Flashcards in Final Deck (207)
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
T or F: Normal visual acuity indicates that the eye is free of disease.
False - does NOT indicate lack of dz
What is the hardest letter to recognize?
What is the easiest letter to recognize?
What are the minimums for legal blindness?
< 20/200 in better eye OR a visual field that subtends an angle of <20 degrees
What chart do you use to indicate acuity for near vision?
What is known as "old vision"?
What is presbyopia?
age-related loss of elasticity in lens => far-sightedness for near vision
Which msls are relaxed for far vision?
When ciliary msls contract, what are they accomodating for?
What is known as the bending of light rays?
refraction (80% cornea, 20% lens)
What is emmetropia?
normal acuity (refraction of cornea and lens match the eye's length)
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)
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)
What condition would have an increased chance of retinal detachment?
axial myopia/high myopia/extreme near-sightedness
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)
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)
What has an increased chance of acute glaucoma?
axial hyperopia and extreme far-sightedness
What is defined as "unequal refraction in different meridians of the eyeball"?
What does an astigmatism cause difficulties in seeing?
What is a "regular" astigmatism?
different degrees of refraction in vertical and horizontal planes => two focal points (right angle)
What is an "irregular" astigmatism?
different degrees of refraction in 2 or more meridians (NOT at right angle)
What are objective blind spots when assessing peripheral vision called?
What are perceived blind spots called when assessing visual fields?
What is blindness in one half of the visual field of one or both eyes called?
What is blindness in one quarter of the visual field of one or both eyes called?
What would a lesion of the midline optic chiasm cause?
What would a lesion of the right optic radiation cause?
left homonymous hemianopia w/ macular sparing
What is "blind island"?
What are "blind islands"?
What is the space b/t the lens and retina filled with?
What is it called when the vitreous thins w/ age and possibly separates from the back of the eye?
posterior Vitreous detachment (PVD)
What are floaters caused by?
tiny bits of vitreous gel or cells that cast shadows on the retina
When do flashes occur?
when vitreous tugs on sensitive retina tissue
What does PERRLA stand for?
1. Pupils Equal in size and Round 2 pupils React to Light 3. pupils Accommodate to near vision
What is used to test the alignment of the eyes in a neutral position?
corneal reflection test
What does the cardinal fields of gaze assess?
1. fixation of eyes 2. conjugate pursuit movements ("yoked" EOMs)
T/F: Ptosis is not always neurologic in origin.
What is the most common cause of congenital ptosis?
localized myogenic dysgenesis (no abnormalities in pupil size)
What is Horner syndrome aka? Are there abnormalities in pupil size?
congenital CN III palsy; there are abnormalities in pupil size
What is the most common cause of acquired ptosis?
acquired aponeurotic ptosis
What are the 2 main findings for acquired aponeurotic ptosis
1. lumps on eyelid (don't squeeze) 2. No abnormalities in pupil size
Are there abnormalities in pupil size with acquired Horner syndrome?
What is acquired myogenic ptosis aka?
ocular myasthenia gravis
What is pupillary dyscoria?
abnormalities in the shape of the pupil
What would malignant melanoma of the iris and ciliary body cause?
What is an apparent absence or defect of tissue?
What is synechia?
adhesion of the iris to the cornea or lens (type of acquired coloboma)
What is inequality in pupil size?
How are the pupillary reflexes affected in physiologic anisocoria?
pupillary reflexes are intact
What type of anisocoria is seen in 20% of the population?
What are the 3 types of anisocoria?
1. physiologic 2. pharmacologic 3. neurogenic
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
What is Argyll-Robertsons pupil a highly specific sign of?
How does acute iritis present?
painful, aching, bloodshot, small pupil (unequal size)
What is the most important thing to do when pt has a bloodshot eye?
compare pupil size side-to-side
Urgency or emergency: anterior uveitis?
true medical urgency
How does acute glaucoma present?
very painful, bloodshot, large pupil
Does acute iritis or acute glaucoma look worse?
acute iritis looks worse/acute glaucoma has worse prognosis
Urgency or emergency: acute glaucoma?
true medical emergency
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
What is a normal variant called for pupillary rxn to light?
What presents with excessive constriction of the pupil and possibly the pupil won't dilate in dark
What presents with excessive dilation of the pupil and possibly won't constrict in bright light?
What is the accommodation triad?
1. accomodative convergence 2. pupillary constriction 3. accommodation of lens for near vision
What an eye deviation that occurs when both eyes are open and uncovered?
tropia (detected by reflection test)
What is an eye deviation that occurs only when one eye is closed or covered?
phoria (not detected by reflection test)
What does the cover-uncover test detect?
what are 2 normal variants for cardinal fields of gaze?
1. hyper-dominant eye 2. physiologic end-point nystagmus of brief duration
When will "undershoot" or "overshoot" be seen?
Pts w/ cerebellar dz OR acute alcohol intoxication (aka homeboy is wasted)
What are jittery eye movements an early indication of?
What is known as non-paralytic strabismus?
concomitant strabismus/constant tropia
T/F: degree of deviation between the eyes with constant tropia varies with position of gaze.
False - does not vary
What does concomitant strabismus imply?
1. abnormality of msl origin or insertion 2. abnormality of msl length
What is seen with paralysis and/or restrictions to movement of EOMs?
non-concomitant strabismus/non-constant tropia
T/F: degree of deviation between the eyes with non-constant tropia varies with position of gaze.
What can cause restricted EOM movement?
1. ophthalmic Graves dz (hyperthyroidism) 2. orbital fx
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
What palsy presents with ptosis and marked eye deviation?
CN III palsy/oculomotor
What palsy presents with pt unable to move eye downward?
CN IV palsy/trochlear
What palsy presents with eye deviated inward from neutral position?
CN VI palsy/abducens (impaired outward gaze)
Which palsy is the most common CN anomaly?
CN VI palsy/abducens
Which palsy presents with a characteristic head tilt?
What is eversion of the eyelid margin?
What are the 2 types of acquired ectropion?
1. involutional (age-related laxity) 2. paralytic (CN VII)
What is an example of paralytic ectropion?
What is inversion of the eyelid margin?
What does acute spastic entropion result in?
orbicularis spasm overwhelms retractors of lower lid
What is a potential complication of entropion?
trichiasis (eyelashes irritate cornea)
What is anterior blepharitis?
Inflammation of eyelid margin (eyelashes and follicles)
What are 2 types of anterior blepharitis?
1. staphylococcal 2. seborrheic
What is posterior blepharitis?
inflammation of meibomian gland (internal hordeolum)
What does external hordeolum present with?
painful, localized, erythematous inflammation of eyelash follicle
What is external hordeolum aka?
what causes most cases of hordeolum?
What increases the blockage rate of sebaceous glands?
High lipid levels
What is a chalazion aka?
retention cyst/internal stye/meibomian cyst/tarsal cyst
How does a chalazion present?
hard, painless swelling of eyelid d/t lipogranuloma formation
What may follow hordeola/blepharitis?
What is xanthelasma?
subcutaneous lipid depositions resulting in well-defined yellowish plaques that are often found near the medial canthus
Where is the lacrimal gland located?
superolateral aspect of orbital cavity
What is dacryoadenitits?
painful inflammation and swelling of lacrimal gland
What is keratoconjunctivitis sicca?
dry eyes d/t insufficient tear production (lacrimal gland)
What can KS be a component of?
What is sjogrens syndrome?
chronic autoimmune disorder with xerostomia, xeropthalmia, and lymphocytic infiltrations of exocrine glands
Where is the lacrimal sac?
superior end of nasolacrimal duct
What is dacryocystitis?
infection of the lacrimal sac
What is injection?
What is covered by the non-visual portion of the cornea?
limbus of the iris
What is a peri-limbal injection?
vasodilation near the limbus of the eye
What implies conjunctival irritation near the cornea with no peri-limbal injection and no intra-ocular involvement?
How does mixed ciliary and conjunctival injection present?
The peri-limbal injection implies corneal disease with intra-ocular involvement
How does ciliary injection present?
The peri-limbal injection implies inflammation of deeper structures with intra-ocular involvement
What is defined as a highly vascular, transparent, modified mucous membrane that is not very pain-sensitive?
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)
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.
What is the most important clinical feature of acute allergic conjunctivitis?
What is chemosis?
conjunctival edema (milky appearance)
What could cause a possible lymphoid follicular response?
acute allergic conjunctivitis
What is adenoviral conjunctivitis aka?
What is the most common cause of viral conjunctivitis?
What are the common pathogens in children that can lead to acute bacterial conjunctivitis?
staph pneumonia and h. influenza
What is considered a strong predictor of acute bacterial conjunctivitis?
mucopurulent discharge that crusts the eyelashes
What is the potential problem with bacterial conjunctivitis involving gonorrhea and chlamydia?
infection spreading to the cornea (starts eating away cornea)
What provides about 85% of refractive power of the eye?
What are the characteristics of the cornea?
transparent, multi-layered, avascular
What is common with foreign bodies near the limbus?
What is a possible concern for peri-corneal injection?
How does the cornea appear with corneal dz?
Is PERRLA intact with corneal dz?
What is considered pain-sensitive and possibly the most densely innervated tissue in mammals?
How can the cornea eventually become pain-insensitive?
infections/lesions that can ulcerate the cornea
How do pts with keratitis d/t herpes simplex present?
vesicular eruptions, photophobia, blurred vision
What is the most common cause of blindness in the US?
herpes simplex keratitis
what is the most common cause of blindness in the world?
chlamydial keratitis (d/t inadequate sanitation)
What does gonococcal keratitis present with?
copious purulent discharge, blurred vision d/t ulcerative keratitis
Urgency or emergency: gonococcal keratitis?
ophthalmologic emergency (=> perforation of cornea)
What produces aqueous humor?
What is normal intra-ocular pressure?
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
What is acute glaucoma aka?
What is a predisposing factor for acute primary angle closure glaucoma?
a "crowded" anterior chamber
What is acute iritis?
inflammation in the anterior chamber (aka anterior uveitis)
Does scleritis present with pain?
Yes, almost always painful
How does allergic conjunctivitis present?
Describe the discharge for bacterial conjunctivitis?
How does ulcerative keratitis present?
purulent discharge, photophobia, and visual changes
How does scleritis present?
pain, photophobia, and possible visual reduction
How does acute iritis present?
"ache", photophobia, mild to moderate reduction of vision, pupils small and slow to react
How does acute glaucoma present?
moderate to severe pain, photophobia, severely reduced vision, pupils are larger and non-reactive
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?
What can cause subconjunctival hemorrhage?
local hypertension, coughing, vomiting or straining
What is described as accumulation of blood in the anterior chamber following trauma?
What is described as elevated benign, yellow fibrovascular connective tissue masses?
What is described as a benign, fleshy, wing-like fibrovascular connective tissue growth?
What does a normal optic disc look like?
flat, well defined margins, bilaterally equal size, round
What is the cup-to-disc ratio?
1 to 2
What are the objectives of an opthalmoscopic exam?
1. check red reflex 2. examine the fundus of the eye
What are linear splinter hemorrhages?
small, superficial intra-retinal hemorrhages
What are linear flame hemorrhages?
larger superficial intra-retinal hemorrhages
What are round dot microaneurysms?
deeper intra-retinal micro-aneurysms that may hemorrhage
What are round blot hemorrhages?
deeper intra-retinal hemorrhages (assoc w/ diabetic retinopathy)
What causes soft exudates/cotton wool spots?
occlusion of pre-capillary retinal arterioles
What causes hard exudates/lipoid exudates?
leaky capillaries or micro-aneurysms. Often appear in rings
What is papilledema aka?
What is papilledema caused by?
increased intra-cranial pressure. Possibly d/t grade IV HTN
What is a cataract?
"waterfall", any opacity in the lens
What is the most common cause of cataract formation?
What is in charge of the fine tuning of the eye?
What type of cataracts have less of an impact on vision?
cortical (radial or spoke-like appearance)
What type of cataracts lead to trouble with vision?
nuclear (yellow-brown deposits and sclerosis)
How do nuclear cataracts appear?
black on red-reflex (mature is visible to naked eye)
What is the most common age-related cataract?
posterior subcapsular cataracts
What is the prime symptom of age-related cataract formation?
decreased visual acuity (hazy or fuzzy vision)
What does the screening exam for cataracts involve?
cataracts cast opacities/shadows/dots in the red reflex
What is the second leading cause of IRREVERSIBLE blindness in the US?
What is primary open-angle glaucoma?
dysfunction of trabecular meshwork over the canal of Schlemm
In which ethnicity is glaucoma more common?
3-5x more common in African Americans
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
What is known as the "sneak thief of vision"?
What is the first indication of POAG?
slow progressive loss of peripheral vision
What is tonometry?
measurement of intra-ocular pressure
What is perimetry?
testing of visual fields
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
What is gonioscopy?
assessment of the iridocorneal angle
What does the degree of glaucomatous cupping correlate with?
degree of vision loss
What is papilledema?
optic disc swelling d/t increased intracranial pressure (vision usually preserved, no pain)
What is splinter hemorrhage caused by?
HTN. Can be observed in papilledema at the disc margin
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
What is one of the target/end organs of systemic HTN?
What is copper wire deformity associated with?
Stage I hypertensive retinopathy
What is A-V nicking assoc. with?
Stage II hypertensive retinopathy (advanced)
What is present in early malignant hypertensive retinopathy (stage III)?
flame and splinter hemorrhages, soft exudates, poss. Areas of retinal edema
What is present in advanced malignant hypertensive retinopathy (KWB stage IV)?
swollen disc/choked disc/ischemic papilledema
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
What percentage of diabetic pts have some degree of retinopathy after 20 years?
Type 1 = nearly all Type 2= 60%
T/F: Diabetic retinopathy has more impact on the retinal arteries.
False - retinal veins
What is the earliest clinical sign of diabetic retinopathy?
Dot and blot and flame hemorrhages, plus soft and hard exudates, and retinal edema are present in what kind of diabetic retinopathy?
What is the typical complaint in a pt with advanced macular edema?
distorted central vision (tested with Amsler grid)
What are the common S/Sx of macular dz?
progressive blurring/loss of central visual acuity, image distortion, central blind spot (scotoma)
What are the 2 most common causes of adult-onset legal blindness in the US?
1. macular degeneration 2. diabetic retinopathy
What takes care of the macular blood supply?
capillary beds in the choroid layer
What is the most common cause of reduced vision in the elderly?
age-related macular degeneration
What is dry (atrophic) macular degeneration?
macular dz without choroidal neovascularization, an ischemic macular degeneration with Drusen formation
What is wet (exudative) macular degeneration?
macular dz with choroidal neovascularization (85-90% of AMD cases)