Optho ALL Flashcards
What 3 things can cause sudden vision loss
- central retinal artery occlusion
- Anterior ischemic optic neuropathy/papillitis/papilledema
- retinal detachment
What 3 things cause chronic vision loss
- Senile Cataract
- Primary open angle glaucoma (glacomatous cupping)
- age related macular degeneration (wet/dry)
what 3 things are associated with trauma
- sub-conjunctival hemorrhage
- orbit trauma / blowout fracture
- hyphema
what is on differential for red eye
- subconjunctival hemorrhage
- follicular conjunictivits (viral and allergic)
- hordeolum / chalaion
- blepharitis
- HSV keratitis
- Bacterial keratitis / hypopyon
- iritis
- Angle closure glaucoma
What 2 common peds issues are encountered?
esotropia, amblyopia
leukocoria
what 2 neuro things have optho findings?
- CN III, VI palsies
2. horners
What are 4 systemic diseases that appear in the eye
- diabetic retinopathy (preproliferative/neovascular)
- Herpes Zoster opthalmicus
- orbital cellulitis
- Graaves orbitopathy
Visual acuity testing
goal is to document best possible vision in each eye wearing glasses
when do you have problems night driving
20/40
when do you have problems day driving and need to read newspaper with magnifier
20/70
When are you legally blind (stil able to care for self)
20/200
When is ambulation impaired (need dog and stick)
finger count of 4
how much of the disk should the cup be
no more than 30-40% of the disk
Retinal artery occlusion presentation
painless acute vision loss. “like a dark curtain coming down.” Relative pupillary defect
Retinal artery occlusion physical
cherry red spot on the macula, vessels are attenuated and have box car appearance
Where does CRAO come from?
GCA or embolic stroke. be careful of embolic or thrombotic events
tx of CRAO
no treatment to recover vision. Opthalmologist may advise pressure lowering
Retinal detachment presentation
rapid vision loss in 1 eye with dark spots, flashers, floaters. Vision like a dark curtain creeping towards the center
Retinal dechment physical
retina will appear detached with loss of vessels and grayish color (maybe corrugated)
retinal detachment urgency
emergent if fovea not involved. If central acuity is lost, you can do repair within the week although sight will not be fully resotred
retinal detachment tx
LASER barricade to pin it down
scleral buckle, vitrectomy
where does retinal detachment come from
vitreous traction on the retina allowing fluid to move underneath and lift the retina
arteritic anterior ischemic optic neuropathy presentation
vision loss, GCA sx of claudication.
arteritic anterior ischemic optic neuropathy physical
fundus has a chalky white appearance (pale, swollen nerve). High ESR, CRP, CBC
arteritic anterior ischemic optic neuropathy urgency
EMERGENCY
arteritic anterior ischemic optic neuropathy tx
start high dose steroids for GCA. temporal artery biopsy
non-arteritic ischemic optic neuropathy associated with?
- microvascular disease
- post-surgical
- small c/d ratio (segmental pallor)
papilledema sx ?
position dependent headaches, pulsatile tinnitus
papilledema findings?
bilateral disc elevation with blurred margins, discs not pallid
senile cataract presentation
painless, progressive vision loss, increasing difficulty with glare
senile cataract physical exam?
lens not clear; nucleus has hazy, yellow-brown appearance
senile cataract forms because…
degenerative clouding of the normally clear crystalline lens with age
senile cataract tx?
surgical extraction
primary open angle glaucoma presentation?
decreased visual fields, defects
primary open angle glaucoma findings?
high disc to cup ratio 0.8. normal vessels, increased IOP
what is the pathophys of glaucoma?
the high IOP (>21 mm Hg) leads to a thinned neuro-retinal rim and cup enlargement
Dry age related macular degeneration presentation
bilateral dimming of vision centrally. intact in extrinsic visual fields
Dry age related macular degeneration exam?
many yellow subretinal deposits called drusen which show atrophy in the central macula
Dry age related macular degeneration tx?
Risk factor management of smoking and vitamin supplementation. non-urgent next available appointment to optho
Wet age related macular degeneration presentation
sudden change and loss of central vision
Wet age related macular degeneration exam?
subretinal fluid and hemorrhages
Wet age related macular degeneration tx?
intraocular injections of anti-VEGF and other antibodies. 1 week to optho
AMD facts
most common cause of severe vision loss of people over 60. hard to read, drive, recognize faces
orbital floor fracture presentation?
ecchymosis around eye, subconjunctival hemorrhage. affected eye appears lower than the normal one. pain
orbital floor fracture exam?
orbital floor fracture with CT showing air fluid level in the maxillary sinus
orbital floor fracture tx?
urgent optho exam and repari of facial fracture within 5 days
sub-conjunctival hemorrhage spontaneous?
don’t worry about it. If pt is anticoagulated, consider checking INR’s
hyphema presentation?
punch in eye and blood pooled in bottom of anterior chamber. Pain with eye, blurry vision
hyphema exam?
layered blood in dependent portion of the anterior chamber. conjunctival injection
hyphema tx?
EMERGENT referral to optho. Put shield over affected eye and monitor intra-ocular pressure. Opthalmologist will manage the possible spontaneous re-bleed which can happen days afterwards
subconjunctival hemorrhage presentation
no trauma, pain or itching, but usually sponatenous
subconjunctival hemorrhage exam?
extravasated blood beneath the conjunctiva without engorgement of conjunctival vessels.
subconjunctival hemorrhage tx?
don’t worry. go home and it will resolve. use artifical tears if irritated
follicular conjunctivitis (adeno) presentation
redness, eye grittiness and discharge. blurry vision. constitutional sx like sore throat and swollen glands
follicular conjunctivitis (adeno) exam?
diffuse conjunctival injection involving bulbar and tarsal conjunctiva. muco-serous discharge. follicular pattern
follicular conjunctivitis (adeno) tx?
self-limited process. use of anti-histamine drops
bacterial conjunctivitis presentation
discharge from eye with tons of goop
bacterial conjunctivitis exam?
moderate discharge from eye with bulbar and tarsal conjunctiva.
bacterial conjunctivitis tx?
erythromycin ointment or 10% sulfacetaminde drops QID x 5 days. Response within 24-48 hours
Chalazion presentation?
painless nodul on eyelid
Chalazion exam?
firm, non-tender nodule on eyelid. no edema, erythema, ulceration
Chalazion tx?
warm compresses at first, persistent, then go for I&D if causing vision change (astigmatism)
Chalazion what is it?
focal area of inflammation of eyelid related to meibomian gland obstruction which makes goopy eye stuff
Blepharitis presentation?
morning crusting of eyelids
Blepharitis exam?
flaky crusting of lashes without discharge. some conjunctiva injection
Blepharitis tx?
warm compresses + erythromycin ointment BID x 2weeks
what does Blepharitis come from?
seborrhea, staph, rosacea
Herpes simplex keratitis presentation?
photophobia, foreign body sensation, tearing of left eye. moderately swollen lid. no discharge. conjunctival injection with no tarsal involement
Herpes simplex keratitis exam?
linear opacity with branching of terminal bulbs in cornea that is grayish white, turning yellow in fluorescein staining. DENDRITE
Herpes simplex keratitis tx
referral to optho within 1-2 days for topical or systemic antiviral agent.
Herpes simplex keratitis comes from?
expression of HSV latent in the trigeminal ganglion. It’s an eye cold sore. can cause keratitis scarring
bacterial keratitis with hypopyon presentation?
contact lens wearer reports 3 days of irritation, increasing discharge and declining vision
bacterial keratitis with hypopyon exam?
irregular white corneal opacity that stains with fluorescein. White cells layering anterior to the iris
bacterial keratitis with hypopyon tx?
emergency referral to optho for empiric topical abx tx and/or cultures
bacterial keratitis with hypopyon sequelae?
corneal ulceration with scarring, perforation, and loss of the eye.
acute angle closure glaucoma presentation?
“worst headache of life” with a red eye. slightly decreased vision in involved eye.
acute angle closure glaucoma exam?
hazy cornea with diffuse injection of the conjunctiva. High IOP
acute angle closure glaucoma tx?
EMERGENCY optho consult with topical beta-blocker and alpha-agonist. Definite treatment is laser iridotomy with fellow eye treatment within several days
infantile esotropia presentation?
baby with crossed eyes with normal development otherwise
infantile esotropia exam?
deviation of eye inwards towards nose
infantile esotropia tx?
optho within a few weeks. confirm ocular misalignment. patch the bad eye to avoid amblyopia in the left eye. strabismus surgery possible
6th nerve palsy presentation
unable to abduct eye. anisocoria
6th nerve palsy tx?
maybe due to microvascular stuff. rule out tumor or infiltrative process with imaging
6th nerve palsy etiology?
elevated ICP, head trauma, meningeal inflammation
3rd nerve palsy presentation
dipolopia with a blown pupil
3rd nerve palsy etiology?
PCA aneurysm with compression if blown pupil. if ischemic, usually a pinpoint pupil
horner syndrome presentation
pain in neck, drooping eyelid, unilateral headache
horner syndrome exam?
one pupil smaller than the other and ptosis
horner syndrome etiology?
traumatic carotid dissection
retinoblastoma presentation
unusual white reflex in pupil (leukocoria)
retinoblastoma exam?
leukocoria
retinoblastoma tx?
urgent referral to opthalmologist for surgery, radiation or other destruction
diabetic retinopathy presentation
diabetic person with worsening vision
diabetic retinopathy exam?
cotton wool spots, exudates on retina and dot blot hemorrhages
diabetic retinopathy tx?
non-urgent referral to optho to check for neovascularization. used to use laser to stop neovascularization. Also can use anti-vegf therapy
Reiter’s syndrome (iritis) presentation?
red eye and light sensitivity. photophobia
Reiter’s syndrome (iritis) findings?
injected eye with ciliary flush. focal opacities in the red reflex are keratic precipitates (cells) on inner surface of cornea (need slit lamp)
Reiter’s syndrome (iritis) tx?
tons of steroids. also workup for other things like TB, sarcoid, syphilis, RA, etc.
HSV opthalmicus presentation?
rash and burning and itching around eye
HSV opthalmicus findings?
eye injection but no discharge
HSV opthalmicus tx?
systemic antiviral therapy within 72 hours
orbital cellulitis presentation?
inflamed, swollen eyelid
orbital cellulitis findings?
post-septal orbital findings - proptosis, reduced vision, relative afferent pupillary defect,restricted EOM.
orbital cellulitis tx?
urgent to hospital for tx with IV abx.
Graves presentation?
bulging eyes, diplopia
Graves findings?
prominent lid retraction with sclera visible above the superior limbus
Graves tx?
thyroidectomy, methimazole
