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686 Cards in this Set
- Front
- Back
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What are the 3 coats of the eye?
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Sclera
Uvea Retina |
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What type of coat is the sclera?
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Fibrous
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What type of coat is the uvea?
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Vascular
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What type of coat is the retina?
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Neural
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What is the progression of layers that light passes through the eye?
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Cornea
Anterior Chamber Pupil Lens Vitreous Layer Retina |
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What is the structure that connects the lens to the ciliary body?
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Lens zonules
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What is the limbus in the eye?
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The point where the cornea turns into the sclera
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What is a function of the indocorneal angle and the Canal of Schlemm?
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Place where aqueous humor can drain
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What are the 3 chambers of the eye?
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Anterior
Posterior Vitreous |
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Where is aqeuous humor produced in the eye?
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Posterior chamber
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What is the role of aqeuous humor in the eye?
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Feeds the avascular tissue of the lens and cornea
If the eye had blood vessels, vision would be blurry |
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What is the dimple in the retina of the eye called and what is special about it?
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Fovea
It is special because it is the point of highest visual acuity |
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The choroid, iris, and ciliary body are part of what coat of the eye?
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Uvea
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What is the structure at which point the retina starts?
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Ora serrata
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What are the 3 parts of the tear film layer of the eye?
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Posterior layer of glycoproteins
-Derived from goblet cells of conjunctiva Watery middle layer -Secreted by lacrimal tissue Anterior oily layer -Meibomian glands and glands of eyelid |
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What are the 6 layers of the cornea in the eye?
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Tear film
Corneal epithelium Bowman's layer Stroma Descemet's membrane Corneal endothelium |
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Does the corneal endothelium of the eye decrease with age?
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Yes, but it is never too late to donate this layer
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What are the 2 functions of the cornea in the eye?
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Refracts light - greatest refractive power in the eye
Physical barier - protects internal structures |
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What does a diopter measure?
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Measures the refractive power of a lens
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Does a larger diopter mean a stronger lens?
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Yes
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What is the refractive power of the cornea and why is this important?
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42 diopters
This is important because it focuses the light on the retina (.024 meters behind cornea) |
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Is the sclera a consistent thickness?
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No, extraocular muscles attach to the thicker parts
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What are the 2 functions of the sclera?
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Physical barrier - protects internal structures
Maintains shape of the globe - keeps the shape even if there is an increase in pressure so the eye doesn't collapse |
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What are the 4 reasons the sclera is not transparent like the cornea?
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Irregular arrangement of collagen fibers
Variable fiber diameter High water content Decrease GAG's on the collagen |
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What is the difference in color of an infant and elderly sclera?
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Infant - blue because pigment shows through
Elderly - sclera is yellow because of fat deposits Eyeball is yellow in jaundice |
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If a patient has cataract surgery, what is the structure should the surgeon be careful to keep intact?
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Posterior capsule
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What part of the lens does the lens material grow from?
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Bow region
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What are the suspensory ligaments in the eye?
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They connect the lens to the ciliary body
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What are 2 functions of the lens?
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Focus light on the retina (fine tunes)
Enable accommodation |
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What are the 4 layers of the iris of the eye?
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Anterior border layer (blood vessels)
Stroma (contains sphincter pupillae muscle) Dilator pupillae muscle Posterior pigment epithelium which gives the eye color -Contains tight junctions and is part of the blood-aqueous barrier |
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What are the 2 functions of the iris of the eye?
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Regulates the amount of light that falls on the retina
Plays role in accommodation |
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How is the dilator pupillae of the iris innervated?
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Sympathetic innervation and the neurotransmitter noradrenaline
Sympatheticomimetics dilate the pupil -Amine oxidase inhibitors (cocaine) Sympatholytic substances (constrict) |
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How is the sphincter pupillae of the iris innervated?
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Parasympathetic innervation and the neurotransmitter acetylcholine
Parasympathetomimetics constrict the pupil -Cholinesterase inhibitors or acetylcholine like substances like pilocarpine Parasympatholytic substances dilate pupil -Atropine |
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What are 4 properties of aqueous humor?
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Provide nutrients for avascular tissues of anterior segment (lens and cornea)
Removes waste Maintains intraocular pressure Contains little proteins and no blood which allows light to pass without scattering |
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What are the 2 structures of the ciliary body and what are their functions?
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Ciliary processes that produce aqueous humor
Ciliary muscles that are involved in accomdation and site of drainage of some aqueous humor |
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What is the mechanism of accomodation and non-accomodation?
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Non-accomodation (see far):
Pupil is large Lens is flat and the zonules are stretched Ciliary muscle is relaxed Accomodation (see near): Pupil is small Lens is round and zonules are relaxed (bend more light) Ciliary muscle is contracted |
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Is the sclera water tight?
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No, it has holes for blood vessels
Aqeuous humor can seep out of the holes to relieve pressure |
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What are the 3 contents of vitreous humor?
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Water - 99%
Collagen Proteoglycan matrix |
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What is the order of layers that a photon flows through the retina?
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Vitreous cavity
Inner limiting membrane Nerve fiber layer Ganglion cells Amacrine cells Bipolar cells Horizontal cells Muller cells Outer limiting membrane Rods and cones Pigment epithelium |
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What are the 2 functions of the retina?
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Transduction of light into an electrical signal (photoreceptors)
Modification of the electrical signal as it travels through the layers of the retina |
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Where are cones and rods located in the eye?
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Rods are more towards the periphery
Cones are more in the center (color) |
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What are the 6 functions of the retinal pigment epithelium?
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Blood-retinal barrier
Photon absorption so no light scatter Retinal adhesion to back of eye Photoreceptor homeostasis Phagocytosis of outer segments of rods/cones Photopigment regeneration to reuse photoreceptors |
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What is the fovea in the eye?
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Cones only
Thinning of retina due to displacement of inner retinal layers leaving only cones and cell bodies |
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What is the optic nerve head in the eye?
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Blind spot due to no rods and cones because the optic nerve is leaving the eye = retinal layers absent
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What is another name for blind spot in the eye?
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Scotoma
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What structure is the fovea located in?
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Macula lutea (yellow spot)
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What are 3 general reasons for doing an ocular exam?
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Primary ocular disease (amblyopia in children)
Secondary findings of systemic disease (diabetes) Secondary findings of neurologic disease (brain tumor) |
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What is the minimum ocular exam that should be performed?
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Visual acuity
Confrontational visual fields Pupils EOM movements Direct opthalmoscopy |
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What is amblyopia?
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Lazy eye
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What is strabismus?
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Crossed eyes
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Should you test each eye individually when you test visual acuity?
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Yes
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What is the Snellen chart and how is it interpreted?
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Tests visual acuity
20/40 = what normal person can see at 40 feet, patient can only see at 20 feet |
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How is Pinhole testing interpreted for visual acuity?
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A pinhole will improve vision if there is a refractive error
If vision improves, get glasses If doesn't improve, may have pathology |
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At what distance should visual acuity be tested for near vision?
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14 inches
If patient is over 40, likely need reading prescription or OTC |
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How is low vision visual acuity tested?
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Move the patient closer to chart and acuity is recorded based on distance (ex. test 10/40 vs. 20/40)
Counting fingers at number of feet Detect only hand motion Light perception only No light perception |
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How is visual acuity tested in the preverbal child?
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Test each eye separately and ask child to fix and follow
Try light stimulus if can't follow object Watch for withdrawal/facial expression in bright light if can't follow dim light |
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What do the abbreviations VA cc and VA sc mean?
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VA cc = visual acuity with correction
VA sc = visual acuity without correction |
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What do the abbreviations OD, OS, and OU mean?
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OD = occulus dexter (right eye)
OS = oculus sinister (left eye) OU = oculus uterque (both eyes) |
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What is myopia?
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Nearsightedness (distance vision is blurry)
Light entering eye focused in front of retina |
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What is hyperopia?
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Farsightedness (near vision is blurry)
Light entering eye focused behind retina |
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What is astigmatism?
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Refractive power of lens and cornea are greater in one meridian than another
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What is presbyopia?
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Loss of accomodation due to increasing age
Begins to occur after age 40 Older lens cells get trapped in the center of the lens (ciliary muscle has to work harder) |
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What is proptosis?
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Eyeball is popped out of head
Seen in Grave's disease and can get nerve damage |
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What is ptosis?
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Droopy eyelid
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What is the sign that is most seen with Herpes Zoster infections?
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Hutchinson's sign = lesions on tip of nose which make it more likely to get an eye lesion
Nasociliary nerve involvement |
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What is the difference between preseptal and orbital cellulitis?
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Preseptal = anterior to septum and confined
Orbital = behind septum |
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How do you test the pupillary reaction?
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Record the size in dark and direct light
Have patient focus on distant object |
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Is there such thing as a normal sized pupil?
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No
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What is miosis versus mydriasis?
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Miosis = small pupil (little "o")
Mydriasis = large pupil |
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What is anisocoria?
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Difference in the size of pupils that may be physiologic or pathologic
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What is the normal pupil response to light?
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Should react to direct light and constrict
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What is the problem if the afferent system (CNII) is not working in the eye?
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Eye doesn't perceive light so pupil doesn't constrict
Pupils will constrict if shine light in contralateral eye though Also called Relative Afferent Pupillary Defect |
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What is the problem if the efferent system (CNIII) is not working in the eye?
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Nerves/muscles will not allow the pupil to constrict
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What are two other causes of problems in pupillary constriction besides the nerves?
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Medication problem
Pupil is scarred down |
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What is the swinging flashlight test?
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Distinguishes optic nerve damage from other causes of vision loss
Shine light in both pupils and see the response |
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What is involved in an oculomotor nerve palsy with pupillary involvement?
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Pupil larger on affected side
Loss of levator function which leads to ptosis Eye turned down and out because only muscles working are superior oblique and lateral rectus |
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If someone has an oculomotor nerve palsy, what pathology should you think of?
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Aneurysm
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If someone has a Relative Afferent Pupillary Defect, what pathology should you think of?
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Blood clot or brain tumor
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What is Horner's Syndrome?
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Damage to the cervical sympathetic nervous system that innervates the dilator pupillae
Ptosis, miosis, anhydrosis (no sweat), enophthalmos (sinking of the eyeball into its cavity) |
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How do you test for Horner's Syndrome?
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Drop 10% cocaine on the eye
Pupil should dilate but it won't if have Horner's = will see a small pupil |
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How many positions should you test eye movement in?
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9
Primary gaze (straight ahead) Left and right Up and down Left up and left down Right up and right down |
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What is esotropia?
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Ocular misalignment in which the eyes are turning in
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What is exotropia?
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Ocular misalignment in which the eyes are turning out
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What is hypertropia?
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Ocular misalignment in which one eye is higher than the other
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What is the difference between tropia and phoria when it comes to ocular misalignment?
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Tropia = constant
Phoria = intermittent |
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What is the Bruckner test?
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Using the direct opthalmoscope to observe the red reflex
Used for detecting ocular tumors, strabismus, cataracts, refractive error, retinal detachment |
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What is hordeolum or chalazion?
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Called a stye
Hordeolum = ciliar follicles Chalazion = meibomian gland |
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What is ectropion versus entropion?
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Ectroprion = eyelid turned out which leads to lots of tears
Entroprion = eyelid turned in |
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What is a subconjunctival hemorrhage?
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A benign broken blood vessel
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What is pinguecuia and pterygium?
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Benign growths in the conjunctiva
Pterygium is more pronounced |
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How do you test for herpes simplex in the eye?
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Stain with fluorescence and look for a purple dendrite pattern
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What is iritis and what are some forms of it?
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Inflammation of the eye
Hypopyon (WBC) Corneal precipitates Iris scarring the lens |
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How do you test for intraocular pressure?
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Tactile exam: palpate gently closed eye with index fingers
-rough estimate -very elevated IOP will have a very hard eye Tonopen = best |
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What is the normal range for intraocular pressure?
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10-21 mmHg
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How do you assess the depth of the anterior chamber?
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Shine light from temporal side of head across the front of the eye, parallel to iris
***Look at nasal aspect of iris -If 2/3 or more of nasal iris is in a shadow then the chamber is narrow and the angle is narrow |
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What is seen in acute angle closure glaucoma?
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Red painful eye
Narow anterior chamber Cloudy cornea Fixed mild-dilated pupil High eye pressure |
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How are a patients visual fields tested?
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Use confrontational field testing
Test each eye individually Have patient count fingers in different quadrants |
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How can you help with viewing the eye under opthalmoscopy?
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Dilate the eye with tropicamide or phenylephrine
Make the lights low for several minutes |
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What is the normal color of the optic nerve under direct opthalmoscopy?
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Pink
If pale yellow, may have optic nerve damage |
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What do the normal margins of the optic nerve look like?
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Sharp
If disc looks swollen or vessels become less distinct as they cross optic nerve = concern for disc edema |
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What should the retinal blood vessels look like under direct opthalmoscopy?
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Should radiate away from optic nerve
May see spontaneous venous pulsations where veins collapse during systole (normal) -nicking: artery can compress the vein when pulses |
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What is the normal size ratio of retinal blood vessels of arteries/veins?
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arteries 2 : veins 3
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What should the macula look like under direct opthalmoscopy?
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Should be directly temporal and slightly inferior to optic nerve
Should see a small yellow reflex* |
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What does the pathology of central retinal artery occlusion look like?
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Cherry red spot
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How do you check for a foreign body in the eye?
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Close eyes and place cotton swab along upper lid crease and evert lid
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What is fluorescein staining used for in the eyes?
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Check for corneal abrasion
Check under cobalt blue light Abrasion = green fluorescence Don't wear contact lenses |
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What are the recommendations for vision screening?
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Low-risk adults <40 - visual acuity every 3 years
Low-risk adults >40 - complete screening exam every 2 years |
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What is the normal reaction to the relative afferent pupillary defect swinging flashlight test?
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Normal = no change or initial constriction upon swinging the light
If they have this effect, the abnormal eye will dilate upon shining the light |
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What is the problem in a relative afferent pupillary defect?
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Ipsilateral optic nerve/tract
or Large retinal lesion NOT A CATARACT |
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What are the 4 features of optic neuropathy?
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Loss of vision
Relative afferent pupillary defect (if this disease is unilateral) Optic disc edema or atrophy However, optic disc can be normal |
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What are the feautures of a typical optic neuritis?
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Young patient
Acute unilateral loss of visual acuity Pain with eye movement Ipsilateral relative afferent pupillary defect Disc edema or more often normal appearing nerve Visual acuity that recovers over time |
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Why does the nerve in optic neuritis more often appear normal?
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Because the neuritis is retrobulbar
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What disease is typical optic neuritis usually associated with?
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Multiple sclerosis
Use MRI to evaluate prognosis, not diagnose Treat with interferons |
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How do you treat typical optic neuritis?
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IV steroids hasten recovery but don't help with visual acuity
Oral steroids = contraindicated because increase rate of new attacks Patients usually improve over time without treatment |
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What are the features of typical ischemic optic neuropathy?
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Older patients
Arteritic and non-arteritic forms Painless acute, unilateral vision loss Ipsilateral relative afferent pupillary defect Swollen optic nerve (rarely retrobulbar) Little visual recovery over time No MS association |
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How do you treat ischemic optic neuropathy?
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No proven treatment for non-arteritic
Must rule out arteritic ischemic optic neuropathy (giant cell arteritis Treatment limited to control risk factors: HTN, DM, hyperlipidemia, nocturnal hypotension |
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What are the features of giant cell arteritis
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Elderly
Headache, scalp tenderness Jaw claudication Fever/malaise Visual loss Association with polymyalgia rheumatica |
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How do you treat giant cell arteritis?
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Stat ESR, CRP, CBC
Immediately start high dose steroids Confirm with 7-10 days with temporal artery biopsy (so don't use a ton of steroids for no reason) |
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What are 3 types of optic nerve lesions?
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Nerve fiber layer loss
Central scotomas Ceco-central scotomas |
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What type of scotoma is associated with a posterior optic nerve / anterior chiasm defect?
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Central scotoma with supertemporal VF defect in contralateral eye
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What visual field defect is associated with a chiasmal lesion?
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Bitemporal visual field loss
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If the optic tract is lesioned (chiasm to geniculate body, what is the visual field defect?
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Contralateral homonoymous hemoanopsia
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If there is a lesion of the optic pathway posterior to the geniculate body, what is the visual field defect?
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Temporal lobe: Upper quadrant homonymous hemianopsia
-Aphasias, hearing loss, hallucinations, memory disturbances, seizures Parietal lobe: Lower quadrant homonymous hemianopsia -Associated with visual neglect, visual agnosia, word recognition difficulties, agraphia Occipital lobe: Congruous homonymous hemianopsia -plus/minus macular sparing -plus/minus monocular temporal crescent -usually without other neurologic signs/symptoms |
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What are the rules of hemianopsia?
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Look up the slide and fill in
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If someone has a cranial nerve palsy, what history is important?
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Monocular or binocular:
If double vision is still present when one eye closed, then it is not strabismus Vertical/horizontal Transient/constant, sudden/gradual Effect at different positions of gaze Trauma? |
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What are the signs of a third nerve palsy?
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Ptosis
Pupil involvement Adduction, elevation, depression deficit |
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What are the most common causes of third nerve palsy?
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**PCA aneurysm - 95% involve the pupil
**Microvascular ischemia - 80% pupil sparing Trauma or brain tumor |
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If the pupil is involved with a third nerve palsy, what is suspected?
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Posterior communicating artery aneurysm until proven otherwise
If partial pupil or partial palsy, can still be aneurysm Can't see with imaging |
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If the pupil is spared with a third nerve palsy, what is suspected?
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Ischemia and can see with imaging
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What are the symptoms of a fourth nerve palsy?
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Adult vertical diplopia
Hypertropia in primary that is worse in contralateral gaze and ipsilateral head tilt Superior oblique is affected |
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What are the most common causes of a fourth nerve palsy?
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Traumatic, congenital, ischemic
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What muscle does the fourth nerve innervate?
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Superior oblique
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What is the deficit in a sixth nerve lesion?
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Abduction deficit with incomitant esotropia
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What are the most common causes of a sixth nerve lesion
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Small vessel disease
Head trauma Increased intracranial pressure Viral Brain tumor |
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What is the problem in a fifth nerve palsy and what is the most common cause?
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Decreased corneal sensation and neurotrophic corneal ulcers
Herpes |
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What is the problem in a seventh nerve lesion and what is the cause?
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Eyelid closure
Exposure keratopathy |
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What is papilledema?
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Optic nerve swelling that is secondary to high intracranial pressure
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What are the symptoms of papilledema?
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Headache
Minimal or no vision problems early with profound vision losses over time |
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What are some general characteristics of papilledema?
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Blurred, swollen margin
Disc hyperemia Peripapillary hemorrhages Loss of spontaneous venous pulsations Usually bilateral Enlarged blind spots |
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How do you make the diagnosis of papilledema?
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Check the BP
Neuroimaging Lumbar puncture if neuroimaging is negative |
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What are the 4 main causes of papilledema?
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Brain tumor
Idiopathic intracranial hypertension Venous sinus thrombosis Severe, acute HTN |
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What is the diagnosis of IIH?
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Diagnosis of exclusion
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What population is IIH most common in?
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Young obese females
Atypical in elderly, thin, or males |
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In IIH, is there normal neuroimaging and CSF analysis?
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Yes
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What is the treatment of IIH?
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Acetazolamide
Surgery if this drug doesn't work: sheath fenestration or lumboperitoneal shunt |
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What is pseudopapilledema?
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Optic nerve head is elevated, but no edema
Vessels are sharp and distinct Spontaneous venous pulsations Crowded disc Optic nerve drusen |
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What are the 3 efferent pupil abnormalities?
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Anisocoria
Pupil abnormally small (miosis) Pupil abnormally large (mydriasis) |
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What is anisocoria?
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Unequal pupils
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What is the problem in miosis?
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Sympathetics
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What is the problem in mydriasis?
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Parasympathetics
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Can systemic diseases cause vision loss?
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Yes
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Do patients usually report vision loss as binocular or monocular?
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Patients often can't tell
They will report loss only in dominant eye |
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If someone has lost their glasses, what should you do when testing them?
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Use a pinhole
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What is tonometry?
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Measures intraocular pressure
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What two general types of problems can cause extraocular motility dysfunction?
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Neurological
Orbital |
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What are the two most common types of eyelid problems?
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Periorbital or orbital cellulitis
(can extend to optic nerve) Thyroid eye disease -often have corneal exposure problems -buldging eye may compress the optic nerve |
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What is media opacity in the eye?
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Any opacity of the clear refractive media: cornea, anterior chamber, lens, vitreous
Will cause blurred vision Usually will not cause afferent pupillary defect (if see abnormal pupil, think neurological) |
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If someone has a corneal opacity, why is it difficult to differentiate the cause?
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Difficult to differentiate edema versus infection without a slit lamp
Conjunctival injection = clue in infection Edema = glaucoma, trauma, uveitis, blunt trauma such as an airbag |
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What is hyphema?
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Blood in the anterior chamber
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What causes hyphema?
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Blunt/surgical trauma
Neovascularization of anterior chamber in diabetes, chronic inflammation, CRVO, tumors |
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What is the most common problem with a cataract?
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Chronic visual loss
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What are the major causes of an acute cataract?
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Trauma
Acute electrolyte imbalance (blood sugar) Occlusion of better eye Intraocular inflammation |
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What are the major causes of lens dislocation?
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Trauma
Marfan's ** Homocystinuria Weill Marchesani Isolated autosomal dominant Sulfite oxidase deficiency Hyperlysinemia |
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What chambers of the eye does uveitis most effect?
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Anterior or Posterior or both
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What type of disorders is uveitis associated with?
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Autoimmune
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What do people with uveitis typically complain of?
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Light sensitivity
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What is 2 common complications of uveitis?
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Fixed pupil
Conjunctival injection (nonuniform redness of conjunctiva) |
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Is a vitreous opacity easy to see with opthalmoscope?
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No
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What are the 2 most common types of vitreous opacity?
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Vitreous hemmorhage
Vitreous inflammation |
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What are the most common types of vitreous hemmorhage?
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Trauma
Neovascularization of retina (Diabetes, sickle cell) Vitreous detachment = high risk for developing retinal detachment Rarely AMD (age related macular degeneration) |
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Where is the macula located?
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Oval area that is temporal and inferior to optic disk
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What is the blood supply to the macula?
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Opthlamic artery, central retinal artery, posterior ciliary arteries
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What types of photoreceptors is the macula associated with?
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Rods and cones
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What type of vision is the macula responsible for?
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Detailed, fine central vision
Ability to drive, read, recognize faces |
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What is the fovea?
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Center of the macula where there are a lot of cones but no rods and no blood vessels
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Does macular disease cause an afferent pupillary defect?
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No
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What is a common symptom of macular disease?
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Metamorphopsia (objects appear distorted)
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What is the pathology in age-related macular degeneration?
|
Defect in Bruch's membrane that can allow access of choroidal vessels to subretinal space which can cause leakage of fluid/blood which = metamorphopsia or central acuity loss
Bruch's membrane contains the basement membrane of the RPE and is the innermost layer of the choroid |
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What is the odd word that is associated with retinal arterial occlusion and what is it?
|
Amaurosis fugas = transient monocular visual loss due to arterial insufficiency (lose blood flow from cartoids)
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If a paitnet is over 50 and reports visual loss in one eye, what should you investigate?
|
Carotids
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What is a carotid atheroma?
|
Source of emboli that transiently interrupt blood flow to retina
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If you restore the blood flow in a carotid retinal arterial occlusion (CRAO), will vision be preserved?
|
Only if the occlusion is only a few hours old
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Is a CRAO embolic or thrombotic?
|
May be either
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What must you rule out in CRAO?
|
Giant cell arteritis in elderly
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How many minutes of interrupted flow to the retina causes permanent damage to the ganglion cells and permanent vision loss?
|
90 minutes
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What is the first main symptom in CRAO
|
Sudden, often complete vision loss in one eye
Painless |
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Which artery in CRAO, if affected, spares the macula?
|
Cilioretinal artery
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What do you see on physical exam in CRAO?
|
Cherry red spot with a swollen retina
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Does the optic disc swell in CRAO? Why/Why not?
|
No because it receives blood via carotid and opthalmic proximal to central retinal artery
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If a family physician suspects CRAO, what maneuver should they do to the eye? What is the purpose of this maneuver?
|
Compress the eye with the heel of the hand, pressing firmly for 10 seconds and then releasing 10 seconds for over 5 minutes
Sudden rise and fall in IOP may dislodge a small embolus before irreversible damage |
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What diseases are retinal vein occlusion associated with?
|
HTN and glaucoma
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What population is most affected by retinal vein occlusion?
|
Old people
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Is retinal vein occlusion associated with hypercoaguability?
|
Rarely
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Are vein occlusions caused by emboli?
|
No
Don't need to do dopplers, echo, MRA, temporal artery biopsy |
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What do you see on physical exam for central retinal vein occlusion?
|
Disc swelling, venous engorgement, cotton wool spots, diffuse retinal hemorrhages
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What is the "blood and thunder" fundus associated with?
|
Central retinal vein occlusion
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If someone has a retinal detachment, what do they see?
|
Flashing light and floaters
Shade or a curtain, usually in one eye |
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What do you see on physical exam in a retinal detachment?
|
Retina is elevated
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Is a retinal detachment an emergency?
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Yes
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What is a macular hole caused by?
|
Traction of the vitreous on the retina
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What is the weakest part of the retina associated with macular hole?
|
Fovea and it is important
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How do you treat a macular hole?
|
Removal of vitreous and membranes on surface can result in closure of hole and improve vision
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What is the difference between papillitis and papilledema?
|
Papillitis: inflammation of optic disc
Papilledema: swelling of the optic disc due to increased intraocular pressure -shows normal visual acuity and pupils as opposed to other |
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What is optic neuritis?
|
Inflammation of the optic nerve which results in loss of myelin surrounding the nerve
Associated with MS |
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|
What are the symptoms of optic neuritis?
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Decreased visual acuity and RAPD
Pain with eye movement |
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What does optic neuritis look like on physical exam?
|
Hyperemic and swollen (or normal if retrobulbar)
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How do you treat optic neuritis?
|
IV steroids
Oral steroids are contraindicated |
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What is ischemic optic neuropathy?
|
Swelling of the disc and visual loss in an older adult associated by splinter hemmorhages
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Where is the visual field loss in ischemic optic neuropathy?
|
Superior or inferior fields
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What is giant cell arteritis categorized under?
|
Ischemic optic neuropathy in patients over 60
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What are the symptoms of giant cell arteritis?
|
Scalp tenderness
Jaw claudication (pain in jaws when chewing) Pain in muscles/joints |
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How do you diagnose giant cell arteritis?
|
ESR, CRP, temporal artery biopsy
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How do you treat giant cell arteritis?
|
High dose systemic corticosteroid (can still do a biopsy after steroids)
May preserve vision in the remaining eye and prevent other vascular occlusions that can lead to stroke |
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What are the 4 medical emergencies in the eye?
|
Acute angle closure glaucoma
Retinal detachment Acute CRAO Giant cell arteritis |
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What are danger signs of red eye
|
Vision loss
Corneal cloudiness Severe pain Circumcorneal injection Fixed pupil Not responding to treatment |
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What are the signs and symptoms of non-traumatic red eye?
|
Less serious (primary care): dry eye, conjunctivitis, blepharitis, stye, pterygium, subjuncitval hemorrhage
More serious (opthalmologists): infectious keratitis, acute glaucoma, iritis, scleritis, dacryocysitis, orbital/preseptal cellulits |
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What is blepharitis?
|
Flaky debris that is around the eyelashes
Redness along the eye margins Oily discharge along eyelids Seborrheic or staphylococcal variants |
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How do you treat blepharitis?
|
Warm compresses and lid scrubs
Topical erythromycin ointment |
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What can blepharitis lead to?
|
Styes
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What are hordeolum and chalazion?
|
Inflammation of eyelid sebaceous glands
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Are hordeolum and chalazion self-limiting?
|
Yes
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How can you treat hordeolum and chalazion?
|
Warm compresses
Incision and drain Kenalog injection |
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What is ocular rosacea?
|
Chronic blepharo-conjunctivitis with thickened secretions
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How do you treat ocular rosacea?
|
Topic metronidazole
Oral tetracyclines |
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What is the most common virus in viral conjunctivitis?
|
Adenovirus from recent URI
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How can one get viral conjunctivitis?
|
URI or pink eye exposure
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What type of discharge is seen in viral conjunctivitis?
|
Serous or mucoid
Absence of mucopurulent drainage |
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Do you see regional LAD in viral conjunctivitis?
|
Yes
Most likely preauricular |
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|
What is the common type of reaction in viral conjuctivitis?
|
Follicular reaction in conjunctiva
-bumpy |
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|
What is the treatment for viral conjunctivits?
|
Cool compresses
Artificial tears Public health - wash hands, don't share towels/forks, no school/daycare |
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What does allergic conjunctivitis present like?
|
Recurrent
History of allergies Serous drainage Chemosis (conjuctival edema) Itching** |
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|
What is the treatment of allergic conjunctivitis?
|
Eliminate agent
Cool compresses and articficial tears Topical antihistamines Vasoconstriction agents (Visine) - look out for the rebound effect Topical NSAIDS Topical Mast cell stabilizers |
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If someone has mucopurulent drainage in the eye, what are you worried about?
|
Bacterial conjunctivits
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Is bacterial conjunctivitis usually bilateral or unilateral?
|
Unilateral
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What are the most common bugs that cause bacterial conjunctivitis?
|
Staph aureus
Streptococcus pneumoniae |
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|
If a neonate or sexually active adult has a severe eye infection, what bug are we worried about?
|
N. gonorrhoeae
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How do you treat bacterial conjunctivitis?
|
Aminoglycosides
Polymixin B Erythromycin Fluoroqinolones |
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|
What is the course of bacterial conjunctivitis caused by N. gonococcus?
|
Hyperacute course
Systemic treatment is necessary STD considerations: public health report |
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|
What is the course of bacterial conjunctivitis caused by Chlamydia?
|
Subacute
Chronic adult conjunctivitis Neonatal conjunctivitis Systemic therapy necessary |
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|
If someone has a subconjunctival hemorrhage, what types of questions should you ask?
|
Do you have bleeding/brusing elsewhere
Antiplatelet/anticoagulant use |
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|
Is subconjunctival hemorrhage serious?
|
Rarely
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|
What is dry eye syndrome?
|
Common
Associated with inflammatory conditions |
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|
How do you treat dry eye syndrome?
|
Artificial tears/lubricating ointment
Cyclosporin drops |
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|
What 3 types of patients is exposure keratopathy associated with?
|
Comatose patients in the ICU
CN VII impairment Thyroid dysfunction (Grave's) |
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|
What is the treatment of exposure keratopathy?
|
Lubricating ointment
Tape lids closed Tarsorrhaphy (stitch eyelids shut) |
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|
What is epscleritis?
|
A sensation of a foreign body in the eye with occasional discomfort
Etiology typically undetected Localized or diffuse variants |
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|
What type of distribution is typically seen in episcleritis?
|
Corkscrew distribution
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What type of pain is seen in scleritis?
|
Deep pain
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|
What type of pattern can scleritis present as?
|
Anterior or posterior
Diffuse or nodular |
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|
How do you treat scleritis?
|
Systemic anti-inflammatory agents
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|
What are the clinic features of herpetic keratitis?
|
History of ocular herpes that are recurrent
Occasionaly have skin lesions Dendritic corneal lesions |
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|
Should you use steroids in herpetic keratitis?
|
Hell no they can cause a disaster
|
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|
How should one fine doctor treat the herpetic keratitis?
|
Topical antivirals or systemic antivirals like acyclovir
|
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|
What is keratitis a broad term form?
|
Inflammation of the cornea
|
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|
What type of opacity do you see in bacterial keratitis?
|
White corneal
|
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|
Is bacterial keratitis painful?
|
Yes
|
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|
What is bacterial keratitis most associated with?
|
Contact lens wear
|
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|
How do you treat bacterial keratitis?
|
Aggressive topical antibiotics
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|
If someone has a corneal abrasion, what should you give them for prophylaxis?
|
Aminoglycosides
Polymixin B Erythromycin Fluorquinolones if they wear contacts |
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|
What are the clinical features of iritis?
|
Photophobia
Deep ocular pain Circumcorneal redness Anterior chamber cells (slit lamp) |
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|
How do you treat iritis?
|
Topical corticosteroids
Cycoplegia/mydriasis Follow-up with a slit lamp exam and monitor a rise in IOP |
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|
What are the clinical features of acute glaucoma?
|
Severe pain
Blurred vision, halos Headache, N/V Fixed dilated pupil Corneal clouding Acute/severe IOP elevation |
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|
What might predisopse someone to acute glaucoma?
|
Asians and eskimos/inuits, Alaskan natives
Hyperopia Topical mydriatics Anticholinergic meds Dim illumination like movie theatres Post anesthesia |
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|
What is the treatment of acute glaucoma?
|
Topical beta blocker
Pilocarpine Systemic carbonic anhydrase inhibitors Osmotic agent |
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|
What are the danger of topical corticosteroids?
|
Worsen herpes infections
Worsen fungal infections Worsen parasitic infections May raise IOP May cause or worsen cataracts |
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|
What are the dangers of topical analgesics?
|
Inhibit corneal epithelial healing
Reduces blink reflex Severe allergic reaction May cause corneal melt or corneal perforation |
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|
What is the leading cause of irreversible central vision loss among people over aged 50?
|
Age related macular degeneration
|
|
|
What is the mild type of macular degeneration?
|
Dry or non-neovascular
|
|
|
What is the severe type of macular degeneration?
|
Wet
|
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|
What is the sign of early/dry macular degeneration?
|
Drusen
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|
What is the Drusen in early macular degeneration??
|
Hyaline bodies deposited in Bruch's membrane that separates the RPE from the inner choroidal vessels
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|
What are the clinical features of neovascular AMD?
|
20% of people with non-neovascular develop sub-retinal neovascularization or neovascular AMD or wet AMD
See the Drusen Neurosensory detachment of RPD Subretinal hemorrhage Decreased visual acuity CEntral scotoma Metamorphopsia |
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|
What is fluorescein angiography and what does it detect?
|
IV injection of dye and retinal photography shows retinal and choroidal vasculature
If the retinal veins and arteries are normal, they don't allow leakage of dye and the RPE acts as a barrier to the dye |
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|
What is the disciform scarring that occurs in AMD?
|
Vascular elements regress which allows the fibrous elements to advance
The neurosensory detachment may disappear and the blood is absorbed Fibrovascular scar replaces Bruch's membrane, RPE, and photoreceptors Vision function is lost at the rea of the scar leaving a permanent central scotoma |
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|
What did the AREDS study shouw for prevention of wet AMD?
|
Vitamins help progression
Zinc and antioxidants |
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|
How do you treat neovascular AMD?
|
Laser photocoagulation for extrafoveal and juxtafoveal lesions
Photosensitizing a dye with a "cold laser" for subfoveal lesions (Photodynamic therapy) Antiangiogenic drugs - Macugen, Avastin, Lucentis |
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|
What did a study of photocoagulation therapy in AMD show?
|
It slows the loss of vision but doesn't prevent all vision loss
|
|
|
What disease is VEGF related to?
|
AMD
VEGF increaes permeability and neovascularization |
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|
What type of drugs are Macugen, Avastin, and Lucentis for AMD?
|
Anti-VEGF therapy
|
|
|
Did Macugen injections help patients with AMD?
|
Yes, prevented some vision loss
|
|
|
What type of anti-VEGF drugs are Avastin and Lucentis?
|
Antibodies against VEGF
|
|
|
What did the MARINA study show with the AMD drugs Avastin and Lucentis
|
Actually helped with vision, nost just preventing loss
|
|
|
What are some future treatments for AMD?
|
Electronic implants
Implantable telescopes Gene therapy |
|
|
What did a study of photocoagulation therapy in AMD show?
|
It slows the loss of vision but doesn't prevent all vision loss
|
|
|
What disease is VEGF related to?
|
AMD
VEGF increaes permeability and neovascularization |
|
|
What type of drugs are Macugen, Avastin, and Lucentis for AMD?
|
Anti-VEGF therapy
|
|
|
Did Macugen injections help patients with AMD?
|
Yes, prevented some vision loss
|
|
|
What type of anti-VEGF drugs are Avastin and Lucentis?
|
Antibodies against VEGF
|
|
|
What did the MARINA study show with the AMD drugs Avastin and Lucentis
|
Actually helped with vision, nost just preventing loss
|
|
|
What are some future treatments for AMD?
|
Electronic implants
Implantable telescopes Gene therapy |
|
|
What is the leading cause of new-onset blindness in working age people?
|
Diabetic retinopathy
|
|
|
What are the two main types of diabetic retinopathy?
|
Non proliferative DR
Proliferative DR |
|
|
Is macular edema association with both proliferative and non-proliferative DR?
|
Yes
|
|
|
What does the basement membrane look like in a diabetic?
|
Thickened BM
Loss of blood-retinal barrier Leaking of plasma or blood into retina |
|
|
What are the microaneurysms that form in a diabetic patient?
|
Pericyte degeneration weakens the wall of the capillary = saccular outpouching
This is due to a proliferative cellular response to focal retinal hypoxia |
|
|
What is the earlist opthalamic manifestation of DR?
|
Microaneuryisms
|
|
|
What is the most frequent cause of vision loss with non-proflierative DR?
|
Macular edema
|
|
|
What is macular edema caused by in DR?
|
Breakdown of inner blood-retinal barrier which leads to separation of the photoreceptors from the RPE
|
|
|
What is an odd manifestation of clinically significant macular edema in DR?
|
Cystic cavities
|
|
|
What technique is used to study macular edema?
|
Fluorescein angiography
|
|
|
What is the treatment of macular edema in DR?
|
Treat leaking microaneurysisms with lasers
Dont laser the fovea |
|
|
When thickening of what structure in macular edema occurs, there is a greater threat of visual loss?
|
Fovea
|
|
|
What is the 3-year risk of moderate vision loss in DR?
|
32%
|
|
|
What are some other changes that occur in non-proliferative DR?
|
Intra-retinal microvascular abnormalities which causes dilation and duplication of the capillary bed at border of non-perfusion
Venous beading (irregular diameter of retinal venules) Acute swelling of axons due to capillary closure |
|
|
What is the reason for changes in non-proliferative DR?
|
Retinal ischemia and capillary obliteration
|
|
|
What type of spots are seen in non-prolierative DR?
|
Cotton wool spots where the nerve fiber layer infarcts
|
|
|
What are the 3 stages in the pathogenesis of proliferative retinopathy?
|
Diffuse retinal ischemia
Vasoproliferative factor Neovascularization: NVD (Disc), NVE (elsewhere), NVI (iris), NVA |
|
|
Where is the neovascularization seen in proliferative DR?
|
Seen elsewhere
Anterior to the retina and into the vitreous Neovascularization of the disc Traction of the vitreous on the NVE and retina |
|
|
What are the 3 outcomes of proliferative retinopathy?
|
Traction retinal detachment
Vitreous hemorrhage Neovascular glaucoma |
|
|
IS there a larger fibrous component in proliferative DR?
|
Yes
|
|
|
What is a traction retinal detachment in proliferative DR?
|
Most of the retina is detached
Small area is still attached |
|
|
How do you treat proliferative DR?
|
Panretinal photocoagulation
-May induce the regression of fibrovascular tissue -Decrease likelihood of traction detachment, vitreous hemorrhage, neovascular glaucoma -50% reduction in severe visual loss Vitrectomy |
|
|
What is the number 1 way to prevent DR?
|
Glycemic control
|
|
|
What are some other risk factors for DR besides diabetes?
|
HTN
Hyperlipidemia Pregnancy Anemia |
|
|
What are some new treatments for DR that are being tested?
|
Intraocular steroid injections to stabilize endothelial cells and retinal barrier and reduce inflammation
VEGF inhibitors to prevent hyperpermeability and neovascularization |
|
|
What is the definition of amblyopia?
|
Decreased visual acuity by at least 2 lines with full refractive correction and no organic pathology evident
"Lazy eye" |
|
|
Are amblyopia and strabismus the same?
|
Hell no
|
|
|
If you autopsy an amblyopic patient, what do you see?
|
Loss of cells in vision center ganglion cells of brain (pathways)
|
|
|
At what age does amblyopia develop?
|
Before 9 years
|
|
|
Is amblyopia usually bilateral or unilateral?
|
Unilateral
|
|
|
In what 2 conditions is amblyopia more common in?
|
Esotropia (crossed eyes)
Eye with greater refractive error |
|
|
Why is it important to detect amblyopia and treat early?
|
Most common cause of unilateral vision loss in children
Prevalence = 2-5% of kids Reversible if treated |
|
|
At what age should amblyopia be treated?
|
Must be treated before 9-10 but best results if treated before 5
|
|
|
What are the 3 main causes of amblyopia?
|
Stabismus (vision in one eye suppressed)
Refractive (anisometropic) Deprivation |
|
|
What is the definition of strabismus?
|
Misalignment of the eye
|
|
|
How does strabismus present in adults?
|
Diplopia (double vision)
|
|
|
How does strabismus present in children?
|
Suppression (no diplopia)
Suppression of the vision can lead to amblyopia (don't make connections in the brain) |
|
|
Does all strabismus lead to amblyopia? Why/Why not?
|
No
May alternate fixation of eyes equally (switch eye back and forth all day) |
|
|
In what condition is amblyopia most likely to come from strabismus?
|
Congenital esotropia
|
|
|
Can small angle strabismus cause amblyopia?
|
Yes, but it is hard to detect (have to shine opthalmoscope in both eyes equally to look for red reflex - simultaneous red reflex test)
|
|
|
What is refractive amblyopia?
|
Large difference in refractive error between eyes (anisometropia)
|
|
|
In what refractive condition is refractive amblyopia most common in?
|
Hyperopia
The more hyperopic eye is at risk |
|
|
Is refractive amblyopia easy to detect?
|
No, so you must screen for it
|
|
|
What 3 tests are used to screen for refractive amblyopia or strabismus?
|
Simultaneous red reflex test
-Shine light into eyes simultaneously and look for red reflex (Should be same) Photo screening Automated refraction |
|
|
What is the definition of deprivation amblyopia?
|
Opacity in visual axis
|
|
|
What types of opacities can cause deprivation amblyopia?
|
Cataract
Corneal clouding/scarring Ptosis Patching |
|
|
What type of amblyopia is the most severe?
|
Deprivation
|
|
|
What type of amblyopia is most easily missed?
|
Refractive
|
|
|
What is heterophoria strabismus?
|
Latent tendency toward misalignment (only apparent after covering on eye)
|
|
|
What is heterotropia strabismus?
|
Manifest deviation that may be intermittent (with both eyes open)
|
|
|
What is orthophoria strabismus?
|
No deviation
|
|
|
What is esotropia strabismus?
|
Crossed eyes
|
|
|
What is exotropia strabismus?
|
Outward deviation
|
|
|
What is hypertropia strabismus?
|
Upward deviation
|
|
|
What is hypotropia strabismus?
|
Downward deviation
|
|
|
What is concomitant strabismus?
|
Strabismus that is the same in all directions of gaze
|
|
|
Is concominant strabismus paralytic or nonparalytic?
|
Nonparalytic
|
|
|
What is incomitant strabismus?
|
Strabismus that varies with direction of gaze
|
|
|
What are the 2 types of incomitant strabismus?
|
Restrictive - ex. thyroid disease
Paralytic - ex. CN VI palsy |
|
|
What are the 3 types of horizontal eye deviations?
|
Congenital esotropia
Duane's syndrome Pseudostrabismus |
|
|
What is congenital esotropia?
|
Inward turning of eye with large angle deviation (20 deg)
|
|
|
When does congenital esotropia usually present?
|
By age 6 months with minimal refractive error
|
|
|
Does congenital esotropia lead to amblyopia?
|
In about 30% of cases
|
|
|
What is the first goal in treating congenital esotropia and how do you do it?
|
Correct the amblyopia first:
Patch the better eye Atropine 1% in better eye to dilate and paralyze the muscles of accommdation to blur the vision MAKE THEM USE THE BAD EYE |
|
|
What is the second part of treating congenital esotropia?
|
Surgery:
Bimedial rectus recession to decrease the action of the medial rectus (pull it back) R&R - recess medial rectus and resect lateral rectus (tighten) |
|
|
What is Type 1 Duane's syndrome?
|
Type 1 = limited abduction (most common)
Abnormal CNIII involvement (LR is innervated by this nerve) Lid fissure of affected eye narrows in adduction |
|
|
What is Type 1 Duane's syndrome confused with?
|
6th nerve palsy
|
|
|
What is pseudostrabismus?
|
Prominent epicanthal folds (looks like Down's)
Central corneal light reflexes so examine the family photos |
|
|
How do you treat pseudostrabismus?
|
Reassurance and observation
|
|
|
What is accommodative esotropia?
|
Acquired form
Occurs in 2-5 year olds that have hyperopia Accommodation: the convergence causes the crossing |
|
|
How do you treat accommodative esotropia?
|
Glasses
PAtching or atropine if amblyopia Strabismus surgery if still have esotropia with glasses |
|
|
What type of nerve palsy can cause an acquired form of esotropia?
|
Cranial nerve VI palsy
|
|
|
If you lose vision in one eye can you get acquired esotropia? What can cause this?
|
Yes
Retinoblastoma, cataract, glaucoma |
|
|
Can strabismus cause vision loss and viceversa?
|
Yes
|
|
|
What are the two types of acquired exotropia?
|
Intermittent: variable onset, age 1-4, progressive, may not be evident
Constant: Progressive intermittent with vision loss in one eye |
|
|
What are the 2 types of vertical deviations in children?
|
Cranial nerve IV palsy (eye will be up and in)
Brown's syndrome In adduction: obliques raise up eye and down In abduction: rectus muscles raise eye up and down |
|
|
What is the paretic vertical deviation that we need to know?
|
Cranial nerve IV palsy
|
|
|
Do you get a hypertropia in the affected eye in a paretic vertical deviation?
|
Yes
|
|
|
What is the symptom of the neck in a paretic vertical deviation?
|
Torticollis - head turn and head tilt away from involved eye
Dont do neck surgery when eye surgery is needed |
|
|
What is the restrictive type of vertical deviation in children?
|
Brown's syndrome
|
|
|
What is Brown's syndrome?
|
Superior oblique tendon restriction that has limited elevation in adduction (eye is always kept down by the tension, so can't be brough back up)
|
|
|
What are the 3 tests for strabismus?
|
Cover testing (for tropia)
Corneal light reflexes Simultaneous red reflexes |
|
|
What are the 4 tests for amblyopia?
|
Simultaneous red reflex testing
Photo screening Visions testing that is appropriate for age Automated refraction |
|
|
How should you counsel parents with a kid that may have amblyopia or strabismus?
|
Tell then vision screening is important
Treatment is very effective Early treatment is better Amblyopia and strabismus don't resolve spontaneously Vision training is not effect |
|
|
What are the 8 aspects of a complete eye examination?
|
Visual acuity
External/adnexa (lids, lashes, sockets) Pupils Alignment/motility Visual fields (confrontation) Anterior segment (in front of the lens) IOP Posterior segment (opthalmoscope) |
|
|
If someone has a chemical burn to the eye, what is the first thing that should be done?
|
Irrigate, Irrigate, Irrigate with normal saline and tap water
|
|
|
After irrigation, what should a physician do to treat a chemical burn of the eye?
|
Topical anesthetic for pain
Check for foreign bodies (solid chemicals) Check the pH Be wary of ruptured globe injuries from pressurized chemical exposure |
|
|
What pH is the most dangerous to the eye?
|
Acid and alkali
|
|
|
Following irrigation of the eye, what should the physican do in a chemical burn?
|
Cycloplegia with scopalamine (lose accommodation)
Antibiotic Pressure patch Referral to optho. |
|
|
If someone has a thermal burn to the eye, what is the first thing that should be done?
|
Lubricate, Lubricate, Lubricate
|
|
|
After lubrication, what should a physician do to treat a thermal burn of the eye?
|
Check for foreign bodies
Don't use tarsorrhaphy Prepare for skin grafting |
|
|
How do you evaluate a corneal abrasion or foreign body in the eye?
|
Slit lamp
Fluorescein assists diagnosis Eversion of eyelids Evaluate for penetrating injuries and co-morbid infections |
|
|
How do you treat a corneal abrasion or foreign body in the eye?
|
Corneal foreign bodies = removed under magnification
-Spud preferred but large gauge hypodermic OK Give a topical cycoplegic Give a topical antibiotic for comfort and prophylaxis Prescribe oral analgesic |
|
|
What should you never prescribe to a patient with a corneal abrasion or foreign body?
|
Topical anesthetic (will use it over and over and will lose the blink reflex = corneal problems)
|
|
|
If there is a perforation or penetration of the globe (fishhook), what are the warning signs?
|
Extensive subconjunctival hemorrhage
Visable corneal or scleral defect Conjunctival laceration Uveal prolapse (looks brown) Irregular pupil Hyphema Lens opacity/dislocation |
|
|
What types of things are important in the history of a patient you suspect a penetration/perforation of the eye?
|
Blunt trauma (rupture)
Sharp object (penetrate) Metal on metal striking Fireworks Hockey |
|
|
What color is bad in eye trauma?
|
Brown
Means the uvea is prolapsed and is leaking |
|
|
What is the first thing you should do when you suspect a ruptured globe/penetration injury?
|
STOP the Exam
|
|
|
Should you give the patient an eye patch when you suspect a globe/penetration injury?
|
No
Apply a Shield or paper cup |
|
|
What drug should you give a patient when you suspect a globe/penetration injury?
|
Antiemetic to prevent Valsalva
|
|
|
Should you apply topical drugs when you suspect a globe/penetration injury?
|
No, give systemic antibiotics
|
|
|
Should you do an MRI when you suspect a globe/penetration injury?
|
No, do a CT of orbit and brain
Do not delay referral when awaiting imaging |
|
|
When you see traumatic hyphema, what do you suspect until proven otherwise?
|
Ruptured globe
Shield that eye and refer |
|
|
What is sympathetic uveitis?
|
Autoimmune condition that incites antigen of retinal, RPE, or choroidal cause
Risk is higher in children |
|
|
How do you treat sympathetic uveitis?
|
Prophylactic surgical removal of traumatized eye
Systemic corticosteroids for active treatment Second line immune suppressives that aren't steroids |
|
|
What type of anatomy is the orbit involved with?
|
Paranasal sinuses and foramens that contain ducts/nerves
|
|
|
If you see a patient that has post-traumatic proptosis, what things should you abstain from?
|
Post-operative Valsalva
Aspirin and plavix Nose blowing |
|
|
How do you treat posttraumatic proptosis?
|
Remove nasal packing
Ocular hypotenstive agents Lateral canthotomy/cantholysis Orbital wall decompression as last resort |
|
|
What type of CT scan should be ordered for an orbital wall fracture?
|
Orbital and maxiofacial
Don't do a brain/head CT because only get an axial view |
|
|
How do you treat an orbital wall fracture?
|
Surgery for restrictive diplopia or enopthalmos
|
|
|
How do you treat an orbital fracture besides surgery?
|
Antibiotic
Mucosal decongestant to relieve blood through nose Corticosteroids Postural drainage (elevate head Abstain from aspirin, NSAIDS, nose blowing to prevent secondary hemorrhage |
|
|
What are the clinical features of traumatic optic neuropathy?
|
Loss of vision
Ipsilateral afferent pupillary defect (must do swinging flashlight test) |
|
|
What is the most common form of traumatic optic neuropathy?
|
Indirect traumatic optic neuropathy
|
|
|
When do you treat a traumatic optic neuropathy?
|
Medical: diffuse hemorrhage or emphysema and elevated IOP
Surgical: Emphysema from elevated IOP, localized hematoma, diffuse hemorrhage unresponsive to therapy Steroid therapy may be indicated |
|
|
What are the danger zones for an eyelid laceration?
|
1. Eyelid margin (repair tarsal plate or will get an orbital notch that tears can flow through and cornea will continually be exposed and dry out)
2. Medial canthus (lacrimal outflow) - patient can devlop chronic tearing 3. Preseptal zone of eyelid: upper eyelid retractors are present (levator and Muller's sympathetic muscle) |
|
|
If there is no fat prolapse, are the eyelid retractor systems affected?
|
No, the wound is superficial
|
|
|
What types eyelid trauma are associated with dog bites?
|
Crushing
|
|
|
What types eyelid trauma are associated with cat bites?
|
Penetration
|
|
|
What organisms are involved in eyelid trauma from dog/cat bites?
|
Pasturella and Capnocytophaga
|
|
|
How do you treat eyelid trauma from a cat or dog bite?
|
Imaging to rule out perforation of the bone
Debride tissues Copious irrigation to reduce pathogens Early primary closure |
|
|
How should you treat eyelid trauma from a laceration?
|
Tetanus prophylaxis
Remove foreign bodies Close with sutures Avoid surgical closure of orbital septum due to retraction or distorition of lid Antibiotics |
|
|
What is the prevalence of primary open angle glaucoma?
|
Second leading cause of irrerversible blindness
Leading cause in blacks |
|
|
What does glaucoma eventally lead to?
|
Permanent blindness
Leads to progressive damage to optic nerve and results in loss of visual field |
|
|
What are the 5 types of glaucoma?
|
X-linked
Primary open angle - most frequent (unknown etiology) Primary closed angle - ocular emergency Secondary glaucoma (steroids or trauma can cause) Low-tension glaucoma (pressure in semi-normal range) |
|
|
What type of glaucoma is a medical emergency?
|
Primary closed angle glaucoma that requires intervention in 24-48 hours
|
|
|
What is the mechanism of glaucoma?
|
Trabecular meshwork is blocked so fluid can't get out and intraocular pressure builds
|
|
|
Are there any symptoms in primary open angle glaucoma?
|
No, silent disease that can lead to end stage where lose vision
|
|
|
What are the 6 risk factors for glaucoma?
|
IOP
Cup to disc ratio Corneal thickness Age Race FH |
|
|
What IOP and corneal thickness combintation most leads to glaucoma?
|
If the IOP was higher than 25 and the cornea was thin = high risk for glaucoma
|
|
|
What ratio of cup/disc ratio suggests glaucoma?
|
0.5 or higher optic cup to disc ratio
( 0 ) o = cup ( ) = disc |
|
|
What are some generalized opthalmoscopic signs of glaucoma?
|
Large optic cup
Asymmetry of the cups Enlargement of the cups |
|
|
What former vice president (38th) is a glaucoma test named after?
|
Humphrey
Looks at circle pressures (all we know about it) |
|
|
What are some focal opthalmoscopic signs of glaucoma?
|
Narrowing/notching of the rim
Vertical elongation of the cup Regional pallor Splinter hemorrhage Nerve fiber layer loss |
|
|
What determines the prognosis of glaucoma?
|
Stage of disease at the time of a diagnosis
Rate or progression Ability to reduce IOP with meds Compliance |
|
|
How should you chronically manage glaucoma?
|
Establish a good baseline
Set a reasonable goal for IOP Lower the pressure Continue to observe the patient to determine whether the pressure goal is met Modify the pressure goal and treatment as indicated by patient's course |
|
|
What 5 meds are used to lower IOP?
|
Prostaglandin derivatives
B blockers Adrenergic agonists (sympathomimetics) Carbonic anhydrase inhibitors Cholinergic agonists (miotics) |
|
|
What type of laser would Dr. Evil like to get his hands on to punch holes in the trabecular meshwork to help with open angle glaucoma?
|
Argon laser
|
|
|
If someone has a severe headache, nausea, vomiting and has a really red eye, what should you worry about if you were a good physician?
|
Acute angle closure glaucoma (emergency)
|
|
|
What does angle mean in glaucoma?
|
The angle between the iris and the cornea
|
|
|
How does a kid with congenital glaucoma present?
|
Epiphoria (tears)
Photophobia (light sensitivity) Belpharospasm |
|
|
What does a normal lens look like and do?
|
Focuses a clear image on the retina
Accommodation Enclosed in a capsule of transparent basement membrane |
|
|
Is the lens innervated or does it have a blood supply?
|
No
|
|
|
How is the lens nourished?
|
Aqueous and vitreous humor
|
|
|
Where are new fibers of the lens produced?
|
Single anterior layer of cuboidal epithelium
|
|
|
What substance increases in the lens as you age?
|
Insoluble protein
|
|
|
What is a cataract?
|
Opacity or discoloration of lens
Can be subcapsular, cortical, nuclear, anterior or posterior |
|
|
What is a mature cataract?
|
Totally opacified cortex
|
|
|
What are the symptoms of a person with a cataract?
|
Blurred vision (depends on size and location of opacity)
Distortion of color |
|
|
What is second sight?
|
Increased nuclear sclerosis in a cataract with increased refractive power of the lens leads to myopia which allows reading without glasses
|
|
|
What color distortion is associated with cataracts?
|
Increasing yellow and brown seen
|
|
|
What are the symptoms of a post subscapular cataract?
|
More rapid decrease in vision
Associated with Diabetes and steroids |
|
|
What is the prevalence of cataracts?
|
70% over 75
Most common cause of decreased vision and most successfully treated conditions |
|
|
What are the indications for cataract surgery?
|
Elective - performed when patients want it to see better
May be required for a doctor to look into posterior part of eye to diagnose retinal disease Rarely required if a person has cataract induced glaucoma or inflammation |
|
|
What structure is to be left intact in a cataract surgery?
|
Capsular bag
|
|
|
Now, what laser would Dr. Evil like to get his hands on if he wants to have evil cataract surgery?
|
YAG Laser to make opening in clouded posterior capsule
|
|
|
Which one is reversible, cataracts or glaucoma?
|
Cataracts
|
|
|
Which disease has symptoms of blurriness, glaucoma or cataracts?
|
Cataracts
Glaucoma has no symptoms |
|
|
What are the general goals of glaucoma and cataract treatment?
|
Glaucoma: reduce IOP
Cataracts: surgery |
|
|
How do you diagnose a cataract?
|
Lens opacity with an obscured view of the retina
|
|
|
How do you diagnose glaucoma?
|
Routine screening, IOP, optic nerve, visual field testing (Humphrey)
|
|
|
How does sickle cell anemia cause retinopathy?
|
The retionaopathy is secondary to ischemia
|
|
|
What genotype is most associated with sickle cell anemia retinopathy?
|
HBSC
Also in HbSS and thalassemia Does not occur in sickle cell trait |
|
|
What are some of the features of sickle cell retinopathy?
|
Retinal arteriole and capillary occlusion
"sea fan" neovascularization Vitreous hemorrhage Tractional retinal detachment May be asymptomatic until laster stage |
|
|
How do you treat sickle cell retinopathy?
|
Give a yearly dilated eye exam
Retinal laser photocoagulation if they have it |
|
|
What can chronic hypertension and arteriosclerosis due to the eye?
|
Mess it up
|
|
|
If a patient has chronic HTN and arteriosclerosis, what is seen in the eye?
|
Arteriolar attenuation
Arteriolar fibrosis A/V crossing changes |
|
|
If a patient has an acute hypertensive retionopathy, what changes are seen in the eye?
|
Flame shaped retinal hemorrhages
Cotton wool spots Lipid exudates due to leaky vessels |
|
|
What can malignant hypertension cause in the eye?
|
Optic nerve edema
|
|
|
How does a physician treat hypertensive retinopathy?
|
Control blood pressure
|
|
|
If a patient has malignant hypertension, what treatment should you worry about?
|
Lowering the BP slowly because a sudden decrease can infarct the optic nerve = permanent vision loss
|
|
|
What are features of thyroid disease that cause eye problems?
|
Eyelid retraction (thyroid stare)
Lid lag on downgaze Proptosis Painless Conjunctival injection (inflammation) Restriction of eye movement which leads to diplopia |
|
|
What is the most common cause of unilateral or bilateral proptosis in adults?
|
Thyroid disease
|
|
|
What is the etiology of thyroid disease?
|
Autoimmune
|
|
|
Is thyroid disease that affects the eyes correlate with hormone levels?
|
No
|
|
|
Can thyroid disease of thy eye progress even when the patient is euthyroid?
|
Yes
|
|
|
What are the 2 phases of thyroid eye disease?
|
Congestive or inflammatory phase
Cicatrical phase |
|
|
What is the congestive or inflammatory phase of thyroid eye disease and how long does it last?
|
Involves the orbiral tissue and extraocular muscles
Lasts 2 years |
|
|
What are some complications that can occur with thyroid eye disease?
|
Corneal exposure (dry eyes)
Diplopia Optic nerve compression which can lead to loss of vision and field defects |
|
|
What is a common way to judge the sizes of the extraocular muscles?
|
CT Scans
|
|
|
If a patient is in the congestive phase of thyroid eye disease, how should they be treated?
|
Radiation
Systemic corticosteroids Orbital decompression |
|
|
If a patient is in the cicatrical phase of thyroid eye disease, how should they be treated?
|
Strabismus surgery
Eyelid and orbital surgery |
|
|
What organ that we are studying can sarcoidosis affect?
|
Eyes
|
|
|
What population of people usually get sarcoidosis?
|
Women from Africa or Hispanic descent
|
|
|
What type of infection is sarcoidosis?
|
Granulomatous
|
|
|
What layer of the eye does sarcoidosis most affect?
|
Uvea (iris, choroid, ciliary body)
|
|
|
What is anterior uveitis in sarcoidosis?
|
See keratic precipitates that look like "mutton fat"
Posterior synechia - adhesions of the iris to the lens capsule |
|
|
What types of cells are in granulomatous infections?
|
Giant cells
|
|
|
What is lacrimal gland infiltration in sarcoidosis?
|
Dry eyes
Enlarged lacrimal gland |
|
|
What is posterior uveitis in sarcoidosis?
|
Choroiditis
Retinal vasculitis Greater chance to involve the CNS |
|
|
What does neurosarcoidosis cause?
|
Optic neuropathy
CN palsy |
|
|
Does sarcoidosis affects veins or arteries more?
|
Veins
|
|
|
What are some signs to diagnose sarcoidosis?
|
Serum calcium
ACE Serum lysozyme CXR |
|
|
How do you treat sarcoidosis?
|
Refer to opthamology
Topical or systemic corticosteroids Immunosuppressive agents |
|
|
What organ can rheumatoid arthritis affects?
|
I
|
|
|
What are the ocular manifestations in rheumatoid arthritis?
|
Dry eyes
Episcleritis Scleritis Corneal ulcers Uveitis |
|
|
What disease is scleritis more specific for?
|
Collagen vascular disease
Usually a systemic autoimmune association |
|
|
Is episcleritis milder?
|
Yes
Vessels move and blanch (will shrink and go away with drops) |
|
|
IS eye pain associated with episcleritis or scleritis?
|
Scleritis
|
|
|
Are deeper vessels more affected in episcleritis or scleritis?
|
Scleritis
|
|
|
What is scleritis also associated with?
|
Wegener's
Lupus Polyarteritis nodosa Sarcoid Syphillis, TB |
|
|
What eye problem can juvenile rheumatoid arthritis cause?
|
Chronic iritis
Can cause complications that lead to cataracts, glaucoma, corneal calcification |
|
|
Chronic iritis in juvenile rheumatoid artheritis is most common in what pheno/genotype?
|
Pauciauricular, RF-negative, ANA positive
|
|
|
What are some nongranulomatous causes of iritis?
|
Ankylosing spondylitis (inflammation in low back)
Reiter's syndrome Behcet's disease TB, Syphillis, HSV, Varicella |
|
|
What is the Reiter's syndrome triad?
|
Urethritis, arthritis, conjunctivitis
|
|
|
Can malignancies affect the eyes?
|
Yes
|
|
|
Where are metaseses in the eye most likely found?
|
Choroid
|
|
|
What are common places that eye cancer can metastasize from?
|
Breast and Lung
|
|
|
What are the types of cancer that are in the eyes?
|
Lymphoma - conunctiva/orbit
Leukemia - hemorrhagic retinopathy or optic nerve infiltration Cancer associated retionopahy that is autoimmune |
|
|
What are some complications of treatment for eye malginancy?
|
Radiation = retinopathy, cataract, optic neuropathy
Chemo - superficial keratitis and optic neuropathy Bone marrow - graph verus host = severely dry eye |
|
|
What eye complications are involved in AIDS?
|
HIV retinopathy
CMV retinitis |
|
|
What do you see on exam when an AIDS patient has HIV retinopathy?
|
Cotton wool spots which is focal capillary occlusion
|
|
|
When does an AIDS patient get CMV retinitis?
|
Low CD4 counts
Leads to hemorrhagic retinal necrosis = vision loss |
|
|
How would you treat CMV retinitis?
|
IV ganciclovir
Ganciclovir implants Protease inhibitors |
|
|
Can syphilis affect the eye?
|
Yes
|
|
|
What 3 types of syphilis can you get in the eye?
|
Congenital - interstitial keratitis and uveitis
Secondary - iritis, choroiditis, peripapillary exudates Latent - chorioretinitis, papillitis, neurosyphillis likely |
|
|
What should you check if you suspect latent syphilis
|
CSF
|
|
|
What is candidiasis of the eye?
|
White yellow retinal infiltrates
|
|
|
What are risk factors for obtaining candidiasis?
|
Long-term central lines
Parenteral nutrition |
|
|
What can herpes zoster affect?
|
Periocular, corneal involvement
Anterior uveitis Caused from activation of latent varicella-zoster |
|
|
What are the general features of intracranial hypertension?
|
Headache
Visual obscurations Visual field defect Optic nerve edema (papilledema) Loss of spontaneous venous pulsations |
|
|
What can cause intracranial hypertension?
|
Brain tumor
Meningitis Venous sinus thrombosis Hydrocephalus Idiopathic intracranial hypertension |
|
|
If you suspect intracranial hypertension, how should you work the patient up?
|
MRI and MRV
Lumbar puncture |
|
|
What complication can intracranial hypertension cause?
|
Optic nerve edema
|
|
|
When putting in eyedrops in a patient eye, where should they be placed?
|
Inferior fornix
NOT the cornea |
|
|
When putting eyedrops in a patient's eye, how can you reduce the chance of systemic absorption?
|
Keeping eyes closed for a few minutes or punctual occlusion
|
|
|
How can a patient better sense if they have a drop in their eye?
|
Refridgerate the drops
|
|
|
What is the topical ocular diagnostic drugs we need to know?
|
Fluorescein dye: becomes green when under cobalt blue light
-Used IV for retinal angiography -No systemic complications but can stain soft contact lenses Anesthetics - allow manipulation of ocular surface or remove foreign body; toxic to corneal epithelium |
|
|
Should you ever prescribe or give an eye anesthetic to a patient?
|
Hell no
|
|
|
What two classes of drugs are used as diagnostic drugs for the pupil?
|
Mydriatics = dilators
Cycloplegia = paralyze accommodation (will all dilate the pupil) |
|
|
What are sympathomimetics?
|
Adrenergic stimulators
Stimulate dilator muscle of iris DO NOT affect accommodation Used in combo with a cycloplegic to widely dilate the pupil |
|
|
Do sympathomimetics have less effect on dark irises?
|
Yes
|
|
|
What is the sympathomimetic drug we need to know?
|
2.5% phenylephrine
|
|
|
What are some cycloplegic drugs?
|
Tropicamide
Scopalamin Atropine |
|
|
What are the side effects of cycloplegics and sympathomimetics?
|
Blurred near vision
Light sensitivity Caution in patient with shallow anterior chambers because can cause glaucoma |
|
|
Why are topical decongestants used in the eye?
|
Weakly adrenergic
Used temporarily to whiten the conjunctiva |
|
|
What are the side effects of topical decongestants in the eye?
|
Conjunctivitis medicamentosa
Rebound effect with long term use Mucosal atrophy Might dilate the pupil Can precipitate angle-closure glaucoma |
|
|
Are topical decongestants in the eye safe for chronic open angle glaucoma?
|
Yes
|
|
|
What are the 4 therapeutic classes of drugs used for allergic conjunctivitis?
|
Lubricants/artificial tears (beware of preservative allergy)
Antihistamines /vasoconstrictors Mast cell stabilizers Combo therapies |
|
|
What meds are used in severe cases of allergic conjunctivitis?
|
Mild topical corticosteroid
Systemic antihistamines such as diphenhydramine Mast cell stabilizer |
|
|
What are the topical anti-inflammatory drugs used in the eye?
|
NSAIDS
|
|
|
When are NSAIDS used for in the eye?
|
Allergic conjunctivitis
Pain control for corneal abrasions Maintain mydriasis in surgery Macular edema |
|
|
What are uses of topical corticosteroids in the eye?
|
Anterior uveitis
External inflammatory disease Post-operative inflammation |
|
|
What are some of the dangers of using topical corticosteroids in the eye?
|
Unmasks and enhances herpetic keratitis
Enhances fungal infections Raise IOP Cause cataracts |
|
|
What a patient has a dry eye, what should be prescribed?
|
Simple artificial tears
Preservative free artificial tears Gels Ointments - most effective but can blur vision Topical cyclosporine (for more severe symptoms) |
|
|
What type of topical antibiotics are most used in the eye?
|
Fluoroquinolones
|
|
|
Should the topical antibiotics in the eye be broad spectrum?
|
Yes
|
|
|
What other types of topical antibiotics are used in the eye?
|
Sulfonamides - can cause Stevens-Johnson syndrome
Polytrim E-mycin acts as a good lubricant Aminoglycosides Fortified antibiotics |
|
|
Do topical antibiotics of the eye usually cause allergy?
|
No
|
|
|
What antiviral drugs are usually used in the eye?
|
Viroptic - pyrimidine analog for topical treatment of Herpes simplex keratitis that interferes with DNA synthesis
-ineffective for herpes prophylaxis Gangcyclovir - nucleoside analog in vitreous implant and used for CMV, EBV, Varicella |
|
|
What are the ocular hypotensives that are used in the eye for glaucoma?
|
Beta blockers
Cholinergics Echothiophate iodide Carbonic anhydrase inhibitors |
|
|
What is the mechanism of action of beta blockers in the eye?
|
Reduces secretion of aqueous humor
|
|
|
What are the side effects of using beta blockers in glaucoma?
|
Exacerbate asthma/COPD
Worsen CHF Bradycardia, hypotension Beta 1 specific = less pulmonary, but hypotensive effect |
|
|
What is the mechanism of action of cholinergics in the eye?
|
Contraction of longitudinal muscle of ciliary body = pulls scleral spur and opens the AC angle
Pilocarpine |
|
|
What are the 2 main side effects of using cholinergics in the eye?
|
Pupillary miosis and headache
|
|
|
What is the mechanism of action of echothiophate iodide?
|
Cholinesterase inhibitor
Prolongs degradation of sucinylcholine and procaine during anesthesia Same side effects as pilocarpine |
|
|
What was the original systemic treatment for glaucoma?
|
Carbonic anhydrase inhibitors
|
|
|
What are the side effects of carbonic anhydrase inhibitors?
|
Paresthesias, GI distrubance, metallic tastes
|
|
|
What are the systemic side effects of using adrenergics such as topical epinephrine for glaucoma?
|
Cardiac arrythmia
Hypertension Depositis in conjunctiva |
|
|
What are the systemic side effects of using alpha-2 agonists for glaucoma?
|
Peds - CNS depression, hypotension, apnea
High rate of local sensitivity issues |
|
|
What is the mechanism of action of alpha-2 agonists in the eye?
|
Decreased aqueous production and increased uveoscleral outflow
|
|
|
What is the mechanism of action of prostaglandin analogs of the eye?
|
Increases uveoscleral outflow
Soon available as mascara |
|
|
What are the side effects of prostaglandlin analogs in the eye?
|
Well tolerate
Hyperemia Darkening of iris Eyelash growth |
|
|
What are the side effects of corticosteroids in the eye?
|
Posterior subscapular cataracts
Increased IOP, permanent vision loss from glaucoma |
|
|
What are the side effects of choloroquines in the eye?
|
Corneal deposits
Bull's eye maculopathy which is irreversible |
|
|
What are the side effects of digitals in the eye?
|
Blurred vision
Abnormal color perception (normal objects appear yellow) Halos on dark objects Images appear frosted Fatigue DO NOT NEED A SCREEN FROM OPTHO |
|
|
What are the side effects of amiodarone (cardiac arrythmia drug) in the eye?
|
Whor shaped corneal epithelial deposits (verticullata)
Optic neuropathy rarely |
|
|
What are the side effects of Diphenylhydantoin (anti-seizure drug) in the eye?
|
Cerebellar-vestibular toxicity
Nystagmus Vertigo Ataxia Diplopia Side effects = reversible |
|
|
What are the side effects of ethambutol (tuberculosis drug) in the eye?
|
Optic neuropahy
Visual loss within one month Visual loss usually reversible |
|
|
What are the side effects of antipsychotics in the eye?
|
Corneal and lens opacities that are reversible
Pigment retinopathy |
|
|
What are the side effects of phosphodiesterase inhibitors (erectile dysfunction) in the eye?
|
Impairment of color discrimination that cause blue vision
Ischemic optic neuropathy |
|
|
What are the side effects of Topiramate (Topamax) (anti-seizure/migraines) in the eye?
|
Ciliary body effusions
Malignant glaucoma Initial symptom may be sudden onset nearsightedness (myopia) |
|
|
What are the side effects of systemic antihistamines in the eye?
|
Decrease lacrimal secretion so warn patients of dry eyes
Atropine like effect resulting in pupil changes or decreased accommodation Warning label for glaucoma patients |
|
|
What are the side effects of calcium channel blockers in the eye?
|
Periorbital edema
Non specific conjunctivitis |
|
|
What are the side effects of nitroglycerin in the eye?
|
Blurred vision
|
|
|
What are the side effects of ACE inhibitors in the eye?
|
Angioedema of eyelids
|
|
|
What are the side effects of niacin in the eye?
|
Cystoid macular edema
|
|
|
What are the side effects of accutane in the eye?
|
Light sensitivity
Conjunctivitis, dry eye Optic neuritis |
|
|
What are the side effects of antidepressants in the eye?
|
Patients report blurred vision
Worsening of dry eyes |
|
|
What are the side effects of hormone replacement therapy in the eye?
|
Pseudotumor cerebri
Dry eye Vasular occlusions |
|
|
What are the side effects of Tamoxifen (breast cancer treatment) in the eye?
|
Pigmentary retinopathy
Corneal deposits |
|
|
Why do people with glaucoma smoke the reefer?
|
Lowers IOP for 3 months but have to smoke it constantly
|
|
|
What are the ciliary body effusions that are caused by Topamax?
|
They cause swelling which pushes the iris forward, blocking the drainage of the aqueous humor which leads to glaucoma
Also pulls the lens forward = blurred vision |
|
|
What is some general normal anatomy of the eye orbit?
|
Fixed boney cavity that is open anteriorly
Close to intracranial cavity, paranasal sinuses |
|
|
Are there any lymph nodes or lymphatics in the eye orbit?
|
No
|
|
|
What are the contents of the eye orbit?
|
Globe
Extraocular muscles Fibroadipose tissue Nerves and vessels |
|
|
How big is the orbit and what do lesiosn of the orbit that ocupy space cause?
|
30 cm cubed
Lesions cause proptosis and determines which way globe is pushed |
|
|
What general type of disease process causes most disease of the orbit?
|
Inflammation
|
|
|
What types of inflammatory lesions cause disease of the orbit?
|
Sinis infections = cellulitis
Thyroid opthamology (Graves) Inflammatory pseudotumors Lymphoid lesions |
|
|
What is thyroid opthalmopathy mainly caused by?
|
Grave's disease
|
|
|
What are the 3 problems that thyroid opthalmopathy cause?
|
Exophthalmos
Lid retraction Enlarged extraocular muscles |
|
|
In thyroid opthalmopathy, what is going on with the enlarged extraocular muscles?
|
Inflammation is restricted to the muscle belly, sparing the tendons and fat
Lymphs, plasma cells, mast cells present GAG's are very evident Variable fibrosis |
|
|
What types of cells are not seen in the enlargement of extraocular muscles of thyroid opthalmopathy?
|
Germinal centers and eosinophils
|
|
|
What is another name for idiopathic orbital inflammation?
|
Orbital pseudotumor
|
|
|
How do you diagnose idiopathic orbital inflammation?
|
Diagnosis of exclusion after ruling out infection, tumor, or Grave's
|
|
|
What are the symptoms of idiopathic orbital inflammation?
|
Pain and proptosis that can be unilateral of bilateral
|
|
|
What structures are involved in idiopathic orbital inflammation?
|
Entire orbit
Lacrimal gland Extraocular muscles Tendon capsules MUCH MORE DIFFUSE |
|
|
What cells are involved in idiopathic orbital inflammation?
|
Lymphs
Plasma cells +/- eosinophils |
|
|
What are the 2 malignant neoplasms of the eyelids?
|
Basal cell carcinoma
Sebaceous carcinoma |
|
|
Do basal cell carcinomas usually metastisize?
|
No, locally invasive
|
|
|
What structures of the eyelid are involved in a basal cell carcinoma?
|
Lower lid
Medial canthus |
|
|
What types of glands do a sebaceous carcinoma arise from?
|
Meibomian, glands of Zeis, caruncle
|
|
|
What population are sebaceous carcinomas see in?
|
Elderly usually
>40 |
|
|
What does a sebaceous carcinoma usually mimic?
|
Blepharitis
Chalazion |
|
|
Is the upper or lower eyelid more affected in a sebaceous carcinoma?
|
Upper lid
|
|
|
Do sebaceous carcinomas spread and why/why not?
|
Yes
They have extensive intra-epithelial involvement |
|
|
What bodily substance do sebaceous carcinomas produce and is used as a diagnostic measure?
|
Lipids
|
|
|
How do sebaceous carcinomas spread?
|
Local invasion
Nodal to the partoid and submandibular glands Hematogenous to lung, liver, brain, skull |
|
|
What is the mortality rate of a sebaceous carcinoma?
|
20%
|
|
|
What in god's green earth is a pinguecula?
|
Localized yellowish-white plaque near the limbus in the conjunctiva
|
|
|
What in god's blue earth is a pterygium?
|
Localized white-pink plaque near the limbus in the conjunctiva
Extends onto the cornea in the plane of Bowman's membrane |
|
|
Which favorite planet of Harey Carey can cause a pinguecula or pterygium?
|
The Sun
Causes solar elastosis |
|
|
Are a pinguecula and pterygium histologically similar?
|
Yes, both have elastosis and fibrosis
|
|
|
What is some general normal anatomy of the eye orbit?
|
Fixed boney cavity that is open anteriorly
Close to intracranial cavity, paranasal sinuses |
|
|
Are there any lymph nodes or lymphatics in the eye orbit?
|
No
|
|
|
What are the contents of the eye orbit?
|
Globe
Extraocular muscles Fibroadipose tissue Nerves and vessels |
|
|
How big is the orbit and what do lesiosn of the orbit that ocupy space cause?
|
30 cm cubed
Lesions cause proptosis and determines which way globe is pushed |
|
|
What general type of disease process causes most disease of the orbit?
|
Inflammation
|
|
|
What types of inflammatory lesions cause disease of the orbit?
|
Sinis infections = cellulitis
Thyroid opthamology (Graves) Inflammatory pseudotumors Lymphoid lesions |
|
|
What is thyroid opthalmopathy mainly caused by?
|
Grave's disease
|
|
|
What are the 3 problems that thyroid opthalmopathy cause?
|
Exophthalmos
Lid retraction Enlarged extraocular muscles |
|
|
In thyroid opthalmopathy, what is going on with the enlarged extraocular muscles?
|
Inflammation is restricted to the muscle belly, sparing the tendons and fat
Lymphs, plasma cells, mast cells present GAG's are very evident Variable fibrosis |
|
|
What types of cells are not seen in the enlargement of extraocular muscles of thyroid opthalmopathy?
|
Germinal centers and eosinophils
|
|
|
Where do most squamous cell carcinomas arise and what causes them?
|
Limbus and they often preceded by intraepithelial dysplastic change
The Sun |
|
|
What is a nevi in the conjunctiva?
|
Benign melanocytic lesion that is often cystic
|
|
|
When should you as a physican be scared of a nevi?
|
When it is located on the fornix, palpebral conjunctiva, or if it extends onto the cornea
|
|
|
What is a primary acquired melanosis of the conjunctiva?
|
Precursor to melanoma
In situ form of melanoma Unilateral, acquired pigmentation Will progress to melanoma if don't treat |
|
|
When do melanomas of the conjunctiva usually occur?
|
Middle age people that have light complexion
|
|
|
How do melanomas of the conjunctiva usually spread?
|
Lymph nodes first then to parotid and submandibular gland
|
|
|
When should you be concerned about melanomas of the conjunctiva?
|
If they spread to the cornea
|
|
|
What causes a keratitis/ulcers of the cornea?
|
Breakdown of normal corneal defense mechanisms such as:
trauma, dry eyes, bullous change, invasive organisms |
|
|
What organisms cause a keratitis/ulcers of the cornea?
|
Bacteria
Viruses (Most likely herpes) Fungi Parasites (amoeba of soft contacts) Look for a distinctive pattern of destruction |
|
|
What can promote stromal necrosis and organism invasion in keratitis/ulcers?
|
Enzymes from PMN's, oranisms, or corneal epithelium
|
|
|
What is a keratoconus of the cornea?
|
Bilateral degeneration of cornea resulting in progressive central thinning
|
|
|
Is keratoconus of the cornea usually inherited?
|
No but some association with Down's and Marfan's
|
|
|
When does a keratoconus of the cornea usually present?
|
Puberty with a severe astigmatism
|
|
|
What histology do you see in a keratoconus of the cornea?
|
Centrally thinned corneal stroma
Breaks in Bownman's membrane Iron deposition Can develop corneal hydrops if rupture Descemet's |
|
|
What is Fuch's Endothelial Dystrophy of the cornea?
|
Bilateral corneal dystrophy
|
|
|
In what population is Fuch's Endothelial Dystrophy of the cornea present??
|
Elderly females
|
|
|
Is Fuch's Endothelial Dystrophy of the cornea indicated for a corneal transplant?
|
Yes
|
|
|
When does the corneal decompensation occur Fuch's Endothelial Dystrophy of the cornea?
|
Later in life due to blurred vision from corneal edema
|
|
|
What is the histology of Fuch's Endothelial Dystrophy of the cornea?
|
Thickened Descemet's membrane with numerous guttata
Secondary corneal edema, bullous change |
|
|
What is the pathology of glaucoma?
|
Optic neuropathy associated with excavation of optic disc and progressive visual field sensitivity
Most have increased IOP, some normal |
|
|
How is glaucoma generally classified?
|
Developmental (congenital)
Primary (idiopathic) Secondary |
|
|
What is the most common of glaucoma?
|
Primary open angle
|
|
|
Is primary open angle glaucoma bilateral or unilateral?
|
Bilateral vision loss
|
|
|
What is the cause of primary open angle glaucoma?
|
Problems with deep drainage of trabecular network
|
|
|
Is primary closed angle (acute angle closure) glaucoma unilateral of bilateral?
|
Unilateral
|
|
|
What is the cause of primary closed angle (acute angle closure) glaucoma?
|
Unilateral blockage of outflow by iris over trabecular meshwork
|
|
|
Is a patient hyperopic or miopic in primary closed angle (acute angle closure)?
|
Hyperopic (farsighted)
They also have small eyes with a shallow anterior chamber |
|
|
What is Glaukomflecken?
|
Associated with primary closed angle (acute angle closure)
Focal damage to anterior lens |
|
|
Is secondary open angle glaucoma unilateral or bilateral?
|
Unilateral
|
|
|
What causes secondary open angle glaucoma?
|
Obstruction of meshwork by cells, pigment, debris, increased episcleral pressure, tumor
|
|
|
Is secondary closed angle glaucoma unilateral or bilateral?
|
Unilateral
|
|
|
What causes secondary closed angle glaucoma?
|
Intraocular disorders
Trauma Systemic disease Tumors Neovascular |
|
|
What is the pathology of secondary closed angle glaucoma?
|
Retina = atrophy of ganglion cell layer and atrophy of nerve fiber layer
Optic disc cupping and nerve atrophy Sclera - thinning Cornea - edema, bullous change, vascularization |
|
|
What structures compose the uveal tract?
|
Iris
Ciliary body Choroid |
|
|
What is a nevi of the uveal tract?
|
Benign melanocytes that collect
|
|
|
Do nevi of the uveal tract usually turn into melanomas?
|
No
|
|
|
What is the most common primary intraocular malignancy of adults?
|
Melanoma of the uveal tract
|
|
|
Are whites or blacks more likely to get a melanoma of the uveal tract?
|
Whites
|
|
|
What types of melanomas of the uveal tract are more aggressive - choroid/ciliary body or iris?
|
Choroid and ciliary body
|
|
|
What effect does hypertension have on the retina?
|
Breakdown of the blood-retina barrier
Leaky endothelium which can lead to edema, exudate |
|
|
What happens to do arteriole in hypertension of the retina?
|
Varying degrees of mural fibrosis (red - copper - silver appearance)
|
|
|
What are cytoid bodies in hypertension of the retina?
|
Cotton wool spots that are caused by retinal infaracts in nerve fiber layer
|
|
|
What can hypertension of the retina lead to?
|
Hemorrhage, papilledema, choroidal infarcts that can lead to retinal detachment
|
|
|
What does background (non-proliferative) diabetic retinopathy cause?
|
Confined beneath the internal limiting membrane
Thickened BM Dropout of pericytes due to loss of autoregulation *** Microaneurysms Leaky vessels due to breakdown of blood-retina barrier |
|
|
What does proliferative diabetic retinopathy cause?
|
Neovascularization that breaches the internal limiting membrane
Hemorrhage at interface of vitreous and retina which leads to further retinal detachment VEGF can drive neovascularization in other areas |
|
|
What type of vision is lost in age-related macular degeneration?
|
Central vision (fovea)
|
|
|
When does AMD usually present?
|
After 75 years old
|
|
|
What is the spectrum of AMD?
|
Dry (atrophic) to wet (exudative)
|
|
|
What happens in atrophic AMD?
|
Atrophy and death of the RPE
Photoreceptor degeneration |
|
|
What happens in exudative AMD?
|
Choroidal neovascularization which leads to subretinal, detached RPE, scars
|
|
|
What is the drusen?
|
Sick RPE
Mounds of abnormal ECM on inner surface of Bruch's membrane |
|
|
What is the neoplasm of the retina called?
|
Retinoblastoma
|
|
|
Where does a neuroblastoma arise from?
|
Sensory retina
|
|
|
Is the retinoblastoma gene genetic?
|
5-10% familial, 80-90% sporadic
40% have germ-line mutation on one allele |
|
|
Is familial retinoblastoma usually unilateral or bilateral?
|
Bilateral
|
|
|
When does retinoblastoma usually present?
|
Less than 3 years old
|
|
|
What do you see in the pathology of retinoblastoma?
|
Destruction of the retina with intraocular spread
Undifferentiated to Differentiated (Rosettes) Extensive necrosis and calcification |
|
|
What is the prognosis in retinoblastoma?
|
Size of primary tumor is not important but what is important is the presence or extent of optic nerve invasion
Extraocular extension into the orbit Mets to bone and brain (some lungs) |
|
|
What is the most common manisfestation of anisocoria with an abnormally small pupil?
|
Horner's syndrome
Physiologic anisocoria Argyll-robertson pupil Pharmacologic |
|
|
What is the problem in Horner's syndrome?
|
Lesion in the sympathetic pathway
First order neuron: hypothalamus, brainstem, spinal cord to T2 Second order neuron: Apex of lung, neck, ICA Third order neuron: Cavernous sinus, orbit |
|
|
What are the 3 main symptoms or Horner's?
|
Ptosis, miosis, anhydrosis
|
|
|
Is Horner's worse in bright or dim light?
|
Dim light
|
|
|
How do you confirm Horner's?
|
Topical cocaine or topical hydroxyamphetamine to localize the lesion
|
|
|
What two tumors must you be aware of if a person presents like Horner's?
|
Children: Neuroblastoma
Adult: Pancoast tumor |
|
|
What trauma should you be wary of if you see Horner's?
|
Carotid dissection
Have neck pain, retinal artery occlusion, transient visual loss |
|
|
What is different about Horner's and physiological anisocoria?
|
Physiological: Both pupil's react and the difference is similar in both bright and dim light
|
|
|
What is Argyll Robertson pupil?
|
Pupil that will constrict when patient focuses on a near object (accommodation) but not when light is entering the eye
|
|
|
What pharmacologic things can mimic Horner's?
|
Flea collars
Pilocarpine |
|
|
What five things can cause anisocoria with abnormally large pupils?
|
Adie's tonic pupil, cranial nerve 3 palsy, physiologic, pharmacologic, iris sphincter trauma
|
|
|
What is Adie's Tonic Pupil?
|
Damage to postganglionic parasympathetic fibers
Vermiform movements of the iris Supersensitivity to pilocarpine |
|
|
What is seen with a cranial nerve III palsy?
|
Eye down and out, ptosis, dilated pupil
If there is an isolated dilated pupil without other signs, then probably not this |
|
|
Who often gets pharmacologic anisocoria with a large pupil?
|
Health care worker with history of exposure to atropine drops or transdermal scoplamine
|
|
|
What can cause an iris sphincter trauma?
|
Ocular surgery or trauma
Diagnose with a slit lamp |
|
|
When a patient comes in with transient visual loss, what should you rule out?
|
Exclude embolic or thromboembolic cause
Exclude carotid or cardiac source Consider hypercoaguable state in young Rule out giant cell arteritis in elderly Look for Hollenhorst plaques (cholesterol embolus in retina) Monocular vision loss Altitudinal field visual loss (curtain over eye) |
