Opthalmology

Front 1

what does 20/40 mean?

Back 1

"Snellen acuity" = distance the pt sees letter/distance the nl person sees letter

Front 2

What if the pt can't see the big E?

Back 2

Then move the pt closer or get them to start counting fingers (CF), Hand movement (HM), light perception (LP)

Front 3

tell me the difference between hyperopia and myopia

Back 3

Hyperopia
• Parallel light in focus behind the fovea (Image falls behind the retina)
• These are people who have great vision now, but in the future will need reading glasses

Myopia (aka. near-sightedness; people that need glasses in order to see)
• Parallel light in focus in front of the fovea (image falls in front of the retina for whatever reason)
• You figure out that as you move image closer to you, the image gets clearer bc the light rays become more divergent. You have enough divergent rays to balance out the focal point.

Front 4

what are the 8 points of the eye exam?

Back 4

- external inspection
- visual acuity
- pupils
- penlight
- pressure (IOP)
- ocular motility
- visual fields
- direct opthalmoscopy (via fundoscope)

Front 5

Man with unilaterally swollen, erythematous right eye, with crusty lesions in V1 dermatomal. Dx?

Back 5

herpes zoster (shingles)

Front 6

• CT showing left eye that’s propped forward. Dx?

Back 6

subperiosteal abscess in left sinus

Front 7

• Lady with trauma to left eye, came to ER the next day with unilateral swollen, erythematous conjunctiva + unilateral exophthalmos. Dx?

- how do you dx?
- how do you tx?

Back 7

carotid cavernous fistula (secondary to trauma)

dx = if you listen to the eye and head, you'll hear a bruit (due to fistula)
tx = angiographic copper coil or glue

Front 8

explain precisely the mechanism of rAPD.

Back 8

light is shone in one eye --> enters the w-ganglion of axons of retina --> goes through optic nerve to the optic chiasm and goes to edinger-westphal nucleus --> from there it travels back through bilateral parasympathetic CN 3 in order to contract BOTH pupils

Front 9

what are the two possible defects for a positive APD?

Back 9

retinal damage or optic nerve lesion

Front 10

name the two eye diseases (that we've talked about) that cause a positive APD

Back 10

Central retinal artery occlusion (CRAO), Anterior Ischemic optic neuropathy (AION)

Front 11

how often should pts have dilated pupil fundoscopy? what are contraindications for dilation?

Back 11

once every 3-5 years after age 40. Every year for the diabetic pt

CI = pts with known, acute narrow angle glaucoma; pts with square pupils

Front 12

what are the conditions that cause painful vision loss? (2)

Back 12

1) acute angle closure glaucoma
2) optic neuritis (think Gail!)

Front 13

pt with HTN, diabetes, 40 pack-year smoking hx arrives at ER with acutely worsened vision in one eye. He didn't want to come in, but after about ten minutes of deciding whether or not to come, he called 911. He's not in pain at all, but wants to know why this is happening to him.
- What is it?
- What is the next step in management?
- How do you treat it?

Back 13

- Central Retinal Artery Occlusion (CRAO, essentially a stroke in the eye, caused by thrombosis, not an embolus)

- if the central retinal artery loses blood supply, the retina can die in 97 minutes!! do a FUNDOSCOPIC exam to check for "cherry red spot" and pale swelling of the retina (due to ischemia)

- Tx: 1) apply pressure on globe (30 min at a time)
2) anterior chamber paracentesis
REMEMBER THAT YOU MUST DO A MEDICAL WORKUP BC OF HIGH CHANCE OF THROWING CLOT TO THE OTHER EYE (ie. echo, elderly pts --> ESR, temporal artery biopsy)

Front 14

what if the patient with suspected CRAO also complained terrible pain in the temple (not the eyes) and pain upon chewing?

Back 14

may have giant temporal arteritis

Front 15

Vitreous hemorrhage is a key finding for which eye condition?

Back 15

diabetic retinopathy (with deposition of exudates, abn neo-vascularization into the vitreous occurs, leading to hemorrhaging)

Front 16

is there an APD in diabetic retinopathy?

Back 16

no

Front 17

how do you monitor diabetic retinopathy?

what is the treatment options?

Back 17

MONITOR = • Fluorosine angiogram (using dye injected into peripheral vein that circulates to the eye, and then take pictures; do this every year to monitor for leakage); Leakage indicates abnormality (compromised endothelial cell)


Treatment
• VEGF inhibitors (Avastin; direct injections into eye)
• Focal Laser therapy – to decrease areas of lipid/exudates
• Peripheral laser photocoagulation – killing off portions of retina so that you don’t get exudate formation and decreases neovascularization.

Front 18

will a pt who comes to the ER with "flashes, floaters and field defect" have a positive APD?

Back 18

no, bc retina takes 1-2 weeks to come off, so acutely, pt won't have detachment (remember that early surgery can rescue from complete retinal detachment via laser, which creates an adhesive scar

Front 19

what is AION?

Back 19

ischemia to the optic nerve itself (2/2 to short posterior ciliary arteries that become ischemic due to emboli). these arteries supply optic nerve head.

Front 20

would you see APD in AION?

Back 20

yes...

Front 21

what are the causes of AION? (2)

Back 21

1) Arteritic (giant cell arteritis →remember also can cause CRAO)
o Dx = biopsy of superficial temporal artery (need to see inflammation and perhaps, “giant cells”)
o Treatment = steroids (to decrease inflammation)

2) Non-arteritic
o HTN, DM, congenitally anomalous optic disc

Front 22

65 y/o woman arrives at ER after attending a Saturday night theatre production. her left eye is acutely painful and swollen. after vomiting once in the tub, she looks at you and you notice her eyes are red as well.

-What is it?
-What's the next step in management?

Back 22

- acute angle closure glaucoma

1. take a history (she should mention "halo around lights", terrible eye pain, vomiting, red eyes due to pressure build up of AH)
2. measure the pressure of her eye (via tonometry)
3. call ophtho consult

Front 23

will pt with glaucoma have apd?

Back 23

no (her pupil is frozen in the mid-cental position)

Front 24

tx of acute angle closure glaucoma?

Back 24

1) acutely, use medical therapy to lower intraocular pressure
2) surgery (iridectomy or cataract replacement) is defintive therapy

Front 25

young female comes to the office complaining of sudden vision loss in one eye. there's pain whenever she tries to move that eye.

when you check for APD, will it be positive?

Back 25

yes, remember that a lesion of the optic nerve is one of two reasons people get positive APDs

Front 26

what is the dx and tx of Optic neuritis?

Back 26

Dx
• MRI brain scan – see white matter lesions to diagnose optic neuritis secondary to MS (due to demyelination and axon death)

Treatment
• Treat the MS (IV steroids, NOT oral steroids bc they precipitate more attacks)
• Neurology consults

Front 27

what kind of steroids do you give a pt with MS? IV or oral?

Back 27

IV steroids!!!!!!!!!!

Front 28

what do you do when a child comes with a possible alkali burn?

Back 28

1) Find out what happened
2) Grade severity of the burn
3) Rule out open globe
4) Irrigate (while you call optho)

Front 29

what rate do you irrigate an alkali burn with?

Back 29

5 liters over 20 minutes

Front 30

pt comes in with "peaked pupil," what do you think it is and how do you manage it? (don't forget what you tell the pt to do or NOT to do...)

Back 30

this is an open (ruptured) globe

Treatment
• Don’t apply pressure to eye!
• Cover the eye (with Styrofoam cup or loose patch) and call optho
• No cleaning, no topical antibiotics, don’t let them eat (they’ve got to be NPO), no bending over or valsalva
• All the patient can do is SIT!!

Front 31

what do you do for a possible corneal abrasion?

Back 31

fluorescent staining and treat with patch (unless there's a foreign body to be removed)

Front 32

2 month old baby comes into the office with chronically medially deviated eyes. he has had labs and blood work done and everything is seemingly normal. his mom asks you what this is and why.

"what do we do?" she asks.

Back 32

accommodation esotropia (either congenital or acquired) where eyes are always hyperoptic (significantly farsighted).

tx= put glasses that lower the eyesight and allow eyes to straighten out

Front 33

Pt wakes up in the morning with a sudden headache + ptosis, comes to ER and you find dilated pupil in one eye. His eyes are down and out. What is it?

Back 33

CN 3 lesion due to aneurysm (most likely)

Front 34

40 y/o guy who goes to ER bc of double vision. Pts head is tilting head to the right side in order to eliminate diplopia. Dx?

Back 34

4th nerve palsy of the left side

o Most common causes in adults = blunt head trauma, intracranial lesions
o In pediatrics = congenital (20%), blunt head trauma (20%)

Front 35

5 reasons for taking pt with strabismus to the OR (extraocular muscle surgery)

Back 35

o If its causing diplopia
o Abnormal head position
o Cosmetic reasons (people want their children to look more normal)
o To restore/maintain binocular visions (binocular visions to enable full 160 degree panorama vision, good stereopsis – seeing things in 3D, motor fusion)
o Ocular asthenopia (in an old person who has a hard time maintaining binocular vision)

Front 36

what is amblyopia? what are 3 causes of unilateral amblyopia?

Back 36

visual impairment without organic pathology

3 causes: early strabismus, anisometropia (one eyes near sighted, the other far sighted; brain will prefer one eye and turn the other eye off), deprivation (rare)

Front 37

how do you treat amblyopia (unilateral)?

Back 37

o Force child to use the “amblyopic eye” by putting a patch over the good eye
o Can only be treated up to around age 7
o But child is strong-willed (won’t wear the patch)
o Easiest way to do this is by dilating the eye (with long-acting drop)
• 1% of atropine (lasts for 1 month)

Front 38

3 causes of asymmetric red reflex

Back 38

strabismus, anisometropia, opacity in ocular media

Front 39

what is another big cause of asymmetirc red reflex?

Back 39

retinoblastoma