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Flashcards in Clinicals Deck (219):
1

Orbital fx eval
1. if adult
2. if child
3. indications for surgery @ 2 wks
4. signs of muscle entrapment
5. racoon eyes

?entrapment (forced ductions -> can use oculocardiac reflex to gage)
1. next day surgery
2. emergent surgery
3. fx>50%, enophthalmia >2mm, diplopia
4. n/v/bradycardia w muscle tug, pain w muscle mvmt
5. orbital hemorrhage -> decompress if compartment syndrome develops (IOP>40)

2

1. optic nerve signs
2. orbital signs

1. RAPD, color plates, red desat, brightness
2. proptosis, ptosis, EOM restriction

3

FB eval
1. modality
2. if glass

1. CT 1mm cuts
2. Ca will still show on CT

4

Signs of herniation
1. temporal uncal
2. cerebellar tonsillar

1. most likely compresses 6th nerve: ICH and clivus is hard. But CN3 is the closest anatomically.
2. downbeating nystagmus (fast/corrective phase is down)

5

Alexander's rule

nystagmus worsens when looking in direction of the nystagmus

6

types of glaucoma
1. phacomorphic: fellow eye at risk? tx?
2. phacolytic. Tx?
3. phacoanaphylactic = phacoantigenic uveitis
4. lens particle
5. angle closure: risk factors? Fellow eye at risk? Tx?
6. 2nd line laser tx meant to help with all types of glaucoma?

1. phacomorphic: big lens from cataract. No. LPI -> CEIOL +/- trabeculostomy
2. phacolytic: porous anterior capsule -> macrophages engulf leaked lens material and closes angle. Drops + diamox -> CEIOL
3. phacoanaphylactic: broken capsule
4. lens particle: iatrogenic after CEIOL
5. asians, hyperopic, mid-dilation. Yes. B/l YAG LPIrotomy +/- trab in affected eye
6. LPiridoplasty: partial thickness holes 360 degrees, meant to contract iris away from angle

7

mgmt of chemical burn

1. document clock hours affected
2. irrigate until pH 7-7.4 (but let proparacaine dry first as it affects pH)
3. check fornices
4. AT + abx + steroids + manage IOP & pain
5. follow daily until epi defects heal

8

mgmt of orbital cellulitis

causes of preseptal vs. orbital

1. IV abx
2. CT to assess surrounding structures
3. involve ENT; operate if optic nerve signs

URI / trauma / severe conjunctivits vs. sinus (usually ethmoid) disease

9

mgmt of subperiosteal abscess
1. <9yo
2. adults

1. IV abx
2. IV abx + OR drainage

10

mgmt of corneal ulcers

1. document size, depth, ?hypopion, ?cell&flare (if pain out of proportion to exam w enlarged corneal nerves and ring ulcers, think acanthemeba/pseudomonas and cx contact lens)
2. culture
3. ocuflox if small & peripheral, otherwise concentrated vanc & tobra alternating q30min
4. once healing, add doxy, vitC +/- steroids

11

indications for PRP

1. CRVO / BRVO
2. ROP
3. vasculitidies

12

postop shallow chamber + high IOP
1. dx?
2. mechanism?
3. tx?

1. malignant glaucoma.
2. aqueous displacement 2/2 posterior pressure (exact mechanism unclear)
3. vitrectomy w hyloidectomy to break hyloid interface.

13

Anisocoria Features
1. good light rxn vs. poor light rxn
2. no dilation lag vs. yes dilation lag
3. good accomodation vs. sluggish accomodation vs. no accomodation
4. dilation w cocaine vs. no dilation w cocaine
5. reversal of anisocoria w apraclonidine
6. dilation w hydroxyamphetamine vs. no dilation
7. constriction w 0.125% pilocarpine
8. constriction w 1% pilocarpine vs. no constriction
9. EOMI rules out which condition?

1. (physiologic, Horner) vs. (Adie, trauma, pharma, 3rd nerve palsy)
2. physiologic vs. Horner
3. Adie vs. trauma vs. (3rd nerve, pharm)
4. physiologic vs. Horner
5. Horner
6. central Horner vs. post-ganglionic Horner
7. Adie
8. 3rd nerve vs. pharm
9. 3rd nerve

14

Mechanism & characteristics of Adie

ciliary body (where parasympathetic live) degeneration ->
1. AchR hypersensitivity
2. slow re-dilation when light is removed
3. can be asymmetric

15

Mechanism & uses of:
1. apraclonidine
2. pilocarpine
3. cocaine
4. hydroxyamphetamine

1. non-specific adrenergic agonist -> mydriatic -> reverses Horner
2. muscarinic agonist -> miotic -> 0.125% reverses Adie, 1% reverses 3rd nerve, no effect on pharm
3. inhibits reuptake of native NE -> mydriatic -> no effect on Horner
4. stimulates release of native NE: reverses central Horner, no effect on postganglionic Horner

16

3rd nerve palsy
1. complete palsy vs. incomplete vs. superior division vs. inferior division
2. pupil involving vs. pupil sparing
3. immediate step of mgmt if pupil-sparing
4. immediate step of mgmt if pupil-involving
5. if 2/2 ischemia, when should function return?

1. abduction only vs. partial limitation in mvmt vs. (limited upgaze, ptosis) vs. (limited adduction and downgaze)
2. compressive (pcomm aneurysm - supramedial to nerve where the parasympathetic fibers are, uncal herniation) vs. ischemic (motor function located deep in nerve and vessels run on the surface)
3. CNS imaging (even if pupil sparing unless clearly ischemic - old+RFs+acute)
4. CTA in >10yo (kids can have ophthalmoplegic migraines). If neg, consider LP
5. within 3 months (but check in 1 wk to make sure pupil has not become involved and there is no aberrant regeneration)

17

ddx for 3rd nerve
1. b/l slowly progressive ptosis and motility limitation, no pupil involvement or diplopia
2. pain and proptosis
3. adduction deficit w horizontal nystagmus of opposite abducting eye, no ptosis
4. asymmetric vertical deviation
5. normal accomodation, eyelid retraction, upgaze paralysis, convergence retraction nystagmus, no ptosis
6. pupil not involved, has headache and jaw claudication

1. chronic progressive external ophthalmoplegia
2. idiopathic orbital inflammatory syndrome
3. INO
4. skew deviation (supranuclear brainstem lesion)
5. parinaud
6. GCA involving long posterior ciliary arteries causing muscle ischemia

18

tests for
1. MG
2. GCA

1. Antibody panel > ice, rest or edrophonium
2. ESR, CRP, platelets

19

Thyroid eye disease
1. findings
2. manifestations of disease, ranked based on severity

1. lagophthalmos, lid flare (2/2 lateral aponeuroses being thicker than medial aponeuroses), lid lag (2/2 thyroxine x-reactivity with epi receptors on Muller's), proptosis (2/2 muscle deposition in older patients and fat in younger patients), conj injection, optic nerve signs, orbital signs
2. compressive optic neuritis > orbitopathy > strabismus > DES

20

ptosis eval

MRD1
MRD2
Levator function
Palpebral function
VF

21

mgmt of dacrocystitis

etiology

1. massage and warm compresses (don't probe or irrigate)
2. PO abx (bactrim, augmentin, keflex)
3. may need surgery to eliminate obstruction but after inflammation has settled (also don't incise 2/2 risk of fistula)

nasalacrimal duct obstruction -> chronic tear stasis -> secondary infection -> can lead to orbital cellulitis

22

tear drainage tests

1. dye disappearance test: look for significant or asymmetric dye at 5 min.
2. Jones 1: fluorescein -> 5 min -> recover it in the nose w cotton tip
3. Jones 2: failed jones 1 -> wash away remaining fluorescein -> irrigate w saline -> some dye in the irrigation means partial obstruction, no dye means full obstruction
3. irrigation

23

ddx for leukocoria

RB, Coat's disease, cataracts, ROP

24

Epiphora, photophobia, blepharospasm in babies
1. dx
2. prognosis
3. tx
4. causes

1. congenital glaucoma.
2. Nerve damage can be reversible as the globe is more stretchy in children.
3. medications + surgery
4. galactosemia, rubella, PHPV

25

cataract surgery in adults vs. children

restorative of VA vs. not

26

5 layers of the cornea

epi (surface cells, wing cells, basal cells) -> bowman’s layer -> stroma -> descemet’s membrane -> endo (single layer)

27

3 layers of the tear film and the cells that produce them

1. oil - meibomian, zeiss, moll
2. water - lacrimal + accessory (Kraus and Wolfring)
3. mucous - goblet cells in the conj

28

Dry eye and
1. contacts
2. lasik

1. contacts are supposed to expand w wetting to create holes for O2 exchange so dry eye patients shouldn't wear contacts
2. lasik severes some corneal nerves and induces dry eye, so optimize tear film prior to surgery

29

cornea epi cell turn over

1-2 wks

30

what to do about corneal transplants in patients with compromised limbus?

must transplant limbal stem cells first or else there is nothing to repopulate the transplanted cornea

31

Orbital wall bones

2,2,3,4, keep the sphenoid off the floor
2 superior: frontal and sphenoid
2 lateral: zygomatic and sphenoid
3 inferior: maxillary, zygomatic, palatine
4 medial: lacrimal, sphenoid, ethmoid, maxillary

32

MRI modalities

enhance vs. hyperintense

vitreous appearance

hyperintensities on T1
hyperintensities on T2

T1: dark water, bright white matter (emphasizes fat)
T2: bright water, dark white matter
T2 flair: dark water, dark white matter (suppresses FREE water = water not in a cell; edema is hyperintense)

post contrast bright (pathologies under 6wks old) vs. no contrast bright

bright on T2, dark on T2 flair

T1: fat, mucin, pigment, subacute blood
T2: demyelination

33

hemi desmosomes vs desmosomes in the cornea

pain and abrasion upon waking in the AM?

attach to basal lamina vs. seals between cells

recurrent erosion syndrome (hemidesmosomes damaged during initial injury so regenerated basal cells cannot attach well); similar to epithelial basement membrane disease

34

are corneal nerves myelinated?

No, to enable transparency

35

superficial limbal vascularization in contact lens wearers

if >2mm, switch to a lens w higher DK

36

normal cell density of endothelium

3000-3500 cells/mm2; do not use for transplant if <2500

37

1. yellow fibers @ 9 and 3 of fundus
2. radial yellow fibers in the 4 quadrants

1. long ciliary nerves
2. short ciliary nerves

38

tumors that go to the eye

GU (RCC, prostate)
lung
breast
unknown

39

avoid which drops in glaucoma?

pilocarpine (muscarinic agonist -> miotic but shifts forward iridolenticular diaphragm)

40

What is Schwalbe's line

border of cornea endo and trabecular endo. @ intersection of corneal wedge.

41

what blocks the angle in NVG?

fibrovascular sheath

42

schaffer's sign

pigmented (RPE) cells in the vitreous. Highly indicative of retinal tear.

43

When do you get RAPD w RD?

when >10% detached; no RAPD w tears

44

types of retinal tears (break)
1. horseshoe
2. perculated
3. dialysis
4. giant

most common regions?
tx?

1. most common, still has traction
2. button, no traction.
3. break @ ora serrata, most commonly caused by blunt trauma that squishes eye sideways
4. >3 clock hrs

superior and temporal
PRP or cryo

45

types of types of retinal detachments (fluid under retina)
1. rhegmatogenous
2. tractional
3. exudative

mac on vs. off

1. 2/2 tear
2. 2/2 fibrosis (e.g. diabetic), no tear
3. 2/2 subretinal fluid from inflammation / infectious (RPE cannot pump all the fluid out)

clinical dx: 20/100. OR next day vs. OR within 1wk.

46

location of ora serrata

5-6mm behind the limbus (thus inject @ 4mm)

47

weiss ring

where the vitreous had attached to the nerve before detachment

48

lattice

area os retinal thinning, usually found in high myopes

49

CRAO:
1. VA
2. region that can be preserved in CRAO and why
3. w/u
4. tx

1. CF/HM
2. horizontal strip from the nerve, supplied by cilioretinal artery, which has a different source
3. GCA, cardiac (echo, CTA for ?dissection), hypercoag
4. not much. Can try ocular massage, YAG to extrude emboli, AC tap to drop IOP and move emobli (tPA mobidity is too high)

50

glaucomflecken

opacities behind the anterior lens capsule

51

mid-dilated fixed pupil, corneal edema, elevated IOP + NVI
1. dx
2. tx

1. NVG
2. AC tap, avastin, PRP

52

dislocated vs. subluxed lens
1. subluxed upward -> dx?
2. pseudoexfoliation = ?
3. tx

entirely detached vs. partially attached
1. Marfan's
2. weak zonules
3. pilocarpine, BB, carbonic anhydrase inhibitor, lens extraction

53

Hyphema
1. when to evacuate
2. risk of re-bleed?
3. tx

1. high IOP, corneal blood stains (which can persist up to 1yr), non self resolving
2. within 1 wk
3. atropine to prevent clot dislodgement, protective shield, restrict activity

54

open globe
1. signs
2. w/u
3. open vs. ruptured globe
4. most likely sites of rupture
5. mgmt

1. Siedel+, peaked iris, 360 hemorrhagic chemosis, flat AC
2. Siedel. CT for ?IOFB (MRI if wood). Don't check for pressure.
3. penetrating vs. blunt trauma
4. behind muscle insertions, where sclera is thinnest
5. fox shield, NPO, IV levaquin 750 q24, tetanus, preop labs (BMP, CBC, PT/PTT, UA, EKG, CXR, hCG)

55

signs of IOFB

entry wound, iris dialysis, transillumination defect

56

OCT layers

posterior hyaloid membrane
internal limiting membrane
retinal nerve fiber layer
ganglion cell layer
inner plexiform layer
inner nuclear layer
outer plexiform layer
outer nuclear layer
external limiting membrane
photoreceptors (inner -> junction -> outer)
RPE
Bruch's membrane
choriocapillaris
choroidal stroma

57

macular star

bartonella

58

trauma severe enough to cause vit heme likely also involves which 2 structures

iritis and retinal defect

59

3 rings of obicularis

pre-tarsal, preseptal, orbital

60

gray line

insertion of orbicularis onto tarsus

61

enophthalmos vs. hypoglobus

sinking in vs. sinking down

62

corectopia

pupil that's displaced (not round and center)

63

contraindications to canthotomy-cantholysis

open globe

64

Corneal ulcer
1. pseudomonas
2. chlamydia/gonorrhea

1. IV fluoro, PO + topical azithro
2. azithro

65

types of eye pain
1. FB sensation
2. burning
3. dull ache
4. photophobia
5. itching

1. FB, keratitis, dry eye
2. lid, conjunctiva
3. scleritis, uveitis, acute glaucoma
4. irtis, keratitis
5. allergy, blepharitis, dry eye

66

patterns of injection
1. conjunctivitis
2. keratitis
3. uveitis
4. scleritis

1. diffuse
2. circumcorneal
3. circumcorneal / ciliary flush
4. focal

67

conjunctivitis
1. acute, watery, follicular conjunctiva, h/o URI
2. acute, purulent
3. chronic, mucopurulent, follicular conjunctiva
4. stringy discharge, chemosis

1. viral -> no tx unless severe, then steroids
2. bacterial
3. chlamydial
4. allergy

68

keratitis = inflammation of cornea
1. acute, h/o trauma
2. gradual, h/o organic trauma
3. h/o recurrence, no infiltrate

1. bacterial
2. fungal -> NO STEROIDS
3. viral

69

corneal abrasion vs. defect

line vs epi ripped away

70

miosis with iridocyclictis?

yes

71

prominent vagal sx (e.g. n/v) in glaucoma patient

acute angle closure

72

maxitrol should be used for how long?

<2wks as it can elevate IOP

73

ptosis:
1. increased PF vs. unable to look down
2. increased MCD
3. absent bells
4. vs. pseudoptosis

all forms have decreased PF & MRD1, increased MFD, no lagophthalmos.
1. static = congenital myogenic vs. progressive myogenic (CPEO, kearns-sayer)
2. mechanical (mass, symblepharon) or aponeurotic
3. progressive myogenic or neurogenic (3rd nerve palsy)
4. (dermatochalasis, enophthalmos) - all measurements nml

74

ptosis repair approaches:
1. LF >10mm
2. LF 4-10mm
3. LF 0-4

1. phenylephrine test for MMR vs ELR
2. ELR
3. frontalis sling

75

chloroma

manifestation of AML: solid collection of leukemic cells outside the bone marrow

76

4 categories of tearing

1. primary hypersecretion
2. secondary (conjunctivitis, allergy, dry eye)
3. lid malposition
4. obstruction

77

retinal lesions: what are they and where are they located?
1. hard exudates
2. drusen
3. cotton wool
4. cystoid macular edema
5. dot-blot
6. flame hemorrhage

1. lipids in OPL = Henle's layer
2. lipids in RPE
3. nerve fiber sheath blocks vessels underneath
4. OPL
5. IPL + INL + OPL
6. RNFL

78

tear testing

1. direct: basal tear secretion. +anesthesia. Nml is >10mm at 5min
2. Schirmer I: basal + reflex. No anesthesia. Nml is >10mm at 5min
3. Schirmer II: distinguish between fatigue block and lack of reflex. +anesthesia and nasal irritation x2min (irritation will overcome fatigue block). Nml is >15mm at 5min

79

normal tear breakup

>10sec

80

crocodile tears with chewing

abberrant nerve regeneration (if Bell's palsy, then to superficial greater petrosal nerve)

81

Pouting of the punctum + pus + conjunctivitis
1. dx
2. species
3. mgmt

1. canniliculitis (conjunctivitis is from vessel dilation 2/2 bacterial exotoxin)
2. actinomyces
3. may need to cut out stone

82

species of bacteria for
1. canniliculitis
2. lacrimal sac

1. actinomyces
2. staph

83

2 valves of the lacrimal sac

1. entrance = valve of rosen-muller
2. exit = valve of hasner

84

mgmt of lacrimal obstructions
1. punctal
2. cannilicular (most common causes?)

1. probing, dilation, punctoplasty
2. intubation, reconstruction, CDCR (5-FU and taxol)

85

congenital lacrimal obstructions
1. structure involved?
2. unilateral or bilateral?
3. most resolve by?
4. mgmt

1. valve of hasner
2. 2/3 unilateral, 1/3 bilateral
3. 1.5mo
4. massage, shrink mucosa (afrin), irrigate, intubate, DCR

86

alarm signs for eyelid malignancies

1. bloody
2. ulcerations
3. madarosis / disruption

87

normal tear meniscus

>0.3mm

88

signs of abnormal tears
1. osmolarity
2. enzymes

1. >300mOsm/L or >8 difference between the 2 eyes
2. MMP, lactoferrin, lysozyme

89

congenital 4th nerve palsy

if right sided:
1. right hypertropia
2. worse w right head tilt
3. worse w right head turn (inducing left gaze)

90

mgmt of hyphema

1. bedrest
2. shield
3. atropine BID (reduces ciliary spasm, prevents lens synechiae, prevents rebleed)
4. PF QID (avoid in kids)
5. monitor IOP and ?corneal staining (indications for washout)

91

dx of retrobulbar?

clinical (pain, decreased VA, orbital signs, IOP > 40)
Don't CT as it takes too long

92

if superior lid lac, look for what other ocular damage?

retinal detachment

93

AACG in renal patient -> use diamox?

yes; no need to consider renal function in acute setting

94

effect of CRVO on retina

diffuse damage

95

path of a CN
1. at what level do you get disconjugate problems?

nucleus -> fascicle (tract of nerve within brain stem) -> nerve -> NMJ -> muscles
1. fascicle and below

96

Hirschberg test:
1. @ edge of pupil = ? diopters
2. @ limbus = ?diopters

1. 15D
2. 45D

97

Papillae vs. follicles
1. follicular conjunctivitis on upper lid = ?

vascularized center vs. non-vascularized center (lymphoid tissue)
1. highly suggestive of chlamydia

98

Frontal eye field
1. location
2. function
3. signs of damage

1. (anterior) FEF -> motor strip -> central sulcus -> sensory strip (posterior)
2. conjugate gaze to contralateral direction
3. looks towards side of lesion (R FEF lesion -> eyes drift right)

99

course of CN VI

exits @ pons-medulla -> slides over clivus -> cavernous sinus -> eye

100

what's between the 2 thalami?

CSF in 3rd ventricle

101

ptosis + miosis + injection
1. dx
2. reaction of pupil in dark
3. if with esodeviation
4. mechanism of injection
5. mechanism of ptosis and anhydrosis
6. if painful
7. sympathetic pathway

1. Horner
2. slow dilation as parasympathetic deactivate
3. localizes lesion to cavernous sinus, where the sympathetics run w CNVI
4. vasodilation by parasympathetics
5. sympathetics innervate the tarsus and sweat glands
6. dissection until proven otherwise
7. hypothalamus -> dorsal side of brain stem -> synapse @ ciliospinal center of Budge C8-T2 -> over lung apex -> under subclavian -> synapse @ superior cervical ganglion -> cavernous sinus w CN6 -> orbit with V1 -> passes ciliary body -> terminates in iris dilators

102

headache + b/l elevated ON and fuzzy borders + enlarged blind spot
1. presumed dx
2. mgmt

1. brain tumor
2. check BP, same day CNS imaging (MRI >CT) -> if no tumor, then LP -> diamox (no diamox until after LP)

103

motility restricted vs. limited

mechanically restricted vs. muscularly limited

104

papilledema
1. if w telangectasias
2. ddx

disc edema specifically 2/2 ICH
1. condition is acute as vessels haven't had time to adjust
2. venous sinus thrombosis, meningitis, hydrocephalus, tumor/pseudotumor

105

C-C fistula
1. S&S
2. 4 types
3. why does the superior ophthalmic vein get easily involved?
4. low flow vs. high flow

engorged episcleral vessels + proptosis + chemosis + increased IOP (prostaglandins won't help because the pathway it promotes now has high pressures)

A: direct lead of carotid into cavernous
B: indirect branches of internal carotid into cavernous
C: indirect brances of external carotid into cavernous
D: indirect branches of both internal and external (most common)

direct connection to cavernous sinus:
inferior vortexes -> inferior ophthalmic vein -> pterygoid plexus -> juglar
superior vortexes -> superior ophthalmic vein -> cavernous sinus -> jugular

50% of low flow will self-thrombose while high flows should be surgically treated to prevent hemorrhagic/ischemic strokes

106

spiral of tillaux

medial 5.5 -> inferior 6.5 -> lateral 6.9 -> superior 7.7

MILS

107

thyroid myopathy deposition pattern

inferior -> medial -> superior -> later

IMSL

108

effect of organophosphate poisoning on pupils

miotic

109

mechanism for anisocoria during migraine

serotonin receptors on the iris

110

what feeds the cavernous sinus posteriorly?

superior and inferior petrosal sinuses

111

NMO vs. MS
1. VA
2. location of extra-ocular lesions
3. extent of optic nerve involvement
4. age
5. location of disease
6. if oligoclonal bands in CSF
7. if +aquaporin 4 ab
8. if very high protein in CSF
9. tx

1. severe loss vs. moderate loss
2. spinal cord vs. CNS (though doesn't have to appear at the same time as optic nerve defects)
3. extensive vs. not
4. late 30s vs. late 20s
5. systemic vs. within CNS
6. 90%MS, 10% NMO
7. 99%NMO
8. NMO (systemic disease needs to break down BBB to be in the CSF and the breakdown increases protein content in CSF)
9. steroids -> plasmapheresis vs. steroids -> disease modifying drugs (MS drugs can actually worsen NMO)

112

RAPD -> ddx?

optic nerve vs. massive retinal problem (localized retinal problem will not give a RAPD)

113

normal artery to vein size ratio in fundus

2:3

114

CRVO fundus findings

engorged veins
hemorrhages

115

disc at risk = ?

small cup (~0.1) -> risk of nonarteritic anterior ischemic optic neuropathy (lots of nerve packed into a small space -> prone to ischemia -> edema from ischemia -> compartment syndrome)

116

arteritic vs. nonarteritic ischemic optic neuropathy
1. symptoms of arteritic
2. if GCA is suspected -> mgmt?
3. average ages
4. location

1. malaise (fatigue, weight loss, appetite loss, fever), headache, jaw claudication, scalp tenderness
2. check ESR, CRP, CBC; start IV solumedrol 1g x3d to protect fellow eye (50% will lose vision in fellow eye in 72hrs); temporal artery biopsy within 1 wk
3. 75 vs. 65
4. b/l vs. unilateral

117

RFs for NAION

amiodarone vs. NAION
amiodarone prognosis?

1. vasculopath
2. PDEi
3. sleep apnea (hyperventilation controls cerebral edema)

amiodarone is b/l, unlikely NAION. Metabolites deposit on nerves to cause NAION-like findings months after initiation of therapy
Amiodarone generally can recover

118

% of GCA patients w vision loss?

30%

119

Biopsy strategy for GCA
1. very high suspicion
2. very low suspicion
3. medium suspicion

why the need to biopsy multiple sites?

1. unilateral bx -> if neg, do other side
2. unilateral bx
3. b/l bx

lesions are not contiguous; try to get ~3cm sample

120

temporal pallor -> ?

nonspecific finding; could be:
1. temporal quadrant is physiologically the thinnest
2. myopes have nerve tilt
3. pathology that specifically affects the temporal quadrant

121

NMO spectrum?

neurosjogrens. Check ANA , SSa and SSb

122

VF loss patterns
1. nasal step
2. arcuate (complete arcuate = Bjerrum)
3. paracentral
4. cecocentral
5. central / enlarged blindspot

1. notch by nasal VF, will develop into arcuate
2. from blind spot to temporal raphe, course above or below the macula
4. optic neuropathies that affect the papillomacular bundle, uncommon in glaucoma (think hereditary, ethambutol, vit def)
5. acute papilledema (once chronic, will turn into arcuate defect)

123

size of stimulus
0
I
II
III
IV
V

most common?
when to use stim V?

0: 1/16 mm2
I: 1/4
II: 1
III: 4
IV: 16
V: 64

most common: III
when VA is 20/200

124

types of VF tests
1. FDT
2. OCTA

1. quick and dirty
2. measure capillary bed in the eye

125

cloverfield pattern on VF indicates?

patient stopped paying attention half way through vs. functional

126

glaucoma = ?

glaucoma RFs

optic neuropathy with characteristic ON/RNFL changes and/or corresponding changes in VF (has nothing to do with IOP)

age
race & ethnicity
decreased ocular perfusion pressure
diabetes
thin CCT (correlates with pliable lamina cribosa, which provides less support to the ONs)
family hx (siblings only)
IOP
myopes
genetics

127

degrees of vision
1. temporally
2. inferiorly
3. nasally
4. superiorly

1. 90
2. 70
3. 60
4. 50

128

distance between points on a HVF
1. 10-2
2. 30-2
3. 24-2

distance between the arcades (macula)

1. 2 degrees
2. 6 degrees (same amount of dots as 10-2 but 3 times the degree coverage)
3. 6 degrees

18degrees = 6mm diameter = central 2 rows/columns on 30-2

129

what size of pupil do you start getting global depressions on HVF?

2.5mm

130

relative position of fovea and optic nerve

optic nerve is superior -> blind spot is inferior to the meridian on HVF

131

size of nerves

1.5mm = 4.5 degrees -> blind spot should only fall on 1 spot of the HVF

132

ASB (apostilb) vs. dB

average sensitivity of fovea

1 asb = 40dB
10 asb = 30dB
100 asb = 20dB

35dB

133

SRF vs. PED

subretinal fluid = between neuro-retina and RPE
PED = pigment epithelial detachment = fluid under the RPE

134

circinate exudate

exudates in a ring = anything focal that leaks (e.g. aneurysm)

135

boat shaped hemorrhage

there is a pocket of fluid inside which blood layered

136

OCT findings
1. shadow behind a pocket of blackness
2. white spots in blackness

1. blood
2. WBC or RBC

137

causes of CNV (choroidal neovascularization)

1. AMD
2. myopia (stretching breaks Bruch’s membrane)
3. CSCR (central serous chorioretinopathy)
4. inflammatory processes (e.g. posterior uveitis)
5. trauma: (choroidal rupture, laser that pop’d Bruch’s)

138

treatment for DME

lucentis

139

FA
1. sequence of fill
2. hypofluorescence
3. hyperfluorescence

1. choroid flush -> artery -> laminar -> AV transit (equally bright) -> late venous (veins brighter) -> -> recirculation
2. capillary drop off / non-perfusion vs. blocked by heme
3. SPLAT
stain: margin intensity grows but not size (scars, drusen, optic nerve)
pool: dye in fluid filled space
leak: margin intensity AND size grow (seen only on late phase)
autofluorescence: from RPE (but macula is dark 2/2 luteal pigments)
transmission/window defect: no growth in margin intensity or size

140

histology of the posterior pole
1. peripheral retina
2. macula
3. fovea
4. retina thickest where?
5. foveola

1. 1 layer of retinal ganglion cells
2. multiple layers of retinal ganglion cells, higher ratio of photoreceptors, RPE with more melanosomes and volumetrically bigger
3. RNFL to INL absent, OPL very thin
4. papillomacular bundle (connection between fovea and disc)
5. pure cones

141

sizes
1. macula
2. disc
3. foveal pit
4. foveal avascular zone

1. 6x6mm
2. 1.5mm
3. 1.5mm
4. 250-600um

142

what thins out retina?

CRAO

143

where do retinal vessels end?

ora

144

types of collagen
I
II
III
IV

I: sclera
II: vitreous (vi-two-eous)
III: cornea stromal wound healing
IV: basement membrane (descemet's, not bowman's, lens capsul, Bruch's)

145

what stains Bruch's membrane?

PAS

146

lasers
1. absorbed by which layer?
2. photocoagulative
3. photoablative
4. photo disruptive
5. photo destructive

1. RPE (thus difficult in blond fundus)
2. heats proteins: PRP
3. breaks chemical bonds: LASIK
4. Mini lighting + thunder: YAG capsulotomy / iritotomy
5. sclerotomies

147

why are high myopes more susceptible to retinal tears?

neither the retina nor the vitreous grow as the eye grows; they just get thinned out.

148

vitreous
1. volume
2. most firmly adheres to where? Other attachments?
3. vs. hyloid

1. 5cc
2. ora (vitreous base) > optic disc, large vessels (thus hemorrhagic PVD)
3. hyloid = components of vitreous; anterior is what complicates cataract surgery

149

where does ciliary body insert?

scleral spur

150

indentation gonioscopy in closed angle due to synechiae?

Don't do as synechiae cannot be forced open

151

modified shaffer staging for gonio

0: closed
1: sees schwalbe's
2. TM
3. scleral spur
4. everything

152

PAS on gonio = ?

peripheral anterior synechaie = sign of closure at some point

153

pathologies on gonio
1. lots of pigment + iris bowed backwards
2. lots of ciliary body + flat iris

1. pigment disperson
2. angle recession

154

cyclodialysis clefts = ? -> ?

ciliary body disinsertion = aqueous now has access to uveoscleral outflow -> hypotony

155

eviscerate vs. enucleate vs. exenterate

leave sclera (shell of globe) vs. take globe but leave extraocular muscles vs. leave nothing

156

iridodialysis vs. cyclodialysis

iris detachment (attaches to ciliary body) vs. ciliary body detachment (attaches to scleral spur)

157

b/l HSV indicates?

atopy. (NOT HIV)

158

artificial tears to avoid?

visine and other a1 vasoconstrictors

159

if suspect mucor

get MRI and call ENT

160

optos photos orientation
1. eyelids
2. superior/inferior
3. nasal/temporal

1. upside down
2. upside up
3. grab the nerve

161

Norms of refractive error in children

2.5yrs = 20/60,
3 yrs = 20/50,
4 yrs = 20/40,
5 yrs = 20/30

162

HVF defects
1. if respecting horizontal raphe
2. if respecting vertical raphe

1. think glaucoma
2. think neuro

163

do corneal ulcers cause focal scotomas?

no

164

how many degrees away from the center is the blind spot?

15 degrees

165

what does "advanced" deficits mean on a HVF?

MD < ~-15

166

SJS ocular signs & mgmt

conjunctival chemosis
fibrin exudates -> symblepharon
if servere -> corneal keratinization

topical steroids
amniotic membrane graft
limbal stem cell transplant

167

penetrating injury vs. perforating injury

no exit vs. through-through (yes exit)

168

corneal infiltrate vs. scar

feathery edges vs. clear edges

169

mgmt of corneal perf

if small (<2mm) : cyanoacrylate glue (will be pushed out naturally) or bandage lens
if large: graft

170

infectious scleritis mgmt?

debridement

171

what's cross fixation?

eyes are crossed -> left eye can see more of the right visual field -> can appear to have abduction limit

172

risk adduction deficit if recessing MR by > ?mm

6mm

173

inferior oblique overaction = ? torsion. Usually unilateral or bilater?

excyclotorsion
bilateral

174

Dissociated Vertical Deviation = ?

alternating hyperphoria where both eyes drift up under cover (no see-saw action)

175

Duane syndrome

most commonly 2/2 6th nerve hypoplasia -> LR innervated by inferior division of CN3 -> contraction of both MR and LR on attempted abduction -> eyeball retraction, poor convergence

176

keratoconus:
1. prevalence and disease course
2. vs. pellucid marginal degeneration vs. keratoglobus vs. posterior keratoconus
3. S&S
4. genetic?

1. 1/2000, starts during puberty and progresses until 3rd or 4th decade
2. focal thinning vs. peripheral thinning vs. global thinning vs. posterior thinning
3. scissoring on retinoscopy, Munson's sign, Rizzuti's sign, Vogt's stria, fleisher ring, enlarged corneal nerves
4. no specific genes but has familial associations

177

Cornea sizes
1. dimensions
2. thickness
3. refractive index
4. radius of curvature -> power
5. layers of epithelium

1. 11mmh x 12mmv
2. 540um
3. 1.376
4. 7.8mm -> 43D
5. 4-6 layers

178

1. palisades of vogt = ?
2. corneal apex = ?
3. angle kappa = ?
4. corneal esthesiometry =?
5. corneal hysteresis = ?

1. where the epithelial stem cells reside
2. point of max curve, temporal to pupil
3. between optical axis (line through center of pupil & lens) and visual axis (line through center of pupil & fovea)
4. tests corneal sensation (compare between 2 sides)
5. corneal stiffness

179

effect on IOP of:
1. corneal edema
2. thick normal cornea

1. IOP artificially low
2. IOP artificially high

180

Corneal dyes stains what?
1. fluorescein
2. rose bengal
3. lisamine

1. epi defect
2. devitalized epi
3. devitalized epi

181

corneal striae
1. horizontal
2. vertical

1. glaucoma
2. kerotaconus vs. forceps during delivery

182

1. corneal dermoid = ?
2. cornea plana = ?

1. normal tissue in the wrong place, appears dense and white
2. congenitally flat cornea

183

1. megalocornea vs. megalophthalmos vs. megaloglobus vs. buthalmos
2. microcornea vs. microphthalmos vs. nanophthalmos

1. cornea >13mm vs. large anterior segment w multiple abnormalities vs. big globe but normal amount of tissue (increased risk of rupture) vs. large globe 2/2 glaucoma
2. cornea <11mm vs. small globe w multiple abnormalities vs. small but anatomically normal globe

184

ICE = ?
tx?

iridocorneal endothelial syndrome = spectrum disorder with 3 variants. ?herpes -> abnormal endo cloning -> reversal of light dark pattern (ICE cells have bright nuclei + bright intercellular borders)

1. Iris nevus = Cogan-Reese: multiple pigmented iris nodules, produced by congracting endothelial membrane. Middle aged F; unilateral
2. Chandler: disease confined to inner corneal surface -> corneal edema
3. Essential iris atrophy: abnormal endothelium spreads onto surface of the iris -> atrophy, corectopia and polycoria

tx w penetrating keratoplasty and endothelial keratoplasty

185

impression cytology findings
1. neutrophils
2. lymphocytes
3. eosinophils
4. basophils and mast cells
5. plasma cells and macrophages
6. multinucleated
7. keratinized
8. cytoplasmic inclusions

1. bacterial
2. viral / chronic
3. allergy / parasites
4. seasonal allergies
5. chlamydial
6. HSV
7. tear dysfunction, mucous membrane pemphgoid, SJS
8. chlamydial

186

tx for neurotrophic ulcer

1. tarsorrhaphy
2. amniotic membrane graft: dissolves after 1-2 wks
3. conjunctival flap

all with abx ppx

187

pterygium excision
1. what to identify and cover afterwards?
2. avoid violation of which layer?
3. med?

1. muscle insertions
2. Bowman's
3. mitomycin C

188

tx for bullous keratopathy

bowman's layer cautery: remove epi -> cauterize corneal surface (will look like PRP scars on the cornea) -> bandage contact lens

189

band keratopathy
1. when to perform?
2. process

1. pain and vision loss
2. debride epi with Tooke knife (the tool prevents violation of Bowman's) -> EDTA to chelate Ca -> remove Ca w Tooke -> micro-drill to polish bowman's layer -> amniotic membrane or BCL

190

Follicular conjunctivits causes

1. molluscum (if extensive, think AIDS; can self resolved but can take years)

191

ring ulcers -> ddx?

1. acanthemaeba
2. proparacaine
3. fungal and HSV (always on the ddx)

192

feathery infiltrate -> ddx?

avoid giving what med?

fungal -> avoid steroids

193

ocular abx coverage
1. G+
2. G-
3. fungal

1. vanc or cef
2. tobramycin
3. natamycin

194

papilledema = ?

pathogenesis from venous sinus thrombosis?
most common site of thrombosis causing papilledema

RNFL findings

effect on cup

always bilateral?

?RAPD

disc swelling specifically due to high intracranial pressures

venous sinus thrombosis -> disrupted CSF flow -> intracranial hypertension
most commonly @ bend between transverse and sigmoid sinus

smooth dome-like elevations with hyper-reflective RNFL layer and hypoechoic areas underneath

obliterates the cup but much later

not always bilateral and often asymmetric (2/2 optic canal size asymmetry)

No RAPD(unlike optic neuropathy), 2/2 no involvement of fast axoplasmic flow, unless chronic leading to damage of RNFL

195

Patton's line vs. choroidal folds

circumferential folds in the retina around the nerve 2/2 disc swelling vs. horizontal folds (can slo be seen in increased pressure)

196

3 imaging signs of nerve swelling

2 fundus findings of true nerve swelling

1. swelling @ ON insertion
2. flattening of posterior scleral surface
3. perineural sheath cuff (bulging of the normal fluid cuff @ nerve insertion site)

1. blurry margins
2. obscured vessels

197

CSF flow

produced by choroid plexus of each ventricle -> lateral ventricle -> interventricular foramen -> 3rd ventricle -> aqueduct -> 4th ventricle -> brain & spinal cord -> drains into arachnoid granulation

198

empty sella = ?

possible cause of empty sella?

chronic pressure in the suprasella cistern -> widens the hole through which the infundibulum passes -> fluid accumulation in the sella turcica -> flattens the pituitary into a banana shape

pseudotumor cerebri

199

macular dysfunction vs. ON dysfunction
1. severe VA loss
2. metamorphopsia vs. central scotoma
3. no RAPD vs. yes RAPD
4. hyperopic shift

1. macular dysfunction
2. macular dysfunction vs. ON dysfunction
3. macular dysfunction vs. ON dysfunction
4. macular dysfunction

200

pseudopapilledema conditions

1. disc drusen
2. myelinated NF
3. tilted disc
4. crowded disc (high hypermetropics)

201

tilted disc syndrome

infranasal disc tilt + hypoplasia of infranasal retina & RPE (allowing the underlying choroid to show through) -> bitemporal hemianopsia (mimics optic chiasm compression)

202

Foster-Kennedy

frontal lobe tumor (most commonly olfactory groove meningioma) -> optic nerve atrophy ipsilaterally 2/2 compression + papilledema contralaterally 2/2 altered CSF flow

203

ddx for transient obscuration of vision (TOV)

migraine
vasospasm
vessel congestion (sometimes BP can adjust to push through)

204

ddx for subretinal heme + PED

Anything that causes CNV
AMD
CSCR
polypoidal choroidal vasculopathy
trauma

205

asian male in 50s-60s with sub-RPE lesions that have vasculature, which fills in late phase (polyps) on ICG

responsive to anti-VEGF?

polypoidal choroidal vasculopathy

no

206

yellow dots on fundus exam -> think what sort of processes?

inflammatory / infectious

VKH, birdshot, AMPPE (early hypo -> late hyperfluorescence)
r/o HIV, syphillus and TB before giving steroids
lymphoma, sarcoid

207

INO
1. physiologic pathway
2. signs of unilateral
3. signs of bilateral

1. iFEF @ cortex -> cPPRF -> cCNVI -> cLR + (iLMF -> iCNIII -> iMR)
2. (i) slow adduction + (c) abducting nystagmus +/- (i) hyperdeviation
3. b/l adduction deficit + b/l abductin nystagmus + vertical gaze-evoked nystagmus + large XT

vertical nystagmus: b/c vertical vestibular pursuit and gaze holding pathways ascend from vestibular nuclei through MLF

large XT: 2/2 midbrain lesions near the CN3 nuclei

208

Dawson's fingers

periventricular ovoids >3mm, suggestive of MS

209

Corneal disease: adenovirus
1. type of virus
2. subtype? self-limited without systemic involvement
3. subtype? flu-like symptoms
4. subtype? URI -> follicular conjunctivitis (+/- chemosis, membranes, conj hemorrhage) + PEK (+/- geographic ulcers) + preauricular adenopathy -> 7-14d later, develops multifocal subepithelial corneal infiltrates
5. viral shedding duration?
6. duration of sxs of EKC
7. mgmt

1. dsDNA, non-envelope, icosahedron
2. follicular conjunctivitis (multiple serotypes)
3. pharyngoconjunctival fever (3, 7)
4. epidemic keratoconjunctivitis (D, 8, 19, 37)
5. 7-14d
6. months to yrs
7. supportive. If mucopurulent discharge, then think bacteria superinfection and give abx (steroids can help resolve pain and infiltrates but prolong disease course)

210

waste-basket terms for sub-retinal hyperreflective material on OCT

SHRM

211

microscopic polyangitis vs. wegeners

microscopic polyangitis has microscopic granulomas and less respiratory symptoms

212

FA hyperfluorescence with guttering, expansile dot and smokestack
1. dx
2. tx

1. CSCR
2. NO steroids and try PDT

213

Role of IOP in glaucoma
1. normal vs. glaucoma IOP distrubtions
2. prevalence and incidence based on IOP
3. IOP of the vast majority of glaucoma patients
4. when to treated isolated IOP elevation?

normal IOP = left skewed bell curve (with long tail of high IOPs). Mean of 16, 2 stdevs = 11 to 21.
glaucoma IOPs are barely shifted over to the right

prevalence based on IOP: steady increase until ~30, then exponential increase
incidence based on IOP: exponential increase

mid-teens

when IOP>50, treat for risk of venous thrombosis, not for glaucoma

214

mgmt strategy of glaucoma

decrease by 30% of damaging IOP; decrease by more if still progression of damage

215

glaucoma involves which layers?

RNFL, GCC, IPL

216

3 reasons for head posturing

1. nystagus null point
2. fusion
3. VF defect

217

CN3 aberrant regeneration patterns

1. lid retraction with CN3 activation
2. pupil constriction with CN3 activation

218

traumatic 6th and/or 7th nerve palsy -> look at what region on CNS imaging?

where the mastoid air cells turn into petrous apex as the 2 nerves travel around there

219

Post-cataract findings
1. Elschnig Pearls
2. Soemmering's Rings

1. random proliferation of the cells which produce lens fibres, along the posterior capsule. Typically in eyes with no postop inflammation
2. regenerating lens substance that has a peripheral disposition