Ophthalmology

Question 1

A 5-day-old infant with severe bilateral purulent conjunctivitis and severe conjunctival chemosis. What is the most likely organism?

Answer 1

Neisseria gonorrhoeae conjunctivitis

Question 2

A 5-day-old newborn presents with severe bilateral purulent conjunctivitis, severe conjunctival chemosis. What is the best treatment?

Answer 2

IM or IV 3rd generation cephalosporin, topical erythromycin, ophthalmology consultation

Question 3

A 10-day-old infant with mild to moderate purulent discharge also associated with a cough and congestion. What is the most likely organism?

Answer 3

Chlamydia conjunctivitis

Question 4

A 14-day-old infant presents with mucoid discharge from both eyes and eyelid swelling. What is the best treatment?

Answer 4

Oral erythromycin. Erythromycin ophthalmic ointment 4 times a day for 1week

Question 5

Excessive tearing, photophobia, frequent spasms of the eyelid, corneal clouding and enlargement of the eye

Answer 5

Congenital glaucoma (immediate referral to pediatric ophthalmology)

Question 6

A newborn is being evaluated in the office for leukocoria. The reflexes are absent in both eyes. What is the next best step?

Answer 6

Immediate referral to ophthalmology—concern for cataract or retinoblastoma

Question 7

An 8-week-old male infant with right eye more watery than the left. There is a golden-colored crust on his eyelashes, more prevalent in the morning. No redness

Answer 7

Nasolacrimal duct obstruction (topical antibiotic if suspected bacterial infection)

Question 8

What is the best initial treatment of nasolacrimal duct obstruction?

Answer 8

Lacrimal sac massage 2–3 times daily

Question 9

Most of the cases of nasolacrimal duct obstruction spontaneously resolve at what age?

Answer 9

6months to 1year with no need for probing or surgery

Question 10

A 2-month-old baby boy presents with alternating deviations in both eyes, no other symptoms

Answer 10

Strabismus—if both eyes are alternating, monitor till 3months of age (refer if persists)

Question 11

A 2-month-old infant presents with left eye deviated inward with no other symptoms

Answer 11

Strabismus—if only one eye is deviating, refer to ophthalmology to exclude underlying pathology

Question 12

The infant in the previous example continued to have left eye deviation at 4months well visit

Answer 12

Referral to a pediatric ophthalmologist

Question 13

How long can a newborn be monitored for poor tracking, lack of fixation, head tilt, nystagmus, or squinting?

Answer 13

If persist beyond 3months of age must be referred to a pediatric ophthalmologist

Question 14

A 9-month-old boy with crossed eyes. O/E: corneal light reflex is centered in both pupils equally; cover test shows no ocular deviation

Answer 14

Reassurance (pseudostrabismus)

Question 15

A 9-month-old boy with crossed eyes. O/E: corneal light reflex is asymmetric; the cover test shows ocular deviation

Answer 15

Referral to a pediatric ophthalmologist

Question 16

Red reflex is asymmetric, absent, dull, or opaque; dark spots in the red reflex; or leukocoria (white reflex). What is the next step?

Answer 16

Referral to ophthalmologist

Question 17

What is the major consequence of delaying the treatment of strabismus or cataract in pediatric patients?

Answer 17

Amblyopia (lazy eye)

Question 18

A 6-month-old infant presents with nystagmus, head nodding, and torticollis. The nystagmus is disconjugate, high frequency, small amplitude, pendular, and intermittent

Answer 18

Spasmus nutans (often disappears after a few years)—brain MRI on spasmus nutans patients to rule out optic nerve glioma that can present exactly like spasmus nutans

Question 19

Child presents with swelling in the eyelid, hyperemia, normal vision, no pain with eye movement, no decrease in eye movement. What is the most likely diagnosis?

Answer 19

Periorbital cellulitis (may be treated with an oral antibiotic as an outpatient)

Question 20

Child with a fever, malaise, proptosis, decreased vision, pain with eye movement, orbital pain and tenderness, decreased eye movement, dark red discoloration of the eyelids, chemosis, hyperemia of the conjunctiva. What is the most likely diagnosis?

Answer 20

Orbital cellulitis (admit for IV antibiotics and ophthalmology consultation)

Question 21

Child is presenting with a painful, warm, swollen, red lump on the eyelid. What is the best treatment?

Answer 21

Warm compresses and massages, topical antibiotic if the lesion is draining

Question 22

Child is presenting with a painless nodule on the left upper eyelid for 5months not responding to conservative measures (warm compresses and lid hygiene). What is the next best step?

Answer 22

Referral to a pediatric ophthalmologist

Question 23

A 5-year-old boy presents with eye pain, foreign body sensation, and tearing after self-inflicted eye injury with a sharp pencil. What is the next best step?

Answer 23

Examine the eye with fluorescein stain (corneal abrasion)

Question 24

Management of corneal abrasion

Answer 24

Topical antibiotic, an oral analgesic, refer to an ophthalmologist if no improvement in 24h

Question 25

Child is presenting with sudden onset of right eye discomfort and blurring of vision after exposure to flying debris of broken glass. What is the next best step?

Answer 25

Ophthalmology consult to rule out corneal laceration and intraocular foreign bodies

Question 26

A 7-year-old is noted to have blood in the anterior chamber of the eye after blunt trauma and pain with extra-ocular movements

Answer 26

Hyphema—emergent ophthalmology consult Sickle cell screening if African-American

Question 27

Management of hyphema

Answer 27

Ophthalmology consult, 45° bed elevation, bed rest, eye shield, analgesia, sedation, topical cycloplegic, and topical steroids

Question 28

Child is complaining of significant pain, bruising, and swelling in the periorbital area after eye trauma; “sunken” appearance to the eye on the affected side; decreased sensation to the cheek, upper lip, and upper gingiva on the affected side; and limitation of upward gaze on the affected side

Answer 28

Orbital floor fractures (due to inferior rectus muscle entrapment)

Question 29

Adolescent girl with obesity is complaining of pounding headache, double vision, nausea, and vomiting; the headache is worse when she is leaning forward. Her vital signs are normal, but she is unable to abduct her right eye. What is the most likely finding in her eye exam?

Answer 29

Papilledema (untreated pseudotumor cerebri can result in permanent vision loss)

Question 30

Child with pink eye, fever, cloudy rhinorrhea, cough, headache, pharyngeal redness with scant exudates, a palpable right preauricular lymph node, profuse tearing, and edematous nasal mucosa. The right eye conjunctiva is hyperemic, and tiny follicles are present on the inner lower lid. What is the best treatment?

Answer 30

Reassurance (pharyngoconjunctival fever commonly caused by adenovirus) Treatment: cold compresses to the eyes, analgesics, rest, and fluids

Question 31

A 7-year-old girl is noted to have a large bloody blotch under the conjunctiva, no history of trauma; she has a runny nose and congestion

Answer 31

Reassurance (viral subconjunctival hemorrhage [enterovirus, or adenovirus infection])

Question 32

A 7-year-old is noted to have a small area of unilateral eye redness in the sclera. The redness was noticed after a forceful sneeze

Answer 32

Reassurance (subconjunctival hemorrhage)

Question 33

Child with watery, itchy eyes bilaterally, mild eyelid edema, along with conjunctival erythema. No mucoid or purulent discharge

Answer 33

Allergic conjunctivitis

Question 34

Child is being treated for allergic conjunctivitis for 2 weeks with oral and topical antihistamine eye drops with no improvement. What is the next best step?

Answer 34

Referral to an ophthalmologist (topical ophthalmic steroids require monitoring of eye pressure)

Question 35

A 3-year-old boy presents with different stage skin bruises; fundus examination shows bilateral multilayered flame shaped retinal hemorrhages. What is the most likely cause?

Answer 35

Child abuse

Question 36

Night blindness, flashes of light, visual loss. O/E: optic nerve waxy pallor, mid-peripheral retinal hyperpigmentation, retinal arteriolar attenuation

Answer 36

Retinitis pigmentosa

Question 37

Pigmentary retinopathy, polydactyly, truncal obesity, kidney dysfunction, short stature

Answer 37

Bardet–Biedl syndrome

Question 38

Syndromes associated with retinitis pigmentosa and hearing loss

Answer 38

Alport syndrome, Waardenburg syndrome, Refsum disease, Usher syndrome

Question 39

A 9-year-old girl with a history of short stature, vision 20/40, her eye exam is significant for optic nerve atrophy. What is the next best step?

Answer 39

Brain MRI (optic nerve atrophy can be associated with a brain tumor)

Question 40

Risk factors commonly associated with retinopathy of prematurity (ROP)

Answer 40

Birth before 30 weeks gestation, or low birth weight

Question 41

Who should screen preterm infants at risk for ROP?

Answer 41

Who should screen preterm infants at risk for ROP?

Question 42

Do preterm infants at risk of ROP should be followed by an ROP experienced ophthalmologist after discharge from the NICU

Answer 42

Yes. Within 4–6 months after discharge because of risk of developing strabismus, amblyopia, high refractive errors, cataracts, and glaucoma