clinical reasoning in p ophthalmology

Question 1

what is neonatal conjunctivitis ?

Answer 1

conjunctival inflammation in thee first month of life
also called ophthalmia neonatorum

Question 2

what are the causes of ophthalmia neonatorum ?

Answer 2

organisms acquired during vaginal delivery :
C. trachomatis
N. gonorrhea
HSV-2
also : streptococci, staphylococci, h.influenza

Question 3

what are the signs associated with ophthalmia neonatorum ?

Answer 3

sticky eye
discharge features :
watery in HSV infection
Mucopurulent in chlamydial infection
purulent in bacteerial infection
severe purulent in gonococcal conjunctivitis

Question 4

how is a diagnosis of ophthalmia neonatorum made ?

Answer 4

mainly a clinical diagnosis
STI symptoms of parents
conjunctival scraping are taken for PCR

Question 5

what is the management for ophthalmia neonatorum ?

Answer 5

referral to a genitourinary specialist for the parents
saline irrigation
chlamydial infection : azithromycin

gonococcal : 3rd generation cephalosporins - ceftriaxone

herpes simplex : topical acyclovir

Question 6

what is the risk associated with IV acyclovir ?

Answer 6

risk of developing encephalitis

Question 7

what is the most common aetiological factor associated wiith congenital cataract ?

Answer 7

autosomal dominant

Question 8

what are the other different causes of congenital cataract ?

Answer 8

cataract associated with metabolic disorders
associated with intra-uterine infections
associated with chromosomal abnotrmalotiies

Question 9

what are the metabolic disorders that can cause congential cataract ?

Answer 9

galactosemia - absence of GPUT enzyme
Lowe syndrome - problem with amino acid metabolism
Mannosidosis - mannosidase defeciency

Question 10

what is the mode of inheritance of each of the metabolic disorders that cause congenital cataract ?

Answer 10

lowe syndrome - x-linked recessive
galactosemia - autosomal recessive
mannosidosis - autosomal recessive

Question 11

what is the characteristic image of thee cataract associated with galactosemia ?

Answer 11

oil droplet cataract

Question 12

what type of diseases are associated with lowe’s syndrome ?

Answer 12

occulocerebrorenal

Question 13

what type of cataract is associated with lowe’s syndrome ?

Answer 13

cortical cataract
also associated with 2ry congenital glaucoma

Question 14

what is the presentation of the cataract associated with mannosidosis ?

Answer 14

punctuate lens opacity arranged in a spoke like pattern in the posterior lens cortex

Question 15

what are thee intrauterine infections associated with congenital cataract ?

Answer 15

rubella
varicella
toxoplasmosis
CMV

Question 16

what are the other associated chromosomal abnormalities that can present with congenital cataract ?

Answer 16

Down’s
edwards syndrome

Question 17

what are the ocular manifestation in Down’s syndrome ?

Answer 17

brushfield spots
myopia
strabismus
keratoconus
congenital cataract

Question 18

what are the ocular manifestations associated with Edward syndrome ?

Answer 18

ptosis
microphthalmous
disc coloboma

Question 19

what is the most common cause of leukocoria in thee pediatric age group ?

Answer 19

congenital cataract
retinoblastoma
ROP

Question 20

what are thee different types of “spots” associated in ophthalmology ?

Answer 20

bitot spots - vitamin A deficiency
brush field spots - Downs syndrome

Question 21

what are the investigations that should be done in cases of congenital cataract ?

Answer 21

US
urine analysis
visual evoked potential
screening for intra uterine infections
refer to a paediatrician

Question 22

what is the significance of a urine analysis in congenital cataract ?

Answer 22

reducing substance after drinking milk in galactosemia
amino acid chromatography for Lowe’s syndrome

Question 23

what is the treatment for congenital cataract ?

Answer 23

depending on the density and visualization of the red reflex :
bilateral dense : surgery between 4-10 weeks of age
bilateral partial : consider careful monitoring
unilateral dense : urgent surgery between 4-6 weeks followed by aggressive anti-ambylopia therapy
partial unilateral : usually treated non surgically with papillary dilatation and part time contralateral occlusion

Question 24

what does thee surgery for congenital cataract include?

Answer 24

removal of the lens matter and insertion of an IOL

Question 25

when can we diagnose congenital ptosis ?

Answer 25

drooping of the eyelid where it covers more than 2 mm of the upper limbus

Question 26

what are the types of congenital ptosis ?

Answer 26

primary myogenic congenital ptosis secondary/acquired congenital ptosis

Question 27

what is the etiology in myogenic congenital ptosis ?

Answer 27

poor levator function due to replacement by fatty tissue absent/poorly developed lid crease

Question 28

what aree thee different causes associated with acquired congenital ptosis ?

Answer 28

neurogenic myogenic mechanical

Question 29

what are the neurogenic causes of acquired congenital ptosis ?

Answer 29

congenital 3rd CN palsy congenital Horner syndrome Marcus Gunn jaw winking syndrome

Question 30

what are the myogenic causes associated with acquired congenital ptosis ?

Answer 30

myasthenia gravis

Question 31

what is meeant by mechanical ptosis ?

Answer 31

ptosis cause by heaviness in the upper eyelid caused by a mass or swelling e.g upper lid hemangioma

Question 32

what are the points that should be examined in ptosis assessment ?

Answer 32

uni or bilateral lid crease Marginal reflex distance norm - 4mm Levator function norm 15 mm

Question 33

what are the indications for surgery in congenital ptosis ?

Answer 33

psychological affection head tilt / chin up position ( abnormal head posture) severity of risk of amblyopia other than that wait till age 4-5 y/o

Question 34

what are the types of correctivee surgeries in congenital ptosis ?

Answer 34

levator resection ( good levator function ) frontalis suspension ( poor levator function )

Question 35

what are the 2 main causes of epiphora ?

Answer 35

either increased production or reduced drainage

Question 36

what are the causees of increased tear productoin ?

Answer 36

congenital glaucoma FB , cornal abrasion Corneal/ conjuncctival infections

Question 37

what are the causes off decreased drainage ?

Answer 37

congenital nasolacriimal duct obstruction obstruction of haasneer valve (NLDO)

Question 38

what are the signs and symptoms of NLDO ?

Answer 38

epiphora and increased tear lake matting of lashes infections of the lacrimal gland lacrimal sac swelling

Question 39

what is the management for NLDO ?

Answer 39

musct first exclude congenital glaucoma conservative : sac compression , warm compresses , erythromycin for associated infections surgery if conservative fails

Question 40

what are the type of surgeries associated with NLDDO ?

Answer 40

probing and dilatation steent insertion