Opthamology Clinical Correlates

Question 1

What are the 8 components of a complete eye exam?

Answer 1

1. vision
2. external anatomy
3. pupils
4. ocular motility
5. anterior segment
6. ophthalmoscopy (dilated)
7. IOP
8. visual fields

Question 2

What are the 3 most common eye issues?

Answer 2

cataracts

macular degeneration

glaucoma

Question 3

What is a cataract?

Answer 3

an opacity of the normally clear lens, caused by age, metabolic disorder, trauma or heredity

Question 4

Surgery for cataracts isn’t done immediately. What are the 3 indications that surgery is necessary?

Answer 4

the severity of visual loss is great

functional needs of the patient

need to improve view of the posterior segment of the eye to care for other ocular pathology

Question 5

After what age does macular degernation start becoming very common>

Answer 5

after age 50, but over 70 in particular

Question 6

What segment of vision is lost in macular degeneration?

Answer 6

central vision

Question 7

What are the two types of macular degeneration?

Answer 7

dry and wet

Question 8

What are the signs of dry macular degeneration?

Answer 8

drusen, pigmentation changes, retina atrophy

Question 9

WHat happens in wet macular degeneration

Answer 9

the defect develps in the deep retinal layers

growth o f blood vessens under the retina - they’re are new and leaky vessels that lead to edema and hemorrhage

the hemorrhage eventually turns fibrotic as it heals, leading to scarring and serious loss of vision

Question 10

WHat are the treatment options for dry macular degeneration?

Answer 10

1. quite smoking
2. take AREDs nutritional supplements
3. manage systemic diseases like HTN

Question 11

What are the treatments for wet macular degeneration?

Answer 11

anti-vegf drugs like avastin to disrupt formation of new blooc vessels

conventional laser treatments if those don’t work

Question 12

What vitamins are helpful in macular degeneration?

Answer 12

antioxidant vitamins - beta carotene, vitamin C and vitamin E

minerals zinc and copper

Question 13

Why do newer vitamin formulas omit the beta carotene?

Answer 13

in smokers, beta carotene increases risk of lung CA

Question 14

In general, what happens in glaucoma?

Answer 14

increased ocular pressure causes optic nerve loss

Question 15

What are the two main types of glaucoma?

Answer 15

open angle and narrow angle (acute)

Question 16

In general, what is the treatment for glaucoma?

Answer 16

lower the eye pressure via medical or surgical (laser) means

Question 17

Describe normal aqueous flow.

Answer 17

the aqueous humor is formed near the ciliary body and then flows through the pupil over the iris down to the trabecular meshwork where it’s absorbed thorugh schlemm’s canal into the aqueous vein

then it drains into the episcleral vein in the conjunctiva

Question 18

WHat happens in open angle glaucoma?

Answer 18

the trabecular meshwork degrades such that the aqueous humor doesn’t drain appropriately and pressure builds up

Question 19

How will the appearance of the optic disc look different on exam in glaucoma?

Answer 19

you’ll get optic nerve cupping = enlarged cup due to loss of rim tissue

this indicates loss of optic nerve fibers

Question 20

What are the signs of glaucoma?

Answer 20

pressure over 30 mmHg

optic nerve cupping = optic nerve tissue loss

shrinking of visual fields/progressive blind spots

Question 21

What technique can be used to quantify loss of optic nerve tissue?

Answer 21

optical coherence tomography (OCT)

Question 22

What are the two basic strategies of glaucoma medications?

Answer 22

decrease IOP by decreasing aqueous production or increases outflow

Question 23

Which form of glaucoma is an eye emergency?

Answer 23

narrow angle = acute glaucoma

Question 24

WHat are the symptoms of acute glaucoma?

Answer 24

acute onset

severe pain with loss of vision

maybe nausea, vomiting

red eye

cloudy cornea

extremely high ocular pressure, over 40 mmHg

Question 25

What is the cause of narrow angle glaucoma?

Answer 25

closure of the angle between the iris and the cornea these people just have a narrower angle and if the pupil dilates too far, it will push the irish right up against the trabecular meshwork such that fluid won't be able to leave the eye at all this builds up pressure in the eye, which pushes the iris even further into the meshwork, making it worse

Question 26

What is the treatment for acute glaucoma?

Answer 26

1. pilocarpine to constrict the pupil and pull the iris away from the angle 2. acetzolamide (diamox) - a diuretic to pull fluid off to lower pressure 3. Immediately refer to ophthamology for peripheral iridotomy

Question 27

What happens in diabetic retinopathy pathogenesis?

Answer 27

increase glucose chronically damages blood vessel walls VEGF is release in response this causes abnormal vasoproliferation new vessels are leaky, so fluid leaks into the retina, fibrosis occurs, causing damage and potentially complete loss of vision

Question 28

What are the clinical stages of diabetic reitnopathy?

Answer 28

nonproliferative diabetic retinopathy preproliferative diabetic retinopathy proliferative diabetic retinopathy

Question 29

What are some of the signs you'd see in nonproliferative diabetic retinopathy?

Answer 29

blot hemorrhages and microaneurysms cotton wool spots (small infarcts) macular edema hard exudates (lipids that leak out with fluid and are left there when fluid is resorbed)

Question 30

What's the gold standard for diagnosing diabetic retinopathy?

Answer 30

fluorescein angiography you inject a dye and then take a picture as the die is in the eye this allows you to see areas of fluid leakage form the vessels can also use OCT

Question 31

How can you treat the macular edema that comes with diabetic retinopathy?

Answer 31

intravitreal injections of steroid triamcinolone

Question 32

What additional symptoms would you see in preproliferative diabetic retinopathy that aren't present in non-proliferative?

Answer 32

intrareitnal vascular abnormalities and venous bleeding

Question 33

What symptoms will you ultimatley see in proliferative diabetic retinopathy

Answer 33

neovascular vitreoretinopathy vitreous hemorrhage = boat hemorrhage fibrosis retinal traction and puckering

Question 34

What is the treatment for diabetic retinopathy?

Answer 34

panretinal photocoagulation it's basically laser treatments along the edges of the retina where it's ischemic - hopes to stop the neovascularization

Question 35

How often should diabetics have dilated eye exams?

Answer 35

yearly!! refer upon diagnosis in type 2 and within 5 years of diagnosis of type 1

Question 36

What happens in hypertensive retinopathy?

Answer 36

after continuous high arterial pressure, the arterioles will narrow and undergo sclerosis

Question 37

What are the signs of hypertensive retinopathy?

Answer 37

flame hemorrhages cotton wool spots optic nerve edema in severe cases arteriovenous nicking "silver wire arteries"

Question 38

What is the treatment for hypertensive retinopathy?

Answer 38

lower the blood pressure!

Question 39

What are the 7 potential causes of sudden visual loss?

Answer 39

amaurosis fugax migraine scotoma retinal detachment retinal artery occlusion retinal vein occlusion temporal arteritis stroke

Question 40

Describe amaurosis fugas

Answer 40

it's a sudden loss of vision in ONE eye lasts only minutes painless it's usually temporary vascular insufficiency (TIA in the eye)

Question 41

What workup should be done first in amaurosis fugax? What was the cause until proven otherwise?

Answer 41

cardiovascular workup first CAD until proven otherwise

Question 42

What would you see in the eye with amaurosis fugax\>

Answer 42

embolic material within a retinal arteriole = hollenhortst plaque

Question 43

Why is a retinal cholesterol emboli (amaurosis fugax) worrisome if it's non-occlusive?

Answer 43

It's a warning sign of future disaster in the vascular system they'll need a full carido workup including carotid US and echocardiogram

Question 44

What are the characteristics of an ophthalmic migrainte?

Answer 44

often acephalgic SCINTILLATING SCOTOMA is the hallmark painless and temporary! involves both eyes, causing hemianopsia usually lasts 20-30 minutes cause: spasm of arteriole in occipital cortex

Question 45

What happens in retinal detachment?

Answer 45

sudden painless loss of partial vision in one eye may be progressive but ALWAYS SUSTAINED - will NOT response spontaneously like an ophthalmic migraine will often accompanied by floaters and photopsias often spontaneous, but can be associated with trauma

Question 46

Is retinal detachment for common in myopia or hyperopia?

Answer 46

myopia

Question 47

What is the treatment for retinal detachment?

Answer 47

surgery they can try to use laster demarcation of the retinal tear, but if that doesn't work they'll do a scleral buckling procedure this involves pushing the eye wall against the retina, thus sealing the tear

Question 48

What happens in retinal arterial occlusion?

Answer 48

sudden severe loss of vision in one eye painless vision loss is usually permanent, but may recover if treated rapidly the cherry red spot indicates acute central retinal artery occlusion

Question 49

What is the goal to treat an arterial occlusion acutely?

Answer 49

you want to push the block to the periphery where the damage will be less rebreathe CO2 (dilate vessels) timolol to lower ocular pressure IV acetazolamide to lower IOP massaging the globe with lids closed

Question 50

Retinal vein occlusion can also occur. It this more serious or less serious than arterial occlusion? With what chronic conditions is it more common?

Answer 50

it's less serious more common with HTN and DM

Question 51

What is the risk for sequellae with retinal vein oclusion

Answer 51

neovascular glaucoma - so refer to ophthamology, but not as urgently as you would with an arterial occlusion

Question 52

What will the eye look like on examination with a central retinal vein occlusion?

Answer 52

a squashed tomato

Question 53

Why is a branched retinal vein occlusion even less serious than a central retinal vein occlusion?

Answer 53

there is less damage to the retina, so there is less risk of serious vision loss

Question 54

What is temporal arteritis?

Answer 54

it's giant cell arteritis an inflammatory conditions that causes HA, scalp tenderness, fever, weight loss, jaw claudicaiton, polymyalgia rheumatica, vision loss - maybe total blindness

Question 55

What are the two ways temporal arterities can affect the eye?

Answer 55

vision loss from: 1. retinal arteriolar occlusion 2. optic nerve infarction

Question 56

What are the potential deadly sequelae of temprla arteritis?

Answer 56

aortic aneurysms or stroke

Question 57

WHat diagnostic tests are run in a temporal arteritis workup?

Answer 57

ESR and CRP will be positive temporal artery biopsy to look for PMNs in the arterial walls

Question 58

What is the treatment for temporal arteritis?

Answer 58

high dose systemic steroids immediately

Question 59

In a visual CVA, visual field loss occurs bilaterally on the ____ side of the cortical lesion.

Answer 59

contralateral

Question 60

What symptoms will you see in a CN3 nerve palsy?

Answer 60

ptosis may have dilated pupil affected eye down and out (think of the hulk)

Question 61

What happens in a CNIV palsy?

Answer 61

paralysis of the superior oblique muscle so VERTICAL DIPLOPIA slight elevation of the affected eye very subtle - refer to ophtho

Question 62

What happens in a CN6 palsy?

Answer 62

paralysis of the lateral rectus affected eye is esotropic (turned in) HORIZONTAL diplopia movement of the affected eye is partially or totally limited in the lateral gaze

Question 63

What are some causes of conjunctivitis?

Answer 63

chemical injury angle closure glaucoma ocular foreign body corneal abrasion uveitis conjunctivitis - bacterial, viral, allergic subconjucntival hemorrhage

Question 64

What are the worst chemical injuries for the eyes?

Answer 64

alkali burns these stick to proteins that stick to the eye and keep buring it - it will burn thorugh the cornea in an hour rinse until pH is neutral

Question 65

What are some symptoms of a corneal abrasion?

Answer 65

sensation of foreign body present - even if gone pain tearing photophobia

Question 66

HOw do you diagnose a corneal abrasion

Answer 66

you use fluorescein staining, which will stain any area of the cornea where there is an abrasion under UB light

Question 67

What 2 things do you need to be careful that you don't miss in a corneal abrasion?

Answer 67

a corneal laceration - these WILL get infected hyphema - blood in the anterior chamber refer both immediately

Question 68

If you see linear abrasions of the cornea, what should you do?

Answer 68

flip the eyelid to see if there is a foreign body stuck under hte lid - rinsing won't get it out

Question 69

How doyou remove a metallic foreign body from the cornea?

Answer 69

you scoop it out with a small gauge needle (if a rust ring is left, if may need to be burred out)

Question 70

What do you NEVER prescribe for corneal abrasions?

Answer 70

topic anesthetics they will NOT HEAL if they use this

Question 71

What discharge iwll be seen with the following: bacterial conjunctivitis viral conjunctivitis allergic conjuncitivis

Answer 71

bacterial = purulent viral = clear allergic = stringy with white mucus

Question 72

What sort of injection will you see in allergic onjunctivitis?

Answer 72

diffuse = involving lids and often bilateral longer history - little discharge, but what's there will be ropey and mucoid itchy eyes

Question 73

Describe anterior uveitis = iritis.

Answer 73

you get ciliary conjunctival injection no discharge light sensitivity deep, achy pain anisocoria keratic precipitates often associated with systemic diseases

Question 74

Describe a subconjunctival hemorrhage?

Answer 74

It's a collection of blood on the surface of the sclera under conjunctiva there is no inflammation, pain, or discharge totally harmless, but patients freak out (causes include trauma, eye rubbing, valsalva, cough/seeze, dry eyes)