Opto 2.0 Flashcards

1
Q

What are the 7 essentials of an eye exam

What parts are examined at a minimum

A

DIPLOMA
Depth IOP Pupils Lamp Ophthalmoscopy Motility Acuity

P-DIVE
Pupil Direct ophth IOP VA EOM

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2
Q

Eyelids are AKA, seperated by ? and meet at the ?

What are their two functions

What structures do they contain

A

Palpebrae, Palpebral fissure, Canthus

Protection
Lacrimal aid- spread new/pump old

Meibomian glands

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3
Q

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

A

Closes eyelid, CN7

Opens upper eyelid, CN 3

Opens upper/lower lid during fear/surprise via sympathetic ANS

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4
Q

What are the 3 spheres (tunics) of the globe

Define Cornea

Define Limbus

A

Fibrous Vascular Nervous

Front window of eye, 2/3 of eye refractive surface (other 1/3- lens)

Sclera and cornea junction

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5
Q

What are the two muscle of the pupil what innervates each muscle

Define Conjunctiva and the two types

Define the Ciliary Body

A

Sphincter- Parasympathetic ANS
Dilator- Sympathetic ANS

Clear membrane covering
Palpebral- eyelid
Bulbar- sclera

Produces aqueous humor
Contains ciliary muscles- alter zonular to change lens

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6
Q

What is the main function of the Ciliary Muscles

Define Choroid

What does this structure provide blood to

A

Near focus- accommodation

Pigmented and vascular layer between retina and sclera, provides blood to retina

Outer retinal layer

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7
Q

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

A

Between cornea and iris- aqueous humor and drainage

Behind iris, in front of vitreous
Aqueous humor

Biconvex; Zonules

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8
Q

Vitreous Humor is transparent gel made of ?

What function does it perform

Retina is the ? liner and referred to as the ?

A

Collagen Protein Hyaluronic Water

Maintains structures

Neural lining, fundus

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9
Q

How many layers of the retina are there

What structures are contained here

What are the two types

A

10 layers, 9 are transparent

Photoreceptors- send signals to brain

Cones- color, visual acuity (6mill/eye)
Rods- black/white, night vision (120M/eye)

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10
Q

Define the Macula and it’s function

What is the name of the central depression in the macula

What is contained here

A

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

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11
Q

Define the Optic Disc

What is the Disc AKA

What are the extra-ocular muscles

A

Nerve/vessels converge and leave eye

Physiologic/anatomic blind spot x 15* temporal

4 rectus (Superior Lateral Inferior Medial)
2 obliques (Superior Inferior)
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12
Q

What movements are the 6 extra-ocular muscles in charge of

What is the term that describes how these muscles work

A
IO: extortion, elevation
SO: intorsion, depression
SR: elevation
LR: abduction
IR: depression
MR: adduction

In tandem, yoked: ipsilateral opposing muscle relaxes

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13
Q

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?

A

Oil- outer, from meibomian glands
Water- middle, from lacrimal glands
Mucin- inner, Goblet cells

Optic= Afferent

OM+P= Efferent

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14
Q

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?

A

Direct and Consensual response

Pretectal /Edinger-Westphal nuclei

Pinhole- establishes visual potential w/ or w/out glasses

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15
Q

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?

A

Right (OD), w/ correction if applicable

Count Motion Light None

20/20 at 10ft (on 20ft chart)= 20/40

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16
Q

When is Near Visual Acuity testing preferred

What distance is this method conducted at

What do abbreviations cc and sc mean?

A

Bed-ridden Pt

14-16”

cc- w/ correction
sc- w/out correction

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17
Q

What does this stand for- “DVA cc 20/20 OD, 20/40 OS”

Define Visual Impairment

Define Visual Disability

A

Distance Visual Acuity w/ correction 20/20 right eye, 20/40 left eye

Condition of the eye

Condition of individual

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18
Q
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=
A
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
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19
Q

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

A

AF- 6
Army- 8, add up/down

Paralysis Entrapment Weakness

Triggers angle closure glaucoma crisis

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20
Q

Medications used for dilation are called ?

What two effects do they cause

What are examples of each kind and how long they last

A

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
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21
Q

When conducting ophthalmoscopy, what are the five structures being assessed

Normal IOP range

What are the two ways to measure IOP

A

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)

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22
Q

How is Anterior Chamber Depth assessed

What finding indicates a shallow chamber is present

This means Pts are at risk for ?

A

Shine light from temporal side

2/3 or more of iris in shadow= shallow chamber d/t iris bowing forward

Angle-closure glaucoma

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23
Q

Define Emmetropia

Define Hyperopia

Define Myopia

A

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

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24
Q

Define Astigmatism

Define Presbyopia

What type of laser is used during SMILE eye surgery procedures

A

Elliptical, refracting power of cornea and lens different across meridians (horizontal, vertical)

Loss of accommodation, progressive lens hardening prevent focus on near objects

Femto

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25
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
26
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)
27
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
28
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)
29
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
30
# 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
31
# 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)
32
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
33
# 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
34
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
35
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
36
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
37
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
38
# 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
39
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
40
# 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 ```
41
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
42
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
43
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
44
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 ```
45
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
46
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
47
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
48
# 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)
49
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
50
? 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 ```
51
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
52
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
53
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
54
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
55
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
56
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
57
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 ```
58
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
59
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
60
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
61
# 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
62
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
63
# 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
64
# 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
65
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 ```
66
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
67
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
68
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
69
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
70
# 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
71
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
72
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
73
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
74
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
75
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 ```
76
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
77
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
78
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
79
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
80
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" ```
81
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
82
# 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
83
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
84
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
85
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
86
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 ```
87
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
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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 ```
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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
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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
91
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
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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
93
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
94
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
95
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) ```
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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)
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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 ```
98
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
99
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
100
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
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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
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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
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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
104
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
105
What is the MC RF for cataract development What are the systemic RFs What is the toxic RF What are the secondary RFs for cataract development
Age related DM Myotonic dystrophy NF-2 Steroids ``` Chronic anterior uveitis Acute congestive angle closure Pathological myopia Degenerative dz (Retinitis pigmentosa) Ionizing radiation Ciliary body tumor ```
106
# Define Nuclear Sclerosis Cataract What term is given for the visual changes these Pts experience Define Posterior Subcapsular Cataracts
Yellow/brown discoloration of nucleus causing blurry distance vision Second site of the aged- more myopic Near vision improves Opacities near posterior lens (Vacuoles, Plaque-like) Near vision decreases
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What are common complaints in Pts w/ Posterior Subcapsular What are the causes for this condition
Glare Difficulty reading ``` DM Ocular inflammation Age <50 Steroids High myopia Ionizing radiation Trauma ```
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# Define Cortical Cataracts What c/c do Pts present w/? What is the MC complaint
Radial/spoke-like opacities (Vacuoles, Cuneiform) ASx until central progression Glare
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What is the MC complaint from Pts w/ cataracts What type of vision can they develop What benefit may these Pts report
Glare w/ oncoming headlights Monocular diplopia Decreased color perception Thickening lens causes "second sight"
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What would prevent Pts w/ cataracts from developing "second sight"? How are cataracts Tx What short term relief trial can be attempted w/ these Pts
Posterior subcapuslr decreases near vision d/t opacity at central lens degrades visual quality Early= Sptectacles Small, central= pupil dilation Large= surgery Pt declines= refractive error correction Mydriasis- scopolamine
111
What are the indications to conduct cataract surgery What are the biggest concerns for Pts going into surgery
To improve visual field Manage ocular Dzs (Glaucoma DRetinopathy AMD Infant deprivational amblyopia) ``` Uncontrolled DM/HTN Anesthesia issues Respiratory dz Anxiety Tremors Epilepsy Recent MI/Stroke ```
112
What is the MC cause of congenital cataracts What are the RFs What is the potential sole manifestation of congenital cataracts
Idiopathic ``` Familial w/ autosomal dominant Chromosomal d/o Galactosemia Intrauterine infection Rubella Lowe syndrome ``` Galactosemia
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What are the different types of Congenital Cataracts
Coronary- deep in cortex around nucleus, like a "crown" Lamellar Anterior polar- flat and insignificant Blue dot- common and innocuous Sutural- along y-suture
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How can Congenital Cataracts present What Hx piece is important during the work up Why is this a Congenital Cataract in infants a surgical emergency?
Infant squinting/keeping eyes shut Abnormal/absent red reflex (Leukocoria) Maternal illness Brain learns to see w/ macula during first 3-4mon of life Surgery prevents irreversible deprivational amblyopia
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What are the two types of Lens Position Anomalys
Subluxation- partial zonular disruption; lens is decentered but partially visible in pupil apperature Dislocation- complete disruption of zonular fibers; displaced out of neutral position in posterior chamber
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What is the MC cause of Lens Position Anomaly What are the other RFs
Trauma- subluxation, 25% or > of fibers are ruptured Marfans- superotemporal subluxation w/ retained accommodation Homocystinuria- inferonasal subluxation/dislocation w/ lost accommodation Other- Acquired syphilis High myopia Ehlers-Danlos
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What are the S/Sxs of Lens Position Anomaly
Monocular diplopia Angle closure glaucoma Iridodonesis (iris quivers) Decentered lens Dec vision Irregular astigmatism Cataracts Asymmetric anterior chamber Phacodonesis (lens quivers)
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? screening test needs to be added to Lens Position Anomaly work ups? How are Lens Position Anomalys Tx by Ophthalmologist
Syphilis Dislocation into anterior chamber- Head manipulation; risk of indenting cornea Surgery Dislocation into vitreous- ASx= observation Surgery Subluxation- Surgery only if Sxs
119
What causes Pts to see floaters What are the possible Dxs if these onset acutely What causes Pts to see flashes
Benign vitreous opacities in vitreous cavity ``` Foreign body Bleeding- DM/Sickle Cell anemia Uveitis- intermediate/posterior Retinal tear Posterior vitreous detachment ``` Traction of vitreous on peripheral retina
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What will be seen if Pts also reports floaters while also having flashes What two types of flashes can be reported that occur w/ migraines
Blood/pigment in vitreous Scintillations Zig-Zag lights
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What are the RFs for Posterior Vitreous Detachments What are the S/xs of this condition How is it Tx
Pesonal/FamHx of tears Intraocular surgery Trauma High myopia Sudden onset black spots/flashing lights Floaters Weiss ring- vitreous opacity in ring shape Photocoagulation Cryotherapy Refer
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What are the Sxs of Vitreous Opacities What are the RFs What type of imaging is needed during Vitreous Opacity work up and why
Floaters, Dec vision ``` DM Acute PVD Retinal vein occlusion Trauma Vasculitis ``` B-scan US- excludes retinal tear/detachment
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Depending on the severity, how are Vitreous Opacities Tx Why is the fovea darker than the surrounding retina and what reflex can be seen here
Vitrectomy Lacks vascularity, Foveolar light reflex- yellow reflex at center of fovea
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In order to view peripheral retinal structures, ? technique is needed Where is the optic nerve viewed at when looking into eye What is the atery/venous make up in this location
Indirect ophthalmoscopic Nasal portion of retina A:V ratio= 2:3 Arteries- thinner, orange/red Veins- larger, crimson A/V cross each other; V/V or A/A don't cross
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What structures supply the retina w/ blood The retina is mostly transparent, but it's epithelium pigment may be called ? colors What does the inner retina contain
Central retinal- inner retina Choroid- outer wall, photo receptors (higher O2 demand) Lightly blond/brunette Nerve fiber layer Ganglion cell nuclei Retinal vasculature
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Axons from the inner retina extend though ? and into ? for ? end result Conditions that cause ischemia will impact ? area of the eye These condition manifest in ? layer
Through optic nerve/chiasm To lateral geniculate nucleus To midbrain for pupillary response Inner retina Nerve fiber layer
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Retinal artery occlusions may involve ? two structures What type of vision loss will be experienced Usually, ? structure will be spared meaning ? vasculature is spared
Central retinal artery- CRAO Branch of retinal artery- BRAO Horizontal hemifield loss Macula- cilioretinal arteries arising from choroidal supply
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What are the RFs for Retinal Artery Occlusions (CRAO) What are the S/Sxs of CRAO What structure may show small portions of sparing
Giant cell arthritis Thrombus/Embolus Collagen-Vascular Dz (SLE) Hypercoagulation (OCP) ``` Hx of Amaurosis Fugax Opacified/white retina (BRAO too) Painless, unilat w/ rising in AM (BRAO too) Cherry red macula (BRAO= emoblus) Afferent pupillary defect (not BRAO) Box-car arterioles (BRAO too) ``` Cilioretinal artery- not spared in BRAO
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What is the prognosis for Pts w/ CRAO Pts w/ CRAO need monitoring for neovascularization in ? areas What are the S/Sxs of Branch Retinal Artery Occlusions
Poor d/t retinal infarction- over time, retinal cloudiness and cherry spots disappear Retina Angle Iris Disc Sudden altitudinal/sectoral field loss
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What is the prognosis for these Pts w/ BRAO What is different about the future events for PTs w/ BRAO compared to CRAO What lab work is immediately ordered for CRAO/BRAO work ups and why
Poor unless relieved, field defect will be permanent CRAO- rarely have neovascularization ESR CRP Platelets R/o GCA if Pt >55y/o
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How are CRAO/BRAO Tx What structures do Retinal Vein Occlusion effect and how do they present What type of vision loss do Pts report w/
Paracentesis Ophthalmic timolol PO Acetazolamide Ocular massage Central Retinal Vein Branch of Retinal Vein Horizontal hemi-field loss w/ respect to horizontal midline
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What is the physiological reason for RVO conditions
Thickening arteriole compresses on vein causing stagnant blood outflow
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What are the RFs for Retinal Venous Occlusions
Hyperlipids Age >65 DM Vasculitis HTN Glaucoma OCPs Tobacco Hypercoagulability Platelet abnormalities Atherosclerosis in adjacent central retinal artery Disc edea/drusen
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What are the S/Sxs of Ischemia CRVO What are the S/Sxs of Non-Ischemic CRVO Of the two types, ? type is more common
Sudden painless unilateral loss of vision Afferent pupil defect Count fingers or worse Poor VA, >20/400 Absent/mild afferent defect Non-Ischemic
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What will be seen on fundoscopic exam of CRVO What will be seen on fundoscopic exam if it's Ischemic CRVO What will be seen on fundoscopic exam if it's non-ischemic CRVO
Dilated, torturous veins Blood-and-Thunder fundus- dot, blot, flame hemorrhage w/ cotton wool spots and exudates Dilated optic disc Prominent cotton-wool spots Extensive retinal hemorrhage Neovascularization of iris/angle glaucoma Mild fundus changes
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What are the prognosis for the CRVO types
Ischemic- poor, half develop neovascularization of iris but retinochoroidal veins may be spared Non-ischemic- later develops into ischemic or chronic macular edema
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S/Sxs of BRVO What will be seen on fundoscopic exams What is the prognosis for these Pts
Sudden, painless unilateral vision loss Superficial hemorhages affect vision but don't cross horizontal midline Cotton wool spots Dilated-tortured veins Narrowed adjacent artery Retinal neovascularization Good- more than half develop collateral vessels to improve VA
138
What are the complications that threaten recovery from BRVOs What is the work up for RVOs
Chronic macular edema Neovascularization located other>disc Other locations cause hemorrhages and tractional detachment of retina BP Ocular exam IOP Afferent defect to differentiate non/ischemic Systemic Hx Blood: CBC ESR Glucose Plasma protein electrophoresis
139
How are RVOs Tx How is RAO Tx
``` DONAD D/c OCPs Opth referal <72hrs Neovasc= anti-VEGF, PRP ASA Dec IOP if needed ``` ``` Ophtho referal then POPO: Paracentesis Optic Timolol PO Acetazolamide Ocular massage ```
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What is the leading cause of blindness in the US for PTs age 20-64 These Pts must have ocular eval to establish baseline w/in ? months of Dx What is the difference in retinopathy prevalence between T1DM and T2DM when newly diagnosed
DM <6mon 1- rare 2- may have But prevalence T1>T2
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What are the RFs for DM
``` Duration- rarely starts 5yrs before/after puberty Poor control Pregnancy- progression linked to 1st-T HTN Nephropathy ```
142
What two hormonal times can influence the acceleration of diabetic retinopathy What are the two classifications of diabetic retinopathy
Pregnancy Puberty ``` Non-proliferative- IRMA Cotton-wool spots Hemorrhages Exudates Mircoaneurisms ``` Proliferative- Late stage, new vessels grow at disc
143
What are the blood vessel changes seen during diabetic retinopathy How does dec VA develop in these PTs
Microaneurysms- inc permeability Endothelium tight junctions- blood-retina barrier Aneurysms have incompetent blood-retina barrier Intravascular fluids leak int retinal tissues Accumulation occurs in fovea
144
What are the 4 severity levels of Non-Proliferative Diabetic Retinopathy
Very Mild- microaneurysms only Mild- Microaneurysms Exudates CWSpots Mod- 20 med-large retinal hemorrhages in 1-3 quadrants or, Mild IRMA Severe- 4-2-1 Rule: 4 quadrants of severe retinal hemorrhages 2 or more quadrants of venous beading 1 or more quadrant of moderate IRMA
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Proliferative Diabetic Retinopathy results from ? ? other issue will be seen that can develop in ? locations What are these Pts at recurrent incident risk for
Ischemia- dec perfusion causes angiogenic factor (VEGF) release to stimulate growth of new vessels ``` Neovascularization- Iris Disk Retina Into vitreous Vascular acrades- MC ``` Fragile vessels= recurrent hemorrhages
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What are the Sxs associated w/ Proliferative Diabetic Retinopathy What are the signs of this condition seen on PE
Unaware of changes even w/ 20/20 vision Floaters- secondary to hemorrhages, described as shower Scotoma ``` Boat shaped hemorrhages Absent red reflex Dot/blot hemorrhages Lacy vessels CWSpots ```
147
How is Diabetic Retinopathy worked up
``` Fasting blood glucose A1C CBC w/ diff Hgb electrophoresis CXR Carotid US Annual fundoscopic exam ```
148
How is Non-Proliferative Diabetic Neuropathy Tx What are the S/Sxs of Diabetic Macular Edema
Glycemic control +Neovascular changes= Anti-VEGF , PRP ``` Gray/opacification of retina ASx Microaneurysms Exudates- yellowish w/ discrete borders Dot-blot hemorrhages ```
149
# Define Retinitis Pigmentosa What is the pathophysiological reason for this condition What do these Pts report as c/c
Group of retinal degenerations d/t inherited genetic defects Lost photoreceptors, rods first Retinal pigment epithelium changes ``` Night blindness (nyctalopia) Peripheral vision loss Photopsia Lost color vision Scotoma ```
150
What may be seen on PE fo Retinitis Pigmentosa What is done for a work up How is Retinitis Pigmentosa Tx
``` Bone-spicule retinopathy Anterior narrowing Normal fundus Golden ring sign- yellow/white halo around disc Posterior subcapsular cataract Optic nerve pallor ``` Electroretinography ``` Vitamin Supplements (ADEK) Low vision aids ```
151
# Define Retinal Detachment What are the 3 types
Retina seperates from pigment epithelium d/t fluid in space Rhegmatogenous- break/tear, common in myopic eyes (higher Rx=higher risk) Exudative- leakage w/out break; tumor below retinal layer Tractional- contraction of fibers on retina; Proliferative Diabetic Retinopathy/Retinopathy of prematurity
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Flashes and Floaters are only seen in ? type of retinal detachment What do Pts report during PE How are these worked up
Rhegmatogenous Curtain/shade pulled down Metamorphopsia- wavy/distorted vision Refer for complete dilated ocular exam Red reflex assists w/ Dx- detachment= lighter reflex
153
How are Retinal Detachments Tx What is the MC cause of legal blindness in in PTs >60 What are the two types
Rhegmatogenous- Pneumatic retinopexy, Scleral buckle Traction- Pars plana vitrectomy ARMD Non-exudative (dry) Exudative (wet)
154
? is the MC abnormality in ARMD What does the abnormality change in the eye What are the RF for developing ARMD
Drusen Yellow deposits deep in retina Limits nutritional support to photoreceptos in outter retina ``` Female Lighter pigmentation Older age Genetics Smoking ```
155
S/Sxs of Dry AMD What will be seen on fundoscopic exam What are S/Sxs of Wet AMD What will be seen on fundoscopic exam
Gradual loss of central vision Macular drusen w/ clumps of pigment in outer retina Metamorphopsia- distorted lines Rapid central vision loss Drusen Chroidal neovascularization Subretinal hemorrhages
156
What are the RFs for progressing from Dry to Wet AMD
Hyperopia Pigment clumps HTN ``` FamHx Large ill-defined drusen Age Blue eyes Smoking ```
157
What is done for AMD work ups
Amsler grid test- degree of central field loss, done daily during f/u and periodic after IV Fluorescein angiography- if sub-retinal neovascular membrane present/suspected Macular slit-lamp eval
158
How is Dry AMD Tx How is Wet AMD Tx
High dose Vit C E Beta-carotene Zinc (AREDS) Smokers= non-beta carotene Anti-VEGF intravitreal injection Laser photocoagulation <72hrs from angiography
159
What is the hallmark of HTN Retinpathy What does the A:V ratio change to What two metal findings may be seen in vessels and what do they mean
Diffuse anteriolar narrowing causing vessel walls to be virtually invisible 1:3-1:4 Copper wire- narrowing anteriolar, yellowing of linear light reflex Silver Wire- sclerosis of vessel
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What are the Sxs of HTN Retinopathy What are the signs of this condition
Blurry/sudden dec vision Scotoma Double vision ``` Macular star- lipid exudates CWspots BRVO/BRAO Retinal edema A:V nicking ```
161
How much Hydroxy/Chloroquine use can lead to toxicity development What are the RFs for developing Hydroxy/Chloroquine Toxicity
>5mg/kg HCQ >2.3mg/kg CQ >5yrs of use Renal Dz Tamoxifen use Retinal/Macular Dzs
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What are the S/Sxs of CQ/HCQ Toxicity What is the prognosis for these Pts How often are eye exam screenings needed
S: Bulls eye maculopathy Sxs: Dec vision, Abnormal color vision, Difficulty adjusting to dark Non-reversible, may progress after stopping Rxs Baseline- within first year Annual- after 5yrs of use
163
What is the path of aqueous humor after production What two structures make the anterior chamber angle Aqueous humor exits the final location via ? structure
Ciliary body, past lens and around iris Into trabecular mesh (area of greatest resistance) at junction of cornea and iris Junction of cornea and iris Schlemms canal
164
What is normal IOP levels When is diurnal variants highest To Dx Glaucoma, what two criteria must be met
10-21 AM>PM Progressive optic nerve damage and, Field loss
165
What are the two broad categories of glaucoma What is a rough estimate to determine if Pt has wide open or closed/narrow angle w/ potential of closure How is this done
Open angle- normal structural out path, MC Closed angle- outflow blocked Angle assessment ``` Pen light near limbus on temporal side Shine light across PTs eyes Observe nasal portion of shadow No shadow= wide open Shadow= bigger shadow= narrower angle ```
166
What is measured to assess the progression of glaucoma What do the two parts that are assessed mean What are the two methods to measure IOP
Cup to disc ratio Smaller number- less visible cup Larger number- bigger risk for glaucoma Non-contact (air puff) Applanation (tonopen, goldmann applanation**)
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? is the only factor of glaucoma that clinicians can actually adjust medically How is ocular HTN Tx What are the RFs that can develop into future glaucoma
IOP Monitor annually ``` FamHx Large C/D ratio Age Thin central cornea High myopia ```
168
What is the pathophysiological process of Primary Open Angle Glaucoma Although the actual mechanism is not known, what are two dysfunctions that can cause POAG What is the only modifiable RF
Loss of retinal fiber layers cause reduced vision Vascular dysfunction- optic nerve ischemia Mechanical- cribiform plate compression of axons IOP >28mmHg= 15x more likely to develop field loss
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How is mechanical dysfunction identified on PE of POAG What kind of decreased vision complaints may present later in Dz What are the RFs for POAG
Sieve-like portion of sclera at base of disc Parts of page are missing Tunnel vision- late Central fixation preserved until late Remaining field- temporal island FamHx- sibling (4x) offspring (2x) Age >50 Race AfAm/Hispanic Diabetes 2-3x
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What POAG RF has no definitive relation to ocular HTN What is the work up for POAG How is this Tx
Systemic HTN Measure IOP Ophthalmoscopy- C/D usually 0.6 or greater Pupil crescent shadow= open chamber Dec aqueous production (BBs: TLCB-olol, A2 agonist: Brim/Apracl-onidine, CA inhibitor: HADB-olamide) Inc aqueous outflow (SympMimetic: Epi/Memantine, Prostaglandin: BULT-prost, Miotics: pilocarpine)
171
What are the RF from using BBs for POAG Tx What are the RFs from using A2 agonists for POAG Tx What are the RF from using sympathomimetics for POAG Tx What are the RFs from using Prostaglandin Analogs for POAG Tx
Dec CO, bronchoconstriction Allergic conjunctivitis Contact dermatitis Exacerbation of HTN Conjunctival hyperemia
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When is surgery indicated for POAG Tx What are the 3 methods of surgical Tx
Optic neuropathy worsens Younger/non-compliant Pts Trabeculoplasty- argon/selective laser Trabeculectomy- shunt, filtering bleb Ciliary ablation- destroys ciliary epithelium
173
? is a variant of POAG What are the RFs for this variant How are they Tx
Low/Normal tension glaucoma, IOP 21 or less w/ open anterior chamber +field and nerve damage ``` Gender F OSA FamHx Age Thinner cornea ``` Same as POAG but more difficult d/t lower starting pressure
174
What are the two processes that cause Acute Angle Closure Glaucoma What are the Sxs if this develops What are the signs seen on PE
Pupil Block- iris pushed forward Non-pupil block- iris positioned anterior, often w/ inflammatory conditions ``` Monocular halos around lights One eye blurry vision Pain w/ photophobia Frontal HA N/V ``` ``` Dilated pupil Injections to conjunctiva Shallow anterior chamber Corneal edema w/ blurry light reflex Lid edema IOP 60-80mmHg ```
175
What are the RFs for AACG Define a Narrow angle
``` Gender F Extreme dilation (walking into dark room) Age 55-70 Race Far Eastern/Indian/Asian Drugs (Anticholinergics, Sympathomimetics) Short/small far sight FamHx Stress ``` Shallow central anterior chamber (space between cornea, iris) w/ no peripheral chamber
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How is AACH Tx What can be given IV if IOP is <50 What is the TxOC
1 drop each w/ 5min between each: Timolol Apraclonidine Predisolone/Dexamethasome Acetazolamide Laser Iridotomy after initial attack is broken
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What is done during a Peripheral Iridotomy What causes Chronic Angle Closure Glaucoma to develop What are the RFs for this to develop
Laser used to make hole made through iris to allow for alternate out flow path Anterior chamber closed permanently by Peripheral Anterior Synechiae (front of iris binds to corneal epithelium) ``` Previous angle closures Proliferative diabetic retinopathy Trauma Uveitis Hypotony Hx trabecular laser Tx ```
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What are the S/Sxs of CACG What would be seen on gonioscopy What is the IOP usually at
ASx Dec vision/fields Intermittend HA Eye pain Blurry vision Broad bands of PAS Optic nerve damage IOP <40
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How is CACG Tx What is the possible etiology of Congenital Glaucoma
Trabeculectomy/Tube shunt: areas not involved by PAS to prevent further synechial closure Goniosynechialysis- physically strips PAS Sturge Weber Syndrome- port wine stain
180
What are the Signs of Congenital Glaucoma What are 3 possible DDx
Enlarged globe and corneal diameter, >12mm before 12mon Corneal edema Tearing Photophobia Blepharospasm Inc IOP Inc C/D ratio- infant may regress once IOP normalizes Megalocornea >14mm Nasolacrimal duct obstruction
181
# Define Descemet's Membrane What can cause this to develop in infants
Linear tears in cornea AKA Haab striae in Congenital Glaucoma Vertical/Oblique= Forcep delivery
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How is Congenital Glaucoma Tx non-op What surgical procedures can be done
PO Acetazolamide- clear cornea prior to goniotomy Topical Levobunolol/Timolol Goniotomy- incises trabecular meshwork Trabeculotomy- if clouding prevents view Trabeculectomy/shunt
183
Secondary Glaucoma is most often in ? PTs d/t ? What causes these Pts to have neurovascular glaucoma This neovascular glaucoma causes ? then secondary glaucoma
Males d/t work/sports/trauma causing angle recession Retinal neovascularization causes iris and angle neovascularization from fibrovascular membrane PAS
184
What are the causes of Neovascular Glaucoma that can lead to Secondary Glaucoma S/Sxs of Neovascular Glaucoma
Retinal artery/vein occlusion Ocular ischemic syndrome Diabetic retinopathy ``` ASx Pain Red around pupil Photophobia Dec vision Normal-elevated IOP ```
185
How is Neovascular Glaucoma Tx What can cause Steroid Response Glaucoma How is it Tx
Timolol Glaucoma filtration surgery- w/ inactive neovascularation PRP for underlying condition 2-4wks of ophthalmic steroids High dose skin creams Inhalers Nasal sprays D/c or decrease use Add IOP lowering med
186
Glaucoma requires ? two things for Dx Without these two, the Dx is just ? Define Hemianopia
Optic nerve damage Visual field loss Ocular HTN Los of half of visual field
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# Define Homonymous Define Scotoma Define Anisocoria
Loss of visual field is same in both eyes Area of reduced/absent vision w/ otherwise intact visual field Unequal pupils >1mm
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? many photoreceptors are in the retina The retina is where the initial ? process takes place ? many ganglion cells are there
126 million (120M rods, 6M cones) Visual processing 1M, surround fovea to form optic nerve
189
Path of visual signals ? is AKA the neural way station Axons leaving here are called ?
Optic nerve- eye to chaism Decussate in chiasm Optic tract- axons leaving chiasm to lateral geniculate Lateral geniculate body Optic radiations
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# Define Visual Cortex What event begins here This event is able to explain ? defect
Radiations converging in occipital lobe Visual interpretation Congruous field defects
191
What are the 11 locations of optic lesions and the type of visual impairment they cause
1: optic nerve- monocular loss 2: optic chiasm- bilateral temporal defect 3: posterior to chiasm- homonymous, same side bilateral 4: nerve and chiasm junction- ipsilateral eye blind, contralateral temporal loss 5 and 8: homonymous hemianopic defect 6: temporal lobe- superior homonymous (pie in sky) 7: parietal- inferior homonymous 9-11: occpital lobe- congruous
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Afferent pathway is d/t ? nerve Efferent pathway is d/t ? nerve What are the two parts of Double Decussation
CN2: optic nerve, divides at chiasm, ends at EW nuclei CN3: EW nuclei through CN3 to make pupils constrict First: chiasm Second: Pretectal and EW nuclei= direct/consensual responses
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# Define Marcus Gunn Pupil If this is found, it means ? but not ? What will be seen on PE
Afferent path dysfunction- failure to transmit messages Underlying d/o present Not associated w/ particular dz Light in abnormal eye= both pupils dilate
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What can cause Marcus Gunn Pupils w/ mild APD What can cause severe Marcus Gunn w/ severe APD
``` BRVO/BRAO Amblyopia Retinal scars Retinal detach ARMD Vitreous hemorrhage ``` ``` Lesion in chiasm/optic tract Optic nerve dz Optic neuritis Pituitary tumor Stroke CRA/VO Ischemic optic neuropathy Glaucoma ```
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What are the two types of Anisocoria Define Adie's Tonic Pupil What will be seen on PE
Physiologic- same difference in dark/light rooms; benign Pathologic- different sizes in dark/light rooms Benign, idiopathic d/t denervation of Parasymp supply to sphincter and ciliary muscle Slow accomodation to light Irregular dilated Poor reaction to light
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Adie's Tonic Pupil is usually seen in ? population What other abnormal PE findings may be present If suspecting Adies Pupil, but EOMs are normal and w/out ptosis, ? Dx is suspected
Unilaterally in women Dec ankle/knee DTRs CN3 palsy
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How is Adies Tonic Pupil Dx confirmed Define Horner's Syndrome What 3 PE findings is this Dx associated w/?
Pilocarpine in both eyes Adies= constrict Normal pupil= won't constrict Injury to sympathetic nerves of face Ptosis- ipsilateral Anhydrosis- facial Miosis- anisocoria worse in dim lights
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Horner's Syndrome can be caused by injury starting in ? runs via ? and near ? What other etiologies may be responsible How is a Dx confirmed
Starts hypothalmus Via upper spinal cord Near carotid artery ``` Brainstem stroke Carotid artery injury Pancoast tumor Cluster HAs Congenital ``` Topical Aproclonidine (Iopidine- a2 agonist) or Cocaine in both eyes Horners- only small pupil will dilate Reversal of anisocoria
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Pt w/ lack of pigmentation to iris should have ? Dx assumed based on congenital etiology Argyll Robertson is more of a syndrome that develops d/t ? causing damage located in ? This syndrome has ? appearance
Horners Syndrome Neurosyphilis- central pupil pathway (retina to EW nucleus) Small pupil Light response- slow or none Accommodates to near vision (light-near dissociation) Bilateral and asymmetric
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Papilledema is defined as ? This develops d/t ? It's finding is Dx as ? until disproven
Bilateral optic disc edema Inc ICP Intracranial mass
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What issues can impede CSF flow and cause papilledema to develop ? idiopathic etiology can cause it's development What are the Sxs associated w/ this Dx
Dural sinus thrombosis Meningitis Aqueductal stenosis Trauma Idiopathic Intracranial HTN d/t pseudotumor cerebri ``` HA w/ N/V Vision loss w/ posture changes Pulsatile tinnitus CN6 paresis= horizontal diplopia Secondary to intracranial mass ```
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What is the presentation/population Papilledema is seen in What is always the first step in a papilledema work up What image needs to be ordered What is the next step if, and only if, this image is normal
IIH w/ obese female Blood pressure MRI w/ contrast LP to measure opening pressure
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How is Papilledema Tx if it's etiology is d/t Pseudotumor Cerebri What is the next step if Pt continues to have visual field deterioration despite the above therapies How does Ischemic Optic Neuropathy present
Furosemide Acetazolamide Weight loss Neurosurgical shunt Neurosurgical shunts Papillitis- disc welling from inflammation
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What are the two etiologies of the papillitis seen in Ischemic Optic Neuropathy This condition is also associated w/ ? other conditions or c/c Pts that are >60y/o w/ Ischemic Optic Neuropathy, type AAION, probably have ? Dx compared to if the PT is middle aged they have ?
Sclerotic/Thrombotic artery occlusion Severe HOTN/blood loss DM/HTN Carotid/Temporal artery dz Proximal muscle/joint aches >60: GCA Mid-age: NAION
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Initially, Pts w/ Ischemic Optic Neuropathy will have ? If this is truly NAION, the optic disc pallor will resolve w/in ? time What will the ESR be if GCA is the cause
Unilateral swollen optic disc 4-8wks >50
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What signs will be present during GCA Arteritic Anterior Ischemic Optic Neuropathy What are the Sxs What are the Sxs that are different during Non-Arteritic Ischemic Optic Neuropathy
Firm, tender temporal arteries Mild anemia 3/4/6 palsy Afferent pupil defect Sudden, painless vision loss Amaurosis Fugax- TIA Starts during morning walks Altered color vision w/ dec VA
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What does the work up for ION include What are the goals of Tx for each type How is AAIOn Tx
Neuroimaging Eval for HTN DM Anemia Westergren ESR and CRP AAION- preserve fellow eye, worse prognosis NAION- observe w/ ASA x 8wks ``` Systemic steroids- IV Methylprednisone x 72hrs then, PO prednisone x 3 days then, 50mg x 4wks or ESR/CRP normalize Temporal artery biopsy ```
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What is possibly the first sign a Pt may have MS What infectious dz could cause this What non-infectious processes could cause this
Optic neuritis Lyme Dz Sarcoidosis SLE
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What are the 3 variations of Optic Neuritis What are the Sxs What Pts is this condition more likely in and w/ ? signs
Retrobulbar- posterior to globe Papillitis- edema of optic disc Neuroretinitis- papillitis w/ inflammation of retinal nerve fibers Unilateral vision loss w/ orbital pain, worse w/ movement Frontal HA 30y/o average Loss of central/altitude visual field Dec color vision Afferent pupil defect
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What is the work up for Optic Neuritis How is this Tx if it's d/t MS
Opthal eval MRI w/ contrast CBC CXR E+ One are of demyelination: Pulsed IV steroids x 3 days then, PO steroids x 11 days then, 4 day taper Two or more lesions on MRI: Same steroid regiment w/ Interferon B-1a after
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What therapy is avoided during the Tx of Optic Neuritis if d/t MS Define Amaurosis Fugax What is a possible physiological cause of this
Start therapy w/ PO Steroids- increased recurrence rate TIA- loss of vision in one eye d/t temporary lack of blood flow to retina that resolves spontaneously Broken clot from carotid artery
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What are the RFs for Amaurosis Fugax What is the name of the plaque that may be seen on PE
``` Atherosclerosis High cholesterol DM Heart Dz Tobacco HTN ``` Hollenhorst
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CN3 palsy will affect ? muscles What is the etiology of this form of palsy What are the S/Sxs of this condition
SR IR IO MR Levator palpebrae Pupil sphincter Vasculopathic- pupil sparing (DM/HTN) Compression- tumor, anuerysm Trauma Ptosis Eye down and out w/ diplopia
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What PE finding is an ominous sign when evaluating CN3 palsy What is the immediate next step if found How is this Tx if no pupil involvement is present
Dilated pupil Stat MRI w/ contrast to r/o aneurysm Cerebral angiography- suspected aneurysm Observe x 3mon, still present= image
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What is the Tertiary Action of SO nerve that would be affected during CN4 palsy What are the etiologies for this type of palsy
Moves eye away from nose Idiopathic Trauma Vasculopathic (DM, HTN) Tumor
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What are the S/Sxs seen w/ CN4 palsy MRI imaging is warranted if ? criteria are met Other than Tx underlying d/o, what else is done for Tx
Vertical/oblique diplopia Objects appear tilted Head tilt to contralateral shoulder Eye doesn't depress w/ adduction <45y/o 45-55y/o w/out RFs Other CN involvement Corrective lens
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CN6 Palsy affects ? nerve What is the MC etiology What are the other possibilities
Abducens innervation to LR muscle Vasculopathic (DM, HTN) ``` Tumor Idiopathic Cavernous sinus dz Intercranial HTN Trauma ```
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What are the S/Sxs seen w/ CN6 Palsy How are these worked up How are these Pts Tx
``` Horizontal diplopia, worse at distance HA Esotropia Abduction deficit Head tilt toward side w/ palsy, minimizes diplopia ``` MRI if w/out vascular RF Ophthalmic eval Strabismus surgery- chronic, stable deviation Occlusion patch for diplopia Prism glasses- temporary
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# Define Preseptal Cellulitis This form of infection doesn't pass ? structure What are the two MC microbes for this Dx and Orbital Cellulitis
Infected inflammation of eye lid Orbital septum Staph A/Strep
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Pts w/ Preseptal Cellulitis may have Hx including ? 5 things What are the Sxs What are the four 'NO' signs
``` Bites, insects Abrased skin Sinusiits Hordeolum Herpes simplex/zoster ``` Periorbital swelling Mild fever Tender, red and swollen lid No Proptosis Restricted motility Optic neuropathy Pain w/ movement
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Preseptal cellulitis lasting 6wks post-Tx needs ? three steps taken How is this condition worked up How are mild cases Tx
InD Hot compress IV Vanc Ocular exam CT scan if trauma in Hx ``` Mild: PO ABX (Augmentin, Cephalexin) ```
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What criteris would place PT w/ Preseptal Cellulitis in Mod-sev categories Once admitted, what ABX are used Orbital Cellulitis is commonly secondary to ? three Dxs
Non-compliant Under 5y/o Toxic appearing IV Vanc and Ceftriaxone Periorbital infection Sinusitis Dental infection
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Pts w/ Orbital Cellulitis may have ? findings in Hx What Sxs may be present What sings are seen
``` Dacryocystitis Impetigo Conjunctivitis Hordeolum Rarely- septicemia ``` Swelling Warm lids Pain Diplopia ``` Fever Inc WBC Dec vision w/ sluggish pupil response Proptosis Restricted/painful ocular motility ```
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How is Orbital Cellulitis Tx What is added for exposure secondary to proptosis When is surgical drainage indicated
Admit IV x 3 days then PO x 1wk: Vanc + AmpSulbactam Erythromycin Large abscess No ABX response x 2-3 days
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What are 3 types of retinal tumors the eye is susceptible to What are the Sxs of a Corneal Abrasion What is absent on exam
Retinoblastoma- rare in Pts <5y/o, present as leukocoria Astrocytoma- non-malignant tumor of CNS made of astrocytes, present as leukocoria Malignant melanoma- ASx Foreign body sensation Involuntary lid closure Tearing Severe pain Discharge
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What provides immediate pain relief for Pts w/ Corneal Abrasion What needs to be carefully avoided w/ these Pts after eval and upon discharge from office? What is a workup include
Topical Anesthetic- Propara/Tetra-caine Topical anesthesia Slit lamp w/ topical anesthetic Lid eversion
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How are Corneal Abrasion Tx What cycloplegic agent may be used for traumatic iritis What also needs to be avoided depending on the etiology
Topical ABX if vegetative matter/contact wearer- FQN Others- Polymyxin B/Trimethoprim Cyclopentolate Patching- nails or vegetative matter
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How often are Corneal Abrasion f/u w/? Why does sleeping in contacts cause irritation How long must these be d/c when Tx
Daily at first 2-3d until healed Dec O2 to cornea= epithelium becomes hypoxic x14 days
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If there is an abrasion associated w/ contact wear irritation, what type of coverage is needed What ABX combo is recommended What types of activities can lead to UV Keratitis
Gram-neg Pseudomonas Fortified Gentamicin or Tobramycin and, Fortified Cefazolin or Vanc Welding Tanning Snow blindness
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When are UV Keratitis Sxs worse and what may be seen on PE How is this Tx Most serious chemical burns to the eye are ? type
6-12hrs after activity Dense punctate staining Analgesic Cyclopentolate Erythromicin Patch the more affected eye Alkali- Bleach Airbags Lye Lime Ammonia
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How long should chemical burns be washed out for What analgesic can be used during the work up part of these burns How are chemical burns Tx
30min Wait 5-10min, measure pH in fornices w/ litmus paper Continue irrigation until neutral pH reached Proparacaine Atropine PO pain meds IOP control/tears PRN Erythromycin
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How are Corneal foreign bodies Tx What ABX are recommended after removal
``` VA before any procedure Globe penetration= Ophth referral Superficial= Topical anesthetic Irrigation CTA/Jewelers forceps ``` Polymyxin B/Trimethoprim FQN
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How are Intra-ocular Foreign Bodies seen on PE What will be seen in the foreign body has been in place for long time What type of defect may be seen w/ Slit Lamp exam
Irregular pupil w/ peak at site of injury Siderosis- deposition of Fe into tissue Trasillumination defect- red reflex where it shouldn't be
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How are Intraocular Foreign Bodies Tx What are the two types of Blow-Out Fx
Shield eye Tetanus IV Vanc and Cycloplegic Surgery always advised Direct: involves orbital rim, extends posterior along floor Indirect: compression of orbital soft tissue, forces transmitted to orbital walls and Fxs w/out rim involvement
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What are the Sxs of Blow-Out Fx What do Pts need to be advised to avoid What are the signs that may be seen
Pain w/ movement Binocular vision Sneezing/blowing nose- communication between orbit and sinus Restricted EOMs Enophthalmos- posterior displaced globe Numb/tingling upper lip/cheek
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What image is used to Dx Blow-Out Fxs and what images need to be avoided for Dx How are these Tx Define Hyphema
CT Avoid plain films for Dx Nasal decongestants x 3days Cephalexin Ice packs for first 48hrs Blood collection in anterior chamber from trauma to iris or ciliary body
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What can cause Hyphemas to spontaneously reoccur What is the MC history What is the next step if Pt is AfAm
Clotting d/o Leukemia Retinoblastoma Spontaneous= abuse Trauma Screen for Sickle Cell
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How are Hyphemas Tx What three Txs need to be avoided
Ophtha consult- mandatory Bed rest w/ head elevation (admit if non-compliant) Shield eye, don't patch Atropine BID Patches ASA NSAIDs
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What needs to be evaluated during lid laceration work up What image may be used to r/o Fxs What muscle function needs to be assessed
Dilate both eyes Eval canalicular/lacrimal system CT Levator muscle
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How are lid lacerations Tx What are the indications to refer to Ophth
Tetanus prophylaxis ABX if contaminated/foreign body suspected ``` Canalicular involvement Ruptured glove Intra-ocular foreign body Levator involement (ptosis) Visible orbital fat= orbital septum perf'd >1/3 lid tissue lost ```
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Scleritis Episcleritis Conjunctivitis ``` Pain D/c Red Onset SystSxs ```
Scler: Sev No Foc/Diff Insid Yes (SNFIY) Epis: Mild No Foc Acute yes (MNFAY) Conjunct: Min Yes Diff Days No (MYDDN) (PDROS)
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LR6 SO4 R3 IO SO SR LR IR MR
Extort/Elevate Intort/Depress Elevate Abduct Depress Add
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Eye muscle distanced What are the two Neuro-Significant nystagmus'
SR: 7.5mm MR: 5.5mm IR: 6.5mm LR: 7mm Vertical/See-saw Brain stem lesions
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When is visual potential the greatest for amblyopia Path from eye to nasolacrimal duct What Sx of Blepharitis is worse in the AM
<8y/o d/t neuroplasticity Punctum Caniculus Sac Duct Epiphora
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Comitant Esotropia is AKA ? and applicable for ? ages This can be d/t ? two things What can cause Non-Comitant Esotropias?
Accommodative: 6mon-6yrs Cataract- sensory deprivation Tumor EOM, CNS
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What type of Nystagmus is test for during sobriety tests What does a See-Saw nystagmus mean What visual issue may Pts complain of
Physiologic Lesion of chiasm or 3rd venticle Parasellar mass Bitemporal heminopia
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What does an Upbeat Nystagmus mean Where can the lesion be located to create this type What finding may be noted if this is d/t drug ingestion
Fast phase is up Brainstem Vermis of cerebellum Upward gaze
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# Define Down Beat Nystagmus This is AKA ? malformation The lesion is usually located ?
Fast phase is down Arnold-Chiari malformation Cerebellum
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Acquired Nystagmus is AKA ? This is usually acquired from neurological dysfunctions from ? What do these Pts also suffer from
Late onset nystagmus Stroke MS Trauma Oscillopsia- creates vertigo effect
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What anti-seizure meds can create an acquired nystagmus Congenital Nystagmus is AKA ? These usually show up <6mon and can be d/t defects located where?
Dilantin Phenobarbital Early Onset Eye, visual pathway
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Congenital Nystagmus can be a s/e of vision loss from ? eye Dzs These PTs are less likely to suffer from ? issue ? is the MC form of conjunctivitis
Albinism Cataracts Glaucoma Oscillopsia Viral
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Dacryadenitis needs to have ? structures evaluated? If this is from an infectious etiology, ? ABX are used ? is MC Sx of late onset strabismus from trauma/stroke or tumor
Parotid glands Augmentin or Cephalexin Diplopia
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? is the metabolic support system of the retina Define the 3 criteria for Clinically Significant Macular Edema
Retinal pigment epithelium Retinal edema <500um (1/3 disc diameter) of fovea center Hard exudates <500um of fovea center Retinal edema over 1 disc area in size and 1 disc diameter of fovea center
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CRAO PE finding First Visual Field defect seen that could indicate possible glaucoma
Scattered Cotton Wool Spots Nasal step
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? PE finding may be seen in advanced cases of POAG Normally w/ POAG, cup:disc is ? How is this Tx
Afferent defect 0.6 or > Refer Prostaglandin analogs
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What are Filtering Blebs associated w/ What is the name to test the angle between cornea and iris
POAG Von Herrick Test
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ON ``` Age Presentation VA VF Disc Pain ```
``` ON: 30y/o F>M w/ HA and vision loss over days 20-20/200 Central scotoma Edema/Hyperemic W/ eye movement ```
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NAION ``` Age Presentation VA VF Disc Pain ```
``` >50 Sudden unilateral vision upon walking 20/100-20/400 Inferior altitude or variable Edema, hemorrhage, small cup No pain ```
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AAION ``` Age Presentation VA VF Disc Pain ```
``` 70y/o F w/ HA, scalp tenderness and jaw claudication 20/400-LP Inferior altitude Edema, normal cup Yes ```
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MC microbe to affect contact wearers Nystagmus that causes Pt to feel like everything is moving and has vertigo is d/t ? type Avoid steroid use during ? two Txs
Acanthomeobae Acquired HSV and Fungal keratitis
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Corneal abrasion in contact wearer needs ? ABX Rx'd Best Dx imaging for assessing diabetic retinopathy Gold standard test to Dx Acute Angle Closure
Fqn Fluorescein angiography Gonioscopy