OPTHO ALL UNDERLINED Flashcards by Demetré Harris

Preseptal cellulitis has NO PROPTOSIS

NO restricted ocular motility
NO PAIN with EOM
And NO Optic neuropathy

Compare this with Orbital cellulitis

As they both presents with a swollen eye/ eye lid 2/2 staph and strep

But cellulitis has Proptosis and Restricted EOM with Pain

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What is the Treatmetn for orbital cellulitis

IV! ABX
( Vanc and ampicillin/ Sulbactam)
x72 hrs then Oral for 1 week

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A child under 5 years old that presents with Leukocoria

Retinoblastoma

Can be unilateral, bilateral or multi focal

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How do you do an eye exam for corneal abrasions

Slit lamp and evert the eye to look for foreign bodies

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Know that alkali burns are worse than acidic burns

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When should you start treatment for chemical injury to the eyes

BEFORE EVALUATON!

Copious irrigation for at least 30 minutes

Wait 5 – 10 minutes after irrigation stopped, then check pH in the fornices using litmus paper

Continue irrigation until neutral pH is achieved

Topical anesthetic (proparacaine)

Evert lids to flush out retained chemicals

IOP should be assessed

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What must you do to look for foreign bodies of the cornea

EVERT the lids

CAPITILIZED IN THE SLIDES

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If a pt has a high speed hx with foreign body of the corneal

What imaging should you order

CT scan !

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A pt that presents with a detetacble penetration site of the eye with an irregular shaped pupil

With a trans illumination defect
(red reflex when there shouldn’t be)

Intraocular foreign body

(Pupil peaked to the point of injury)

UNDERLINED: CT SCAN!!

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Who should lid lacerations be treated by

Refer to oPHthomology
If:

It involves canalicular system

Associated with ruptured globe/intraocular foreign body

Involves levator (ptosis present)

Visible orbital fat (indicates penetration of orbital septum)

Extensive tissue loss (more than 1/3 of lid)

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A pt presents with an irregularly dilated pupil that reacts poorly to light

(Responds with SLOW accommodation)

Typically unilateral and mc in women who also have a loss of DTRs

Think

Adíes tonic pupil

2/2 Denervation of parasympathetic supply to the sphincter pupillae and the ciliary muscle

Confirming diagnosis

Instill 0.125% pilocarpine in both eyes
Adie’s pupils will constrict (hypersensitive)
Normal pupils will not constrict

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A pt presents with a small, slow reacting or not at all reacting to light pupil
However does respond to accommodation (light near dissociation)

Think

Argyle Robertson Pupil

Assoc with syphillis

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Is papilledema bilateral or unilateral

Bilateral

Sign of underlying D/o with pressure in or on the nerves of the brain ( mass, or CSF flow)

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What must the Nuero imaging be to do a LP

NORMAL!

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A pt presents with a unilateral swollen disc with flame shaped hemmorages

What is the DDx

Thing Ischemic Optic Neuropathy
(AAION if over 60 -GIANT CELL Arteritis)
(NAION if under 60)

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What is the ESR in giant cell arteritis

ESR is greater than 50 (in red on the slides)

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An older pt presents with sudden painless vision loss
That often starts unilaterally then progresses to bilateral

Think

NAION or AION

Also look for Headache, Scalp tenderness, Jaw Claudication

R/o TIA
HTN, DM, and Anemia

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A female pt presents w/ unilateral vision loss with orbital eye pain with EOM developing over Days
Frontal HA and globe tenderness

Think

Optic neuritis, may be 1st sign of MS

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Should you start optic neuritis pts on oral steroids/>?

NO!!
Start on IV pulitile steroids
Oral can increase incidence rates

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What is LR6SO4

Lateral Recutus CN6

Sup. Oblique CN4

All others are controlled by CN III
(SR, IR, IO, MR, Levator palpebrae, and pupillary sphincter)

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A pt presents with an eye that is “down and out”

What CN palsy

III

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A pt with a down and out and DILATED pupil =

BAD!!

MRI to R/o aneurysm

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A pt has unilateral hypertrophic in primary and left gaze

And the inferior oblique overreacts w with up and left gaze

What palsy?

CN IV

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A pt with a unilateral left gaze defect, in that one eye can look left but the other eye remains fixed

. what CN palsy

CN VI

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A pt with a stroke and now CN VI palsy should get what surgery

Strabismus surgery for chronic stable deviation

What is the blood supply to the inner retina? The outer retina?

Inner: Central retinal artery | Outer: The choroid Supplies the phot receptors

What is the Tx for Giant Cell arteritis

High dose steroids

A pt that has Blood and thunder fundus Think

Central Retinal Vein Occlusion

What are the differences of Ischemic vs non ischemic retinal vein occlusion

Can be DDx with APD reflex Ischemic will have the defect and non ischemic wont

When would you use Intravitreal anti VEGF injections or PRP

If Neovascularization or macular edema present with Retinal vein occlusion

IS retinopathy common in Type I dm ?

Rare, more common in type II DM is the leading cause of blindness in the US ages 20-64

What is the 4-2-1 rule for Non proliferative DM retinopathy

Severe – 4-2-1 rule Any of the following: -4 quadrants of severe retinal hemorrhages -2 or more quadrants of significant venous beading -1 or more quadrants of moderate IRMA

A pt with DM retinopathy with neovascular changes should get what approach to tx

Referral to ophthalmology Anti-VEGF injections Pan Retinal Photocoagulation (PRP)

What is the common complaint of a pt with retinitis pigmentosa and what is the classic sign

Difficulty driving at night And golden ring sign: Yellowish-white halo surrounding optic disc Eventually replaced with pigmentation

A pt that has flashes and floaters in a retinal detachment Has what type of detachment

Rhegmatogenous

What is the hallmark of hypertensive retinopathy

Diffuse arteriolar narrowing “Copper-wire vessel” – arteriolar narrowing —Yellowing of the linear light reflex “Silver wire” – sclerosis of the vessel

Can you use tamoxifen and chlorpoquine together

No | Can cause blindness

“Bulls eye maculopathy” Think

Chloroquine toxicity

How will a nuclear congenital cataract present

opacity within the fetal nucleus of the eye

How will an anterior polar congenital cataract present in the eye

Often flat and visually insignificant

How ill a leticonus congenital cataract present

A protrusion in the lens capsule Anterior or posterior -May be opacified

What is the tx approach to congenital cataracts

This is an emergency Referral to Peds and ortho stat!

What is the differnce between subluxation and dislocation of the lens

Subluxation - Partial disruption if the zonular fibers - The lens is decentered but remains partially visible in the pupillary aperture Dislocation - Complete disruption of the zonular fibers - The lens is displaced out of the natural position in posterior chamber

If we see quivering of the iris or lens think

Subluxation or dislocation

Vitreous opacities in the shape of a ring (Weiss rings ) Think

Vitreous detachment Refer to optó/optho Photocoagulation/cryotherapy may be necessary if retinal break/tear/detachment occurs

How can you r/o vitreous opacities and retinal tears

B scan ultrasound May need to treat with vitrectomy

What is the prominent feature of Scleritis

Severe boring eye pain That radiates to the jaw, forehead, or brow Awaken from sleep

Blue appearing scleritis Think

Necrotizing scleritis

Phenylephrine test for scleritis

Phenylephrine 2.5% topically | —After 15 min scleral vessels DO NOT blanch

What disorder is assoc with ant. Uveitis

HLA-b27 d/o

Most common cause of posterior uveitis

CMV

What is the most common severe infection affecting the eye

CMV in HIV pts Most common finding are cotton wool spots

Treatment for CMV uveitis

Infx dz referral HAART tx and oral valganciclovir

If a pt has necrotizing rheumatoid arthritis of the eye What can you not give them

Topical steroids Increases risk of perforation Just give lubricants and nsaids

Should you give topical steroids in herpes simplex keratitis

No can lead to ocular perforation

What is one of the most common causes of bacterial keratitis

Contact lens wearer

A pt has outdoor eye truama involving vengativa matter Think

Fungal keratitis Will see a feathery white opacity +/- hypopyon DO NOT USE TOPICAL STEROIDS

What drugs cause corneal pigmentation | ICAP

Indocethacin Chlorquinilone Amioderone Phenothiazines Just Dc the drug

What is munsons sign

Pointed eyeball seen in keratoconus

What is arcus senilis

Gray, white or yellow deposits in the peripheral cornea Age-related change Abnormal hyperlipoproteinemia in younger patients - Under 40? - Check systemic lipids!

What is the physical exam finding for viral conjunctivitis

``` Preauricular lymphadenopathy (tender) -Differentiator of viral vs bact ```

What is the approach to chlamydia conjunctivitis

SEND to ophthalmology ASAP! | Corneal ulcer from gonococcal can perforate quickly!

If you see mucopurulent D/c It’s

Bact conjunctivitis

A pt with conjunctivitis and intense itching Think

Allergic conjunctivitis

Which invades the cornea Pterygium or pinguecula ?

Pterygium

What is the Most common cause of bilateral and unilateral proptosis in adults

Thyroid eye D/z

Tx for thyroid eye dz

Mild Artificial tears Head elevation at night Eyelid taping ``` Moderate to severe: Oral prednisolone Orbital decompression Repair of lid retraction Orbital radiation Strabismus surgery ```

What is the permanent tx for lagopthalmos

Temporary -Suture lids together (tarsorrhaphy) Permanent -Gold weight surgically inserted into upper lid

3 types of eye deviations

Orthophoria -No deviations Heterophoria: -Normal deviation Not present on cover-uncover Eso, Exo, Hyper, Hypo, Cyclo Heterotropia: -Deviated (intermittent or constant) when using both eyes Picked up on cover-uncover test Eso, Exo, Hyper, Hypo, Cyclo