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90 Cards in this Set
- Front
- Back
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note structures
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note structures
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note structures
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What is the uvea?
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Middle layer of the eye (pink layer all around)
1) Anterior: Iris, Ciliary body 2) Posterior: Choroid (vascular layer) |
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Uveitis ; etiology
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1) Infection: Bacterial/spirochetal- cat scratch disease, syphilis, tuberculosis, leprosy, and Lyme disease
Viral- cytomegalovirus, herpes zoster, and herpes simplex 2) Trauma or surgery 3) Systemic immune-mediated disease: Ankylosing spondylitis: HLV-27, Reactive arthritis: HLV-27 (Strong correlation with lupis (autoimmune)), Crohn’s disease, Psoriatic arthritis, Juvenile rheumatoid arthritis, Sarcoidosis, Multiple sclerosis |
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Uveitis; S/S
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1) Anterior uveitis: Redness (injected look, spidery look, or patches), Pain (photophobia), Photophobia
- Minimal symptoms if inflammation begins insidiously (ie juvenile rheumatoid arthritis) 2) Posterior uveitis: More likely to be painless (without redness, but more often causes blindness, usually have a anterior uveitis as well), Floaters (virtuous fluid that is floating around in the posterior chamber) - Redness not a prominent feature unless anterior uveitis is present |
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Tx of Anterior Uveitis
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- Tx of an infectious agent is directed toward the responsible agent: Antibiotic, Antiviral
- Noninfectious cases generally treated with topical glucocorticoids and a dilating drop (helps relieve pain) |
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Tx of Posterior Uveitis
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Posterior uveitis is generally not responsive to topical medication: Tx with periocular and rarely intraocular glucocorticoid injections, or the use of oral steroids
Immunosuppresive meds to address underlying disease process |
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Chronic uveitis increases risks of what complications?
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- Cataract
- IOP (elevated intraocular pressure) - Glaucoma - Retinal problems (swelling or detachment) Blindness |
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What symptoms of uveitis should lead to immediate referral?
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1) Visual deficit
2) Irregular pupil shape or dilation 3) Pain 4) Photophobia |
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Cataracts; Definition
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opacity of the lens that causes partial or total blindness
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Risk factors for cataracts?
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Age
Smoking Alcohol consumption Sunlight exposure (use sunglasses/hats) Trauma to eye Diabetes Mellitus Systemic corticosteroids and possibly high doses of inhaled steroids Diuretics |
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Most common form of cataracts?
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Nuclear:
Forms in the nucleus (center of lens) Due to natural aging changes |
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Three classifications of cataracts?
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1) nuclear
2) cortical 3) subcapsular |
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S/S of cataracts?
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- Blurry vision (different then when just not wearing glasses)
- Faded colors - Light from sun appears brighter - Glare from car headlights (very common) Typically bilateral, although not symmetrical |
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Eval of cataracts?
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1) Suspect in any patient with complaints of a painless, progressive loss of vision***
2) Lens opacity can be confirmed with a nondilated fundus examination with the ophthalmoscope 3) Refer 4) Correction of “myopic shift” can potentially delay surgery |
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Treatment of cataracts?
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Surgery to remove the opacified lens and replace it with an intraocular lens:
- Outpatient via: Standard extracapsular cataract extraction or phacoemulsification (lens gets broken up with small incision and is then reabsorbed, new lens is put in place) Patients can typically resume normal activity the same day of surgery; avoid heavy weights, being upside down, relatively quick surgery. |
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irregular red reflex
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- sign of congenital cataracts.
- should be evaluated at birth - cataract surgery is treatment of choice |
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Dislocated lens (subluxation or luxation of the lens):
Causes? S/S? |
Causes:
1) Blunt trauma to the eye or head 2) Systemic conditions 3) Hypermature cataract S/S: Visual disturbance-extreme hyperopic or myopic shift possible. Slit lamp will show displaced lens Complications: Secondary angle closure glaucoma or corneal damage Management: Non-surgical options are the first choice, surgery pursued if complications |
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Definition of Conjunctivitis?
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Inflammation of the bulbar and/or palpebral (tarsal) conjunctiva
Conjunctiva – thin, filmy membrane that lines surface of eyelids and covers sclera only and some of the top and bottom of eye |
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Most likely diagnosis in a patient with red eye and discharge: be sure to consider alternatives however
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Conjunctivitis
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Causes of conjunctivitis:
Acute Bacterial Hyperacute Inclusion & Trachoma Neonatal |
Acute Bacterial –
Staphylococci aureus in adults Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Moraxella catarrhalis in children Hyperacute - Neisseria gonorrhoeae Inclusion & Trachoma - Chlamydial Neonatal – Chlamydia, N. gonorrhoeae |
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Differential diagnosis of conjunctivitis?
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1) Anterior uveitis (less disgarge, iregular pupil)– iris, cilliary body, choroid
2) Angle-closure glaucoma (acute and painful) 3) Ocular trauma 4) Keratitis (simple inflammation)– corneal infection 5) Corneal ulcers/foreign body |
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Viral Conjunctivitis Presentation
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1) Injection, watery or mucoid discharge, burning
2) Tarsal conjunctiva (under the upper/lower eyelid) may have a follicular or “bumpy” appearance 3) may have viral prodome (preceding the event) with adenopathy (lymph nodes enlarged) 4) Palpable preauricular lymphadenopathy (behind the ear, more common in viral) |
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Viral Conjunctivitis Treatment/Management
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Symptomatic - Cold compresses are soothing
Most resolve spontaneously within days to weeks – usually 1 to 3 weeks Topical antibiotic could be considered in isolated situations to prevent secondary bacterial infection |
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Acute Bacterial Conjunctivitis Presentation?
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- Injection
- Mucopurulent discharge: greater in bacterial - Matted eyelids and eyelashes - Mild discomfort (if painful think uvitis) - Vision normal - Usually unilateral but may be bilateral |
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Hyperacute Conjunctivitis etiology and presentation?
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Etiology:
Neisseria species; particularly N. gonorrhoeae Presentation: 1) Copious purulent discharge within 12 hrs. of inoculation 2) Rapidly progressive 3) Includes redness, irritation, tenderness, lid swelling, and tender preauricular adenopathy |
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Hyperacute Conjunctivitis Treatment/Management?
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1) Ophthalmologic emergency
2) confirmed by culture 3) Copious irrigation with saline solution 4) 1 g ceftriaxone (rocephren) IM |
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Two forms of Chlamydial Conjunctivitis?
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Trachoma
Inclusion conjunctivitis |
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Trachoma presentation?
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- Majority are asymptomatic
- Repeated follicular inflammation leads to eyelid scarring - Eyelid scarring leads to entropion (folding inward) and subsequent trichiasis (eyelashes touching the eye) - Eyelash abrasion leads to corneal opacification and blindness |
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Neonatal Conjunctivitis (Ophthalmia Neonatorum) (<1month)
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Septic:
Chlamydia: most common cause Neisseria gonorrhoeae Diagnosis/Treatment: - “Gold Standard” is isolation by culture - No treatment necessary for chemical conjunctivitis - Specific treatment tailored to culture confirmation |
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Keratoconjunctivitis Sicca (Dry Eyes) S/S?
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Common disorder, especially in elderly women
1) Redness 2) Scratchy feeling/foreign body sensation 3) Blurred vision 4) Photophobia 5) Difficulty in moving the eyelids Diagnosis: - Exam is often normal Treat with ocular lubricant, not a red eye component that constricts the blood vessels |
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Keratoconjunctivitis Sicca (Dry Eyes) etiology?
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1) Hypofunction of the lacrimal glands
2) Excessive evaporation of tears 3) Mucin deficiency 4) hormone replacement therapy * more common in older women |
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Types/Etiology of Allergic Conjunctivitis?
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Acute – sudden onset hypersensitivity reaction caused by environmental exposure
Seasonal – predictable, chronic course that corresponds to specific pollen seasons Perennial – mild, chronic environmental exposure, usually indoor |
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Allergic Conjunctivitis Pathophysiology?
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Classic Type I IgE-mediated hypersensitivity
Mast cells interact with allergens & release chemical mediators (degranulation). |
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Allergic Conjunctivitis Presentation
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1) Itching, Tearing, Burning
2) Watery, mucoid, stringy discharge 3) Red, edematous eyelids 4) Conjunctival injection & edema (chemosis) Large “cobblestone” papillae on upper tarsal conjunctiva |
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Pterygium Definition?
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triangular patch of hypertrophied bulbar subconjunctival tissue, extending from the medial angle of the eye to the border of the cornea and beyond. Caused by UV light, irritants, common in tropical regions. Results in degeneration of conjunctival stroma replaced by thickened, tortuous elastotic fibers. 90% located nasally
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Pinguecula Definition?
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Yellowish spot of proliferation on the bulbar conjunctiva near the sclerocorneal junction. Thought to result from chronic solar radiation which alters collagen and elastic tissues of conjunctival stroma. Resulting in a yellow elevated nodule on either side of cornea
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Subconjunctival Hemorrhage:
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bleeding underneath the conjunctiva
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Foreign Body Pathophysiology?
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- Usually clipped or broken metallic particles
- Particles embed in cornea with significant force - Foreign object sets off an inflammatory cascade - If not removed can cause infection and/or tissue necrosis |
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Foreign Body complications?
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1) Rust ring
2) Prolonged foreign body: Infection risk, requires referral 3) Globe perforation: Leakage of fluid from site of foreign body embedding |
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Treatment of foreign body?
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Check Visual Acuity prior to removal
(1) Attempt removal with sterile saline irrigation (2) Attempt removal with damp sterile cotton swab (3) Attempt removal with 25 gauge needle |
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Ophthalmology referral indications: foreign body?
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1) Difficult foreign body to remove
2) Rust ring formation at cornea 3) Signs of perforation of globe with foreign body 4) Signs of corneal ulcer formation: Haze at base of corneal defect or Fluorescein staining persists >72 hours 5) Central corneal defects |
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Corneal Abrasion Pathophysiology (2)?
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1) Superficial – involving epithelial layer only
- Epithelium adjacent to any insult expands in size to fill in defect, usually within 24-48 hours - Most heal quickly and completely without scarring 2) Deep – penetrating Bowman’s membrane but not rupturing Descemet’s membrane |
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Corneal Abrasion s/s?
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- Blurred vision
- Foreign body sensation - De-epitheliazed area stains with fluorescein dye - History - Eye examination - visual acuity Complications Recurrent corneal erosion (10%), secondary infx, ulcer |
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Corneal Ulcers etiology?
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1) Infection – most common (bacteria, viruses, fungi, or amoebas)
2) Non-infectious (severe dry eyes, severe eye allergies, inflammatory disorders, exposure and neurotrophic keratitis) |
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Bacterial Keratitis Pathophysiology:
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- Direct corneal trauma
- Chronic eyelid disease - Tear film abnormalities - Hypoxic trauma from contact lens wear - Microbial invasion |
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Bacterial Keratitis presentation?
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1) Usually unilateral; redness, acutely painful, photophobia
2) Reduced visual acuity, tearing 3) Focal, stromal infiltrates with epithelial excavation. Corneal edema surrounding the infiltrate 4) May have thick, ropy mucopurulent discharge |
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Herpes Zoster Ophthalmicus; Presentation Hallmark?
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A vesicular rash that involves the first (ophthalmic) division of the fifth cranial nerve that presents in a dermatomal distribution and respects the midline
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Hutchinson’s sign
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If tip of nose is involved, eye is involved in ~ 75% of cases Herpes Zoster Ophthalmicus
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Hyphema
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Circulating or layered red blood cells in anterior chamber
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Arcus Senilis
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The deposition in the corneal periphery of a gray to white or yellow band of opacity. Associated with aging (and men). Most common corneal degeneration
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Scleritis: Often a manifestation of system disease
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1) Infections
2) Thyroid 3) Collagen disorders 4) Idiopathic (50%) |
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Scleritis etiology
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Usually bilateral, diffuse, nodular or necrotizing
Anterior scleritis: May cause scleral thinning Posterior scleritis: May cause exudative retinal detachment S&S: - Severe pain, photophobia, red eye, decreased vision - Pain is best indicator of disease progression Treatment: Systemic NSAIDs Treat underlying cause |
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HORDEOLUM
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1) Infection of meibomian glands – usually internal and less circumscribed
2) Infection of ciliary glands (Zeis and Moll) – usually external and focal 3) Pain with palpation, cutely swollen and edematous eyelid, normal vision |
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CHALAZION
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1) A non-infectious, granulomatous inflammation of a meibomian or Zeis gland
2) Hard nodule, painless, upper or lower eyelid, may follow a hordeolum 3) Large or persisting > 1 month can refer |
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BLEPHARITIS
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Common, chronic inflammation of the eyelids
1) Anterior - Involves the eyelid skin, eyelashes and associated glands. Bacteria (Staphyloccal), seborrheic dermatitis; a lot, flaky skin problem 2) Posterior - Involves the meibomian glands. Acne rosacea, seborrheic dermatitis |
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BLEPHARITIS; Pathophysiology
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Excess lipid production causes:
Reduced lipid layer of tear Increased formation of debris Ideal environment for bacteria |
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Lacrimal Apparatus
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1) Outer oily layer
2) Middle watery layer 3) Inner mucinous layer |
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DACRYOCYSTITIS
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- inflammation of the lacrimal sac
1) Chronic mucosal degeneration (use of anticholinergic response like Benadryl) 2) Ductile stenosis (narrowing of the ducts) 3) Stagnation of tears (increases risk for infection) 4) Bacterial overgrowth Tx: Warm compresses Systemic antibiotics if febrile IV antibiotics if infection is severe |
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Dacryostenosis
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Nasolacrimal Duct Obstruction
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Dacryocystocele
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- Noted at or shortly after birth.
- Both proximal and distal portions of nasolacrimal system are obstructed. - Urgent refer to ophthalmologist |
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ENTROPION
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Inversion of the anatomical eyelid margin towards the globe
1) Pseudo: Trichiasis = aberrant lashes 2) Involutional (aging) 3) Cicatricial = scarred (burns, Steven-Johnson Syndrome, surgery) Tx: with lubricants usually works, botox injections for lower lid |
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ECTROPION
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Eversion of the anatomical eyelid margin away from the globe
Etiology: Paralytic, aging, cicatricial (burns, surgery) |
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Xanthelasma
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Yellow plaques that occur most commonly near the inner canthus. More common on upper eyelid than lower. Range from soft ~ semisoft ~ calcareous.
One half are associated with elevated plasma lipid levels, low HDL, or other altered lipoprotein composition |
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Trichiasis
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Abnormally positioned eyelashes that grow toward the globe. Causes irritation to the cornea and potential scarring
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Myopia
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Nearsightedness:
- Light entering the eye focuses in front of the retina - Or cornea is steeper and/or eye is elongated - Results in poor distance vision |
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Diagnosis/Tx of myopia
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- Squinting
- eye strain - not being able to see the board Tx: - (-) diopters (concave lens) - Surgical procedures-RK, PRK, CLEAR, Lasik, ICL (allows lens to remain in place) |
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Hyperopia
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Farsightedness:
- Light entering the eye focuses behind the retina - Or cornea is flatter and/or eye is shorter than normal |
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Diagnosis/Tx of hyperopia
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- Difficulty seeing up close
- Often has blurred distance vision also - Eye fatigue when reading Tx: - Many children are born with hyperopia and “outgrow” - Dilated eye exam necessary in children - + diopters (convex lens) |
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Astigmatism
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- Irregular curvature of cornea; Oblong instead of spherical
- Causes light rays to focus on two different points in the eye resulting in blurred vision at all distances |
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Presbyopia
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- Crystalline lens loses flexibility and ability to accommodate for near vision
- Found in majority of people over age 40 - Treatment-reading glasses, bifocals, and trifocals |
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Visual Development of children?
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1) Birth:
Visual system is immature 2) 3 months of age Ability to follow an object typically established 3) 6 months of age Eye movements coordinated 4) Visual acuity reaches the adult level of 20/20 by 3-5 |
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Visual Assessment of a one month old?
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make eye contact and begin to look at objects close to their face
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Visual Assessment of a 3 month old?
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begin to observe hands while holding them close to their face
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Visual Assessment of a 4 month old?
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begin to watch activity around them
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Visual Assessment of a 6 month old?
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observe surroundings and recognize favorite people, toys, or food at a distance
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U.S. Preventive Services Task Force (USPSTF) recommends one vision screening to detect
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amblyopia and strabismus for all children before school entry, preferably between the ages of 3 and 4 years, with particular attention to ocular alignment.
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Strabismus
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- Ocular misalignment: “crossed eyes” or “wandering eye”
- Can occur in one or both eyes, and in any direction 1) Esotropia (inward) 2) Exotropia (outward) deviation greater when looking at distant object 3) Assess by distant and up close vision acuity |
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Common presenting sign of retinoblastoma (though itself is not common)
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Strabismus
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Pseudostrabismus
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Optical illusion in which the wide nasal bridge or epicanthal folds hide the nasal sclera
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Ambylopia
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- Functional reduction in the visual acuity of an eye
- Caused by disuse or misuse during the critical period of visual development 1) Unequal refractive errors 2) Deprivation-cataract, ptosis, eyelid hemangioma |
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Amblyopia- Types
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1) Strabismic
2) Anisometropic or refractive 3) Deprivational |
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Amblyopia- Strabismic
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- Abnormal binocular interaction:
Causes foveas of the two eyes to be presented with different images - Visual cortex suppresses the image from one eye: Long-term suppression results in amblyopia |
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Amblyopia- Anisometropic
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- Differing images presented to foveas due to unequal refractive errors. Typically eye with greater refractive error is “turned off”
- Most common in hyperopic patients - Often not found until child old enough for traditional vision testing due to lack of external abnormalities |
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Amblyopia- Deprivational
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- Congenital cataracts or corneal opacities
- Ptosis - Vitreous hemorrhage ***Least common and most severe form |
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Periorbital (preseptal) cellulitis:
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infection of the eyelid and surrounding skin anterior to the orbital septum.
- occurs much more frequently |
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Orbital (postseptal) cellulitis:
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infection of the orbital tissues posterior to the orbital septum; includes fat and muscle contained within the bony orbit
- Affects movement of the eye |
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Orbital/preseptal cellulitis; etiology
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Orbital:
- Extension of infection from adjacent sinuses, especially the ethmoid sinuses - Sinusitits is highly correlated with orbital cellulitis but not visa versa Preseptal: Contiguous spread of infection from local facial or eyelid trauma, insect bites, previous URI, conjunctivitis, or chalazion |
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Clinical presentation: orbital/preseptal cellulitis
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Preseptal only:
1) Erythema and edema of the eyelid 2) Tenderness or pain 3) Fever With orbital as well: 4) Proptosis (forward deviation of the eye, buldging, or exophthalmos) 5) Decreased extraocular movements 6) Decreased vision 7) Diplopia ***Blood cultures should be obtained with suspected orbital cellulitis |
