x files Flashcards
how do you manage corneal ulcer
give topical antibiotic eye drops, swab, refer to ophto
how do you manage globe penetration
my need IV abx
URGENT refer to ophtho
best dilator to use in adults
tropicamide
best dilator to use in kids
cyclopentolate
most concerning drug for someone about to have cataract surgery?
flomax–floppy iris syndrome
what are the signs of parinaud’s
convergence/retraction nystagmus and upward gaze palsy
is cataracts reversible or irreversible vision loss
reversible because surgery
how do you distinguish between preseptal and orbital cellulitis
orbital causes pain and affects eye movements
how do you test for sarcoidosis?
ACE levels
serum Ca
CXR
then either serum protein electrophoresis or lacrimal gland bx
what do you do if an exotic dancer and contact lens user complains of spot on cornea that lights up with flouresciene
refer to ophtho
most common cause of loss of vision in HIV positive patient with low CD4 count
CMV retinitis
what eye pathology should you suspect in an asian lady
closed angle glaucoma
what is a concomitant strabismus
manifest eye deviation
if you have trauma to the orbit and patient presents with subcutaneous emphysema of eyelid, what should you suspect
ethmoid bone fracture
what is a common symptom of cataracts
difficulty driving at night
what medications should you worry about in a patient going for cataract surgery
TAMSULOSIN–floppy iris syndrome
is an alpha-1 antagonist
what drug is contraindicated in a patient with HTN and renal calculi
diamox
it is a carbonic anhydrase inhibitor which increases the risk of renal calculi and is also used to treat glaucoma
which of the following is NOT a cause of leukocoria? cataract retinoblastoma high refractive error not aligning ophthalmoscope properly
high refractive error is NOT a cause of leukocoria
what muscles are involved when the patient looks down and to the left
left eye–IR
right eye–SO
in a patient who has had HTN for a long time, what would you expect to see on retina exam
copper/silver arterioles
in a patient with less long standing HTN, what might you expect to see on retina exam
flame hemorrhages and exudates
what effect does HTN have on the retina
get arteriolar sclerosis–> thickening of vessel wall–> increased width of central light reflex
this progresses to the light reflex occupying the width of the vessel–> copper wire arterioles
when the light reflex is totally obscured, you get silver wire arterioles
severe A/V nicking can lead to BRVO–> retinal hemorrhages and cotton wool spots
what effect can an acute rise in BP have on the retina
fibrinoid necrosis of the vessel wall–> exudates, cotton wool spots, and flame shaped hemorrhages
what is the difference between a tropia and a phoria
tropia–> manifest (always present)
phoria–> latent, only comes out during crossover test or when take away ability of eyes to communicate with each other
if a patient’s left eye is slightly misaligned, approximately to the same degree in all directions, what do they have?
concomitant strabismus
what is the treatment of strabismus
patching and glasses
what causes amblyopia in a kid
strabismus
refractive error
form deprivation (i.e cataracts, corneal scarring, ptosis)
should you treat amblyopia with pilocarpine?
NO
this is a cholinergic and will thus cause constriction not dilation
what is true about amblyopia
can be present in both eyes
can you still do patching in a kid with amblyopia who is 10 years old
yes tho may not work as well
will a patient need cataracts after surgery?
yes
define amblyopia and management
loss of VA in absence of detectable organic disease (strabismic or refractive)
manage by detecting early and referring to ophtho
define strabismus and management
misalignment of the eyes
refer to ophtho
define esotropia/esophoria
deviating inwards towards the nose (most common)
define exotropia
outward deviation
how do you detect a tropia
cover tests (does eye move when the cover is removed?…if moves in, exotropia/moves out, esotropia/moves up, hypotropia/moves down, hypertropia)
how do you detect a phoria
alternating cover test–> esophoria if uncovered eye moves out/exophoria is uncovered eye moves in
how do you perform a swinging light test
have patient look/focus on a distant object in a low light room
27 year old patient has left dilated pupil, right constricted pupil in bright light. what does she have
left adie tonic pupil–> dilated pupil that is slow to constrict and re-dilate and decreased reflexes
nothing we can do
is benign, idiopathic, found in young women, unilateral
what lens would you give to a patient who cant see at a distance and cant read up close
myopic and presbyopic
a patient presents post cataract surgery with some sort of opacification/haziness on ophthalmoscopy. what is the problem
posterior capsule opacification
how does NPDR (non proliferative diabetic retinopathy) present
first manifestation–> micro aneurysms
retinal findings–> dot and blot hemorrhages, hard exudates, cotton wool spots (infarct of the nerve fibre layer) and macular edema
how does PDR (proliferative diabetic retinopathy) present
retinal ischemia leads to neovascularization over the optic disc or elsewhere–> fragile vessels can bleed into the vitreous and can lead to traction retinal detachment
how do you treat NPDR
laser and anti-VEGF
how do you treat PDR
laser burns—can do panretinal photocoagulation (PRP laser) and anti VEGF
how do you manage a corneal ulcer as a family doc
patch eye and evaluate in the morning
what do you use to evaluate macular degeneration
amsler grid
how does acute angle closure glaucoma present
red eye that is painful fixed mid dilated pupil tearing nausea/vomiting halos headache
what medication should you NOT use in a patient with both glaucoma and asthma/COPD
beta adrenergic blockers (-“olol”)
these treat glaucoma by reducing formation of aqueous humour but can cause bronchospasm in asthmatics
how does pilocarpine work in treating glaucoma
cholinergic
increases aqueous humour flow through trabecular meshwork
can cause decreased vision and headaches
name an alpha 2 andrenoreceptor agonist and how does it work to treat glaucoma
brimonidine tartrate
decreases aqueous production and increases uveoscleral aqueous outflow (non trabecular meshwork)
can cause dry mouth, headache, fatigue
what med should you not use in a patient with HTN and glaucoma
epinephrine (adrenergic stimulators)
causes cardiac arrhythmias and increased BP
how do prostaglandin analogues treat glaucoma and what are the side effects
-“prost”
increases aqueous flow outflow though the uveoscleral path
can cause darkening of iris
name the only oral glaucoma drugs
carbonic anhydrase inhibitors -“amide”
what are side effects of carbonic anhydrase inhibitors used to treat glaucoma
-“amide”
paresthesias, anorexia, GI disturbance, headache, predisposes to renal calculi
dont use in HTN
lady comes in with new onset floaters, whats the cause
either retinal detachment or PVD
what condition is characterized by a cherry red spot
CRAO
spot forms due to ischemia to the rest of the retina but the macula is supplied by the choroidal artery (from the posterior ciliary artery) instead of the central retinal artery so when you get CRAO only the macula is well perfused causing it to appear as a cherry red spot
what condition is suggested by flame hemorrhages
HTN retinopathy
how does wet AMD differ from dry
in wet AMD, you get choroidal neovascularization
where do people notice vision loss in AMD
changes tend to be confined to the posterior pole so losses in central vision often are more pronounced
how do you manage hyphema
refer URGENTLY
how do you manage an orbital puncture
hard shield
NO antibiotic
if a woman has herpes simplex keratitis and had vesicles above her forehead, what could she also have
iritis
what condition requires the most urgent treatment in the ER
lye splash in the eye
how do you treat chemical burns
irrigate excessively and refer
patient comes in with a deep lid laceration close to the canthus–what is most likely also damaged
lacrimal canaliculi
patients has thyroid eye disease and massive proptosis. what symptoms would they NOT have
pain on eye movement
WILL have:
dry eyes
corneal abrasions likely
diplopia on side gaze
what vision abnormality is caused by thyroid eye disease
horizontal diplopia
if a young woman who is morbidly obese, what will you most likely find on ophthalmoscopy?
papilledema (pseudotumour cerebri predisposition)
what abnormality is caused by an optic chiasm lesion? (i.e is a person has a pituitary tumour close to the optic chiasm)
bitemporal hemianopsia
what symptoms are associated with amaurosis fugax
transient sudden monocular vision loss
when is a person considered legally blind
20/200 after corrected vision
what should you NOT give a person with macular degeneration
anti-metabolites
patient comes in after blunt trauma to the eye–what do you do
get more history
what do you do if you see RBCs in the anterior chamber on ophthalmoscopy
URGENT referral (hyphema)
what should you use to dilate a patients eye
tropicamide 0.5%… lasts only 6 h
what should you do if a patient comes in with allergies?
oral antihistamine (not topical)
what do you do for penetrating globe injuries?
shield and refer
do NOT manipulate the eye
lady in an accident, loses glasses, face mashed up. vision in ER is 20/200. ifn o eye damage, what improvement can you expect on pinhole
unsure–20/30?
risk factors for open angle glaucoma
age
african american heritage
patient working with nail gun…now foreign body sensation. see corneal abrasion with fluorescein. what do you do
URGEN X RAY of skull bones
girl with orbital fracture blows nose and feels crepitus. what did she also break
ethmoid
how do you diagnose glaucoma in the office
ophthalmoscopy (cup:disc ratio)
…or vision field testing
what test does not test for sarcoid
protein electrophoresis
neighbour in cariboo doing lawn work, gets stuff in his eye, on inspection there is no corneal abrasion, normal red reflex, everything normal. what do you do
urgent/same day ophtho referral
you are on call hospitalist… 92 year old lady has red eye but swats everyone away when they come near. what do you do
evaluate her yourself as could be acute angle closure glaucoma
person comes to office with some conjunctival injection and discharge–otherwise normal. no corneal damage. what do you prescribe
topical abx–broad spectrum for bacterial conjunctivitis
what is a change you do NOT expect with aging
increased contrast sensitivity
patient has gradual change in vision loss starting to affect function, especially driving at night. whats the problem
cataracts
management of corneal ulcer
patch
management of globe perf
shield, no drops
what does a white eye reflex suggest
absence of red reflex is a cataract or retinoblastoma
what is optic neuritis
inflammation and demyelination of optic nerve
causes acute vision loss with peri-ocular pain exacerbated by eye movement
RAPD if fellow optic nerve healthy
associated with MS
recover vision within weeks to months
use IV corticosteroid not oral
what condition is optic neuritis associated with
MS
what is the treatment for optic neuritis
IV corticosteroid (not oral
what is ION
acute vision loss from microvascular infarction of optic nerve
sudden, PAINLESS, UNILATERAL loss of vision
anterior portion of nerve most vulnerable (AION) –> arteritic AION is associated with GCA and non arteritic AION which is also associated with disc ededma, unilateral vision loss upon waking either upper or lower vision
what condition is characterized by unilateral vision loss on waking that is either the upper or lower area
non arteritic ION
management of CRAO
urgent referral
EMERGENCY
presentation of BRAO
partial vision loss
presentation of CRVO
blood and thunder
NOT an emergency
how does optic neuritis present
sudden decrease in VA
clear ocular media
swollen disc
RAPD (disc swollen and hyperemic)
management of optic neuritis
refer non urgently and give IV steroids
what are the signs of GCA (giant cell arteritis)
over 60 temporal headaches jaw claudication neck discomfort sudden vision loss RAPD swollen disc loss of vision
define RAPD
relative afferent pupillary defect
management of GCA
order ESR/CRP
if elevated, give high dose systemic steroids and IMMEDIATE ophtho referral
what conditions should you refer URGENTLY
retinal detachment
acute CRAO
ischemic optic neuropathy if suspected to be related to GCA
signs of retinal detachment and management
floaters
flashing lights
peripheral visual field loss
URGENT referral
what is the first thing you can detect in glaucoma?
peripheral visual field loss–> scotomas
hard to detect early on
symptoms of chronic angle closure glaucoma
intermittent
low grade sx–headaches, blurred vision
when to refer someone with AMD to ophtho
recent decrease in VA
recent metamorphosia
recent scotoma
ophthalmoscopic findings of drusen, degenerative changes in RPE, choroidal neovascularization, poor central vision
what are drusen
yellow hyaline nodules
can be associated with AMD
danger symptoms of the red eye
blurred vision
severe pain
photophobia
colored halos
REFER
danger signs of red eye
reduced VA ciliary flush corneal opacification corneal epithelial disruption pupillary abnormality shallow AC depth elevated IOP proptosis
REFER
what should you do for a traumatic optic neuropathy (i.e maxillofacial trauma)
refer
how urgent are orbital factures
semi urgent
does uveitis cause changes in vision
posterior uveitis does cause visual field loss and scotoma
patient with bump on eyelid, painful. doc had given abx PO. no effect. what do you do?
apply warm compresses 4x daily
massage the lid
apply topical abx
refer for incision and curretage if no resolution in 4 weeks
symptom of bilateral INO
nystagmus of both eyes
how do you investigate Horners
carotid U/S
management of temporal arteritis
IV corticosteroids and bx
what are symptoms of a cranial nerve III palsy
complete paralysis of the oculomotor nerve
causes both horizontal and vertical diplopia, severe ptosis of the upper eyelid, inability to move eye inward, upward or downward
pupil may be dilated and unresponsive
common causes of CN III palsy
intracranial aneurysm microvascular infarction within nerve trauma cerebral herniation brain tumour
management of CN III palsy
emergent imaging and angiography
what muscle is affected when a person has a lac in their upper eyelid and cannot open eye
levator palpebrae superioris
in a question about brainstem and the orbits, which statement is false
something about syphilis
which conditions mimic functional blindness with all eye exams being normal
cortical blindness
guy comes in with high BP, no previous eye problems, wakes up one morning with decreased vision in one eye
NAION
