Optho Flashcards
When do infants begin to develop the ability to fixate?
At 6 weeks of age
*Fix at Six
When does color perception develop?
2 months of age
When does binocular vision with convergence ability develop?
3 months of age
When does preference for patterns, including faces develop?
4 months of age
What is the visual acuity of a newborn?
20/200
By one year of age, what is visual acuity?
20/30
What refers to the ability to see a moving target, follow it, and then return to the original gaze?
Optokinetic Nystagmus
What is one of the earliest reflexes that infant develop in the first few months of life?
Optokinetic Nystagmus
What is pendular nystagmus?
Equal velocity movements in both directions (to and fro)
What is pendular nystagmus often a sign of?
Underlying disorder like MS or spinocerebellar disease
What is jerk nystagmus characterized by?
Slow phase back to central position with a quick gaze laterally
When is jerk nystagmus normal?
When a child gazes far upwardly or laterally
What is a benign, transient disorder without known cause that is characterized by pendular nystagmus, intermittent head tilt, and nodding or head bobbing?
Spasmus nutans
What can spasmus nutans be mistaken for?
Muscular torticollis
True or False: Spasmus nutans is self-resolving
True
What is the loss of visual acuity due to active cortical suppression of the vision of one eye?
Amblyopia
What can cause amblyopia?
Result of deprivation due to:
- Ptosis
- Dense congenital cataract
- Persistent strabismus
- Extended eye closure
What is an inward turning eye called (a form of strabismus)?
Esotropia
What is an outward turning eye called (a form of strabismus)?
Exotropia
What is mild farsightedness where parallel rays are focused behind the retina- distant objects are seen more distinctly than near ones?
Hyperopia
True or False: Most children normally have mild hyperopia
True
What is the refractive state most likely to be seen in a 3 year old?
`Hyperopia
What should you think if a child resists you covering an eye during the cover test?
That’s his good eye- If one eye is abnormal and you attempt to cover the good eye, he will resist you
What is deviation of the alignment of one eye in relation to the other?
Strabismus
When is eye alignment more difficulty?
When significant focusing effort is required (as with significant hyperopia)
When can strabismus become more significant?
When significant focusing effort is required
What test is used for strabismus?
Corneal light reflex test (Hirschberg test)
How is the corneal light reflex test performed?
Shine a penlight on both eyes and expect a symmetrical light reflex
Why is screening for strabismus crucial?
Untreated strabismus results in amblyopia if not detected by age 6
What is the loss of use of the nondominant eye and permanent loss of binocular vision?
Amblyopia
What are infants born with Sturge Weber at risk for?
Glaucoma
Child born with a port wine stain… what needs to be addressed?
Glaucoma
What is violaceous discoloration describing?
Port wine stain
What is seen in a child with strabismus during the “cover test”?
- Child looks at one particular spot
- Eye with strabismus deviates instead of fixating on object
What happens during the cover test with accommodative esotropia?
When one eye is covered, the uncovered eye moves outward to fix on spot
What happens during the cover test with accommodative exotropia?
When one eye is covered, the uncovered eye moves inward to fix on spot
What is pseudostrabismus?
When eyes appear to deviate, but actually due to other factors
What are some things that can cause pseudostrabismus?
Extra skin covering inner corner of eye, broad/flat nose, eyes set unusually close together or far apart
What is done for strawberry hemangiomas of the eye?
May resolve without any intervention unless on or near eyelid and interfering with vision (then they may need to be dealt with early on)
How does congenital glaucoma present?
Tearing, photophobia, blepharospasm, corneal clouding, redness, edema, progressive enlargement of the eye
Why does concern for glaucoma require prompt referral to an ophthalmologist?
Need to measure intraocular pressure and may need surgery
What are 3 important associations to know with congenital cataracts?
- Rubella
- CMV
- Galactosemia
Besides rubella, CMV, and galactosemia what are other things you can see congenital cataracts with?
- Hereditary
- Other infections (TORCH)
- Metabolic/genetic syndromes (parathyroidism, Smith-Lemli-Opitz)
- Other ocular malformations
What should you consider with a clumsy child who runs into objects or spills liquids more often than the average child?
Faulty depth perception- Child with a cataract
What are external hordeolums also called?
Styes
What causes Styes?
Inflammation and infection (usually staph) of sebaceous glands in the eyelid)
What are the mainstays of treatment for Styes?
Warm compresses and possibly topical antibiotics
What are styes due to?
Inflammation and possible infection of the follicles and/or sebaceous glands
What might be needed for a stye if warm compresses and topical antibiotics don’t work?
I&D
When are oral antibiotics required for a stye?
Never
What is the first step in the evaluation of an infant with congenital cataracts?
Evaluation of the parents for cataracts (50% inherited as an autosomal dominant condition
What % of cataracts are inherited as an autosomal dominant condition?
50%
What is a chalazion?
Lipogranuloma
What causes a chalazion?
Chronic inflammation of one of the small oil-producing glands secondary to retention of secretions
What are chalazions due to?
Chronic inflammation (not bacterial infection)
True or False: Chalazions are typically painless?
True
Patient with a 4 month history of a painless nodule on her upper eyelid…treatment?
Referral to ophthalmology for surgical excision (this is a chalazion)
What is the difference between a Stye and Chalazion?
Styes: Red, angry, painful (like a pimple)
Chalazion: Cool, painless, chronic
What is the initial treatment for a nasolacrimal duct obstruction?
Massage the duct 2-3 times per day
What should be done if there is evidence of infection in nasolacrimal duct obstruction?
Topical antibiotic treatment
When are oral antibiotics needed for a blocked nasolacrimal duct in an infant?
Never
If a blocked tear duct isn’t resolved by 12 months of age, what should be done?
Ophthalmological consultation
2 month old with excessive tearing of left eye and mucoid discharge. Tears pool on left eyelid and cheek. Child has nasal congestion and coughs occasionally. Pregnancy/delivery were unremarkable. Appropriate Management?
Conservative measures for a blocked nasolacrimal duct (massage and warm compress)
- Topical antibiotics only if there was erythema and other signs of infection
- Chlamydia pneumonia needs more persistent staccato cough or CXR findings and eye discharge would need to be bilateral.
What two things both present with edema and redness around the eye?
Preorbital and orbital cellulitis
Which is more serious… Preorbital or orbital cellulitis?
Orbital (since it is an infection invading the eye itself
What are some buzz words that would tip you off to orbital cellulitis?
- Compromised vision
- Proptosis
- Decreased extraocular movement
- Pain exacerbated by eye movement
What can cause orbital cellulitis?
- Spread of skin infections (insect bites)
- Sinusitis
- URI
- Dental infection
What is the most common bug in orbital cellulitis when the infection is caused by initial skin infection?
S. Aureus
What are 4 bacteria to think of with orbital cellulitis that spread from the respiratory tract or sinuses (besides S. Aureus)?
- Strep pyogenes
- Peptostreptococcus
- Bacteroides
- Non-typeable H. Flu
Why is it important to note if someone with orbital cellulitis is immunized?
Because Hib can cause this (if patient immigrated from a developing country, assume they are unimmunized)
What may be needed to differentiate between orbital and periorbital cellulitis and is indicated to document the extent of involvement in orbital cellulitis?
CT scan
What needs to be done for kids with orbital cellulitis?
Admit them to the hospital for IV antibiotics and consult ophthalmology
What can periorbital (or preseptal) cellulitis be treated with?
Oral antibiotics that cover typical skin and respiratory flora
True or False: Periorbital cellulitis can spread to become orbital celluilitis
True
If there is decreased EOM or proptosis, what type of cellulitis are you likely dealing with?
Orbital
Red, swollen, periorbital area which is itchy/pruritic (rather than painful)…?
Insect bite or allergic reaction (rather than an infection)
What are some findings seen with a corneal abrasion?
- Photophobia
- Tearing
- Intermittent sharp pain
- Irregular red reflex
- Dulled corneal light reflex
What test/finding is a slam dunk for a corneal abrasion?
Fluorescein staining of cornea
What eye problem should you consider with an irritable infant?
Corneal abrasion
Once a corneal abrasion is confirmed with fluorescein, what should be done?
Topical antibiotic treatment
True or False: A semi pressure patch for 24 hours is routine for treatment of a corneal abrasion?
False… no longer considered to be routine treatment
Patient with symptoms of corneal abrasion following mild trauma… what is the first thing to do?
Fluorescein stain the eye (not prescribe topical antibiotic)
What is seen on funduscopic view in retinitis pigmentosa?
- Optic disc with “waxy pallor”
- Narrow arterioles
- Retinal pigment deposition
Funduscopic exam with pallor in the center of the optic disc, narrow arterioles coming off the optic disc, retinal pigment deposition on the periphery…?
Retinitis pigmentosa
What syndrome can retinitis pigmentosa be seen with?
Usher Syndrome
What is seen on funduscopic exam with retinal hemorrhages?
Flame-shaped hemorrhage
What clinical scenario are retinal hemorrhages often seen in?
Child abuse (NAT)
Which two groups should be screened for ROP?
- Birthweight less than 1500g or GA less than 32 weeks
2. Birthweight 1500-2000g with unstable clinical course, judged to be at risk
When do you screen for ROP?
31-34 weeks post-conception or 4-6 weeks after birth (whichever is later)
What is the greatest risk factor for developing ROP?
Prematurity (with gestation less than 28 weeks)
What is the risk for developing ROP in an infant greater than 37 weeks gestation on oxygen?
Very low (retinal vascularization is almost complete at this gestational age)
Most likely risk factor for ROP?
Very low birthweight or prematuriy
*Exposure to O2 or maintenance of sats >95% doesn’t influence progression of ROP
What is ROP inversely proportional to?
Birthweight and gestational age
What is opthalmia neonatorum?
Conjunctivitis in the first 4 weeks after birth
What are 4 most frequent causes of opthalmia neonatorum?
- S. Aureus
- S. Epidemidis
- S. Pneumoniae
- M. Catarrhalis
*Can also be seen with Chlamydia, Neisseria, and HSV
What type of conjunctivitis typically develops 5-14 days after delivery and has a watery discharge that progresses to a mucopurulent discharge?
Chlamydial conjunctivitis
What is done to prevent chlamydial conjunctivitis?
Erythromycin ointment at birth (prophylaxis)
What % of infants with chlamydial conjunctivitis have coinfection at other sites?
50%
What could chlamydial conjunctivitis progress to?
Pneumonitis (co-infection)
How is chlamydial conjunctivitis treated?
Oral eryhtromycin x14 days
What 2 things does topical erythromycin applied to the eyes after birth prevent?
- Chlamydial conjunctivitis
2. Neisseria conjunctivitis
Which is more severe, chlamydial or neisseria conjunctivitis?
Neisseria
How does neisseria conjunctivitis present?
Hyperacute, hyperpurulent conjunctivitis 24-48 hours after birth
How is neisseria conjunctivitis treated?
IV ceftriaxone (+frequent saline lavage)
If you have an infant with neisseria conjunctivitis, what else do you need to look for?
Disseminated GC disease
What time-frame does neonatal HSV conjunctivitis present?
1-2 weeks after birth
True or False: Skin vesicles are often absent in HSV conjunctivitis?
True
What is treatment for HSV conjunctivits?
IV acyclovir (hospital admit + optho consult)
How does conjunctivitis present?
- Erythema of conjuntiva (pink or red eye)
- Discharge (clear to purulent)
- Eye matting
Name 4 symptoms of conjunctivitis
- Foreign body sensation
- Itching
- Burning
- Photophobia
Child with a red eye who wears contact lenses… what do you do?
Referral to optho for definitive care
18 year old, red and irritated right eye, took out contacts ~10 hours ago, no improvement. Conjunctiva is irritate, can’t keep eye open, fundoscopic exam normal, PERRL, no discharge. Diffuse uptake of fluorescein. Next step?
Refer to optho- Could be gram - infection or ulceration of corneal epithelium
*Simple corneal abrasion is focal uptake of stain
Name 5 bugs that can cause bacterial conjunctivitis
- S. Aureus
- S. Epidermidis
- S. Pneumoniae
- M. Catarrhalis
- Pseudomonas
In a child who is unimmunized, what specific bug must you remember for bacterial conjunctivitis?
H. Flu type B
What is treatment for acute bacterial nongonococcal conjunctivitis?
None- Benign and self-limited
-Can do topical antibiotics to quicken resolution and limit spread
What should you think for a child with a hyperacute presentation of conjunctivitis with severe extremely purulent discharge and pseudomembrane formation?
N. Gonorrheae or N. Meningitidis
What should you do if you suspect Neisseria conjunctivitis?
Urgent optho referral, admission, IV abx
What is the most common cause of viral conjunctivitis?
Adenovirus
What can you recommend for symptom relief in viral conjunctivitis?
- Artificial tears
2. Cool compresses
True or False: Topical antibiotics and steroids can be given for severe viral conjunctivitis?
False- Abx not recommended and steroid drops contraindicated
When do you refer to optho for viral conjunctivitis?
If no symptom improvement in 2 weeks
What is important to remember to counsel patients on with viral conjunctivitis?
HIGHLY CONTAGIOUS
-Avoid touching eyes, shaking hands, sharing towels, wash hands frequently
What are the symptoms of allergic conjunctivitis?
- Eye itching
2. Watery or mucoid discharge
What helps to distinguish allergic conjunctivitis from bacterial conjunctivitis?
Intense itching
What helps to distinguish allergic conjunctivitis from viral conjunctivitis?
- Presence of other atopic conditions (allergic rhinitis and atopic dermatitis)
- Viral more likely to start in one eye, allergic starts in both eyes simultaneously upon exposure to allergic trigger
Name 3 systemic conditions that present with conjunctivitis
- Kawasaki
- Measles
- JIA
How does conjunctivitis present with Kawasaki disease?
- Non-purulent
- Bilateral
- Peri-limbal sparing
How does conjunctivitis with measles present?
Exudative conjunctivitis
What can happen in JIA that might be confused with conjunctiovitis?
Uveitis
When should you prescribe topical eye steroids?
NEVER… only optho should be doing this
What words in a question stem involving eye trauma should prompt referral to optho?
- Pupil irregularity
- Significantly reduced visual acuity
- Orbital fracture
- Decreased extra-ocular eye movements
What is a collection of blood between the cornea and iris (usually following eye trauma)?
Hyphema
What is treatment for a hyphema?
- Immediate referral to optho
- Admit
- Bed rest with head at 30 degree angle (decrease IOP)
True or False: A patch is needed for treatment of hyphema?
False: Need a shield
Where is the fracture in a blowout fracture?
Orbital wall or floor
Blunt trauma to eye, double vision when looking to one side, dysconjugate gaze to one side, pupillary reflexes intact?
Blowout fracture
Severe eye pain and tearing, no diplopia, no dysconjugate gaze
Corneal abrasion
Blood in the anterior chamber, possible visual impairment, no diplopia
Hyphema
Eye pain and severe photophobia without diplopia
Traumatic iritis
Visual deficit in peripheral field (curtain like), no dysconjugate gaze
Detached retina
