Opto 2.0 Flashcards
What are the 7 essentials of an eye exam
What parts are examined at a minimum
DIPLOMA
Depth IOP Pupils Lamp Ophthalmoscopy Motility Acuity
P-DIVE
Pupil Direct ophth IOP VA EOM
Eyelids are AKA, seperated by ? and meet at the ?
What are their two functions
What structures do they contain
Palpebrae, Palpebral fissure, Canthus
Protection
Lacrimal aid- spread new/pump old
Meibomian glands
3 muscles located w/in the eyelid:
Function and innervation of Orbicularis Oculi muscle
Function and innervation of Levator Palpebrae Superioris muscle
Function and innervation of Mueller’s Muscle
Closes eyelid, CN7
Opens upper eyelid, CN 3
Opens upper/lower lid during fear/surprise via sympathetic ANS
What are the 3 spheres (tunics) of the globe
Define Cornea
Define Limbus
Fibrous Vascular Nervous
Front window of eye, 2/3 of eye refractive surface (other 1/3- lens)
Sclera and cornea junction
What are the two muscle of the pupil what innervates each muscle
Define Conjunctiva and the two types
Define the Ciliary Body
Sphincter- Parasympathetic ANS
Dilator- Sympathetic ANS
Clear membrane covering
Palpebral- eyelid
Bulbar- sclera
Produces aqueous humor
Contains ciliary muscles- alter zonular to change lens
What is the main function of the Ciliary Muscles
Define Choroid
What does this structure provide blood to
Near focus- accommodation
Pigmented and vascular layer between retina and sclera, provides blood to retina
Outer retinal layer
Where is the Anterior Chamber located and what does it contain
Where is the Posterior Chamber located and what is it filled with
What shape is the lens and what structures keep is suspended
Between cornea and iris- aqueous humor and drainage
Behind iris, in front of vitreous
Aqueous humor
Biconvex; Zonules
Vitreous Humor is transparent gel made of ?
What function does it perform
Retina is the ? liner and referred to as the ?
Collagen Protein Hyaluronic Water
Maintains structures
Neural lining, fundus
How many layers of the retina are there
What structures are contained here
What are the two types
10 layers, 9 are transparent
Photoreceptors- send signals to brain
Cones- color, visual acuity (6mill/eye)
Rods- black/white, night vision (120M/eye)
Define the Macula and it’s function
What is the name of the central depression in the macula
What is contained here
Posterior pole of retina- fine, central vision
Fovea- 4mm temporal and 0.8mm inferior to optic nerve
Mostly cones, 1/3 of all nerve fibers
Define the Optic Disc
What is the Disc AKA
What are the extra-ocular muscles
Nerve/vessels converge and leave eye
Physiologic/anatomic blind spot x 15* temporal
4 rectus (Superior Lateral Inferior Medial) 2 obliques (Superior Inferior)
What movements are the 6 extra-ocular muscles in charge of
What is the term that describes how these muscles work
IO: extortion, elevation SO: intorsion, depression SR: elevation LR: abduction IR: depression MR: adduction
In tandem, yoked: ipsilateral opposing muscle relaxes
What are the 3 layers of tears from out to in and where is each layer made?
What type of pathway is the optic nerve?
What type is the oculomotor and parasympathetic?
Oil- outer, from meibomian glands
Water- middle, from lacrimal glands
Mucin- inner, Goblet cells
Optic= Afferent
OM+P= Efferent
Define Double Decussation
Where does this chiasm occur in the brain
When conducting an exam, what is the next step if vision is >20/40 and why?
Direct and Consensual response
Pretectal /Edinger-Westphal nuclei
Pinhole- establishes visual potential w/ or w/out glasses
What eye is tested first during VA
What are the next tests done if Pt can’t read chart
If Pt or chart have to be moved, what does 20/20 at 10ft equal to?
Right (OD), w/ correction if applicable
Count Motion Light None
20/20 at 10ft (on 20ft chart)= 20/40
When is Near Visual Acuity testing preferred
What distance is this method conducted at
What do abbreviations cc and sc mean?
Bed-ridden Pt
14-16”
cc- w/ correction
sc- w/out correction
What does this stand for- “DVA cc 20/20 OD, 20/40 OS”
Define Visual Impairment
Define Visual Disability
Distance Visual Acuity w/ correction 20/20 right eye, 20/40 left eye
Condition of the eye
Condition of individual
Visual Impairment to Visual Disability: 20/12 to 20/20= 20/25 to 20/70= 20/80 to 20/160= 20/200 to 20/400 - CF 10ft= CF 8ft to 4ft=
20/12 to 20/20= normal 20/25 to 20/70= near normal 20/80 to 20/160= moderate low 20/200 to 20/400 - CF 10ft= severe low/legally blind CF 8ft to 4ft= profound low
AF and Army flight physicals have ? many cardinal points
What are the 3 things being evaluated for
Why is dilated ophthalmoscopy not done if PT has shallow anterior chamber depth
AF- 6
Army- 8, add up/down
Paralysis Entrapment Weakness
Triggers angle closure glaucoma crisis
Medications used for dilation are called ?
What two effects do they cause
What are examples of each kind and how long they last
Mydriatics
Adrenergic stimulating- stimulate iris dilator
Cholinergic blocking- paralyze iris sphincter
Adrenergic: Phenylephrine- 3hrs
Cholinergic: max 20-30/45/90/45/40 Tropicamide- 2-6hrs Cyclopentolate- 24hrs Homatropine- 2-3 days Scopolamine- 4-7 days Atropine- 1-2wks
When conducting ophthalmoscopy, what are the five structures being assessed
Normal IOP range
What are the two ways to measure IOP
Macula
Red reflex
Optic disc (physiologic cup)
Retinal circulation/background
10-21mmHg
Hand held tono-pen w/ anesthetic (latex allergy check)
Non-contact tonometry (air puff)
How is Anterior Chamber Depth assessed
What finding indicates a shallow chamber is present
This means Pts are at risk for ?
Shine light from temporal side
2/3 or more of iris in shadow= shallow chamber d/t iris bowing forward
Angle-closure glaucoma
Define Emmetropia
Define Hyperopia
Define Myopia
Normal, objects at infinity are seen clearly w/ unaccommodating eye
Far sight, axial length is short, image falls behind retina
Near sight, axial length is long, image falls before retina
Define Astigmatism
Define Presbyopia
What type of laser is used during SMILE eye surgery procedures
Elliptical, refracting power of cornea and lens different across meridians (horizontal, vertical)
Loss of accommodation, progressive lens hardening prevent focus on near objects
Femto
How are visual disorders Tx w/ corneal refractive surgery
Why would Intacs be placed in eyes
Corneal Cross-linking procedures use ?
Conductive keratoplasty
Lasers (PRK LASIK SMILE)
Radial keratotomy
Irregular cornea
Riboflavin
What is a surgical complication from LASIK
Folds in the flap after surgery may cause eye problems depending on ? category
What is the equation for glasses Rx
Flap button holes- microkeratome
Complete, De-centered, Folds
Macro/Micro-striae
(Sphere) - (Cylinder) x (Axis)
What is the difference in Glasses Rx sphere
What is a cylinder used to correct
What does axis mean
Myopia (-)
Hyperopia (+)
Astigmatism
Astigmatism orientation in eye
What are the 3 types of eye deviations
When a tropia is congenital, what happens with the difference of eyes
Orthophoria- no deviation, eyes point in same direction w/ eyes open and closed
Heterophoria (phoria)- normal deviation, not present on un/cover, seen w/ alternating cover/uncover. Covered eye deviates (fusion broken)
Heterotropia (phoria)- both eyes deviated, seen w/ un/cover test
One eye suppressed to prevent diplopia development
Deviated most will have amblyopia (worse vision)
Phoria and Tropia AKA while ? prefix is not used when naming phorias
Define Strabismus and how is it confirmed on PE
Define Concomitant Strabismus
Phoria- latent
Tropia- manifest
Hypo- reference hyper eye
Misalignment of eyes, Cover-Uncover Test or Hirschberg
Non-paralytic- misalignment equal in all directions;
Leads to amblyopia and bad VA
Define Incomitant Strabismus
How are these tropias induced from vasculopathic tumors identified on PE depending on the cause
Misaligment of eyes varies w/ direction of gaze d/t nerve/mechanical restrictions
CN3: aneurysm; R eye straight, L eye down/out and dilated
CN4: congenital/trauma; R eye horizontally abducted, L eye horizontally adducted
CN6: cranial pressure; R eye straight, L eye adducted
Define Nystagmus and how many are there
Many Pts w/ this will suffer from ?
Nystagmus is classified into ? two general types
Involuntary oscillation of eye; 45 types
Partial sightedness or legally blind
Physiological- normally evoked
Pathological- congenital (<6mon) acquired (>6mon)
Nystagmus can also be classified by ? two movement patterns
What is the work up process for a nystagmus
How are these Tx
Pendular- equally paced in each direction
Jerk- slow drift w/ rapid return to origin
Hx (Drug Infancy Vertigo ETOH TBI FamHx)
Ocular exam w/ Ophth referral
Toxin screen
CT/MRI
Alternating nystagmus= Baclofen; not for Ped Pts
Severe/disabling= retrobulbar injection w/ botulinum
Define Amblyopia
What are the etiologies of Amblyopia
Defective vision w/out anatomic damage; “Lazy Eye”
Occlusion- ptosis, incorrect patching, cataracts
Refractive- anisometropia: large refractive difference
Strabismus- deviated eye becomes amblyopic
Organic- toxin, nutrional
How are suspected amblyopias worked up by age of identificaiton
What is a DDx that needs to be considered and what PE finding will be poor in these Pts
What vision result is of low concern
<2y/o= function
2-5y/o= VA w/ picture cards
Strabismus w/ light reflex/cover test
Epicanthus
Red reflex
2-5y/o w/ VA 20/40 w/ equal eyes
How are amblyopias Tx
Refractive- hyperopia more common; place image on retina
Obstruction: ptosis/cataract/scar correction
Strabismus: atropine/patch better eye 2-6hrs/day;
>11y/o- polycarbonate contact in good eye
Surgical correction w/ eyes are equal
What two structures are lateral to the medial canthus?
Define Ectropion and Entropion
Both can have ? Sxs d/t ? issues
Canthus - Caruncle - Plica semi-lunaris
Ect: Outward turning of lid
En: Inward turning of lid
Foreign Irritation Tearing Burning
Ect: punctual malposition
En: lashes abrading globe
What are the etiologies of Ec/Entropions
Both are Tx w/ ?
Ect: Paralytic- CN7 Involution- lower lid lag d/t age Cicatricial- lower lid scar Mechanical- mass on lower lid
Ent:
Involutional- lower lid lag d/t age
Cicatricial- scarring on conjunctival surface
Tx w/ surgery
Define Lagophthalmos
What are the Sxs Pts present w/ and why
What signs will be seen on PE
Inability to close eyes
Burning Foreign Irritation Tears- failure of lacrimal pump
Inability to close eyes
Exposure keratopathy
What are the etiologies of Lagophthalmos
How are these Tx
Proptosis Age induced lid laxity CN7 palsy (Bells palsy) Trauma scars Surgical correction of ptosis/blepharoplasty
Mild: tears/gel/ointment w/ tape at bedtime
Mod-Sev: Tarsorrhaphy until definitive gold weight surgically placed in upper lid
Define Ptosis
What Sxs do Pts present w/
What are the etiologies of this condition
Drooping upper lid
Obstructions
Cosmetics
Difficulty reading
Secondary amblyopia in kids
Myasthenia gravis- worse w/ upgaze Acquired (levator aponeurosis) Congenital malformation (levator muscle) Horners (Miosis Anhidrosis Ptosis) 3CN palsy w/ opthalmoplegia
How is Ptosis Tx
Define Blepharitis
What are the presenting Sxs
Tx primary condition
Congenital/Acquired- surgery tightens aponeurosis or resects levator muscle
Scaling of lid margins proximal to lashes
Burning Blurred Photophobia Irritation Epiphoria- excess tearing
What are the signs of blepharitis
What are the MC causes
Dandruff Erythema of lid margin Recurrent/mild conjunctivitis Manipulated meibomian glands Lost lashes Scales
Demodex- mites
Meibomian dysfunction- chalazia
Seborrhea- brow/scalp dandruff
Staph- hordeola
How is blepharitis Tx
Hordeolums are AKA ? and present as ?
Daily baby shampoo lid scrubs Warm compress x 10min w/ massage ABX: Erythromycin (Staph infection) Doxy (Meibomian dysfunction)- 1/4 dose taper over 6mon
Stye- painful nodule/pustule on lids
What are the signs of Hordeolums
What are the etiologies
How are these Tx
Erythematous nodule external to skin/internal to conjunctiva
Staph infection involving sebaceous glands
PO Doxy if w/ blepharitis Erythromycin ointment Warm compress w/ massage Surgical incision- compress/ABX fail x 4wks or, Pt requests rapid relief
What are the risks of performing surgical excision of hordeolum (styes)
What are the etiologies of chalazions
What are the S/Sxs
Scarring leading to en/ectropion
Lipogranulomatous inflammation from meibomian gland obstruction
Mildly tender, firm, demarcated lid nodule
Grayish discoloration on conjunctival surface
How are chalazions Tx
Define Dacryocystitis
What are the S/Sxs of Dacryocystitis
Warm compress w/ massage
Triamcinolone injection if persists x 4wks (c/i dark Pts)
Surgery- no resolution x 1mon= incision and curettage of meibomian gland
Inflammation of lacrimal sac
Mucopurluent d/c
Erythema
Painful tearing
Cellulitis, pre-septal
What are the etiologies of Dacryocystitis
How are these Tx or when is admission needed
When is surgical intervention needed and what is the name of the procedure
Bacterial infection
Nasolacrimal duct obstructed
Fever= IV ABX and admit Warm compress w/ massage Augmentin 500mg q8hrs InD if large Topical drops w/ PO ABX
Chronic or once acute episode is over:
Dacrycystorhinostomy- creates anastomosis between lacrimal sac and nasal mucosa via bony ostium
Define Dacryoadenitis
What are the S/Sxs
What is the un/common and rare etiologies
Inflamed lacrimal gland
Pain
Erythematous
Lateral lid swelling
Tearing
Common: Idiopathic
Uncommon: Autoimmune (Sacoidosis Vasculitis Sjogrens)
Rare: bacteria/viral (Mono/Mumps)
How is Dacryoadenitis worked up
How are these cases Tx
Autoimmune Hx
CT of orbit
Lacrimal gland biopsy
Unsure etiology= Systemic ABX w/ reassess x24hrs
Inflammation: Tx w/ PO steroids, response should be <48hrs
Infectious: Augmentin 250-500mg q8hrs or,
Cephalexin 250-500 q6hrs
? are the more common types of carinomas to affect the lids
Pts usually present w/ ? c/c
These are usually Tx by
B/SCC
ASx
Mohs removal (Basal) Radiation- unwilling/able to have surgery
What are the 3 types of conjunctiva
? is a common microbe etiology for viral conjuctivitis
What are the S/Sxs
Palpebral- covers inner eyelid
Fornix- meeting point of bulbar and palpebral
Bulbar- overs sclera
Adenovirus
Discomfort Redness Watering Sore
Contralateral side affected 3-7d later, less severe
What is seen on PE of viral conjunctivitis
What is the differentiator for this Dx
Why can Pts develop decreased vision and become photosensitive
Follicular response- small dome shaped lymphoid nodule w/ no central blood vessel
Tender pre-auricular adenopathy
Subepithelial infiltrates from response to viral Abs
How is viral conjunctivitis Tx
When/why would ABX be used
What Pt education piece needs to be given
Self limited
Cold compress
Artificial tears
Topical steroid- if SEI/pseudo/membrane
Secondary bacterial infection concern
Highly contagious
Since any bacteria can cause bacterial conjunctivitis, what are the 3 MC causes
What 3 must always be considered though
If one of these other 3 considerations is the cause, ? is the next step for the Pt
Staph A / Strep pneumo / H influenza
C trachomatis
N gonorrheoeae
N meningitidis
Opth ASAP- risk for gonococcal corneal ulcer perf
What are the S/Sxs of bacterial conjunctivitis
What can give these Pts the ‘hyperacute’ appearance
How are these cases worked up if Neisseria is the suspected etiology
Adhesion to lid
Irritation
Redness
Mucopurulent d/c
Gram stain, Culture
Other- broad ABX
How is non-gonococcal conjunctivitis Tx w/ ABX
How are these Tx if Neisseria spp and Chlamydia are the cause
What is done different if corneal involvement exists w/ Neisseria spp/Chamydia etiolgies
Trimethoprim/Polymyxin B QID x 7d
Besi/Moxi-floxacin QID x 7d
Ceftriaxone 1gm IM (PCN allergy= Cipro 500mg x 5d)
Azithromycin 1g PO x 1 or,
Doxy 100mg bid x 7d
Admit w/ Ceftriaxone 1g IV q12-24hrs
Topical Fqn
Allergic conjunctivitis can be caused by ? type of hypersensitivity
What are the S/Sxs of Allergic Conjunctivitis
Type 1
Chemosis Conjunctival papillae w/ prominent central blood vessel D/c, watery/stringy Intense itch Conjunctival injections Erythema/edema
How is Allergic Conjunctivitis Tx w/ topical meds depending on severity
What PO anti-histamines can be used
Mild- artificial tears
Moderate- Topical antihistamine/mast cell stabilizer (Olopatadine/Ketotifen)
Severe- topical steroid (Loteprednol)- q2hr x 2d, then QID x 7d, then BID x 7d
Cetirizine
Diphenhydramine
Fexofenadine
How do Subconjunctival Hemorrhages present
What are the six possible etiologies
What two meds need to be asked about in the Pt Hx
ASx in one sector, possibly whole sclera
HTN - Valsalva
Trauma - Orbital mass
Bleeding d/o - Idiopathic
Warfarin, ASA use
How are Sub-conjunctival Hemorrhages worked up
What are the 3 indications to get a CT to r/o masses
How are these Tx
BP IOP Coags EOM
Restriction EOM
Elevated IOP
Proptosis
Artificial tears for irritation
D/c ASA if elective
Define Pinguecula and Pterygium
What regions are these PTs commonly from
How are the two differentiated
White-yellow bump on conjunctiva at the 3 or 9 o’clock positions
Equitorial w/ dry/sun exposed living
Ptery- invades cornea
Ping- doe not invade
What S/Sxs can be seen in Pingueculas and Pterygium cases
How are these Tx
When is surgery indicated
Redness
ASx, typically
Dec vision
Artificial tears
Severe= topical steroids
Pterygium interferes w/ sight or close to visual axis
Excessive irritation reported
Define Phlyctenule
What causes these to grow
If these can’t be referred, tx at primary level w/ ? Rx combo
Nodule growth at limbus
Hypersensitivity to Staph proteins
Tobra and Dexameth/Lotaprednol
Define Conjunctival Nevus
Rarely these can progress into malignant melanoma, ? population does this occur in and what PE finding indicates it
Why would a biopsy be warranted and all suspicious lesion need ? done to them
ASx benign pigmented lesion, freely mobile over sclera
Middle age - elderly
Blood supply through conjuctiva
Growth/change in appearance
Resected
What are the 3 main concerns for Pts w/ conjunctival lacerations
What work up is done for these w/in the eye clinic
How are conjunctival lacerations Tx
Ruptured globe
Foreign body- intra-ocular/orbital
Fluorescein stain Ocular exam R/o scleral involvement Dilated fundus CT consideration
<1cm= Erythromycin TID and monitor >1cm= surgical closure
Thyroid Eye Dz is AKA ? and seen in ? conditions
This eye condition can precede or follow ? Dx by years
This Dx claims ? MC fact about adult health
Graves Ophthalmopathy- Hyper/Hypo/Euth-thyroid
Glandular Dz
MC cause of bi/uni-lateral proptosis in adults
What do Thyroid Eye Dz Pts present w/ as c/c early in condition
What are late c/cs
Photophobia Redness Tearing Burning Puffy lids in AM
Persistent swelling
Chemosis
Double vision
What are the sings of Thyroid Eye Dz
What is done for this condition’s work up and f/u
How is the Dz confirmed w/ imaging
Acuity/field loss Lagophthalmos Lid retraction Exophthalmos Swelling Restricted motility
Thyroid panel
Normal= careful monitoring
CT
How is mild Thyroid Eye Dz Tx
What are the 3 classifications of conjunctivitis and predominant Sx for each
Cornea is the primary ? element of the eye, so any injury to it results in ?
Artificial tears
Tape eyelid
Elevate head at night
Viral: adenopathy
Bacterial: d/c
Allergic: itching
Refractive, Visual impairement
Define Keratitis
What are the layers of the cornea from out to in
Corneal erosions are damage to ? layer but can be stained w/ ? for evaluation
Inflammation of the cornea
Epithelium Bowman's membrane Stroma Descements membrane Endothelium
Epithelium, NaFl- Seidel’s sign
Corneal erosion is the result of ? three things?
Corneal ulcers are damage to ? layer
How does the difference in pain indicate the cause of the ulcer
Dryness
Inflammation
Exposure
Stromal
Bacteria/Fungal- painful and aggressive
Sterile infiltrate- minimal pain on peripheral cornea secondary to contact lens wear
What are the S/Sxs that corneal ulcers can present w/
What visual finding may be seen on PE
What are five facts about sterile ulcers
Hypopyon D/c Tearing Pain Injection Photophobia
Focal white opacity on cornea
Dense= corneal infiltrates
Less painful
Minimal-no d/c
No iritis, corneal edema, infiltrates
What are the Sxs of Herpes Simplex Keratitis
What is unique about the symmetry of this condition
What will be seen if you stain Herpes Simplex Keratitis
Conjuctival injection
Redness
Irritation
Photophobia
98% unilateral
Epithelial dendrites
Advanced- stromal scarring/vascularization
How is this Herpes Simplex Keratitis Tx
Define Bacterial Keratitis
What are the 5 MC causes
Refer
Avoid topical steroids (possible perf)
Topical/PO anti-virals
Bacteria colonization on cornea that interrupts intact epithelium leading to proliferation and ulceration
Pseudomonas Moraxella Serratia Staph Strep
Bacterial Keratitis is MC seen in ? populations
What other etiologies can cause this
Contact lens wear especially if over night wearer
Compromised Immune defenses Aqueous tear deficiency Recent corneal dz Trauma Structure changes of eyelid
What are the signs of Bacterial Keratitis
What are the Sxs and are also identical w/ ? Dx
How is Bacterial Keratitis Tx
Ulcerated epithelium Anterior chamber reaction Hyperemia Adherent exudate Corneal infiltrate Edema
Pain Red Photophobia D/c
Fungal keratitis
Topical Flqn
Tobra/Cipro-mycin- contact lens wear w/ d/c of wear
Refer to Opto/Ophtho for culture
Vision threatened= fortified ABX q30min
What causes Fungal Keratitis
What chronic/long standing condition can cause this
What is the MC and other Signs of Fungal Keratitis
Contact use
Outdoor eye trauma w/ vegetation
Recent surgery (cataract/refractive)
Topical CCS
Chronic keratitis secondary to ocular Dz (herpes)
Anterior chamber reaction
Conjunctiva injection
MC- Epithelial feathery white opacity
Fungal Keratitis can be confused w/ Bacterial Keratitis, how is fungal differentiated
How is the Fungal form Tx
What Tx needs to be avoided
Bacterial= yellow-white
Culture
Surgical debridement- debulking, inc ABX penetration
Topical Natamycin/Amphotericin B
PO Flu/Vori-conazole
No topical steroids
Corenal pigmentation is usually drug related to ? drugs
What is the good news about this Dx
How is it Tx
Amiodarone- whirl shaped deposits
Hydroxy/Chloroquine- corneal deposits
Indomethacin
Phenothiazine
Rarely causes vision loss
D/c drug
What is the etiology of Recurrent Corneal Erosions
Recurrent Corneal Erosion is commonly caused by ? and also caused by ?
How does this condition present
Poor epithelial adhesion
Dog claws
Degeneration/dystrophy
Middle night/morning pain- Pain Blurry vision Redness "sharp pain w/ opening eye" or "felt like eyelid was stuck onto front of eye"
What are early and late signs seen in Recurrent Corneal Erosions
How are these Tx
What can be done for Pt to ease accomodative spasms of the eye
Early: epithelial defects w/ fluorscein
Late: cornea irregularity
Tx abrasion first: Muro128 qid (hypertonic Na ointment)
Bandage contact lens if large area
Severe= laser surgery
Dilation
Define Keratoconus
What will Pts present w/?
Severe cases may have to be Tx w/ ?
Dz of unknown etiology causing thinning of central cornea
Increased myopia Irregular astigmatism (poor vision even w/ glasses)
Corneal transplant
What two PE sign is associated w/ Keratoconus
Define Arcus Senilis
Since this is usually d/t age related changes, ? underlying Dx is suspected if Pt is younger
Munson- bulging lower lid from thinning cornea
Vogt Striae
Gray/White/yellow deposits on peripheral cornea
Abnormal hyperlipoproteinemia
<40- check systemic lipids
What do PTs report w/ if they have Arcus Senilis
What will be seen on PE to solidify Dx
What are the functions of the sclera
No effect on vision
Clear area between deposit and limbus
Protection from in/out forces
Attachment site for EOMs
Sclera is composed of what two layers
It is made up by what two components
How thick is it and where is it the thickest
Outer- episclera: loose vascular tissue w/ visible vessels
Inner- stroma
Collagen
Elastic fibers
0.3mm-1.0mm, thickest at posterior aspect
Episclera joins to ? capsule via strands of tissue
What is the function of this capsule
Episcleritis is more prevalent in ? population and commonly d/t ? but can be from ? d/os?
Tenon’s capsule- dense CT that encases globe
Sheaths for tendons at EOM insertions
Young adults, idiopathic Herpes zoster Rosacea Syphilis Collagen dz (RA, SLE) Thyroid dz
How does Episcleritis present to clinic
What is absent on this presentation
How are these cases worked up
Hx of episodes
Acute redness w/ mild, localized pain
Normal VA
Sectorial, engorged episcleral vessels
No d/c
Hx: rash arthritis STD
External exam
Slit lamp w/ anesthesia
What are two findings on PE that differentiate Episcleritis as the Dx from other possibles
How is this condition Tx
Half of Scleritis cases are idiopathic and the other half are d/t CT Dzs like ?
Injected vessels moved w/ CTA
Phenylephrine x 15min= episcleral blanching (scleritis won’t blanch)
Refer for Dx confirmation
Mild: Tears Cold compress
Mod-Sev: Topical steroids (Fluorometholone, Loteprednol) and PO NSAID
Wegeners Relapsing polychondritis AS Polyarteritis nodosa RA SLE
Other than the CT Dzs, what are the other RFs for developing Scleritis
On average, these Pts are different from those that get Episcleritis in what way
What is the prominent feature of this condition
Gout
Infection (Herpes, Zyphilis)
Trauma
Older
Severe, boring eye pain that radiates to jaw/forehead
Other than the prominent Sx, what other S/Sxs can Scleritis present w/
How is this condition worked up
Tearing Bluish-hue (necrotizing anterior) Decreased vision Inflammation Photophobia
Pheylephrine topical (won’t blanch)
Slit lamp w/ green light- avascularization indicates necrotizing
Fundus exam to r/o posterior scleritis
Skin Joints Cardio Resp
What are the five Scleritis classifications
Diffuse Anterior: widespread inflammation in anterior segment
Nodular Anterior: immovable inflamed nodules
Necrotizing Anterior w/ Inflammation: extreme pain, associated w/ systemic Dz
Necrotizing Anterior w/out Inflammation: ASx, associated w/ longer Dz, esp RA
Posterior Scleritis- unrelated to systematic Dzs
How is Diffuse/Nodular Scleritis Tx
What is the next step if there is no improvement
What medication is used if immuno-suppressive therapy is needed
All refer to Ophthalmology
NSAIDs
H2 blocker (Ranitide)
No improvement w/ NSAID= PO Prednisone
Clophosphamide
How is Necrotizing Scleritis Tx
Since the Tx of Posterior Scleritis is similar to Diffuse/Nodular, what are the risks associated with the therapy methods
Graft patch if perf present NSAID/Prednisone Clophosphamide Ranitide Refer- Rheum
Cyclophosphamide- toxicity
Rituximab- empirical
Glucocorticoids
What are the 3 parts of the uveal tract
Define Uveitis
What are the three types of uveitis
Iris- only visible part
Ciliary body- produces aqueous humor
Choroid- behind sclera and retina, blood supply to retina
Inflammation of the uveal tract
Anterior Intermediate
Posterior
Anterior Uveitis is synonymout w/ ? two words
What are the associated RFs for this Dx
Iritis and Iridocyclitis
Infection (Syphillis, TB) Malignancy (Lymphoma) JA Other (Sarcoidosis Idiopathic Trauma Surgery) Syphilis/TB HLA-B27 pos (AS, Reiters)
What are the S/Sxs of Anterior Ubeitis
This condition can present with keratic precipitates, what are the two types and what etiology does each have
Irregular pupil Flare- proteins in aqueous Hypopyon- cell collection at bottom of anterior chamber Nodules- Koeppe/Busacca Redness Injection/flush Photophobia Floating cells
Fine/white= non-granulous
Mutton Fat= granulomatous)
Lab work is needed during an Anterior Uveitis work up, especially during ? types
What labs are needed
Bilateral Granulomatous Recurrent
CXE HLA-B27 ESR ACE PPD RPR/VDRL FTA
How is Anterior Uveitis Tx depending of the severity
What topical steroid is used for Tx?
What is the prognosis for these Pts
Cycloplegics-
Mild-Mod: Scopolamine
Severe: Atropine
Prednisolone
First time non-granulomatous= excellent
Recurrent granulomatous= poor
Trifecta of what three conditions makes up Posterior Uveitis
What is the MC microbe to cause this condition in healthy/AIDS Pts
What other infections can cause this
Vitreitis Choroiditis Retinitis
Healthy: Toxoplasmosis
AIDS: Cytomegalovirus
Toxocariasis
TB
Syphilis
What are the S/Sxs of Posterior Uveitis
What is the most severe infection of the eye
Who is it seen in and what is the prognosis
Floaters
Inflammatory
Swelling w/ edema of disc
Hemorrhages
CMV retinitis
CD4 <100
Blindness <6mon
Posterior Uveitis/CMV retinitis is seen in ? other ImmComp states other than AIDS
What is uncommonly reported in Pts w/ CMV Retinitis
What Sxs may be reported
Transplant
Lymphoma
Leukemia
Pain/Photophobia
Dec vision
Floaters/Flashes
Scotomata
What is the MC sign seen in CMV Retinitis
What other signs may be seen on exam
How is this Tx
Cotton-wool spots
Keratic precipitates (stellate shapes) Vitreous cells Hemorrhages w/ retinal whitening= necrosis
W/ IDz Provider
HAART
PO Valganciclovir 900mg BID x 3wks then 1/day
How is Posterior Uveitis Tx
What part of the body has the highest protein concentration
However, this structure lacks ?
Tx systemic Dz
Anterior involvement= topical steroid w/ cycloplegic
Ophth referral
Lens
No vessels or nerves
What are the 3 layers of the lens and their responsibilities
Capsule- thin, semipermeable membrane around entire lens; Molds the lens during accommodation
Cortex - anterior and posterior; Produces fibers for life;
Held by zonules equatorially for accomodation
Nucleus
