Other Ocular Conditions - Exam 3 Flashcards
____ 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
_____ Outward turning of the lower eyelid. Also common the _____. What is the tx?
Ectropion
elderly
sx: excessive tearing, exposure keratitis, or a cosmetic problem
_____ 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
___ is drooping of the eyelid. Can be caused by 3 neurological conditions, name them
Ptosis
Horner’s syndrome
Third nerve palsy
Myasthenia gravis
What are the 4 different causes of ptosis?
congentital
acquired
mechanical
aponeurotic
Types of ptosis: _______ Dysgenesis of the levator palpebrae superioris. Abnormal insertion of it’s aponeurosis into the eyelid
Congenital
Types of ptosis: _____ Trauma, eye surgery, systemic symptoms, family history, contact lense use, diplopia
acquired
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
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
______ is the distance between upper lid margin and light reflex. what is considered severe?
marginal reflex distance
4mm or more
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
_______ stimulates alpha-adrenergic receptors in the superior tarsal muscle (Muller’s muscle) of the eye lid
Oxymetazoline eye drops used in ptosis
_____ muscle maintains elevation of the upper eyelid
superior tarsal muscle (Muller’s muscle)
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
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
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
What are the tear film components of the eye?
Aqueous - hypofunction of the lacrimal glands
Mucin
Lipid
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
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
When a dry eye is fluorescein stained, what will you see?
Defects in the corneal epithelium
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
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
What does the Tear Break Up Time measure?
Estimates mucin content
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
______ 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)
