Pediatric Ophth/Strabismus AAO Self-Assessment Flashcards
A 10-year-old child has open angle glaucoma and asthma. Which of the following adrenergic agents is most appropriate for managing this patient's glaucoma? Betaxlol Timolol Brimonidine Apraclonidine
Brimonidine is an alpha-2 adrenergic antagonist. It effectively reduces intraocular pressure in some cases of pediatric glaucoma, but can cause lethargy, hypotonia, hypothermia, and serious CNS depression in young children. Iopidine is an alpha-2 adrenergic agonist that has been useful for short-term intraocular pressure reduction in children, but tends to result in tachyphylaxis and allergy in young children. Timolol and betaxolol are topical beta-blockers and should not be used in children with asthma.
A 7-year-old boy corneal presents with pseudodendrites from herpes zoster ophthalmicus. What is the preferred management of this patient?
Topical antiviral medication
Systemic antiviral medication
Topical corticosteroids and antibiotics
Systemic corticosteroids and antibiotics
Herpes zoster ophthalmicus is rare in children. Pertinent clinical features include epiphora and vesicle formation on the head and eyelids. Uveitis may also be present. Immunocompromised children are at greater risk for developing the disease. Management includes systemic antivirals (eg, acyclovir, famciclovir, valacyclovir), moist compresses, topical antibiotics for cutaneous lesions, and topical lubricants. Topical corticosteroids and cycloplegics are used for stromal or disciform keratitis or uveitis, not features mentioned for this child.
An otherwise healthy 6-month-old child is diagnosed with a 2-mm epibulbar dermoid tumor of his left eye. The child is playful and appears asymptomatic. Which of the following is the most appropriate next step in the management of this patient? Ultrasound biomicroscopy Observation Immediate surgical excision Topical lubrication
There is no urgency in removing epibulbar dermoids unless symptoms or management of localized inflammation are present, and persist despite medical treatment. The most frequent symptom is local irritation, which can be managed with topical lubricants. Significant astigmatism can also result which can require spectacle correction. Contact lens wear may become limited due to irritation of the lens rubbing on the dermoid. Surgical removal of epibulbar tumors can result in residual corneal scarring.
In what location does a dacryocele typically present as a bluish swelling? Above and lateral to the medial canthus Below the lateral canthal tendon Below and nasal to the medial canthus Above the lateral canthal tendon
A dacryocele occurs when a distal blockage causes distention of the tear sac. Retrograde debries and tears causes a kink in the common canaliculus. When retrograde movement is blocked, decompression is prevented, resulting in the accumulation of secretions that stagnate in the tear sac. A dacryocele presents as a bluish swelling just below and nasal to the medial canthus. Dacryoceles typically bulge anteriorly below the medial canthal tendon and nasal to the canthus. Dacryocele may be associated with nasal obstruction (nasal mucocele), which can result in respiratory distress. A frontal sinus mucocoele can present with bluish selling above and nasal to the medial canthus and thus must be distinguished from a dacryocoele.
A 13-year old female presents with asthenopia, blurred near vision, and difficulty reading. On examination, the patient is noted to have an exophoria at near, a remote near point of convergence, and poor near fusional convergence amplitudes. Which of the following is the most appropriate next step in treatment?
Plus lenses and base-in prisms for reading
Bilateral medial rectus muscle resections
Orthoptic exercises (“pencil push-ups”)
Bilateral lateral rectus muscle recessions
Treatment of convergence insufficiency often includes orthoptic exercises, particularly near point exercises such as “pencil push-ups” or stereograms. Base-in prism reading glasses are usually used if the patient fails to respond to orthoptic exercises. When patients have combined convergence and accommodative insufficiency, plus lenses and base-in prisms for reading may be beneficial. Medial rectus muscle resections are used rarely when nonsurgical treatments have been unsatisfactory. Lateral rectus muscle recessions are not usually used for treatment of convergence insufficiency.
A 29-year-old woman has a history of esotropia that was diagnosed at 4 years of age and treated with glasses and patching for a few months. She has had decreased vision in her right eye for as long as she can remember. She has noticed more crossing of her right eye in the past few years and would like it corrected. Her best-corrected visual acuity is 20/100 OD with a -0.50 sphere and 20/20 OS with a +0.50 sphere. Your examination reveals a 20-prism-diopter right esotropia in primary and side gaze. The esotropia decreases to 5 prism diopters in up gaze and increases to 30 prism diopters in down gaze. The remainder of her ocular examination is normal. Which of the following would be the best procedure to correct this deviation?
R and R OD with infraplacement of the medial rectus muscle and supraplacement of the lateral rectus muscle
Bilateral recessions of the medial rectus muscles with infraplacement
Resection of the right lateral rectus, recession of the right medial rectus, and recession of the right inferior oblique
Resection of the right lateral rectus muscle and recession of the right medial rectus muscle (R and R OD)
This patient demonstrates a V-pattern esotropia and decreased visual acuity in the right eye, presumably resulting from amblyopia. The esotropia could be corrected with a recession and resection procedure of either eye or bilateral medial rectus recession. Because the patient has significant visual impairment, it is reasonable to restrict surgery to the poorer eye if possible. Correction of the V pattern can best be achieved by vertical displacement of the horizontal rectus muscles. In this case, the medial rectus should be infraplaced and the lateral rectus supraplaced. An inferior oblique muscle recession is indicated only if the inferior oblique muscle is overacting and there is an associated incomitant vertical deviation.
Which of the following is not a common complication of retinopathy of prematurity? Cataract Refractive error Strabismus Retinal detachment
Infants with retinopathy of prematurity have a greater tendency than full-term infants to develop refractive errors and strabismus. Severe retinopathy of prematurity is commonly associated with retinal detachment and closed-angle glaucoma. Although lens opacities may occur as a consequence of stage V retinopathy of prematurity with phthisis, they are much less common than the other conditions.
Despite maximal medical management and prior surgery, a 5-year-old boy with Sturge-Weber syndrome presents for evaluation of progressive glaucoma OD. Anterior segment examination shows the corneas are clear with horizontal diameters 13 mm OD, 11 mm OS. Intraocular pressures measured 26 mmHg OD, 17 mmHg OS. Which treatment should be considered next? Goniotomy Trabeculectomy Trabeculotomy Drainage implant
Glaucoma is the most common and serious complication in children with Sturge-Weber syndrome. Glaucoma develops in about half the cases. Therapy with topical drops can be effective, but when medical management fails, surgery is indicated. Setons or aqueous drainage devices have been shown to be useful for management of intractable glaucoma in patients with Surge-Weber syndrome. Goniotomy and trabeculotomy are not appropriate treatment methods in patients with Sturge-Weber syndrome who have failed previous surgical and medical management. Trabeculectomy in the absence of mitomycin-C is also unlikely to be successful in this patient.
What type of tropia is usually a V-pattern strabismus? Intermittent exotropia Refractive esotropia Infantile esotropia Sensory exotropia
V-pattern strabismus is a pattern in which the eyes are more adducted in downgaze than in upgaze. The etiology is unknown except in cases of extraocular muscle palsies. Multiple theories suggest primary or secondary muscle dysfunction, which can involve inferior oblique muscle overaction, superior oblique muscle underaction, horizontal rectus muscle dysfunction, or extorsion of the globe and bony orbit which may lead to a V- or A- pattern. Infantile esotropia usually presents with a V-pattern. Refractive esotropia, intermittant exotropia and sensory exotropia are not commonly V-patterned.
When managing a vertical strabismus associated with thyroid eye disease, how should the timing of strabismus surgery be related to proptosis surgery?
Perform strabismus surgery after orbital decompression
Perform strabismus surgery before orbital decompression
Perform strabismus surgery after eyelid surgery
Perform simultaneous strabismus surgery and eyelid surgery
In patients with thyroid eye disease, surgical management is indicated for diplopia or an anomalous head posture. Orbital decompression may adversely affect ocular motility and eyelid position. As a result, eyelid and extraocular muscle surgery should be deferred if orbital decompressive surgery is contemplated. Strabismus surgery may affect eyelid position. Thus, eyelid surgery should be deferred if extraocular muscle surgery is contemplated.
A 3-month-old infant has a history of a difficult birth with prolonged hypoxia. The child is noted to have severe neurologic impairment, including poor visual response. The ocular examination demonstrates no apparent visual fixation responses. Wandering ocular movements are present, but are not typical of nystagmus. The remainder of the examination, including assessment of the pupils, retina, and optic nerve, appears normal. Which of the following is the best method for predicting the visual outcome?
Following the patient with sequential examinations
CT scan
Visual evoked responses
Electroretinogram
An electroretinogram can aid in ruling out a retinal abnormality, but is unlikely to be helpful in this case since the damage is most likely at a higher level in the visual system. Many studies have attempted to use visual evoked response (VER) to help in determining visual prognosis in infants following cortical visual loss, but they have reported conflicting results. At the present time, it appears that the flash-evoked VER is not reliable enough to aid in predicting the visual outcome of infants who suffer a neurologic insult. CT scan or MRI of the brain may offer better clues than VERs in predicting visual outcome; however, the results are not conclusive. The best method for predicting a child’s visual outcome appears to be sequential examinations during the first year or two of life.
A 21-year-old woman presents with exotropic Duane’s syndrome. Which one of the following surgical options is most likely to benefit this patient?
Resection of the medial rectus muscle in the uninvolved eye
Recession of the lateral rectus muscle in the involved eye
Resection of the medial rectus muscle in the involved eye
Recession of the lateral rectus muscle in the uninvolved eye
Recession of the lateral rectus muscle in the involved eye is most likely to benefit patients with exotropic Duane’s syndrome in the presence of primary position deviation. The procedure also eliminates any existing head turn. When patients with exotropic Duane’s syndrome have a deviation greater than 20 prism diopters in primary position, recession of the lateral rectus muscle in both eyes should be performed for maximum benefit. Resection of the medial rectus muscle in the involved eye will worsen globe retraction in patients with exotropic Duane’s syndrome, and for this reason, the procedure should be avoided. Recession of the lateral rectus muscle in the uninvolved eye alone will have minimal to no effect on the patient’s ocular alignment. Resection of the medial rectus muscle in the uninvolved eye will also have minimal to no effect.
A 3-month-old infant presents with a history of constant epiphora since birth. On examination the patient appears relatively comfortable and is found to have epiphora with mucopurulent discharge from both eyes. Fluorescein solution is placed into the tear film of each eye, and the patient is noted to have significant retention of the fluorescein dye with failure of the dye to appear in the nose after 15 minutes. The remainder of the exam is normal. Which of the following is the most likely diagnosis?
Congenital nasolacrimal duct obstruction
Bilateral punctual atresia
Congenital glaucoma
Bilateral conjunctivitis
Obstruction of drainage below the lacrimal sac tends to occur in 5% of newborns and is usually caused by a thin mucosal membrane at the distal end of the nasolacrimal duct. Symptoms consist of epiphora and mucoid or mucopurulent discharge. The impatency of the drainage system can be confirmed by placing fluorescein solution in the tear film and noting retention of the dye in the tear film after 5-10 minutes. The dye will also fail to appear in the nose or pharynx after 10-15 minutes. Conservative management involves nasolacrimal massage with topical broad spectrum antibiotics. Initial surgical management involves nasolacrimal duct probing. Conjunctivitis may have discharge that is serous, mucopurulent, or purulent. Patients with conjunctivitis tend to have burning, stinging, foreign body sensation, ocular discharge, and matting of the eyelids. Congenital glaucoma is associated with epiphora, photophobia, and blepharospasm. The cornea also tends to be enlarged with corneal clouding. Punctal atresia is usually ruled out by inspection.
Which of the following is not a classical feature of incontinentia pigmenti?
Retinal dysplasia
Peripheral retinal vascular anomalies
Increased incidence in male infants
Skin lesions presenting soon after birth
Incontinentia pigmenti is an uncommon familial disorder affecting the skin, bones, teeth, central nervous system, and eyes. It is thought to be inherited as an X-linked dominant disorder that is usually lethal in males, and therefore leads to a marked female predominance. Ocular abnormalities occur in about 35% of cases. Peripheral retinal vascular anomalies are common. The most serious complication is retinal dysplasia, which is associated with severe visual loss.
The parents of a 5-month-old boy bring him into your office concerned that he does not seem to see anything. He was the product of a full-term, uncomplicated pregnancy and had no neonatal problems. Developmental history reveals that he is rolling over and starting to sit unsupported. On your examination, the child does not fixate or follow but will blink at a bright light. Cycloplegic refraction reveals +3.00 sphere OD and +3.50 sphere OS. Pupils are round, equal in size and briskly reactive to light, without a relative afferent pupillary defect. He has full ductions and versions, an approximately 20 PD exotropia, but no nystagmus or wandering eye movements. He also has clear media and a normal fundus. What does this child most likely have? Refractive amblyopia Delayed visual maturation Leber's congenital amaurosis Foveal hypoplasia
Infants with profound sensory visual loss, such as that caused by Leber’s congenital amaurosis or foveal hypoplasia, should demonstrate sluggish pupillary reaction and nystagmus by 2 to 4 months of age. Infants with high refractive errors will still fixate on a light and on large objects that are up close, such as a face, but this child does not do so. Poor visual attention in an otherwise normal baby is the hallmark of delayed visual maturation. Often these infants perform very well when tested with preferential grating acuity tests, such as Teller acuity cards, despite their lack of interest in lights and faces. Delayed visual maturation is a diagnosis of exclusion, confirmed only in retrospect. Although most infants with this diagnosis will demonstrate normal visual behavior by 1 year of age without specific therapy, careful follow-up every 3-4 months is warranted until the child demonstrates normal visual behavior or additional findings become apparent.
