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109 Cards in this Set

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It consists of a group of ocular diseases characterized by changes in the optic disk, loss of visual sensitivity, and loss of visual field.
glaucoma
g
In galucoma, Aqueous humor is initially produced by the ________ epithelial cells in the posterior chamber.

It then flows through the pupil between the posterior surface of the iris and the lens to enter the anterior chamber.

After circulating within the anterior chamber, the aqueous humor leaves through the _____________ of the anterior chamber angle to enter the canal of _______.
ciliary body, trabecular meshwork, schlemm
c b, t m, s
occurs as a result of closure of pre-existing narrow anterior chamber angle, when dilation of the pupil causes the iris to touch the lens.

This obstructs the flow of aqueous humor from the posterior chamber through the pupil and into the anterior chamber.

The ciliary body in the posterior chamber continues to produce aqueous humor, which leads to rapid rise in the intraocular pressure (IOP).
primary acute closed angle glaucoma
p a c a g
occurs in elderly persons (owing to physiologic enlargement of the lens), those who suffer from hyperopia, and Asians.

Angle closure may be precipitated by pupillary dilation, and thus can occur from sitting in a darkened theater, at times of stress, or, rarely, from pharmacologic mydriasis.
acute closed angle glaucoma
a c a g
may be observed with anterior uveitis or dislocation of the lens.

Symptoms are the same as in primary acute closed-angle glaucoma, but differentiation is necessary because of differences in management.
secondary acute closed angle glaucoma
s a c a g
Patients with ____________ usually seek treatment immediately, because of extreme pain, headache (or brow ache), photophobia, and blurred vision, though there are subacute cases.

The blurred vision is associated with rainbow-colored halos around lights.
acute closed angle glaucoma
a c a g
The patient often looks very sick.

Nausea, vomiting, and abdominal pain may occur, and acute glaucoma must be remembered in the differential diagnosis of an acute abdomen (something that will require surgery, inflammation)
acute closed angle glaucoma
a c a g
The eye is red with peri-limbal (“ciliary”) injection.

The cornea is hazy and steamy (because of corneal edema).

The pupil is moderately dilated and non-reactive to light.
acute closed angle glaucoma
a c a g
The globe will be “rock hard”.

The visual acuity will be decreased.

Tonometry reveals elevated intraocular pressure - IOP is often > 50 mm Hg (normal IOP: 10 to 24 mm Hg).
acute closed angle glaucoma
a c a g
the anterior chamber is shallow.

This is demonstrated by a penlight held laterally and directed nasally.

In an eye with a normal anterior chamber, the entire iris will be illuminated by the penlight.

In an eye with a narrow angle or shallow anterior chamber, a shadow is cast on the nasal side of the iris secondary to the forward bowing of the iris (crescent shadow).
acute closed angle glaucoma
a c a g
Initial treatment in _______________ is control of intraocular pressure by decreasing the production of aqueous humor and increasing its outflow.
primary closed-angle glaucoma
p c a g
A topical beta-blocker such as timolol solution (Timoptic) 0.5%, 1 to 2 drops q 10 to 15 minutes for 3 doses, then 1 drop q 12 hours may be used.
primary closed-angle glaucoma
p c a g
Additionally, a single 500 mg IV dose of acetazolamide (Diamox), followed by 250 mg PO qid, is usually sufficient.

Osmotic diuretics such as IV mannitol, 1 to 2 grams/kg, can also be used.

Once the intraocular pressure is reduced below 40 mm Hg, topical 4% pilocarpine (Pilocar), 1 drop q 15 minutes for 1 hour, then qid, is used to constrict the iris and relieve the obstruction to the flow of aqueous humor, thereby increasing aqueous humor outflow.
acute closed angle glaucoma
a c a g
The IOP should be checked hourly after treatment is initiated until an emergent ophthalmology consult can be obtained and definitive treatment can be initiated.

The unaffected eye will also have a narrow anterior chamber and should be treated prophylactically with pilocarpine.
acute closed angle glaucoma
a c a g
The definitive treatment is laser peripheral iridotomy (a transverse division of some of the fibers of the iris, forming an artificial pupil), which should also be performed prophylactically on the fellow eye.

If it is not possible to control the intraocular pressure medically, glaucoma drainage surgery may be required.
acute closed angle glaucoma
a c a g
In ______________, systemic acetazolamide is also used, with or without osmotic agents.

Further treatment is determined by the cause.
secondary acute closed-angle glaucoma
s a c a g
characterized by gradually progressive - over a period of months or years - excavation (“cupping”) and pallor of the optic disk with loss of vision varying from slight constriction of the peripheral fields to complete blindness.
chronic glaucoma
c g
In this, the intraocular pressure is elevated due to abnormal drainage of aqueous humor through the trabecular meshwork. (it drains but it drains poorly)
chronic glaucoma
c g
In this, the intraocular pressure is elevated due to obstruction of flow of aqueous humor into the anterior chamber angle.
chronic glaucoma
c g
In this disorder, intraocular pressure is not elevated above the normal range, but the same pattern of optic nerve damage occurs, probably due to vascular insufficiency that may also play a role in primary open-angle glaucoma.
normal-tension glaucoma
n t g
chronic or acute glaucoma:The cause of the decreased rate of aqueous humor outflow in primary open-angle glaucoma has not been clearly established.

The disease is bilateral, and there is an increased prevalence in first-degree relatives of affected individuals and in diabetics.
chronic
occurs at an earlier age, is more frequent in blacks, and may result in more severe optic nerve damage.
primary open angle glaucoma
secondary __________ may result from uveitis or the effects of trauma.
open-angle glaucoma
o-a g
T or F:Patients with chronic glaucoma have no symptoms initially.
T
on examination there may be slight cupping of the optic disk, observed as an absolute increase - or an asymmetry between the two eyes - of the ratio of the diameter of the optic cup to the whole optic disk (cup-disc ratio). Increased cup:disc ratio
chronic glaucoma
c g
The visual fields gradually constrict, but central vision remains good until late in the disease. (peripheral field loss)

Tonometry, ophthalmoscopic visualization of the optic nerve, and central visual field testing are the best studies for diagnosis and follow-up.

The diagnosis depends upon identification of consistent abnormalities in at least two of these parameters.
chronic glaucoma
c g
The normal range of intraocular pressure is _______.
10 to 24 mm Hg
Except in acute cases, the diagnosis of glaucoma is not made on the basis of one tonometric measurement, since intraocular pressure is influenced by various factors.

The diagnosis of _______ is not always straightforward, hampering the effectiveness of screening programs.
chronic glaucoma
c g
Topical ______ such as timolol (Timoptic), 1 drop bid, continue to be popular anti-glaucoma agents.


They are contraindicated in patients with reactive airway disease or heart failure.
beta andrenergic blocking agents
b a b a
A topical _______ anhydrase inhibitor (such as dorzolamide {Trusopt} 2%) can be used in addition to a beta-blocker, or as initial therapy when beta-blockers are contraindicated.

Oral _________ anhydrase inhibitors (acetazolamide {Diamox}) may be used on a long-term basis if topical therapy is inadequate and surgical or laser therapy is inappropriate.
carbonic, carbonic
c c
In chronic glaucoma, Laser ____________ (photocoagulation of the trabecular meshwork of the eye with a laser) is used as an adjunct to topical therapy to defer surgery, and is also advocated as primary treatment.

Surgery is generally undertaken when intraocular pressure is inadequately controlled by medical and laser therapy, but it may also be used as primary treatment.
trabeculoplasty
t
In chronic glaucoma, _________ (surgical opening of the canal of Schlemm) remains the standard procedure.
trabeculotomy
t
___________ and deep sclerectomy with collagen implant are two alternative procedures that avoid a full-thickness incision into the eye, and may prove to be as effective as trabeculotomy.
viscocanalostomy
v
Untreated chronic glaucoma that begins at age 40 to 45 will probably cause complete blindness by age 60 to 65.

Early diagnosis and treatment can preserve useful vision throughout life.

In primary open-angle glaucoma, the aim is to reduce ___________ to a level that will adequately reduce progression of visual field loss.
intraocular pressure
i p
In the most serious cases, intraocular pressure must be reduced to less than ____ mm Hg.

In normal-tension glaucoma, it may be necessary to achieve even lower intraocular pressure.

Surgery is nonetheless generally required.
16
The _________ tract consists of the iris, the ciliary body, and the choroid
uveal
u
Inflammation of the iris is referred to as iritis.

Inflammation of the ciliary body is referred to as cyclitis.

Inflammation of the choroid is referred to as choroiditis.

Any combination of iritis, cyclitis, or choroiditis is referred to as _____(inflammation of the uveal tract).
uveitis
u
characterized by ciliary injection (limbal flush), pupil constriction, decreased visual acuity, and tearing.
iritis
i
Inflammation of the uveal tract causes protein and white blood cells to escape into the aqueous humor.

Slitlamp examination reveals “flare” and “cells” in the anterior chamber.

This is manifested clinically as ________________.
blurred vision
b v
light scatter from the slitlamp beam secondary to inflammatory cells and proteins circulating within the aqueous humor, and has the appearance of a “headlight-in- fog”.
flare
f
refers to the finding of inflammatory cells in the anterior chamber, having the appearance of “dust-in-a- movie-projector-light”.
cells
c
A common symptom with ______ is pain with accommodation, which has been shown to be highly specific for iritis.
iritis
i
Other symptoms include photophobia (which is a main symptom), headache, and pain with consensual light reflex
iritis
i
Photophobia occurs secondary to spasm of the ciliary body with pupillary constriction.

A simple way to detect this spasm is to cover the affected eye, and shine a light in the unaffected eye.

If this causes pain in the covered eye, _____ and ciliary spasm should be suspected.
iritis
i
pain with accomodation,
photophobia,
headache,
pain with consensual light reflex, and ciliary spasm with unreactive pupils
uveitis
u
the presence of _______ requires a search for associated systemic illness such as arthritis, Sjogren’s syndrome, herpes simplex virus, and herpes zoster virus.
uveitis
u
_____ can be precipitated by trauma to the orbit (traumatic ______).
iritis, iritis
i, i
Topical analgesics (DO OR DO NOT) significantly reduce the pain of uveitis or iritis.

Topical cycloplegics and corticosteroids are prescribed.

Prompt ophthalmology follow-up is important.



(If pain not reduced w/topicals, it is indicative of a deeper problem)
do not
is any opacity of the lens of the eye.

It may involve a small part of the lens, or the entire lens.

The degree of opacification is variable.
cataract
c
Cataracts may develop secondary to the natural aging process, trauma, congenital causes, or medication use.

__________ is by far the most common type.

Most persons over the age of 60 have some degree of lens opacity.

Excessive sun exposure and cigarette smoking predispose to cataract development.
senile cataract
s c
insidious onset of decreased vision is the main clinical feature.

Usually, far vision acuity is affected more than near.
cataract
c
On physical examination, there is a translucent yellow discoloration in the center of the lens.
cataract
c
As the ________ matures, the retina will be increasingly more difficult to visualize, until finally the fundus reflection (red reflex) is absent, and the pupil is white.
cataract
c
Treatment involves intracapsular (the lens and entire capsule are excised) or extracapsular (the posterior lens capsule is left) extractions of the ________.
cataract
c
Functional visual impairment is the prime criterion for surgery
cataract
c
With the development of ultrasonic fragmentation (photoemulsification) of the lens nucleus, it is now possible to perform ________ surgery through a small incision without suturing the wound, thus reducing complications.
cataract
c
Retinal Disorders Associated With _________ Diseases:

Diabetic Retinopathy
Hypertensive Retinopathy
Cytomegalovirus Retinitis
systemic
s
In the normal retina, the _________ are smaller and brighter
arteries
The ___________ retinal area is the most common site of detachment
superior temporal
s t
Patients often complain of an acute onset of monocular, decreased visual function and may describe a shadow or curtain descending over their eye.
retinal detachment
r d
Other complaints include cloudy or smoky vision, “floaters”, or “flashes of light”.
retinal detachment
r d
Funduscopic exam may reveal a billowing or tent-like elevation of the retina compared with adjacent areas.

The elevated retina often appears out-of-focus and gray.
retinal detachment
r d
A new onset of “floaters” associated with flashing lights indicates a ________ or detachment until proven otherwise.

All cases of __________ must be referred immediately to an ophthalmologist.
retinal tear, retinal detachment
r t, r d
Patients with ________________ complain of sudden visual loss, or abrupt onset of “floaters” that may progressively increase in severity
vitreous hemorrhage
v h
The eye is not inflamed, and the clue to diagnosis is the inability to see fundal details clearly despite the presence of a clear lens.
Vitreous Hemorrhage
v h
Causes include diabetic retinopathy, retinal tears (with or without detachment), retinal vein occlusions, exudative age-related macular degeneration, trauma, and subarachnoid hemorrhage.

In all cases, examination by an ophthalmologist is essential
vitreous hemorrhage
v h
is the leading cause of permanent visual loss in the elderly.

It increases in incidence with each decade over age 50
age-related macular degeneration
a r m d
The exact cause of age-related macular degeneration is unknown, but macular degeneration may be secondary to the toxic effects of some drugs.

Degeneration of the macula may be evidenced by the accumulation of retinal _________.
drusen
d
In age-related macular degeneration, _________ appear on funduscopic exam as small, discrete, round, yellow punctate deposits, usually in the macular region.
hard drusen
h d
In age-related macular degeneration, _________ are larger, paler, and without discrete margins.
soft drusen
s d
In age-related macular degeneration, most patients with _______ have good vision, although there may be decreased visual acuity and distortion of vision.
drusen
d
There is no effective treatment, however, if detected early, ____________ may respond minimally to laser treatment.

Patients with drusen need ophthalmology evaluation every 6 to 12 months, or sooner if visual distortion or decreasing visual acuity develops.
macular degeneration
m d
characterized by a sudden, painless, and marked unilateral loss of vision.
central retinal artery occlusion
c r a o
Most of the fundus is pale due to retinal edema, but the fovea does not have the edema, and thus appears as a cherry-red spot.

This produces the hallmark on funduscopic exam: a pale retina with a cherry-red colored fovea.
central retinal artery occlusion
c r a o
History should focus on how long ago the episode occurred.

If the loss of vision occurred recently, attempts to restore blood flow may be beneficial if performed in a very narrow time window after the acute onset.

This may be accomplished by:
1. Laying the patient flat.
2. Administering high concentrations of inhaled oxygen.
3. Decreasing intraocular pressure with topical beta-blocker ophthalmic drops or IV acetazolamide.
4. Ocular massage.
central retinal artery occlusion
c r a o
temporal arteriits should be strongly considered in all pts presenting w signs and symptoms of
central retinal artery occlusion
c r a o
Apply direct pressure to the eye with the heel of your hand for 5 to 15 seconds, then release.

Repeat this several times.

The goal is to create a sudden rise and fall of the intraocular pressure that may dislodge the embolus and improve retinal perfusion.

What is this called and when is it indicated?
occular massage, central retinal artery occlusion
o m, c r a o
Emergency ophthalmology referral is necessary.

Prognosis is poor even with immediate treatment.

A work-up for valvular and atrial thrombus is warranted to prevent further damage.
central retinal artery occlusion
c r a o
The hallmark of ___________ is a sudden onset of unilateral, painless visual loss (but more gradual than that of central retinal artery occlusion).
central retinal vein occlusion (CRVO)
c r v o
Funduscopic exam classically reveals multiple hemorrhages of various sizes and shapes around the disk; and dilation and tortuosity of the venous system.

This is called “blood and thunder” fundus.
central retinal vein occlusion (CRVO)
c r v o
Ocular massage is to be avoided in _______________!

The severity of visual loss is variable.

All patients should be referred urgently to an ophthalmologist.
central retinal vein occlusion
c r v o
(“fleeting blindness”) is usually caused by retinal emboli from ipsilateral carotid disease.
amaurosis fugax
a f
Noninvasive evaluation of the carotids can be accomplished using duplex ultrasonography and magnetic resonance angiography (MRA).

Emboli from cardiac sources (such as atrial fibrillation) may also be responsible, therefore EKG and echocardiography may be indicated.
may also be a result of choroidal or retinal vascular spasm, in which case calcium channel blockers may be effective.
amaurosis fugax
a f
The visual loss is usually described as a curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes, and a similar curtain effect as the episode passes.
amaurosis fugax
a f
is the leading cause of new blindness among US adults aged 20 to 65.

It is broadly classified as nonproliferative and proliferative.
diabetic retinopathy
d r
retinopathy shows dilation of veins, capillary microaneurysms, flame or splinter hemorrhages (located in the superficial nerve fiber layer of the retina), dot and blot hemorrhages (located deeper in the retina), retinal edema, and hard exudates.
nonproliferative diabetic retinopathy
n d r
tiny, weakened blood vessels which have ballooned out, appearing as small dots in the retina.

They represent the earliest clinical sign of diabetic retinopathy.
Microaneurysms
m
In diabetic retinopathy, ___________ are caused by proteins and lipids from the blood, leaking into the retina through damaged blood vessels.
hard exudates
h e
They appear as refractive, creamy or yellowish, often bright lesions with sharp margins, sometimes in a ring-like structure around leaking capillaries.
hard exudates
h e
is the leading cause of legal blindness in non-insulin dependent diabetes mellitus (NIDDM).
nonproliferative retinopathy
n r
characterized by soft exudates, intraretinal microvascular abnormalities, and venous beading (neovascularization).

Vitreous hemorrhage is a common sequela.
proliferative retinopathy
p r
also known as “cotton wool spots”, which are pale white or grayish areas in the retina with soft, fuzzy edges, resulting from infarcted nerve fibers.
soft exudates
s e
In diabetic retinopathy, these occur where blood vessels have blocked and localized areas of nerves have been damaged.
soft exudates
s e
Without treatment, the visual prognosis of which is worse: proliferative retinopathy or nonproliferative retinopathy
proliferative
__________ is occasionally present at the time of diagnosis of type 2 diabetes (NIDDM).

Treatment includes optimizing control of blood glucose and any associated hypertension or hyperlipidemia.

Excellent glucose control is beneficial in any stage of diabetic retinopathy because it delays the onset, and slows the progression of diabetic complications in the eye.

Laser photocoagulation is helpful in the treatment of macular edema.
nonproliferative retinopathy
n r
In diabetic retinopathy, ___________ must be recognized early and treated by panretinal laser photocoagulation to prevent blindness.

Neovascularization is all too often diagnosed only at the time of vitreous hemorrhage.
proliferative retinopathy
p r
Patients with diabetes should have _________ ophthalmoscopic examination through dilated pupils.

Examination by an ophthalmologist is recommended in type 1 diabetes (IDDM) of more than 5 years’ duration, at the time of diagnosis in type 2 diabetes (NIDDM), if ocular symptoms develop, or if there are suspicious findings of retinopathy.
yearly
y
In this disorder, Blurred vision can also occur from acute increases in serum glucose, causing lens swelling and a refractive shift even in the absence of retinopathy.
diabetic retinopathy
d r
The retinal arteries become more tortuous and narrow and develop abnormal light reflexes (“silver-wiring” and “copper wiring”).
hypertensive retinopathy
h r
In hypertensive retinopathy, _________occurs when the arteries, especially those close to the disk, become full and somewhat tortuous and develop an increased light reflex with a bright ________ luster.
copper wiring, coppery
c w, c
In hypertensive retinopathy, __________ occurs when a portion of a narrowed artery develops such an opaque wall that no blood is visible within it.
silver wiring
s w
In this disorder, there is increased venous compression at the retinal arteriovenous crossings (“arteriovenous nicking”).
hypertensive retinopathy
h r
Cotton-wool spots, retinal hemorrhages, and microaneurysms are the most common ophthalmoscopic changes seen in AIDS patients.

________________ occurs when CD4 counts are below 50/µL.
Cytomegalovirus (CMV) retinitis
c r
Patients are often asymptomatic until there is involvement of the fovea or optic nerve, or until retinal detachment develops.

They may complain of the gradual onset of the following visual sensations: floaters, scintillating scotoma (quivering blind spots), decreased peripheral visual field, and metamorphopsia (a wavy distortion of vision).
Cytomegalovirus (CMV) retinitis
c r
a wavy distortion of vision
metamorphopsia
m
quivering blind spots
scintillating scotoma
s s
is a necrotizing virus that is spread hematogenously so that damage is concentrated in the retina adjacent to the major vessels and the optic disk.
CMV
It is characterized by progressively enlarging yellowish-white patches of retinal opacification, which are accompanied by retinal hemorrhages, giving the characteristic “pizza-pie” or “cheese and ketchup” appearance.
Cytomegalovirus (CMV) retinitis
C R
The commonly used agents are intravenous or intravitreal ganciclovir, foscarnet, and cidofovir.

Reactivation of disease, and therefore, eventually complete loss of vision, can only be delayed rather than prevented.
Cytomegalovirus (CMV) retinitis
c r