ophthalmology back to basics review

OphthalmologyBack to Basics

ReviewMarch 29, 2011

Dr. Andrew Toren

MCC Objectives

•Eye Redness

•Pupil Abnormalities

•Amblyopia / Strabismus

•Acute / Chronic Visual Loss

Pupil Abnormalities• Rationale

• Pupillary disorders of changing degree are in general of little clinical importance. If only one pupil is fixed to light, it is suspicious of the effect of mydriatics. However, pupillary disorders with neurological symptoms may be of significance.

• -Causal Conditions

1. Local disorder of iris

2. Anisocoria (unequal/asymmetric pupils)

• Post eye surgery

• Impaired pupil constriction (third nerve palsy, tonic pupil, mydriatics)

• Impaired pupil dilatation (Horner syndrome) (hypothalamus/brain stem/spinal cord lesions)

• Impairment of pupil constriction (without anisocoria)

• Unilateral (optic nerve or retinal lesion)

• Bilateral (diabetes, syphilis, midbrain lesion, hydrocephalus, factitious)

1. -Key Objectives

a. Determine whether there has been previous ocular inflammation, trauma, loss of vision, or eye pain in order to begin ruling out local disorders.

b. -Objectives

• Through efficient, focused, data gathering:

◦ Differentiate clinically between the various mechanisms of pupil abnormalities.

• List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:

◦ Select patients in need of referral for further investigation.

1. Conduct an effective plan of management for a patient with pupil abnormalities:

2. Select patients in need of referral for management.

a. Applied Scientific Concepts

• Outline function of cranial nerves and demonstrate how to examine them.

• Describe the mechanism of pupillary constriction

Eye Redness• Rationale

• Red eye is a very common complaint. Despite the rather lengthy list of causal conditions, three problems make up the vast majority of causes: conjunctivitis (most common), foreign body, and iritis. Other types of injury are relatively less common, but important because excessive manipulation may cause further damage or even loss of vision.


1. Lids/Lashes/Orbits/Lacrimal system

• Blepharitis (infectious, allergic)

• Hordeolum (stye)/Chalazion

• Foreign body

• Cellulitis (pre-septal, orbital)

• Naso-lacrimal duct obstruction

• Conjunctiva/Sclera

a. Conjunctivitis (viral, bacterial, chlamydial, allergic, also neonatal)

b. Subconjunctival hemorrhage

c. Episcleritis/Scleritis

d. Pinguecula/Pterygium

e. Cornea (corneal abrasions, contact lens overwear)

• Keratitis, infectious

• Foreign body (refer if not better in 24 hours)

• Anterior chamber/Iris

a. Iritis/Iridocyclitis/Uveitis

b. Glaucoma, acute

c. Hypopyon

d. Hyphema

e. -Key Objectives

• Determine whether the condition requires prompt referral.

• -Objectives


a. Differentiate causal conditions that are benign from those that require prompt referral.

b. Determine if vision is affected (reading with affected eye), is there foreign body sensation (inability to open and keep eye open is objective evidence), photophobia, trauma, discharge persisting throughout the day, headache and malaise, nausea and vomiting.

c. Determine visual acuity first, then if there is corneal opacity or infiltrate, aversion to light in uninvolved eye, pupil light reaction (not fixed or pin-point), purulent discharge, redness pattern, WBC or RBC in anterior chamber.

d. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:

◦ Select investigations for diagnosis and required prior to initiation of therapy.

• Conduct an effective plan of management for a patient with eye redness:

◦ Outline management for two of the three most common causes of eye redness, conjunctivitis and foreign body.

◦ Select patients in need of referral.

Acute Visual Loss• Rationale

• Loss of vision is a frightening symptom that demands prompt attention; most patients require an urgent ophthalmologic opinion.


1. Glaucoma (acute angle closure)

2. Haemorrhage (diabetic retinopathy, may be traumatic, penetrating, hyphema)

3. Nervous system/Vascular

• Retinal artery/Vein occlusion (TIA/CVA)

• Migraine

• Occipital infarction/Haemorrhage (TIA/CVA)

• Trauma

1. Blunt (global rupture, corneal abrasion, choroidal rupture, lens dislocation)

2. Penetrating (globe penetration ( intra-ocular foreign body, corneal/lens perforation, optic nerve injury)

3. Haemorrhage (may be traumatic, penetrating)

4. Other (carotid-cavernous sinus fistula, chemical splash)

a. Retinal/Macular/Optic disc problems

• Optic neuritis/Optic nerve injury

• Retinal detachment (may be traumatic)

• Anterior ischemic optic neuropathy/temporal arteritis

• Acute macular lesion

1. Infectious/Inflammatory

2. Other (drug toxicity, functional visual loss)

3. -Key Objectives

• Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely).

• Examine the eye with external, direct ophthalmoscope, visual fields, and pupils.

• -

Acute Visual Loss• Objectives


◦Determine whether the loss is monocular or binocular, and if binocular, is it hemianopic, any exposure to agents or trauma.

◦Determine character of visual loss, since important associated systemic conditions (diabetes, hypertension, temporal arteritis) or similar past events may suggest cause.

◦Differentiate causes of visual loss by examination of cornea, pupil, lens, retina, optic disc, and visual fields (listen for murmurs, carotid bruits).

◦Determine the presence of a foreign body, abnormal extraocular musculature, pupillary reflex.

• List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:

◦Since vast majority of cases will be referred urgently, all tests will be arranged by specialist.

• Conduct an effective plan of management for a patient with acute loss of vision:

◦Select patients in need of specialized care.

Chronic Visual Loss• CHRONIC VISUAL DISTURBANCE/LOSS

• -Rationale

• Loss of vision is a frightening symptom that demands prompt attention on the part of the physician.


1. Pre-retinal conditions

a. Corneal disorders (dystrophy, scarring, edema)

b. Lens disorders (age related, traumatic, steroid-induced)

c. Glaucoma (primary, secondary)

• Retinal dysfunction

1. Diabetic (retinal edema, retinopathy)

2. Vascular insufficiency

3. Tumors

4. Macular degeneration or dystrophy

a. Post-retinal lesions

b. Optic chiasm lesions (pituitary adenoma)

c. Lesions anterior to the optic chiasm (optic nerve/monocular)

• Compressive optic neuropathy

• Intracranial (masses)

• Orbital (thyroid disease)

1. Toxic/Nutritional (nutritional deficiencies, tobacco-alcohol amblyopia, methanol)

2. Hereditary optic neuropathies

d. -Key Objectives

e. Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely).

f. Perform direct ophthalmoscope examination of the eye.

• -Objectives


◦ Determine whether the visual loss is monocular or binocular.

◦ Differentiate causes of visual loss by examination of cornea, lens, retina, and optic disc.

1. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:

a. Perform visual acuity and field-testing.

b. List indications for fluorescein angiography.

c. Conduct an effective plan of management for a patient with chronic visual loss:

◦ Select patients in need of specialized care.

• -Applied Scientific Concepts

• Back to Top

1. Outline the anatomical pathways involved in vision (pre-retinal structures, retina, optic nerve and its pathway through the chiasm, occipital optic cortex).

2. Explain potential visual field defects with lesions at various areas in this pathway

Key Objectives• Acute / Chronic Visual Loss

• Know how to examine the eye & common causes

• Eye Redness

• Know how to manage and when to refer the patient

• Pupil Abnormalities

• Know the main causes of pupil abnormalities

• Amblyopia / Strabismus

• Know what amblyopia is / know the differential and treatment for misaligned eyes

Resources

•Basic Ophthalmology, American Academy of Ophthalmology , Cynthia A. Bradford; MD

•http://www.ophthobook.com/

Eye redness

•by the end of this lecture students will be able to:

•know a differential diagnosis for a red eye

•be able to differentiate between serious vision threatening, benign, and non urgent causes of a red eye

examination of the eye

•visual acuity - don’t forget pinhole!

•pupils

•conjunctiva: pattern of injection

•discharge

•evert lids: papillae or follicles?

• lymph node

•Topical Anesthesia

•Light Source

•iPhone/Eye Chart

•Paper Clips (plastic coated)

•Topical Anesthesia

•Light Source

•iPhone/Eye Chart

•Paper Clips (plastic coated)

HOW TO EXAMINE THE EYE FOR DUMMIES

slit lamp examination

•cornea: fluorscein staining (abrasions, dendrites), opacities

•anterior chamber: depth, cells

•intraocular pressure

history

•timing

•visual changes

• pain, photophobia, tearing

• discharge

•other risk factors: prior episodes, contact lens use, medical comorbidities

the usual suspects•blepharitis

•conjunctivitis

•viral

•allergic

•bacterial

•subconjunctival hemorrhage

•foreign body

•pterygium

the red eye

•Non-Traumatic

•Traumatic

blepharitis• Inflammation of the lid margin

(crusting/redness of lids)

•Causes ‘gritty’/foreign body sensation, often concomitant with other ocular surface disease

•Associated with recurrent hordeolum (styes) or chalazia

• Improvement with warm compresses/lid hygeine, artificial tears, tetracycline

the usual suspects

•herpes simplex keratitis

•herpes zoster

•bacterial keratitis

•corneal ulcer

•iritis / episcleritis / scleritis

conjunctivitis

•Bacterial - most common in children

•Viral - most common in adults

•Allergic - bilateral, frequently c/o ‘itch’

bacterial conjunctivitis

•Signs:

•Discharge - purulent vs mucopurulent

Question

•What type of neonatal conjunctivitis occurs on the first day?

Pitfalls: Adult Conjunctivitis

• Adult Hyperacute Conjunctivitis

• Gonococcus

• Signs/symptoms of severe infection

• Rapid onset

• Chlamydial Conjunctivitis

• Sexually active adolescents/adults

• Unilateral, Follicular reaction

• Chronic (>3 weeks)

• Microtrak

• Oral Tetracyclin


• Usually self limited

• Treatment necessary?

• Limits spread

• Shortens course

• Patient comfort

• Prevents recurrence

• Prevents chronic staph conjunctivitis


therapy• Choice of antibiotic depends on other factors:

• Polysporin

• no prescription required

• Polytrim

• Low cost

• Well tolerated

• Fucithalmic

• BID dosing

Pitfalls in Treatment

• Avoid

• Gentamicin

• Epithelial toxicity

• Steroid containing solutions

• Garasone

• Tobradex

• Blephamide

• Increase IOP, Cataract

• Geographic Herpes

• Worsen Infection

• Corneal Spread

• Frequent switching of drops

Viral Conjunctivitis

•History: Infectious Contacts, URTI, Drops/Drugs

•Etiology: Adenovirus

•Treatment: No specific therapy

•Cool compresses, artificial tears, infectious precautions

Allergic Conjunctivitis

•Symptoms: ITCHING

•Signs: mild redness, conjunctival chemosis, watery discharge, papillary hypertrophy

•Treatment: cold compress, antihistamines, non-steroidal drops, mast cell stabilizers, topical corticosteroids

Subconjunctival Hg•What is the appropriate

management of a large subconjunctival hemorrhage

•A) Stop any anticoagulation and observe for improvement

•B) Observe. If no resolution in 1-2 weeks refer to ophthalmology

•C) Observation only

•D) If large, refer to ophthalmology

Subconjunctival Hemorrhage

bacterial keratitis

•much less common

•pain, reduced vision

•management:

•Large/Central Ulcer: Culture, Fortified antibiotics, urgent referral

•Small Ulcer: topical gtts, refer

Pterygium

Herpes Simplex Keratitis

•Unilateral, often have previous history

•Pain -variable, photophobia,

•Dendrites, Follicular conjunctivitis

•Management:

•Topical trifluridine 1% (Viroptic) 9X/day ± cycloplegia, refer

•NO STEROIDS!

Iritis/Episcleritis/Scleritis

Increasing Ocular In

flammation

Increasing Syste

mic

Complications

Pingeculitis

EpiscleritisLocalized Scleritis

Diffuse ScleritisNodular Scleritis

Necrotizing Scleritis

Episcleritis

•Symptoms: Often asymptomatic, Mild irritation and/or photophobia

•Signs: Sectoral Redness, superficial injection, localized tenderness

•Systemic Associations: RA, SLE, Seronegative spondyloarthropathies

•Treatment: Tears, Topical/Oral NSAIDS

Scleritis• Symptoms: Pain (Dull, Achy, Deep, Boring), Photophobia,

Tearing

• Signs: Bluish red injection, deeper structures, nodules, necrosis

• Systemic Association in 50%, high 5 yr mortality - needs investigation

• Collagen Vascular

• Rheumatoid arthritis

• Lupus

• Wegner’s

• Treatment: Topical/Oral Steroid/NSAIDS/Immune suppression

Angle Closure Glaucoma (aka Pupillary Block)

•Symptoms: dramatic presentation, significant pain, ocular headache, nausea and vomiting, decreased vision, colored haloes

•Signs: fixed mid-dilated pupil, steamy cornea, shallow anterior chamber, ELEVATED IOP

Angle Closure

•Treatment:

•Pilocarpine 1%

•Pressure lowering medication:

•Topical / IV / PO

•Definitive Management: Laser Iridotomy

Traumatic Red Eye

•Red Flags

•Loss of vision

•Loss of red reflex

•Flat anterior chamber

•Tear shaped pupil

•Uveal prolapse

the usual suspects•blepharitis - warm compresses, lid

hygeine, artificial tears

•conjunctivitis

•viral - cool compresses, contact precautions, observe

•allergic - avoidance, antihistamine, allergy gtts

•bacterial - broad spectrum antibiotic gtts

•subconjunctival hemorrhage -observe

•foreign body

•pterygium

the usual suspects•herpes simplex keratitis - refer

•herpes zoster - refer

•bacterial keratitis - broad spectrum antibiotics, refer if no improvement

•corneal ulcer - broad spectrum Abx, refer

•iritis / episcleritis / scleritis - dilate, refer

•angle closure glaucoma - refer urgently

Trauma•Hyphema

•Gross (visible) or micro (visible only on slit lamp exam)

•Rx - Cylcoplegia, rest, refer

•Traumatic Mydriasis

•Orbital Fracture - CT scan, refer (repair ~1 week), no nose blowing, beware in children of White Eye-Blow Out Fracture

when to refer•vision changes

•pain, severe headache, nausea/vomitting

•corneal abnormalities or opacities

•fluorescein staining

•shallow anterior chamber

•increased IOP

•marked purulent discharge

•trauma

•proptosis

Urgent referral - time sensitive

•acute angle closure glaucoma

•corneal ulcers

•trauma - eg ruptured globe

•endophthalmitis

Urgent referral <48hrs

•acute anterior uveitis (iritis)

•scleritis

•nasolacrimal infections

Pupil Abnormalities

Anatomy - Pupillary Response

•Afferent Pathway - CNII

•Efferent Pathway - CNIII parasympathetic, sympathetic

Parasympathetic Efferent

Sympathetic Efferent

Irregular Pupil• Mechanism: damage to compliance of iris or iris

musculature

• Trauma – visible tears in margin or sphincter

• Iridodialysis – outer edge of iris is torn away from its ciliary attachment

• Synechiae – can result from intraocular inflammation causing adherence to lens or cornea

• Neovascularization – can distort & impair reactivity

• Malformations: coloboma, aniridia

• Cataract surgery!

Anisocoria

•Inequality in diameter of the 2 pupils

•Efferent disturbances of pupil size usually unilateral

•Degree of anisocoria greater in:

•Dim light – weakness in dilator muscle (or physiologic) of smaller pupil

•Small Pupil

•Bright light – weakness of sphincter of bigger pupil

•Large Pupil

Dim Light / Small Pupil

•Physiologic: <2mm

•Horner’s

•Pharmacologic: cholinergic - stimulation of parasympathetic efferent pathway

•Eg Pilocarpine

Features

• Miosis

• Ptosis -2-3 mm

• upside-down ptosis (1-2 mm) of the lower lid

• Leads to pseudoenophthalmos

• Anhydrosis

• Other features:

• transient dilation of conjunctival vessels, increased accomodation

• In longstanding cases heterochromia of the iris may occur (the affected side being less pigmented)

Horner’s•Tests:

•Cocaine - Is Horner’s present or absent?

•Blocks re-uptake of norepinephrine in the neuromuscular junction

•NB: apraclonidine (alpha-agonist)

•Hydroxyamphetamine - Is1st/2nd vs 3rd order Horner’s?

•Causes release of norepinephrineAAO, Neuro-Ophthalmology

Bright Light / Large Pupil

•Damage to parasympathetic outflow to iris sphincter muscle

•Oculomotor nerve (CNIII) paresis

•Tonic Pupil

•Intermittent dilation of one pupil caused by inhibition of parasympathetic pathway

•Trauma to sphincter

•Pharmacologic stimulation: Anti-cholinergics

CN III Palsy•Pupil Involvement?

•Assume to be aneurysm!

•Complete vs Incomplete?

•Young vs Vasculopathy & Diabetic?

•Needs urgent neuroimaging - CTA MRI/MRA, angiography

AAO, Neuro-Ophthalmology

Large Pupil: Others• Tonic Pupil

• Longstanding

• Aberrant regeneration

• Light-near disassociation

• Pharmacologic

• Red cap drops, Anticholinergics eg scopolamine

• Test with Pilocarpine

• Traumatic Mydriasis

Amblyopia/Strabismus

Extraocular Muscles


Important Questions

• Does the diplopia resolve when 1 eye is covered? (i.e. monocular vs. binocular)

• Is it the same in all fields gaze (comitant) or does it vary with gaze direction (incomitant)?

• Is it horizontal, vertical, or oblique?

• Is it constant, intermittent, or variable?

4th Nerve Palsy• Congenital

• Asymptomatic until 40-60yo (↓ fusional amplitudes)

• Chronic head tilt – check old photographs

• Ischemic

• Patients older than 50yo with ischemic risk factors

• Expect resolution within 3 months

• Others: Trauma; MS, tumour, hydrocephalus, aneurysn, Idiopathic, Graves and Myasthenia

• Neuroimaging: little diagnositc value initially

• Medical Work-up & Observe

CN III Palsy


6th Nerve Palsy• Causes esodeviation

• Ischemic – most common

• Patients older than 50yo with ischemic risk factors

• Expect resolution within 3 months

• Other important causes: Tumours, Trauma, raised ICP, demyelinating disease

• Investigations:

• Adults > 50yo

• Medical work-up (BP, fasting BG, lipid profile)

• Lack of recovery after 3 months --> MRI

• Patients < 50yo

• Rarely ischemic --> must image (MRI/FLAIR)

• Consider LP, Tensilon test


INO

•Internuclear Ophthalmoplegia

•Ipsilateral Impaired ADduction

•Contralateral ABducting nystagmus

•See most often in demyelinating disease• Mneumonic: INO = Insufficient Nasal Output

Diplopia Summary• Remember the 4 questions

• Determine onset and course

• Check pupils in CN3 palsy

• Pupil-involving needs imaging (CTA or MRI)

• Other indications for imaging

• Non-resolving (presumed ischemic) CN palsy

• Younger patients (< 50yo)

• Value of a Tensilon test in MG

• In older patients, consider GCA (ESR, CRP)

Amblyopia

•Decreased vision in eye from disuse of eye during development (~before age 8)

•Causes include:

•Refractive error

•Strabismus

•Early detection is key

Strabismus

•Disruption of binocular vision

•Binocular fusion develops <4-6months

•Most common cause is accommodation from hyperopia

•Rx with glasses

•Rx amblyopia with patching if necessary

Cover/UnCover

•Tropia : the eyes are turned all the time.

•Hyper/Hypo/Exo/Eso

•Phorias: eye deviations that are only present some of the time eg .stress, illness, fatigue, or when binocular vision is interrupted.

Acute / Chronic Visual Loss

•Red Eye

•Pupil Abnormalities

•Diplopia

•Amblyopia

Causes of Acute Visual Loss

• Cornea:

• Surface disorders - eg. exposure kerathopathy, dry eye

• Corneal Edema (Acute ACG, other corneal diseases)

• Anterior Chamber:

• Hemorrhage - eg. Neovascularization in Ischemia/Diabetes

• Vitreous:

• Hemorrhage from Ischemia/Diabetes

• Retina:

• Vascular-occlusive disease, macular degeneration, hemorrhage, retinal detachment

• Optic Nerve:

• Temporal Arteritis / Giant Cell Arteritis vs non-arteritic anterior ischemic optic neuropathy (NAION); Optic Neuritis; compressive lesions

Chronic Visual Loss

•Glaucoma

•Diabetic Retinopathy

•Age Related Macular Degeneration

•Cataract

Sample Questions

•28y.o. day care worker with 3 days of red eye

Case 1

• Vision 20/25 OU• Pupils normal• Conjunctiva injected• Discharge clear• Cornea clear• AC deep and quiet• IOP 18• Preauricular node palpable• Hx: no contact lens use, recent URTI

Case 2•9 y.o. female complains of red eye

for 1 week

• Vision 20/60 OD, 20/20 OSPupils smallConjunctiva: ciliary injectionDischarge wateryCornea clearAC cellsIOP 14• no preauricular node• Hx: photophobia, recent limp

Case 3•68yo. male c/o of burning, foreign

body sensation in both eyes (OS>OD)• vision: 20/25 OD, 20/30 OS

• conjunctival: injected

• discharge: tearing, discharge in the am

• cornea: debris on cornea, no fluorescein staining

• AC / IOP / lymph nodes: unremarkable

• Hx: worse with new eye gtts recently

• A 43 female presents with 5 days of pain and redness in her left eye. She has no discharge and conjunctival chemosis. She has a history of rheumatoid arthritis. Which of the following tests would you order next:

1. Conjunctival swabs

2. Corneal swabs

3. CBC, ANA, RF, ACE, and CXR

4. Ophthalmic slit lamp assessment

Case 4

• A 42 female presents with 3 days of pain and redness in her left eye. She reports halos in her vision and a dull pain. Which of the following would be the next appropriate steps:

1. Visual acuity

2. Slit lamp examination for the presence of anterior chamber cell

3. Conjunctival swabs

4. Systemic investigations for connective tissues and rheumatologic diseases

5. Intraocular pressure measurement

6. Dilated fundus examination

Case 5

• A 44 male presents with 7 days of foreign body irritation and blurry vision in his left eye following an unknown foreign body in eye while working in machine shop. Which of the following would be the next appropriate steps:

1. Visual acuity

2. Slit lamp examination

3. Eversion of the upper eyelid

4. Conjunctival swab

5. CT orbits



Case 6

• A 44 female with a history of 2 days of severe boring pain in her right eye. presents with a red eye to the clinic. She has a history of 5 days of discomfort in both eyes. Vision is unaffected. On exam her eye looks as follows. What is the appropriate initial treatment:

1. Oral steroids

2. Topical lubrication

3. Indomethacin 50mg po tid

4. Topical bacitracin and polymyxin B

5. Homatropine 1% 1 gtt tid

6. Topical antihistamines drops

Case 7

• A 42 male presents with halos, intraocular pain and an IOP of 65 with corneal edema. The next steps in management of his condition would include which of the following:

1. Slit lamp examination and fundoscopy

2. IV Mannitol

3. Topical levobunolol 0.5%

4. Topical pilocarpine 4%

5. Oral acetazolamide 500 bid for 7 days

6. Urgent ophthalmology referral

7. Topical prostaglandins drops

Case 8

• A 43 male presents with a history of rheumatoid arthritis presents with a red eye for 5 days self medicated with topical steroids. Slit lamp examination shows a corneal dendritic lesion with terminal bulbs and mild anterior chamber inflammation. Treatment would include the following:

1. Topical levobunolol 0.5%

2. Immediate ophthalmic referral

3. Topical steroid drops

4. Trifluoridine 1% 1gtt q2h

5. Valtrex 1g po tid

Case 9

• A 45 male with presents with 7 days of foreign body irritation and redness in her left eye following foreign body in eye while working in machine shop. Which of the following would be the next appropriate steps:

1. Visual acuity

2. Slit lamp examination

3. Eversion of the upper eyelid

4. Conjunctival swab

5. CT orbits



Case 10

• A 4 day old male with presents profuse mucopurulent discharge in both eyes. What is the management of this patient?

1. Urgent ophthalmology consultation

2. Topical silver nitrate

3. Conjunctival gram stain

4. Conjunctival culture

5. Blood cultures

6. Cefotaxime 100–150 mg/kg/day IV or IM, 12 hourly


Case 11

• A 64 year old male with a diffuse red eye, mild discharge and pain in his right eye. His pupil is newly dilated and fixed at 6mm and unresponsive to pilocarpine 2%. What is the management of this patient?

1. Urgent Ophthalmology Consultation

2. Measurement of intraocular pressure

3. CT Angiogram or MRA/MRV of the head

4. ESR, CRP, and CBC


Case 12

• An 76 year old male presents with complaint of double vision. History of diabetes and high blood pressure. His pupil are reactive and IOP is normal. What is the next step in management of this patient?

1. Urgent CT head scan

2. Measurement of blood glucose, triglycerides, and cholesterol

3. CT Angiogram or MRA/MRV of the head

4. ESR, CRP, and CBC

5. Patch affected eye

Case 13

• A 2 month old child is noted to have a significantly large esotropia. What is the most important next step the physician should perform?

1. Detailed family history for strabismus or neoplasm

2. Doll’s eye manoeuvre

3. MRI of head +/- abdomen

4. Genetic testing

5. Examine old photo graphs

6. Reassurance

Case 14