Opthal Flashcards
Six Week Old
Opthal findings
Fix and Follow - smiling and visually responsive
Six Months - Opthal
Reach for small objects (If intact motor)
12 months opthal
Reach for tiny 100/1000s
2-3 years opthal
Picture Matching - Kay Picture (Assuming developing language)
Onset of Nystagmus by 8-12 weeks?
Can be bilateral major visual defect or primary motor
Motor
Congenital nystagmus
Abnormal phase is drift off- fast turn is in ‘intact’
How long is still - 1/100 of second then perceive
30fps
Conjugate nystagmus less bad than divergent/see-saw
INO - Brainstem demyleniation
Adduction deficiet, nystagmus on abduction lateral gze
Sensory
Anything that reduces vision in first 4 months
Albinism
Bilateral Cateratcs
Saccadomania - Opsiclonus - multiplanar - encephalopathy (immune compromised onc patients) or neuroblastoma
Indication for referral for VA
6/12 or worse
Colour Vision Ax:
Boys - RG colour vision 1:20
Ischihara Plates
Closest colour matching
Optic neuritis (with inflammation of optic nerve - along with opthalmaplegia)
Visual Field
Test via toy
Expect 155 degrees
Refixation movement
Move from behind
Duction?
Version?
Duction is single eye movement
Version is movement of both
Squint?
Ambylopia?
Esotropia is IN
Exotropia is OUT
Light Reflex - ?Position
Nasal bridge - flat bridge = webbing = false impression - pseudostrabismus
Cover test - Cover the good eye, squinting eye will take up fixation, uncover
Eye that turns more often is suppressed/ambylopia
Ampylopia - reduced vision due to poor input/strabismus - suppressed to avoid diplopia
Cf. Adults who get diploplia
Leucocoria?
Cataract (Nuclear is early in lens development) If cause known - isolated lens protein genes- AD>XL>AR
Intrauterine infections - Rubella (not other TORCH stuff)
Retinal Detachment
Retinoblastoma - Rb - AD of single allelle - “best solid tumour” - Avoid Radiation - Systemic Chemo/Local Chemo/Intrarterial via femoral access/intravesicular
“Glint in the eye”
RAPD?
Relative afferent pupillary defect = swinging light test
Normal eye - direct and consenual
Bad eye - dilates
Optic Nerve analysis - compares AFFERENT pupil input in response
Non-organic vision loss
Optic Neuritis
If intact ‘disproves’ vision loss
Optic Nerve - What can you see?
Normal disc - clear
Severe pappilodema. - blurry edges and can’t see vessels on disc + haemorrhages
Septic Optic Dysplasia -Bilateral optic disc hypoplasia- Midline abnormalities - abesnt septum pellucidum, anterior pituarity (GH)
DRUSEN - Deposits - Elevate “swollen” disc - outline of disc is irregular - can still see vessels, ?Pseudopappilodema - with ?Benign intracranial hypertension
Field Defect patterns
Horizontal field defect - OPTIC NERVE (crescent across
Vertical cut off - Chiasmal or back (Where the nerves cross)
Globe defects for:
Marfans
Golden Harr
Golden Harr- Extra bit on globe - “Limbal dermoid” (Hemifacial microsomia/jaw/preauricular)
Corneal Dermoid (DDx Glaucoma/Cataract)
Marfans - “missing bit” subluxed lens due to zonule protein error of fibrillin?
Homocystinuria - Sulfur metabolism - zonule weakness
Opthalmic Squint?
Failure of binocular control
Abnormalities of convergence or divergence
High refractive error - over convergence by brain with increasing accomodation
Vs. failure of muscles
Head Tilt?
Torticollis
Hearing Loss
Binocular driven - cover eye - straight head
For example SO(CNIV), can’t use ‘reading muscle” down and in - therefore will compensate by using up and out posture
Mx of SQUINT
Confirm Measure vision Document Diploplia Measure deviation Measure refraction Investiage for ocular/nonocular disease
Then: Prescribe glasses
Prescribe patches/drops for ambylopia
Consider Surgery
Treat any amblyopia
Overcome diplopia
Maximis binocular depth - improve field
Improve cosmesis (Don’t look ‘shifty’)
REFER If
If Obvious then refer including if <6/12
Can’t exclude
If Any SQUINT after 6/12
Watery or Sticky Eyes?
Screen for scleral redness - infection/inflammation
First few days with pus ++ - gonococcal conjunctivitis - Ophthalmia neonatorum - can penetrate/invade epithelial surface unlike staph
Red skin may be contact dermatitis - polyvisc or dry eye ointment aroudn skin - “water proofs”
Epiphoria - probe if >12/12
SPONTANEOUS RESOLUTION before
If ITCHY then allergic
If JUST watering without discharge consider glaucoma
Acute painful red watery eye
Foreign body
Corneal abrasion
Subtarsal (vertical lines on fluorscein)
Amazing Eye Facts?
Pulling a face when wind changes
Champagne cork to eyeball analogy
Blow out fracture?
“Trigger finger” tendon on superior oblique through pulley - over convergence and ‘stuck’
//
Eyeball held as per champagne cork with wire cage of tendons - not the eyelids
- increased pressure causes optic nerve ischaemia - painful eye movements, proptosis - swelling of conjunctiva
//
Can’t look up - tear drop sign
Unequal Pupils?
Anisocoria:
Worse in high light or low light
If in high light then issue is still dilated eye - CNIII - Down and out due to unopposed LR (out) and SO (down)- straight out from brain stem
If worse in low level the issue is constricted eye - HORNERs - Oculosympathetic pathway
HORNERs is miosis (constricted)
Ptosis (droopy top eyelid)
If neck - not sweating
If congenital - different eye colours/heterochromia
Test Horners with 5% cocaine - Blocks Noradrenaline resorption - Dilation in normal eye -
DDx NEUROBLASTOMA (CXR/Urinary Catecholamine/?MRI/?MIBG)
Colobomas in which genetics?
CHARGE Associatino
Congenital Glaucoma
Too much fluid Big eye Cloudy Cornea - due to torn epithelium and swelling Tearing Photophobia
Optic Nerve damage if left along time/adult
Corneal damage early
Medical Mx of eye drops - systemic absorption via nasal mucosa (alpha agonist - CV collapse) CI in <2yo, (beta blocker) - maximise local absorption by occlusion
Carbonic Anhydrase Inhibitor - Dimox = acteazolamide - Shared biochem for choroid plexus and cillary body (‘hypertension of the eye’)
Aniridia - whats the relevance?
Do a microarray - ?chromosome 11
Do a renal U/S
May have WILMS Tumour
PAX6 Gene next to WT on 11q
T21 Opthal?
Any possibility- all eye problems are common Squint Cataract Refractive errors Blocked tear ducts Glaucoma occasionally
Cerebal palsy opthal?
50% strabismus
Retinopathy of prematurity - opthal?
Zone of retinal maturity
Distance from optic nerve
Torturosity of vessels is PLUS disease.
Almost is pre-plus.
Treat: TYPE 1 Disease That is : Zone I with any plus Zone I stage 3 ROP Zone II Stage 2 or 3 ROP with Plus
BOOST Trial - lower O2 will increase mortality but only reduce ROP slightly
91-95% better balance than lower targets
Juvenile Chronic Arthritis - What Opthal Cx
Scarring between iris and lens with irits (Anterior uveitits)
@ risk of cataract and glaucoma
Rx inflammation with steroids (Also cataract and glaucome as ADR of steroids)
Max in PANAFY - Pauci-articular, ANA +ve, Female, Young
Screening until age 12
Pauci/Poly - ANA +ve 3-4/12 monthly r/v
Pauci/Poly - ANA -ve 6/12ly r/v
Systemic 12/12
