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Clinical Medicine - Opthamology


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What are the 7 important things to ask while taking a patient's history?
1. Duration—how long has the patient had the problem?
2. Reason—why are they there to see you and how did the problem happen if there was an event that caused it
3. Frequency
4. Location
5. Onset
6. Pain
7. Signs and symptoms
What is the first thing you check in a eye exam?
The first thing to check is visual acuity (use the Snellen chart)
what are the symptoms in a chemical burn eye injury?
-Pain, photophobia (light sensitivity),decreased vision, colored halos around lights
-Mild to moderate- eye is hyperemic, conjunctival swelling, lid edema
what are the more frequent and severe types of chemical burns?
alkaline burns, it is considered a medical emergency.
what are the sxs of a ruptured globe?
pain, decreased vision, history of trauma
what are the five critical signs of a ruptured globe?
a. Ruptured Globe: severe subconjunctival hemorrhage often 360 degrees of bulbar conjunctiva
b. deep or shallow anterior chamber compared with other eye
c. hyphema- often with clotted blood
d. limitation of EOM- greatest in direction of rupture
e. intraocular contents may be outside globe
what is the tx for a ruptured globe?
Once diagnosed with penlight or slit lamp avoid any additional testing until surgery to avoid pressure on the globe which would risk extrusion of the intraocular contents
what are the precautions that should be taken for a ruptured globe once dx?
⬢ Eye shield to protect
⬢ No food or drink(NPO)
⬢ Systemic antibiotics- ex. Cipro 200mg to 400 mg p.o./I.v.,bid
⬢ Tetanus toxoid prn
⬢ Antiemetic to prevent valsalva
⬢ Bed rest with bathroom privileges
⬢ Determine when last meal =determines when surgery will be performed
⬢ CT scan and B scan- SURGICAL REPAIR ASAP
what are the symptoms of hyphema?
pain, blurred vision, history of blunt trauma, photophobia, lacrimation
what are the critical signs of hyphema?
blood in the anterior chamber, layering/clot or both, classically described by amt of AC they occupy, total may be black or red (Black is an 8 ball)
what does the hyphema workup consist of?
⬢ History-mechanism force and direction
⬢ Exact time of injury
⬢ Time of visual loss
⬢ Complete ocular exam-rule out rupture or penetrating injury
⬢ External and periocular exam
⬢ Quantitate and draw extent and location
⬢ IOP, dilation, B scan, CT
what is the tx of hyphema?
⬢ ALL patients confined to bedrest
⬢ Elevate head 30 degrees
⬢ No strenuous activity
⬢ Eye shield (NO PATCH)
⬢ Atropine 1% drops tid
⬢ Mild analgesics only- acetaminophen
⬢ Avoid sedatives
⬢ Mild steroid drops are used to prevent iritis
⬢ Thorough history is critical: the event, medications and previous ocular history
⬢ Systemic blood disorders such as sickle cell, hemophilia, etc.
⬢ Systemic testing for sickle cell and bleeding disorders
⬢ Controversy regarding hospitalization
what is keratitis and how is it caused?
An inflammation of the cornea. there are many etiologies: Contact lens wear, dry eye, fungal, herpetic,viral and on and on..
what are the symptoms of keratitis?
Patients will complain of irritated eyes, sometimes red, with foreign body sensation
how is keratitis dx?
Diagnosed using fluorescein (causes any area of damage to appear green when viewed under special light)
T/F: Keratitis can cause hyphema.
what is subconjunctival hemorrhage?
Marked by well defined area of blood between the bulbar conj. and sclera
what is the most common quote in pts with subconjunctival hemorrhage?
“My eye is bleeding”—if you take a tissue and touch the external eye, there is no blood.
what is subconjuctival hemorrhage caused by?
trauma, sneezing, heavy lifting, vomiting, coughing, valsalva- straining while constipated
what is the treatment for subconjunctival hemorrhage?
⬢ Cold compresses, hot compresses, artificial tears, and bed rest
⬢ Usually resolves in 2 weeks
what are the tests to perform in a subconjunctival hemorrhage that is recurrent?
⬢ PT
⬢ aPTT
⬢ Fasting blood sugar
⬢ Blood pressure
⬢ Lipid profile
⬢ Carotid Doppler
⬢ Sickle dex and HIV testing
what is preceptal cellulitis?
warm, erythematous, tender swelling of the lids
what are the symptoms for preceptal cellulitis?
a.low grade fever and elevated white cell count
b.normal vision, pupils and eoms
c.upper respiratory infection or sinusitis
d.lid trauma
f.conjunctivitis, dacryocystitis
what are the symptoms of orbital cellulitis?
same symptoms as preseptal, but orbital involvement leads to diplopia and vision loss
what are the symptoms of bacterial conjunctivitis?
-Unilateral or bilateral
-Burning and irritation
-Heavy mucopurulent discharge
-Lids possibly adherent
what are the symptoms of viral conjunctivitis?
-Bilateral, possibly asymmetric
-Itch, burning, soreness
-Watery discharge
-Preauricular lymphadenopathy
what is conjunctivitis usually caused by?
usually come from an Upper Respiratory Infection
what is the tx for conjunctivitis?
treat with an antibiotic (not really helpful for viral, but may be used)
what are some classic examples of causes of orbital trauma?
hit in the eye with a baseball, fell down, car accident, punched in the eye- look for abuse
what are the symptoms/presenting factors of orbital trauma?
patients can have orbital blow out fracture, retinal detachments, vitreous detachments
-Person will usually see double and cannot look up
-dacrorhinitis (DCR)—inflammation of the lacrimal sac
what are the major findings of open angle glaucoma?
-No symptoms usually
-Elevated IOP
-Optic nerve cupping
-Treated with drops to lower IOP
-Laser treatment options
what are the major finding of acute angle glaucoma?
-Unilateral blurred vision
-Halos around lights
-Intense pain and photophobia
-Vasovagal symptoms
-Mid-dilated pupil
-Conjunctival redness,lid edema
-Corneal edema
-Markedly increased IOP
-Narrow anterior chamber angles
-Ophthalmic emergency
the cup to disk ratio is 10-20% of the disk in a normal patient. what is the disk ratio in a glaucoma patient?
a ratio of 40-60% is often seen with glaucoma
what are the causes of acute painless vision loss?
⬢ Vitreous hemorrhage
⬢ Retinal detachment
⬢ Ret. Artery occlusion
⬢ Vein occlusion
⬢ Wet macular degen.
⬢ Ischemic optic neuropathy
⬢ Optic neuritis
⬢ Cerebral infarct
⬢ Functional loss due to stress
what are the causes of acute painful vision loss?
⬢ Corneal ulcer
⬢ Uveitis
⬢ Angle closure glaucoma
⬢ endophthalmitis
Bilateral field loss that respects the vertical meridian is almost always associated with?
lesions including or posterior to the optic chiasm
Monocular field loss results from direct involvement of the what?
eye or optic nerve anterior to the chiasm
chronic progressive vision loss can be caused by?
⬢ Refractive error
⬢ Cataract
⬢ Open angle glaucoma
⬢ Dry macular degeneration
⬢ Brain tumor
what is central retinal artery occlusion?
-retina becomes white
-may be a clue to future heart problems
-occurs because of plaque in the vessel, need to refer pt for blood work
-can also have a Branched Retinal Artery Occlusion
what is the macula?
the central most area of the retina that produces the clearest vision
macular degeneration is often related to what?
the degeneration is often age related
what are the risk factors for macular degeneration?
heredity, smoking, drinking, drugs
what are the two forms of macular degeneration?
-2 forms: wet and dry
a. wet causes more acute problems
b. dry causes more chronic problems
what is an ethmoid sinus osteoma?
a rare tumor in the ethmoid sinus that can press on ocular nerves
what are the sxs of ethmoid sinus osteoma?
produces focusing problems, extraocular muscle problems, and unevenly dilated pupils
what is Emmetropia?
normal vision
what is myopia?
what is hyperopia?
what is presbyopia?
natural loss of accomodative capacity with age
what is astigmatism?
distorted image due to two different curvatures of the cornea. the refractive errors in the horizontal and vertical gaze differ.
how are cataracts defined?
any opacity in the crystalline lens
what is senile cataract?
age-related cataract
what are the four types of cataract?
Posterior subcapsular
Dense white
where does nuclear cataract occur?
occurs in the nucleus of the lens; usually in age >50; graded according to the patient vision (e.g. “20/30 cataract”)
where does cortical cataract occur?
occurs in the cortex of the lens
where does posterior subcapsular cataract occur?
in posterior capsular space of the lens, more debilitating than any other type; occurs earlier than others; produced in DM and steroid-users often
what are the symptoms of cataracts?
o Visual loss or blur – slowly progressive
o Night glare
o Monocular diplopia – i.e. double vision in one eye
o Fixed spots in the visual field
o Reduced color perception
o Changes in near vision:
 Nuclear cataract: improvement of near vision; AKA “second sight”
 Posterior subcapsular cataract: decreased near vision
o Opacification of the lens
what is done on an eye exam to dx cataracts?
o Best seen after dilation of the pupil
o Look through direct ophthalmoscope held about 6 inches from patients eye or by using a slit lamp biomicroscope
how are cataracts txed?
o Early nuclear cataract: change glasses prescription
o Small central opacities: pupillary dilation may improve vision, but usually cannot be used as a long-term treatment option
o Cataract surgery: replacement of lens with implant
what is the prognosis of cataracts surgery?
Excellent prognosis: 95% obtain improved vision
what are the risks associated with cataract surgery?
o Include infection and bleeding which can lead to blindness
o Infection risk: 0.02%
o Retrobulbar hemorrhage (very dangerous): 0.1%
o Intraocular hemorrhage: 0.6%
what is an after-cataract surgery complication?
Secondary membrane and retinal detachment
what is a secondary membrane?
o Posterior capsule opacifies, producing visual distortion
how is a secondary membrane txed?
YAG laser capsulotomy
what are the symptoms of Thyroid eye disease in mild cases?
-Irritation and burning
-Foreign body sensation
what are the symptoms of Thyroid eye disease in moderate cases?
-Double vision – due to eyes being shoved forward or impaired muscle function
-Aching discomfort
-Blurred vision
what are the symptoms of Thyroid eye disease in severe cases?
Visual loss and pain from severe corneal ulceration (due to corneal drying from inability to close eyes, especially at night)
what are the signs of Thyroid eye disease?
o Gradual onset
o Lid retraction with superior and inferior scleral show (Barbara Bush has this)
o Lagophthalmos – inability to close eyes (may lead to ulceration; also seen in Bell Palsy)
o Restricted ocular motility
o Exophthalmos – eyes bulging forward (AKA proptosis)
o Loss of visual acuity, visual field, and color vision
What is the etiology of Thyroid eye disease?
o Thyroid abnormality: hypo-, hyper-, or eu- thyroid
o Autoimmune thyroiditis (Hashimoto’s disease – a transient thyroid problem)
o Ophthalmic disease may precede or follow glandular disease by many years
o Most commonly, it develops shortly after treatment for hyperthyroidism
o The visual loss can be caused by enlarged extraocular muscles compressing the apical portion of optic nerve (compressive optic neuropathy) – diagram was given
what is the diff dx of thyroid eye disease?
o Conjunctivitis
o Orbital pseudotumor
o Myasthenia gravis – a disease exhibiting great fatigue
o Orbital tumor
what is the workup of thyroid eye disease?
o Complete battery of thyroid tests
o Careful monitoring of thyroid status if normal findings
o CT scan or MRI
o Thorough eye exam and computerized visual field testing
what is the tx for thyroid eye disease?
o Mild cases: artificial tears should suffice for eye symptoms; treat thyroid disease
o Moderate to severe cases: elevate head of bed and reduce ocular congestion
o Oral prednisone – more severe cases
o Orbital radiation – more severe cases
o Orbital decompression – more sever cases
what is the follow up for thyroid eye disease?
o Ophthalmic exam every 3-6 months during active phase and then yearly
o Visual field testing as needed to exclude possibility of compressive optic neuropathy
what is the function of the retina?
translates light energy into impulses that are perceived as vision
what do you never grade an optic nerve by?
what are some common diseases of the retina?
o Diabetic retinopathy
o Hypertensive retinopathy
o Retinal artery occlusion
o Retinal vein occlusion
o Age-related macular degeneration (ARMD)
o Cytomegalovirus retinitis
o Posterior vitreous detachment
o Retinal detachment
what is the leading cause of blindness in the western world in people under the age of 50?
what are the 3 basic forms of diabetic retinopathy that may result in loss of vision?
-Proliferative diabetic retinopathy (pre-proliferative disease is more easily controlled)
-Diabetic macular edema
-Ischemia of the macula
what is Proliferative diabetic retinopathy?
⬢ Results from ischemia
⬢ Angiogenic factors released cause neovascularization
⬢ Can occur at the optic nerve (high risk condition) or at any location in the retina or at the iris causing neovascular glaucoma
what are the symptoms of Proliferative diabetic retinopathy?
• May be 20/20 – therefore, patient must be screened
• Vision decrease is slow or sudden
• Floaters - possible vitreous hemorrhage, described as “shower”
• Blind spots in the vision
what are the sns of proliferative diabetic retinopathy?
• Neovascularization seen on the optic nerve, retina or iris surface
• Pre-retinal “boat-shaped” hemorrhages
• Cotton wool spots
• Venous beading, dilation or engorgement
• Dot and blot hemorrhages
• Vitreous hemorrhage – loss of red reflex
• Areas of tractional retinal detachment possible
• Whitish fibrovascular tissue on retinal surface along vascular arcades and above optic nerve
what is the differential dx of proliferative diabetic retinopathy?
• Diabetes
• Vascular occlusion
• Radiation retinopathy – may look identical to diabetic retinopathy
• Blood dyscrasia
• Anemias
• Retinal emboli
• Carotid disease, aortic arch syndrome, carotid cavernous fistula
• Uveitis – sarcoidosis
what is the workup for proliferative diabetic retinopathy?
• Lab tests include
o Fasting blood glucose level
o Oral glucose tolerance test
o Hemoglobin A1C (Hb A1C) – an article on this was given
 Important in diabetic evaluation
 Diabetic eye disease – closely associated with Hb A1C
 Indicates blood glucose level control over the previous 4-6 weeks – a better test than the glucose level test, which may be normal when tested and vary greatly and frequently
o CBC with differential count
o Hemoglobin electrophoresis
o Serum protein electrophoresis
o Angiotensin converting enzyme (ACE) titer
• Clinically, carotid ultrasound or chest x-ray as indicated
what is the tx of proliferative diabetic retinopathy?
• The diabetic control and complications trial has shown that tight glycemic control decreases the progression of diabetic retinopathy, nephropathy, and neuropathy
• The clinician’s (our) role is essential
• Prompt referral indicated
• Retinal Laser photocoagulation – localized destruction of the retina to prevent spread of pathology
what is Diabetic Macular Edema?
⬢ Earliest detectable clinical change in vasculature is the formation of microaneurisms
⬢ Fluid leaks into retinal tissue and may accumulate in foveal area which leads to decreased visual acuity
what are the sxs of diabetic macular edema?
⬢ May have none, but still require laser treatment
⬢ Possible decreased vision: may be unilateral or bilateral
what are the sns of diabetic macular edema?
• Graying or slight opacification of retina from edema in macula
• Microaneurisms adjacent to retinal veins (may be at any location)
• Dot and blot hemes (i.e. “hemorrhages”)
• Cystoid changes in fovea
• Hard exudates (may form circinate ring)
what is the differential dx for diabetic macular edema?
• Diabetes
• Vascular occlusions – CRVO or BRVO (central retinal vein occlusion and branch retinal vein occlusion)
• Hypertensive retinopathy
• Radiation retinopathy
• Choroidal neovascularization (usually associated with ARMD)
• Macroaneurisms associated with hypertensive retinopathy
what is the tx for diabetic macular edema?
⬢ Tight glycemic control
⬢ Specialist referral
⬢ Laser photocoagulation to decrease further decline in visual acuity by reducing amount of macular edema (ETDRS)
what is hypertensive retinopathy?
 Hallmark – diffuse arteriolar narrowing
 Chronic hypertension results in thickening of vascular wall with a concomitant narrowing of vessel lumen
 Normal A/V ratio is 2:3 – may change to 1:3 or 1:4 in this case
 Copper wire vessel (a dated term) - yellowing of the linear light reflex seen on the surface of a narrowed arteriolar vessel
what are the sxs of hypertensive retinopathy?
-Vision may be normal, slightly blurred, or suddenly decreased
-Blind spot in the vision may be reported
-Double vision may occur
what are the sns of hypertensive retinopathy?
-Diffuse arteriolar narrowing -chronic hypertension
-Focal spasm - acute hypertension
-A:V crossing changes
-Sclerotic vessels
-Cotton wool spots
-Lipid exudates with macular star
-Retinal edema
-Macroaneurysm may cause acute loss of vision
-Bilateral disc edema and swelling indicates accelerated hypertension or renal failure
-Exudative retinal detachments indicate preeclampsia in pregnant patients
what is the tx of hypertensive retinopathy?
 Treat the underlying hypertension
 Treat the systemic vascular disease or renal disorders
 Chronic hypertensive retinopathy does not require specific ophthalmic treatment
 Acute hypertensive retinopathy with papilledema-prompt control of systemic blood pressure, usually requires inpatient management with imaging studies to rule out intracranial lesion
 Decreased vision, retinal macroaneurysm, BRAO,or BRVO, an exudative maculopathy-
 MUST refer for possible laser
 Preeclampsia or eclampsia, infant is delivered and exudative detachments usually resolve postpartum
 Permanent visual loss from pregnancy-associated complications is rare and may result from retinal or occipital lobe ischemia
what is retinal artery occlusion?
-May involve central retinal artery (CRAO) or a branch of the central retinal artery (BRAO)
-Unilateral involvement may only be noticeable after the patient closes the uninvolved eye – they may not realize the deficit
-Cilioretinal arteries supply a portion of the macula in up to 20% of persons – may save central vision if a problem occurs
-Retinal whitening may fade with time
-CRAO may cause ischemia to the macula
-A soft glistening yellow embolus conforming to the blood vessel lumen or forming a Y-shaped obstruction at a branch point is usually a cholesterol embolus (Hollenhorst plaque) that arises from the carotid arteries
-A hard, whitish plaque may represent a calcific embolus from an abnormal heart valve
what are the sxs of retinal artery occlusion?
-A sudden, painless unilateral loss in vision and -A sudden, painless visual field loss corresponds to a horizontal hemifield in cases of BRAO, ex. A superior BRAO causes an inferior field defect
-Amaurosis fugax (transient loss of vision) – implies an impending CRAO or BRAO with a classic description of a curtain descending over vision that clears over several minutes
what are the sns of retinal artery occlusion?
-A relative afferent pupillary defect is present (also know the term consensual response)
-If seen within first few hours of onset may not yet see retinal edema
-Embolus may be seen at level of optic nerve in CRAO
-Embolus may be seen at a branch point of an arteriole in BRAO
-Cherry red spot – a classic sign
-Arcuate retinal whitening corresponds to retinal distribution of occluded vessel
-Segmentation or boxcarring of retinal vessels
-Cilioretinal sparing may be present, if fortunate
what is the etiology of retinal artery occlusion?
-Carotid atherosclerotic disease
-Cardiac valvular disease
-Giant cell arteritis (GCA) – jaw claudication, scalp tenderness, tongue pain, or polymyalgia rheumatica and its associated symptoms
-Thrombosis from hypercoagulative states
-Lipid emboli resulting from trauma
-Sickle cell anemia
-Polyarteritis nodosa
-Corticosteroid injections around the head and neck
what is the workup for retinal artery occlusion?
-Evaluate- age of patient, any known systemic conditions
-Auscultate carotid arteries and heart listening for bruits or murmurs
-If patient is over 55, inquire about giant cell arteritis symptoms
-Neurologic history and exam
-Carotid ultrasound or angiography
-Cardiac echography
-Lab eval. Modified for each patient
what is the tx for retinal artery occlusion?
-Emergency eye physician consult indicated to confirm or rule out retinal artery obstruction
-Poor visual prognosis- efforts directed toward dislodging an embolus and moving it downstream to minimize the amount of retinal involvement
what are the meds used to tx retinal artery occlusion?
• Carbogen treatment may dilate the retinal vasculature
• IV or oral diamox (500mg) is administered (use alternative if sulfa allergy) – a diuretic
• Topical beta blocker (timolol 0.5%)
• Sublingual nitroglycerin
what is the most effective way of dislodging an embolus from a retinal artery occlusion?
Anterior chamber paracentesis by the eye doctor
central retinal vein occlusion involves how many quadrants of the retina
all four quadrants
Branch retinal vein occlusion (BRVO) involves how many quadrants of the retina?
one quadrant with an arcuate pattern-corresponds to area of drainage of vein
what are retinal vein occlusions?
-Relatively common in older population
-Noticed when cover one eye
-Usually at site of A/V (arteriole/venule) crossing – a pressure occlusion
-Associated with systemic hypertension
what are the sxs of retinal vein occlusion?
-Sudden or gradual
-Painless blurry vision or loss of vision
-Severe unilateral pain, redness and vision loss may represent neovascular glaucoma-occurs 3 months after RVO
-Unilateral visual field loss corresponds to a horizontal hemifield in BRVO
what are the sns of retinal vein occlusion?
-Relative afferent pupillary defect most commonly in cases of ischemic CRVO
-Blood and thunder fundus (compare to RAO, where there is whitening seen instead)
-Dilated and tortuous veins
-Flame-shaped hemorrhage
-Vitreous hemorrhage may occur
-Cotton wool spots
-Macular edema
-Exudates common
-Neovascularization of retina and iris
what is the workup for retinal vein occlusion?
-Evaluate for systemic hypertension
-Lab evaluation
-Test for thyroid eye disease and tumors- can cause compression of central retinal vein as it exits the eye
what is the tx for retinal vein occlusion?
-Mandatory ophthalmic exam within 48-72 hours of diagnosis
-BRVO with macular edema may result in decreased vision-laser photocoagulation
-Follow up- CRVO assessed every month for 6 months by the eye doc
what is Age Related Macular Degeneration (ARMD)?
-The most common cause of legal blindness in the western world
-Commonly affects individuals over age 65
-Cause is unknown
-Risk factors include older age, female gender, lighter pigmentation, and smoking
-May have a genetic component
-Degeneration of supporting structures of outer retina and photoreceptors responsible for deterioration of vision
what are the sns/sxs of ARMD?
-THE MOST COMMON abnormality seen is DRUSEN
-Drusen-yellowish deposits deep to the retina, may be small yellowish crystals or larger soft-yellow deposits
-Drusen may be localized to fovea or peripheral along arcades
-Deposits usually multicentric, giving the appearance of a bumpy fundus
-Drusen limit the nutritional and metabolic support to outer retina
what are the two types of ARMD?
what is atrophic ARMD?
•AKA “dry” form
•more common
•Pallor (whitening) of macular area is seen
what is exudative ARMD?
•AKA “wet” form
•occurs as neovascularization which originates from choroidal vasculature, leaking fluid and lipid, which may bleed
•End-stage: large subretinal scar (disciform scar)
what are the sxs of ARMD?
-Onset of blurry vision-gradual or acute
-Wavy or distorted vision-metamorphsia
-Intermittent shimmering lights-photopsia
-Central blind spot
what are the sns of ARMD?
-Decreased visual acuity
-Amsler grid distortion
-Multiple, large, soft drusen with pigment mottling  worse prognosis
-Loss of normal pigmentation, with yellow-white geographic atrophy
-Subretinal or intraretinal blood or serous fluid
-Serous retinal detachment
what's the workup for ARMD?
o Amsler grid
o Fluorescein or indocyanine green angiography
o Family members evaluated
what's the tx for ARMD?
o Acute vision changes-refer within 24 hours
o Laser photocoagulation
o Subretinal surgery (experimental at this time)
o Low vision aids - magnification
o “Preservision” vitamins have been shown to improve patients with moderate to severe AMD (including vitamins A, C, E, and zinc)
o One company makes a vitamin with leutien (not FDA-tested)
o “Visudyne” – a new procedure for wet ARMD
what is Posterior Vitreous Detachment?
-Vitreous is only attached to the retina in two places – these can break with age
-Occurs in most individuals with time – fifth to seventh decade of life
-Occurs more often in highly myopic individuals – earlier age
-Retinal tears or breaks may occur
what is the sx of posterior vitreous detachment?
-Flashing lights and/or floaters
what is the tx for posterior vitreous detachment?
-Indirect ophthalmoscopy must be performed within 24 hours
-No treatment indicated
-Laser or cryotherapy if any new retinal tears or breaks
what is retinal detachment?
-Occurs when fluid separates the retina from the underlying pigment epithelium
-Several types (not discussed in this lecture)
what are the sxs of retinal detachment?
-Flashes and floaters
-Visual field loss described as a curtain, shadow or bubble of fluid
-Decreased vision
what are the sns of retinal detachment?
-Relative afferent pupillary defect
-Visual field loss unilateral, unless traumatic
-May be sectoral, quadrantic, hemifield, or total
-Retinal hydration lines, or rugae, have an appearance like ripples on a pond
what is the workup for retinal detachment?
-Difficult to diagnose with direct ophthalmoscopy
-Simple technique with a direct opththalmoscope to compare the reflexes of the two eyes
-An eye with a retinal detachment may have a lighter colored reflex (yellow or orange)
what is the tx for retinal detachment?
-Refer for immediate evaluation
-Surgical intervention necessary – retinal detachment may lead to blindness if not treated
what were the discussed diseases of the optic nerve?
⬢Nonarteric ischemic optic neuropathy
⬢Arteritic ischemic optic neuropathy (AION)
⬢Optic neuritis
the aqueous humour is produced by what?
produced by epithelium of ciliary body
what is the pathway of the aqueous humour in the eye?
•Flows past the lens, around the iris, into Schlemm’s canal via the trabecular meshwork, and then into aqueous and episcleral veins
what is glaucoma?
-Damage from glaucoma is manifested by optic nerve cupping which results in characteristic patterns of visual field loss
-Classically respects the horizontal meridian
-Visual acuity and central field remain normal until late in the disease process – may take some time before patient realizes this loss
general stuff about open angle glaucoma...
-Most cases are this type
-No symptoms, usually
-Elevated IOP is seen
-Optic nerve cupping
-Treated with drops to lower IOP
-Laser treatment options
general stuff about angle closure glaucoma...
-Unilateral blurred vision
-Halos around lights
-Intense pain and photophobia
-Vasovagal symptoms: nausea, vomiting, abdominal pain
-Mid-dilated pupil
-Conjunctival redness, lid edema
-Corneal edema
-Markedly increased IOP
-Narrow anterior chamber angles
-Ophthalmic emergency!!!
what is scotoma?
area of partial or complete visual loss
what is hemianopia?
impairs half of the visual field
what is homonymous hemianopia?
implies post chiasmal
what is quadrantopia?
smaller defects which may be superior or inferior (superior = temporal lobe, inferior = parietal lobe)
what is bitemporal hemianopia?
at the chiasm such as pituitary tumor
what is altitudinal hemianopia?
occurs with vascular damage to retina
what are scintillating scotomas?
flashes of light
what are the sxs of Non-Arteritic Anterior Ischemic Optic Neuropathy?
a sudden, painless loss of vision frequently noted on arising in the morning
what are the sns of Non-Arteritic Anterior Ischemic Optic Neuropathy?
-unilateral swollen optic disc, often segmented with flamed- shaped hemorrhages results in optic disc pallor as edema resolves over 4-6 weeks
-Altitudinal field defect common
-Relative afferent defect if fellow eye is normal
-Results from atherosclerotic or thrombotic occlusion of arteries supplying optic disc
-Associated with hypertension, diabetes, coronary artery disease and other vascular conditions
what is the diff dx for non-arteritic anterior ischemic optic neuropathy?
-Arteritic anterior ischemic optic neuropathy
-Optic neuritis
-Infiltrative optic neuropathy
-Asymmetric papilledema
-Compressive optic neuropathy
what's the workup for non-arteritic anterior ischemic optic neuropathy?
-Westergren erythrocyte sedimentation rate (ESR)
-Evaluation for hypertension, diabetes, and anemia
what is the tx for non-arteritic anterior ischemic optic neuropathy?
-None has proven effective: IV steroids and oral steroids are uncertain
-Daily aspirin may reduce incidence in fellow eye
-Follow up with visual fields at 2 weeks and 2 months
-Mild improvement in central vision may occur in 50% of patients
-Simultaneous or rapidly sequential ant. Ischemic optic neuropathy suggest arteritis
what are the sxs of giant cell arteritis? (aka temporal arteritis)
-Sudden vision loss in one or both eyes
-Vision loss frequently extreme
-Headache, scalp and temple tenderness
-Myalgia, arthralgia
-Low grade fever
-Weight loss, anorexia
-Jaw claudication (a very important correlation!)
what are the sns of giant cell arteritis?
-Frequency of disorder increases with each decade
-Rare younger than 50, occasional from 50-59, more often over 60
-Pale optic disc swelling or only minimal disc changes out of proportion to vision loss
-Temporal arteries often firm, tender or pulseless
-Sed rate is usually greater than 50, but can be normal
-Mild anemia is common
-Third, fourth or sixth cranial nerve palsy may occur
-Vision loss from central retinal artery occlusion can occur
-Relative afferent pupillary defect in unilateral cases
-Vision loss is caused by vasculitic occlusion of arteries to the optic disc
what is the diff dx for giant cell arteritis?
-Nonarteritic anterior ischemic optic neuropathy
-Compressive optic neuropathy (minimal disc signs)
what is the workup for giant cell arteritis?
-ESR immediately (sed rate)
-Temporal artery biopsy within days of corticosteroid
-Neuroimaging if uncertain
-Chest x-ray, elecrolyte levels, blood glucose
what is the tx for giant cell arteritis?
-Immediate corticosteroid; IV methylprednisolone 250 mg every 6 hours for 3 days with acute vision loss followed by oral, daily doses
-Prednisone 80-100 mg orally if GCA suspected but no vision loss has occurred
-Follow-up with a second biopsy of contralateral temporal artery if first biopsy negative but strong clinical suspicion
-Long term corticosteroids with slow taper requires careful monitoring for side effects
what are the sxs of optic neuritis?
-a unilateral vision loss over several days
-Pain with movement of eyes
-Transient neurologic disturbances
-Spontaneous recovery over weeks
what are the sns of optic neuritis?
-2/3 of patients have initially normal appearing discs, 1/3 have disc edema
-Central field loss common
-Relative afferent pupillary defect but may be absent
-Spontaneous near complete recovery within months
what is the diff dx for optic neuritis?
-Compressive optic neuropathy
-Carcinomatous meningitis
-Radiation induced optic neuropathy
-Toxic or nutritional optic neuropathy (bilateral)
what is the workup for optic neuritis?
-Ophthalmic evaluation
-MRI of brain and orbits with contrast
-CBC, electrolytes and chest x-ray if corticosteroids
what is the tx for optic neuritis?
-White matter plaques found on MRI= IV methylprednisilone (250mg) every 6 hours for 3 days (optional 10 day oral taper)
-Without white matter changes, IV steroids have no proven long-term advantage but often used in ONE EYED patients or those with severe vision loss
what is papilledema?
(edema and inflammation of the optic nerve at its point of entrance into the eyeball)
-etiology increased intracranial pressure often cause by tumor of the brain, infections such as meningitis or encephalitis pressing on the optic nerve
-blindness may result very rapidly unless relieved
what are the sxs of papilledema?
-Headache, nausea, vomitting
-Brief, transient episodes of vision loss with postural changes
-Pulsatile tinnitus
-Horizontal diplopia from paresis of cranial nerve 6
what are the sns of papilledema?
-Optic disc edema present in both eyes
-Visual loss not acute except for enlarged blind spot
-Pseudotumor cerebri- females aged 12-40
-Unilateral or bilateral sixth cranial nerve paresis may occur
what is the etiology of papilledema?
-Elevated intracranial pressure caused by
-Intracranial mass
-Impediment of cerebrospinal fluid flow
-Idiopathic intracranial hypertension associated with obesity and some meds (vitamin A, tetracycline and corticosteroids)
what is the diff dx of papilledema?
-Pseudopapilledema-anomalous optic discs
-Bilateral optic neuritis
-Bilateral anterior Ischemic optic neuropathy
-Bilateral infiltrative optic neuropathy
-Hypertensive retinopathy
what is the workup for papilledema?
-Blood pressure
-MRI with contrast
-Lumbar puncture
-Neurosurgery and neurology consult
-Ophthalmic and neurologic consult
what is the tx for papilledema?
-For idiopathic intracranial hypertension
-Weight loss
-Neurosurgical shunt or optic nerve sheath fenestration
-Follow up with frequent formal visual field testing
how can visual acuity be tested?
Vital Sign,.Snellen Chart, Picture or Tumbling “E” Chart for illiterate or pre-verbal patients.Test each eye separately. Record the distance from the chart patient can read letters. (ex. 20/30, 20/200) Always check visual acuity with glasses/lenses on.
how is the pinhole helpful?
corrects most refractive errors. Compensates for missing or forgotten eyeglasses. Alternative to pinhole handheld ophthalmologic scope. Patient dials up or down with the lens until image is clear. (ex 20/30 w/ -8 lens.), Finger counting, hand motion , light perception
how is the external eye exam performed?
Inspect the skin around the eye, lids, lid margins, conjunctiva, presence or absence of d/c, preauricular adenopathy, lice on the eye lids.
-prognosis is better for patients who can detect SOME light through an injured eye than no light at all
what should be noticed about the pupils in an exam?
size, equality, response to light and accommodation.
what is miosis?
constriction, suggests ciliary spasm
what is mydriasis?
dilation. Consensual photophobia: shining light in the unaffected eye cause pain in the affected eye.
what is the purpose of the slit lamp?
magnification of structures anterior to the iris, including the anterior chamber, cornea, and conjunctiva, foreign bodies in the cornea or conjunctiva. Better assessment of corneal defects/infiltrates than the ophthalmoscope.
why is lid eversion useful?
identifies foreign bodies under the upper lid. Single and double lid inversion. Need special retractor
what is the tool used for measurement of IOP?
what is a NL IOP?
12-21 mmHg
what are other ways to measure IOP?
-Goldmann-type application tonometer- gold standard requires significant training and skill / eye specialist.
-Tonopen: Commonly used by GPs, EPs, FDs as screening tool.
-Shiotz tonometer: Metal tonometer / mechanically indents the cornea. With this instrument, the lower the measurement, the higher the pressure. It is cumbersome to use. Patient must be supine. This method is rarely used
-Eye ballottement: gentle palpation of both eyes in the setting of acute angle-closure glaucoma /one eye is harder than the unaffected eye.
what is seen in a direct funduscopy exam?
uses ophthalmoscope. Can see only central area of retina, disc, macula. Cannot see periphery.
what is seen in an indirect funduscopy exam?
done by eye specialist. Allows visualization of retina periphery. Able to pick up early retinal detachments as most start at the periphery and are not visible with the ophthalmoscope.
what is conjunctivitis?
Injected conjunctiva - red eye & purulent D/C usually starts in one eye, but spreads to the other in 48 hrs.
what are the sxs of conjunctivitis?
-Crusted lids- c/o irritation
-Spared deep orbital pain
-No visual loss.
-pupil, cornea, and ant. chamber - wnl.
tx of bacterial conjunctivitis?
Staph, Strep, H. flu - most common causes in adults. TX: Sulfacetamide ( Bleph 10), Cipro( ocuflox) Tobramycin ( Tobrex) . NO steroids. Avoid aminoglycosidic abx, due to toxicity in eye (tobramycin)
what is gonococcal conjunctivitis?
Very aggressive, incubation period hrs to 2 wks. Spread is usually oculogenital, i.e. at birth. Can occur w/ oral sex. Copious d/c “ waterfall of pus”, Gram (-) diplococci,
what is the tx for gonococcal conjunctivits?
TX: parental A.biotics(Rocephin)
what is chlamydia conjunctivitis?
rare in US. Trachoma ( a type of chlamydia) #1 cause of blindness in world. Mucoid D/C assoc. w/ preauricular lymph nodes, enlargement of bulbar conjunctival follicles,
what is the tx for chlamydia conjunctivitis?
TX: zithromax or doxy.
what is viral conjunctivitis?
leading cause of red eye, #1 cause are adenoviruses. Copious watery d/c, redness, lid edema. Highly contagious esp. among families. Abx not helpful
what is allergic conjunctivitis?
Seasonal; c/o burning & itching, Chemosis (swelling of bulbar conjunctiva). T
what is the tx for allergic conjunctivitis?
X: remove allergen, topical vasoconstrictor and antihistamines. Topical ketorolac (toradol) is approved by the FDA for TX. Steroids are used by eye specialists.
what is blepharitis?
acute or chronic inflammation of eyelids caused by variety of bacterial, viral, or parasitic. Requires daily regimen of lid hygiene, baby shampoo, e-mycin ointment if staph is suspected. Lice can fester here also
what is pinguecula?
benign degeneration of the conjunctiva related to UV light exposure and aging, appear as a fatty-looking yellow spot, usually on the nasal aspect of the conjunctiva.
what is Pterygium?
raised yellow fleshy lesion usually on the nasal aspect of the bulbar conjunctiva. Caused by yrs of UV light exposure.
what is a corneal abrasion?
Defects of corneal epithelium
what are the causes of corneal abrasion?
trauma from small objects( incl. Contact lenses).
what are the sns and sxs for corneal abrasion?
Painful, c/o f b sensation, tearing, dec. visual acuity,
-Fluorescence staining- corneal defect. Heals in 2-3 days.
what is the tx for corneal abrasion?
topical a.biotc ointment or drops, cycloplegics, no patch( unless abrasion > 10mm), No statistical difference in healing: patched vs unpatched. No reduction of pain in pts.whose eye was patched.
-pain meds, Topical NSAIDS ( 0.5% Acular - ketorolac), f/u 24-48 hours
Contact lens wearers: inc. risk of infected abrasions (AKA ulcerative keratitis). Extended wear soft lenses : 10- 15 fold risk of infection.
what is superficial keratitis?
AKA Punctate keratopathy on fluorescence stain. Causes: UV light( welders/ skiers), contacts, topical medications, dry eyes, blepharitis.
what are corneal ulcers?
-About 30,000 cases/yr.
-Can be abrasions which get infected, or post surg.
-Slit Lamp: Cornea appears hazy, raised margin around crater
-(+) Flour. Staining.
what is the tx for corneal ulcers?
Aggressive TX: admission/ topical ciprofloxin
what is Acute Anterior Uveitis?
-Most cases are idiopathic. Other causes : viral infect, HSV, HZ, AIDS, LYME, syphilis, foreign bodies, blunt trauma.
-Classically: eye is injected w/ marked hyperemia adjacent to the iris (the limbus) - “limbic flush”
-Exam: Consensual light reflex or accommodation causes significant pain in the affected eye.
-Severe inflammation cause a hypopyon ( pus in the ant chamber).
what is the hallmark for acute anterior uveitis?
-Hallmark on Slit lamp: cell (sparkle) & flare Smoke).
what is the tx for acute anterior uveitis?
steroids, cycloplegics. Potential for long-term sequelae.
what is HSV Keratitis?
-S&S: irritation, tearing, photophobia, blurred vision.
-Previous hx often of cold sores, genital lesions, recent steroid use, immunosuppressive dis.
-Corneal sensation is decreased. in 80% of cases.
-Slit lamp & Fluorescein shows pathognomonic dendrites.
what is the tx for HSV keratitis?
& steroids. Consult ophthalmologist before using steroids
what is herpes zoster?
-Reactivation of chicken pox along the ophthalmic branch of the trigeminal nerve.
-If lesion is on tip of nose then suspect corneal involvement.
what is the tx for herpes zoster?
what is acute angle glaucoma?
-obstruction of trabecular meshwork
-S&S: eye pain, decreased. vision, haloes around lights, N/V
-IOP often 50-70 mm Hg.
-narrowed ant. chamber on the oblique flashlight test.
what is the tx for acute angle glaucoma?
topical B blockers, topical Alpha adrenergic agents, acetazolamide, steroids, pilocarpine, iridectomy
what is open angle glaucoma?
one of the leading causes of blindness, affects millions.
-Elevated IOP: overproduction or decreased removal of aqueous humor.
-Risks, Inc. age, African- American, HTN, Family HX, DM, Nearsightedness, long term steroids, injury or trauma to the eye.
-No symptoms.
-Chronic illness, painless, visual field lost before vision loss. *Elevated IOP often occurs, but not necessary.
-Must examine the optic disc. Look for “cupping”- enlargement of the central cup. Cup : disc ration of > .5 is often seen, but not necessary.
-HRT: Heidelberg Retina Tomography: combines laser scanning camera w software that evaluates optic nerve.
what is the tx for open angle glaucoma?
Eye drops B. Blockers or alpha adernergic agents, pilocarpine, laser surgery to facilitate drainage or combination
what are cataracts?
any opacity of the lens
-Single most common cause of poor vision.
-Cause: age, UV light, Long term steroids, congenital, trauma, inflammation.
-S&S: blurred vision poorly corrected by pin hole. Excessive glare, especially at night.
what is the tx for cataracts?
Lens implant
what is corneal perforation?
-Cause: blunt or penetrating trauma, infections, inflammation.
-Classic findings: flat or shallow ant. chamber, uveal prolapse,
-(+) Seidel test ( clearing or dilution of fluorescene, representing leaking aqueous.
- Never push on the eye in suspected corneal perforations.
what is the tx for corneal perforation?
what is Endophthalmitis?
most dreaded ocular infection. Deep infection of the eye. Poor prognosis. Patients most at risk: recent eye surgery.
what are the possible causes of a swollen eye?
infections, inflammatory processes, tumors. CT scan is test of choice.
what is Periorbital cellulitis (AKA preseptal cellulitis)?
infection anterior to the orbital septum- the tissue of the lids.
-S&S: swelling & tenderness around eye.
what is Orbital cellulitis (AKA post septal cellulitis)?
infection involves the orbit.
-Usually results from spread of sinusitis, especially the ethmoids. And maxillary dental abscesses
-Organisms: Stalph, Strep, H. Flu.
-Complications: cavernous sinus thrombosis, subdural empyema, meningitis.
what is Lacrimal Duct Obstruction?
Congenital nasolacrimal duct obstruction occurs in up to 70% of healthy newborns.
-S&S: eye watering, crusting, mucoid d/c w/out conjunctival injection in an otherwise healthy newborn.
-Most cases resolve spontaneously by age 1. Manage conservatively
what is Dacryocysitis?
Inflammation or infection of the nasolacrimal duct.
-May be acute or chronic.
-Occurs in children w/ congenital or acquired nasolacrimal duct obstruction.
what are the sns and sxs of acute Dacryocysitis?
-S&S: Acute DAC = eye d/c & crusting.
what is the tx of acute Dacryocysitis?
-TX: IV Abx to cover Staph & Strep. Often need early duct probing by specialist.
what are the sns and sxs of chronic Dacryocysitis?
-S&S: Chronic DAC.: low grade inflammation of lacrimal sac in setting of nasolacrimal obstruction..
what is the tx of chronic Dacryocysitis?
-TX: topical ophthalmic Abx & elective nasolacrimal duct probing
what is a Hordeolum?
(Sty) acute infection of modified sebaceous glands (of Zeiss)
-usually staph.
-red swelling that points forward.
what is the tx of a hordeolum?
resolve spontaneously, bursting onto skin; abx ointment/drops, warm compresses
what is Chalazion?
( Meibomian cyst, “Lid Lump”)
-Chronic problem due to blockage of meibomian gland.
-Meibomian glands secrete a fatty material related to sebum onto the lid margin. This helps prevent tears from spilling onto the skin. The cyst can compress cornea causing astigmatism.
what is the tx for chalazion?
what is Entropion?
Edge of the eyelid turns inward so eyelashes rub on the cornea.
-due to age, also scarring of conjunctiva from chronic infection - Trachoma
-Painful and can cause scarring of cornea & blindness.
what is the tx for entropion?
what is Ectropion?
Lower eyelid sags away from eyeball, like a bloodhound..
-Causes, old age, paralysis of facial muscles like Bell’s Palsy.
-Exposed conjunctiva can become inflamed.
what is the tx for ectropion?
what is acute vision loss?
-Divide pts by age and type of vision loss. Partial loss or complaints of flashing lights or floaters suggests retinal detachment.
-Nontraumatic vision loss under age 50 is almost always due to optic neuritis (symptom of MS). Over age 60, vascular causes predominate with temporal arteritis rarely occurring before age 65
what is Acute Vision Loss Under Age 50: Optic Neuritis (ON)?
-occurs between age 15 -45. Rapid over hours, maximal at 2 weeks
-Vision loss w/ alteration in color vision.
-Classically it is said w/ ON: the patient doesn’t see anything and the doctor doesn’t see anything.
-DX: decreased vision and afferent pupillary defect.
-association of ON w/ Multiple Sclerosis
what is central artery occlusion?
-Causes: Atherosclerotic obstruction, vasospasm, embolism, systemic hypotension.
-Associated w/: HTN, DM, ASCVD, hypercoagulable states (i.e..cancer), migraines.
what are the sns and sxs of retinal artery occlusion?
-S&S: Sudden painless loss of vision.
-Classic funduscopic finding :pale edematous retina, w/ a cherry red spot Prognosis is poor.
what is central retinal vein occlusion?
-Abrupt or gradual decrease in vision: cause unknown, see flames radiating from cornea
-Usually older individuals in association with HTN, DM, ASCAD, and Hyperlipidemia
-Fundoscopic exam: retinal hemorrhages dilated veins, and swollen optic disk
what is the tx for central retinal vein occlusion?
-No effective treatment. Prognosis for recovery directly related to visual acuity at presentation
what is temporal arteritis?
AKA giant cell arteritis or granulomatous arteritis
-Rapid or sudden loss of vision by a ischemic optic neuropathy or CRAO
-Occurs in elderly above age 65
what are the sxs of temporal arteritis?
temporal tenderness, induration of temporal arteries, increases ESR (often >100)
what is the dx for temporal arteritis?
temporal artery BX.
what is the tx for temporal arteritis?
IV steroids
what is macular degeneration?
-causes vision loss, mostly central and critical detailed vision. Disease of the elderly, slow and progressive over many years
-scattered pale dots, spots, or modeling on the macular (called drusen)
-2 types, wet and dry
-Wet = leakage of fluid or blood around the central fovea, can be treated with laser
what is Amblyopia?
Subnormal visual acuity in one or both eyes despite appropriate correction of any significant refractive error
what is organic amblyopia?
-Organic: Pathologic change affecting visual pathways: ( i.e.: trauma, retrolental fibroplasia, retinoblastoma, hypoplasia of the optic nerve
what is functional amblyopia?
-Functional: No pathologic alteration of the retina or visual pathways. Vision impairment is due to deprivation of sensory stimulation (disuse) or to inhibition (misuse). Most common cause is strabismus, in which the amblyopia results from the lack of use or active suppression of macular vision in the deviating eye.
what is Strabismus?
(imbalance of extraocular muscles)
-common in infants and young children
-may be a sign of serious eye disease
-may cause amblyopia
what is retinal detachment? TX?
-sudden flashes of light or shower of floaters in infected eye
-risks are high myopia, previous detachment in either eye, trauma, cataract operation without lens implant
-often begin at the periphery but if they involve the macula can lead to loss of vision. TX: laser
what is a subconjunctival hemorrhage?
disruption of blood vessels w/in the normally clear conjunctiva.
-patient coughs or rubs their eye.
-Can occur spontaneously
-If recurrent, think coagulopathy
-Usually no treatment.
-If very large it may obstruct visualization of a ruptured globe.
-A circumferential elevated dense subconjunctival hemorrhage is highly suspicious for a ruptured globe.
what is the tx for subconjunctival hemorrhage?
If globe intact, then again, no treatment.
what are corneal abrasions?
-Partial or complete removal of the corneal epithelium
-Symptoms: pain, tearing, foreign body sensation, blepharospasm
-Topical anesthetics (tetracaine, proparacaine[opthetic]) make exam easy
-Fluorescence strips: dye taken up by damaged corneal epithelium
-Always look for retained foreign bodies
-Tetanus prophylaxis
how is a clean corneal abrasion txed?
-TX:Antibiotic ointment or drops
-patch vs no patch
-cycloplegic drops( dilating drops)relaxes ciliary body spasm which can cause a deep ache.
-re-exam in 24-36 hours and referral to ophtho., oral analgesics.
-Never prescribe topical anesthetics- Why? Ulcer/blindness
how is a dirty corneal abrasion txed?
(dog or cat sctraches) use broadspectrum abx drops q 1-2 hours, never patch, f/u critical, rabies prophylaxis if an animal scratch.
what are contact-related corneal abrasions?
-Can lead to corneal ulcers and blindness.
-Never patch
-use antibiotic drops q 1-2hours to cover pseudomonas
-ophtho referral. No contacts until cleared.
how are Foreign Bodies of the conjunctiva removed?
-can be removed with topical anesthetic and a cotton tip applicator moistened w/ saline.
-Know how to evert lid.

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