diagnosis? What causes it?
Reduction in visions from opaque blood blocking the light. Will have poor red reflex. Caused by: trauma or conditions causing neovascularization. Associated with subarachnoid hemorrhage.
What is this?
Vitreous hemorrhage - fuzzy image because looking through RBS suspended in vitreous
What is this?
Image of lenticular changes
What are the different kinds of retinal diseases?
1) Retinal detachment 2) Macular disease 3) Retinal vascular occlusions 4) Inflammatory processes such as: infections chorioretinitis, vasculitides, idiopathic inflammation
How will a patient present with a retinal detachment?
Complaints of flashing lights, followed by a shower of floaters and than a curtain or cloud in their vision. This will be PAINLESS! Can cause APD, May see elevated retina with folds. Choroidal background is indistinct. Early treatment = better prognosis
What is this?
Retina is ballooned forward and there is fluid causing elevation = retinal detachment
What is macular disease?
PAINLESS reduction in visual acuity. Can be stopped by eating lots of green leafy vegetables
What are the most common causes of macular disease?
sub retinal neovascularization from age related macular degeneration
How will a patient with macular degeneration present?
PAINLESS reduction in visual acuity, + or - APD, Central metamorphopsia (wavy vision)
What is metamorphopsia?
Combination of squeezing and spreading of the cones cause and overall distortion of the image. The lines of the Amsler Grid are distorted and non uniform
What is Retinal Vascular Occlusion?
TRANSIENT MONOCULAR loss is fleeting (amaurosis fugax). Common in patients over 50. always suspect carotid circulation to be the problem (atheroma causing an emboli occluding blood flow from the carotid). 50% FIVE YEAR MORTALITY RATE: MAKE SURE PATIENT HAS GOOD MEDICAL MGMT (due to underlying carido prob)
What is a central retinal artery occlusion?
Sudden PAINLESS and complete visual loss “like a curtain being drawn over the eye” causing permanent damage to the ganglion cells and inner retina. Caused by narrowed arterioles (this is why after several hours the cell death occurs and causes white retinal edema). The fovea will stand out like a cherry red spot.
When do you see a cherry red spot?
In a central retinal artery occlusion and ganglioside lipidoses form metabolic dystrophy (Tay Sachs and Niemann Pick)
What is this?
Cherry red spot - occurs because the tissue is thinner than the other tissue and can see the posterior circulation more readily. There will be a cilio-retinal artery that will provide fluid to the tissue so that you don’t lose it all.
How do you treat a Central Retinal Occlusion?
This is a true ophthalmic emergency. Treat with firm digital compression for 10 second cycles and try to dislodge the embolus. Paracentesis of the anterior chamber to dislodge the embolus by changing the intravascular pressure/resistance. Most effective within hours of the occlusion.
What is a retinal vein occlusion?
PAINLESS subacute loss of vision, severe, causes HTD, DM, vasculopathies.
What will you look for in someone with a retinal vein occlusion?
Disc swelling, venous engorgement, cotton wool spots and diffuse retinal hemorrhages. “Blood and thunder fundus”
How do you treat a retinal vein occlusion?
ASA daily, laser treatment. Can lead to neovascular glaucoma
What is this?
Retinal Vein Occlusion - when the hardened artery crosses the softer vein, will occlude it and the vein will leak out. Will have good visual recovery.
What is optic neurtis?
Inflammation of the optic nerve. May be retrobulbar without visible optic nerve pathology or maybe associated with MS, intracranial mass or aneurysm
How will a patient with optic neuritis present?
With reduced visual acuity, positive APD, contrast sensitivity and diminished visual field. EYE MOVEMENTS WILL BE PAINFUL!
What is this?
Image of optic neuritis
How do you treat optic neuritis?
MRI to rule out a tumor or aneurysm. If MS, may treat with high dose of methylprednisolone 1 g IV over 45 min daily for 5 days. DO NOT TREAT WITH PO STEROIDS. ALWAYS IV FIRST!!!!
What is papillitis?
optic nerve inflammation
What is papilledema?
Swelling of the optic disc CAUSED BY INTRACRANIAL PRESSURE. BILATERAL optic nerve swelling
What are the causes of papilledema?
pseudo tumor cerebri, intracranial hemorrhage, malignant hypertension (overweight, 20-30, female, dull headache)
What is an Ischemic Optic Neuropathy?
Optic nerve edema causing PAINLESS loss of vision. Altitudinal field defect is common. Can be arteritis (giant cell arteritis aka temporal arteritis) or Nonarteric anterior ischemic optic neuropathy. Can completely wipe out the nerve
What is Giant Cell Temporal Arteritis and how will it present?
Systemic disease rarely in patients <55 yrs old. Will complain of malaise, headache, fever, weight loss, pain and tenderness of the muscles and joints (polyalgia rheumatic), SCALP TENDERNESS or discomfort when combing hair and JAW CLAUDICATION (most diagnosable)
What type of labs do you obtain for unexplained sudden vision loss, CRAO, or cranial nerve palsy?
Always obtain a Westergren Sedimentation Rate (ESR-Westergren) and C-reactive protein (CRP) (CRP will show up before the sed rate so make SURE that you do this because you are using steroids to treat these!
When do you treat with steroids?
When the sed rate is over 60, treat with high does (100 mg) of corticosteroids (and add an H2 blocker or PPO to protect the stomach) and obtain a TEMPORAL ARTERY BIOPSY FOR DEFINITIVE DIAGNOSIS. DO NOT WAIT TO TREAT!
What are the shortcomings a using a biopsy?
May be inconclusive, skip areas, require large pieces of the vessel. If one if negative, the other temporal lobe biopsy is not done so generally diagnose based on the treatment response.
What is this?
Giant cell temporal arteritis
What will a biopsy show with giant cell temporal arteritis?
enlargement of medial wall with interruption of the elastic lamina, skip lesions are common
What are the complications of Giant Cell (temporal) arteritis?
BILATERAL profound loss of vision and other systemic sequelae I treated too late (40% chance the other eye will be involved)
What can cause traumatic optic neuropathy?
History of trauma, vision loss, positive APD, may or may not have other ocular damage, shearing of the vascular supply to the optic nerve. Compression can cause hematoma in the optic canal, optic nerve avulsion, or bone fragment impinging the nerve. Prognosis is poor. Tx with steroids or neurosurgery
What is homonymous hemianopia?
loss of the same side of both visual fields often after the chiasm (will los temporal side in one eye and nasal side in the other)
What is temporal hemianopia?
loss of the right half of the field in the R and the left half in the left. Lesion in the chiasm.
What is cortical (central, cerebral) blindness?
Extensive bilateral damage to the cerebral visual pathway. Will present with COMPLETE LOSS OF VISION, NORMAL PUPILLARY LIGHT RESPONSE, and NORMAL FUNDUS EXAM
What causes cortical blindness?
When the afferent pupillary fibers separate from those carrying visual info at the level of the optic tracts which end at the lateral geniculate nucleus.
What is functional (nonphysiologic) visual loss?
Bizarre vision changes due to hysteria (extreme emotions stress) or malingering (seeking gain). Physical findings will present without issue. One eye can be blind, the other normal, no APD, normal stereopsis
How do you test and treat nonphysiologic visual loss?
Good history, consider the “magic drop test” (convince patient that this drop will cure their condition). Diagnosis by testing visual acuity by starting with the smallest line and asking them to patient to letters. Encouragement and pushing the patient may give a surprise.
