Other Ocular Conditions - Exam 3 Flashcards by Johannah Crumpton

____ is the Inward turning of the lower eyelid. What is the MC pt population? What is the permanent tx? what is the temporary tx?

Entropion

elderly pts

permanent: surgery -> if lashes rub on the cornea

temporary ->Botulinum toxin injections

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_____ Outward turning of the lower eyelid. Also common the _____. What is the tx?

Ectropion

elderly

sx: excessive tearing, exposure keratitis, or a cosmetic problem

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_____ Abnormal contraction of eyelid muscle. What causes it? what is the tx?

Blepharospasm

Stress, tiredness, neurological condition

tx: Alleviate stress, decrease caffeine
Botulinum toxin injections

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___ is drooping of the eyelid. Can be caused by 3 neurological conditions, name them

Ptosis

Horner’s syndrome
Third nerve palsy
Myasthenia gravis

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What are the 4 different causes of ptosis?

congentital
acquired
mechanical
aponeurotic

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Types of ptosis: _______ Dysgenesis of the levator palpebrae superioris. Abnormal insertion of it’s aponeurosis into the eyelid

Congenital

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Types of ptosis: _____ Trauma, eye surgery, systemic symptoms, family history, contact lense use, diplopia

acquired

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Types of ptosis: ______ Stretching and redundancy of eyelid skin and subcutaneous fat. Enlargement or deformation of the eyelid from infection, tumor, trauma or inflammation

Mechanical

aka think growth of a tumor

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Types of ptosis: _______ Dehiscence or stretching of the ____ tendon.
Elderly - loss of connective tissue elasticity.
Sequelae of eyelid swelling

aponeurotic

aka natural tissue break down
loss of elasticity

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______ is the distance between upper lid margin and light reflex. what is considered severe?

marginal reflex distance

4mm or more

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What are the two treatment options for ptosis?

Nonsurgical: Oxymetazoline eye drops

sx: usually done in pts who have obscured visual field due to ptosis

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_______ stimulates alpha-adrenergic receptors in the superior tarsal muscle (Muller’s muscle) of the eye lid

Oxymetazoline eye drops used in ptosis

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_____ muscle maintains elevation of the upper eyelid

superior tarsal muscle (Muller’s muscle)

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Fleshy, triangular encroachment of the conjunctiva onto the NASAL side of the CORNEA involvement
Usually due to prolonged exposure to wind, sun, sand and dust (think outdoors)
Become inflamed and may grow
typically bilateral

What am I?
What is the tx?

Pterygium

Artificial tears
NSAIDS or weak corticosteroids may be needed
Surgery if severe or impairs vision or severe ocular irritation

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Yellowish-orange, slightly raised conjunctival lesion
Arises from the limbus and stays confined to the conjunctiva, DOES NOT crossing over onto the cornea
can be nasal or temporal
benign, due to exposure to dust

What am I?

Pinguecula

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Keratoconjunctivitis Sicca is ____. What are some risk factors? What is the highlighted one?

dry eye syndrome

Age
Female gender
Hormonal changes
Systemic diseases
Contact lense wearers
Systemic medications
Ocular medications
Nutritional deficiencies
Vit A Def
Decreased corneal sensation
Ophthalmic surgery - especially corneal refractive surgery
Low humidity environments

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What are the tear film components of the eye?

Aqueous - hypofunction of the lacrimal glands
Mucin
Lipid

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Dry eye is due to ____ or _____

Defective spreading of tear film: eyelid abnormalities, conjunctival abnormalities, proptosis

Increased evaporative loss: environmental factors, meibomian gland function, allergies

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Dryness
redness
foreign body sensation
excessive mucus secretion
itching
light sensitivity
blurred vision
gross exam is normal
Absence of tear meniscus at lower lid margin
Yellowish mucus strands in lower conjunctival fornix
Bulbar conjunctiva loses its normal luster and may be thickened, edematous and hyperemic

What am I?

Dry eye

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When a dry eye is fluorescein stained, what will you see?

Defects in the corneal epithelium

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When a dry eye is Rose Bengal and Lissamine Green stained, what will you see?

Defects in the corneal and conjunctival epithelial cells

mucous plaques- semi transparents, white to grey slightly elevated lesions

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What is the Schirmer’s test? What dz is it used in?

Measures tear production by wetting of a filter paper

dry eye

A filter paper is placed inside of the lower eyelid.
After 5 minutes the filter is removed and tested for its moisture content

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What does the Tear Break Up Time measure?

Estimates mucin content

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What is the tx for dry eye? What do they contain?

Artificial Tears: tid-qid
ointment at night

Cellulose - maintain viscosity
Polyethylene glycol or polyvinyl alcohol - a spreading agent that prevents evaporation
Preservative - prevent contamination

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______ Polycyclic peptide that inhibits both cellular and humoral immune responses by inhibiting interleukin-2, a proliferative factor needed for T-cell activity. Increases tear production d/t inflammation reduction

Cyclosporine (Restasis)

what are some additional treatments for dry eye?

Environmental strategies: Humidified, moisture chamber glasses, swim goggles Insertion of punctal plugs to retain lacrimal secretions

_____ opacity of the crystalline lens. May cause blurred/distorted vision and can lead to blindness

Cataracts

What is the leading cause of blindness in WV?

cataracts

What are some risk factors for cataracts? What are the 3 major highlighted ones? What is the MC one?

+**Age related - most common and #1 cause**+ Exposure to UVB light Glaucoma Smoking and Alcohol use Congenital Intrauterine infections - Rubella, CMV Inborn errors of metabolism - galactosemia Traumatic **Secondary to systemic disease - DM, myotonic dystrophy, atopic dermatitis **Corticosteroids (long term - ex: pt on systemic steroids for rheumatoid arthritis for years) radiation therapy Uveitis

Progressive blurring of vision, usually gradual Glare, especially in bright light or when driving at night Development of nearsightedness Monocular double vision Cloudy lens Early: can be seen through dilated pupil Late: Retina becomes more difficult to visualize until fundus reflection is absent and pupil is white What am I? What is the tx?

Cataract refer to ophthalomogy: Sx

_____ is the leading cause of blindness in DEVELOPED countries

Macular degeneration

Loss of central vision; usually bilaterally Peripheral vision maintained What am I? What are the types?

Macular degeneration Atrophic - “dry” or “non-exudative” Neovascular - “wet” or “exudative”

What are some associated factors for macular degeneration?

Age White race Sex - slight female predominance Family history, hypertension, hyperlipidemia Cigarette smoking

GRADUALLY progresses to bilateral vision loss Atrophy and degeneration of the outer retina and retinal pigment epithelium Retinal drusen are present What am I? What is the slam dunk finding?

atrophic (dry) macular degeneration Retinal drusen

____ are hard, discrete, yellow, retinal deposits made from extracellular lipids/proteins. Commonly seen with _____

retinal drusen dry macular degeneration

_____ new vessels grow between the retina or retinal pigment epithelium and Bruch’s membrane (innermost layer of choroid). What is released? The vision loss is ____

Neovascular (wet / exudative) macular degeneration Vascular endothelial growth factor released more rapid and severe

_____ is the innermost layer of the choroid

Bruch's membrane: new vessels grow and leak here in wet macular degeneration

What is the tx for macular degeneration?

refer to ophthalmology **Inhibitors of vascular endothelial growth factors (VEGF)** important to have good BP control no smoking Vit C and E Zinc Copper Carotenoids no specific treatment for atrophic degeneration

_____ is a signal protein produced by cells that stimulates vasculogenesis and angiogenesis.

Vascular endothelial growth factor (VEGF)

_____ is also called acute angle closure glaucoma. ____ is chronic glaucoma. The ______ is an area of tissue in the eye located around the base of the cornea, near the ciliary body and is responsible for draining the aqueous humor.

narrow angle open angle trabecular meshwork

_____ neuropathy to the optic nerve, with or without elevation in intraocular pressure. What is a common ophthalmologic exam finding?

glaucoma cupping

_____ is the second leading cause of blindness in WV

glaucoma

In glaucoma, the angle between the ____ and _____ in the anterior chamber is decreased, usually because the lens is located too far forward and presses against the ____

cornea and iris iris

_____ is the sudden increase of intraocular pressure causing damage to the optic nerve. What is a normal IOP? What can it lead to?

angle close glaucoma normal pressure is 8-21mmhg permanent blindness if left untreated

What are the risk factors for angle closure glaucoma?

asian descent family hx female age 40-50 hyperopia certain medications

What is secondary angle closure glaucome due to?

Anterior angle chamber becomes occluded as a result of: Conditions that PUSH the ciliary body forward Conditions that deform the iris so that it is retracted into the angle (PULLING)

Lens located too far forward anatomically and rests against the iris. This is _______

primary angle closure the angle closes

S/S typically appear at night d/t lower light causing mydriasis (dilation of pupil) Vision loss or decreased vision **Halos around lights Headache Severe eye pain Nausea and vomiting Cupping of optic disk IOP often over 50mmg, leading to a hard eye on palpation Corneal edema or cloudiness “Red, steamy cornea” Conjunctival redness What am I? What are the highlighted s/s?

angle closure glaucoma S/S typically appear at night d/t lower light causing mydriasis (dilation of pupil) Halos around lights Cupping of Optic Disk Corneal edema or cloudiness “Red, steamy cornea”

______ is the gold standard for diagnosing angle closure glaucoma. Views the _____ angle

Gonioscopy: use slit lamp to dx angle closure iridocorneal

_____ refers to putting posterior pressure on the eyeball with the lens used for _____. The pressure will widen the angle if it is not scarred completely closed; the extent to which scarring has produced angle-closure helps to determine the severity and chronicity of the angle-closure.

Indentation gonioscopy gonioscopy

What is the tx of angle closure glaucoma? What do you need to keep checking?

Initial treatment is reduction of IOP and control of IOP agents aimed at increasing outflow or decrease inflow **place pt supine **Acetazolamide and when IOP drops then Pilocarpine recheck IOP every 30-60 minutes

_____ is an carbonic anhydrase inhibitor. What is the MOA?

Acetazolamide decreases production of aqueous humor

Once the IOP drops, then _______. What type of medication? What is the MOA?

Pilocarpine cholinergic increases outflow of aqueous humor/decreases resistance causes miosis (constriction of pupil)

**What is the DEFINITIVE treatment for angle closure and open angle glaucoma? This allows aqueous humor to travel directly from the _____ to _____

Laser peripheral iridotomy posterior to anterior chamber

What is the entire initial management of acute angle closure glaucoma?

EMERGENT REFERRAL TO OPHTHALMOLOGY WHILE WAITING ON AMBULANCE -LIE ON THEIR BACK -ACETAZOLAMIDE 500MG PO or IV -PILOCARPINE 2% EYE DROPS -ANALGESIA -ANTIEMETIC

Chronic, usually bilateral disease optic neuropathy degeneration and slow blockage of trabecular meshwork which slowly reduces the outflow of aqueous humor progressive peripheral vision loss cupping of optic disc What am I? What is the highlighted s/s?

chronic glaucoma peripheral vision loss

What are the risk factors for chronic glaucoma?

older than 50 black and white family hx elevated IOP HTN DM CVD hypothryoid peripheral visual field loss

____ is the leading cause of blindness amoung black people

chronic glaucoma

What are the screening recommendations for a comprehensive eye exam for adult pt without risk factors for eye disease?

For adult patients without risk factors for eye disease: every 5 to 10 years in patients <40 every two to four years in patients 40 to 54 years every one to three years in patients 55 to 64 years every one to two years in patients ≥65 years.

What are the screening recommendations for a comprehensive eye exam for adult pt WITH risk factors for eye disease?

For patients with risk factors for glaucoma (eg, Black or Hispanic persons, or those with a family history of vision loss from glaucoma): every one to two years in patients <40 and ≥55 years every one to three years in patients age 40 to 54 years

Comprehensive eye exam and you find ____ on a fundoscopic exam, need to send a referral

cupping

Glaucoma is defined as an ______ rather than a disease of high pressure alone

optic neuropathy

What are some tests that will help you dx chronic glaucoma? What will a fundoscopic exam show? What is the handheld device called? What IOP is considered an emergent referral?

Fundoscopic Exam Visual Field testing Intraocular pressure - tonometry Cupping diameter of >50% of the vertical diameter Schiotz tonometry - handheld device IOP over 40

What types of therapy are included in chronic glaucoma?

meds laser surgery

What is first line therapy for open angle glaucoma? What is the MAO?

topical prostaglandins: Latanoprost (Xalatan) - generic Tafluprost (Zioptan) - no preservatives Bimatoprost (Latisse) - lengthens eyelashes selective agonist of prostaglandin receptor; increase the outflow of aqueous humor, dropping IOP

Ocular - conjunctival hyperemia, eye irritation, increase in number and length of eyelashes, changes in iris and lash pigmentation, foreign body sensation SE of _____

Topical Prostaglandins: Latanoprost (Xalatan) - generic Tafluprost (Zioptan) - no preservatives Bimatoprost (Latisse) - lengthens eyelashes

What are 2nd line treatments for open angle glaucoma?

Topical Beta Blockers: timolol (Timoptic) Topical Alpha-2 Adrenergic Agonists Apraclonidine Cholinergic Agonists pilocarpine

____ MOA reduce IOP by interfering with cyclic adenosine monophosphate (cAMP), (cAMP is used to produce aqueous humor in the ciliary process of the eye). What are two SE?

topical beta blockers: timolol bradycardia and hypotension

_____ MOA causes the iris to dilate (mydriasis), decreasing congestion in the blood vessels of the conjunctiva leading to reduction in IOP by reducing the production of aqueous humor. What are the SE? CI?

Topical Alpha-2 Adrenergic Agonists Apraclonidine SE: allergic conjunctivitis, hyperemia, ocular pruritus CI: Don’t use with MAOIs Tricyclics CNS depressants, alcohol, BB, cardiac glycosides, or other antihypertensives

______ causes the pupil to constrict. As pupil is constricted, _____ attached to trabecular meshwork are contracted, opening up _______, increasing outflow of aqueous humor and decreasing IOP

Cholinergic agonists: pilocarpine ciliary muscles Schlemm’s canal

______ are used in open angle glaucoma but not as effective and used as an alternative medication. Can be used as an adjunct medication. **When can they NOT be used?

Topical Carbonic Anhydrase Inhibitors: Acetazolamide (Diamox) **allergy to sulfonamides (sulfa drugs)

_____ MOA slows the action of the enzyme carbonic anhydrase (directly inhibits the production), leading to decreased production of aqueous humor and lowering IOP

Topical Carbonic Anhydrase Inhibitors: Acetazolamide (Diamox)