TMOD Flashcards
Management/ Tx for optic neuritis
- Refer for MRI (strong association with multiple sclerosis, need to check for plaques of demyelination present)
- *if clear no tx
* if pt likely to develop MS, tx with IV corticosteroids for 3 days followed by oral steroids for 11-15 days along with interferon beta 1-a
*stabilize for 2-3 years
- do not use oral steroids as mono therapy because higher chance of reoccurrence
RTC for optic neuritis
1-3 months
*if tx with steroids RTC more frequent for IOP check.
Tx for chronic conjunctivitis caused by chlamydia (inclusion conjunctivitis)
Inclusion: Single dose of oral Azithromycin, followed by daily use of oral doxycycline 100mg po BID
or erythromycin 500 mg po BID for 7 days
or
Topical erythromycin or tetracycline ointment BID- TID-QID for 2-3 weeks
- caused by serotypes D-K
*Hx of vaginitis, cervictis or urethritis
Tx for Gonorrhea
Aggressively with IV or IM ceftriaxone (cephalosporin)
Or
Macrolides (azithromycin, clarithromycin, clindamycin, erythromycin, lincomycin)
Tx MRSA (4)
- Bactrim
- clindamycin
- doxycycline
- vancomycin
RTC for NPDR
6 months - year
RTC for PDR
Every 3 months
Tx for retinal artery occlusions needs to be initiated ___ minutes of onset
90 minutes of onset
* otherwise afflicted tissues will die from lack of oxygen
Tx for retinal artery occlusions includes reducing pressure in the eye. What are the methods?
- hyperventilation into paper bag (respiratory acidosis and subsequent vasodilation)
- digital massage
- systemic acetazolamide (IV or po)
- topical hypotension drugs (Timolol q15 minutes)
- paracentesis (puncture corneal at 6 o’clock position to rapidly bring down high IOP)
GCA (giant cell arteritis) diagnostic testing
- ESR
- CRP
- carotid Doppler
- platelets
- temporal artery dissection
Young patients who develop a vein occlusions may have ______ blood or take what meds?
Hypercoaguable blood or take oral contraceptives
90 day glaucoma
Patients develop glaucoma within 90 days after a retinal vein occlusion, get neovascular glaucoma from very ischemic eye secondary to vein occlusion
Tx for retinal vein occlusions
No tx unless edema or neovascularization is present
* Tx neovasc (NVI, angle, NVD or neovasc glaucoma) with PRP
* Tx macular edema with intravitreal anti-VEGF monthly for first 6 months
RTC for vein occlusions
Monthly for first 6 months (check for edema or neovascularization)
*refer for full cardiac evaluation
*oral contraceptives discontinued
* HTN, report to PCP, aspirin prophylactically
Tx for OIS
- URGENT referral for treatment of HTN Or cardiovascular disease (carotid Doppler)
- neovascularization treated with PRP and anti-VEGF
- neovascular glaucoma tx with surgery
RTC for ROP
monitor every 1-2 weeks until peripheral retina has become vascularized
RTC sickle cell retinopathy
Annual dilated exams
*tx neo with anti-VEGF, laser photocoagulation, cryotherapy
*pt should also have hematology consult
Pt edu for lattice degeneration and snail track
Symptoms of RD, RTC ASAP if symptomatic
RTC for pt treated for RD
1 day
1 week
2 weeks
1 month
2 months
3 months
6 months
12 months
Tx/management for retinoschisis
- in kids, pt edu about avoiding rigorous physical activity because minor trauma can lead to hemorrhage or detachment
- RTC every 6 months
Tx for ectopia lentis (displacement of natural lens)
- Remove dislocated lens
- refractive error correction
- tx underlying disease
Tx & RTC for ocular HTN
- RTC: Monitor every 3-6 months for signs of glaucoma
- if stable, reduce frequency
- if IOP > 24 mmHg, prophylactic use of ocular hypertensive drops reduce risk of VF loss
Tx & RTC for PXF
Monitor IOP every 6-12 months
If IOP causing damage, refer for ALT or SLT
*poor response to topical therapy
RTC & tx for exfoliative glaucoma
(PXF —> exfoliative glaucoma (most common secondary glaucoma)
Monitor IOP every 3 months
- tx with ocular hypotensives, SLT/ALT and filtration procedure
Tx and RTC for pigmentary glaucoma
Tx with LPI
RTC every 6 months for IOP check
Tx for plateau iris
LPI
Tx chemical burns
OCULAR EMERGENCY
1. Irrigate with saline solution until pH neutral
2. Evert lids and sweep fornices with cotton tip for any trapped offending agents
3. Once neutral, use PF ATs every hour
4. Topical antibiotics QID or oral for severe
5. Cycloplegic or pressure patch for pain
6. Topical steroids for severe to reduce inflammation
7. Corneal debridement if necessary or surgery if symblepharon
Tx for hyphema
Goal is to stop the bleeding
*pt must be on bedrest with bathroom privileges or minimal movement
* keep head elevated to allow blood to pool inferiorly and wear a shield
* discontinue anti-coagulants (aspirin)
* use topical atropine or scopolamine to immobilize iris
* tx inflammation with topical steroids
RTC for hyphema
Daily for first week and upon improvement reduce frequency
*RTC four weeks after traumatic event for gonioscopy and dilated exam
NO GONIO on initial exam
But you can do GAT
What is hypotony defined as?
IOP below 6 mmHg
Hypotony is caused by excessive outflow or reduced production of aqueous humor.
What are the causes of excessive outflow leading to hypotony?
- Surgery
- Trauma
These factors increase the drainage of aqueous humor from the eye.
What can cause reduced production of aqueous humor?
- Medications (b-blockers, CAI)
- Uveitis shutting down the ciliary body
Both factors contribute to lower intraocular pressure.
What are common symptoms of hypotony?
- Asymptomatic
- Mild to severe pain
- Reduced vision
- Epiphora
Patients may not always show symptoms.
What are the signs of hypotony during examination?
- IOP below 6 mmHg
- Shallow anterior chamber
- Hyperopic shift
- Corneal edema and folds
- Aqueous cells and flare
- Edema of retina, macula, and disc
- Tortuosity of retinal vasculature
- Positive Seidel sign if trauma/surgery is present
These signs indicate the structural changes in the eye due to low pressure.
What is Phthisis Bulbi?
End-stage condition of the eye characterized by 2/3 normal size and no vision
It results from intraocular disorganization and calcification.
What are the potential presentations of a patient with Phthisis Bulbi?
- Hemorrhaging
- Inflammation
These symptoms are associated with the advanced degeneration of the eye.
What is the primary goal of treatment for hypotony?
Manage the underlying etiology
Treatment varies based on the specific cause of hypotony.
What should be done if an open wound is present in a hypotony case?
- Treat with topical antibiotic
- Close with:
- Bandage contact lens
- Pressure patch
- Cyanoacrylate glue
- Sutures
These methods help prevent infection and promote healing.
How should pharmacological causes of hypotony be addressed?
Discontinue the medication
Identifying and stopping the offending drug is crucial.
What treatment is recommended for uveitis in the context of hypotony?
- Topical steroid
- Cycloplegic
These medications help reduce inflammation and pain.
What is the treatment for edema associated with hypotony?
Topical sodium chloride (Muro 128)
This treatment helps in managing corneal edema.
What is the focus of treatment for advanced cases of Phthisis Bulbi?
- Preventing pain
- Improving cosmesis
Management aims to enhance the quality of life for affected patients.
What treatments can be used for painful eyes in Phthisis Bulbi?
- Topical steroids
- Cycloplegics
- Enucleation
Enucleation removes the eyeball but preserves extraocular muscles and orbital contents.
How can cosmesis be managed in patients with Phthisis Bulbi?
- Cosmetic shell
- Enucleation with a prosthetic eye
These options help improve the appearance of the affected individual.
RTC herpes simplex keratitis
2-7 days to ensure resolution
*check IOP
*if long term, pt prescribed oral acyclovir 400mg BID, prophylactically
What are the treatment options for Toxocariasis?
Steroids (topical, periocular, or systemic routes)
The choice of steroid route depends on the severity of the inflammation.
When should vitrectomy be considered in Toxocariasis?
When vitreoretinal traction bands form or when the condition does not improve or worsens with medical therapy
Vitrectomy is a surgical procedure to remove the vitreous gel from the eye.
What is the role of laser photocoagulation in Toxocariasis?
Consider laser photocoagulation of the nematode if it is visible
Laser photocoagulation can help to destroy the nematode and reduce inflammation.
Tx for AAION caused by GCA
Immediate Tx with methylprednisone IV for 3 days
+ oral prednisolone (taper, 1-2 years)
* treat for 6 months to prevent vision loss in fellow eye
What is the first line of treatment for patients with GPC?
Discontinuation of contact lens wear
GPC stands for Giant Papillary Conjunctivitis
What type of medications may be used if symptoms persist in GPC?
Topical medications, typically a mast cell stabilizer
Mast cell stabilizers help alleviate symptoms without further medical treatment
Under what circumstance might a low-dose topical steroid drop be considered for GPC?
In cases where GPC is unusually severe
Example: loteprednol 0.2% to 0.5% qi.d
When should a patient follow-up for re-evaluation of GPC signs and symptoms?
In a period of 2-4 weeks
What may be necessary to prevent recurrence of symptoms in GPC?
Continue with a mast-cell stabilizer chronically
When can contact lenses be reintroduced for a patient with GPC?
Once the patient’s signs and symptoms have improved
What type of contact lenses may be recommended for patients with GPC?
Daily disposable contact lenses
This is often recommended to enhance tolerance and hygiene
What adjustment might be made to a patient’s contact lens hygiene regimen if they had GPC?
Changing to a hydrogen peroxide based solution
What should be done initially for patients diagnosed with GPC?
Contact lenses should be discontinued until symptoms resolve.
GPC stands for Giant Papillary Conjunctivitis.
What are some modifications to lens design and solutions to prevent recurrence of GPC?
Modifications include:
* Changing to preservative-free or hydrogen peroxide based cleaning system
* Adding enzymatic cleaners
* Reducing contact lens wearing time
* More frequently replacing contact lenses
Daily disposable lenses are the most preferred for replacement.
True or False: Patients with GPC can continue wearing their contact lenses without any changes.
False
Contact lenses should be discontinued until symptoms resolve.
Fill in the blank: To prevent recurrence of GPC, patients may need to switch to a _______ cleaning system.
preservative-free or hydrogen peroxide based
These systems are less likely to irritate the eyes.
What type of contact lenses are most preferred for patients with GPC?
Daily disposable lenses
They help reduce the risk of recurrence by allowing for frequent replacement.
Tx for vertebrobasilar insufficiency
Control hypercoagulable state with prophylactic use of daily aspirin
Tx and RTC for Irvine Gass Syndrome
Treat CME with topical NSAID with topical steroid (responds well within 3-6months)
Ketorolac 0.5% QID
prednisolone acetate 1% QID
RTC in 4-6 weeks after initial tx to determine response to topical drop therapy, monitor monthly and taper steroid accordingly
If no response, oral NSAIDs, oral steroids or oral acetazolamide
Tx for primary congenital glaucoma
Surgical
Goniotomy (if cornea is transparent)
Or
Trabeculotomy (if cornea is not transparent)
Tx CRVO
(OCT shows CME)
Intravitreal VEGF
For persistent macular edema: steroid implant (Ozurdex)
Or laser photocoagulation
RTC for CRVO
1 month after initial tx with anti-VEGF
VA 20/40 or better
*1-2 months for 6 months
If worse than 20/200, RTC monthly
Injections RTC 6 weeks
Tx/management for RP
15,000 IU oral Vitamin A Supplement
Sunglasses
Low vision consult
*patient will likely be legally blind by their 40’s
Tx/management for Stargardt
Supplement DHA
UV blocking sunglasses
Low vision aids
Genetic counseling
*NO VITAMIN A
(Help slow down accumulation of lipofuscin)
Tx for Best disease
No treatment unless CNV present
Treat CNV with anti-VEGF injections and/or laser photocoagulation
- autosomal dominant
- abnormal EOG, normal looking fundus when young
IIH dx confirmation
- MRI to r/o brain mass or hydrocephalus
- If MRI unremarkable, lumbar puncture and evaluate opening pressure (opening pressure will be elevated in IIH, but CSF should be unremarkable in its composition)
* high CSF pressure is > 250 mmH2O with normal CSF composition
- rule out other cause of papilledema
IIH is of unknown etiology and must meet this criteria:
1. Signs and symptoms of increased ICP
2. High CSF pressure (>250 mmH2O) with normal CSF composition
3. Normal neuroimaging
4. Normal neurogenic exam findings (except papilledema or CV VI palsy)
5. No identifiable cause, such as a certain medication
true or false
Acute attack of angle closure glaucoma should be considered broken if the IOP returns to normal levels
FALSE!!!
Attack is NOT broken UNTIL:
IOP is normal ✅
Pupil is miotic ✅
Angle is OPEN ✅
*if angle is not open the IOP will raise again to very high levels!
RTC for acute angle closure glaucoma
1 day
- 2 days after attack, patient should also be referred for LPI, and then LPI for fellow eye 1-2 weeks later to prevent IOP spike)
TX/management for GPC
Topical mast cell stabilizer and antihistamine drops
Example; pataday QD or Zaditor bid
For moderate GPC, refit SCL, decreased CL wear time, new contact solution (hydrogen peroxide based) and a weekly enzyme
RTC 2-4 weeks to ensure GPC is resolving and symptoms are improving
*fit into dailies instead
Tx for myasthenia gravis
Oral acetylcholinesterase inhibitors
Example: pyridostigmine 60 mg QID
Can be increased but not beneficial more than 120 mg q2h
Tx for brown syndrome
No treatment required, may be self limiting depending on etiology
If inflammatory etiology can treat with steroid injection near trochlea or oral steroids
Also may have muscle surgery for abnormal head position or large hypotropia
Tx for thyroid eye disease
Start with orbital decompression
Then strabismus surgery (if diplopia), then eyelid surgery
*proptosis addressed first, then strabismus and then lid retraction
Initial treatment for fusional vergence dysfunction
Convergence training with VT
Divergence training with VT
Management of optic nerve melanocytoma
Monitor with fundus photography every 6 months
*rare for malignant transformation
* melanocytoma of the optic disc is a variant of a melanocytic nevus
* deeply pigmented
What additional testing should be included with a diagnosis of choroidal melanoma?
- Blood testing
- Chest x-ray
- Abdominal CT scan
*should all be performed to rule out possible metastasis
*poor prognosis, patient eventually develops metastatic disease
Tx for AAION
Emergency!!! Tx with systemic steroids
Tx with IV methylprednisone for 3 days + oral prednisone
Tx to achieve field expansion and help patient not bump into things with a right homonymous hemianopia
Two 40 diopter Fresnel prism segments, placed BO over right eye in Peli fashion
* purpose of prisms is to move light from non-seeing field and provide cue for patient to scan environment
* patient must learn and practice in order for Fresnel prisms to be grounded into lens
* 40 D fresnel prisms provide 20 degrees of field expansion (1 degree for every 2 diopters of prism)
Common medication treatment for lupus
Hydroxychloroquine (Plaquenil)
* retinopathy can occur with 6.5 mg/kg/day or a cumulative dose greater than 1000g
Tx for trichotillomania
Psychotherapy and pharmacological intervention
RTC for
Conjunctival nevus
RTC 6-12 months
*photo documentation and monitor for changes or signs of malignancy
*pt edu to wear sunglasses and less UV exposure
Tx for marginal keratitis
Tx concurrent blepharitis first
* warm compress
* eyelid hygiene
* fluoroquinolone AB QID
* bacitracin or erythromycin ung QHS
If moderate to severe and patient symptomatic
* low dose topical steroid QID (loteprednol or pred 0.25%) MUST USE IN CONJUNCTION WITH AB
Laser Tx for proliferative diabetic retinopathy
PRP (pan retinal photocoagulatiom)
* laser destroys parts of the retina, which eliminates need for oxygen and reduces VEGF
Tx for polypoidal choroidal vasculopathy
Focal laser photocoagulation or PDT for extrafoveal lesions
*can treat the entire lesion and the polyps
RTC for ICE syndromes
1-3 months
*check IOP
Tx for ICE syndromes
Often no treatment necessary BUT;
If IOP increased: topical anti-glaucoma drops
If corneal edema: topical hypertonic (sodium chloride, Muro 128)
If severe: corneal transplant (penetrating keratoplasty)
Tx for epiblepharon in a 6 year old
PF artificial tears
* should resolve spontaneously as patient’s face elongates and corrects eyelid tissue and lashes
Management of pupil sparing complete cranial nerve 3 palsy
Tx for dellen
AT’s PF QID and bland ointment QHS
*Bandage CL if severe
*pressure patch 24 hours
RTC 1-7 days after initial Tx
*adjacent to elevated tissue
s/s: FBS, thinning next to limbus
Tx for active syphilis infection
IV penicillin G followed by IM penicillin G
- use tetracycline is patient allergic to penicillin
Tx for viral conjunctivitis
Pt edu about contagious nature of disease and advise to avoid contact with other people, wash bedsheets and towels, condition is self limiting
* it will get worse before it gets better
- topical steroids and cyclosporin for subepithelial infiltrates in EKC
- preservative-free artificial tears or tear ointment four to eight times per day for 1 to 3 weeks. (Advise single-use vials to limit tip contamination and spread of the condition)
- Cool compress several times perday.
- anti-histamine drops (e.g.,epinastine0.05%b.i.d.) if itching is severe.
RTC for adenoviral conjunctivitis
2-3 weeks
What is the most appropriate spectacle Rx for this patient?
Pt is 7 year old Hispanic male
Give full prescription
OD: -1.75 -0.50 x 180
OS: -8.00 -1.00 x 180
*pt is a myope with intermittent exotropia and amblyopia (anisometropia)
* manage amblyopia by correcting their refractive error first, full time for 4-6 weeks and then re-eval VA
True or false
Full time occlusion is recommended for constant strabismus
True
Tx for patient with anisometropic amblyopia
- Correct refractive error, wear full time
- Re-evaluate in 4-6 weeks, check VA if improvement
- If no improvement, part time direct occlusion or VT
Part time occlusion is recommended for what kind of strabismus?
Intermittent strabismus
