3 Ophthalmic Emergencies

Question 1

Pupil involving or pupil sparing

Partial or complete extraocular muscle dysfunction

Answer 1

oculomotor nerve palsy

Question 2

Most commonly observed fluorescin angiographic sign ( to reveal delay in retinal arterial filling) is what?

Answer 2

Arteriovenous transit time greater than 11 seconds

Question 3

Blood supply to inner layers of retina is from what vessel? Unless which vessel is present? In what % of eyes?

Answer 3

central retinal artery

-unless a Cilioretinal artery is present (35%)

Question 4

Irreversible damage to sensory retina (w/ central retinal artery occlusion) occurs when?

Answer 4

After 90 mins of central retinal artery obstruction/occlusion (but in some cases people regain vision even if occluded for several hours)

Question 5

• Loss of parasympathetic input = pupil responds poorly to light
• Wide range of dysfunction in levator palpebrae and extraocular muscle

Answer 5

Pupil involving oculomotor nerve palsy

Question 6

Risk factors for retinal artery occlusion:

Answer 6

Same atherosclerotic risk factors for:

• stroke
• heart disease
• at risk for end-organ damage such as stroke

Question 7

Low dose ASA decreased incidence of CVA and visual loss in patients with what condition?

Answer 7

Giant Cell Arteritis

Question 8

Color duplex ultrasonography

Answer 8

diagnostic tool being investigated for giant cell arteritis, may replace need for biopsy

Question 9

Retinal ischemia results from disease processes affecting which vessels?

Answer 9

Afferent vessels from common carotid –> intraretinal arterioles

Question 10

• Carbogen inhalation
• Acetazolamide infusion
• Ocular massage
• Paracentesis
• IV vasodilators

Answer 10

Therapies for central retinal artery occlusion

Question 11

Cherry red spot is seen bc/ macula receives blood from choroid, surrounding retina is pale

Answer 11

Central Retinal Artery Occlusion

Question 12

Condition that can overlap giant cell arteritis

• not associated w/ rheumatic, infectious, or neoplastic disorders
• occurs in older adults w/ elevated ESR

Answer 12

polymyalgia rheumatica

Question 13

Watchful waiting

Answer 13

Management for pupil sparing COMPLETE oculomotor palsy (bc/ no direct tx can alter course of the disease)

Question 14

• age 50+
• new onset localized HA
• temporal artery tenderness/decreased temp artery pulse
• ESR of at least 50
• abnormal biopsy of artery

Answer 14

3 or more of these suggests giant cell arteritis

Question 15

After starting high dose corticosteroids when suspicious for giant cell arteries, when does ESR decline to normal level

Answer 15

4 to 6 weeks of meds

Question 16

• Diplopia
• Ptosis
• Eye pain
• HA
• Pupillary dilation
• monocular blurry vision

Answer 16

Sxs of oculomotor nerve palsy

Question 17

Complete loss of somatic function (lid and oculomotor)

Answer 17

Pupil-sparing oculomotor nerve palsy

Question 18

Leading cause of central retinal artery occlusion in patients under 40?

Answer 18

Emboli from the heart

Question 19

• HA
• neck/torso/shoulder/pelvic pain
• fatigue
• malaise
• jaw claudication
• fever
• amaurosis fugax “fleeting vision loss”

Answer 19

Common sxs of giant cell arteritis

Question 20

Leading cause of central retinal artery occlusion in patients over 40?

Answer 20

Cholesterol emboli (Hollenhorst plaque) - from atherosclerotic disease

Question 21

Time from appearance of contrast media (within temporal retinal aa –> until major veins in temporal retinal vascular arcade are completely filled)

Answer 21

Ateriovenous transit time

Question 22

Sudden painless loss of unilateral vision

Answer 22

Arterial Occlusive Disease: central retinal artery occlusion

Question 23

What is almost always involved when an aneurysm or lesion is cause of oculomotor nerve palsy?

Answer 23

Pupil (rule of the pupil)

Question 24

Must be assumed to be caused by an aneurysm until proven otherwise

Answer 24

non-traumatic pupil involving oculomotor nerve palsy (evidence of progression to pupilary involvement)

Question 25

Etiology is idiopathic, but is associated w/ chronic inflammatory process w/ large arteries and elevated cytokines

Answer 25

Giant cell arteritis

Question 26

Gold standard for detecting intracranial aneurysms

Answer 26

catheter angiography

Question 27

• Normal reacting pupil

- Minimal impairment of somatic function

Answer 27

Partial oculomotor nerve palsy

Question 28

What causes most oculomotor nerve palsies?

Answer 28

• Microvascular injury in subarachnoid space or cavernous sinus (most common)
• Brainstem lesions (microvascular infarct)
• Aneurysmal compression, tumor, inflammation, vasculitis, trauma (less common)

Question 29

Acute vision loss and high suspicion for giant cell arteries. What’s the next step?

Answer 29

Promptly begin corticosteroid therapy (prednisone 40-60 /day) in patients with or without amaurosis fugax (fleeting vision loss). W/ this therapy their sxs should resolve within 2 - 3 days

Question 30

Oculomotor nerve does what to pupil?

Answer 30

Constricts (parasympathetic)

Question 31

• Non-invasive imaging

- Daily observation for 7 - 10 days

Answer 31

Management for pupil sparing PARTIAL oculomotor nerve palsy

Question 32

Systemic, inflammatory, vascular syndrome that affects temporal arteries

Answer 32

Giant cell arteritis