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
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
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
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
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
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”
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
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
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
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
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
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
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
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)
? 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
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
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
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
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
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
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
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
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
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
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
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
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
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
What is the physiological reason for RVO conditions
Thickening arteriole compresses on vein causing stagnant blood outflow
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
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
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
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
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
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
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
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
What are the RFs for DM
Duration- rarely starts 5yrs before/after puberty Poor control Pregnancy- progression linked to 1st-T HTN Nephropathy
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
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
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
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
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
How is Diabetic Retinopathy worked up
Fasting blood glucose A1C CBC w/ diff Hgb electrophoresis CXR Carotid US Annual fundoscopic exam
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
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
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
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
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
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)
? 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
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
What are the RFs for progressing from Dry to Wet AMD
Hyperopia
Pigment clumps
HTN
FamHx Large ill-defined drusen Age Blue eyes Smoking
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
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
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
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
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
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
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
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
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
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**)
? 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
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
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
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)
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
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
? 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
? 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
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
Define Visual Cortex
What event begins here
This event is able to explain ? defect
Radiations converging in occipital lobe
Visual interpretation
Congruous field defects
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
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
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
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
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
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
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
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
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
Papilledema is defined as ?
This develops d/t ?
It’s finding is Dx as ? until disproven
Bilateral optic disc edema
Inc ICP
Intracranial mass
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
LR6 SO4 R3
IO
SO
SR
LR
IR
MR
Extort/Elevate
Intort/Depress
Elevate
Abduct
Depress
Add
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
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
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
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
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
Define Down Beat Nystagmus
This is AKA ? malformation
The lesion is usually located ?
Fast phase is down
Arnold-Chiari malformation
Cerebellum
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
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
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
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
? 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
CRAO PE finding
First Visual Field defect seen that could indicate possible glaucoma
Scattered Cotton Wool Spots
Nasal step
? 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
What are Filtering Blebs associated w/
What is the name to test the angle between cornea and iris
POAG
Von Herrick Test
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
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
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
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
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
