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Physical Exam 2 Didactic Midterm > Ophthalmic Exam > Flashcards

Ophthalmic Exam Flashcards

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1
Q

define triage timelines

A
  • Emergent – Requires care within 1 hour
  • Urgent – Requires care within 4 to 6 hours
  • Semi-urgent – Requires care within 24 hours
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2
Q

give examples of emergent eye conditions

A

Chemical Splash/ Burn

Painless Unilateral Vision Loss:

  • Central Retinal Artery Occlusion
  • Arteritic Anterior Ischemic Optic Neuropathy secondary to GCA

Acute Ocular Trauma

  • blow out fx
  • Enophthalmos and/or vertical displacement of eye

Penetrating Injury

Severe Unilat Pain w/Vision Loss

  • Acute Angle Closure Glaucoma

Cellulitis: periorbital

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3
Q

give examples of urgent eye conditions

A

FB

Corneal Abrasion

Sudden Onset Diplopia:

  • oculomotor palsy III
  • Trochlear palsy IV
  • abudcens palsy VI

Acute Onset Flashes and Floaters

  • Posterior Vitreal Detachment (PVD)
  • Retinal Detachment (RD)

Sudden Onset Red Eye

  • Subconjunctival Hemorrhage
  • Conjunctivitis - viral, bacterial, Epidemic Keratoconjunctivitis, allergic
  • Keratitis – Microbial Keratitis aka Corneal Ulcer, Herpes Simplex
  • Uveitis (Iritis) - Acute Anterior Uveitis
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4
Q

give examples of semi-urgent eye conditions

A

Chalazion

Hordeolum (stye)

Cellulitis –

  • Preseptal Cellulitis:
  • Orbital Cellulitis: EMERGENCY STAT opth consult, hospitalzation
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5
Q

Tx of chemical burns/ splashes

A

IRRIGATE min 30 mins - normal saline is best, use tap water if thats all you have

determine ofending chemical and pH - normal 7.0-7.3

STAT ophthal consult through ED once pH is normalized

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6
Q

when dealing w/ a Penetrating Injury is it important to ALWAYS -

A

Cover eye with shield and send for STAT ophthalmology consult through ED

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7
Q

emergent causes of Painless Unilateral Vision Loss

diagnostic characteristic?

A

Central Retinal Artery Occlusion

  • VA in range of counts fingers to NLP
  • Usually patient with Hx of HTN, carotid occlusive disease, cardiac valve disease – typically secondary to arterial embolus to eye via Ophthalmic Artery
  • Will see diffuse whitening of retina with “cherry red spot” in macula
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8
Q

Nonarteritic Anterior Ischemic Optic Neuropathy si/sx

A

EMERGENT Painless Unilateral Vision Loss

If loss reported upon awakening

note inferior hemisphere field loss +/- good to fair VA

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9
Q

Secondary to transient non/hypo-perfusion of Short Posterior Ciliary Arteries surrounding/nourishing the optic nerve

Will see optic nerve head edema +/- splinter hemorrhages

A

Nonarteritic Anterior Ischemic Optic Neuropathy

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10
Q

In patient presenting w/ Painless Unilateral Vision Loss

Consider Arteritic Anterior Ischemic Optic Neuropathy secondary to Giant Cell Arteritis if:

A
  • Patient >55yo
  • Temporal scalp tenderness +/- jaw claudication
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11
Q

emergent Severe Unilat Pain w/Vision Loss is likely ??

A

Acute Angle Closure Glaucoma

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12
Q

Si/Sx Acute Angle Closure Glaucoma

A

Severe Unilat Pain w/Vision Loss

nausea/vomiting,

reporting rainbow or halos around lights

Vision reduced secondary to hazy, edematous cornea

IOP >45mmHg

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13
Q

Tx Acute Angle Closure Glaucoma

A

RAPIDLY ↓IOP

  • topical BB - (timolol)
  • CAI (dorzolamide, brinzolamide)
  • alpha agonist (apraclonidine)
  • PO acetazolamide or methazolamide

Requires STAT referral to ophthalmology for LPI once edema clears

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14
Q

Tx FB

A

Superficial - irrigate out

Cotton tipped swab, sponge spear or 25G or smaller needle - oblique approach with bevel up tangent to surface

Rx broad-spectrum antibiotic QID – tobramycin

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15
Q

NEVER Rx anesthetic bc??

A

melt the cornea

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16
Q

Tx corneal abrasion

A

topical broad-spectrum AB QID – tobramycin

Possibly bandage CL for comfort if defect extensive

Homatropine cycloplegia to relax Ciliary Body and decrease pain

PO analgesics as required

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17
Q

proper technique to remove corneal abrasion

A
  • Remove gently from edge of defect in toward center of defect with spud or other fine instrument
  • Attempting to remove in opposite direction may result in healthy tissue being removed
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18
Q

Sudden Onset Diplopia is caused by?

A

nerve palsy

III – Oculomotor:

IV – Trochlear

VI – Abducens -

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19
Q

CN III Palsy – Oculomotor is an emergency IF??

A

•aneurysm -> pupil fixed and dilated or minimally reactive

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20
Q

muscle innervation

III – Oculomotor:

IV – Trochlear

VI – Abducens

A

III – Oculomotor: Superior, Inferior, Medial Rectus, Inferior Oblique, Levator Palpebrae

  • Anyueisms
  • Microvascular

IV – Trochlear –> Superior Oblique

VI – Abducens –> Lateral Rectus

  • In adults, due to:
  • Microvascular disease
  • Lesion in Cavernous Sinus
  • Trauma
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21
Q

Etiology & Si/Sx of CN III Palsy

A

CN III Palsy – Oculomotor

Si/Sx

Eye is down and out

upper lid ptosis

pupil dilated (microvasc vs aneurysm)

  • aneurysm - pupil fixed and dilated or minimally reactive
  • Microvascular - pupil normally reactive secondary to DM or other systemic disease
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22
Q

differentiating b/w causes of CN III palsy

  • Aneurisms
  • Microvascular
A

look at pupil!!

aneurysm - pupil fixed and dilated or minimally reactive

•Microvascular - _pupil normally reactiv_e secondary to DM or other systemic disease

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23
Q

Si/Sx of CN IV palsy

A

trochlear

Vertical/tilted diplopia with compensatory head tilt to opposite side,

•Diplopia worse in downgaze (SO - non-emergent)

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24
Q

Si/sx CN VI palsy

causes in adults?

A

abducens

Horizontal diplopia with affected eye turned in (LR)

•In adults, due to:

  • Microvascular disease
  • Lesion in Cavernous Sinus
  • Trauma
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25
dx?
CN III palsy oculomotor ## Footnote Eye is down and out upper lid ptosis pupil dilated (microvasc vs aneurysm)
26
dx?
VI – Abducens •Horizontal diplopia with affected eye turned in (LR)
27
Acute Onset Flashes and Floaters dx? causes?
**Posterior Vitreal Detachment (PVD)** - \>50yo **Retinal Detachment (RD)** - younger pt * trauma * high myopia * recent ophthalmic surgery
28
si/sx of ## Footnote Posterior Vitreal Detachment (PVD) vs Retinal Detachment (RD)
Flashes that were followed by floaters ## Footnote **PVD** - no loss/decrease vision and no peripheral field loss **RD** - sense of a veil or shade being pulled over visual field
29
Most common reason patient presents for emergent eye care
Sudden Onset Red Eye
30
Sudden Onset Red Eye is likely caused by
Subconjunctival Hemorrhage Conjunctivitis Keratitis – serious Uveitis (Iritis)
31
Sudden Onset Red Eye that is typically noticed by someone else
Subconjunctival Hemorrhage
32
QuickVue (Quidel) point-of-care test help dx?
Viral Conjunctivitis - test for adenovirus
33
Pseudomembrane is seen w/ what type of conjunctivitis
Epidemic Keratoconjunctivitis
34
what is the "Rule of 8’s” condition?
Epidemic Keratoconjunctivitis 1st 8 days: red eye with fine corneal staining * 2nd 8 days: focal epithelial lesions/pseudomembrane * 3rd 8 days: subepithelial infiltrates
35
type of conjuctivitis in patient who: often recent URTI self/family member
Viral
36
si/ sxBacterial Conjunctivitis tx
purulent discharge mattering of lashes _Tx_: broad spectrum antibiotic 7-10 days * Fluoroquinolone TID/QID * Tobramycin QID (avoid gentamycin) * Polytrim (trimethoprim/polymyxin B) QID (kids) AzaSite (azithromycin) BIDx2d then QHSx10d (kids
37
tx of allergic conjunctivitis
topical antihistamines/mast cell stabilizers * Rx vs OTC ketotifen fumarate or olopatadine * Avoid vasoconstrictors
38
dz that is aggressive in CL wearers si/sx tx
**Microbial Keratitis aka Corneal Ulcer -** Pseudomonas can penetrate cornea in \<72hrs **Si/sx** pain, photophobia, tearing, +/- mucopurulent discharge Decreased vision if on/near visual axis _Whitish infiltrate underlying (+) staining epithelial defect_ **Tx:** fluoroquinolone - Loading dose in-office then hourly * Possible fortified tobramycin or vancomycin * STAT referral for eye consult if near visual axis
39
dendritic lesions with terminal endbulbs ”Great masquerader” dx?
Herpes Simplex Keratitis
40
unilateral, deep pain with significant photophobia No discharge Redness maximal at the edge of cornea “Circumlimbal Flush” Dx and Tx??
**Acute Anterior Uveitis** _Primary etiolog_y - Idiopathic, Traumatic, Autoimmune , Facial Herpes Zoster Recurrence or bilateral presentation -\> systemic **Tx:** Topical corticosteroids – inflammation cycloplegia for pain relief and to prevent posterior synechiae Refer for eye consult within 24 hours
41
less concerning diagnosis of Painful Eyelid Tx?
**Chalazion** - hot compress **Hordeolum (stye)** - same as above, * may drain if pointing at lid margin * Rx topical antibiotic ointment after draining **Preseptal Cellulitis:** antibiotics appropriate for sinusitis – z-pack
42
differentiate ## Footnote Chalazion Hordeolum (stye)
**Chalazion**: _non-infectious_ inflammation of _Meibomian Gland_ within the eyelid **Hordeolum (stye):** _infection_ of lash follicle and associated _Glands of Zeis and Moll_
43
Resolving \_\_\_\_\_may leave small, painless lump in lid * Dead PMN cells * May be referred for excision if cosmetic problem
**chalazion** ## Footnote Hordeolum (stye) - nothing left behind
44
differentiate ## Footnote Preseptal Cellulitis: Orbital Cellulitis
**Preseptal Cellulitis**: Infection of tissue anterior to orbital septum _Tx_: antibiotics appropriate for sinusitis – z-pack **Orbital Cellulitis:** Infection of tissues anterior to and/or posterior to the orbital septum _Tx:_ meningitis-dose abx
45
Si/Sx ## Footnote Preseptal Cellulitis: Orbital Cellulitis:
**Preseptal Cellulitis:** * Tenderness * Warmth * swelling and redness of lid area * VA not affected, EOM function normal, no proptosis **Orbital Cellulitis:** * preseptal-like signs and symptoms + * high fever * proptosis * malaise
46
painful and very concerning eye conditions
**Orbital Cellulitis**: Infection of tissues anterior to and/or posterior to the orbital septum **Si/Sx** * Tenderness, Warmth. swelling, redness of lid * VA not affected * EOM function normal * high fever, malaise * proptosis _Tx:_ antibiotics appropriate for sinusitis – z-pack * Monitor closely for worsening * Refer for opth consult w/in 24 hrs
47
Proptosis is seen in ?? ## Footnote Preseptal Cellulitis: Orbital Cellulitis:
Orbital
48
Yellow or whitish-yellow deposits in or around macula - Drusen dx?
macular degeneration
49
Tortuosity: twisted, winding vessels ("nicking")
HTN retinopathy
50
copper wiring?
Attenuation: narrowing of arterioles
51
"whitish" optic nerve head
optic nerve atrophy
52
blurred optic disc margins
optic nerve head edema
53
# define hyphema hypopyon
hyphema - blood in anterior chamber hypopyon - WBC in anterior chamber
54
red reflex of ocular macula are abnormal in a child if? what dz?
white glow in a child = retinoblastoma
55
glaucoma is characterisitic of what on slit lamp exam?
opacities ("dark spots")
56
Fundus Exam consists of
* Optic nerve head (nasal to the macula) * Peripapillary area (area immediately around optic nerve head) * Vasculature (retinal arteries and veins; exit optic nerve head and branch throughout the retina) * Macula (temporal to optic nerve head) – evaluate last since uncomfortable for the patient
57
optic nerve head exam is normal: abnormal:
**normal**: slightly orange-pink hue; white inside the cup **abnormal:** whitish, - indicator that there has been some form of optic nerve atrophy
58
Disc Margin Evaluation normal abnormal
**normal** margins should appear flat, clear, and distinct **abnormal**: Large C/D - glaucoma •increasing C/D ratio over time can indicate loss of nerve fibers resulting in a thinning neuroretinal rim
59
Retinal Vasculature Evaluation differentiate Arterioles: Venules:
**Arterioles**: * narrower * brighter red * •2/3 size of venules **Venules**: * wider * darker, deeper red
60
•Irregularity at A/V crossing may be diagnostic??
hypertensive retinopathy)
61
Presence of hemorrhages or cotton wool spots diagnostic –
BAD, diabetic
62
Evaluation of the Macula: when should it be done? normal vs abnormal
Save for last and reduce illumination **Normal** * Retinal sheen around macula in children * •Macula should appear flat **abnormal** * Yellow or whitish-yellow deposits in or around macula - Drusen = macular degeneration * Hard: small, well-defined * Soft: “fluffy,” poorly defined
63
Tonometry is a measure of?? normal values??
* IOP * Normal” range between 8 and 20mmHg
64
conditions associated w/ elevated IOP decreased IOP
**•Elevated IOP** can result in damage to the Optic Nerve = _Glaucoma (angle- closure)_ * Results from inefficient drainage from or over-production of aqueous **•Decreased IOP** - uveitis
65
appalation tonometry vs tonopen
**appalation**: “Gold Standard” is Goldmann applanation tonometry Requires slit lamp and judgement aligning mires **tonopen** Does not require a slit lamp Gives a digital readout
66
Steps to using tonopen
1. Instill 1 drop proparacaine in each eye 2. Place OcuFilm cover on instrument 3. Press button to turn on (XL-Black, AviaBlue) 4. Gently tap center of cornea - NOT too hard! 5. Will hear click with each successful measure and beep when all readings acquired 6. Averaged IOP will show in window with confidence value
67
findings that woukd make you susoect intraocular FB
* Seidel Sign * Iris tear * Corneal laceration
68
If insult has penetrated Anterior Limiting Lamina (Bowman’s Membrane), fluorescence??
•will see fluorescence in the corneal stroma and possibly anterior chamber
69
Fluorescein will not stain conjunctiva dx??
•laceration
70
Fluorescein Staining Technique
1. Wet the strip with a drop of sterile saline or eyewash NOT contact lens solution or water 2. Wait at least 30 seconds to view the eye with cobalt blue light 3. The longer you wait, the more you might see as permeates into epithelium through weakened tight junctions between cells 4. Stains epithelium by diffusing between cells or pooling in areas where epithelium is disrupted or missing
71
General steps to fully utilize Direct Ophthalmoscopy:
Inspect the ocular media Examine the anterior segment Examine the retina
72
73
Anterior Segment Examination includes
1. Optic Nerve Head Examination 2. Disc Margin Evaluation 3. Optic Nerve Head Evaluation 4. Retinal Vasculature Evaluation 5. Evaluation of the Macula
74
seidels sign
assesses for the _presence of aqueous humor leakage_ from the anterior chamber. Fluorescein - is an orange to red color. * When diluted, turns green under cobalt blue light _positive_ when the fluorescein dilutes in the aqueous humor --\> will _fluoresce bright green_
75
Microbial Keratitis aka Corneal Ulcer will need a STAT referral for eye consult if ???
near visual axis
76
tx of Microbial Keratitis aka Corneal Ulcer
fluoroquinolone - Loading dose in-office then hourly • Possible fortified tobramycin or vancomycin eye consult within 4-6hrs after starting antibiotics
77
what triage & presenting symptom Central Retinal Artery Occlusion Arteritic Anterior Ischemic Optic Neuropathy secondary to Giant Cell Arteritis if:
emergent ## Footnote Painless Unilateral Vision Loss
78
what presenting si/sx and triage? ## Footnote Acute Angle Closure Glaucoma
emergent Severe Unilat Pain w/Vision Loss
79
presenting si/sx and triage ## Footnote Nerve palsy: III – Oculomotor, IV – Trochlear , VI – Abducens
Sudden Onset Diplopia urgent
80
presenting si/sx and triage ## Footnote Posterior Vitreal Detachment (PVD) Retinal Detachment (RD)
Acute Onset Flashes and Floaters urgent
81
presenting si/sx & triage ## Footnote Subconjunctival Hemorrhage Conjunctivitis – Viral vs Bacterial vs Allergic Keratitis – Microbial vs Herpetic Uveitis
Sudden Onset Red Eye urgent
82
presenting si/sx and triage ## Footnote Chalazion Hordeolum (stye) Cellulitis – Preseptal Cellulitis & Orbital Cellulitis:
**painful eye & semi-urgent** Chalazion Hordeolum (stye) Cellulitis – Preseptal Cellulitis **painful eye & emergent** Orbital Cellulitis:
83
Acute Anterior Uveitis si/sx
unilateral, deep pain with significant photophobia No discharge Redness maximal at the edge of cornea “Circumlimbal Flush” Anterior chamber cells and flare
84
•Peak fluorescence at “normal” pH of \_\_?
7.6
85
NaFl requires ____ \_\_\_\_ illumination to fluoresce
Colbalt Blue

Physical Exam 2 Didactic Midterm (4 decks)

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