Optho Flashcards
Medial Wall Fracture of the orbit involves
ethmoid and sphenoid sinus
Inferior wall fracture of the orbit can involve
maxillary sinus and inferior rectus muscle entrapment
Expothalmos
bulging of the eyeball, anterior protrusion from orbit
Enopthalmos
Recession of the eyeball, posterior displacement within the orbit
CN III controls which muscles
- Oculomotor nerve
- levator palpebrae superioris (lifts/elevates eyelid)
- superior rectus: elevates, adducts, medially rotates eye
- inferior rectus: depresses, aabducts laterally rotates tehe eye
- medial rectus: adducts the eye
- inferior oblique: pulls the back of the eye down (elevates, abducts, laterally rotates the eye)
CN IV controls which muscles
- trochlear nerve
- superior oblique
- pulls the back of the eye up
- depresses, abducts and internally rotatest the eye
CN VI controls which muscles
- abducens nerve
-
lacteral rectus
- abducts the eye
Oculomotor Nerve Palsy
CNIII palsy
- ptosis (eyelid droop)
- dilated pupil (dilator pupillae active)
- eye abducted (LR is active)
- eye depressed (SO active)
Abducent Nerve Palsy
CN VI palsy
- adducted eye (Medial Rectus is active)
Where does aqueous humor drain out of the eye
- through the trabecular network and the Canal of Schlemm
- regulates the intra-ocular pressure
3 layers of the eye
-
Fibrous
- outer, white portion (sclera) + cornea
-
Choroid/Vascular Uvea
- middle, blood vessels and ciliary body related structures
-
Neural layer:
- inner, contains the retina with the photo receptors
Lens flattening vs bulging
- flattened lens for distance vision
- bulged lens for near vision
Ciliary body
ring of smooth muscle attached to the lens
- macula lutea
-
fovea centralis:
- highest concentration of cones for bright light and color vision
- blood vessels
-
optic disc:
- area where blood vessels and optic nerve exits
- no photo receptors = “blind spot”
- area where blood vessels and optic nerve exits
Define Fundus
it is the inner surface of the back of the eye, where the retina is located
Lacrimal Gland
- produces watery lacrimal fluid (tears)
- contains lysozyme to prevent bacterial growth
- located above and slightly lateral to the eye
meibomian (tarsal) glands
- produces a thin oil which it release through multiple ducts inside the eyelid
- maintains a protective layer over the eye that keeps the eyelids from sticking together
Moll’s (ciliary) glands
- create eye boogers
- produce a gritty lipid on the margin of the eyelid
- extra active at night
- prevent bacterial growth and pathogen entry
Glands of Zeis (sebaceous)
- secretes oil onto the eyelashes
- lubricates the eyelashes
ocular conjunctive vs palpebral conjunctiva
- ocular conjunctiva: on the surface of the eye
- palpebral conjunctiva: inside the eyelid
What is contained within and the function of the lacrimal apparatus?
- produces and collects tears
- includes:
- lacrimal gland: produces tears
- the tears then collect in the lacrimal sac as they drain out of the eye
- then they drain down into the nasolacrimal duct to the nasal cavity
Miosis
constricted pupil
- when the sphincter pupillae contracts via parasympathetic innvervation
mydriasis = dilated pupil
- bright light
- parasympathetic innervation (Ach)
- CN III
- opioids (morphine, heroine)
mydriasis
- pupil dilates
- when the dilator pupillae contracts via sympathetic innveration
miosis = constricted pupil
- CN V stimulation
- anti-cholinergics
- serotonin, SSRIs
- NE
- stimulant drugs
- opioid withdrawal
Pupillary light reflex
- constriction of both pupils in reponse to light
- CONSTRICTION (miosis)
- sensory portion: CN II, retina, optic nerve, optic chiasm, optic tract to midbrain
- Motor portion: parasympathetic innervation via both oculomotor nerves CNIII to both sides of iris
- DILATION (mydriasis)
- motor: sympathetic innervation via CN V
*
- motor: sympathetic innervation via CN V
Anisocoria
asymmetric pupil
can be variant or pathological
Pineal gland and vision
sleep and wake cycle
hypothalamus and vision
sleep and wake cycle
superior colliculus and vision
visual reflexes
Left vs right Visual Field Processing
myopia
impaired distance vision
- impaired distance vision
- aka “nearsightedness”
- when you have an elongated eyeball
- treated with a concave lense
Hyperopia
impaired near vision
- “farsightedness”
- when you have a short eyeball
- treated with a convex lense
- when you have a short eyeball
presbyopia
- type of hyperopia (loss of near vision) due to aging
emmetropic
normal vision
congenital glaucoma
- incorrect development of the eye’s drainage system before birth
- sxs: enlarged eyes, cloudiness of the cornea, and photosensitvity
autosomal recessive inheritance
Congenital Cataracts
- clouding of the lens of the eye
- part of many birth defects
- Most important:
- non-dysjunctions
- Down syndrome (trisomy 21)
- Trisomy 13
- non-dysjunctions
inherited retinal degeneration
a group of progressive, visually debilitating diseases
- lead to blindness caused by mutations in genes that cause photoreceptor cell death and associated vision loss
- include: retinitis pigmentosa
- inherited 3 ways: autosomal dominant, autosomal recessive and X-linked recessive
Strabismus genetics
- autosomal dominant and autosomal recessive inheritance
Iritis
most common form of uveitis
- inflammation of the iris
- s/sxs: ciliary flush, miosis, photophobia, and severe throbbing pain
- unilateral, blurred or decreased vision
- tx: topical steroid drops
Posterior Uveitis
uvea = choroid, ciliary body + iris
- s/sxs: blurred or decreased vision due to problems with blood flow (in the choroid), unilateral
- tx: systemic glucocorticoids
Episcleritis
inflammation of the episclera
- s/sxs: distinguished from scleritis by lack of severe pain & lack of photophobia
- mild irritation of the palpebral conjuctiva
- diagnosis: slit lamp exam, blanching with phenylephrine
- tx: supportive care
- systemic NSAIDs
Scleritis
inflammation that involves the sclera and deep episclera
- women age 30-50 with connective tissue disease
-
s/sxs:deep, boring ache, photophobia, unilateral, focal or diffuse eye redness
- can have nodular or necrotizing
- diagnosis: clinical with slit lamp
- tx: systemic corticosteroids and/or systemic immunosuppresive therapy (consult rheum AND ophtho)
Keratitis
inflammation of the cornea
- if bacterial:
- staph, pseudomonas
- risk factors: Bells palsy (dry eye surfaces) and improper contact lens use
- s/sxs: sudden pain in the eye, redness, reduced vision, photophobia, ciliary injection, hazy cornea, conjunctival erythema
-
diagnosis:
- clinical, slit lamp, fluorescein
-
tx: topical fluoroquinolones (moxifloxacin)
- DO NOT PATCH
Endophthalmitis
infection/inflammation of the inner eye
- usually caused by staph epidermidis or staph aureus
- usually after surgery or penetrating ocular trauma
- s/sxs: intense conjunctival hyperemia, loss of red light reflex, eyelid edema, hypopyon, ocular pain, vision loss
- tx:
- intravitreal abx, maybe add IV abx
Astigmatism
variable curvature of the cornea or lense → difficult to focus light
- s/sxs: headache, eyestrain, distorted or blurred vision at any distance
- tx: cylindrical lense to correct shape
Myopia
“nearsightedness”
- point of focus is in front of retina b/c eye is too long or lense is too curved
- can see near objects but not far objects
- dx: visual acuity testing
- tx: concave lense
Hyperopia
“farsightedness”
- point of focus is behind the retina b/c the eyeball is too short or the lense is too flat
- can see distant objects but not near ones
- dx: visual acuity testing
- tx: convex lens
Strabismus
misalignment of one or both eyes
- stable ocular alignment not usually reached until ag 2-3mo, still persisting at 4-6 months? refer
- types: hypertropia (upward), hypotropia (downward), esotropia (inward), exotropia (outward)
- dx: cover-uncover test
- tx: patch the normal eye, eyeglasses, corrective surgery if severe
acute narrow angle-closure glaucoma
increase IOP leading to damage of the optic nerve (emergency)
- risk factors: hyperopia, >60yo, asian, hyperopia, females, narrow angle or large lens
-
s/sxs: sudden onset of severe ocular pain, unilateral, halos around lights and tunnel vision (loss of peripheral vision)
- N/V, HA
- dx: tonometry (IOP>21mmHg), optic disc blurring
-
tx: combination of topical agents (timolol, apraclonidine, pilocarpine) + systemic agents (PO/IV acetazolamide or IV mannitol)
- topical beta blockers
- alpha 2 agonists (aproacloonidine, brimonidine)
- miotics/cholinergics (pilocarpine, carbachol)
- prostaglandins (latanoprost)
- definitive tx: iridotomy
Chronic open angle glaucoma
- slow, progressive painless, bilateral peripheral vision loss
- risk factors: AFrican American, >40yo, family history, DM
- s/sxs: usually asymptomatic until late into onset
- tunnel vision progressing to central vision loss
- physical exam: cupping of optic disc (increased cup to disc ratio) [larger cup inside the disc]
- tx: prostaglandin analogs (1st line) latanoprost,
- beta blockers (timolol)
- alpha 2 agonists (brimonidine, apraclonidine)
- carbonic anhydrase inhibitor (acetazolamide)
- laser therapy
- surgery = last line
Amblyopia
decreased visual acuity of one eye due to disuse during visual development
- **needs to be treated before age 8 if you want to avoid SEVERE vision loss**
- risk factors: strabismus, refractive errors (astigmatism, myopia, hyperopia), congenital cataract
- s/sxs: decreased visual acuity
- diagnosis: early screening
- tx: eyeglasses, patch the normal eye, cataract removal, tx of strabismus, atropine drops
Amaurosis Fugax
transient monocular vision loss that lasts minutes and spontaneously recovers
- usually a retinal ischemia or emboli, TIAs, giant cell arteritis, migraine, lupus
- risk factors: DM, heart disease, smoking, HTN, hyperlipidemia, age, cocain use
- s/sxs: vision loss that descends over the visual field (often described as a curtain or shade) that usually resolves within the hour
- dx: clinical diagnosis
- tx: tx the underlying vascular issue
Central Retinal Vein Occlusion
-
risk factors: associated with Afib and carotid disease
- HTN, advancing age, glaucoma, DM
-
s/sxs: sudden onset, severe, painless unilateral vision loss
- blood and thunder of the retina
- dx: fundoscopy
-
tx: globe massagem, refer to optho/ED
- decrease IOP
- tx HTN!
Central Retinal Artery Occlusion
-
risk factors: associated with Afib and carotid disease
- HTN, advancing age, glaucoma, DM
-
s/sxs: sudden onset, severe, painless unilateral vision loss
- cherry red spot on pale macula
- dx: fundoscopy
-
tx: globe massagem, refer to optho/ED
- decrease IOP
- tx HTN!
Vitreous Detachment
- can be associated with trauma
- hemorrhage in pts with DM
- s/sxs: complaints of mild vision loss, floaters, cobwebs or flashes of light
- refer to optho
Hyphema
blood in the anterior chamber of the eye
- referral, eye shield
Hypopyon
collection of neutrophils and fibrin in the anterior chamber of the eye
- often associated with endophthalmitis
- referall to surgery and intravitreal abx
Globe Rupture
ophthalmologic emergency
- significant visual acuity impairment, diplopia
-
dx: r/o intraocular foreign body, check visual acuity
- DO NOT TOUCH EYE
-
tx: ABCs, and stabilization
- apply rigid shield cup, keep head elevated at 30-40 degrees (do NOT want to increase IOP)
- CT orbits if stable
- immediate surgical referral
Blowout Fracture
fracture of the inferior floor of the orbit
- “trap door” or “white-eye fracture” in children = elastic bones can snap shut on muscle or other tissue
- s/sxs: decreased visual acuity, diplopia, eyelid edema
- dx: CT scan = teardrop sign (herniation of the orbital fat inferiorly
-
tx: nasal decongestant, avoid blowing nose or sneezing, corticosteroids
- abx: ampicillin-sulbactam, or clindamycin
- surgery if severe
Diabetic Retinopathy
gradual, bilateral, painless vision loss
- most common cause of new, permanent vision loss in 20-74yos
can have non-proliferative: microaneurysms, cotton wool spots, hard exudates, blot and dot hemorrhages
or
proliferative retinopathy: neovascularization, and maculoedema
- dx: fundoscopy, vital signs
-
tx: non-proliferative = glucose control, laser treatment
- proliferative = VEGF inhibitors (bevacizumab), laser photocoagulation, treatment, glucose control
Hypertensive Retinopathy
- associated with malignant HTN (uncontrolled high blood pressure)
- can be associated with non-proliferative retinopathy: microaneurisms, cotton wool spots, hard exudates, drussen bodies, flame hemorrhages
- or proliferative retinopathy: neovascularization + maculoedema
- dx: fundoscopy + vital signs
-
tx: tx the HTN!!
- non-proliferative: laser treatment
- proliferative: VEGF inhibitors (bevacizumab), laser photocoagulation
Retinal Detachment
When retina separates from the choroid
- risks: myopia, previous cataract surgery, advancing age, trauma
- s/sxs: sudden onset, unilateral,, **flashes of light**, floaters, spreading cutrain of darkness
- dx: fundoscopy or ocular u/s
-
tx: keep pt supine with head turned toward side of detachment
- emergent referal to retinal specialist to seal the defect
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- emergent referal to retinal specialist to seal the defect
Macular Degeration
most common cause of permanent legal blindness in adults >75yo
- dry (atrophic): most common type and progressive (spanning over decades)
- wet (neovascular or exudative): occurs more rapidly and is more severe
-
s/sxs: bilateral progressive central vision loss,
- central scotoma, metamorphopsia (straight line appears bent)
-
dx: dry = drusen bodies
- wet = new, abnormal vessels that can cause hemorrhaging and scarring
- fundoscopy, AMSLER GRID
- management of dry: zinc and vitamins C&E can slow progression
-
tx of wet: intravitreal VEGF inhibitors (bevacuzimab, ranicuzimab) = decrease new and abnormal vessel growth
- laser photocoagulation
Orbital Cellulitis
- preseptal orbital cellulitis = outside of the orbit
- postseptal orbital cellulitis = inside the orbit (especially from sinus infection from the ethmoid sinus
-
s/sxs:
- preseptal and postseptal = tenderness, edema, erythema, discoloration of eyelid and fever
- postseptal = decreased ocular mobility, pain with eye movement, proptosis, and decreased visual acuity
- dx: clinical, high resolution CT scan
-
tx: admission + IV abx
- vancomycin + ceftriaxone or cefotaxime (3rd gen)
- preseptal = outpatient if older than 1 year oral clindamycin (to cover MRSA)
Papilledema
optic disc swelling associated with increased intracranial pressure
- pressure of brain on optic nerve = swelling of optic disc
-
s/sxs: headache, nausea, bilateral blind spots, vision can be preserved
- swollen optic disc with blurred margin
- dx: fundoscopy, MRI or CT scan to r/o mass effect, lumbar puncture to test pressure of CSF
-
tx: acetazolamide (decreases production of aqueous humor and CSF production) [carbonic anhydrase inhibitor and diuretic]
- tx the underlying cause
Optic Neuritis
inflammation of the optic nerve often due to acute inflammatory demyelination of the optic nerve
- associated with women 20-40yo, multiple sclerosis, and ethambutol
-
s/sxs: unilateral, painful vision loss
- decrease in color vision, central scotoma over hours to a few days, ocular pain worse with movement
- 1/3 of pts have papillitis ( optic disc swelling)
-
dx: clinical, MRI orbit, brain and spinal cord
- swinging flashlight test
-
tx: IV corticosteroids (methylprednisone) followed by PO corticosteroids
- neuro and optho referral
ptosis
drooping of eyelid
can be associated with CN III deficit or levator palpebrae muscle
referral to optho
Proptosis
- aka exopthosis, protrusion of the eyeball
- **most common in adults with Graves Disease (hyperthyroid)
- **most common in children with orbital cellulitis**
- s/sxs: red flags = eyepain/redness, HA, loss of vision, diplopia, fever, pulsating or neonatal
-
dx:
- acute unilateral = infection or vascular disorder
- chronic unilateral = tumor
- CT, MRI
- order thyroid function testing
-
tx: lubricate the cornea, systemic corticosteroid to reduce edema
- may need surgery
Hordeolum
aka stye = abscess of the meibomian gland, gland of Moll, or Gland of Zeiss)
- staph aureus
- s/sxs: pain, warm, erythematous, nodule or pustule on eyelid
- diagnosis: clinical
-
tx: warm compresses, can use oral abx if accompanied by preseptal orbital cellulitis (dicloxacillin or erythromycin)
- can add topical abx if actively draining (erythromycin or bacitracin)
Entropion
inversion of the eyelid
- usually associated with advancing age, but can also be postinfection, trauma, or blepharospasm
- s/sxs: foreign body sensation, tearing, red eye
- diagnosis is clinical
- tx: surgery = refer to optho
Ectropion
- eversion of the lower eyelid
- caused by advancing age, relaxation of tissue, cranial nerve VII palsy, and post-traumatic/surgical changes
- s/sxs: tearing (because puncta are no longer in contact with the eye) dry eye
- diagnosis is clinical
-
tx: lubrication eye drops at night
- tear supplements
- definitive tx = surgery, refer to optho
Chalazion
non-infectious blockage of internal Meibomian sebaceous gland, or zeiss gland
- often associated with acne rosacea
-
s/sxs: non-tender localized eyelid swelling on the conjunctival surface of the eyelid
- often larger, firmer, slower growing, and less painful than hordeolum
- diagnosis is clinical
-
tx: warm compresses, abx eye drops
- referral to optho for injection of glucocorticoid or incision + curettage if does not resolve
Blepharitis
infection of the eyelids
- acute ulcerative: staph or HSV
- acute non-ulcerative: allergic
- chronic: meibomian gland dysfunction or seborrheic dermatitis
- s/sxs: pruritus or burning of eyelid margin, conjunctival irritation and tearing, photosensitivity, sensation of foreign body
- dx: slit lamp
-
tx: supportive
- warm compresses, cleansing of eyelid, keratoconjuctivitis sicca tx PRN
- can use abx for acute ulcerative and chronic or topical corticostosteroid of nonulcerative
Dacrocystitis
infection of the lacrimal sac
- often caused by staph aureus and strep
-
s/sxs: pain, erythema, edema around lacrimal sac
- pressure on lacrimal sac may exude mucoid or purulent material through the puncta
- diagnosis is clinical
-
tx: mild = warm compresses and 1st gen ceph, or penicillinase-resistant penicillin (PO)
- IV abx
- not responding to tx? consider MRSA
Corneal Abrasion tx
abx ointment (aminoglycoside tobramycin, gentamicin), or erythromycin and pupillary dilation
plus the tetanus immunization!!!
pterygium
benign growth of the conjunctiva that results from chronic actinic irritation
- more common in sunny, dry, hot climates
-
s/sxs: fleshy, trianngular growth of the bulbar conjunctiva that can spread across the cornea and induce astigmatism/affect vision
- pinguecula doe NOT affect the cornea
- diagnosis is clinical
-
tx: arifical tears or short course of topical corticosteroids, reassurance
- referral if starting to affect vision for surgery
Ocular Herpes
corneal infection with HSV
-
s/sxs: ocular pain, foreign body sensation, photophobia, blurred vision, watery discharge
- dendritic lesions with fluorescein stain
- dx: dendritic ulcer or viral cx
- tx: topical ganciclovir or trifluride OR PO acyclovir or valacyclovir
Cataract
thickened lens associated with aging, smoking, DM, long-term steroid use, trauma, congenital, and children exposed to too much O2
**leading cause of reversible blindness**
-
s/sxs: cloudy/blurry vision, glare in vision (especially at night), halos, perception of faded color, yellowing/browning of vision
- NOT PAINFUL
- absent red light reflex, opaque lens
- cortical spokes, or posterior subcapsular
- dx: slit lamp exam
- tx: surgery
Subconjuctival Hemorrhage
usually result of minor local trauma, straining, sneezing, or coughing
- diagnosis is clinical
- tx: reassurance = should resolve within 2 weeks
