phase II ophtho Flashcards
pt presents w/ warm, erythematous, tender lid, w/ proptosis and painful restricted ocular motility. What is the w/u and treatment?
CT scan of orbits and sinuses + admit to hospital. Start IV abx for 72 hrs then 1 week oral meds orbital cellulitis
pt. has hx of sinusitis and hordeolum. presents w/ tender red swollen lids. There is no proptosis, optic neuropathy,, or pain w/ eye mvmt. what is the treatment
Mild: oral abx (augmentin) mod to sev: admit for IV preseptal cellulitis
pt. presents w/ erythematous, tender, tense swelling over the nasal aspect of the lower eyelid extending around the periorbital nasally. Mucupurulent discharge can be expressed from the punctum when pressure is applied over the lacrimal sac. What is the treatment?
refer to ophtho children: augmentin adults: cephalexin if either are FEBRILE then admit consider dacryocystorhinostomy dacryocystitis
pt. presents w/ swelling and tenderness over outer 1/3rd of upper eyelid. may be associated w/ hyperemia of the palpebral lobe of the lacrimal gland. what etiology is MC? What is the treatment?
inflammatory MC associated w/ lymphoproliferation and sarcoidosis. Can be seen w/ mumps. empirically treat w/ abx for 24 hrs. if viral then cool compresses dacryoadenitis
pt. presents w/ intense eye itching. Bilateral erythema, stringy mucoid discharge and conjunctival PAPILLAE w/ prominent CENTRAL BLOOD vessel. what is the trx?
topical meds: Mild: artificial tears mod: topical antihistamine/mast cell stabilizer (olopatadine, ketotifen) severe: (topical steroid (loteprednol) oral antihistamine: cetirizine, fexofenadine, loratadine allergic conjunctivitis
patient presents w/ acute red eye, complaining of gritty/foreign body sensation. Had recent URI. Has FOLLICULAR response w/ NO central blood vessel. Pt. also has preauricular lymphadenopathy and diffuse injection w/ watery discharge. what is the MC cause and what is the treatment?
adenovirus, strict hand washing and should resolve in 2-3 weeks. HIGHLY contagious for 10-12 days (as long as eyes are red). Let them know that it may infect the other eye in a few days. viral conjunctivitis
pt. presents w/ redness, foreign body sensation, and purulent white-yellow discharge that causes eyelids to stick together especially in the morning. What is the common cuae? and what is the treatment?
staphylococcus aureus (blepharitis), staph epi, HIB (children w/ otitis media) topical abx: trimethoprim/polymxin B or fluorquinolone for 5-7 days HIB: oral augmentin if associated w/ dacryocystitis then systemic abx
bacterial conjunctivitis
what is the treatment if you suspect neisseria or chlamydia conjunctivitis?
Gonococcal ceftriaxone 1gm IM, hospitalize IV ceftriaxone q 12-24 rhs if corneal involvement topical fluoroquinolone if corneal involement chlamydia azithromycin 1g po single dose or doxy 100 mg BID 7 days
what does the munson sign correlate w/?
keratoconus: thinning of central cornea. bulging on lower lids from thinning central corena causeing bulging of inferior cornea
gray, white, or yellow deposits in the peripheral cornea?
arcus senilis either from an age related change or abnormal hyperlipoproteinemia (<40 check lipids)
younger adult pt. presents w/ sectoral redness in one or both eyes. the eye does not have a bluish hue and blanch w/ application of topical phenylephrine. The injected vessels can also be moved w/ a q tip. the patient has a hx of (ROSACEA, atopy, collagen vascular disease, gout, rheumatoid arthritis, SLE, syphilis and thyroid). what is the treatment?
refer to optho mild: cold compress, artificial tears. mod to severe: topical steroid alternate is oral steroids episcleritis
older adult presents w/ severe BORING eye pain that radiates to forehead, brow, and jaw that awoke them from sleep. They have inflammation of the slcera, episclera, and conjunctival vessels. The injection cannot be moved w/ q tip and do not blanch w/ epinephrine. The sclera is somewhat blude. what is the treatment and common cuaes?
connective tissue disease (RA, wegener granulomatosis, SLE, polyarteritis nodosa, IBD, anklylosing spondylitis) refer to ophtho Histamine 2 blockers (ranitidine) w/ these treatments NSAIDs (ibuprofen, naproxen, indomethacin) 3 tried before considering failure systemic steroids: prednisone 1 week then tapered if no improvement w/ steroids immunosuppressive therapy
pt. presents w/ pain, redness, photophobia, and pain in the affected eye when a light is shone in the fellow eye. On inspection the eye has CELLS and FLARE in the anterior chamber, ciliary flush (injection surrounding the cornea), and keratic precipitates. what are some causes?
HLA-B27 (ankylosing spondylitis, reactive arthritis (reiter’s), psoriatic arthritis, IBD, Behcet diseaes, Lyme disease, JIA (4 or fewer joints?), sarcoidosis, herpes, syphilis, TB trx: cycloplegic agent (scopalamine and atropine) topical steroid (prednisolone) anterior uveitis (iritis)
what can cause posterior uveitis?
toxoplasmosis
patient presents w/ inflammatory cells in the viterous causing HAY findings with fundoscopic exam. they also have decreased vision and floaters/
posterior uveitis
nuclear cataract does what?
blurs distance vision more than near vision (yellow or brown discoloration of central part)
posterior subcapsular cataract does what?
opacities near posterior aspect of lens causes glare and difficulty reading MC.
infant that has opacity of lens at birth and may keep eyes close, w/ leukocoria and has hx of mother w/ rubella and baby has galactosemia, lowe syndrome.
congenital cataract EMERGENCY: brain lears to see w/ macula in first 3 to 4 months of life
pt. presents w/ slowly progressing visual loss. glare when dirving at night and reduced color perception. May have a decresed red light reflex. PE reveals opacification of the normally clear lens.
cataracts, refer to ophtho.
what is the associated w/ salt and pepper retinopathy?
rubella infection
what causes bull’s eye maculopathy, w/ blurred vision and night blindness?
chloroquine (anti-malarial)
what causes whorl keratopathy?
amiodarone
MC cause of cataracts?
age related (senile)
what is the MC sever infection of the eye?
cytomegaly
what is the treatment for a conjunctival laceration?
r/o ruptured globe and if <1 cm erythromycin and > 1cm surgical closure
when do you not want to patch for a corneal abrasion?
if the pt. had vegetative matter/fingernails involved or if pt. wears contact lenses
what do you have to do for a corneal abrasion?
evert the eylid so you can look for foreign body and slit lamp
what should you do for a ruptured globe?
you should shield it, never patch. Get immediate surgery.
what is the treatment for herpes simpex keratitis?
dont use steroids, refer and give topical acyclovir
when to patch for strabismus?
patch the good eye for 2-6 hrs per day. leave the patch until either the vision improves or their is a failure of 3 consecutive patching cycles. F/u is per 1 week of age.
what is the treatment for bacterial keratitis?
refer to eye clinic; topical fluoroquinolone and fortified antibiotics give every 30 min around the clock. alternating tobramycin/gentamyicin and cefazolin/vancomycin
what defect is described as a feathery white/yellow opacity?
fungal keratitis
what is the treatment for fungal keratitis?
refer to ophtho, for surgical debridement. Then know it’s going to be a fungal medication. NO TOPICAL STEROIDS
what is described as a severe/boring eye pain?
scleritis
what cataracts are assoicated w/ diabetes, trauma, radiation, and inflammation?
posterior subcapsular
what are damaged when a lens dislocates?
zonular fibers, think marfan, homocystinuria, syphilis
what is the normal A:V ratio?
2:3, veins and arteries travel together, but veins do not cross veins and arteries do not cross arties
painless vision loss, w/ marked whitening of the retina and a cherry red spot or box car segmentation in artioles. Ciliretinal artery is spared and there is a relative afferent pupillary defect. what is the work up?
retinal artery occlusion, if only hemifield vision is lost then branch of retinal artery. W/u includes immediate ESR to r/o giant cell arteritis. trx includes ophtho referral, no effective treatment
how can the macula be spared in retinal artery occlusion?
ciliretinal arties arise form choroidal blood supply
painless vision loss, pE shows blood and thunder, tortuous veins, flame shaped hemorrhage, cotton wool spots and neovascularization. what is the workup?
decide if its ischemic or non ischemic. ischemic >= 6 or more cotton wool spots. vision typically worse than 20/400. appt. w/in 48 - 72 hrs w/ ophtho. discontinue birth control and start aspirin
retinal vein occlusion
what is the MC cause of blindness over the age of 60?
age related macular degeneration
pt has drusen (yellow spots on retina), gradual loss of CENTRAL vision, distortion of straight lines. what is the work up?
amsler grid testing and IV flurescin angiography and ask family history
difference between wet and dry macular degeneration?
dry: gradual loss, drusen, clumps of pigment on outer retina
wet: rapid onset of visual loss, distortion of straight lines, drusen, choroidal neovscularization, subretinal hemorrhages
what is the treatment for dry and wet macular degeneration?
dry: vitamin C, E, betacarotene, zinc
wet: laser photocoagulation done w/in 72 hrs of angiography
what are the 3 types of retinal detachment?
- rhegmatogenous, exudative, traction
what causes a rhegmatogenous retinal detachment?
liquified vitreous
what causes exudative and traction retinal detachment?
exudative doesnt fully come off, think of it moving depending on change in position typically cuased by something below the retinal layer
taction: diabetic retinopathy
pt has flashes and floaters, decreased vision w/ curtain or shade pulloed down. describes vision as wavy. They have an afferent pupillary defect. pe shows retinal hydration lines (ripple on a pond), and a decreased red light reflex in the affected eye. diagnosis and treatment?
retinal detachment, bedrest, surgery (photocoagulation)
risk factors for glaucoma?
- old
- african-american
- HTN
- fam hx
diabetes
what is the gold standard for assessing pupil pressure?
goldmann applanation, cup to disc .6 or greater is bad
what are the treatments for open angle glaucoma?
decreasing production of aqueous, increasing the flow of aqueous
trabeculoplasty
trabeculectomy
ciliary body ablation
what medications decrease the production of aqueous?
- beta blockers
- lol - alpha- 2 agonists
- onidine - carbonic anhydrase inhibitors
- zolamide
what medications increase the flow of aqueous?
- sympathomimetics
- epi - prostaglandin analogs
- oprost - miotic agents
- pilocarpine
pt. presents w/ blurred vision, intense ocular pain, frontal head ache, vasovagal sx, and halos around lights. Pe shows mid-dilated pupil and corneal edema w/ blurring of light reflex. The patient has short, far sighted eyes. what is the work up and treatment?
IOP
toc is laser iridotomy after inital attack broken
timolol, acetazolamide IV, Isosorbide IV, mannitol IV
what will you see on PE for chronic angle closure glaucoma?
broad bands of PAS (peripheral anterior synichea)
what is the treatment for chronic angle closure gluacoma?
surgery
- goniosynechialysis
- iridotomy
what 2 things are required to diagnose glaucoma?
progressive vision loss and optic nerve damage
argyll robertson is associated w/ what?
neurosyphilis (accommodates, but does not react)
pt. presents w/ small pupil that does not react to light, but accomodates normally to near vision. what is the the w/u?
VDRL, FTA-abs, treponemal testing
pt. presents w/ dilated pupil that reacts pooly to light, and accomodates sluggish and tonic. what is the w/u? How would you differentiate between this and CN III palsy?
test DTR, instill .125% pilocarpine and pupils will constrict. normal pupils will not constrict
there is no ptosis like there is in cranial nerve III palsy
in horner’s syndrome the ptosis is on the same side as what?
the miotic pupil
what are the cuases of horners?
stroke, injury to carotid artery, pancoast tumor, cluster HA
how can you get the diagnosis for horner’s pupil?
instill cocaine and the normal pupil will dilate, the affected pupil will not because it the sympathetic stimulation is damaged
bilateral optic disc edema is caused by what?
increased intracranial pressure
- intracranial mass, impediment of cerebrospinal flow, idiopathic intracranial HTN (pseudotumor cerebri)
what cranial nerve palsy is associated w/ papilledema? what can cause vision changes in papilledema?
sixth cranial nerve, postural changes, pulsatile tinnitus
an obese pt. comes in complaining of transient vision loss and increase in her blind spot. diagnosis trx?
BP first step
then MRI w/ contrast followed by lumbar puncture
trx for pseudotumor cerebri- weight loss, acetazolamide, neurologic shunt
pt. presents w/ disc swelling form inflammation (papillitis). They have sudden VA loss and UNILATERAL swollen disc. they have flame-shaped hemorrhages and optic disc palor. What is the w/u and treatment?
ESR and CRP, evaluate for HTN, Diabetes and anemia
what is another name for arteritic ischemic optic neuropathy?
giant cell arteritis, treat w/ 250 mg methylprednisolone then switch to prednisone
optic neuritis is associated w/ what?
MS
pt. presents w/ orbital pain, especially w/ eye mvmt and unilateral vision loss over hours to days, w/ color vision loss. pt states they had flu like symptoms about a week prior. what is the dianosis and w/u?
optic neuritis
MRI
what is the treatment for optic neuritis?
one area of demylination: pulse IV steroid
MRI w/ 2 mor more characteristic lesions: interferon B
DONT START W/ ORAL STEROID
how is the eye turned in CN III palsy?
down and out
what to do if you suspect CN III palsy and there is a dilated pupil?
stat MRI!!
what way is the eye pointing in 4th nerve palsy?
vertical diplopia w/ head tilt
what is the leading cause of blindness in US for ages 20-64?
diabetes
what is the difference between proliferative and non-proliferative diabetic retinopathy?
hemorhages, micro-aneurisms, exudates
new blood vessel growth
where is the MC place that neovasularization occurs in Diabetic retinopathy?
vascular arcdes
what are the PE signs for diabetic retinopathy?
fine lacy BC on optic nerve, retina, iris, Boat shaped pre retinal hemorrhages, dot blot heme, cotton wool spots, loss of red reflex
what is the treatment for diabetic retinopathy?
tight glycemic control, referral to ophthalmology for Pan retinal photocoagulation
pt. presents w/ decreased visual acuity, what is the w/u?
diabetic macular edema
what are the signs of hypertensive retinopathy and what are the hallmarks?
diffuse arteriolar noarrowing, AV ratio changes 1:4 from 2:3, copper wire vessel, silver wire vessel
pt. presetns w/ extreme sudden vision loss, HA, scalp tendnernes, jaw claudication. They are ?60 and have an ESR > 50. what is the treatment?
IV methyprednisolone 250 mg IV q 6 hr for 72 hrs then prdnisone 80 -100 mg po qd (maintenance)
pt presents w/ muscle weakness that improves w/ rest and worsens w/ activity. they have variable ptosis and fatigue w/ sustained upgaze. what is the w/u?
edrophonium cloride (tensilon)
acetycholine receptor test
ice pack test
what appears w/ bacterial endocarditis?
roth spots, flame shaped hemorrhage, and cotton wool
pt. presents w/ necrotizing scleritits, scleral thinning, and anterior uveitis. diagnosis?
rheumatoid arthritis
pt. presents w/ kayser fleisher rings and sunflower cataract. what else would they have
renal disease and cirrhosis, neurologic disorders and psychiatric problems
what is the w/u for corneal foreign body?
VA before anything and a CT scan if high speed injury
if there is a superficial foreign body, what do you do?
removed under local anethesia, then remove residual rust ring if present. Trx w/ polymyxin B/trimethoprim or fluroquinolone
what do you do for an intraocular foreign body?
shield over eye, IV abx w/
what cancer is associated w/ hyphmea?
retinoblastoma and leukemia
what kind of shield do you put on a hyphema?
cycloplegic agent twice daily
what do you have to do for a blow out fracture?
evaluate EOMs
what can cause posterior uveitis aka inflammatory cells w/in the vitreous and hazy finding w/ funduscopic exam?
toxoplasmosis
following ocular surgery, presents w/ decreased foveal reflex and cysts behind fovea.
