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232 Cards in this Set

  • Front
  • Back
Why evert the upper eyelid?
To examine the tarsal conjunctiva for foreign body
How do you evert the upper eyelid?
1) Ask the patient to look down
2) Apply slight pressure with a q-tip or finger
3) Pull the lid margin up gently
How do you test accommodation?
1) Ask patient to fixate on an object far away
2) Ask patient to refocus on an object about 10cm away
What can corneal light reflex tell you?
Whether there is convergent/divergent squint or pseudosquints.
Why does one check for Red Reflex?
It shows:
1) Dark areas --> corneal, lens, or vitreous opacity
2) Gray color --> retinal detachment
Why should you approach temporally when trying to look at the fundus?
Because you want to see the disc before the pupil contracts. The pupil will contract once light hits the macula.
What are six difficulties in fundus examination?
1) Uncooperative patient
2) High myopia
3) Corneal, lens, or vitreous opacity
4) Poor ophthalmoscope
5) Bright room
6) Small pupils
What is a comon short-acting mydriatic used for looking at the fundus?
Tropicamide
1) acts in less than 30 minutes
2) lasts for about 4 hours

(Note: atropine is a bad choice b/c it lasts for a week)
What can the cover-uncover test reveal?
A squint
What is a synoptophore?
A machine with specially designed pictures to measure accurately the angle of a squint and to test the ability of the patient to see with both eyes together (biocular single vision).
What is gonioscopy?
Checking the filtrating angle of glaucoma patients.
What is tonometry?
The measurement of intraocular pressure (IOP).
What is the most commonly used tonometer?
The Goldmann Applanation Tonometer.
What is perimetry?
A more accurate measurement of visual fields using a small 5mm target moving into view from the periphery.
What is Scotometry?
The measurement of visual field deficits using a small target on a screen. It generally assesses the central 30 degrees of the field of view.
Where is the blind spot found?
15 degrees lateral to the point of fixation.
What can computerized visual field testing/perimetry allow for?
Screening for glaucoma and pituitary tumors.
What are the most common tests for color vision?
Ishihara test and Farnsworth Munsell 100 hue test
What does fundal fluorescein angiography involve?
1) Fluorescein dye is injected intravenously
2) serial fundal photgraphs are taken to show the retinal and choroidal circulation.
What is ultrasound used for in the eye?
1) evaluate the posterior segment when the ocular media is opaque.
2) measure corneal thickness
3) measure axial length of eye
4) provide data required lens power for an IOL implantation
What is CT particularly useful for in ophtho?
1) Orbital tumors
2) Localization of intraocular foreign bodies
3) Neuro-op disorders
What is MRI particularly useful for in ophtho?
1) Soft tissue changes
2) Demyelinating lesions
What are ways of measuring Macular Potential Acuity (the acuity one can achieve after a procedure)?
1) test acuity with pinhole
2) Potential Acuity Meter (PAM)
3) Laser inferometer
4) Blue Field entoptoscope
What is Electroretinography (ERG) useful for?
1) Diagnosis of retinal dystrophy (e.g. retinitis pigmentosa)
2) Assessing visual function in vitreous hemorrhage
What is Electrooculography useful for?
It measures retinal pigment epithelial function
What is Visual Evoked Response useful for?
It indicates whether there is optic nerve disease (decreased response).
What does slit-lamp examination allow?
1) magnified examination of anterior segment
2) examination of filtration angles
3) IOP measurement with applanation tonometer
4) vitreous and retinal examination with special contact lens
What does indirect ophthalmoscopy allow?
Good binocular examination of retinal periphery. This is especially useful in retinal detachment or cloudy media.
Optic disc color
1) Pink
2) Temporal side usually paler
Optic disc margin
1) sharp and flat
2) nasal margin may be relatively blurred and raised (in hypermetropia)
3) There are many normal variations (e.g. pigmentation, myopic crescent)
Optic disc -- cup
1) varies in size and depth
2) situated at center of disc and slopes temporally
Cup/disc ratio
the ratio of the diameter of the optic disc cup to the optic disc
Retinal vessel color: Which are lighter -- arteries or veins?
Arteries
Retinal vessel diameter
1) arteries are narrower than veins
2) ratio of artery to vein diameter is about 2:3
Retinal vessel crossing -- do arteries or veins cross anteriorly?
Arteries cross anterior to veins at arteriovenous crossing
Fundus background color
1) fundal background is red b/c of choroidal vessels and retinal pigment layer
2) fundal bg is darker in pigmented races
3) in lightly-pigmented people, large choroidal vessels are seen against the white sclera
4) the fundal bg has a tesselated (tigroid) appearance in myopia -- stretch marks?
Macular area color -- is it darker or lighter than the rest of the fundus?
Darker than the rest of the fundus. At the center, there should be a normal foveal light reflex.
What 3 things are most lid conditions related to?
1) inflammation
2) malposition
3) tumors
What is the most common condition of the orbit?
Exophthalmos. It indicates the possibility of thyroid disease or a space-occupying lesion.
Blepharitis
Inflammation of the lid margin
What are the two main types of blepharitis?
1) Squamous blepharitis
2) Ulcerative blepharitis
Squamous blepharitis
1) Associated with dandruff or seborrheic dermatitis
2) presents with small white scales at the roots of the eyelashes
3) eyes are chronically irritable
Ulcerative blepharitis
1) due to staph infection of follicles at the lid margin
2) accompanied by loss of lashes, deformity of lashes (trichiasis)
Treatment for blepharitis
1) removal of crusts with boiled cotton wool
2) antibiotic ointment for ulcerative blepharitis
3) lotion to control dandruff in squamous blepharitis
Stye (hordeolum)
1) A small abscess of the eyelash follicle
2) seen clinically as a small inflamed nodule

Sx:
1) acute irritation
2) local pain

Tx:
1) local heat (warm compress)
2) removal of follicle
3) optional abx
Chalazion (Meibomian cyst)
Defn:
Blockage of the duct of a tarsal gland that leads to a cyst

Pres: painless nodule at the tarsal plate becomes inflamed

Tx:
1) local heat
2) topical abx
3) systemic abx (rare)
4) surgery (if large)
Allergic or Contact Dermatitis
Defn: allergy due to cosmetics/medication (often sulfas) causes edema, inflammation of skin around eyelids

Tx:
1) stop exposure/med
2) topical steroid cream
Herzes zoster opthalmicus (HZO)
Pres:
Pain and skin vesicles (which may become secondarily infected) in the distribution of V-1

If the nasociliary nerve is affected --> skin lesions on one side of the nose and risk to eye of:
1) corneal inflammation
2) iridocyclitis
3) secondary glaucoma

Tx:
1) general hygiene
2) local abx to prevent 2ary infxn
3) local steroids to eye if keratitis or irdocyclitis
4) antivirals in acute phase

After: can experience post-herpetic nerualgia -- prolonged pain over scalp and eye
Ptosis
Defn: drooping upper lid

Types:
1) unlitateral/bilateral
2) complete/partial
3) congenital/acquired
What does a patient with bilateral ptosis look like?
They will have their head tilted backwards so that they can see through the narrowed palpebral fissure
Congenital ptosis
Cause: dystrophy of levator palpebrae sperioris muscle

NH: can lead to amblyopia

Tx:
1) surgery to shorten LPS muscle
What are the causes of acquired ptosis?
1) senile degneration of levator aponeurosis
2) CN III lesion
3) Horner's syndrome
4) myasthenia gravis, other myopathies
5) trauma to lids
6) inflammation of lid
7) tumor
Lid Retraction
Defn: The upper lid does not cover the upper edge of the cornea

Causes:
1) overactivity of levator muscle from hyperthyroidism

Tx:
1) Control of hyperthyroidism, if that is the cause
2) Plastic bridging of the lens (tarsorraphy)
3) recession of the levator muscle
Entropion
Defn: Inversion of the lid margin. It is associated with inturned eyelashes (trichiasis)

Cause:
1) scar tissue of the conjunctival surface (common in end-stage trachoma)
2) spasm of orbicularis oculi (spastic entropion)
3) weakness of eyelid tissues (senile entropion)

Cmplx:
1) chronic conjunctivitis
2) corneal abrasion
3) corneal ulceration

Tx:
1) lubricants
2) surgical eversion of the lid
Ectropion
Defn: eversion of lid margin

Sx:
1) tearing (epiphora) due to failure of tears to access the lacrimal drainage apparatus
2) exposure conjunctivitis or keratitis

Cause:
1) weakness of orbicularis oculi -- CN VII lesion or senile weakness
2) scar tissue on skin of eyelid (cicatricial ectropion)

Tx: If disruptive, surgery to restore eyelid to normal position
Trichiasis
Defn: inturned eyelashes

Sx:
1) unilateral red eye from chronic irritation of the cornea or conunctiva
2) Associated with entropion

Tx:
1) destruction of follicles of inturned lashes by diathermy or cryotherapy
2) surgical eversion of eyelid
Xanthelasma
Defn: fatty deposit in the skin, usually bilateral and occurring at the medial part of the upper lid. can sometimes develop on lower lid

Sx: none

Tx: surgical removal solely for cosmetic improvement
Basal cell carcinoma (rodent ulcer)
Pres: Appears on the lower lid margin as a raised nodule with a pearly rolled edge

Cmplx:
1) ulceration
2) infiltration into adjacent tissues --> can lead to loss of eye or bone invasion

Does not metastasize

Tx:
1) surgery
2) radiotherapy
What are consequences of blockage of the nasolacrimal duct?
1) tearing
2) infxn of lacrimal sac (chronic dacrocystitis
3)reflux of mucopurulent material when pressure is applied to lacrimal sac
What is a dacryocystorhinostomy?
The creation of a new drainage channel in response to dacryocystitis
Orbital cellulitis
Pres:
1) unilateral, intesnse lid edema
2) chemosis (edema of the conj)
3) restriction of eye movements

Cause:
1) spread of infection to the orbit from one of the paranasal sinuses

Cmplx:
1) cavernous sinus thrombosis (can be fatal)

Tx (urgent):
1) systemic abx
2) x-ray of sinuses
3) ENT consult
Preseptal cellulitis
Milder than orbital cellulitis

Pres:
1) swollen, inflamed lids
2) no proptosis
3) no change in ocular movements

Tx:
1) abx
Exophthalmos
Defn: proptosis or forward protrusion of the eyeball

Pres:
1) lower lid margin no longer covers limbus

Cause:
1) thyroid dz
2) space occupying lesion behind eyball (optic nerve tumor, hemangioma, lymphangioma from middle, meningioma, nasopharyngeal cancer, metastatic tumors)

Should be distinguished from lid retraction and myopia

Tx:
1) removal of space-occupying lesion
2) protection of cornea, potentially with tarsorraphy (plastic bridging of lid)
Bacterial conjuunctivitis
Pres:
1) bilateral red eyes
2) yellowish mucopurulent discharge, sticky eyelids in morning
3) gritty/foreign body sensation in eye

Tx:
1) local antibiotic eyedrops every three hours
Viral conjucntivitis
Pres:
1) bilateral watering red eyes
2) photophobia with associated keratitis
3) preauricular and submandibular lymphadenopathy
4) fever + URI

Tx:
1) none
2) steroids if corneal involvement
3) abx if concern of bacterial infxn
Allergic conjunctivitis
Pres:
1) intense pruritis
2) watering red eyes

Cause:
1) vasomotor rhinitis
2) drug/cosmetic rxn
3) hay fever

Tx:
1) antihistamine (eyedrop + oral)
2) no steroids
Spring catarrh (vernal conjunctivitis)
Pres:
1) large flat papillary conjunctival thickenings on upper tarsal conjucntiva

Tx:
1) steroid drops
Chronic non-specific conjunctivitis
Sx:
1) dryness
2) irritation
3) burning
4) redness
5) watering
6) pain

Worse on exposure to all types of irritants
Dry Eye (keratoconjunctivitis sicca)
Cause:
1) defective tear formation
2) Sjogren's (dry eyes, dry mouth, arthritis)
3) RA
4) SLE
5) Sarcoidosis
6) Stevens Johnson's syndx

Cmplx:
1) corneal ulceration

Tx:
1) tear substitues
2) punctal plugs
3) tarsorrhaphy
Unilateral red eye
1) Dangerous!

Cause:
1) acute closed-angle glaucoma
2) irits
3) keratitis
4) corneal ulcer
5) foreign body
6) scleritis
7) acute closed angle glaucoma
Subconjunctival hemorrhage
Pres:
1) unilateral red eye

Cause:
1) rubbing of eyes or severe coughing --> capillary rupture --> sub-conj hemorrage

Tx:
1) None -- takes 2 wks to reabsorb
2) Exclude blood dyscrasia if recurrent
Trachoma
Cause:
1) Chlamydia trachomatis

Pres:
1) acute conjunctivitis
2) Herbert's pits -- follicles at the limbus at the limbus that indicate infxn
3) pannus formation in upper cornea
4) cyclical reinfection
5) bacterial superinfection
6) entropion
7) trichiasis

Tx:
1) local abx (tetracycline)
2) oral abx (sulfa)
3) surgical correction of entropion/trichiasis
Pinguecula
Defn:
1) tiny, cream-colored, slightly raised opaque lesion on conj, usually nasal

Sx:
1) none

Cause:
1) sun exposure

Tx:
1) none
2) cosmetic surgical removal
Pterygium
Defn:
1) a triangular fleshy wing of conj that encroaches on cornea, usually nasal side
2) some are thick/fleshy, some are avascular/flat
3) can cause mild astigmatism

Cause:
1) sun exposure

Tx:
1) surgical excision if encroaches on cornea by >= 3 mm, exposed can be covered with conj. graft
Conjunctival melanoma (nevus)
1) usually harmless
2) can be removed for cosmetic reasons
3) malignant conj melanoma is rare
What are common causes of corneal ulcer?
1) HSV infxn
2) bacterial infxn
3) trauma
4) dry eye
HSV dendritic ulcer
Defn: a serious infxn of the cornea caused by Herpes simplex virus

Cmplx:
1) disciform keratitis
2) recurrence during periods of stress
3) perforation

Tx:
1) antiviral (icoxuridine
2) debridement
3) NO steroids, even if quiet!
Small marginal corneal ulcers
Pres:
1) assoc with ulcerative blepharitis

Cause:
1) hypersens. to Staph antigens

Tx:
1) abx eyedrops
2) steroids
Bacterial corneal ulcer
Dx:
1) unilateral red eye, painful, watering, photophobic

Cause:
1) P. aeruginosa
2) staph
3) strep

Risk factors:
1) contact lens wear
2) corneal trauma
3) immunosuppression

Tx:
1) abx
2) gram stain, cultures for specific tx
Epiphora
excessive tearing
Complications of severe corneal ulcers
Blindness from:
1) corneal scarring
2) corneal perforation
3) secondary glaucoma
4) panophthalmitis
Fungal corneal ulcer
1) Poor prognosis
2) Often precipitated in immunosuppressed state (e.g. steroid tx)
3) Tx is local or systemic antifungals
What are common causes of corneal opacity?
1) healed hsv keratitis
2) ulcer trachoma
3) trachoma
4) trauma
5) keratomalacia from vit A deficiency

If severe, can be treated with corneal graft
Arcus senilis
Defn:
1) a white ring at the periphery of the cornea
2) caused by lipd deposits in limbal area
3) does not affect central cornea
4) harmless
What are common corneal dystrophies?
1) Keratoconus
2) Fuchs' endothelial dystrophy
Keratonus
Defn:
1) dystrophic condition in young adults
2) cornea becomes conical in shape

Cmplx:
1) myopia
2) severe irregular astigmatism

Tx:
1) contact lenses
2) corneal graft
Fuchs' endothelial dystrophy
Pres:
1) corneal edema
2) corneal opacity

Cmplx:
1) Severe visual loss

Tx:
1) Corneal graft
Non-ulcerative (interstitial) keratitis
NH:
1) patch of vessels with corneal opacity
2) residual opacity
3) ghost vessels

Tx:
1) local steroids
2) corneal graft
Common Indications for Corneal Graft
1) post-cataract surgery bullous keratopathy
2) keratoconus
3) corneal dystrophies
4) corneal opacities
5) corneal ulcers
Hypopyon
Pus in the anterior chamber
Causes of cataracts
1) develops over time (senile cataract)
2) trauma
3) drug toxicity (esp. steroids)
4) diabetes
5) hypoparathyroidism
6) uveitis
7) retinal detachment
Cataract definition
An opacity in the clear lens taht blocks or scatters light rays.
Methods of Cataract Removal
1) Intracapsular method
2) Extracapsular method (including phacoemulsification)
Intracapsular Cataract extraction
removal of the whole lens together with its capsule
Extracapsular cataract extraction
1) nucleus and cortex of lens are removed through an opening in the anterior capsule (anterior capsulectomy)
2) requires a good operating microscope
3) Ultrasonic disintegration of the lens nucleus (phacoemulsification) allows removal of the cataract through a small (3mm) incision
What are the differences between traditional extracapsular cataract extraction and phacoemulsification?
Phacoemulsification gives:
1) faster rehab
2) less post-op astigmatism

Traditional method:
1) less expensive
2) less equipment needed
3) essentially the same visual result
Why place an IOL after cataract surgery?
1) to replace the lens without thick glasses or contacts
2) excellent post-op vision
Is cataract surgery inpatient or outpatient? What type of anesthesia is required?
Outpatient. Usually, only local anesthesia is required.
What are potential complications of cataract surgery?
1) enophthalmitis (infxn of the entire eye)
2) wound leaks
3) glaucoma
4) severe astigmatism
5) opacification of posterior capsule
6) retinal edema
7) retinal detachment
What conditions can involve secondary cataract formation?
1) iridocyclitis
2) retinal detachment
3) trauma
Glaucoma definition
Damage to the optic nerve (usually due to increase in IOP)
Open-angle glaucoma overview
1) develops insidiously
2) slow and progressive damage to the optic nerve
3) visual loss with few or no other sx
Acute closed-angle glaucoma
1) develops suddenly
2) involves pain
3) sudden visual loss
4) congestion of the eye
5) painful unilateral red eye
Primary open-angle glaucoma
Cause:
1) defective trabecular meshwork at the filtration angle --> rise in IOP

Dx:
1) visual field loss
2) glaucomatous cupping of the optic disc
3) (usually, but not always) increased IOP

NH:
1) frequent changes of glasses
2) vague tiredness and ocular discomfort
3) increased difficulty reading
Ocular hypertension
IOP greater than 20 mmHg. Is indicative, but not alone diagnostic of glaucoma
Visual field loss in chronic open-angle glaucoma
1) arcuate scotoma
2) loss of nasal visual field
Optic cup in glaucoma
1) The optic cup is increased in size in glaucoma
2) a cup/disc ratio of > 0.5 is suspicious of glaucoma
3) In advanced chronic open-angle glaucoma, the cup reaches the edge of the disc and the retinal vessels dip sharply over the edge of the cup
Prevention of glaucoma
1) difficult in open-angle glaucoma b/c of lack of sx
2) periodic IOP measurement in people over 40 yo
3) familial tendency, so make sure relatives of patients get examined
Medical therapy for glaucoma
1) Pilocarpine -- cholinergic agonist
2) Timolol -- beta blocker
3) adrenaline
4) propine (adrenaline prodrug
5) acetazolamide (CA inhib)
6) latanaprost (prostaglandin agonist)
7) apraclonidine (Adrenaline agonist)
8) dorzolamide (CA inhib)
9) brimonidine (alpha agonist)

New: neuroprotective agents
Surgical treatment for glaucoma
1) laser trabeculoplasty (laser treatment of trabecular meshwork)
2) trabeculotomy -- communication btwn anterior chamber and outside of eyeball (sub-conj space)
3) trabeculectomy
Why are antimetabolites (mitomycin C, 5-FU) used in trabeculectomies?
Antimetabolites (including mitomycin C and 5-FU) are used in trabeculectomies to prevent scarring.
Acute closed angle glaucoma
1) common in middle-aged pts

Cause:
1) iris periphery suddenly apposes itself to corneal periphery, blocking the filtration angle --> preventing aqueous outflow --> rise in IOP

Pres:
1) unilateral red eye
2) blurred vision
3) pain/headache

Signs:
1) epithelial edema --> corneal haze
2) semi-dilated, non-reactive pupil

Tx (urgent):
1) medical
2) surgery (trabeculectomy, trabeculotomy)
Medical therapy for closed-angle glaucoma
1) Pilocarpine (every 10 minutes for first hour)
2) IV acetazolamide
3) oral acetazolamide
4) osmotic agents (glycerol or mannitol)
5) analgesic
Surgical treatment for closed-angle glaucoma
1) laser iridotomy (argon or YAG laser)
2) iridoplasty (contracting laser burns)
3) surgical peripheral iridectomy
4) traculectomy (if failed medical therapy)
What is the risk of closed-angle glaucoma in the second eye?
50% in five years.
This is why prophylactic peripheral iridectomy or laser iridotomy should be performed on the second eye after acute closed angle glaucoma in the first eye.
Subacute closed angle glaucoma
Sx:
1) transient blurred vision
2) seeing "halos" (rainbow colors around lights)

Dx: by gonioscopy
Conditions resulting in secondary glaucoma
1) iridocyclitis
2) hyphaema (blood in anterior chamber)
3) new iris vessels (rubeosis iridis) following central retinal vein occlusion or proliferative diabetic retinopathy --> hemorrhagic glaucoma (neovascular glaucoma)
4) complication of mature cataract
5) complication of intraocular tumor
Iridocyclitis (iritis)
Defn: inflammation of the iris and ciliary body

Pres:
1) painful unilateral red eye
2) photophobia
3) mild pain
4) blurred vision
5) watering

Findings:
1) flare (proteins)
2) white cell deposits (keratic precipitates on posterior surface of cornea
3) iris may adhere to anterior capsule of lens (posterior synechia)

Cmplx:
1) secondary glaucoma
2) secondary cataract

Cause:
1) joint dz (ankylosing spondylitis)
2) TB
3) viral infxn

Tx:
1) cycloplegics (atropine, homatropine) to dilate pupil, relieve pain
2) steroid drops
Chorioretinitis
Defn: inflammation of the choroid and the retina

Pres:
1) visual loss

Cause:
1) usually unknown
2) toxoplasmosis
3) syphilis, TB, sarcoid, toxocariosis, histoplasmosis

Tx:
1) systemic steroids
2) therapy for specific infxns
Benign choroidal melanoma (nevus)
Defn:
1) flat, round, pigmented choroidal lesion
2) rarely causes any visual disturbance
3) raised lesions are likely malignant
Malignant choroidal melanoma
Defn:
1) a pigmented, raised lesion of the choroid

Pres:
1) retinal detachment
2) vitreous hemorrhage
3) secondary glaucoma

Tx:
1) enucleation of the eye
2) irradiation
3) photocoagulation
4) surgical excision
Choroidal metastasis
Pres:
1) flat, multiple deposits at the posterior pole
2) assoc with exudative retinal detachment

Tx:
1) radiotherapy
Central retinal artery occlusion
NH:
1) sudden visual loss in one eye
2) blindness in that eye within minutes

Findings:
1) constricted retinal arteries (threadlike)
2) milky white fundus (retinal edema)
3) cherry-red spot on macula
4) optic atrophy after a few weeks
Predisposing factors for central retinal vein occlusion
1) HTN
2) DM
3) Arteriosclerosis
4) Open-angle glaucoma
5) Hypercoagulable state
Findings in Central Retinal Vein Occlusion
1) Tortuous engorged vessels
2) untilateral disc edema
3) hemorrhages + soft exudates
CRVO prognosis
Bad for elderly, moderate for younger people
Rubeosis iridis
development of new vessels on iris
1) due to ischemia of retina
2) can cause secondary glaucoma (thrombotic)
Findings in Brach Retinal Vein Occlusion
1) fan-shaped distribution of retinal flame-shaped hemorrhages radiating from arteriovenous crossings
2) macular edema
Predisposing factors for Branch Retinal Vein Occlusion
1) HTN
2) Arteriosclerosis
3) DM
Retinal Detachment
Separation of the retinal neurosensory layer from the RPE
Regmatogenous
Involving a break
Degenerate retina has what characteristic?
It is thin
Sx of retinal tear
1) many floaters -- recen onset
2) flashes of light
Dx of retinal detachment
1) Dilate
2) View with indirect ophthalmoscope --> better view of peripheral retinal than direct
Tx for retinal tears
Make an adhesive scar with:
1) Photocoagulation
2) cryoapplication
Push back with:
1) silicone
2) drainage of SRF
3) gas injection and vitrectomy
Exudattive Retinal Detachment causes
1) malignant choroidal melanoma
2) severe uveitis
3) toxemia of pregnancy
Traction retinal detachment causes
Fibrous detachment:
1) proliferative diabetic retinopathy
2) penetrating injury
3) ROP
Juvenile macular dystrophy
1) Bilateral
2) Symmetric
3) gradual progression
4) painless
5) visual loss
AMD findings
1) Pigmentary clumps
2) Patches of atrophy
3) Drusen (colloid bodies) -- under RPE
Will a patient go completely blind due to AMD?
No, peripheral vision should be preserved
Central serous retinopathy: how?
fluid from choroidal capillaries --> through RPE --> accum under macula --> self-limiting, benign
Degenerative myopia
1) familial
2) proe pronouced chorioretinal atrophy at posterior pole, surounding disc
2) increased axial lenght of eye
3) Cmplx: ret. det.
4) No treatment
Retinitis Pigmentosa
All types of inheritance
NH:
1) poor dim light vision
2) Progressive loss of peripheral visual field
3) 1st - 2nd decade
4) blindness by 5th to 6th decade
Findings:
1) retinal pigment proliferation - brown, spider-like
2) waxy-yellow disc
3) attenuate retinal vessels
Types of vitreal degeneration
1) synchisis scinillans -- posterior vitreous detachment
2) white deposits
3) asteroid bodies
Common systemic conditions affecting the eye
1) DM
2) HTN
3) thyroid dz
4) RA
5) Vit A deficiency
6) onchocerciasis
DM changes
1) decreased visual acuity
2) EOM paralysis (CN 3 or 6)
3) Rubeosis iridis
4) sluggish pupillary constriction/dilation
5) senile cataract
Classifications of Diabetic retinopathy
1) background DR
2) proliferative DR
Background diabetic retinopathy
1) retinal microaneurysms
2) round dot hemorrhages
3) hard exudates - yellow
Pre-proliferative diabetic retinopathy
Vascular obstructive changes
1) soft exudates -- cotton wool spots
2) large blot hemorrhages
3) dilated/segmented veins, venous loops --> ischemic retinal damage, loss of capillar circulation
Percent of patients with diabetic retinopathy that progress to proliferative DR
10%
Definition of Proliferative DR
Neovascularization on retinal surface and at optic disc
Cmplx of Proliferative Diabetic retinopathy
1) Vitreous hemorrhage
2) Fibrous tissue formation --> traction ret. det.
Tx for prolif DR
1) laser photocoag
2) regular fundus exams with dilation
3) fluorescein angiography
Effects of HTN on arterioles in young, older
Young: arteriolar constriction
Middle age: thickening, sclerosis
1) widening of light reflex
2) copper/silver wiring
3) arteriovenoius nipping
4) potentially: BRVO
Findings in HTN
1) thickening
2) copper/silver wiring
3) AV nipping
4) flame hemorrhages
5) soft exudates (cotton wool spots)
Keith-Wagner classification of hypertensive retinopathy
1) thickening
2) AV nipping
3) flame hem
4) papilledema, hard exudates
all indicate vessel state elsewhere
Pre-eclamptic HTN
1) HTN changes
2) bilateral exudative inferior retinal detachment
Severe anemia findings
1) flare hem
2) soft exudates
Hyperviscosity (e.g. polycythemia vera) findings
1) retinal hem
2) soft exudates
3) edema
4) looks simlar to CRVO
Sickle cell
1) fibrovascular proliferation
2) localized chorioretinal scars
3) vitreious hemorrhage
4) traction ret det
Peripheral retinal vasculitis + vitreous hemorrhage (Eales' dz)
1) recurrent vitreous hem
2) abnormal peripheral ret. veins
Hyperthyroidism
1) lid retraction
2) lid lag
3) exophthalmos
4) poor convergence
5) infrequent blinking
Causes of Thyroid exophthalmos
1) orbital edema
2) lyphocyte infiltration
Thyroid exophthalmos findings
1) Inability to elevate eyes
2) difficulty closing the eyelids (lagophthalmos) --> exposure keratitis
AIDS findings
1) cotton-wool spots
2) neoplasms (e.g. Kaposi's sarcoma) of eyelid, conjunctiva, orbit
3) neuro-op lesions
4) CMV retinits (cheese piza -- white lsions + hemorrhage)
5) T. gondii, HSV, HZO, candida, PCP
Vit A def
Keratomalacia
1) drying of conj (xerosis)
2) corneal ulcer, peforation
Onchocerciasis (river blindness)
1) jinja fly bite --> microfilariae
Cmplx
1) irits
2) secondary claucoma
3) cataract
4) vitreoretinal damage
Leprosy
1) affects eye in 30% of cases
2) CN VII paralysis -- OO, leads to ectropion, lagophtalmos
3) Keratitis
4) Madarosis (loss of eyebrows/lashes)
5) Anterior uveitis
Syphilis
1) Can affect eye at any stage
2) uveitis
3) congenital syphilis
$) bilateral interstiial keratitis
5) chorioretinal scars
RA
1) Dry eyes
2) Episcleritis --> scleromalacia
3) Chloroquine --> maculopathy + corneal deposits
4) steroid therapy --> cataracts
Acne rosacea
1) chronic conjunctivits
2) blepharitis
3) severe superficial keratitis + cornea neovascularization
4) Tx w/ steroids
Stevens Johnson syndrome
1) severe conjunctivitis
2) corneal scarring
Causes of Unilateral proptosis
1) mucocele of the sinus
2) infiltration of orbit by nasopharyngeal carcinoma
Disc swelling findings
1) blurring of disc margin
2) swelling of optic nerve head
3) "filling in" of cup
4) venous pulsations absent
5) veins dilated
6) small hemorrhages around disc
7) edema
Papilledema vs. Papillitis
Papilledema
1) passive disc swelling due to increased ICP
2) bilateral
3) normal vision

Papillitis
1) inflammation of optic nerve
2) unilateral
3) visual loss (usually with central scotoma)
4) dilated, unreactive pupil
Retrobulbar neuritis
1) pain on eye movmenet
23) usdden blurred vision
3) defective color vision
4) central scotoma
Tx: steroids
Causes of optic atrophy
1) optic neuritis
2) meningitis
3) encephalitis
4) CRAO
5) ischemia of optic nerve
6) Retinitis pigmentosa
7) glaucoma
8) vit B def
9 syphilis
Chiasmal lesion
1) bitemporal hemianopsia
2) causes
1) pituitary adenoma (chromophobe)
2) suprasellar cyst (craniopharyngioma)
Causes of large pupil
1) mydriatic drugs
2) optic neuritis
3) CN III paralysis
4) optic atrophy
5) trauma to sphincter
6) retinal dz
7) Adie's tonic pupil
Causes of small pupil
1) Miotic drugs (e.g. pilocarpine, morphine)
2) iritis
3) syphilis
4) Horner's syndrome
Irregular pupil
1) Congenital iris defect
2) posterior synechiae
3)syphilis
$) surgery
Marcus Gunn pupil
Afferent pupillary defect
Argyll Roertson pupil
accommodates but doesn't react
3rd nerve palsy
1) ptosis
2) down (SO) and out eye (lat. rectus)
3) dilated pupil
6th nerve palsy
convergent squint
4th nerve palsy
1) elevated when adducted (due to IO)
2) compensatory head tilt
Causes of EOM paralysis
1) Trauma
2) DM
3) Arteriosclerosis
4) Aneurysms
EOM paralysis: Separation of image side by side or above one another?
1) Side by Side -- 6th nerve
2) Above -- 3rd or 4th nerve
EOM paralysis: Direction of maximum gaze separation?
Direction of action of affected muscle
EOM paralysis: Which eye gives fainter image?
The one with the paralyzed EOM
Myasthenia gravis
1) diplopia
2) bilateral ptosis
Nystagmus defn
Involuntary oscillatory movement of eyes
Nystagmus types
1) Jerk (cerebelloum or vestibular problem)
a) slow component
b) fast component

2) Pendular (ocular) nystagmus
a) no slow or fast component
b) caused by poor vision, inability to fixate
Common injuries
1) chemicals
2) flying particles
3) sharp instrument
4) blunt injury
5) w/ head injury
6) welding burns
Chemical injury tx
dilute chemical ASAP
Alkali burn cmplx
Can penetrate eye
1) corneal damage
2) cataract
3) iridocyclitis
4) glaucoma
Why are acids somewhat less dangerous than alkalis?
They coagulate collagen --> forma a barrier to eye petnetration --> less damage to internal structures
Corneal foreign body sx
1) photophobia
2) congestion
3) irritation
--> remove w/ blunt instrument to decrease risk of perforation
Penetrating would cmplx
1) damage to cornea or lens
2) intgraocular hemorrhage
3) retinal damage
4) prolapsed iris
Blunt injury cmplx
1) hyphema (blood in anterior chamber) due to torn BV in iris
2) damage to pupillary sphincter
3) secondary glaucoma
4) blood-stained cornea
5) lens dislocation
6) vitreous hem
7) ret det
Blowout fracture
1) usually floor of orbit --> IR, IO affected
2) diplopia
3) limited eye movement
Welding burns
due to intense UV light
Sx:
1) Photophobia
2) blehparospasm
3)pain
4) watering
Tx:
1) patching
2) analgesics
Myopia types (2)
1) physiologic
2) pathologic --> degenerative changes of retina, macula in partiuclar
Hypermetropia
Far-sightedness, image behind the retina
Astigmatism
1) Cornea or lens is not spherical --> has greater power in one meridian
2) corrected with cylindrical lens
3) pathological causes:
a) corneal scarring
b) keratoconus
Presbyopia
weak accommodation (usually with age)
Cmplx/sx of contact lens wear
Sx:
1) pain
2) watering
3) photophobia
4) eyelid spasm

Cmplx:
1) corneal edema
LASIK
Laser-Assisted Intrastromal Keratomileusis
Aphakia
Eye without lens (usually after cataract extraction)
DDx for white pupil (leukocoria)
1) Retinoblastoma
2) ROP
3) Congenital cataracts
4) Persistent primary hyperplastic vitreous
5) Coats' dz -- exudates from abnormal retinal vessels
6) Endophthalmitis
7) Organized vitreous hemorrage
Retinoblastom
1) Most common intraocular malignancy
2) white pupil (leukocoria)
3) high malignancy

Tx/Mgmt
1) Chemo
2) Radiotherpay
3) Photocoagulation
4) cryoapplication
5) enucleaiton
ROP
1) more common in babies who receive O2

Tx:
1) Photocoag
2 Cryotherapy
3) vitreous surgery
Types of strabismus/squints
1) Paralytic
2) Non-paralytic
Effects of suqints in children
1) amblyopia (lazy eye)
2) Failure to develop binocular single vision
3) cosmetic blemish -->< emotional, socioeconomic problems
Convergent squint = esotropia
1) assoc. w/ hypermetropia
Tx: glasses for farsightedness
Divergent squint
1) usually develops in kids > 3 y.o.
2) Assoc w/ myopia
Causes of Amblyopia
1) ptosis
2) corenal scar
3) cataract
4) contgential nystagmus
Causes of Infective conjunctivitis in kids
1) gonorrhea
2) staph
3) strep
4) hemophilus
5) pneumococus
6) HSV
7) chlamydia

Tx: Abx
Tx of late canalization of nasolacrimal duct
1) astringent eyedrops
2) massage of lacrimal sac
Congenital cataracts
1) do surgery in first 6 months --> prevent amblyopia
2) Lens can be aspirated b/c nucleus is soft in kids
Congenital Glaucoma
1) buphthalmos (ox eye -- increase in corneal, eye size)
2) Tears in Descemet's membrane --> corneal edema, irritation, watering, photophobia

Pres:
1) photophobia
2) tearing
3) large opaque cornea
Neurofibromatosis
Neurofibromas in
1) eyelids
2) orbit
3) retina

Optic nerve gliomas
Tuberous sclerosis
1) retina or optic disc has yellowish raised nodule that looks like a mulberry
Sturge-Weber
1) capillary hemangioma (choroidal)
2) congenital glaucoma
von Hippel-Lindau
Hemangioma
1) retinal exudates
2) hemorrhages
3) ret det

Tx: photocoag, cryotherapy
Cuase of coloboma of iris or choroid
Incomplete closure of choroidal fissure
Lid defects
1) ptosis
2) coloboma of lid (Kleinfelter's)
3) obstruction of lacrimal apparatus
Lens defencts
1) Marfan's
2) Homocystinuria
Optic disc defects
1) Optic pits
2) Hypoplasia of optic nerve
Antenatal infections
1) Toxoplasmosis
2) Rubella
3) Syphilis

(ToRcheS)
Congenital rubella
1) congenital cataract
2) nystagmus
3) pigmentary changes in retina
Congenital Toxoplasmosis
1) chorioretinal scar at macula