Unit 7 - 1 Scheme

Front 1

OLD CARTS

Back 1

Onset, location, duration, character, aggravating factors, relieving factors, timing, severity

Front 2

Vision is blurry for hours or days. Sometimes their glasses help but sometimes they don’t. Sometimes they see better without their glasses. They have an otherwise normal eye exam.

Back 2

Poorly controlled diabetic; shifts in blood sugar cause osmotic shifts in the lens which change the refractive power

Front 3

The patient reports periodic blurry vision. It is often worse when reading, working on the computer, or driving (tasks that decrease blinking frequency). Vision is initially excellent, then gets worse, and is improved with closing or rubbing the eyes.

Back 3

Transient - tear film

Front 4

: Visual symptoms include transient blackouts or whiteouts of vision that may have progressed to complete vision loss in one eye. Systemic associations may include fevers, fatigue, malaise, weight loss, night sweats, shoulder and hip pain (POLYMYALGIA RHEUMATICA), scalp tenderness, and jaw claudication.

Back 4

Transient - optic disc giant cell arteritis

Ischemic optic neuropathy due to inflammation within arteries

Front 5

Back 5

optic disc giant cell arteritis

Chalky, pale disc
Poor vision
Relative or frank afferent pupillary defect (APD)

Front 6

Recent viral injury

Back 6

Meningitis

Front 7

History of hypercoagulability

Back 7

Cerebral venous sinus thrombosis

Front 8

Young female with weight gain

Back 8

Pseudotumor cerebri

Front 9

Transient blackouts when patients head is down. Diplopia (CN6 palsy)

Back 9

Increased intracranial pressure

Front 10

Testing for increased intracranial pressure (papilladema)

Back 10

Fundoscopic exam shows disc edema; complete neurologic exam should be performed

Lumbar puncture (including opening pressure as well as laboratory tests)
MRI/MRV

Front 11

Amaurosis fugax

Back 11

Loss of vision in one eye due to temporary lack of blood flow to retina; may indicate impending stroke similar to TIA

Front 12

Sudden loss of vision in one eye that lasts seconds to minutes. It may be associated with other neurologic symptoms if the patient has had a stroke.

Back 12

Amaurosis fugax

Front 13

Back 13

Migraine aura; can be confused with amaurosis fugax (temp lack of blood flow to retina); colorful lights with slowly emerging blind spot in the same field of vision in both eyes - lasts 30-60 minutes

Front 14

Back 14

Carotid stenosis; can cause transient vision loss by blocking blood flow to retina (amagurosis fugax); work up for additional cardiac and vascular risk factors

Front 15

flashes of light, floaters, and a visual field defect or asymptomatic

Back 15

Retinal detachment

An ultrasound can show the detachment

Front 16

Back 16

Vitreous debris; vitreous hemorrhage; usually painless

history may include DM, sickle cell, fungemia

Front 17

Back 17

Vitreous debris; vitreous hemorrhage; usually painless

history may include DM, sickle cell, fungemia

Front 18

Back 18

Endophthalmitis with viritis

hx may include dm, sickle cell, fungemia

Front 19

Cherry red spot

Back 19

Central retinal artery occlusion; CRAO has an afferent pupillary defect (APD)

Front 20

Hx of vascular risk factors, htn, glaucoma

Back 20

Central retinal vein occlusion; CRVO will have APD if defect is severe; blood backs up

Front 21

Vascular risk factors; VISION LOSS AFTER WAKING UP IN MORNING

Back 21

Nonarteritic ischemic optic neuropathy; damage to optic nerve from insufficient blood supply

vision loss in morning bc of blood pressure fall during sleep (nocturnal arterial hypotension)

APD present on exam; initially optic disk appears hyperemic

Front 22

Hx of vascular risk factors

Back 22

Stroke; visual field defect corresponding with the location of the stroke and a normal dilated eye exam

Front 23

Ketchup/mustard

Back 23

K/M fundus + vision loss + AIDS = CMV

Front 24

salt and pepper fundus

Back 24

Congenital rubella and syphilis "Salt and pepper" fundus; can also have cataracts and glaucoma

Front 25

Sudden onset, deep eye pain often with nausea and vomiting. Initially halos around lights and blurred vision but may progress to vision loss.

Affected eye feels firm and APD present

Back 25

Glaucoma

Red eye without discharge, fixed and mid dilated pupil, hazy cornea and an APD; eye feels firm in touch in comparison to other eye

Front 26

Back 26

Normal

Front 27

Pain with eye movement; often NORMAL dilated eye exam intiially

Back 27

Optic neuritis; check MRI for additional plaques indicating MS

Front 28

Pt is stressed out and can't see

Back 28

Malingering/conversion syndrome; can use exam techniques to stimulate a visual response in pts who claim they can't see. Can also evoke visual potential in brain response to visual stimuli

Front 29

Back 29

Keratoconus scarring

Front 30

Back 30

Mucopolysaccharidosis

Front 31

Back 31

corneal ulcer; can be acute or chronic pending cause; can lead to scarring

Front 32

Back 32

Leukocoria; retinoblastoma; calcifications can be seen on ultrasound and CT scan; mri used to detect extraocular spread of tumor

Front 33

Poor night vision

Bony spicules in the peripheral retina, attenuation of the vessels, waxy pallor of th disc and sparing of the macula until very late in the disease

Back 33

Retinitis pigmentosa;

Front 34

Gradual or sudden decreasing vision

Back 34

Diabetic retinopathy; do dilated eye exam

Front 35

Back 35

Macular degeneration

Front 36

Diplopia, protosis, decreased vision. Could be slow or acute onset

Back 36

Enlarged extraocular muscles; leads to compression of the optic nerve at the orbital apex; seen in thyroid disease

Front 37

Back 37

Lid retraction seen in thyroid dz; often asymmetric

Front 38

Back 38

Optic nerve glioma (tumor); lead to vision loss through compression or direct invasion; can also cause proptosis and diplopia

Front 39

Monocular vs Binocular

Back 39

Monocular: Pt has double vision with one eye open
Binocular: Double vision is only present when both eyes are open

Front 40

Keratoconus

Back 40

Corneal dystrophy associated w progressive deformation of the cornea

Front 41

Marfan's

Back 41

Dislocated lens

Front 42

Ehler's Danlos

Back 42

Dislocated lens

Front 43

Astigmatism

Back 43

Irregularly shaped cornea or lens; causes light to bend abnormally

Front 44

Pt reports diplopia or blurring of images while reading or working on the computer that resolves with blinking

Back 44

Monocular Diplopia: Tear film

Front 45

Pinhole device

Back 45

Only lets a small, central amount of light through to the retina; can resolve symptoms in monocular diplopia

Front 46

Binocular Diplopia

Back 46

"If I close either eye, I see single again." This can be LIFE THREATENING so do not ignore a pts complaint of new onset, binocular double vision

Front 47

Cranial nerve pneumonic to extraoculars

Back 47

SO4LR6 - all others are three

Lateral Rectus - 6
Superior oblique - 4

Everything else is 3, including elevating the eyelid and pupillary constriction

Front 48

what muscles are controlled by CN3

Back 48

superior, inferior and medial rectus

Front 49

Acute onset of double vision and ptosis

Back 49

Aneurysm of the post. communicating artery

Front 50

Subacute onset of double vision and ptosis

Back 50

CN3 compression from tumor

Front 51

Congenital CN4 palsy

Back 51

most dont have diplopia bc contralateral head tilt to accomodate

Front 52

Function of the superior oblique

Back 52

Controlled by trochlear nerve; intorts and depresses the eye

Front 53

Basilar skull fracture

Back 53

CN6 palsies; the nerve takes a sharp 90 degree turn intracranially which places it at risk for injury due to stretch with increased intracranial pressure.

Front 54

Explanations for extraocular movement deficits which do not fit on specific cranial nerve pattern

Back 54

MG, orbital pathology, cavernous sinus pathology, CNS pathology

Front 55

With variability and fatiguability

Back 55

Myasthenia gravis; ptosis mcc but can also affect extraocular movements causing diplopia

Front 56

Dx of MG?

Back 56

Tensilon test; acetylcholinesterase inhibitor increases Ach in NMJ to overcome AchR ab temporarily

AchR test (but negative in 50% of pts with ocular MG)

Front 57

Back 57

muscle trapped in orbital fracture; can limit vertical gaze and is a surgical emergency

since many nerves enter from the posterior orbit and travel to corresponding muscles any inflammatory or infectious process within the orbit can cause EOM disturbance

Front 58

Back 58

Thyroid eye disease

Hint 58

Muscles become enlarge and fibrotic which causes restriction of that muscle. The most commonly involved muscles are the inferior rectus and medial rectus although all may become involved.

Front 59

Back 59

Orbital tumor:

May infiltrate one or more extraocular muscles or cause movement disruption by mass effect. Shown to the left is an adenocystic carcinoma of the lacrimal gland which can cause downward and medial displacement of the globe leading to diplopia.

Front 60

Back 60

Binocular diplopia


As seen in the anatomy of the cavernous sinus at the right, several cranial nerves that innervate the extraocular muscles are in close proximity. Therefore any lesion in this area can lead to involvement of multiple nerves.

Given that V1 branch of CN 5 also travels in the area, patients may have sensory deficits or pain in that dermatome.

Examples include:
Vascular lesions – fistulas
Infectious/Inflammatory – often spread from the sinuses
Tumors – from sinuses, pituitary, meningiomas, metastases

Front 61

Back 61

Internuclear opthalmoplegia

Lesion om MLF that connects CN3 and 6 nuclei to coordinate medial and lateral rectus for horizontal gaze

Can be caused by small microvascular event or demyelinating dz such as MS in younger pts