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Ophthalmo and neurosurg1 Flashcards

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1
Q

Visual acuity testing distance

A

20 ft (6m)

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2
Q

20/40 acuity means:

A

20/ smallest line pt can read

Or

What pt can see at 20, a nl person can see at denominator

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3
Q

Testing hierarchy for low vision

A

Snellen acuity

Counting fingers

Hand motion

Light perception with projection

Light perception

No light perception

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4
Q

When does a child gain normal visual aquity

A

2-4 yr

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5
Q

Definition of legal blindness

A

Best corrected visual acuity that is 20/200 or less

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6
Q

Minimum visual requirement to operate a non-commercial automobile

A

20/50, with both eyes open and examined together.

120° Continuous horizontal visual field.

15° continuous visual field above and below fixation.

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7
Q

Visual acuity testing in newborn

A

Cannot be tested conventionally

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8
Q

VA testinf in 3mo-3 yr

A

Can only access visual function, not acuity

Test each eye for fixation symmetry using an interesting object

Normal function= central, steady, maintained

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9
Q

VA testing from 3yr until alphabet known

A

Pictures or letter cards/charts

Tumbling E chart

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10
Q

Colour vision testing

A

Ishihara pseudoisochromatic plates

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11
Q

Indications for color vision testing

A

Testing for optic nerve function:
Optic neuritis
Chloroquine use
Thyroid ophthalmopathy

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12
Q

Visual field testing

A

Confrontation

Automated testing

Amsler grid (tests for central/paracentral scotoma in pts with AMD)

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13
Q

PERRLA

A

Pupil Equal
Round
Reactive to Light
Accommodation

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14
Q

Shallow anterior chamber

A

Light shown tangentially from temporal side

If > 2/3 of nasal side of iris in shadow= shallow chamber

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15
Q

Gold standard method for assessing anterior chamber depth

A

Gonioscopy

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16
Q

Stain for de-epithelialized cornea

A

Fluorescein dye

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17
Q

Stain for Devitalized corneal epithelium

A

Rose Bengal dye

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18
Q

Normal IOP

A

9-21 mmHg

Has diurnal variation

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19
Q

Gold-std for measurement of IOP

A

GAT, using slit lamp

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20
Q

Contraindications to pupillary dilation

A

Shallow anterior chamber

Iris-supported anterior chamber lens implant

Potential neurologic abnormality requiring pupil evaluation

Caution with cardiovascular disease

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21
Q

Nerve to superior oblique muscle

A

CN IV

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22
Q

If myopia started after the age 25 think of

A

DM

Cataract

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23
Q

Complications of myopia

A

Retinal tear/detachment

Macular hole

Open angle glaucoma

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24
Q

Accommodative esotropia may develop in

A

Hyperopia

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25
Complications of hyperopia
Angle-closure glaucoma
26
Age of presbyopia
> 40 yr Decreased accommodative ability of lens due to decreased deformability
27
Exophthalmus
Protrusion > 18 mm
28
Inv for exophthalmos
CT/MRI head/orbit U/S orbit TFT
29
Most common cause of exophthalmos in adults
Grave’s
30
Most common cause of exophthalmus in children
Orbital cellulitis
31
Inv for enophthalmus
CT/MRI
32
The systemic manifestations of infection in preceptal cellulitis
Fever: may be present WBC: moderate elevation ESR: Normal or elevated
33
Tx of preseptal cellulitis
Systemic ABx (HI, S. Aureus, Strep) Amoxicillin-clavulanate If severe: Treat as orbital cellulitis If child < 1 yr: Treat as orbital cellulitis
34
Mx of orbital cellulitis
Admit B/C x2 Orbital CT IV AB (ceftriaxone, vanco) x 1wk Surgical drainage of abcsess Close F/U
35
Meds causing dry eye
Anticholinergics Antihistamines BB Diuretics
36
Which nerve palsy causes dry eyes?
CN VII
37
Vitamin deficiency causing goblet cell dysgenesis
Vit A
38
Inv for dry eye
Rose Bengal/Fluorecein staining (punctate staining of cornea) Schimmer test
39
Tx of dry eye
Preservative-free artificial tears Ointment at bedtime Short course of mild topical CS Omega3 fatty acids orally Eyelid hygiene Ophthalmic cyclosporin for moderate cases Surgical Treat underlying
40
Inv for epiphora
Fluorescein dye Jone’s dye test to detect lacrimal drainage obstruction
41
Dacryocystitis organism
S. Aureus S.pneumoniae Pseudomonas
42
Tx of dacryocystitis
Warm compress Nasal decongestant Systemic and topical AB If chronic: Obtain culture by aspiration After resolution of infection: Dacryocystorhinostomy
43
Dacryoadenitis organisms
S. Aureus Mumps EBV VZV N. Gonorrhea
44
Tx of dacryoadenitis
Warm compress NSAIDs Systemic AB if bacterial If chronic: treat underlying
45
Most common type of ptosis
Aponeurotic ( disinsertion/dehiscence of levator aponeurosis)
46
Meds causing ptosis
Pregabalin Opioids Heroin
47
Tx of ptosis
Surgery
48
Underlying causes of trichiasis
Entropion Involutional age change Chronic inflammatory lid disease Trauma Burns
49
Tx of trichiasis
Topical lubricants Eyelash epilation Electrolysis Cryotherapy
50
Causes of entropion
Aging Cicatricial (trauma, surgery, burn, zoster) Orbicularis oculi muscle spasm Congenital
51
Tx of enteropion
Lubricant Evert lid with tape Surgery
52
Causes of ectropion
``` Aging Paralysis of CN VII Cicatricial Mechanical Congenital ```
53
Tx of ectropion
Lubricant Eyelid taping overnight Surgery
54
Stye (hordeolum) micro-organism
S. Aureus
55
Stye Tx
Warm compresses Lid care Gentle massage Resolves within 2 wk +/- incision and drainage
56
Chalazion site of disease
Meibomian (chronic granulomatous inflammation)
57
Tx of chalazion
Warm compress If no improvement after 1 mo: Incision and curettage If chronic recurrent lesion: Bx
58
Toothpaste sign
Blepharitis: Discharge with pressure on lids
59
Etiology of anterior blepharitis
Staph: (ulcer, dry scales) Seborrheic: no ulcer, greasy scale
60
Etiology of posterior belpharitis
Meibomian glands dysfunction
61
Complications of blepharitis
Recurrent hordeola Conjunctivitis Keratitis Corneal ulceration/neovascularization
62
Tx of blepharitis
Warm compress Lid massage Lid washing Topical/systemic AB +/- short course of topical steroids if severe Omega 3
63
Pinguecula
Hyaline and elastin deposit No involvement of cornea Associations: sun and wind exposure, Aging
64
Tx of piguecula
Lubricating drops Surgery for cosmesis
65
Pterygium
Fibrovascular Encroachment on cornea Can induce: astigmatism, decreased vision
66
Tx
Lubricants for irritative symptoms Excision for: Chronic inflammation Treat to visual axis Cosmesis One-third recur
67
When to suspect globe rupture in subconjunctival hemorrhage?
360° hemorrhage and Hx of trauma
68
Tx if subconjunctival hemorrhage
Resolves spontaneously in 2-3 wk
69
Inv for subconjunctival hemorrhage
Not needed if negative Hx Medical/hematologic w/u if recurrent
70
Tx of allergic conjunctivitis
Avoidance Cool compresses Non-preserved artificial tears Oral/topical antihistamines Topical mast-cell stabilizers: Cromolyn Ketotifen Olopatadine Topical CS
71
Onset of atopic conjunctivitis
Late adolescence, early adulthood Perennial
72
Papillae in atopic conjunctivitis
Tarsal papillary hypertrophy
73
Tx of atopic conjunctivitis
CNI oint Topical CS
74
Conjunctivitis in contact lens wearers
Giant papillary conjunctivitis Superior palpebral conjunctiva
75
Tx of giant papillary conjunctivitis
Clean, change or discontinue use of contact lens Topical CS
76
Vernal conjunctivitis timing
Seasonal (warm weather)
77
Papilla of vernal conjunctivitis
Large papillae on superior palpebral conjunctiva
78
Conjunctivitis with corneal ulcer and keratitis
Vernal
79
Time course of vernal conjunctivitis
In children Lasts for 5-10 y
80
Tx of vernal conjunctivitis
Non-preserved artificial tears Topical CS Topical cyclosporine
81
Main virus causing conjunctivitis
Adenovirus
82
How long is viral conjunctivitis contagious?
Up to 12 days
83
Tx of viral conjunctivitis
Cool compress Topical lubricant Proper hygiene to prevent transmission Self-limiting
84
Organisms causing bacterial conjunctivitis
S. Aureus S. Pneumoniae H. Influenza M. Catarrhalis If neonate or sexually active: N. Gonorrhoeae
85
Bacterial conjunctivitis which invades cornea
Gonorrhea
86
The most common cause of conjunctivitis in neonates
C. Trachomatis Causing inclusion conjunctivitis
87
Tx of bacterial conjunctivitis
Topical broad spectrum ABs Systemic AB of indicated (neonates, children) Self-limited Course of 10-14 d w/o treatment. 1-3 d with treatment
88
Follicles usually seen in
Viral and chlamydial conjunctivitis
89
Infective conjunctivitis with papilla
Bacterial
90
Conjunctivitis with LAP
Viral Chlamydial LAP: pre-auricular , submandibular
91
Onset of gono/chlamy conjunctivitis
Neonatal gono: First 5 d Neonatal chlamy: 3-14 d Adults if sexually active
92
Chlamydia disease in the eye
Trachoma Inclusion conjunctivitis
93
Leading infectious cause of blindness in the world
Trachoma caused by chlamydia
94
Tx of trachoma
Oral azithromycin Topical tetracycline
95
Inclusion conjunctivitis
Chronic Chlamydia Follicles
96
Tx of inclusion conjunctivitis
Oral: Azithro Tetra Doxy
97
The most common cause of conjunctivitis in newborns
Inclusion conjunctivitis caused by Chlamydia
98
Episcleritis
F>M Mostly idiopathic 1/3 bilateral Pain and discomfort
99
Associations of episcleritis
Collagen vascular disease Infections (VZV, HSV, syphilis) IBD Rosacea Atopy
100
Interpalpebral red eye
Episcleritis
101
Tx of episcleritis
Self-limited (recurrent in 2/3) Topical CS Oral NSAID
102
Differentiation of episcleritis vs scleritis
Phenylephrine blanches redness in episcleritis
103
Scleritis assiciations
Collagen vascular: SLE, RA, GPC, AS TB, Sarcoidosis, Syphilis Gout, thyrotoxicosis Staph, pneumococcus, pseudomonas, HSV Chemical/physical agents Idiopathic
104
The best indicator of scleritis progression
Pain Quality of pain: deep, boring
105
Scleritis symptoms
Pain Photophobia Decreased vision Red eye
106
Topical erythromycin for prevention of ophthalmia neonatorum
Questionable efficacy
107
Effective means for preventing ophthalmia neonatorum
Screening all pregnant women for gonorrhea and chlamydia infection, Tx and F/U of those infected Testing mothers who were not screened, during delivery
108
Infants of mothers with untreated gonococcal infection at delivery:
Receive ceftriaxone
109
Infants of mothers with untreated chlamydial infection at delivery:
Close F/U for signs of infection
110
Scleromalacia perforans
Strong association with RA Asymptomatic Anterior necrotizing scleritis No inflammation May cause scleral thinning
111
Types of scleritis
Anterior: Pain radiating to face Scleral thinning Necrotizing Posterior: Rapidly progressive blindness Exudative RD more common in women and elderly
112
Tx of scleritis
Systemic NSAID Systemic steroid Systemic immunomodulators Treat underlying (indicator of poor control)
113
Tx of corneal foreign body
Remove with sterile needle under local anesthetic and magnification Topical AB (pseudomonas coverage if abrasion from organic material) Topical NSAID (risk of corneal melt with prolonged use) Cycloplegic (relieves photophobia) Patch
114
Tx of corneal abrasion
Topical AB (pseudomonas coverage if abrasion from organic material) Topical NSAID (risk of corneal melt with prolonged use) Cycloplegic (relieves photophobia) Patch
115
DDx of recurrent corneal abrasions
Previous traumatic corneal abrasion Corneal dystrophy Idiopathic
116
Tx of recurrent corneal abrasion
Same as corneal abrasion Topical hypertonic saline oint at bedtime for 6-12 mo Topical lubrication Bandage contact lens Anterior stromal puncture Phototherapeutic keratotomy
117
Etiology ofcorneal ulcer
Infection (bacterial > viral) Exposure, abrasion, foreign body, contact lens Conjunctivitis, blepharitis, keratitis Vit A deficiency
118
Tx of corneal ulcer
Urgent referral Culture Topical AB/ h
119
Inv for corneal ulcer
Seidle test (fluorescein under cobalt blue filter)
120
Corneal hyposthesia in
Viral keratitis
121
HSV epithelial keratitis form
Dendritic lesion Terminal end bulbs Stain with fluorescein Also: Other forms of infectious epithelial keratitis Stromal keratitis Endotheliitis
122
Complications of HSV keratitis
Scarring Chronic interstitial keratitis Secondary iritis Secondary glaucoma
123
Tx of HSV keratitis
Topical trifluridine Or Systemic acyclovir Debridement of dendrite NO STEROIDS INITIALLY (unless by ophthalmologist and with caution)
124
Herpes Zoster ophthalmicus P/E
Pseudodendrite Superficial punctate keratitis Corneal hyposthesia
125
Herpes Zoster ophthalmicus complications
``` Keratitus Ulceration Perforation Scarring Secondary iritis Secondary glaucoma Cataract Muscle palsy (CNS involvement) Severe PNH ```
126
Tx of Herpes Zoster ophthalmicus
Immediate oral antivirals If immune-mediated keratitis/iritis: topical CS/cycloplegics Erythromycin oint if conjunctival involvement
127
Associations of keratoconus
Down Atopy Vigorous eye rubbing Contact lens
128
Broken cornea kayers in keratoconus
Bowman Descemet
129
Tx of keratoconus
Correction with spectacles Or Rigid gas-permeable contact lens Corneal collagen cross-linking Tx (halts progression) Intrastromal corneal ring segments (can flatten the cone) Penetrating keratoplasty Deep anterior lamellar keratoplasty
130
Reasons for decreased vision in keratoconus
Stromal edema Scarring Irregular astigmatism (Bilateral)
131
Arcus senilis
Hazy white ring <2 mm wide Clearly separated from limbus Bilateral Benign Corneal degeneration due to lipid deposition No visual Sx
132
Significance of arcus senilis
<40 yr associated with hypercholestrolemia
133
Kayser-Fleischer ring
Brown-yellow-green Peripheral cornea Starts inferiorly Deposits of copper in descmet’s membrane Wilson Tx: underlying
134
Munson’s sign
Detects keratoconus Bulging of lower eyelid when pt looks downward
135
Associations of iritis/iridocyclitis
Usually idiopathic CTD: HLA-B27: reactive arthritis, AS, PsA, IBD Non-HLA-B27: Juvenile idiopathic arthritis Infectious: Syphilis, lyme, toxo, TB, HSV, herpes zoster Others: Sarcoidosis, trauma, post-ocular surgery, large abrasion
136
Iritis effect on IOP
Decreases IOP Exception: If severe, HSV, VZV, can cause inflammatory glaucoma (trabeculitis)
137
Tx of iritis/iridocyclitis
Mydriatics Steroids Systemic analgesia
138
Indication of W/U in iritis/iridocyclitis
If recurrent
139
The major site of inflammation in intermediate uveitis
Vitreous
140
Causes of intermediate uveitis
Mostly idiopathic Sarcoidosis Lyme MS
141
Snowballs, snowbank
Snowballs: vitrous aggregates of inflammatory cells Snowbank: gray-white fibrovascular plaque at the pars plana Both are signs of intermediate uveitis
142
Tx of intermediate uveitis
Steroids Immunosuppressive agents Vitrectomy Cryotherapy/ laser photocoagulation to the snowbank
143
Posterior uveitis causes
``` Syphilis TB HSV CMV Histoplasmosis Candidiasis Toxoplasmosis Toxocara ``` Immunesuppression predisposes to above infections Behcet Malignancies
144
Pain and uveiitis
Anterior: Ocular pain Globe tenderness Brow ache Intermediate: - Posterior: -
145
Uveitis with visual field loss
Posterior uveitis
146
Tx of posterior uveitis
CS
147
Most common cause of reversible blindness all over the world
Cataract
148
The most common cause of cataract
Age related
149
Underlying etiologies for cataract
``` DM Wilson Galactosemia Homocystinuria Hypocalcemia Traumatic Intraocular inflammation Steroids Phenothiazines Radiation High myopia ```
150
Congenital cataracts presentation
Altered red reflex Leukocoria
151
Second sight phenomenon is seen in
Cataract Patient is more myopic than previously noted Patient may read without previously needed reading glasses
152
Cortical cataract seen in:
Aging DM
153
Cause of nuclear sclerosis cataract
Age-related
154
Posterior subcapsular cataract causes
Steroids Intraocular inflammation DM Trauma Radiation Aging
155
Tx of cataract
Surgical: Phacoemulsification
156
Indications for cataract surgery
If vision loss leads to functional impairment To aid management of other ocular diseases Congenital cataract Traumatic cataract
157
Complications of cataract surgery
RD Endophthalmitis Dislocated IOL macular edema Glaucoma Posterior capsular opacification
158
Etiology of lens dislocation
Marfan Homocystinuria EDS lens coloboma Syphilis Traumatic
159
Complications of dislocated lens
Cataract Glaucoma Uveitis
160
Tx of dislocated lens
Surgical replacement
161
Etiology of posterior vitrous detachment
Syneresis due to age
162
Complications of posterior vitreous detachment
Retinal tear Retinal detachment Bleeding
163
Treatment of posterior vitreous detachment
R/O retinal tear/detachment No specific treatment
164
Vitreous hemorrhage etiologies
Proliferative diabetic retinopathy Retinal tear/detachment Posterior vitreous detachment Retinal vein occlusion Trauma
165
Tx of vitreous hemorrhage
R/O RD by U/S B-scan If non-urgent: Expectant Mx. Blood resorbs in 3-6 mo Surgical: Vitrectomy RD repair Retinal endolaser to possible bleeding sites
166
Vitreous/retinal hemorrhage in child
R/O child abuse
167
Etiology of endophthalmitis
Most common: post operative Penetrating injury Endogenous spread Intravitreal injection Bacterial > fungal
168
Tx of endophthalmitis/vitritis
Ocular emergency If LP vision or worst: Admit Immediate vitrectomy Intravitreal AB If HM or better: Vitreous tap fir culture Intravitreal AB Topical fortified AB Tetanus Px if post-traumatic
169
Fundoscopy of central/branch retinal artery occlusion
Cherry-red spot Retinal pallor Cotton wool spots Cholesterol emboli at arteriole biforcations
170
Tx of CRAO
Emergency Restore blood flow within 2 h: Massage the globe (10s compress, 10s release x5’) ``` Decrease IOP: Topical BB IV acetazolamide IV mannitol Anterior chamber paracentesis ``` Nd:YAG laser embolectomy Intra-arterial or intravenous thrombolysis
171
When does irreversible retinal damage happen in complete RCAO
> 90 min
172
Central/brand retinal vein occlusion etiologies
``` Arteriosclerotic vascular disease HTN DM Glaucoma Hyperviscosity Drugs (OCP, diuretics) ```
173
Fundoscopy of CRVO
Blood and thunder Diffuse retinal hemorrhage Cotton wool Venous engorgement Swollen optic disc Macular edema
174
Complications of CRVO
Neovascularization Secondary glaucoma Vitreous hemorrhage Macular edema
175
Tx of CRVO
Treatment available for complications: Photocoagulation Anti-VEGF CS injection Ranibizumab
176
Curtain of blackness
Retinal detachment
177
IOP in retinal detachment
Decreases
178
Tx of retinal detachment
Emergency Rhegmatogenous: Scleral buckle Pneumatic retinopexy Vitregtomy+ gas injection Tractional: Vitrectomy +/- membrane removal/ scleral buckling/ intraocular gas or silicon oil Exudative: Tx of underlying
179
Px of RD
If symptomatic tears (flashes, floaters): | Seal off with laser/cryotherapy
180
Retinotis pigmentosa
Mostly:AR Rod > cone photoreceptor degeneration and retinal atrophy
181
Sx of retinitis pigmentosa
Night blindness Tunnel vision Decreased central vision Glare (posterior subcapsular cataract)
182
Fundoscopy of retinitis pigmentosa
Bone-spicule pigment clumping in mid-periphery of retina Pale disc Narrowed arteriols
183
Investigations for retinitis pigmentosa
Electroretinography Electrooculography
184
Tx of retinitis pigmentosa
No Tx Vit A and Vi E Cataract extraction
185
Most common cause of irreversible blindness in west
AMD
186
Types of AMD
Non-exudative (dry): Slow progression Drusen Geographic RPE atrophy Can progress to wet form Exudative (wet): Choroidal neovascularization. Can result in detachment of RPE and retina. Hemorrhage/lipid deposition into sub-retinal space. Elevated subretinal mass (disciform scarring, severe central vision loss).
187
RFs for AMD
Female Age FHx Smoking Caucasian Blue irides
188
Sx of AMD
Progressive central vision loss Metamorphosis
189
Inv for AMG
Amsler grid Fluorescein angiography OCT imaging
190
Tx of AMD
Dry: ``` Monitor Low vision aids Anti-oxidants Green leafy vegetables Sunglasses/visors ``` Wet AMD: Intravitreal anti-VEGF Laser photocoagulation (for neovascularization) PDT with verteporfin No Tx for disciform scarring
191
Substance increasing the risk of lung cancer and its substitute
Carotenoid Substitute: lutein + zeaxanthin
192
Normal cup/disc ration
0.4 or less
193
Which cup/disc is suspicious of glaucoma?
C:D > 0.6 C:D difference between eyes > 0.2 Cup approaches disc margin
194
Most common form of glaucoma
Primary open angle glaucoma
195
minor RFs for Primary open angle glaucoma
Myopia HTN DM Hyperthyroidism Chronic topical CS Previous ocular trauma Anemia/hemodynamic crisis
196
Eye surveillance in ophthalmic CS users
If > 4wk Yearly exam
197
Earliest sign of Primary open angle glaucoma
Optic disc changes Increased C:D ratio C:D asymmetry between eyes > 0.2
198
Eye exam in Primary open angle glaucoma
Increased C:D ratio Thinning, notching of neuroretinal rim Flame-shaped disk hemorrhage 360° peripapillary atrophy Nerve fiber layer defect Large vessels nasally displaced ``` Visual field loss: Paracentral defect Arcuate scotoma Nasal step Central vision (late) ```
199
Major RFs for Primary open angle glaucoma
IOP > 21 Age African ethnicity Familial Thin central cornea
200
Tx of Primary open angle glaucoma
Increase aqueous outflow: Topical cholinergics Topical PG analogues Topical a-adrenergics Decreased aqueous production: Topical BB Topical/oral carbonic anhydrase inhibitor Topical a-adrenergics Laser trabeculoplasty Cyclophtocoagulation Trabeculotomy Minimally invasive glaucoma surgery
201
Follow up of primary open angle glaucoma
Serial optic nerve head examination Serial IOP measurement Serial visual field testing
202
The only modifiable risk factor that has been proven to prevent progression of glaucoma
Elevated IOP
203
Normal tension glaucoma
Normal IOP Primary open-angle glaucoma Women > 60 ``` Associations: Migraine Peripheral vasospasm Systemic nocturnal hypotension Sleep apnea ``` Tx: underlying
204
Secondary open angle glaucoma
Steroid Trauma Pigmentary dispersion syndrome Pseudoexfoliation syndrome Causing meshwork obstruction
205
RFs for primary angle-closure glaucoma
``` Hyperopia Age > 70 F FHx Asian and inuit Mature cataract Shallow anterior chamber Pupil dilation (stress, darkness, anticholinergics) ```
206
Cornea and pupil in open angle vs angle-closure glaucoma
Open: nl Angle-closure: Corneal edema Fixed, mid-dilated pupils
207
Tx of primary angle-closure glaucoma
Emergency Miotic drops (pilocarpine) Multiple topical IOP lowering agents (BB, AA, Choli) Hyperosmotic agents (oral glycerine, IV mannitol)
208
Secondary angle-closure glaucoma
Uveitis Neovascularization (proliferative diabetic retinopathy, CRVO)
209
Test for loss of sympathetic innervation
4-10% cocaine Will cause dilation of normal pupil (prevents re-uptake of NE) No dilation if loss of sympathetic fibers
210
Eye receptors
a1: Mydriasis B2: Ciliary muscle relaxation Increased aqueous humour production M3: Miosis Accommodation (ciliary contraction)
211
Differentiating pre- vs post-ganglionic sympathetic lesions
0.125 % epinephrine: If dilated : postganglionic (increased receptors) Normal pupil: no dilation
212
Pre- vs post-ganglionic parasympathetic lesion differentiation
0.125% pilocarpine If constriction: pupil constricts Normal pupil: no constriction
213
Idiopathic/physiologic anisocoria
20% of population Round Regular <1 mm difference Reactive to light/accommodation Responds to miotic/mydriatics Post eye surgery
214
Argyll-Robertson pupil
Abn miotic pupils (<3mm) Poor light response, better accommodation Irregular Usually bilateral
215
Site of lesion in Argyll-Robertson pupil
Midbrain
216
Horner’s syndrome
Unilateral Abn miotic + Ptosis + anhydrosis + pseudoenophthalmus Round Brisk light and accommodation response
217
Anisocoria in Horner
Worse in the dark
218
Site of lesion in Horner
Sympathetic system
219
Adie’s tonic pupil
Abn mydriatic pupil (impaired constriction) Irregular F>M Poor light response Better accommodation Hypersensitivity to dilute pilocarpine
220
Anisocoria in Adie’s tonic pupil
Worse in light
221
Site of lesion in Adie
Ciliary ganglion
222
Pupil in CN III palsy
Mydriatic Fixed in acute phase at 7-9 mm Round Constricts with pilocarpine
223
Anisocoria in CN III palsy
Worse in light
224
If no pupil response to mydriatic/miotics
Problem at iris sphincter level
225
If Horner pupil dilated with hydroxyamphetamine,
Central or preganglionic lesion
226
Etiologies of Argyll-Robertson pupils
Syphilis DM MS Encephalitis Chronic alcoholism CNS degenerative diseases
227
Marcus Gunn pupil
RAPD Lesion in visual afferent pathway anterior to optic chiasm Does not occur with media opacity Pupil reacts poorly to light/ better to accommodation
228
Most common intra-ocular malignancy in adults
Mets | Breast, lung
229
Most common primary intra-ocular malignancy in adults
Melanoma
230
Most common intra-ocular malignancy in children
Neuroblastoma mets
231
DDx of RAPD
``` Large RD BRAO CRAO CRVO Advanced glaucoma Optic nerve compression Optic neuritis (most common) ``` CATARACT NEVER PRODUCES RAPD
232
HIV retinopathy
Most common retinopathy in HIV Cotton wool Intraretinal hemorrhage
233
CMV retinitis
CD4 < 50 ``` Necrotizing Hemorrhage Vasculitus Brushfire Pizza pie ``` Progression to other eye in 4-6 wk
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Tx of CMV retinitis
Gancyclovir Foscarnet (IV, intravitreal)
235
Necrotizing retinitis of HIV
``` HSV VZV Toxo Disseminated choroiditis Pneumocystis carinii Mycobacterium avium intracellulare Candida ```
236
Candidal endophthalmitis
Fluffy White-yellow Superficial retinal infiltrate. May eventually result in vitritis Tx: systemic amphoB, oral fluconazole
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Toxoplasmosis retinitis
Focal Gray-yellow-white Chorioretinal Surrounding vasculitis Vitreous infiltration Visual impairment more with congenital form
238
Tx of toxo retinitis
Pyrimethamine Sulfonamide Folinic acid Clindamycin +/- steroid
239
Most common cause of blindness in young people in north America
DM
240
Loss of vision in DM due to:
Progessive microangiopathy: Macular edema Progressive retinopathy: Neovascularization, retinal detachment, vitreous hemorrhage Rubeosis iridis: Neovascularization of iris, glaucoma
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Non-proliferative diabetic retinopathy findings
Microaneurysms Dot and blot hemorrhage Hard exudate (lipid deposits) Macular edema
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Advanced non-proliferative diabetic retinopathy
Microaneurysms Dot and blot hemorrhage Hard exudate (lipid deposits) Macular edema Plus: Venous beading in at least 2 of 4 quadrants IRMA (intraretinal microvascular anomalies) in at least 1 quadrant. Dilated leaky vessels Cotton wool spots
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Proliferative diabetic retinopathy
Neovascularization of iris, disc, retina => Neovascular glaucoma Vitreous hemorrhage Retinal detachment
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Screening for diabetic retinopathy in DM 1
5 yr after Dx, annually All pts >12 y, annually All pts entering puberty, annually
245
Screening for diabetic retinopathy in DM 2
Start examination at time of Dx, annually
246
Screening for diabetic retinopathy in Pregnancy
Gestational diabetes: No need for screening DM1/2: Ocular exam in T1 and close F/U throughout
247
Effect of pregnancy on diabetic retinopathy
Can exacerbate
248
Tx of diabetic retinopathy
Tight control of blood sugar BP control If clinically significant macular edema: Focal laser Intravitreal CS Intravitreal anti-VEGF If proliferative DR: Pan-retinal laser photocoagulation If non-clearing vitreous hemorrhage: vitrectomy If tractional retinal detachment in PDR: Vitrectomy
249
Lens changes in DM
Earlier senile cataract Hyperglycemic cataract due to sorbitol accumulation Sudden refractive changes by changes in blood glucose level
250
DM and extraacular muscle palsy
CN III infarct CN IV and VI Course: Usually recover within few month
251
Optic nerve and DM
Optic neuropathy due to infarction of optic disc/nerve
252
Most common manifestation of HTN in the eye
Retinopathy
253
Acute HTN retinopathy
Retinal arteriolar spasm Superficial retinal hemorrhage Cotton wool Optic disc edema
254
Chronic HTN retinopathy
AV nicking Flame/blot retinal hemorrhages Microaneurisms Cotton wool
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Effect of medical therapy on DR
Reduction in DR rate by: Intensive glycemic control Intensive combination treatment of dyslipidemia (But not HTN)
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MS optic neuritis treatment
IV steroid, taper to oral form | DO NOT TREAT WITH ORAL CS IN ISOLATION, this increases likelihood of eventual MS
257
Most common source of Amaurosis Fugax
Ipsilateral carotid
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Amaurosis Fugax sign/symptoms
< 5-10 min Hollenhorst plaques
259
Effect of thyroid gland treatment in Grave’s on ophthalmopathy
None!
260
Pathophysiology of Grave’s ophthalmopathy
Sympathetic overdrive Inflammatory infiltrate of orbital tissue
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Course of Grave’s ophthalmopathy
Initially: inflammatory Followed by: quiescent cicatricial phase
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Tx of Grave’s ophthalmopathy
Tx of hyperparathyroidism Corneal exposure: Hydration Diplopia/ proptosis/ compressive optic neuropathy: CS (acute phase) Orbital bony decompression RT of orbit Strabismus/ eyelid problem: Surgery once inflammation subsides
263
Most common eye manifestation of collagen vascular diseases
Keratoconjunctivitis sicca
264
Negative Bx for GCA, next step?
Bx the other side
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Mutton fat keratitic precipitates
Sarcoidosis
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Sarcoidosis eye Sx
Granulomatous uveitis Optic neuropathy Oculomotor abnormalities Visual field loss
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Strabismus in children < 4mo
Sometimes resolves Esp if: Intermittent deviation Variable Measures < 40 prism diopters
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Incomitant (paralytic strabismus)
Most often acquired Neural, muscular, structural causes Diplopia: common Amblyopia: uncommon
269
Concomitant strabismus (nonparalytic)
Gradual or shortly after birth Infancy No restriction in ROM of eye Monocular, alternating, intermittent Diplopia: uncommon Risk of amblyopia (unless alternating or intermittent)
270
Accommodative esotropia seen in
Hyperopes (constantly accommodating) Reversible with correction of refractive error
271
Average age of onset of accommodative esotropia
2.5 yr
272
Non accommodative esotropia
50% of childhood strabismus Mostly idiopathic Maybe due to monocular visual impairment or divergence insufficiency
273
The most common cause of amblyopia
Strabismus (esp esotropia)
274
Detection of amblyopia
Holler test: Young child upset if good eye is covered Quantitative visual acuity by age 3-4 yr, using picture charts, matching game
275
Amblyopia Tx less successful if not treated by age:
8-10yr A trial should be given no matter what age
276
Prognosis of amblyopia
Good if treated < 4yr
277
Mx of amblyopia
Strabismus: Restore ocular alignment + patching until 8 yr Anisometropia: Glasses Patching if visual acuity difference persist after 4-8 wk Deprivation amblyopia: Treat underlying Patching
278
In anisotropia, amblyopia happens in which eye?
The more hyperopic eye
279
Indications for safety glasses or poly carbonate lenses in amblyopia
If visual equity in worse eye < 20/50
280
Mx of leukocoria
Urgent referral
281
DDx of leukocoria
``` Cataract Retinoblastoma Retinal coloboma ROP persistent hyperplastic primary vitreous Persistent fetal vasculature Toxocariasis RD ```
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Most common primary intraocular malignancy in children
Retinoblastoma
283
Retinoblastoma
1/3 bilateral Malignant Leukocoria/strabismus
284
Mx of retinoblastoma
Screening of siblings/offspring U/S or CT: calcified mass RT Chemo Laser Cryopexy Enucleation
285
RFs for retinopathy of prematurity
Non-black race Low GA Birth weight < 1500g High O2 exposure after birth
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Tx of ROP
If fibrovascular tissue: Laser: standard treatment Cryo Anti-VEGF (off-lable) If retinal detachment: Watch carefully Vitrectomy Scleral buckle
287
Prognosis of ROP
High rate of myopia
288
Nasolacrimal defect presentation
At 1-2 mo of age
289
Sx of nasolacrimal system defects
``` Epiphora Crusting Discharge Recurrent conjunctivitis Mucopurulent discharge with pressure ```
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Tx of nasolacrimal obstruction
Massage over lacrimal sac Spontaneous resolution within 9-12 mo If no resolution, referral for duct probing
291
Dx of ophthalmia neonatorum
Stains, cultures
292
Epiphora in infant
R/O congenital glaucoma Nasolacrimal obstruction
293
First thing to check when ocular trauma
Visual acuity
294
Referral of eye trauma if:
``` Decreased VA Shallow anterior chamber Hyphema Abnormal pupil Ocular misalignment Retinal damage ```
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Mx of penetrating eye trauma
Initial Mx: refer immediately ABC Don’t press on eye globe Don’t check IOP if possibility of glob rupture Check VA/ EOM Rigid eye shield Keep head 30-45° elevated NPO Tetanus status IV AB (depending on trauma mechanism): Mostly gram positives If foreign body: bacillus If organic matter: fungal Usually: AG+ Cefazolin R/O foreign body CT orbit
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Post traumatic infectious endophthalmitis
Increased risk if delayed repair (>24h) If intra-ocular foreign body: Early vitrectomy and foreign body removal (within 24h) Extreme pain+ hypopyon + vitritis Obtain samples AB (IV, intravitreous)
297
Shaken baby syndrome
No external signs Respiratory arrest Seizures Coms Extensive retinal/intravitreal hemorrhage
298
Inv for blow-out fx
Plane film (Water’s, lateral) CT: AP, coronal
299
Tx of blow-out fx
Refrain from coughing, blowing nose +/- Systemic AB Surgery if: Fx > 50% orbital floor Diplopia not improving Enophthalmus > 2mm
300
Indicative of poor prognosis in eye chemical burn
Opaque cornea Alkali burn
301
Tx of chemical burn
Immediate irrigation with water or buffered solution ED: Irrigate with IV drip and eyelid retracted until pH physiologic Swab upper/lower fornices DO NOT ATTEMPT TO NEUTRALIZE Cycloplegic drops Topical AB and patching Topical CS (<2wk if persistent epithelial defect)
302
Drops for red itchy eyes
Anti-histamines: Sodium cromoglycate Decongestants: Nephazoline Phenylephrine (Rebound vasodilation with overuse)
303
Abulia in damage to
Frontal lobe
304
Disinhibition in damage to
Frontal lobe
305
Apathy
in damage to
306
Executive function impairment in damage to
Frontal
307
Defect in orientation and judgment in damage to
Frontal
308
Primitive reflex re-emergence in damage to
Frontal
309
Upgoing babinski in damage to
Contralateral frontal
310
Pronator drift in damage to
Contralateral frontal
311
Lesion in frontal eye fieldcauses
Gaze towards destructive lesion Gaze away from seizure focus
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Lesion in occipital lobe
Contralateral homonymous hemianopsia
313
Dressing apraxia in damage to
Parietal, either side
314
Cortical sensory loss in lesion of
Parietal, either side
315
Lower homonymous hemianopsia in lesion of
Parietal, either side
316
Damage to dominant parietal lobe
In attention or extinction of non-dominant side Aphasia Gertsmann syndrome
317
Non-dominant parietal lesion
Hemispatial neglect Apraxias Agnosias
318
Antegrade amnesia in damage to
Hippocampus (temporal lobe)
319
Upper homonymous hemianopia
Temporal lobe
320
Hemiballismus in damage to
Subthalamic nucleus
321
Parinaud syndrome
Supranuclear upward gaze palsy Damage to pineal gland/ dorsal midbrain
322
Decerebrate/decorticate posture in damage to
Decorticate: above red nucleus Decerebrate: below red nucleus
323
Damage to cerebellar vermis
Truncal ataxia Dysarthria
324
Damage to cerebellar hemisphere
Intention tremor Ipsilateral limb ataxia Fall towards side of lesion
325
Compensatory reserve of ICP Volume
Young: 60-80 Elderly: 100-140
326
Cerebral perfusion pressure
MAP-ICP Almost constant cerebral blood flow in CPP 60-150
327
Circumstances under which cerebral autoregulation mechanism is not able to keep constant CBF
``` High ICP (Cerebral perfusion pressure < 40) MAP > 150 MAP < 50 Increased CO2 O2< 50 Brain injury ```
328
Normal ICP
Adults: 10-15 mmHg Children: 3-7 mmHg Infant: 1.5-6 mmHg >20: moderate elevation >40: severe elevation
329
Gold std for ICP measurement
Intraventicular cath
330
MAP target in TBI
> 80
331
Sx of acutely elevated Icp
``` H/A N/V Lethargy Significant decline in GCS Subtle optic disc changes Visual changes uncommon CN VI palsy Sunset eyes, esp in children with obstructive hydrocephalus Often herniation syndromes occure Focal deficits present ```
332
Sx of chronic ICP elevation
``` H/A N/V Irritability Inattentiveness LOC: Nl or modestly decreased Obvious papilledema Optic atrophy/blindness/enlarged blond spot Full EOM Herniation if acute on chronic FND can be present ```
333
Inv fir suspected ICP rise
CT/MRI | +/- ICP monitoring
334
Mx of elevated ICP
Head elevation: 30° Fever Mx Prevent hypotension Ventilate to pCO2: 35-40 pO2: >60 mmHg 20% IV mannitol Maintain sBP > 90 Dexa (if tumor, abscess) Sedation Paralysis Barbiturate induced coma Drain CSF Decompressive craniectomy
335
Goals in ICP rise Tx
Tx when ICP > 20 Goal: ICP < 20 MAP > 90 CPP>65 Goals in trauma: MAP > 80 in traumatic brain injury MAP 85-90 in spinal cord injury
336
Effect of barbiturate coma Tx on ICP rise outcome
Decreased mortality No effect on neurologic outcome
337
Associations of pseudotumor cerebri
Dural sinus thrombosis Obesity Hypervitaminosis A Reproductive age Mense irregularity Addison/Cushing IDA Polycythemia vera Steroid withdrawal Tetracycline Amiodarone Lithium Nalidixic acid OCP
338
Neurologic deficit in pseudotumor cerebri
CN VI palsy
339
Visual Sx in pseudotumor cerebri
VA deficit Field deficit Papilledema Optic atrophy Blindness
340
Course of pseudotumor cerebri
Self limited
341
Inv for pseudotumor cerebri
MRI (+/- contrast): Slit-like ventricles Distended perioptic sub-arachnoid space LP: Opening pressure > 20 Normal CSF Ophthalmologic exam: VA/Field defect Papilledema
342
Tx of pseudotumor cerebri
Wt loss Fluid/salt restriction Acetazolamide :(decreased CSF production) Thiazide/furosemide If failure: Serial LP Shunt Optic nerve sheath decompression F/U + repeat imaging + ophthalmo F/U
343
Most common cause of non-communicating hydrocephalus
Post-infectious CSF absorption block
344
Magnetic gait seen in
Normal pressure hydrocephalus
345
Triad of Hakim
Ataxia(magnetic gait) Incontinence Dementia NPH
346
Inv for hydrocephalus
CT/MRI U/S through anterior fontanelle in infants ICP monitoring
347
Tx of hydrocephalus
External ventricular drain Intermittent LP Surgery for underlying
348
Shunt infection organisms
S. Epidermidis S. Aureus P. Acnes Gram-negative becilli
349
Inv for suspected shunt infection
Shunt tap B/C CBC
350
Headache which is relieved by lying down in pts with shunt:
Over shunting
351
Overshunting investigations
CT: slit ventricles, subdural hematoma
352
DDx for ring enhancing lesion on CT with contrast
Mets Abscess Glioblastoma Infarct Contusion Toxo Lymphoma Demyelination Resolving hematoma Radiation necrosis
353
Inv for brain cancer
``` CT MRI stereotactic Bx (tissue, molecular markers) Mets w/u Tumor markers ```
354
Tx of brain tumors
If slow growing/benign: Conservative (serial Hx, PE, imaging) CS (reduce ICP, cytotoxic edema) Pharmacologic treatment for pituitary adenoma Surgical excision Shunt RT Chemo
355
New onset communicating hydrocephalus in cancer pts
Suspicion of leptomeningeal carcinomatosis
356
Most common brain tumor in <15yr
Supratentorial: Astrocytoma Infratentorial: Meduloblastoma
357
Most common brain tumor > 15 yr
Supratentorial: Adtrocytoma (GBM) Mets (most common overally) Infratentorial: Mets
358
Brain mets
Most common intracranial tumor in adults Often at: Gray-white matter junction Temporal-parietal-occipital lobe junction
359
Inv for mets
``` Find source: CXR CT abdomen/chest U/S abd Mammo Nuclear scan/PET ``` CT+ contrast for brain +/- MRI
360
Tx of brain mets
Phenytoin/levotiracetam Dexa + ranitidine ``` Chemo RT (if discrete, deep seated, inoperable): Stereotactic RT if < 3 lesions WBRT if multiple lesions Post-operative adjuvant RT ``` Surgical: If single/solitary
361
Most common cancers metastasizing to brain
Lung > breast
362
Astrocytoma
Cerebral hemispheres >> other sites CT: hypodense MRI T1: hypointense MRI T2: hyperintense Low grade: Calcification No enhancement High grade: Enhancement Central necrosis
363
Tx of astrocytoma
Low grade diffuse: Surgery (better outcome) RT (prolongs survival) Chemo (for progression) ``` High grade (anaplastic, GBM) Goal: prolong quality survival Surgery +RT +Temozolomide ``` Multiple gliomas: WBRT +/- chemo
364
Meningioma
Arises from arachnoid membrane Calcified Hyperostosis of adjacent bone Bx: psammoma bodies F> M Increase in size with pregnancy (progesterone receptor) Middle age Association with NF2
365
Inv for meningioma
``` CT with contrast: Homogeneous, dense enhancement Dural tail Well circumscribed Usually solitary ``` MRI with contrast Angiography (arterial supply, venous involvement)
366
Tx of meningioma
Conservative if: Asymptomatic and non-progressive Surgery(1st std therapy) If symptomatic or documented growth Endovascular embolization: If highly vascularized, to facilitate surgery Radiation: If <3cm, partially occluding superior sagittal sinus
367
Vestibular Schwannoma
Slow-growing If bilateral: NF2 Middle age <2cm: hearing loss, disequilibrium, tinnitus Compression on CN VIII, CN VII, CN V (>2cm) > 4cm: cerebellar signs, BS signs, hydrocephalus...
368
Inv for acoustic neuroma
MRI with contrast 2nd choice: CT contrast Audiogram Brainstem auditory evoked potentials Caloric test
369
Tx of acoustic neuroma
Expectant: If small, hearing preserved, high perioperative risk, elderly RT ``` Surgery if: >3cm BS compression Edema Hydrocephalus ``` Testing family members for NF2 mutation
370
CN palsies in pituitary adenoma
CN III CN IV CN V1, V2 CN VI
371
Order of function impairment in pituitary adenoma
``` GH LH FSH TSH ACTH PRL ```
372
Pituitary apopexy
Sudden expansion of mass due to hemorrhage or necrosis ``` Abrupt: H/A Visual disturbance Ophthalmoplegia Reduced mental status Panhypopituitarism DI ```
373
Inv for pituitary adenoma
Formal visual fields CN testin Endocrine tests: PRL level, TSH, 8 AM cortisol, fasting glucose, FSH/LH, IGF-1 Lytes, urine lytesand osmolality MRI +/- contrast
374
Tx of pituitary adenoma
Apoplexy: Rapid CS Surgical decompression Prolactinoma: Dopamine agonist Cushing: Cyproheptadine (serotonin antagonist) Ketoconazole Acromegaly: Octreotide +/- bromocriptine Endocrine replacement Surgcal
375
Nerves in cavernous sinus
CN II, III, IV, V2, VI

Med (25 decks)

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