midterm new Flashcards by Norhannafarina Hamdag

Categories of Pupil Abnormalities

❖ ABNORMAL PUPIL SIZE
❖ ABNORMAL PUPIL REACTIONS

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❖ ABNORMAL PUPIL SIZE

Adie’s Tonic Pupil
Horner’s Syndrome

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Parasympathetic block

Adie’s Tonic Pupil

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Sympathetic block

Horner’s Syndrome

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❖ ABNORMAL PUPIL REACTIONS

Marcus Gunn Pupil
Parinaud’s Syndrome
Argyll Robertson Pupil

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Afferent Defect

Marcus Gunn Pupil

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Central Defect
Lesion is in interneurons
Affector->Physiological Connectors->Interneuron->PC->Effector

Parinaud’s Syndrome

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also a Central Defect othe than parinuad’s syndrome

Argyll Robertson Pupil

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Any lesion located from the retina to the pretectal nucleus is considered a _______________

relative afferent pupillary defect

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Any lesion located from preganglionic to postganglionic fiber is considered a _________

relative efferent pupillary defect

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➔ Also known as Relative Afferent Pupillary Defect (RAPD) / (APD) or pupillary escape

MARCUS GUNN PUPIL

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➔ This indicates damage at or anterior to the LGN (afferent pathway) specifically to the retinal ganglion cells to optic chiasm of one eye

MARCUS GUNN PUPIL

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➔ It is caused by a damage that is unilateral or asymmetric (never bilateral) as seen in several retinal diseases (severe), optic nerve disease, lesion behind the eye etc.

MARCUS GUNN PUPIL

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◆ Lesions behind the eye such as tumors developed at the optic nerve
◆ Retinal diseases such as DR
◆ Glaucoma (especially unilateral)
◆ Tumors such as pituitary adenoma (usually develops at optic chiasm)

MARCUS GUNN PUPIL

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➔ Always unilateral
➔ Defects are always on the retina itself or optic nerve all the way to optic chiasm (so, problems are also always in afferent)

MARCUS GUNN PUPIL

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➔ Location: anterior to the LGN

MARCUS GUNN PUPIL

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diseases that cause marcus gunn (6)

CRAO
CRVO
BRVO
Optic Atrophy
Marked Retinal Detachment
Asymmetric POAG

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Loss of vision due to: (5)

will not produce the Marcus Gunn response

corneal
lenticular
vitreous
refractive
emotional causes

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An _________ is anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass.

When this happens, the blood flow is stopped by the embolus. An embolus is often a small piece of a blood clot that breaks off (thromboembolus).

embolus

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An _____ is often a small piece of a blood clot that breaks off (thromboembolus).

embolus

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tell me what you see in a fundus

In the fundus, a small circle can be found which is the optic disc (always located nasally).
In the optic disc, the optic nerve is also present. Together with the optic nerve, there are blood vessels that can be seen. And from there, you can observe the thickest blood vessels. And usually, the optic nerve can also be seen together with the CRA and the CRV.

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The function of the Central retinal artery

supply oxygen, nutrients, etc to the retina.

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if there is clotting (thrombus, embolus, etc), it blocks the flow of blood vessels to enter inside the retina.

CRAO

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when CRA is blocked because of clotting, the retina will be affected and there will be a lack of _____

oxygen

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CRA is the main supply of _______ to the retina. (2)

nutrients oxygen

Expect a ________ since retina is damaged (no oxygen/nutrients supply)

Marcus Gunn pupil

In the optic disc, there are main blood vessels that branch out small blood vessels. These branches are blocked

Branch Retinal Vein Occlusion

Very common in end stage glaucoma (naipit na ang ON so hinay2 nangamatay ang ON fibers)

Optic Atrophy

atrophy means

degenerating/dying

Color of optic disc is ____ in retinal damage Normal is yellow.

PALE

is marcus gunn present when optic nerve is dead?

yes

it is a serious event, which may result in complete blindness. Retina, especially 1st and 2nd layers, is like a curtain which can be easily separated if there is a problem.

Marked Retinal Detachment

Common retinal detachments can be experienced to patients with severe:

diabetic retinopathy (end stage)

- Normal color of fundus:

red-orange

- When the retina is detached, some portion of the fundus will still appear red-orange, but the portion where retina is removed appears ____.

grayish

is when you shine a light in the fundus, it reflects back, so red-orange and that is the retina (as it receives the light). So when the retina is detached, there is also no red-orange reflex that can be seen, so it would be pale/grayish.

mechanism of an ophthalmoscopy

Other eye has glaucoma, the other has none.

Asymmetric Primary Open-Angle Glaucoma

type of glaucoma which is asymptomatic or “silent killer”

Open angle

type of glaucoma which is painful, “emergency”

Angle-closure

Glaucoma = increased IOP due to: (2)

A. Increased AH production B. Blocked drainage / trabecular meshwork

How does the AH flow inside the eye?

The AH originates at the ciliary process The AH travels to the posterior part of the iris then passes thru the pupil all the way to the anterior chamber The AH will now be drained in the trabecular meshwork. So if there are problems in the flow, glaucoma occurs.

When there is increased AH production, drainage can’t keep up. When there is too much AH, it pushes back the vitreous humor until the optic nerve will get stuck This only happens gradually, not immediately

OPEN ANGLE glaucoma

-Usual sign experienced by px with this type of glaucoma: sudden blackening of vision, then back to normal, black again, then normal..

open angle glaucoma

which part of the eye produces aqueous humor?

ciliary process

division of ciliary body

ciliary process ciliary body

muscle responsible for accommodation

ciliary muscle

category of glaucoma which is hereditary is nature

primary

category of glaucoma which is acquired

secondary

- Blocked trabecular meshwork - Most common is due to diabetic retinopathy (especially if px has no drug maintenance, either the eyes or kidneys will be affected)

CLOSE ANGLE GLAUCOMA

Our eyes are sensitive when it comes to changes in the blood If there is an increase in blood sugar, there will be a __________ Therefore, the retina will not get its nourishment.

decrease in oxygen in the eyes.

WHAT HAPPENS WHEN THERE'S LACK OF OXYGEN IN THE EYES

retina will produce its own blood vessels to have enough supply of blood

different stages of DR: (3)

(1) background, (2) non-proliferative, (3) proliferative

Proliferative means

growing

Type of DR where theres new blood vessels are developing in response to low oxygen in the eyes

Proliferative DR

new blood vessels are developing in response to low oxygen in the eyes but these new small blood vessels are very fragile. So they easily rupture. When small blood vessels rupture, it is called ___________.

microaneurysm

what is microaneurysm

when small bv rupture

initial symptom of microaneurysm

blurring of vision

Due to low oxygen of the eyes, the retina produces new blood vessels. To produce these new blood vessels, it also releases ____ therefore, producing small blood vessels, so it proliferates.

vascular endothelial growth factor (VEGF)

So if eyes continue to produce VEGF, from the posterior, it will travel to the anterior. So, as it travels to the anterior, the blood vessels of the iris will also proliferate due to VEGF. So with an increased VEGF, blood vessels will proliferate until the trabecular meshwork is blocked hence, glaucoma occurs. This type of angle-closure is specifically called:____

angle-closure neovascularization glaucoma

stimulates the formation of blood vessels

vascular endothelial growth factor

It is the most common type of glaucoma here in the PH

close angle glaucoma

Patient is in pain, an immediate emergency and surgery procedure is needed. But first, to relieve the pain, a mannitol is given to the px.

close angle glaucoma

close angle glaucoma symptoms (3)

dilated pupil swollen cornea (corneal edema) pale fundus.

patient has diabetes. Patient neglected it, px got diabetic retinopathy. His DR got worse, it became Proliferative DR, so the blood vessels inside the eyes are growing. Due to low oxygen because of increased blood sugar, new blood vessels are needed to form in order to supply the retina. However, these new blood vessels are very small and fragile. Therefore, it easily ruptures (microaneurysm). When the retina forms new blood vessels, it also releases a chemical called VEGF. This will then travel to the anterior chamber where the blood vessels of the iris will also proliferate causing the trabecular meshwork to be blocked. When TM is blocked, AH cannot be drained causing angle-closure neovascularization glaucoma.

Marcus Gunn Pupil – Method of Diagnosis

Method of diagnosis: Swinging Flashlight Test In an affected eye with Marcus Gunn, the consensual response is greater than the direct response.

A. When light is directed into the right eye → (normal direct and consensual response of that eye) → both eyes are smaller B. When light is directed into the left eye → (normal direct and consensual response of that eye) → both eyes are smaller C. Swinging the light back to the other eye causes normal pupil constriction.

Patient with No Pupillary Defect

A. When light is directed into the normal eye → (normal direct and consensual response of that eye) → both eyes are smaller B. When light is directed into the affected eye → both pupils are larger (slightly dilate) C. Swinging the light back to the other eyes causes normal pupil constriction.

Patient with Marcus Gunn

if it’s an afferent defect, the pathway is from the ____ (5) Any problem related to the retina and the optic nerve, it has a Marcus Gunn pupil.

retina, optic nerve, optic chiasm, optic tract before the LGN

➔ A parasympathetic condition that is central and bilateral in nature.

ARGYLL ROBERTSON PUPIL

➔ Characteristics of argyl robertson pupil

◆ Dilates poorly in the darkness ◆ Responds poorly or does NOT respond to light ◆ Normal near response (Light-near Dissociation)

➔ It is caused by any interruption in the pattern of CN2 to CN3 or Any interruption of both afferent pathway and the central inhibitory fibers VENTRAL to the aqueduct

ARGYLL ROBERTSON PUPIL

Common causes of argyll robertson pupil (3)

◆ Neurosyphilis (caused by treponema pallidum affect the CNS → Tabes dorsalis) – uses affects Edinger-Westphal nuclei ◆ Long term Diabetes ◆ Alcoholism

- Normal in near - Abnormal in direct and indirect light reflex - Lesion is commonly found in the EW. The PN is normal and intact.

argyl robertson pupil

Typically, the pupil constricts to light and dilates to dim light. The Argyll Robertson pupil occurs when a disease interferes with the light reflex pathway, thereby inhibiting the pupil’s natural response to bright light. Specifically, Argyll Robertson pupils don’t constrict in response to light but do constrict to focus on a nearby object. The presence of Argyll Roberton (AR) pupils is typically a highly specific sign of tertiary syphilis however, they can be caused by other underlying conditions, such as diabetes and multiple sclerosis.

Also known as Whore’s Pupil

ARP

Reasons why Argyll pupil is called as Whore: (2)

Multiple sex partner → syphilis (STD) It accommodates

Tertiary syphilis is the most common cause of the Argyll Roberston pupil. Caused by a bacteria called Treponema pallidum, syphilis is typically transmitted sexually, but the infection can also occur transplacentally, from an infected pregnant individual to their fetus. Over time, untreated syphilis can become tertiary syphilis, a late-stage infection marked by damage to the Edinger-Westphal nucleus, the part of the pupillary light reflex pathway in the brain that signals the pupil to constrict in response to bright light.

The bacteria, treponema pallidum, comes from the reproductive system then it will travel to the CNS to the brain to the spinal cord, causing _______.

syphilis

BACTERIA CAUSING SYPHILIS

treponema pallidum

Slowly progressive degeneration of the spinal cord that occurs in the tertiary (third) phase of a syphilis a decade or more after originally contracting the infection

Tabes Dorsalis / syphilitic myelopathy

■ Syphilis has 4 types:

a. Primary b. Secondary c. Latent d. Tertiary

■ When syphilis is left untreated for many years, it will manifest into ______

neurosyphilis

■ Syphilis is a sexually transmitted infection that is spread through direct sexual contact with ____. Can be treated.

syphilis sore

■ Tabes Dorsalis and Neurosyphilis will manifest in the ____

tertiary syphilis

○ This form of neurosyphilis is also rare. It can start to affect the spinal cord 20 years or more after the initial syphilis infection. ○ It is characterized by a triad of clinical symptoms namely gait, unsteadiness, lightning pains, and urinary incontinence.

● Tabes Dorsalis / syphilitic myelopathy

○ This form of neurosyphilis is also rare. It can start to affect the spinal cord 20 years or more after the initial syphilis infection.

● Tabes Dorsalis / syphilitic myelopathy

tabes dorsalis is characterized by a triad of clinical symptoms

gait unsteadiness lightning pains urinary incontinence.

Is a chronic disorder of carbohydrate metabolism due to relative or absolute insulin deficiency

Long-term Diabetes

Is a disease of the pancreas

Long-term Diabetes

When a person has diabetes, the _____either cannot produce enough insulin, uses the insulin incorrectly, or both

pancreas

organ secreting insulin

pancreas

There are 2 types of Diabetes:

A. Type 1 – hereditary B. Type 2 – acquired

Insulin works together with glucose (sugar) in the bloodstream to help it enter the body’s cells to be burned for _____. If the insulin isn’t functioning properly, glucose cannot _____the cells. This causes glucose levels in the blood to rise, creating a condition of high blood sugar or diabetes, and leaving the cells without fuel

energy enter

The normal flow of blood sugar in the body: Along the bloodstream, there are _____ (3).

nutrients oxygen glucose (sugar)

The normal flow of blood sugar in the body: Along the bloodstream, there are nutrients and oxygen, and also sugar (glucose). Glucose is responsible for cell metabolism for energy. Glucose needs to go to cells but before they enter into the cell, glucose will partner together with insulin (insulin comes from pancreas specifically in the islets of langerhans). Once cells receive glucose, they can work functionally because it now has energy.

insulin comes from pancreas specifically in the

islets of langerhans

The problem here is that the pancreas does not produce enough insulin. Therefore, only a small portion of glucose can enter the cells. The remaining portion remains in the bloodstream and will not be metabolized anymore, causing hyperglycemia.

TYPE 1 DIABETES

The problem here is that the person eats too much food. So when they eat too much, the fats will get stuck in the receptors of the cells. So, the insulin is normal and the glucose is now ready to partner with insulin, but both cannot enter in the cells because there is blockage of fats. Diet should consider low food intake and exercise more to burn the fats (cholesterol).

TYPE 2 DIABETES

Since glucose cannot pass and enter in the cell, the body ____. So what the patient does is he eats more and more food to get energy. So when a patient eats more, its manifestation is called as ____.

weakens polyphagia

type 2 diabetes: So when you eat more, blood sugar also increases (________) but still glucose cannot be utilized due to absence of insulin. So what the body does is to _______for the blood sugar to be flushed out. This is called ___

hyperglycemia urinate polyuria

So when a patient experiences excessive urination (______), he also experiences dehydration. So what the patient does is to always drink water

polyuria

Disorders with afferent pathway defect (3)

amaurotic pupil/ AAPD/TAPD marcus gunn pupil/ RAPD werncke's heminopic pupil

Disorders that has an efferent pathway defect (3)

argyll robertson pupil (ARP) tonic pupil/adie's pupil mydriasis

A_______ is a blood clot that forms in a vein.

thrombus

the medical term for always drinking water (excessive thirst).

polydipsia

abnormal pupil size refers to:

anisocoria

it is the difference with pupil size between the eyes

anisocoria

types of anisocoria

-physiological anisocoria -pathological anisocoria

type of anisocoria due to normal difference in balance or parasympathetic and sympathetic drive to the pupils

physiological anisocoria

hallmarks of physiological anisocoria (2)

- lessens when measure in bright light - brisk and normal measures in accommodative targets

a type of anisocoria due to the denervation of the sympathetic and parasympathetic block

pathological anisocoria

a type of abnormal pupil reaction where the defect is afferent

marcus gunn pupil

a type of abnormal pupil reaction where the defect is afferent

marcus gunn pupil

a type of abnormal pupil reaction where the defect is central (2)

parinaud's syndrome argyll robertson pupil

sympathetic vs parasympathetic NS type of metabolism

sympa- catabolic para- anabolic

sympathetic vs parasympathetic NS nickname

sympa- fight or flight system para- rest and repair system

other name based on locations

sympathetic vs parasympathetic NS other name based on locations

sympa- adrenergic/ thoracolumbar para- cholinergic/ craniosacral

sympathetic vs parasympathetic NS location of control

sympa- thoracic and upper lumbar segments of the spinal cord (T1-L2) para- brainstem and sacral spinal cord

sympathetic vs parasympathetic NS ocular structures

sympa- T1-T3 para- midbrain and pons paroli

sympathetic vs. parasympathetic NS outflow

sympa- spinal cord (T1-L2) para- cranial nerves (CN 3,7,9,10)

the sympa and para outflows are controlled by what?

hypothalamus

this integrates the anatomic and neuroendocrine system to preserve body homeostasis

hypothalamus

hypothalamus receives signals from all parts of the nervous system, afferent input from the viscera and information concerning the _____ in the blood, this input is integrated whitin the hypothalamus and transmitted to the lower centers in the ____ and spinal cord

hormone levels brainstem

oculat structures innervated by sympa NS vs. Para NS

sympa: dillator pupillae ciliary muscle (inhibitory effect) mueller's muscle lacrimal glands (hyposecretion) choroidal and conjuctival bv (constricted) para: shincter pupillae ciliary muscle (excitatory effect) lacrimal glands choroidal and conjunctival bv (dilated)

percentage of fibers (sphincter pupillae)

percentage of fibers (ciliary muscle)

97%

stimulation of ciliary muscles lead to what?

accommodation

stimulation of sphincter pupillae leads to?

miosis

cranial nerve right after nucleus

CN7

ventral root is between?

C1 and T2

what comes after vidian nerve?

maxillary nerve

CN3 leads to ____ division

superior

T1-T2 is the ciliospinal ____ of the bridge

center

hypothalamus is the _____ neuron

first/central neuron

addies tonic is a _______ block

parasympathetic block

it is the build up of protein amyloid

amyloidosis

5 conditions that can cause adie's tonic pupil

autonomic neuropathies amyloidosis herpes zoster orbital injury extensive panretinal coagulation or cryotherapy

the lesion in adies tonic is located at the

ciliary ganglion

it is the denervation of PG nerve supply of the short ciliary nerve to sphincter and ciliary muscle

adie's tonic pupil

what are the signs and symptoms of adie's tonic pupil? (8)

1. mydriasis and cycloplegia 2. internal ophthalmoplegia 3. light-near dissociation 4. slow constriction and reduction after light or near stimulus 5. oval pupil 6. sudden BOV 7. photophobia 8. reduction in knee jerk reflex

this type of disorder is common in young women (3rd to 5th decades) it is unilateral and the affected eye us dilated

adie's tonic pupil

this is a disorder which reacts poorly to light has a poor direct and consensual reponse

adie's tonic pupil

reacts strongly but slowly and tonic to near targets redilates very slowly when patient refixates at distance

adie's tonic pupil

method of diagnosis in adie's tonic pupil

raective with 0.125% pilocarpine (hyperactive since a normal eye reacts to 0.5%)

treatment of adie's tonic pupil

-directed towards the symptom -accommodation problem (bifocals) -photophobia (diluted pilocarpine or cosmetic contact lenses)

it is a sympathetic block where the lesion is at the superior cervical sympathetic ganglion or its pupillary fibers via nasociliary nerve, through long ciliary nerve which innervates

horner's syndrome

horner's syndrome is a sympathetic block where the lesion is at the _________ or its ______ via ______, through ______ which innervates: mueller's muscle dilator pupillae sweat glands of neck and face

superior cervical sympathetic ganglion pupillary fibers nasociliary nerve long ciliary nerve

in horner's syndrome, the long ciliary nerve which innervates: (3)

mueller's muscle dilator pupillae sweat glands of neck and face

common cause of horner's syndrome

lung cancer

types of sympathetic block in horner's syndrome:

preganglionic (neoplasm at brain) central (stroke) post ganglionic (vascular origin)

signs and symptoms of horner's syndrome (4)

-mueller's muscle at eyelid (lid retraction, sympathetic injury, partial blapharoptosis) -dilator pupillae (mydriasis, sympathetic injury, miosis) -sweatglands of neck and face (sweating, sympathetic injury, facial anhidrosis) + iris heterochromia (congenital) -pupils react normally to light and near

method of diagnosis in horner's syndrome

1. dark dilation test -> (2) 2.1 normal dilation 2.1.1 physiologic or benign anisocoria 2.2 delayed or incomplete dilation 2.2.1 cocain test 2.2.1.1 normal 2.2.1.2 pathologic 2.2.1.2.1 hydrosyamphetamine test 2.2.1.2.1.2 horner's syndrome 1st/2nd neuron lesion 2.2.1.2.1.2.2 horner's syndrome 3rd neuron lesion

it is a type of drug which is indirect acting from erythroxylon coca

cocaine

from erythroxylon coca, also has local anesthetic properly with ISA

cocaine

this drug's mechanism of action is it blocks reuptake of NE at post ganglionic nerve

cocaine

the ocular effects of cocaine: (3)

vasodilation local anesthesia mydriasis

this drug's mechanism of action is enhance the release of norepinephrine at post synaptic postganglionic neuron (3rd neuron)

1% hydroxyamphetmine

this drug's use if for mydriasis (central and preganglionic lesions) in postganglionic lesions, they don't dilate using this drug

1% hydroxyamphetmine

pinching neck should ______ pupil

dilate

cranial nerve for opening eye

CN3 oculomotor

cranial nerve for closing eye

CN 7 facial

ipsilateral

same side direct light reflex

contralateral

opposite side indirect

pupil have abnormal shape

dyscoria