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70 Cards in this Set

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5 thing to ask about acute visual loss
transient vs. persistent
monocular or binocular
abrupt vs. hours, days wks
pts age and pmh
documented normal vision in the past
None
Exam in acute visual loss
visual acuity
confrontation field testing (uncovers homonymous hemianopia)
pupillary reaction (damage to retina or nerve will send less light to brainstem -> Marcus Gunn pupil)
Ophthalmoscopy
Penlight exam (for corneal disease)
Tonometry for glaucoma
None
What is the Marcus Gunn pupil
when light moved from normal to abnormal eye the pupil of abnormal eye will continue to dilate (relative afferent pupillary defect) = positive swining flashlight test
What is the relative afferent pupillary defect represent
Damage to afferents is a sign of monocular visual loss
What are the 4 clear refractive media of the eye?
cornea
anterior chamber
lens
vitreous humor
None
Damage to clear refractive media causes what symptoms
blurred vision but no relative afferent pupillary defects
What 2 things can cause altered pupillary reflexes
miosis in acute iritis
middilated and fixed pupils in acute angle-closure glaucoma
None
What is observed in corneal edema?
sudden opacificiation of the cornea -> dulling of light reflecting off the cornea resulting in ground glass appearance
What is the most common cause of corneal edema?
increased IOP. Conreal edema is what causes vision loss in angle closure glaucoma
What condition can mimic corneal edema?
acute infection or inflammation (HSV keratitis)
What two conditions cause gradual onset of vision loss due to coreal edema?
damage to corneal endothelium by dystrophies or following cataract surgery
Blood in the anterior chamber is known as ____
hyphema
What 4 conditions predispose to hyphema?
abnormal vessels due to:
tumors
DM
intraocular SGY
chronic inflammation
None
What 2 conditions can alter hydration of the lens
Suddent changes in blood sugar or serum electrolytes can cause large fluctuations in refractive error interpreted as visual loss by pt
In what case does cataract produce acute visual loss
When it progresses rapidly
What 3 conditions will cause vitreous hemorrhage
trauma, retinal neovascularization (DM & retinal vein occlusion), and subarachnoid hemorrhage (aneurysm rupture)
Under what conditions should vitreous hemorrhage be suspected
Clear anterior chamber and lens but retina cannot be seen
3 inflammatory processes affecting the retina that will result in acute visual loss
infectious chorioretinitis
vasculitides
idiopathic inflammation
None
What are the symptoms of retinal detachement
Large number of floaters then shade over the vision in one eye, relative afferent pupillary defect in involved eye
What is found on retina in retinal detachmeht
elevated retina +/- folds and indistinct choroid background
What causes suddent visual loss ini macular disease?
bleeding from neovascular net formed in macular degeneration
____ is a defect of central vision in which shapes of objects appear distorted, seen due to neovascularization in macular degeneration
metamorphopsia
What is the treatment for metamorphopsia
laser surgery before progression to significant and permanent visual loss
Loss of vision in one eye lasting for several minutes is suspicious for ____
amaurosis fugax, suspect ipsilateral carotid artery disease
What are the 3 signs of central retinal artery occlusion
suddent painless and often complete visual loss
Vascular stasis is seen in __(time range)__ of central retinal artery occlusion
minutes to hours
What are the two thing seen in vascular stasis
narrowing of arterial blood columns
interruption of venous blood columns -> appearance of bloxcarring - rows of corpuscles are separated by clear intervals
None
How long after centra retinal artery occlusion will the cornea become opalescent?
Several hours
What causes the cherry-red spot in central retinal artery occlusion?
pallor of the perifoveal retina standing out in contrast to the normal color of the fovea, also seen in Tay-Sachs and Neimann-Pick due to metabolite deposition
What causes swelling of the optic disc?
Occlusion of the ophthalmic or carotid artery (proximal to the origin of the central retinal artery) - some vision may be spared in complete centra retinal A occlusion
In what case can part of the retina be spared in central retinal artery occlusion?
If part of the retina is supplied by choroidal circulation via a celioretinal artery
What causes pallor of the disc in the blinded eye months after central retinal artery occlusion?
As the edema resolves and ganglion cells die their axons atrophy
How long is the window for treating central retinal artery occlusion
Several hours
What techniques could potentially dislodge the embolus blocking the central retinal artery?
rise in fall in IOP by pressing and releaseing the eye in 10sec intervals for 5 min
injeciton of anesthetic and paracentesis of anterior chamber
None
What can be used to treat branch retinal artery occlusion
ocular massage
What causes branch retinal artery occulusion
usually embolus
5 signs of central retinal vein occlusion
disc swelling
venous engorgement
cotton wool spots
diffuse retinal hemorrhages
subacute onset
None
What is the treatment for central retinal veing occulsion?
No standard treatment, not a true ophthalmic emergency
What are 4 risk factors for central retinal vein occlusion
age
HTN
atherosclerotic vascular disease
disease affected blood viscosity (polysythemia vera, SCD, leukemia/lymphoma)
None
What 3 things take place as central retinal vein occulsion resolves?
swelling resolves
shunt vessels develop from retinal to choroidal circulation
and ocular neovascularization (risk of neovascular glaucoma - need laser)
None
What is the initial appearance of the optic nerve in acute visual loss in optic nerve disease?
nerve may or may not look normal but pupillary response is abnormal
What causes optic neuritis
usually idiopatic
may be associated with MS
None
What is the appearance of the optic nerve in optic neuritis
hyperemic and swollen
What is the prognosis for return of vision after optic neuritis?
good
What is the treatment for acute optic neuritis
corticosteroids
Classic presentation for retrobulbar optic neuritis (5 items)
young adult
vision loss over hours - days
pain with eye movement
normal ophthalmic exam but poor vision
afferent pupillary defect
None
What is the differential diagnosis for retrobulbar optic neuritis?
comprehenssive optic neuropathy
How is retrobulbar optic neuritis diagnosed?
MRI or CT, will show lesion compressing nerve
What are 2 subtypes of optic neuritis and findings
retrobulbar optic neuritis
papillitis
significantly decreased vision
relative afferent pupillary defect
None
What is papillitis?
Inflammation of the optic disc or papilla
What is papilledema?
swelling of the optic disc from increased ICP, bilateral
In papiledema what is the effect on visual acuity and pupillary reflexes
These are normal but some pts have momentrary bulurring or transient oscurations of vision
What is the long term effect of acute papilledema
minor alternations in vision if any
What should be suspected in an older pt with swelling of the disc and visual loss
vascular event (ex. giant cell atreritis), noninflammatory
What is the presentation of ischemic optic neuropathy? (5)
pale, swollen disk
+/- splinter heme and
loss of vusial acutity and visual field
None
What is the pattern of visual loss seen in schemic neuropathy?
altitudinal
superior or inferior field
None
What are the symptoms of systemic giant cell arteritis? (4)
malaise
limb girdle pain
scalp tenderness/pain combing hair
pain on chewing (jaw claudication)
None
What test should be ordered for an elderly pt with ischemic optic neuropathy or unexplained ophthalmoplegia
ESR, look for >60 for giant cell arteritis
What is the treatment for giant cell arteritis?
high dose corticosteroids
What will be find on temporal vessel biopsy in giant cell arteritis? (3)
giant cells
fragmentation of the elastica with surrounding chronic inflammation
occlusion of the vessel
None
What is the chance for contralateral eye involvement in nonarteritis ischemic optic neuropathy?
40% chance
loss of vision on one side of both visual fields is called ____
homonymous hemianopia
What can cause homonymous heminanopia?
occlusion of one of the posterior cerebral arteries with infaction of occipital lobe, or MCA occlusion (will have other symptoms)
What tests should be ordered in a patient with homonymous hemianopia?
cerebral CT or MRI
What causes cortical blindness
extensive bilateral damate othe cerebral visual pathways -> complete vision loss
What are the 2 findings on ophthalmic exam in a patient with cortical blindness
normal pupillary reactions
normal fundus
None
What is the prognosis of a pt with cortical blindess
either improvement or death due to severe neurologic damage
What causes functional acute visual loss
hysteria or malignering
What are the findings in functional visual loss?
normal pupillary reactions
normal stereopsis if one eye is "affected"
None
Why can chronic visual loss be an acute discovery?
Vision is normal in one eye and the patient does not notice