Peds & Strabismus Flashcards
1
Q
Corneal light reflex tests should be used to evaluate binocular alignment for what patients?
A
Patients with poor vision in one or both eyes (can’t fixate). Unable to cooperate to allow cover testing or poor vision with poor fixation.
2
Q
Hirschberg method
A
Corneal light reflex based on premise - 1 mm of decentration corresponds to 7 degrees or 15 diopters of ocular deviation of the visual axis.
3
Q
Krimsky method
A
corneal light reflex test - reflections produced on both corneas by penlight at near fixation
4
Q
Bruckner
A
direct ophthalmoscope to obtain red reflex simultaneously in both eyes
5
Q
Major amblyoscope method
A
corneal light reflex test uses separate target illumination which can be moved to center the cornea light reflection, deviation read off of scale
6
Q
In what cardinal position is the left superior oblique muscle the prime mover
A
down to the right
7
Q
Cardinal positions
A
prime mover is 1 muscle of each eye, together called yoke muscles. 6 cardinal positions
8
Q
9 diagnostic positions of gaze
A
6 cardinal positions plus straight up and down and primary
9
Q
Draw the 6 cardinal positions of gaze and the prime movers
A
2 o’clock: LSR, RIO 3 o’clock: LLR, RMR 5 o’clock: LIR, RSO 7 o’clock: RIR, LSO 9 o’clock: RLR, LMR 11 o’clock: RSR, LIO
10
Q
Syndromes a/w ocular-cutaneous albinism
A
Chediak-Higashi syndrome Hermansky-Pudlak
11
Q
AR disorder with mutation in lysosomal trafficking regulator protein that renders inadequate phagocytosis, pyogenic infections involving respiratory and cutaneous sx. Rarely survive past 10 years
A
Chediak-Higashi
12
Q
AR disorder characterized by ocular-cutaneous albinism, bleeding problems from platelet abnormality
A
Hermansky-Pudlak syndrome
13
Q
Iris transillumination defects, fundus hypopigmentation, decreased melanin distribution in the RPE and choroidal tissue
A
Ocular albinism
14
Q
Infant aphakia treatment study group finidng
A
IOL implantation in infants age 1 to 6 months is a/w higher rates of adverse events requiring furter surgery and no better grating acuity at 1 year
15
Q
Greatest risk for isoametropic amblyopia
A
Astigmatism
16
Q
Features of brain scan and CSF in child with IIH
A
NORMAL sized or SMALL ventricles Normal CSF
17
Q
risk factors for IIH
A
viral infections, drug use (tetracycline, corticosteroids, vitamin A, nalidixic acid, thyroid medications, GH), central venous sinus thrombosis
18
Q
Feature characteristic of congenital ptosis
A
decreased levator function poorly formed eye crease Results from dystrophic development of levator withotu innervational abnormalities
19
Q
Length of lid tissues and levator in congenital ptosis
A
Not longer than normal
20
Q
M/c blockage location in congenital NLDO
A
valve of hasner
21
Q
What genetic disorder is congenital iris ectropion most commonly seen in
A
NF1 Also seen in prader-willi syndrome or facial hemihypertrophy
22
Q
Corneal crystals
A
cystinosis
23
Q
Eye movement abnormality can occur in healthy infants in first months of life
A
intermittent esotropia
24
Q
Epiblepharon
A
congenital anomaly with horizontal fold of skin adjacent to lower eyelid, causing inward rotation of lashes against cornea (occurs in chubby cheek and asians)
25
Eversion of eyelid margin secondary to vertical deficiency of skin
congenital ectropion
26
enlargement of lateral aspect of palpebral fissure with downward displacement of temporal half of lower eyelid
Euryblepharon
27
Age at which infant maintains fixation and reacts with facial expressions
6-8 weeks
28
Age interested in bright objects
2-3 months
29
Age at which nasal bias for smooth pursuit should have resolved, eyes orthotropic and fix-and-follow response to small (2-4 inches in diameter) toy
3-4 months
30
Patient with sporadic aniridia must be evaluated for..
Wilms tumor with renal ultrasonography which must be repeated until molecular genetic analysis r/o 11p13 deletion and confirms an intragenic PAX6 mutation
31
Method recommended for assessing the refractive state in amblyopia
Cycloplegic retinoscopy
32
Congenital eyelid malformation that would require early repair
eyelid coloboma (eyelid cleft, eyelid notch) - risk of exposure keratopathy
33
Preferred surgical procedure to treat upshoots and downshoots in Duane syndrome
Y-splitting of lateral rectus muscle
34
Treatment for vision-threatening periocular hemangiomas
oral propranolol
35
Laboratory test that should be ordered for patient with enlarging infantile capillary hemangioma and Kasabach-Merritt syndrome
platelet count - sequestration of platelets within large vascular lesion such as hemangioma leading to thrombocytopenia
36
What is isoametropic amblyopia (b/l ametropic amblyopia)
bilateral decreased VA due to large approximately equal uncorrected refractive errors in the 2 eyes of child
37
Type of hyperopia and myopia that carry risk of inducing isoametropic amblyopia
Hyperopia exceeding 4.00 D-5.00D and myopia exceeding 5.00-6.00D
38
Type of amblyopia induced by capillary hemangioma
Anisometropic amblyopia - induces astigmatic refractive error (8 diopters of astigmatism)
39
What is anisometropic amblyopia?
Dissimlar refractive error in 2 eyes
40
Epiblepharon
condition in which the eyelid pretarsal muscle and skin ride above the eyelid margin to form a horizontal fold of tissue that causes the cilia to assume a vertical position
41
A pattern exotropia frequently a/w...
Superior oblique overation
42
V pattern exotropia frequently a/w...
Inferior oblique muscle overaction
43
When is A pattern considered clinically significant
difference between upgaze and downgaze is at least 10 PD
44
When is V pattern considered clinically significant
at least 15 prism diopters
45
Surgery that would most benefit an 18-month old child with V-pattern infantile esotropia and bilateral DVD
bilateral MR recessions and bilateral IO recessions
46
IO recession will address
V pattern and DVD
47
Leading cause of blindness in the word
cataract 48% of cases, glaucoma 12%
48
M/c strabismus in FAS
esotropia
49
FAS features
craniofacial - short palpebral fissures, telecanthus, strabismus (esotropia), ptosis, ON hypoplasia, tortuosity of retinal vessels
50
Most likely cause of chin up posture
V-pattern exotropia
51
Most likely cause of chin down posture
A-pattern exotropia
52
Occur in up to 1/4 of all horizontal strabismus cases
A-pattern or V-pattern strabismus
53
M/c mode of inheritance of NF1
AD (however 50% of patients have (-) FHx)
54
Following surgery for congenital cataract, what finding predisposes a child to glaucoma
Small corneal diameter (microcornea) or persistent fetal vasculature
55
M/c ocular finding in neonate with congenital rubella syndrome (CRS)?
Unilateral or bilateral pigmentary retinopathy (25%-50%) "salt-and-pepper" Cataract (15%) Glaucoma (10%)
56
5 yo F with 1-month h/o intermittent nasal discharge, tearing, itchy eyes, conjunctiival injection. Initial therapy?
Oral antihistamines - useful if nasal congestion less effective for ocular sx but better tolerated in children
57
Inheritance pattern for most patients with primary congenital glaucoma?
SPORADIC (rarely AR)
58
Finding of a DVD is a/w?
congenital strabismus
59
Pattern of strabismus a/w aberrant innervation of LR muscles in upgaze?
Y pattern (pseudo-overaction of inferior obliques)
60
Patient with A-pattern exotropia will adopt this head posture.
Chin down
61
For a paretic or restricted eye in fixation, what term describes the deviation of alignment?
SECONDARY - deviation measured when the paretic or restricted eye is fixating
62
What is the primary deviation?
deviation measured when the nonparetic eye is fixating.
63
What is a consecutive devation?
Strabismus that is in the direction opposite to one that the patient had originally.
64
Most common intraocular finding in NF1?
iris melanocytic nodules (Lisch nodules)
65
Diffuse choroidal hemangiomas found in this phacomatoses?
Sturge-Weber syndrome
66
Capillary hemangioblastomas of the retina or optic disc
von Hippel-Lindau syndrome
67
Preoperative test that is most helpful in assessing opportunity for single binocular vision after strabismus?
Amblyoscope - tests for retinal correspondence
68
Exodeviation that orthoptic exercises are most appropriate initial therapy for?
Convergence insufficiency
69
Draw Cardinal positions
70
CRS (25%-50%) variation from finely stippled, bone spicule-like, small, black, irregular masses to gross pigmentary irregularities with coarse, blotchy mottling. Stationary or progressive.
71
Epiblepharon
72
Capillary hemangioma - risk for anisometropic amblyopia
73
Ligneous conjunctivitis
74
V-pattern exotropia
75
Neurofibromas in NF1 m/c finding in eye would be iris melanocytic nodules (Lisch nodules)
76
Large-angle constant exodeviation before age 6 months
Infantile exotropia (XT)
77
Risks a/w infantile XT
neurologic impairment or developmental delay
78
Another name for Tuberous sclerosis complex
Bourneville-Pringle disease
79
Retinal astrocytic hamartomas are seen in this disease with what frequency?
Tuberous sclerosis (Boruneville-Pringle) in 40% of patients
80
Retinal lesions more common in patients with this tuberous sclerosis mutation?
TSC2 (16p13.3)
81
Vogt triad
Seen in tuberous slerosis:
(1) facial sebaceous adenomas (angiofibromas)
(2) mental deficiency
(3) Seizures
82
What additional eye motility abnormality do patients with infantile strabismus commonly have?
dissociated vertical deviation (DVD)
83
Asymmetric smooth pursuit, which is better in the temporal-to-nasal direction
infantile esotropia
84
Cause for exotropic duane syndrome
abnormal development of the abducens nerve/nucleus resulting in anomalous innervation of the lateral rectus muscle by aberrant branches of oculomotor nuclei.
Globe retraction and palpebral fissure narrowing are caused by simultaneous activation of horizontal recti
85
Type II Duane syndrome
Exotropic (less common)
86
Type I Duane syndrome
Esotropic (more common)
87
Surgical treatment for Duane syndrome
lateral rectus muscle recession in one or both eyes
88
Constant tearing with copious mucus discharge in neonate
nasolacrimal duct obstruction
89
Constant tearing with minimal mucopurulence in neonate
punctal or canalicular agenesis
90
Intermittent tearing with mucus discharge in neonate
intermittent obstruction of NLD, most likely 2/2 swollen inferior turbinate mucosa a/w upper respiratory tract infection or allergy
91
Indications for strabismus surgery
Improving functional vision by
decreasing diplopia
relieving asthenopia
improving ocular alignement
establishing or restoring stereopsis
expanding binocular visual fields
shifting bision to central location (reduce head turn)
92
This procedure shifts the null point to the primary position
Kestenbaum-Anderson procedure
93
What ophthalmic disorder is moyamoya disease associated with?
morning-glory disc anomaly
94
Morning-glory disc anomaly
(1) Basal encephalocele in patients with midface anomalies
(2) PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial lesions, cardiac and eye anomalies)
(3) Carotid circulation (moyamoya)
95
For patient with DVD, what motility anomaly accompanies the upward movement?
Extorsion and exodeviation of the globe
96
Procedure effective in simultaneously treating dissociated vertical deviation and inferior oblique overaction?
Inferior oblique anteriorization
97
What is a DVD?
Dissociated vertical devation - an innervational disorder in which either eye slowly drifts upward and outward with extortion when the eye is occluded or there is visual inattention.
98
When does a DVD develop?
Typically by age 2 years commonly in infantile strabismus, typically with esotropia or exotropia (50%)
99
What type of misalignment is an alternating acquired esotropia?
Comitant deviation (deviation does not vary in different gazes)
100
What is the most frequent cause of childhood visual impairment in developed countries?
retrogeniculate visual impairment (cerebral visual impairment CVI) - visual deficits related to pathology posterior to the lateral geniculate nucleus.
101
Frequently found additional ophthalmic finding in pseudopapilledema that supports this diagnosis?
Hyperopia - optic discs with small cup-disc ratios can resemble papilledema are commonly seen in hyperopic eyes.
102
What is the most severe ocular complication of Stevens-Johnson syndrome?
Corneal ulcer
103
For a child with optic nerve hypoplasia, what visual acuity would be consistent with the diagnosis?
20/20 to NLP correlating well to integrity of macular fibers.
104
What congenital lens abnormality is typically associated with a marked abnormal and disorganzied eye?
congenital aphakia
105
rare autosomal condition in which there is bilateral displacmeent of the pupil, usually inferotemporally, and dislocation of the lens in the opposite direction
ectopia lentis et pupillae
106
lens that is smaller, round, and bilateral
spherophakia
107
Positive angle kappa in this disorder
pseudoexotropia
108
Clinical features of infantile esotropia?
(1) Deviation greater than 30 PD
(2) Overelevation in adduction
(3) DVD
(4) Low hyperopia (1.00 - 2.00 diopters)
109
What congenital ocular disorder is most ommonly associated with paradoxical pupillary reaction?
Inherited retinal dystrophies
110
Where is the origin of the superior oblique?
Orbital apex above the annulus of zine
111
origin of inferior oblique
orbital rim
112
Beneficial effect on VF can occur as a result of strabismus surgery?
Expansion of binocular visual field following surgery for esotropia
113
DFE findings with coats disease
yellow subretinal and intraretinal exudates associated with retinal vascular abnormalites--often telangiectasia, tortuosity, aneurysmal dilations, and avascularity--with variable clinical presentation from mild changes to total RD
114
Preferred surgical treatment to treat exodeviation from sensory exotropia caused by macular scar in right eye
lateral rectus recession and medial rectus resection in the right eye
115
What is the most common serious ocular complication in Sturge weber syndrome?
Glaucoma - occurs in 70% of SWS patients
116
"Hard" stop at end of horizonatl passage during probing of lacrimal system is characteristic of what condition?
successful probing to the nasal bone of lacrimal sac
117
In what genetic disorder is pupillary block glaucoma most likely to occur?
Weill-Marchesani syndrome - a/w microspherophakia - dislocate into AC
118
Type of uveitis most common in children
anterior uveitis - m/c idiopathic, related to trauma, or a/w juvenile idiopathic arthritis
119
Micropthalmos, iris and ciliary body colobomas, retinal dysplaisa, cartilage within the ciliary body coloboma
trisomy 13 (Patau)
120
Conditions with intraocular cartilage
Ciliary body colobomas in trisomy 13
medulloepitheliomas
persistent fetal vasculature (persistent hyperplastic primary vitreous, PHPV)
121
Synophthalmia
fusion of 2 optic vesicles and evelutally globes (seen in trisomy 13)
122
Non-ocular bnormalities in trisomy 13
microcephaly
holoprosencephaly (failure of forebrain to divide into 2 hemispheres)
single orbit
nasal proboscis
digital defects
urogenital defects
cardiac defects
123
Optic nerve finding in periventricular leukomalacia
optic nerve cupping
124
M/c cause of glaucoma-like optic nerve cupping in preterm infants
Periventricular leukomalacia (prominent cause of cerebral (retrogeniculate) visual impairment
125
Funnel-shaped excavation of the posterior fundus involving the optic disc
morning glory anomaly - PHACE syndrome (posterior fossa malformations, hemangiomas, arterial lesions, cardiac and eye anomalies)
126
CHARGE syndrome
Coloboma
Heart defects
choanal Atresia
mental Retardation
Genitourinary abnormalities
Ear abnormalities
127
if no Fhx of primary congenital glaucoma, what is chance that parent with PCG will have child with PCG?
2% - usually sporadically but occasional AR
128
Four chromosomal loci and genes for primary congenital glaucoma
GLC3A, GLC3B, GLC3C, GLC3D
LTBP2 and CYP1B1
129
M/c exodeviation
intermittent exotropia
130
Type of amblyopia most likely to respond to treatment in teenager without prior therapy
anisometropic amblyopia
131
What material are the extraocular muscle pulleys primarily composed of?
elastin
also smooth muscle and collagen
132
Oral medication for treatment for infant with ophthalmia neonatorum secondary to chlamydia trachomatis infection
oral erythromycin
133
Procedure most often recommended to correct oculomotor deviation in primary position and reduce or eliminate face turn in esotropic duane syndrome?
Recession of medial rectus muscle on the involved/inturning side
134
Name 3 congenital cranial dysinnervation disorders
Duane syndrome
Mobius syndrome
congenital fibrosis syndrome
135
18 mo old boy who underwent bilateral NLD probing 6 months ago p/w recurrent epiphora and mucopurulent discharge from each eye. Next step?
nasolacrimal duct probing
136
Extraocular muscle disorder that pseudoptosis be associated with
hypotropia
137
Treatment for cyclic esotropia
Surgery for maximum angle of esotropia
138
Curvilinear tears in descemet membrane
primary congenital glaucoma - Haab striae are seen because of rapid stretching of the cornea
139
linear tears in descemet membrane
forceps injury
140
Indications for treatment for toxoplasma gondii chorioretinitis
immunocompromsied patient
dense vitreous opacity
large lesions greater than 1 DD
multiple lesions
decreased VA
frequent recurrences or retinitis theratening the ON or macula
141
Antimicrobial regimen for toxoplasma gondii chorioretinitis
combination of sulfonamide such as sulfadiazine and pyrimethamine or trimethoprim/sulfamethoxazole, clindamycin and azithromycin alone or in combination
142
Inheritance pattern for ectopia lentis et pupillae
autosomal recessive pattern
143
Vergences
movements of the eyes in opposite directions
144
What is the most commonform of intermittent exotropia?
**Pseudodivergence excess exotropia** - larger deviation at distance than at near. With monocular occlusion or with +3.00 lenses at near, the deviation becomes minimal.
145
Preferred treatment for allergic conjunctivitis in a child after oral antihistamines?
Topical H1-receptor blocker or mast cell stabilizing drop
146
Clinical features of brown syndrome
(1) Deficient elevation in adduction (with widening of palpebral fissure and downshoot of involved eye)
(2) improved elevation in abduction
(3) V pattern
147
Most significant risk factor for developing ROP
**gestational age** and birth weight
148
What anatomical feature of the inferior oblique muscle differs from that of the other extraocular muscles?
Its origin is on the medial side of the orbit
149
primary action of the inferior oblique
extorsion
150
Tx for congenital CMV infection
intravenous ganciclovir
151
intraventricular calcifications, microcephaly, fever, jaundice, hearing loss, retinitis (retinal whitening, edema, perivascular sheathing, intraretinal hemorrhages), optic nerve abnormalities, microphthalmos, cataract, uveitis
Congenital cytomegalovirus infection
152
M/c cause of visual impairment in children with abusive head trauma?
cortical or cerebral injury
153
"ragged-red" fibers
Mitochondrial myopathy
154
Visual acuity at 3 months
20/120 range
155
Demographic and epidemiologic characteristics of pediatric uveitis
Pediatric uveitis accounts for 2%-14%
Slight female preponderance
Mostly bilateral
Age 8-9 at diagnosis
no FHx (not inherited)
156
M/c cause of pseudopapilledema in children
optic disc drusen
157
Clinical finding suggests a bilateral rather than unilateral SO muscle palsy?
large V pattern
158
Most appropriate initial therapy for high accommodative convergence/accommodation (AC/A) esotropia?
bifocal spectacles - reduce need for accommodation at near and allow potential development of fusion and stereopsis
159
Classic clinical triad of primary congenital glaucoma
Epiphora
photophobia
blepharospasm
160
Corneal diameter that is suggestive of glaucoma in a newborn
\> 11.5 mm
161
Corneal diameter that is suggestive of glaucoma in a 1 year old
\> 12.5 mm
162
Corneal diameter that is suggestive of glaucoma in any child
\> 13.0 mm
163
Primary purpose of the 4-diopter base-out prism test?
Used to document a facultative scotoma in a patient with no manifest deviation
Documents the presence of a small macular scotoma in a patient with monofixation syndrome and either a microstrabismus or no manifest deviation
164
An object that is projected onto a noncorresponding retinal point is seen singly. What is this called?
Panum's area -
165
What muscles are supplied by the medial muscular branch of the ophthalmic artery?
Inferior rectus
Medial rectus
Inferior oblique
166
What muscles are supplied by the lateral muscular branch of the ophthalmic artery?
Lateral rectus
superior rectus
superior oblique
levator palpebrae superioris
167
Clinical finding that can distinguish orbital cellulitis from preseptal cellulitis
chemosis
168
Mechanism of action of botulinum toxin
prevents release of acetylcholine from **presynaptic** motoneurons
169
mode of inheritance of incontinentia pigmenti
X-linked dominant - presumed lethal effect on hemizygous male fetus
170
What is the principal reason that patients with oculocutaneous and ocular albinism have decreased vision?
foveal hypoplasia
171
retrobulbar anesthesia results in this position of eye
**incyclotorsion and depression of eye** (III and VI anesthetized - abduction, supraduction, excyclotorsion wound not occur) trochlear nerve lies outside annulus of zinn and results in intact incyclotorsion and infraduction
172
When distinguishing congenital motor nystagmus (infantile nystagmus syndrome) from acquired nystagmus, what clinical finding is most useful?
Abnormal head position - patients with congenital motor nystagmus (CMN; infantile nystagmus syndrome) often adopt an abnormal head position to take advantage of the better vision that is possible at a null point
173
Earliest sign of anterior segment ischemia following strabismus surgery
**Anterior chamber cell and flare**
More severe -\> corneal epithelial edema, descemet membrane folds, irregular pupil, anterior segment necrosis and phthisis bulbi can occur
174
Best way to measure ocular misalignment that does not rely on sensory or motor response from patient
Krimsky test
175
Haab striae
176
A pattern - SO overaction
177
V pattern
178
V pattern (would addopt chin up position)
179
periungual fibroma, facial sebaceous adenomas (angiofibromas) cafe-au-lait spot, cortical tubers
180
Astrocytic hamartoma in TSS
181
esotropic (Type I) Duane syndrome
182
NLDO
183
Optic nerve hypoplasia
184
Coats disease - yellow subretinal and intraretinal exudates
185
esotropic duane syndrome tx is recession of MR of left eye
186
toxoplasma gondii chorioretinitis
187
Ectropia lentis et pupillae
188
Brown syndrome
189
Lisch nodules - hamartomas
190
posterior embryotoxon
191
forceps trauma - vertical oblique breaks
192
ragged red fibers
193
R SO palsy
194
Haab striae
195
Hyperacute conjunctivitis
196
197
molluscum contagiosum
198
**Coats disease**
extensive **subretinal fibrosis** with areas of exudation throughout the macula and hemorrhage with light bulb aneurysms temporally. There is a **fibrous nodule** with surrounding subretinal fluid in the inferior macula and additional fluid temporal to the macula.
199
FA prediction of this fundus
extensive capillary dropout, light bulb aneurysms, and dilated telangiectatic vessels.
