systemic disease Flashcards
What 3 events occur in every case of acute inflammation?
- Vascular dilation
- Structural change (from dilation)
- PMN (neutrophils)
PMN’s are the firemen, first to come. They are most common.
*These are also granulocytes.
We just got done saying that PMN’s are the main cell type in ACUTE inflammation.
What is the main cell types in CHRONIC inflammation?
- Macrophages
- Lymphocytes
- Plasma cells
These are mononuclear cells
What are some diseases that lead to chronic inflammation?
-Persistant infection (H. Pylori )
-Prolonged exposure to toxic agents (Asbestos)
-Autoimmune Disease (RA)
Is granulomatous inflammation a subcategory of chronic inflammation or acute inflammation?
Chronic inflammation.
What cells are inflated in Granulomatous inflammation?
Macrophages.
Graulomatous = Macrophages
Macrophages are big fluffy cells and their job is to wall things off
What are examples of conditions that may cause granulomatous inflammation?
- Bacterial: TB, Leprosy, Syphilis
- Fungal: Histo, Blastomycosis
- Foreign Body: Sutures, Vascular Graft
- Unknown: Sarcoidosis
What ion enters a cell if it doesn’t get enough oxygen?
Na+ (the cell gets salty from being deprived)
-The Na inside the cell causes water to come in and make it enlarged, swollen, leading to cell DEATH.
-This same thing occurs in macular ischemia.
What are the 4 different types of necrosis and where would I find it in the body?
- Coagulative: heart, we see it with a Heart Attack.
- Liquefactive: Lung, we see this in fungal cases
- Caseous: Lung, see it in TB (cheesy in the lung)
- Fat
What medications are used to Tx TB?
RIPE
R- Rifampin
I - Isoniazid
P- Pyrazinamide
E- Ethambutol
Which one of the tb drugs can be used in isolation?
Isoniazid
Which TB drug cases pink tears?
Rifampin
“Think RifamPINK”
Which TB drug can cause a bilateral retrobulbar optic neuritis? What does it look like?
ETHAMBUTOL
-most important drug to know in all of optometry because it can cause 20/200 VA OU, but the eye looks normal, and no APD.
What are the 4 hypersensitivity reactions and the key players involved in each?
Type 1: A - Anaphylactic (IgE): Mast cell (histamine), Ca2+
Type 2: C - Cytotoxic (IgG, IgM): Rheumatic fever, Rh Dz
Type 3: I - Immune mediated (Antigen-antibody complex): Lupus, autoimmune reactions
Type 4: D - Delayed (T-lymphocyte)
*The only one that doesn’t have an antibody.
-i.e. Tb test, delayed contact dermatitis, corneal transplant reaction
- phlyctenulosis (staph infection -> bleph)
What ocular drug(s) blocks H1 receptor but does not stabilize mast cells? Combo?
Emedastine
(always used in combo, Naphcone-!)
What drug(s) targets calcium and prevents it from entering cells, thus preventing histamine release?
Mast cell stabilizers, stop Ca.
- Alocrile
- Alomide
- Alamast
- Cromolyn sodium
Which drugs block histamine receptors and stabilize mast cells?
“BEZPOP”
- Bepreve
- Elestat
- Zatador
- Patanol
- Optivar
- Pataday
These block voltage gated Ca channels and Histamine
What type of hypersensitivity reaction is Lupus?
Type 3 - Immune mediated
What is the classic profile of a person who gets lupus?
-Women more than men
-30 y.o.
Does Lupus have a positive ANA?
Others
Yes
Two conditions that have a positive ANA include:
-Lupus
-JRA (non-granulomatous and is -RF)
-RA
What are the ocular manifestations of Lupus? (and other autoimmune diseases)
-Dry eye (most common!)
- recurrent episcleritis, peripheral keratitis
-Neuro-opthalmic complications: (disk edema, papilledema)
-Around eyes - Malar Butterfly rash.
Malar rash = Lupus.
Pt wakes up in the morning not feeling great, their small joints are stiff bilaterally.
Name that condition.
Who?
Rheumatoid arthritis.
Women, 50 y.o.
-Bilateral joints stiff in morning.
How does rheumatoid arthritis differ from osteoarthritis?
- Rheumatoid arthritis:
-SMALL JOINTS
-BILATERAL
-Pain in the morning - Osteo-arthritis:
-BIG JOINTS
-doesn’t have to be bilateral.
-moving throughout the day initiates pain.
What blood tests would come back positive in the case of Rheumatoid arthritis?
Rheumatoid Arthritis
+ RF (rheumatoid factor)
+ ANA
What is the #1 thing RA pts will complain about ocularly?
Dry eye
T or F: the Dry eye experienced by RA pt is aqueous deficient.
TRUE
Second ocular condition we think about in RA pts is….. SCLERITIS.
What is the name of scleritis in a RA pt?
Scleromalacia Perforans
-Necrotizing w/out inflammation, not painful.
-Can have a blue sclera.
This is the #1 cause of scleritis in pts
What is the #1 reason a child would come into the clinic with a uveitis?
Prentation?
JIA - Juvenile Idiopathic Arthritis
“young girl comes in w/ fever and Uveitis”
-If there is arthritis it only affects ONE JOINT, pt is more likely to have uveitis.
What test will be positive in case of JIA?
+ ANA.
What ocular finding will occur on the cornea in a pt with JIA?
Band Keratopathy - occurs on Bowmans.
Pt comes in with Superior Nasal Thinning of the cornea.
Name the condition:
Terrians Marginal Degeneration.
-30 y.o. man against the rule, cocky.
20 y.o. guy who is so frustrated he could cry but never has a red eye.
Name the condition:
Treatment
1 complaint - something in my eye. Foreign body sensation.
Thygeson’s
-Crumb defects central cornea, bilateral.
-Barely stain (unlike SPK).
-Use a steroid like FML
AA female with inflammation.
Name the condition:
What test would you do?
Sarcoid!
ACE blood test
Then, chest X-ray.
-If I see a pt who has granulomatous uveitis, think to do a chest x-ray.
What cells are responsible for forming the granulomas in Sarcoidosis?
Macrophages.
What are 7 eye finding associated with sarcoid?
Start at the front of the eye and move backwards:
- Dacryoadenitis
- Dry eye
- Granulomatous uveitis
- Vitritis
- Vasculitis (periphlebitis)
- Optic neuritis - worst thing
- CN 7 inflammation (bell’s like inflammation)
Young male comes in with the worst uveitis you have ever seen. What do you ask him?
-What condition are we worried about?
-Do you have any lower back pain? (or neck pain)
-Ankylosing spondylitis
What tests do we do for Ankylosing Spondylitis?
-Lower back x-ray
- HLA-B27
Which conditions are positive for HLA-B27?
“UCRAP”
U- ulcerative colitis
C- Crohns
R -Reactive uveitis
A- Ankylosing spondylitis
P- Psoriatic arthritis
Pt comes in with Urethritis and uveitis, what test will you run?
HLA-B27 will be positive in cases of Reactive Arthritis (Reiter’s syndrome.
“can’t pee, see, climb a tree”
Men > Women.
What occurs with Psoriatic arthritis?
-What test will you run?
“Think sore arthritis”
-Sores -> plaques on joints that leads to bilateral joint stiffness.
-They could have an Anterior Uveitis as well.
Test: + HLA-B27
What is the breakdown of conditions that cause non-granulomatous uveitis versus granulomatous uveitis?
- Non-Granulomatous (PMNs - Neutrophils)
a. Idiopathic (70%)
b. UCRAP/JIA (30%)
-Ankylosing is the #1 cause of non-gran. - Granulomatous (macrophage)
a. Sarcoid
b. TB
A likely test question:
What is the #1 cause of non-granulomatous uveitis (other than idiopathic)?
Ankylosing Spondylitis
What do we call granulmatous lesions in the eye?
What is the name for them if they are on the pupil margin versus everywhere else?
Mutton FAT KP - granuloma in the eye
Pupil margin: Koeppe “think Kolbee, got it in the hole, near the pupil margin”
Busacca: everywhere else.
What does it mean when we say syphilis is the great mimic?
It can present as non-granulomatous or granulomatous
All of the following conditions may affect the optic nerve EXCEPT:
syphilis
sarcoidosis
systemic lupus erythematosus
rheumatoid arthritis
rheumatoid arthritis
Where does neural control of our respiration occur in our brain?
In the Medulla Oblongata.
(neural control of breathing)
Name the condition:
A 50 y.o. women who says I have a HA or Scalp tenderness or Achy Jaw.
Temporal Arteritis.
How does Jaw claudication differ from TMJ in terms of symptoms?
Jaw claudication -> Tired Achy feeling
TMJ -> sharper pain
The temporal artery is a terminal branch off from what artery?
External carotid.
You think the pt in your chair has temporal arteritis, what lab will you order?
- ESR
- CRP
- CBC/WBC
Gold standard: biopsy
What is one down-side of biopsy of the temporal artery?
You could have inflammation at one portion of the temporal artery and not another.
Thus, you could biopsy a portion that is not affected and you R/O Giant cell went actually you do have a pt with giant cell and it is just inflamed elsewhere.
this is called a skip lesion
what are some examples of local factors that could affect wound healing?
local: decreased blood supply, inability to form clots, local infection
What does the temporal artery inflammation have to do with vision?
It inflames medium sized vessels and the SPCA are medium sized vessels.
Thus it can prevent blood flow to the optic nerve and cause an AION.
T or F: you will wait for the lab & biopsy results to come back before initiating Tx for Giant cell.
Other tx?
FALSE.
We could potentially be dealing with very serious inflammation thus we put them on STEROIDS ASAP. In addition, use a baby aspirin to prevent stroke.
60 y.o. male, unilateral loss of VA in one eye.
Compare and contrast NAION vs AION:
What conditions are associated with a NAION?
NAION occurs in 90%
-HTN
-Diabetes
-Ischemic conditions
Associated with:
-Noturnal HTN, Bradycardia
-Sleep apnea
-Disk at risk
-Viagra
Only affects 1 eye
60 y.o. male, unilateral loss of VA in one eye.
Compare and contrast NAION vs AION:
What conditions are associated with a AION?
AION occurs in 10%
giant cell is an AION
-Inflammation, Vasculitis of medium sized blood vessels. short posterior ciliary arteries
Sx:
-Jaw claudication, neck pain, scallop tenederness, ANOREXIA.
We must r/o polymyalgia rheumatic when considering Giant cell arteritis.
What symptoms would a pt with Polymalgia Rheumatica have?
They will have pain or stiffness in neck, shoulders, or hips.
-it can be very sudden or occur over a gradual period.
Name the condition:
Vasculitis-inflammation of the vessels that affects:
1. Respiratory tract
2. Lungs
3. Kidneys
Wegener’s granulomatosis aka Granulomatosis with Polyangitis
What ocular manifestation can Wegener’s granulomatosis have?
aka: granulomatosis with polyangiitis
Can cause
-Granulomatous Sclerouveitis
-retro-orbital mass and proptosis
-Corneal ulcerations.
Scleroderma is a skin vasculitis that can cause shrinking of the skin.
What ocular effect may this lead to?
-Shrinking of skin around conj
-Dry eye
Gout is formed by uric acid crystals. They are pointy and can end up in joints.
Which joint is most often affected by gout?
What foods cause gout ?
MTP: Metatarsophalangeal joint
“think Men Toe Pain”
-This is referred to as podagra
-Most amount of uric acid in red meat and beer.
What ocular manifestation can occur with GOUT?
BAND KERATOPATHY
-another type of crystals that can occur in the eye (Ca+ crystals, can also get Ca+ crystals with Gout, not only ureic crystals)
-occurs in bowmans
What drug is used to treat Gout?
Allopurinol: it inhibits xanthine oxidase to decrease uric acid levels.
There are two disease of immunodeficiency we need to know about, what are they?
Hint: One is congenital and one is acquired.
- Congenital Immunodeficiency - Deficiency of IgA
- Acquired immunodeficiency (AIDS)
Congenital Immunodeficiency - Deficiency of IgA
Where do we find IgA?
- tears
- Respiratory tract/Mucosal membranes
- Breast Milk (if IgA is pumped into breast milk it leaves mothers mucosal surfaces deficient of IgA and leads to cavities in teeth)
Congenital Immunodeficiency - Deficiency of IgA
If we don’t have IgA in the tear film, what do we worry about?
-Keratinazation of the Cornea (Bitot’s spots)
-w/out IgA, we will get more infections which increases risk of keratinization of cornea.
What is the MOA of the drugs we use to Tx AIDS?
We use drugs that block Reverse Transcriptase, they are called azidothymidine (AZT)
Acquired Immunodeficiency - AIDS.
What is AIDS caused by? (MOA)
RNA virus that uses reverse transcriptase to become a DNA virus.
It is super sneaky! HIV starts out as an RNA virus that then uses this enzyme to convert itself into DNA…
Pt comes in with flu like symptoms: they are tired, achy, fever.
What test can you run if you are suspicious of HIV?
- Elisa (screening)
If Elisa is positive then we do:
2. Western blot
(alphabetical order E, then W)
-A positive E and W has a 99.9% specificity for HIV.
After a diagnosis of HIV has been made, what cell count do we watch closely?
CD4. These are the cells that help fight infection.
What is a normal CD4 cell count?
500-1500.
What CD4 count do we begin to be concerned about?
At what CD4 count do we say a pt has progressed from HIV to AIDs?
Concerned: <500
AIDS: <200
What causes the death in AIDS patients?
It is no the virus itself that kills a person.
The virus kills off the cells that fight infection, thus a pt can die of the opportunistic infections that are able to hurt them because the immune system is down.
What are some opportunistic infections found in HIV pts? (5)
- CMV retinitis
- Pneumocytic pneumonia (PCP)
- Toxo
- Tb
- Karposis’s Sarcoma (a Herpes virus, can get it around the eyes)
How do we treat CMV retinitis if it infects an HIV pt?
We treat with Gangcyclovir
Now onto SKIN LESIONS
What is a papilloma caused by?
HPV or Cervical cancer.
What is Xanthelasma caused by?
Increase in cholesterol.
-Bilateral medial portion of eyelid.
-Can also be due to just AGE (no big deal here)
What is Molluscum contangiosum caused by?
-DNA Pox virus
Appearance: dome-shaped waxy umbilicate nodules.
In kids Molluscum is normal and go away on their own.
Molluscum is not normal to have in adults. What condition can Molluscum be associated with in adults?
If a pt has molluscum all over their body, think HIV. Something is immunocompromising in their body allowing the Dz to spread.
-Can get moluscum as an STD.
What ocular finding can occur with Molluscum?
Follicular conjunctivitis
CHAT - it is toxic.
Name the condition:
Pt with telangiectasias of the skin and Rhinophyma.
Acne Rosacea.
-we know it has triggers such as spicy food, alcohol.
What ocular findings can occur with Acne rosacea?
Lid things:
1. hordeola
2. Chalazia
Cornea things:
3. Dry eye
4. Keratitis
What three conditions cause Telectasias?
- Basal Cell Carcinomas
- Acne Rosacea
- Coat’s disease
What type of Hypersensitivity is allergic contact dermatitis?
Delayed, Type 4.
It can be caused by Medication, Makeup.
-Acute periorbital swelling
-conj. chemosis, redness, itching, and tearing.
Name the condition:
What is it caused by?
-Honey-colored crusted lesions
IMPETIGO
-Caused by gram + bacteria, usually staph.
What could you use to Tx Impetigo, Staph?
- Bacitracin (very gram +)
- PCNs (Dicloxacillin is very gram +)
- 1st gen cephalosporins (they start very gram +, good one would be Keflex)
NOTE: 1st gen fluoroquinolone would not be a good option because they start gram -.
HSV 1 and HSV 2
HSV -1 Is the cold sores, it is most common and almost everyone has it. (takes 1 to get type 1)
HSV -2 is the STD (takes two to get type 2)
Which one is more likely to have ocular SE?
Type 1
-We are more likely to touch mouth and then eye, and type 1 is just more common.
What is the most likely situation when HSV type 2 would get in the eye?
When a baby is born, the mom has the active Dz and passes it to the baby.
-Herpetic Keratitis Neonate
T or F: once you have HSV 1 or 2, you always have it.
Where?
TRUE
-The virus will hide in ganglion cells.
Trigeminal ganglion
Which drugs can be use prophylactically to prevent flare ups of Herpes?
- Gancyclovir
- Acyclovir
What is the Main Ocular SE from HSV?
Dendritic Keratitis
What percent of HZV pts have ocular involvement?
How does it involve the eye?
25% get ocular involvement.
-Hutchingson’s sign (V1 - nasociliary nerve)
Can also get: blepharitis, uveitis, true dendritic keratitis (stains with nafl in center + terminal bulbs)
Name the condition:
Middle Eastern (turkish) young adult with Recurrent Hypopyon
What are the 4 associated lesions/ulcers?
BECHET’S DISEASE
Pts must have two of the following lesions/ulcers:
1. Recurrent oral ulcers
2. Genital ulcers
3. Eye lesions
4. Skin lesions
Review: What is the only condition that causes Recurrent Hypopyon?
BECHET’s DISEASE
Malignant Melanoma is a cancer of melanocytes.
What layer does it occur in?
What is the #1 prognostic factor?
What UV ray is most likely to cause it?
Malignant Melanoma
- Occurs in Stroma BASAL layer (same layer as BASAL cell)
- DEPTH of Invasion is #1 prognostic factor
- UVB most causative (atmosphere blocks UVC which is most dangerous)
What does A,B,C,D stand for when determining severity of a Melanoma?
A -Asymmetry
B -Border
C -Color
D -Depth
What is the #1 skin cancer?
BASAL Cell Carcinoma. Make up 94% of skin cancers.
What is the classic appearance of basal cell carcinoma in the beginning?
“EARLY PEARLY”
Later on:
-Telangectasia
-Can bleed (ulcerations)
BASAL cell and SQUAMOUS cell can look similar later on and it is hard to differentiate.
But early on they have different appearances. We said that BASAL is early pearly. How does Squamous present early on?
Scaly
Scaly actinic keratiosis -> Squamous cell carcinoma.
Basal cell begins in squamous basal layer, what does squamous cell carcinoma begin in?
Stratum spinous.
Name the condition:
Name the ocular complication that can result of it:
Port Wine Stain.
Sturge-Weber
-Unilateral Glaucoma
-occurs b/c episcleral veins are responsible for draining fluid through Schlem’s canal. Congestion of those veins/capillaries can lead to increase pressure and glaucoma.
What is an astrocytic Harmartoma?
What condition causes Astrocytic Harmatoma?
Other name?
Retinal astrocytic hamartomas are glial tumors of the retinal nerve fiber layer that arise from retinal astrocytes. Sometimes referred to as “mulberry lesions”
TUBEROUS SCLEROSIS
Which of the following conditions is the MOST common ocular infection in patients with AIDS?
Toxoplasmosis
Tuberculosis
Cytomegalovirus
Herpes simplex
Cytomegalovirus
What ocular manifestations can result from Down Syndrome?
“GECKOS” Think of a little boy with down syndrome who is obsessed with geckos.
G- glaucoma
E- epicanthal folds
C- cataracts
K- Keratoconus
O- X
S- Strabismus
What conditions cause Keratoconus?
“TDOME”
T- Turner’s
D- Down syndrome
O- Osteogenesis Imperfecta
M- Marfan’s
E -Ehlers-Danlos
[also mitral-valve prolapse]
GENETIC GENDER DISORDERS
What is the condition in which an individual has a XXY chromosomes?
Klinefelter’s syndrome
“think Calvin is a guy but he is less manly, so he has two X’s and one Y”
-ends up with some female characteristics.
What conditions is characterized by an individual having only one x chromosome (not two)
Turner’s syndrome
“Tina Turner is a girl that has an X but is missing the second X.
What ocular complications can result from Turner’s syndrome?
BV problems! Must know them
“Tina turner has a hard time turning”
- Strabismus
- Amblyopia
- Reduced Acc.
- Convergence insuffiency
Also Keratoconus:
T- Turner’s
D- Down syndrome
O- Osteogenesis Imperfecta
M- Marfan’s
E -Ehlers-Danlos
Name the condition:
Get a host of big tumors randomly. Can cause tumor in the retina -> Retinal Angiomas.
Inheritance pattern
Von HIPPel Lindau Disease
“think you RET with your HIPS”
*Autosomal DOMINANT
Name the condition:
Triad consisting of -
1. Neurofibromas: clusters of nerve tissue (could present as an optic nerve glioma)
2. Cafe au last spots (coffee w/milk)
3. Lisch nodules on iris
What do we worry about?
Inheritance?
Neurofibromatosis
Type 1 aka Von Recklinghausen’s dz
*Autosomal DOMINANT
*We worry about these tangles of nerve tissue compressing the optic nerve
Pt with a AD connective tissue disorder who was told he cannot play basketball (even though he is tall) b/c he has heart problems w/ his aorta and has floppy valves.
What things are we worried about with the eye?
Silent diagnosis: Marfan’s syndrome
Eye problems:
1. Subluxation of the lens
2. Retinal detachments
3. Keratoconus
What direction will the lens sublux in the case of MARFANS?
Will sublex UP.
“think you look up at Marphans pts (b/c they are super tall) and that its the direction the lens moves”
What condition causes the lens to sublux down?
Homocystinuria.
What ocular condition is Autosomal Dominant?
BEST’S disease
Name the condition:
Inheritance pattern
Slow body movements as well as slow eye movements.
Problems with:
-Pursuits
-Voluntary Saccades
-Refixation
Huntington’s Chorea
“think while HUNGTING you need to make very slow movements to not startle the deer”
*Autosomal DOMINANT
If a pt has 4 or more CHRPEs what are we concerned about?
Inheritance
Colon Cancer!
4 or more CHRPEs is referred to as bear tracks. This is indicative of Gardener’s Syndrome which is a variant of Familial Adenomatous Polyposis
*100% of these patients with FAP get colon cancer :(
-Autosomal DOMINANT
Are CHRPE’s hyperplasia or hypertrophy?
Hypertrophy (increased size)
(not increased # hyperplasia)
Autosomal Recessive Disorders.
How does the inheritance pattern work for these conditions?
Name 3 AR Diseases:
Both mom and dad have to be carriers for it to be present in a child and there is still then only a 25% chance of the child having it.
These are usually pretty severe and show up right after birth.
3: Sickle Cell, PKU, Tay Sachs
What condition is caused by a DNA issue that switches a G (glutamic acid) to a V (valine) in a Red blood cell?
Sickle Cell
Commonly think of AAs having sickle cells.
What tests will help us Dx Sickle cells?
- Decrease Hemoglobin
- Normal Mean Corpusule volume (MCV, normal size even though the shape is weird)
- Increase in Reticulocytes (increases in new baby blood cells being produced by bone marrow)
- Increase Billirubin (Jaundice)
- Blod smear - can see the sickle cells
Why is billirubin elevated in Sickle Cell pt’s?
Our bodies recognize that the sickle cells are abnormal send macrophages to break them down.
the products produced from the breakdown of sickle cells by macrophages is HEME BILLIRUBIN.
The heme & Billi is processed in the liver so soon the liver is overworked and won’t be able to put all the bilirubin into bile. So we look for excess bilirubin in the blood to determine if a pt has sickle cells. Will cause Jaundice.
How does sickle cell affect the eye?
- SEA fan retinopathy
-Get extra vessels growing into the vitreous to give the tissue O2 (b/c other vessels are clotted). - Tractional RD
-The vitreous pulls on the neo and can cause a tractional RD.
What conditions can cause a Tractional RD?
D- Diabetes
R- retinopathy of prematurity
S- Sickle cell
DRVOS
V - vein occlusion
O- OIS
Name the condition:
Neurodegenerative Dz that causes Seizures and a cherry red spot
Tay-Sach’s disease.
Two conditions that causes cherry red spot
1. Tay-Sach’s
2. CRAO
Name the condition:
Lipid disorder that causes telangectasia in the belly button or on the elbow and whorl keratopathy in boys.
FABRY’s Disease.
The only systemic dz to cause whorl keratopathy.
Name this tough condition.
Kids that are tired and don’t want to walk.
Duchenne Muscular dystrophy
-caused by the gene encoding dystrophin.
Name the condition:
Condition characterized by abnormal type 1 collagen synthesis. Can cause blue sclera, KCN, and Megalocornea.
OSTEOGENESIS IMPERFECTA (brittle bone dz)
4 spots of type 1 collagen:
1. Bowmans -> KCN (TDOME)
2. Bones -> Brittle bones
3. Stroma -> Megalocornea
4. Sclera -> Blue sclera
What 2 medications can cause a blue sclera?
- Minocycline
- Steroids
Leber’s Optic Neuropathy:
Do pts lose peripheral or central vision?
Central Vision.
Which of the following 3 ocular manifestations are associated with Marfan’s syndrome?
Keratoconus
Glaucoma
Retinal detachment
Strabismus
Lens subluxation
Congenital cataracts
Keratoconus
Retinal detachment
Lens subluxation
What is the first test we do if we suspect ANEMIA?
-what would we expect in the case of anemia?
CBC
-it will let us know the Hemoglobin count. Anemia will result in decreased Hemoglobin
What is the second test we do or look at to determine the TYPE of ANEMIA?
Mean corpuscular volume
There are three groups of Anemias. Ones with:
1. Decreased MCV (small blood cells)
2. Normal MCV
3. Large MCV (large size)
Each class has two types of anemia within.
Which two types of Anemias are under the decreased MCV category?
- Iron Deficiency anemia (50% of all anemias)
- Aplastic Anemia
A rare one is Thalassemias: condition that prevents the formation of Hemoglobin.
Which 4 drugs can cause aplastic anemia?
Condition?
“these Drugs IMPACT your bones”
“METH Treats Marrow Poorly”
- D-Diamox
- I-
- M-METHotrexate, Methazolamide
- P-Pyridimine
- A-Azetazolamide (CAI)
- C-Chloramphenicol (the eye drop that can cause aplastic anemia)
- T-TriMETHoprim
Condition that can cause aplastic Anemia: Multiple Myeloma
Which two Anemias have Normal MCV?
- Sickle cell (abnormal shape, but normal size)
- Anemia of Chronic dz
-old age,
-HTN, Diabetes
What two dietary supplements are needed to make Red Blood Cells?
- Vit B12
- Folic acid
Which two Anemias have Large MCV?
- Vit B12 deficiency
- Decrease Folic acid
“lacking dietary substances leads to larger cells”
What are the two functions of Parietal cells?
Parietal cells secrete:
1. HCL
2. Intrinsic factor
What is the function of intrinsic factor?
To allow for ABSORPTION of VITAMIN B12
What is the function of Vitamin B12?
Allow your body to to make RED blood cells!
Therefore, if you have any problem with your Parietal cells or a Deficiency of B12, you cannot make red blood cells correctly and will develop Anemia.
name of vitamin B12
cobalamin
Name the condition:
A cancer of plasma cells.
Multiple Myeloma (low yield)
-occurs in the bone marrow and results in immature plasma cells.
-Extra Ca is produced which is hard on Kidney’s.
We just got done talking about RED blood cells and now we are going to go onto WHITE blood cells.
Name the condition:
Cancer of Lymph tissue. Pt commonly has fevers at night and have a large lymph node.
Lymphoma.
-will result in enlarged lymph nodes.
what are the two different categories of Lymphomas?
- Hodgkins (40%)
- Non-Hodgkins (60%)
What very unique cell is present in Hodgkin lymphoma?
Reed Sternberg Cell
“Hedgehog REEDS”
What virus is associated with Hodgkin lymphoma?
Ebstein Barr.
“Hedgehogs REEDS so he can pass the BARR exam” He will be a very studious lawyer.
What two non-unique cells are associated with non-Hodgkin Lyphoma?
T or B cell.
Difficult question:
What condition has Auer Rod cells?
Acute Myeloblastic Leukemia (AML)
Another difficult question:
Which conditions has a Philadelphia chromosome?
Chronic Myelocytic Leukemia (CML)
Which conditions have a worse outcome:
Lymphocytic or Myeloblastic?
Myeloblastic have BAD outcomes :( “mean conditions, bad outcomes”
-Each Myelo condition has its own characteristic cell to tell that it is bad. Review:
1. Auer Rod -AML
2. Philadelphia -CML
-Lymphocytic have good outcomes :)
What two subcategories are under ACUTE Leukemia?
- Acute Myeloblastic (AML) - “Acute Mean Auer Rod”. Poor outcome.
- Acute Lymphoblastic Leukemia (ALL)
-“All kids survive, good outcome”
What are the two subcategories under CHRONIC Leukemia?
- Chronic Myelocytic Leukemia (CML)
-“C Me Later (CML) in PHILLY”
-Poor outcome, super high WBC count. - Chronic Lymphocytic Leukemia (CLL)
-More common, better outcome.
T or F: ACUTE Leukemia typically occurs in older pt’s
FALSE
-“Acute, think kids are cute”
-Problem with BLAST cells which are the baby cells that should not be in the blood but are present there.
CHRONIC Leukemia typically occurs in older pt’s.
What is the main problem with white blood cells in this case?
There are too many white blood cells.
Normal WBC count is 10,000.
These pts have 100,000.
Think hard…..
What retinal condition can occur due to Leukemia?
ROTH SPOT
-a retinal hemorrhage w/a white spot in the middle. (the white is cotton wool spot)
-Endocarditis can also cause a ROTH spot
All of the following medications may cause aplastic anemia EXCEPT:
methazolamide
tetracycline
acetazolamide
chloramphenicol
tetracycline
What does the root ‘Penia’ mean?
Decrease cell number
What does the root ‘Cytosis’ mean?
Increase cell number
What does the root ‘philia’ mean?
Increase number
What do each mean?
- leukopenia
- Leukocytosis
- Neutrophilia
- Thrombocytosis
- Pancytopenia
- Thrombocytopenia
- Decrease leukocytes (WBC)
- Increase leukocytes (WBC)
- Increase neutrophils
- Increase thrombocytes (platelets)
- Decrease in all cells (RBC, WBC, platelets)
- Decrease thrombocytes (Platelets)
What is the difference between non-inflammatory edema and Inflammatory edema?
- Non-inflammatory edema: protein poor, Transudative fluid.
“someone who translates from place to place is often poor - transudative -> protein poor” - Inflammatory edema: Rich with protein, Exudative fluid.
“An exudative person is someone who would be rich”
Candle wax dropping and dilation of vessels with fluid leaking out would be which kind of inflammation?
-Protein poor or rich?
Protein rich.
What is an example of non-inflammatory Edema?
- Increase organ pressure (CHF- Fluid will back up in the lungs b/c it can’t be pumped elsewhere)
- Decrease plasma oncotic pressure (edema post surgery)
- Lymph obstruction (Lymph nodes removed)
- Sodium retention (eating a lot of salty chinese food)
What cell is damaged in the case of diabetic macular edema?
Pericytes.
The pericytes line the blood vessels and when the are damaged, blood and fluid will leak out.
What is the term for a blood clot that stays put?
Thrombosis
What are the three reasons for blood clots?
Virchow’s Triad:
1. Stasis - basically blood is not flowing so it stays there and swirls. Swirling blood = clotting blood.
2. Injury to endothelial wall - blood will clot to stop from bleeding
3. Alterations in BLOOD
a. Protein C or S deficiency
b. Factor 5
c. Acquired reason for Alteration in blood -> oral kckontra
ceptive use (increase risk of blood clot)
Note: Birth Control + Smoking (increase risk of blood clot)
Where do blood clots usually form?
Deep Veins System (legs)
-rare to occur in arteritis b/c there is a lot of pressure there. Doesn’t have a chance to sit and swirl.
If you have a blood clot in the veins that breaks off (embolis), where does it go?
through the heart and land in the lungs. (pulmonary Embolism)
Veins -> Lungs
If you have a blood clot in the artery that breaks off, where does it go?
To the brain and causes a stroke :(
Arteries -> brain (stroke)
If we see a young pt come in with a BRVO, what do we likely think it is due to if it is a Girl?
how about for a boy?
Girl -> Oral contraceptives
Boy -> Alteration in blood like protein C or S deficiency
Thrombus is the cause for 95% of emboli.
What are the other major causes?
“FAT BAT”
F- fractures in long bones can send fat clots up
A- Air: pneumophilax
T- Thrombus
B- bacteria. Endocarditis in the heart. vAlves flip up the bacteria
A- amniotic fluid 0> after a women gives birth, can have amniotic clot that forms
T- tumor (cancer)
Why does shock occur in the context of a cardiovascular issue?
Organs are not getting enough fluid.
What are the four different kinds of shock?
- Cardiogenic - heart stops (Heart attack)
- Hypovolemic - not enough blood in the body to get to all the organs (large bleed or lots of diarrhea)
- Septic - Infected with bacteria.
- Anaphylactic
decrease blood volume leading to shock
What is an aneurysm?
a blood vessel that gets too big.
-An aneurysm is when the balloon enlarges in an area causes by a weakening of the artery wall. Can lead to a rupture.
Aneurysms are associated with Marfan Syndrome patients also
An arterial thrombosis is LEAST likely to embolize to which of the following organs?
Heart
Brain
Kidneys
Spleen
Heart
Which one of the following conditions causes inflammatory edema?
Congestive heart failure
Malnutrition
Neoplasm
Angiogenesis
Angiogenesis
What does Atherosclerosis form from?
It originals starts as a fat plaque, this leads to inflammation at the site and then the body comes in to try and heal it and macrophages and platelets come to the ‘rescue’ but end up actually walling off the vessel more leading to a heart attack.
What are the risk factors for atherosclerosis?
- Over 50y.o.
- Family Hx
- Increase cholesterol
What should pt’s over 50 take to help prevent a Heart attack?
A baby aspirin (81mg)
-remember that children under the age of 11 CANNOT have aspirin so we shouldn’t call it baby aspirin.
If someone has Chest pains who is sitting in my chair, how much aspirin should I give them?
325mg.
What would the 4 best things to give a pt is they are having a Heart Attack?
“MOAN”
- Morphine
- Oxygen
- Nitroglycerine
- Aspirin
What is the rule of 50’s for Cholesterol?
Rule of 50’s
HDL, want it to be > 50
LDL, want it to be less than 130
Triglycerides, want to be less than 150
Total cholesterol, want to be less than 200
Review for incase I am given a panel of lab values.
What should the Total cholesterol be?
Less than 200.
How can too much cholesterol manifest in the eye?
Cornea arcus in a younger person.
What are some characteristics of Carotid artery disease?
-Artery in your neck
-Plaque = decrease volume and Increase velocity of blood.
If a clot breaks off in the Carotid artery, where will it go to?
The brain - STROKE
What is the % chance of you having HTN if you are 70 years old?
75%.
What is pre-hypertension?
-Do you treat?
120-139
don’t treat.
What are some risk factors for HTN? (4)
- Age
- Race (African Americans are most likely, asians are least likely)
- Diabetes
- Smoking
What treatments do we have for HTN? (4 drug classes)
- ACE inhibitors
- Diuretics
- Beta Blockers
- Calcium channel blockers
What is the pathway of blood through the heart?
- Right atrium -> Tricuspid -> Right Ventrical -> Pulmonary artery -> Lung -> Pulmonary vein -> Left Atrium -> Bicuspid (Mitral) -> Left ventricle
What do the sounds LUB, DUB indicate?
LUB: closing of Tricuspid and Bicuspid
DUB: closing of the pulmonary valves
What usually causes Left heart failure?
-Heart Attack
-this kills the cells on the left side of the heart and prevents it from pumping blood into the body. This blood sits in the left portion of the heart and causes blood to get backed up in the lungs.
What are the SE of left sided heart failure?
- Fluid in the lungs
- Shortness of breath
“the problem is with the lungs BECAUSE the fluid is accumulating in the lungs… makes sense”
-Dyspnea on exertion
What is the #1 cause of Right sided heart failure?
Left sided heart failure.
(think the Left side is usually the problem. It is also the side that leads to the whole body and in my mind it has to do the most work).
What are the SE of a right side heart failure?
Edema in legs and abdomen.
“The problem is with fluid in the rest of the body BECAUSE no blood is able to then get into the Right atrium and fluid gets backed up outside of the heart”
What drugs are associated with Heart Failure?
Digoxine
-I have a NaK for getting digits. These same channels are located in the heart and can affect contractility.
What are risk factors for congestive heart failure?
1 is heart attack
-smoking is another one
-COPD
-Pulmonary HTN
What lab can be done to test for Congestive Heart Failure?
BNP = too much fluid
-can also do an echocardiogram.
What hypersensitivity reaction is Rheumatic fever?
what bacteria is associated with it?
- Cytotoxic - Type 2 hypersensitivity reaction: IgG and IgM
- Strep comes in and lands on the heart valve
Bacterial endocarditis, what is the ocular manifestation of it?
Roth Spot
embolis from the bacteria gets flicked off the heart valve, goes to the eye and causes a Roth spot.
-Leukemia can also cause Roth spots.
What is the #1 cause of heart palpitations?
Premature Ventricular Complexes (PVCs)
Which of the following systemic conditions is LEAST likely to result from atherosclerosis?
Myocardial infarction
Diabetes
Stroke
Congestive heart failure
Diabetes
Pt comes in saying I couldn’t feel my arm for a couple of mins or I couldn’t see for a couple of mins.
What do you think happened to the pt?
They had a TIA (transient ischemic attack)
It is called transient because they last less than 24 hours.
What are the two different types of TIA?
1.Carotid artery TIA
2. Vertibrobasilar TIA
How will the symptoms differ for a Carotid artery TIA versus a Vertibrobasilar TIA?
- Carotid artery TIA
-ipsi vision loss (amaurosis fugal) - Vertibrobasilar TIA
-diplopia, ataxia, vertigo, dysarthria.
-Unilateral or Bilateral VA loss
*more severe symptoms with vertibrobasilar because the vertebral artery comes up the back of the neck to the visual cortex.
What is a Hollenhorst plaque and what can it inform us about?
Hollenhorst plaque is a plaque from the carotid that breaks off and reaches the eye.
-it tells us that there are probably multiple other TIAs present in the body. These pts should be referred immediately.
What is a stroke?
Some part of the brain not getting enough fluid/blood. Cells need the O2 from the blood.
How long do strokes last?
Strokes last longer than 24 hours and tend to stick around.
What is the #1 risk factor for strokes?
HTN
Can think that if the vessels are clogged, the pressure of blood within them is going to rise resulting in HTN
What are the two types of strokes?
- Ischemic Stroke
- Hemorrhagic stroke
Which stroke is more common?
- Ischemic Stroke
- Hemorrhagic stroke
Ischemic Stroke BY FAR.
-80% of strokes are ischemic.
What are the risk factors/causes for ischemic strokes?
- Diabetes
- Increased cholesterol
-A clot prevents blood flow and that prevents the connecting tissue from getting oxygen.
The second kind of stroke (>24) hours is hemorrhagic stroke.
What is the etiology behind these bad boys?
-There is something like an aneurysm (thin balloon) that has burst and leads to blood flowing out of the vessel instead of reaching the target tissue. It is seeping out elsewhere, sot he target tissue is not getting enough oxygen and is dying.
What is the #1 cause of a hemorrhage stroke?
SUBARACHNOID HEMORRHAGE
-this will cause pts to say, this is the worst HA of my life
Hemorrhagic strokes usually occur due to an aneurysm in the brain, what is the most common location of the aneurism/stroke?
Posterior Communicating (within the circle of willis)
-the junction between the PCOM and the internal carotid.
-alos leads to a CN3 palsy and possibly a blown pupil because the fibers run there as well.
If a stroke occurs and affects the anterior cerebral artery, which portion of head will it affect?
ANTERIOR CEREBRAL
Frontal Lobe
Seizures can occur b/c of fever or lack of sleep.
When there are multiple seizure we worry about what condition?
Epilepsy (recurrent seizures)
If we have a seizure lasting more than 5 mins what condition are we worried about?
Status Epilepticus.
MEDICAL EMERGENCY
What is Syncope?
When you pass out but come back to quickly.
Headaches are a big deal for us because a lot of pts will come to use and want to know if the HA is eye related.
What are the 5 main types of HA’s?
- Cluster
- Tension
- Migraine
- Temporal Arteritis
- Brain Tumor
Who gets CLUSTER HAs?
-Men (30-50)
-Smokers/drinkers at increased risk.
When do CLUSTER HAs occur within a day?
Early morning.
Where are Cluster HAs located?
-Unilateral above the eye
-Can get IPSIlATERAL red eyes and/or nasal stuffiness and can cause a transient or permanent psi HORNER’S Syndrome.
Memory trick to remember that Cluster HA’s can cause Horner’s like symptoms.
“Men who smoke and drink a lot get are Horny and Cluster messes”
Easy question:
Why do tension HAs occur?
From tension
-Band distribution
i.e. after staring at a computer all day.
How long do MIGRAINES last for?
4-72 hours.
-have triggers (don’t wake you up b/c need to have a trigger)
-can get aura beforehand
-Women greater then men
Temporal Arteritis HA, pt’s will complain of HA on side of their head. Maybe some jaw claudication and so forth.
What tests will we run to R/O temporal arteritis?
- CRP
- ESR (sed rate)
- CBC
- Temporal artery biopsy.
Tx: steroids immediately.
What is a very Characteristic Symptom of a HA induced by a BRAIN TUMOR?
-They INTERRUPT SLEEP.
-IF you wake up each night with a HA and it is getting worse.
-Usually have a secondary condition with a brain tumor other than just the HA.
*i.e. can’t move part of the body.
Which of the following headaches may cause an ipsilateral Horner’s syndrome?
Cluster
Migraine
Tension
Temporal arteritis
Cluster
Which of the following types of visual field defects is LEAST suggestive of a stroke?
- Macular sparing homonymous hemianopsia
- Macula only homonymous hemianopsia
- Macula involved homonymous hemianopsia
- Macula only homonymous hemianopsia
B/c that would mean it only occured in the occipital lobe and no where else.
Which of the following is the GREATEST risk factor for a stroke?
Hypertension
Hyperlipidemia
Age
Family history
Hypertension
Name the condition:
Pt with Neck Stiffness + Papilledema.
Meningitis!
Pt needs to go to the hospital.
-Ocular manifestation of Meningitis is papilledema.
What is the Triad of Meningitis Symptoms?
- Fever
- HA
- Neck Stiffness
What is the most common Primary (starts in the brain) malignant brain cancer?
Glioblastoma multiforme
What is the most common benign brain tumor?
Meningioma
Pt comes in with Bitemporal Hemianopsia, what kind of tumor do we suspect?
Pituitary Adenoma
What will the pituitary gland secret in excess if it is enlarged?
PROLACTIN
-P rolatin produces milk. Pt may come in saying they have leaky breasts.
What is the name of the cell in the peripheral nervous system?
Schwann Cell
What is the name of the cell in the central nervous system?
Oligodendrocytes
Tough set of symptoms, try to name the condition:
Pt is tired, doesn’t feel well, has problems with walking or bowel/bladder.
Multiple Sclerosis.
MS is super HIGH YIELD
MS occurs in northern latitude areas.
What is a possible association/etiology?
It is thought that it is due to a lack of vitamin. D in a mother during the winder time. Leading to female babies born in summer months that don’t have the Vit D they need later in life and presents with MS.
Is the demyelination with MS central or peripheral?
Central nervous system!
-Leads to ganglion cell destruction :(
What do you need to do in order to Dx MS?
Pt needs to have MRI done to diagnose
-Pt needs to have 2 separate lesions on two different occasions to be diagnosed.
-Lesions must be separated by time (a month or so apart) and space (in two different spots in the body or brain)
How would optometrists be able to visualize the demyelination occurring in MS pt’s?
OCT will allow optometrists to be able to see thinning of the Ganglion cell layer and NFL
RPEOOIIGNI
A lesion of the optic nerve may cause Internuclear Ophthalmoplegia.
What ocular effect will a lesion in the right MLF have?
-a lesion of the MLF
-Right MLF lesion will result in Right eye not being able to ADDuct and will result in nystagmus of Left eye bc it is able to look left but then sees double so it starts to shake.
What is the MLF?
What nerves does it consist of?
It is a track that connects CN’s 3, 4, 6, 7.
CN’s 3 - 7 and then think “no high 5’s in the MLF”
Looks like it connects most of the midbrain and pons mostly.
Midbrain 3, 4
Pons 5, 6, 7, 8
Medula 9, 10, 11, 12
What percent of MS pt’s will get optic neuritis?
25%! (most common presenting symptom)
-Can have:
1. Pain on eye movements
2. Diplopia
3. APD
4. Internuclear ophthalmoplegia
a lot of pt’s with MS are going to have ocular issues so this is important to know
More symptoms of MS from Dr. H’s notes
Oscillopsia, diplopia, gaze palsies
- Vertigo
- Trigeminal neuralgia
- Internuclear ophthalmoplegia, nystagmus
- Crossed motor/sensory syndromes
- Hemifacial spasm, continuous facial myokymia
- Ataxia, tremor, dysarthria
Sudden, non-progressive monocular Vision loss!
What is Uhthoff’s Phenomenon?
Occurs with multiple sclerosis.
These pt’s report a decrease in VA with Increase in body temperature.
Think “Uhhh its hot in here” -Uhthoff’s phenomenon.
Who gets MS more, males or females?
Who are more affected by the disease, males or females?
-Females get the disease more often.
-However, MS in a male has worse prognosis
T or F: if you have a later diagnosis you have a better prognosis.
MS
-False! This is counterintuitive. Younger onset results in less damage from it.
What is Guillain-Barre syndrome?
It is kinda the opposite of MS. MS affects central nervous system and this condition affects peripheral nervous system.
Body’s immune system attacks part of peripheral nervous system (Schwann cell membranes)
-“MS attacks Oligodendrites affecting the CNS”
-Acute inflammatory demyelinating polyneuropathy resulting in acute ascending motor paralysis
Memory trick for key findings of Guillian-Barre syndrome
Guillain’s Island - Man trying to survive, eats undercooked meat or from Jejuni Juice. He has trouble walking (works from the down up) and holds in his Pee so that he retains his fluids. He would like a Gin and Tonic (tonic pupils), he has salt in his system from salt water and gets papilledema.
50% of Guillian-Barre syndrome follow onset of what?
viral or bacterial infection
-flu or URI
-Viral gastroenteritis
-Campylobacter Jejuni (from eating undercooked poultry)
-Small number of cases have been known to occur after a medical procedure, such as minor surgery (including epidural)
What are the Systemic Findings associated with Guillain? (motor, sensory, autonomic)
Motor Dysfunction
-Symmetric limb weakness evolves over days to weeks
-Proximal lower extremity weakness ascends to involve upper extremities
-Lower extremity > trunk > intercostal > neck > cranial muscles [works its way from the bottom up]
Sensory Dysfunction: Paresthesia & pain generally begins in toes & fingertips
Autonomic Dysfunction
-Cardiovascular signs (tachycardia, bradycardia)
-Urinary retention & constipation
What are the Ocular findings associated with Guillain?
“He holds in all of his P’s”
-Facial myokymia
-Palsies: Cranial nerve palsies in 50%: VI (abducens) and VII (facial) most common; III-V, IX-XII may be present
-Ptosis
-Pupils (tonic)
-Papilledema due to Proteins
How do we Treat Guillian?
-Supportive therapy: Respiratory assistance or Plasmapheresis
What is the Prognosis for Guillain?
Most recover, 3% may die (Respiratory failure or Complications of care)
Ptosis and diplopia at the end of the Day.
Name the condition.
Myasthenia Gravis
Myasthenia gravis is an autoimmune disease that affects which receptors in the body?
NICOTINIC acetylcholine receptors
Because… Muscarinic receptors are the ones located on SMOOTH muscles (Sphinctor, Ciliary, Lacrimal gland)
Nicotinic receptors are located on SKELETAL muscles (Levator, EOMS)
What kind of tumor may MG patients get?
A Thymus Tumor
-Tumor Thymus (which is a gland that is suppose to go away as we age)
What are the two ocular SE that usually present with MG?
- Diplopia
- Ptosis
at the ned of the day.
Pt’s alway have respiratory weaknessess.
What protein deposit is in the brain leading to Alzheimers?
Beta Amyloid
What are the three A’s when thinking about Alzheimer’s disease?
A -Amyloid protein deposits in the brain
A- age. Older pt’s get the Dz
A-Aricept. The drug used to Treat Alzheimers.
What is the MOA of Arecept?
Arecept is an AchE inhibitor which results in an increase in ACH in the body.
How does Alzheimer’s differ from vascular dementia?
Alzheimers results in a very gradual loss of memory whereas Vascular dementia is a very quick loss of memory.
Vascular dementia: small lacunar infarcts on vessels that slow signal to brain.
What is Parkinson’s Caused by?
Decrease in Dopamine in the brain.
brain (Substania nigra, corpus striatum & basal ganglia which coordinate smooth & balanced muscle movement)
Parkinson’s is caused by too little Dopamine.
What condition is characterized by too much dopamine?
Schizophrenia
What is the name for abnormal aggregates of protein within nerve cells (essentially the lack of dopamine is replaced with protein in Parkinsons and that has a special name)
Lewy Body
What bucket are our parkinson’s drugs located in?
Bucket #3: Adrenergic Agonists.
-contains Alpha 1, Alpha 2, Beta 1, Beta 2 agonists as well as Dopamine Agonist drugs.
What are the dopamine agonist drugs?
“hey MAN, BRO, pass the METH & AMPHETAMINE”
- aMANtadine
- BROmocriptine
- METHylphenidate
- AMPHETAMINE
also levodopa or Carbidopa
Is parkinson’s a tremor with movement or rest?
REST “a parked car”
-characterized by a pill rolling tremor.
-Cogwheel rigidity
Also lack of arm swinging on one side and stooped posture
What are the symptoms/signs of too little dopamine?
“TRAP”
T- tremor at rest
R- Rigidity
A- Akinesia (difficulty starting mvmt)
P- Postural instability.
What are the ocular Signs associated with Parkinson’s?
- Blephrospasm (trying to compensate for dry eye caused by inability to blink properly)
- Chronic blepharitis
- Dry eyes
- Glabellar tap reflex (Myerson sign)- “tap forehead, if you do it long enough, a normal pt will stop reacting and no longer blink. A Parkinson’s pt cannot stop blinking if tapped on forehead”
- Reduce saccades & pursuits
- “Staring Look” “staring causes dry eye and blepharitis, blepharospasm is to combat the dry eye”
-Mask-Like Face
-Infrequent blinking
-Restricted vertical gaze w/ chin tuck
Chart comparing Parkinson’s tremor versus Essential tremor
What is the name for a condition in which blood collects between the skull and the dura?
Epidural Hematoma
What is the name for a condition in which venous blood collects between the dura and arachnoid space?
Subdural hematoma
What drug may increase the occurrence of a subdural hematoma?
Warfarin i.e. Coumadin
What symptoms should you watch with any head trauma?
- Changes in pupillary size (a blown pupil may signal an impending uncle herniation).
-this is why we use pen lights to look at eyes in the ER. - Nausea or vomiting
- Loss of consciousness
What is the classic sign with horner’s syndrome?
- Ptosis
- Miosis
- Anhydrosis
What conditions commonly cause sympathetic lesions btwn the hypothalamus and the cilio-spinal center of Budge?
Stroke
What symptoms will occur in the case of a horner’s that is due to a stroke in the brain?
All thee of the triad.
- Ptosis
- Miosis
- Anhydrosis
What condition commonly causes a sympathetic lesion at the 2nd location between the cilospinal center of budge and the superior cervical ganglion?
What will the Symptoms?
- Pancoast tumor.
All thee of the triad.
- Ptosis
- Miosis
- Anhydrosis
What condition causes a lesion around the superior cervical area?
What are the SE?
Carotid artery dissection
- Ptosis
- Miosis
- Anhydrosis of just the upper face (there is an extra lower branch of sweat fibers that can then innervate the lower face)
When do you see anisocoria w/ Horners the most?
In the Dark (because the pupil will not dilate)
What is another disease that causes anisocoria most prominent in the dark?
Syphilis
Horny and Syphilis are the two things that are worse in the dark.
Review: which HA can cause horner’s like symptoms?
Cluster HA
Which of the following conditions is LEAST likely to be associated with myasthenia gravis?
Thyroid disease
Rheumatoid arthritis
Thymoma
Ankylosing spondylitis
Ankylosing spondylitis
I have no idea why..
-MG is associated with thyroid dz (internet says so)
Which of the following brain tumors may be associated with a junctional scotoma?
Glioblastoma multiforme
Meningioma
Schwannoma
Pituitary adenoma
What does vf look like?
Pituitary adenoma
Because junctional scotomas occur on one aspect of the chiasm
Junctional scotoma. The patient has a right central scotoma and superior temporal field defect in the left eye.
-Inferior fibers cross anteriorly in the chasm, causing a superior temporal field defect.
Name the condition:
I’m thirsty all of the time and i’m peeing all the time and my stomach hurts”.
DIABETES
-one of the primary insults of diabetes is the eye.
What tests would I run to check for diabetes? (what results would I suspect if they had diabetes)
1st check glucose levels.
-if pt had diabetes, I would expect them to be sky-high (500mg/dL).
-Normal glucose is 126.
What is causing glucose levels to be sky high in pt’s with diabetes?
Their pancreas has stopped working. They have no beta cells left to produce insulin.
What are the 3 main functions of insulin?
- Store glucose in tissues
- Decrease hepatic glucose production.
- Decrease Lipolysis (decreases the breakdown of fat)
What is one thing we worry about w/pt’s who have type 1 diabetes?
Diabetic Keroacidosis
-b/c the glucose is stuck in the blood their tissues don’t have any to use so the body starts breaking down other things for energy
-The body starts to break down proteins and fats and gets into a metabolic acidosis state. When this happens the brain stats to shut down and pts appear tired and sometimes act or look like they are drunk.
Name the condition.
“fluffy grandma comes in to check her sugar and it is 200. We ask, are you thirsty/peeing a lot? -no, not really…”
Type 2 DM - don’t have problem with insulin production, but with peripheral resistance
Type 2 diabetic pt’s don’t get diabetes ketoacidosis.
What SE’s do type 2 pt’s get?
- Retinopathy
- Nephropathy
- Neuropathy
-unfortunately these will all occur at some point.
Which one is more genetic, type 1 or type 2 diabetes?
Type 2
(even though you would think type 1)
Name the condition:
A pt comes in saying they are thirsty, peeing a lot but we test their glucose and its normal.
Diabetes Insipidus (looks like diabetes but its not.)
-it is marked by extreme thirst and polyuria resulting from a lack of ADH.
-ADH’s job in the kidney is to go to the nephron and pull water out of it and put it in the body again.
-W/out ADH, your body can’t pull water out of the nephron when it is needed (when you are thirsty) and it will cause you to pee all the time.
How long does a Hemoglobin A1C monitor the glucose levels over?
3 months (90) days.
Normal is less than 7%
When does a Type 1 diabetic individual need to have an eye exam?
-within 5 years after diagnosis
When does a Type 2 diabetic individual need to have an eye exam?
-At the time of diagnosis! and every year after that.
(we don’t know how long they have had it for)
Name the condition:
Pt comes in feeling tired and overweight.
Hypothyroidism
What will a lab result for hypothyroidism look like?
The #1 test is TSH, it will be high
Low T3 and T4
Where is the Thyroid gland located?
It is located in the front of the neck. It is the most anterior gland and looks like a bowtie.
What is the most common condition causing hypothyroidism?
Hashimoto’s Thyroiditis.
-Hashimotos is an autoimmune dz that attacks the thyroid gland.
What lab will be positive if a pt has Hashimotos?
+ANA
Name the condition:
Pt comes in who is extremely hyper, hair is falling out and pt is losing weight.
Hyperthyroidism.
What will blood tests reveal if a pt has hyperthyroidism?
- TSH will be low
- T4 will be high.
What is the #1 cause of hyperthyroidism?
Graves Disease.
-Graves is an autoimmune response.
What ocular SE do we think about with graves disease?
- Proptosis
- Upper lid retraction
- Superior Limbic Keratoconjunctivitis (SLK)
Think if you are hyper, you want to be looking around at everything (proptosis), you are excited so your lid is retracted. Then you get dry eye because you have been looking all over the place.
Grave’s disease can cause spontaneous diplopia. Which extraocular muscles is the most commonly affected in a patient afflicted with Grave’s disease?
Inferior rectus.
GRAVES DZ is HYPERTHYROIDISM.
IMSLO muscles most affected are inferior rectus, medial rectus.
What kind of diplopia is most likely to occur due to graves? (thyroid)
Horizontal or Vertical.
Vertical is affected first.
Where is the Parathyroid located?
They are the little spots on the thyroid gland (on the bowtie)
What does the parathyroid do?
Releases Parathyroid hormone.
-PTH takes Ca+ from the bones and puts it in the bloodstream.
“maybe think PARAthyroid puts Calcium AROUND (PARA) the thyroid.”
What is Parathyroids worst enemy?
Calcitonin (Calcitonin puts Ca+ into the bones)
What will happen if you have hyperparathyroid?
Increase PTH, Increase calcium in the blood will result in:
- Renal/kidney stones
- Hurts bones
- Bother muscles.
- BAND KERATOPATHY
What will happen if you have hypoparathyroid hormone?
Decrease parathyroid, decreases Ca in the blood will result in:
- Cataracts
- Conjunctivitis
- Blurry vision
- Decreased muscle contraction (tenty)
- UVEITIS
What is the most common cause of hypoparathyroidism?
You were hyperparathyroidism and had your thyroid removed and now you are hypo.
these pts will need to have calcium supplements.
What is the function of the Adrenal glands?
To secrete Adrenaline (steroids)
What is Addison’s disease?
Autoimmune atrophy of the adrenal glands.
Tx: add more steroid (ADDison’s ADD more steroid)
What is Cushing’s syndrome?
Hypercortisolisum
too much steroid in the body. Majority of cases result from chronic prescribed corticosteroids.
What signs are associated with Cushing’s syndrome?
Central obesity (steroids = sugar)
Moon face
Buffalo hump
What are the general side effects of too much steroid (cortisol)?
-Osteoprosis early in life
-HTN
-Fat redistribution
-Decrease healing time
-Cataracts
-Glaucoma
(too much sugar, hurts your bones, blood pressure, fat, decreases healing time, gets in the lens, and can cause glaucoma)
What is Pheochromocytoma?
Tumor that releases epi and norepinephrine.
TUMOR OF ADRENAL GLAND
What ocular SE can occur if a pt has a Pheochromocytoma?
Papilledema
What are the SE of a Pheochromocytoma?
“the P’s”
- high blood Pressure (HTN)
- heart Palpitations
- Pain (HA)
- Palor (pale)
- Perish (pt feels like they are doomed)
- Papilledema.
Which of the following complications is LEAST likely to occur due to diabetes mellitus?
Retinopathy
Uveitis
Cataracts
Glaucoma
Uveitis
What 3 lab tests should we run when thinking about the renal system?
- BUN (High = Dz)
-blood ureic nitrogen - Creatine (> 1 = Renal Dz)
- Glomerulous Filtration rate. (low = Dz)
Every test is high in the case of Dz except GFR.
What are the 2 things that cause chronic renal failure (which is more common)?
- Diabetes - sugar damages the filtration unit
- HTN - pressure damages the filtration unit
What are two types of glomerular disease?
- Nephritic Syndrome
- Nephrotic syndrome
What conditions are associated with NephrITIC syndrome?
- HTN
- Edema
- Hematura
- Blood casts
If a pt has nePHROtic, what will we see in the urine?
How much?
PROtein (greater than 3.5grams of protein)
What is Pyelonephritis?
Infection of the kidney
What is the #1 Bacterial STD in the US?
Chlamydia.
What is the #1 viral STD in the US?
HPV
When we see chlamydia in the eye, does it produce acute or chronic red eye?
CHRONIC
CHlamydia = CHRonic red eye.
What other ocular side effect do we think of when we see chlamydia?
LARge INFERIOR palpebral follicles
How do you treat Chlamydia?
Azithromycin
-1 gram, 1 time.
Alternative would be Doxy 100mg BIDx 10 days
What STD commonly co-exists with Chlamydia?
Gonorrhea.
Which we has been pounded into our head as having acute mucopurulent discharge.
How do we treat gonorrhea?
Cefriaxone (we AXE gonorrhea)
250mg IM in the body.
Plus: Azitro or Doxy for the chlamydia that often presents with it.
What condition is associated with Treponema Pallidum?
Syphilis
-The great mimicker
Syphilis tends to run in three phases what are they?
Stage 1: Chancre (painless ulcer). If Tx w/ PCN at this stage, they will not go onto stages 2 or 3
Stage 2: Mimic portion-can look like the flu, muscle aches, lesions in the eye. Eye and Kidney.
Stage 3: Nervous system and ophthalmic lesions. Argyl Robinson Pupil (small pupil don’t constrict in light, but at near)
What other conditions can syphilis cause in the eye?
- Interstitial Keratitis (90%).
-Herpes can also cause this - Salt and Pepper Fundus
- Uveitis
- Cranial Nerve issues & optic neruopaties
- Chorioretinitis & Vitritis
- Agyll Roberson pupil
What lab tests do you do with syphilis?
- RPR, VDRL (+ means they have Dz Right now)
- FTA-ABS or TPPA (+ means they have Hx of Dz. They are specific for the bacteria Treponema Pallidum)
- EIA, MFI, Syphilis IgG
- Neg. means you don’t have dz
+ Pos means you need to do all the above tests.
What class of drugs are used to Tx benign prostatic hypertrophy (BPH)?
-alpha 2 blockers
i.e. Flomax
These are the Zosin and Losin drugs
-Tamsulosin
-Prazosin
-Terazosin
What is the ocular SE of alpha 2 blockers?
Normal functions of alpha 1 receptors is to Dilate the eye and Vasoconstrict blood vessels
Thus Alpha 2 BLOCKERs lead to:
-Miosis (FES)
-dilation of blood vessels (decrease blood pressure)
What is the #1 cancer in men?
1 cancer in women is breast cancer.
Prostate cancer
What is the #1 cancer both M & F die from?
Lung cancer.
What are the lab tests for benign prostatic hypertrophy?
-PSA
-Ocuvit (an ocular vitamin that can false elevate PSA)
Which hormones are involved in breast feeding?
- Oxytocin -> milk ejection (posterior pituitary )
- Prolactin -> milk production (anterior pituitary)
*there is a big push for breast feeding due to the immunoglobins
What is the #1 cause of cervical cancer?
HPV
What drug is used to treat breast cancer?
Tamoxifen
What are the ocular SE of Tamoxifen
“think of the C’s”
- Crystallin retinopathy
- Clots -> CRVO, BRVO
- Cornea -> Whorl Keratopathy
- Cataract
- Cancer -> can cause uterine cancer.
Neural tube defects are caused by a decrease in what?
Folic Acid
If you don’t have enough folic acid what kind of anemia can you have?
Anemia with Increased MCV and decreased Hgb.
-pregnant women, alcoholics, dietary issues
Rubella: if mom has it and it is passed to the baby, what ocular SE may result?
- Micropthalmia
- Glaucoma (probably due to the eye being so small)
- Cataracts
think of a small RUBY
If a pt comes in with congenital cataracts, what conditions do I need to think of?
- Rubella
- Galactosemia (too much galactose)
Syphilis: if mom has it, it can be passed onto the baby.
What SE can it cause?
- CNS disorders
- Interstitial keratitis
Toxo: can it be passed to a baby?
Yes, can result in still birth. OR if the baby survives, they will likely have a retinochoroditis in one eye. can result in a vitritis when pt turns 20.
TOXO - from cat litter (parasite)
What does cerebral palsy mean?
That the baby didn’t get enough oxygen at some point.
What two things can cause peptic ulcer dz?
- H. Pylori
- Chronic NSAID use
-NSAIDS stop Cox which stops prostaglandins. Prostaglandins normally protect the stomach (from acid). Thus, without them like in the case of chronic NSAID use, peptic ulcer Dz can form.
What is Barriets Esophagus?
Acid causes a change in cell type (Metaplasia, one mature cell type to another mature cell type)
Squamous cells -> Columnar cells.
This can then lead to esophageal cancer.
What are the two types of inflammatory bowel disease?
- Crohn’s Dz
- Ulcerative colitis
Crohn’s and ulcerative colitis are positive for what test?
HLA-B27 +
UCRAP
What ocular SE can both Crohn’s and Ulcerative colitis have?
Uveitis!
Which inflammatory bowel disease has skip lesions?
Crohn’s or Ulcerative Colitis
Crohns.
Crohns has Skip lesions and a Cobblestone appearance.
“think skipping down a cobblestone road with Crohns”
Where does Uclerative colitis start and where does it move to?
Starts in the Rectum and moves to the Colon.
What ocular finding is associated with colon cancer?
Multiple CHRPES on the fundus -> gardener’s syndrome -> colon cancer.
Get a colonoscopy!
What condition is characterized by a Kayser-Fleicher ring and a Sunflower cataract?
Wilson’s Disease (Hepatolenticular degeneration)
-Copper!!
Think of Wilson the volleyball floating in the water, it is a copper ring and a sunflower growing out of it.
What is the tx for Wilson’s disease?
PenicillAMINE
Penicillamine is not well tolerated, what three ocular SE can result from treating Wilson’s Dz with Penicillamine?
- Myasthetia (diplopia, ptosis)
- Optic Neuritis
- Ocular Pemphigoid (fluid filled blisters)
Idk what is worse, the copper or the SE from the drug to tx it.
What lab test can you do to test the liver?
- AST
- ALT
Note: a lot of things can elevate these two values such as Tylenol, Alcohol.
What are 3 main categories of things that may inflame the liver and cause Hepatitis?
- alcohol
- Fatty liver
- Viral
question:
What is the primary route of infection of patients diagnosed with hepatitis C?
Blood transfusion
Intravenous drug use
Contaminated food
Sexual contact
Tattoos and piercings
Intravenous drug use
Which of the Hepatitises has fecal oral transmission?
A and E
The vowels go with the bowels.
Which of of the Hepatitises have vaccinations?
A and B
