board review ophthalmology by stacey singer-leshinsky r-pac
TRANSCRIPT
Board ReviewOphthalmology
ByStacey Singer-Leshinsky R-
PAC
Vision Image focused by cornea and lens onto
retina Light absorbed by photoreceptors in retina
(rods and cones) Macula: cones only. Detailed vision Fovea: cones dense. Best visual acuity Choroid: provides nutrition to retina Cornea: covers iris, pupil, anterior chamber Palpebra: protect globe Cathus: where lids meet
Terms Ptosis: drooping of eyelid Ectropion: lower lid outward Entropion: lower lid inward Proptosis: exophthalmos Visual acuity Visual fields: scotomas Direct pupillary response Consensual pupil response
Terms Miosis: constriction Mydriasis: dilation: sympathetic Anisocoria: unequal: Adies tonic pupil: poor light reaction Argyll robertson: small irregular.
Syphilis Convergence Divergence
Terms Emmetropia: light focused on retina
perfect Myopia: near sighted. Need lens for
distance. Globe long Hyperopia: Far sighted. Need lens for
near. Globe short Presbyopia: lens cannot accommodate
for near objects. Can’t increase refractive power.
Eyelids/conjunctiva/Lacrimal Gland
Pterygium Conjunctiva begins to
grow onto cornea Etiology is UV sunlight
and dry conditions Clinical:
Blurred vision Eye irritation-Itching,
burning During growth appears
swollen and red
Eyelids/conjunctiva/Lacrimal Gland
Pterygium Complications:
blockage of vision as grows onto cornea
Management: Eye drops to moisten
eyes and decrease inflammation. Surgical excision
Eyelids/Conjunctiva/Lacrimal Gland
Hordeolum Acute localized infection or
inflammation of eyelid margin to hair follicles of eyelash or meibomian glands. Blockage or infection with staph
Clinical manifestations: Tender, red, swollen, pain Vision acuity normal
Diagnostics- none Management: resolves spontaneously,
topical antibiotic, warm compresses, might need I/D
Eyelids/Conjunctiva/Lacrimal Gland
Entropion Lower eyelid inward Etiology: older, weakness of muscle
surrounding lower part of the eye Clinical manifestations:
Redness, light sensitivity, dryness Increased lacrimation, foreign body
sensation. Lashes scratch cornea Diagnostics none Management: Artificial tears,
epilation of eyelashes, botox, surgery
Eyelids/Conjunctiva/Lacrimal Gland
Ectropion: Lower eyelid outward exposing
palpebral conjunctiva Etiology: Older , 7th nerve palsy.
Obicularis oculi muscle relaxation Clinical manifestations:
Excessive lacrimation Drooping eyelid Redness, photophobia, dryness, foreign
body sensation Diagnostics: none Management: Artificial tears, surgery
Eyelids/Conjunctiva/Lacrimal Gland Blepharitis:
Inflammation of eyelids (lid margins). Etiology: S. aureus (ulcerative) or a chronic
skin condition(non-ulcerative). Two forms:
Anterior: affects outside lids where eyelashes attach. Caused by bacteria or seborrheic
Posterior: Inner eyelid. Caused by problems with meibomian glands in eyelid (gland plugging). Caused by acne Rosacea or seborrheic
Eyelids/ConjunctivaLacrimal Gland Blepharitis
S Aureus: Itching, lacrimation,
tearing, burning, photophobia
Seborrheic: lid margin erythema, dry
flakes, oily secretions on lid margins, associated dandruff
Diagnostics: none
Eyelids/ConjunctivaLacrimal Gland Blepharitis-Management
Anterior: Hygiene. Remove scales with baby
shampoo. Apply Bacitracin or or erythromycin
Posterior: Expression of meibomian gland on regular
basis. If corneal inflammation need oral antibiotic. Artificial tears, cool compresses
Eyelids/Conjunctiva/Lacrimal Gland Chalazion:
Localized sterile swelling of upper or lower eyelid due to blockage of meibomian gland If ruptures, granulation tissue results.
Secondary to hordeolum Risks: Blepharitis, acne rosacea
Eyelids/Conjunctiva/Lacrimal Gland
Chalazion Hard non-tender swelling Painless, present for weeks to months Conjunctiva red and elevated near
lesion May distort vision if near cornea Diagnostics: none, biopsy Management:
Warm compresses Injection or corticosteroid or I/D if no
improvement Sugery
Eyelids/Conjunctiva/Lacrimal Gland
Conjunctivitis: Viral Inflamed palpebral and bulbar
conjunctiva. Etiology: Viral: Adenovirus type 3
Clinical Unilateral or bilateral edema and
hyperemia of conjunctiva Watery discharge Ipsilateral preauricular lymphadenopathy. May be associated with pharyngitis, fever,
malaise Management:
Warm compresses Sulfonamide drops to prevent secondary
bacterial infection, topical vasoconstrictors
Eyelids/Conjunctiva/Lacrimal Gland
Bacterial Conjunctivitis Etiology:
S.pneunoniae, S. aureus, moraxella Transmission is direct contact Clinical manifestations:
Copious purulent discharge from both eyes (yellow/green)
Mild discomfort/sticky eyes Complications: corneal ulcer Diagnosis: gram stain Management: topical antibiotics
such as polytrim, fluoroquinolones
Chlamydial/GonococcalConjunctivitis Serotypes A, B, Ba and C
cause trachoma, and serotypes D through K produce adult inclusion conjunctivitis
Chlamydial (inclusion) conjunctivitis is found in sexually active young adults.
Diagnosis can be difficult. Look for systemic signs of STD.
Chlamydial/GonococcalConjunctivitis
Eye infection greater than 3 weeks not responding to antibiotics.
Mucopurulent discharge Conjunctival injection Corneal involvement uveitis
possible Preauricular lymphadenopathy Conjunctival papillae Chemosis: membranes that line
eyelids and surface of the eye (conjunctiva) are swollen.
Conjunctival papillae
Chlamydial/GonococcalConjunctivitis Diagnosis:
Fluorescent antibody stain, enzyme immunoassay tests
Giemsa stain: Intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocytes and lymphocytes.
Management: Oral: Tetracycline, Azithromycin,
Amoxicillin and erythromycin Topical: erythromycin, tetracycline
or sulfacetamide Gonococcal: ceftriaxone 1g IM, and
then 1gm IV 12-24 hours later.
Eyelids/Conjunctiva/Lacrimal Gland
Allergic conjunctivitis Etiology: allergen. Release of inflammatory mediators leading
to vascular permeability and vasodilation Clinical
Itching /Tearing /Redness stringy discharge photophobia and visual loss Hypertrophic palpebral conjunctiva with
cobblestone papillae No preauricular nodes
Management: Topical antihistamines, topical vasoconstrictors, mast cell degranulation inhibitors, topical steroids
Eyelids/Conjunctiva/Lacrimal Gland
Dacryocystitis Nasolacrimal obstruction
leading to sac infection Etiology: Acute:
S. aureus, B-hemolytic strep. Chronic: S. epidermidis, candida
Chronic Dacryocystitis etiology: mucosal degeneration, ductile
stenosis, stagnant tears, bacterial overgrowth
Eyelids/Conjunctiva/Lacrimal Gland
Dacryocystitis Clinical manifestations:
Pain, redness, swelling to tear sac Purulent discharge from sac
Diagnostics: none , CT for etiology
Management: Children: Oral Augmentin,
antibiotic drops Adults: Keflex/Augmentin, topical
antibiotic drops Warm compresses
Eyelids/Conjunctiva/Lacrimal Gland
Conjunctival Foreign bodies Trauma to conjunctiva Clinical manifestations:
Acute pain, foreign body sensation Redness, tearing Visual acuity might be affected
Diagnostics: Visual acuity Fluorescein staining Evert eyelids
Management: Local anesthetic Normal saline flush/ sterile cotton tip applicator Antibiotic ointment Referral if not healing
Eyelids/Conjunctiva/Lacrimal Gland Periorbital/ Orbital Cellulitis
Orbital septum: is a membranous sheet in the upper eyelid attached to the edge of the orbit, where it is continuous with the periosteum. Etiology is hordeolum, chalazion, conjunctivitis, dacryocystitis.
Periorbital cellulitis: Remains anterior to orbital septum. Limited to the eyelids
Orbital cellulitis: Posterior to orbital septum in orbit. Unilateral/ young. Risk is sinus infection or entrance through ethmoid bone. Treat aggressively to avoid extension to meninges and brain via cavernous sinus.
Eyelids/Conjunctiva/Lacrimal Gland
Periorbital/ Orbital cellulitis Periorbital cellulitis: conjunctival injection, fever,
edematous erythematous periorbital soft tissue, EOM nontender, normal IOP, normal visual acuity, normal sensation.
Orbital cellulitis: little conjunctival injection, fever, edematous erythematous periorbital soft tissue, tenderness with EOM, elevated IOP, impaired visual acuity, sensation can be impaired.
Diagnosis: CT soft tissue orbital infiltration, cultures
Management: Admission, broad spectrum antibiotics, surgery.
Cornea Corneal Abrasion
Superficial irregularity from trauma or foreign body, contact lens
Clinical manifestations: Severe pain Redness/photophobia Excessive tearing Foreign body sensation Decreased visual acuity Eye usually closed Rust ring if metallic object
Cornea Corneal Abrasion
Diagnostics Fluorescein staining Evert lids, check for foreign body
Management: Remove foreign body Antibiotic ointment Eye patch with pressure Oral pain meds Follow up
Cornea Corneal Foreign body
Trauma to cornea. Inflammatory response. Rule out intraocular foreign bodies. Clinical manifestations:
Pain/photophobia/redness Foreign body sensation Blurred vision History of trauma Eye closed Ring infiltrate surrounding site if >24 hours
Cornea Corneal Foreign body
Diagnostics: Visual acuity Fluorescein stain Evert eyelids CT/MRI
Management: Topical anesthetic Antibiotic ophthalmic ointment Eye patch Oral pain medication Follow up
Orbit Blow out fracture
Associated with trauma to orbit
Examine facial bones, sinuses, eyes
EOMs Orbital films Optho referral.
Hyphema Blood in anterior chamber between iris and cornea due to torn
blood vessels within the iris and ciliary body Etiology: Spontaneous or post trauma. Clinical manifestations:
History: blunt trauma eye pain, decreased vision, photophobia, evaluate for globe rupture.
Management: Head elevated, decreased eye ROM, analgesics, mydriatic, topical steroids, eye shield.
Complications: rebleeding, reduced vision, glaucoma (increased IOP due to obstructed drainage of aqueous humor).
.
Globe Iritis
Acute anterior uveitis. Intraocular inflammation of iris and
ciliary body. Clinical manifestations:
Circumcorneal injection (redness around cornea): ciliary flush
Moderate deep aching pain/photophobia Blurred vision Small irrregular non reactive pupil
Globe Iritis
Diagnostics: Slit-lamp examination
(keratitic precipitates WBC on epithelium)
Management Ophthalmologist
consult Mydriatics Corticosteroids Complications: loss of
vision
Globe Optic Neuritis
Inflammation of optic nerve Associated with multiple sclerosis, viral infections Clinical manifestations:
Unilateral acute visual loss Improves in 2-3 weeks Pain with eye movement Color vision loss Marcus gunn pupil (when light is applied to affected
eye, it fails to constrict completely. However when light is shown in consensual eye, both constrict)
Refer to ophthalmologist
Globe Diabetic retinopathy
Leading cause of blindness in adults in USA
Abnormal growth of retinal blood vessels secondary to ischemia.
Nonproliferative: confined to retina.
Capillary micro aneurysms Dilated veins Flame shaped hemorrhages
Proliferative Neovascularization Can lead to retinal detachment
Globe Diabetic Retinopathy
Clinical manifestations: Decreased visual acuity/color vision retinal hemorrhage retinal edema Neovascularization macular exudate
Globe Hypertensive Retinopathy
Atherosclerosis. Vasoconstriction and ischemia due to hypertension
Clinical manifestations: Decreased visual acuity Retinal hemorrhage, retinal
edema, cotton wool exudates, copper/silver wiring, A/V nicking, optic disc swelling
Globe Retinopathy
Management: Type II diabetes need annual follow up Treatment is surgery- laser
photocoagulation and vitrectomy.
Globe Retinal Detachment
Leakage of vitreous fluid leads to detachment
Spontaneously or second to trauma
Clinical manifestations: Visual loss Floaters/flashing lights as initial
symptoms Retinal tear on fundoscopic exam
Management: Ophthalmology consult and laser surgery
Globe Retinal Artery Occlusion
Occlusion of the central retinal artery by embolus leading to visual loss
Common in elderly with hypertension, Diabetes, giant cell arteritis
Clinical manifestations: Painless loss of vision. Cherry red spot on fovea Swelling of the retina Optic nerve is pale Cotton wool spots to area affected
Globe Retinal Artery
Occlusion Diagnostics
Look for other reasons for emboli
Management: Ophthalmologist
consult immediately Ocular massage Need cardiac workup Thrombolysis
Globe Cataract:
Opacities of the lens. Clinical manifestations:
Hazy, blurred distorted vision. Loss of color vision.
Opaque lens on examination. Pupil white, fundus reflection is absent.
Management is surgery
Globe Macular degeneration
Loss of central vision due to degeneration of cells in macular.
Risk factors include age, sun exposure.
Gradual loss of central vision, blurred vision, scotoma. Peripheral vision preserved.
Management: No effective treatment, Might respond to laser therapy.
Globe Glaucoma
Eye emergency Disease of optic nerve. Abnormal
drainage of aqueous from the trabecular meshwork
Leads to increased ocular pressure, ischemia, degeneration of optic nerve, blindness.
African Americans at risk, Diabetics, migraine, older age group
Globe Open-Angle Glaucoma
Poor drainage of the aqueous through the trabecular meshwork causing damage to optic nerve and visual loss. Narrow angle.
Clinical manifestations: Asymptomatic until late Slow progressive peripheral field visual loss Increased cup: disc ratio
Management: Miotic drops such as pilocarpine to reduce amount of aqueous humor produced and increase the outflow.
Globe Angle Closure Glaucoma
Closure of preexisting narrow anterior chamber
Clinical manifestations: Ocular pain/decreased vision Halos around lights Conjunctiva injected/cornea
cloudy Pupil mid-dilated N/V Visual field defects/
enlarged optic disk with pallor
Globe Angle Closure Glaucoma
Diagnostics: Tonometry Field testing
Management: Open Angle Glaucoma: B Adrenergic blocking eye
drops (timolol, levobunolol), epinephrine eye drops, alpha 2 agonists, surgery
Closed Angle: Decrease IOP by laser. Iridotomy, systemic acetazolamide, osmotic diuretics, pilocarpine
Globe Strabismus
Cannot align both eyes simultaneously. Leads to diplopia. May occur in one or both
eyes. Types
Non paralytic- Short length or improper insertion of extraocular
muscles. Deviation is constant in all directions of gaze.
Paralytic- Weakness of extraocular muscles. Deviation varies depending on the direction of gaze.
Globe Strabismus
Types: Convergent: esotropia
Divergent: exotropia
Hypertropia: upward deviation Hypotropia: downward deviation
Management: Exercise or surgery.
Globe Strabismus
Clinical manifestations: Esotropia or exotropia Both eyes can not align simultaneously One eye wanders when patient tired, eventually eyes
turn outward constantly Diagnostics: Cover/uncover test Management:
Check visual acuity if Amblyopia patch good eye Surgery Corrective lenses. Can lead to amblyopia and blindness if not corrected.