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1

What does normal visual acuity imply?

1. ocular media are relatively clear 2. fovea centralis is intact. 3. CN II and visual pways are intact. 4. visual centers are intact

2

T or F: Normal visual acuity indicates that the eye is free of disease.

False - does NOT indicate lack of dz

3

What is the hardest letter to recognize?

B

4

What is the easiest letter to recognize?

L

5

What are the minimums for legal blindness?

< 20/200 in better eye OR a visual field that subtends an angle of <20 degrees

6

What chart do you use to indicate acuity for near vision?

Rosenbaum chart

7

What is known as "old vision"?

Presbyopia

8

What is presbyopia?

age-related loss of elasticity in lens => far-sightedness for near vision

9

Which msls are relaxed for far vision?

ciliary msls

10

When ciliary msls contract, what are they accomodating for?

near vision

11

What is known as the bending of light rays?

refraction (80% cornea, 20% lens)

12

What is emmetropia?

normal acuity (refraction of cornea and lens match the eye's length)

13

What is it called when parallel light rays come to focus in front of the retina?

refractive myopia and near-sightedness. (refractive power of cornea/lens is too great)

14

What is it called when parallel light rays come to focus way in front of the retina?

axial myopia/high myopia and extreme near-sightedness (eyeball is too long for refractive power of eye)

15

What condition would have an increased chance of retinal detachment?

axial myopia/high myopia/extreme near-sightedness

16

What is it called when parallel light rays come to focus behind the retina?

refractive hyperopia and far-sightedness (refractive power of cornea/lens is too little)

17

What is it called when parallel light rays come to focus way behind the retina?

axial hyperopia and extreme far-sightedness (eyeball too short for refractive power of eye)

18

What has an increased chance of acute glaucoma?

axial hyperopia and extreme far-sightedness

19

What is defined as "unequal refraction in different meridians of the eyeball"?

astigmatism

20

What does an astigmatism cause difficulties in seeing?

fine detail

21

What is a "regular" astigmatism?

different degrees of refraction in vertical and horizontal planes => two focal points (right angle)

22

What is an "irregular" astigmatism?

different degrees of refraction in 2 or more meridians (NOT at right angle)

23

What are objective blind spots when assessing peripheral vision called?

negative defects

24

What are perceived blind spots called when assessing visual fields?

positive defects

25

What is blindness in one half of the visual field of one or both eyes called?

hemianopia

26

What is blindness in one quarter of the visual field of one or both eyes called?

quadrantanopia

27

What would a lesion of the midline optic chiasm cause?

bitemporal hemianopia

28

What would a lesion of the right optic radiation cause?

left homonymous hemianopia w/ macular sparing

29

What is "blind island"?

scotoma

30

What are "blind islands"?

scotomata

31

What is the space b/t the lens and retina filled with?

vitreous

32

What is it called when the vitreous thins w/ age and possibly separates from the back of the eye?

posterior Vitreous detachment (PVD)

33

What are floaters caused by?

tiny bits of vitreous gel or cells that cast shadows on the retina

34

When do flashes occur?

when vitreous tugs on sensitive retina tissue

35

What does PERRLA stand for?

1. Pupils Equal in size and Round 2 pupils React to Light 3. pupils Accommodate to near vision

36

What is used to test the alignment of the eyes in a neutral position?

corneal reflection test

37

What does the cardinal fields of gaze assess?

1. fixation of eyes 2. conjugate pursuit movements ("yoked" EOMs)

38

T/F: Ptosis is not always neurologic in origin.

TRUE

39

What is the most common cause of congenital ptosis?

localized myogenic dysgenesis (no abnormalities in pupil size)

40

What is Horner syndrome aka? Are there abnormalities in pupil size?

congenital CN III palsy; there are abnormalities in pupil size

41

What is the most common cause of acquired ptosis?

acquired aponeurotic ptosis

42

What are the 2 main findings for acquired aponeurotic ptosis

1. lumps on eyelid (don't squeeze) 2. No abnormalities in pupil size

43

Are there abnormalities in pupil size with acquired Horner syndrome?

Yes

44

What is acquired myogenic ptosis aka?

ocular myasthenia gravis

45

What is pupillary dyscoria?

abnormalities in the shape of the pupil

46

What would malignant melanoma of the iris and ciliary body cause?

acquired coloboma

47

What is an apparent absence or defect of tissue?

coloboma

48

What is synechia?

adhesion of the iris to the cornea or lens (type of acquired coloboma)

49

What is inequality in pupil size?

anisocoria

50

How are the pupillary reflexes affected in physiologic anisocoria?

pupillary reflexes are intact

51

What type of anisocoria is seen in 20% of the population?

physiologic

52

What are the 3 types of anisocoria?

1. physiologic 2. pharmacologic 3. neurogenic

53

What is an example of neurogenic anisocoria that presents with a dilated pupil w/ sluggish and delayed rxns?

Right Adies tonic pupil/Adie's pupillotonia

54

What is Argyll-Robertsons pupil a highly specific sign of?

neurosyphilis/tabes dorsalis

55

How does acute iritis present?

painful, aching, bloodshot, small pupil (unequal size)

56

What is the most important thing to do when pt has a bloodshot eye?

compare pupil size side-to-side

57

Urgency or emergency: anterior uveitis?

true medical urgency

58

How does acute glaucoma present?

very painful, bloodshot, large pupil

59

Does acute iritis or acute glaucoma look worse?

acute iritis looks worse/acute glaucoma has worse prognosis

60

Urgency or emergency: acute glaucoma?

true medical emergency

61

How do you differentiate acute glaucoma/iritis from conjunctivitis/pink eye?

conjunctivits is not an intra-ocular inflammation. Conjunctivitis does NOT cause changes in pupillary size or shape

62

What is a normal variant called for pupillary rxn to light?

Hippus

63

What presents with excessive constriction of the pupil and possibly the pupil won't dilate in dark

miosis

64

What presents with excessive dilation of the pupil and possibly won't constrict in bright light?

mydriasis

65

What is the accommodation triad?

1. accomodative convergence 2. pupillary constriction 3. accommodation of lens for near vision

66

What an eye deviation that occurs when both eyes are open and uncovered?

tropia (detected by reflection test)

67

What is an eye deviation that occurs only when one eye is closed or covered?

phoria (not detected by reflection test)

68

What does the cover-uncover test detect?

Phoria

69

what are 2 normal variants for cardinal fields of gaze?

1. hyper-dominant eye 2. physiologic end-point nystagmus of brief duration

70

When will "undershoot" or "overshoot" be seen?

Pts w/ cerebellar dz OR acute alcohol intoxication (aka homeboy is wasted)

71

What are jittery eye movements an early indication of?

MS

72

What is known as non-paralytic strabismus?

concomitant strabismus/constant tropia

73

T/F: degree of deviation between the eyes with constant tropia varies with position of gaze.

False - does not vary

74

What does concomitant strabismus imply?

1. abnormality of msl origin or insertion 2. abnormality of msl length

75

What is seen with paralysis and/or restrictions to movement of EOMs?

non-concomitant strabismus/non-constant tropia

76

T/F: degree of deviation between the eyes with non-constant tropia varies with position of gaze.

True

77

What can cause restricted EOM movement?

1. ophthalmic Graves dz (hyperthyroidism) 2. orbital fx

78

Non-concomitant/non-constant EOM palsy will have the worst deviation and double vision occuring when the pt looks in what direction?

In the direction of the weak msl

79

What palsy presents with ptosis and marked eye deviation?

CN III palsy/oculomotor

80

What palsy presents with pt unable to move eye downward?

CN IV palsy/trochlear

81

What palsy presents with eye deviated inward from neutral position?

CN VI palsy/abducens (impaired outward gaze)

82

Which palsy is the most common CN anomaly?

CN VI palsy/abducens

83

Which palsy presents with a characteristic head tilt?

CN IV

84

What is eversion of the eyelid margin?

ectropion

85

What are the 2 types of acquired ectropion?

1. involutional (age-related laxity) 2. paralytic (CN VII)

86

What is an example of paralytic ectropion?

Bells palsy

87

What is inversion of the eyelid margin?

Entropion

88

What does acute spastic entropion result in?

orbicularis spasm overwhelms retractors of lower lid

89

What is a potential complication of entropion?

trichiasis (eyelashes irritate cornea)

90

What is anterior blepharitis?

Inflammation of eyelid margin (eyelashes and follicles)

91

What are 2 types of anterior blepharitis?

1. staphylococcal 2. seborrheic

92

What is posterior blepharitis?

inflammation of meibomian gland (internal hordeolum)

93

What does external hordeolum present with?

painful, localized, erythematous inflammation of eyelash follicle

94

What is external hordeolum aka?

stye

95

what causes most cases of hordeolum?

staph aureus

96

What increases the blockage rate of sebaceous glands?

High lipid levels

97

What is a chalazion aka?

retention cyst/internal stye/meibomian cyst/tarsal cyst

98

How does a chalazion present?

hard, painless swelling of eyelid d/t lipogranuloma formation

99

What may follow hordeola/blepharitis?

Chalazia

100

What is xanthelasma?

subcutaneous lipid depositions resulting in well-defined yellowish plaques that are often found near the medial canthus

101

Where is the lacrimal gland located?

superolateral aspect of orbital cavity

102

What is dacryoadenitits?

painful inflammation and swelling of lacrimal gland

103

What is keratoconjunctivitis sicca?

dry eyes d/t insufficient tear production (lacrimal gland)

104

What can KS be a component of?

Sjogren syndrome

105

What is sjogrens syndrome?

chronic autoimmune disorder with xerostomia, xeropthalmia, and lymphocytic infiltrations of exocrine glands

106

Where is the lacrimal sac?

superior end of nasolacrimal duct

107

What is dacryocystitis?

infection of the lacrimal sac

108

What is injection?

Bloodshot eye

109

What is covered by the non-visual portion of the cornea?

limbus of the iris

110

What is a peri-limbal injection?

vasodilation near the limbus of the eye

111

What implies conjunctival irritation near the cornea with no peri-limbal injection and no intra-ocular involvement?

peri-corneal injection

112

How does mixed ciliary and conjunctival injection present?

The peri-limbal injection implies corneal disease with intra-ocular involvement

113

How does ciliary injection present?

The peri-limbal injection implies inflammation of deeper structures with intra-ocular involvement

114

What is defined as a highly vascular, transparent, modified mucous membrane that is not very pain-sensitive?

conjunctiva

115

What are the 3 parts of the conjunctiva?

1. palpebral (thicker layer, inner surface of eyelids) 2. fornix (junction of palpebral and ocular conjunctiva) 3. ocular conjunctiva (thinner layer, non-corneal)

116

What is the difference between peri-corneal injection and conjunctivitis?

Aside from location of redness, findings are the same. Peri-corneal is very localized to conjunctiva near non-visual portion of cornea.

117

What is the most important clinical feature of acute allergic conjunctivitis?

Ocular itching

118

What is chemosis?

conjunctival edema (milky appearance)

119

What could cause a possible lymphoid follicular response?

acute allergic conjunctivitis

120

What is adenoviral conjunctivitis aka?

pink eye

121

What is the most common cause of viral conjunctivitis?

adenovirus

122

What are the common pathogens in children that can lead to acute bacterial conjunctivitis?

staph pneumonia and h. influenza

123

What is considered a strong predictor of acute bacterial conjunctivitis?

mucopurulent discharge that crusts the eyelashes

124

What is the potential problem with bacterial conjunctivitis involving gonorrhea and chlamydia?

infection spreading to the cornea (starts eating away cornea)

125

What provides about 85% of refractive power of the eye?

cornea

126

What are the characteristics of the cornea?

transparent, multi-layered, avascular

127

What is common with foreign bodies near the limbus?

peri-corneal injection

128

What is a possible concern for peri-corneal injection?

keratoconjunctivitis

129

How does the cornea appear with corneal dz?

Cloudy/hazy

130

Is PERRLA intact with corneal dz?

yes

131

What is considered pain-sensitive and possibly the most densely innervated tissue in mammals?

cornea

132

How can the cornea eventually become pain-insensitive?

infections/lesions that can ulcerate the cornea

133

How do pts with keratitis d/t herpes simplex present?

vesicular eruptions, photophobia, blurred vision

134

What is the most common cause of blindness in the US?

herpes simplex keratitis

135

what is the most common cause of blindness in the world?

chlamydial keratitis (d/t inadequate sanitation)

136

What does gonococcal keratitis present with?

copious purulent discharge, blurred vision d/t ulcerative keratitis

137

Urgency or emergency: gonococcal keratitis?

ophthalmologic emergency (=> perforation of cornea)

138

What produces aqueous humor?

ciliary body

139

What is normal intra-ocular pressure?

14-20 mmHg

140

What are the indications of a deeper inflammation involving the iridocorneal angle/ciliary body?

mixed conjunctival and ciliary injection, ciliary injection, pupil is NOT normal, NO PERRLA

141

What is acute glaucoma aka?

closed-angle glaucoma

142

What is a predisposing factor for acute primary angle closure glaucoma?

a "crowded" anterior chamber

143

What is acute iritis?

inflammation in the anterior chamber (aka anterior uveitis)

144

Does scleritis present with pain?

Yes, almost always painful

145

How does allergic conjunctivitis present?

Itching, burning

146

Describe the discharge for bacterial conjunctivitis?

mucopurulent

147

How does ulcerative keratitis present?

purulent discharge, photophobia, and visual changes

148

How does scleritis present?

pain, photophobia, and possible visual reduction

149

How does acute iritis present?

"ache", photophobia, mild to moderate reduction of vision, pupils small and slow to react

150

How does acute glaucoma present?

moderate to severe pain, photophobia, severely reduced vision, pupils are larger and non-reactive

151

What is described as a rupture of conjunctival and/or episclerotic blood vessels with bleeding into the potential space b/t the conjunctiva and sclera?

subconjunctival hemorrhage

152

What can cause subconjunctival hemorrhage?

local hypertension, coughing, vomiting or straining

153

What is described as accumulation of blood in the anterior chamber following trauma?

traumatic hyphema

154

What is described as elevated benign, yellow fibrovascular connective tissue masses?

pinguecula

155

What is described as a benign, fleshy, wing-like fibrovascular connective tissue growth?

pterygium

156

What does a normal optic disc look like?

flat, well defined margins, bilaterally equal size, round

157

What is the cup-to-disc ratio?

1 to 2

158

What are the objectives of an opthalmoscopic exam?

1. check red reflex 2. examine the fundus of the eye

159

What are linear splinter hemorrhages?

small, superficial intra-retinal hemorrhages

160

What are linear flame hemorrhages?

larger superficial intra-retinal hemorrhages

161

What are round dot microaneurysms?

deeper intra-retinal micro-aneurysms that may hemorrhage

162

What are round blot hemorrhages?

deeper intra-retinal hemorrhages (assoc w/ diabetic retinopathy)

163

What causes soft exudates/cotton wool spots?

occlusion of pre-capillary retinal arterioles

164

What causes hard exudates/lipoid exudates?

leaky capillaries or micro-aneurysms. Often appear in rings

165

What is papilledema aka?

"choked disc"

166

What is papilledema caused by?

increased intra-cranial pressure. Possibly d/t grade IV HTN

167

What is a cataract?

"waterfall", any opacity in the lens

168

What is the most common cause of cataract formation?

aging

169

What is in charge of the fine tuning of the eye?

lens

170

What type of cataracts have less of an impact on vision?

cortical (radial or spoke-like appearance)

171

What type of cataracts lead to trouble with vision?

nuclear (yellow-brown deposits and sclerosis)

172

How do nuclear cataracts appear?

black on red-reflex (mature is visible to naked eye)

173

What is the most common age-related cataract?

posterior subcapsular cataracts

174

What is the prime symptom of age-related cataract formation?

decreased visual acuity (hazy or fuzzy vision)

175

What does the screening exam for cataracts involve?

cataracts cast opacities/shadows/dots in the red reflex

176

What is the second leading cause of IRREVERSIBLE blindness in the US?

Glaucoma

177

What is primary open-angle glaucoma?

dysfunction of trabecular meshwork over the canal of Schlemm

178

In which ethnicity is glaucoma more common?

3-5x more common in African Americans

179

What is the classic progression of POAG?

gradual and insidious increase in IOP. Can lead to atrophy of optic n., displacement of physiologic cup, and nasal displacement of retinal vessels

180

What is known as the "sneak thief of vision"?

POAG

181

What is the first indication of POAG?

slow progressive loss of peripheral vision

182

What is tonometry?

measurement of intra-ocular pressure

183

What is perimetry?

testing of visual fields

184

What should you look for while performing an ophthalmoscopic exam of the optic disc (for POAG)?

increased cup-to-disc ratio, nasal displacement of retinal vessels, loss of continuity of retinal vessels, optic nerve atrophy

185

What is gonioscopy?

assessment of the iridocorneal angle

186

What does the degree of glaucomatous cupping correlate with?

degree of vision loss

187

What is papilledema?

optic disc swelling d/t increased intracranial pressure (vision usually preserved, no pain)

188

What is splinter hemorrhage caused by?

HTN. Can be observed in papilledema at the disc margin

189

What can be observed in advanced papilledema?

obliterated cup, flame hemorrhages (optic disc), soft exudates (cotton wool spots, retina), hard exudates (lipoid exudates, disc margins), vision problems

190

What is one of the target/end organs of systemic HTN?

the eye

191

What is copper wire deformity associated with?

Stage I hypertensive retinopathy

192

What is A-V nicking assoc. with?

Stage II hypertensive retinopathy (advanced)

193

What is present in early malignant hypertensive retinopathy (stage III)?

flame and splinter hemorrhages, soft exudates, poss. Areas of retinal edema

194

What is present in advanced malignant hypertensive retinopathy (KWB stage IV)?

swollen disc/choked disc/ischemic papilledema

195

What are the ways diabetes can cause vision changes?

1. transient refractive errors 2. diabetic cataracts 3. glaucoma 4. diabetic retinopathy 5. diabetic macular edema

196

What percentage of diabetic pts have some degree of retinopathy after 20 years?

Type 1 = nearly all Type 2= 60%

197

T/F: Diabetic retinopathy has more impact on the retinal arteries.

False - retinal veins

198

What is the earliest clinical sign of diabetic retinopathy?

microaneurysms

199

Dot and blot and flame hemorrhages, plus soft and hard exudates, and retinal edema are present in what kind of diabetic retinopathy?

non-proliferative

200

What is the typical complaint in a pt with advanced macular edema?

distorted central vision (tested with Amsler grid)

201

What are the common S/Sx of macular dz?

progressive blurring/loss of central visual acuity, image distortion, central blind spot (scotoma)

202

What are the 2 most common causes of adult-onset legal blindness in the US?

1. macular degeneration 2. diabetic retinopathy

203

What takes care of the macular blood supply?

capillary beds in the choroid layer

204

What is the most common cause of reduced vision in the elderly?

age-related macular degeneration

205

What is dry (atrophic) macular degeneration?

macular dz without choroidal neovascularization, an ischemic macular degeneration with Drusen formation

206

What is wet (exudative) macular degeneration?

macular dz with choroidal neovascularization (85-90% of AMD cases)

207

What could be considered a retinal detachment prodrome?

a sudden "shower of spots" (photopsia or floaters)