ophthalmology

Question 1

xanthelasmas

Answer 1

aka xanthelasma palpebrum
etiology - hyperlipidemia, esp high LDL in young adults
presentation - soft yellow-orange plaques on eyelids or medial canthus
check for atheroscelorosis

Question 2

scleral icterus

Answer 2

jaundice of the sclera
(NOT melanin deposits in african americans)
check for s&s of liver of hemolytic diseases

Question 3

thyrotoxicosis

Answer 3

s&s - stare, exophthalmos, goiter
check for lids lag, tachycardia, moist velvety warm skin, fine hair, detachment of nail from nail bed (onycholysis), exposure keratitis
systemic disease - thyroid (AKA graves disease)

Question 4

marcus -gunn pupil

Answer 4

afferent pupillary defect

consensual response normal on both sides but direct abnormal on affected side

Question 5

adie’s pupil

Answer 5

large, unilateral pupil
slow accommodation and reaction to light
reduced reaction to light

Question 6

argyll-robertson pupil

Answer 6

accommodate but do no react to light

sign of syphillis

Question 7

horner’s syndrome

Answer 7

ptosis, miosis - pupil small but briskly reacts to light and accommodation, and anhidrosis

Question 8

pterygium

Answer 8

etiology - constant exposure to sun, wind, sand, or dust
pathophysiology - may interfere with vision
s&s - triangular-shaped, fleshy path of conjunctival tissue encroaching onto cornea, often bilateral, can become inflamed and may grow, eye redness and irritation
tx - none required if no vision threatening growth, induction of astigmatism or severe irritation (surgery)
- prolonged symptoms - lubricating eyedrops, short course topical NSAIDs or weak steroid eyedrops

Question 9

pinguecula

Answer 9

s&s - yellow, slightly-raised, conjunctival nodule near palpebral fissure, often bilateral and common in pts under 35, no corneal involvement, inflammation common
tx - none required, prolong - lubricating eyedrops, short course topical NSAIDs, weak steroid eyedrops

Question 10

viral conjunctivitis

Answer 10

aka pink eye
etiology - adenovirus, highly contagious
-2ndary to HSV, enterovirus, coxsackievirus
s&s - bilateral with copious, watery discharge, foreign body sensation, palpable pre-auricular LAD possible
tx - self limited except for HSV (normal - 10-14 days)
- 2ndary bacterial infection -topical anti-bacterials
- cool compresses, topical antihistamine, vasoconstrictor

Question 11

bacterial conjunctivitis

Answer 11

etiology : s. aureus., strept. pneumoniae, haemophilus spp., pseudomonas spp. moraxella spp.
s&s - copious, purulent discharge, no blurring, mild discomfort
tx - self limiting but topical antibiotics clears in 2-3 days vs 10-14 days

Question 12

gonococcal conjunctivitis

Answer 12

etiology - n. gonorrhoeae
pathophysiology - infected genital secretion, often during birth
s&s - copius, purulent discharge, corneal involvement can quickly lead to corneal perforation -> occular emergency
dx - stained smear and culture of the D/C
REFER
tx - systemic ceftriazone via IV with corneal involvement and IM if cornea not involved
- oral antibiotics after loading ceftriazone - erythromycin, tetracycline or doxycycline
- cover for chlamydia exposure

Question 13

Neonatal conjunctivitis

Answer 13

chemical - irrigate ASAP
bacterial - gonorrhoeae, staph, strep
chlamydia
viruses incl. herpes

Question 14

allergic conjunctivitis

Answer 14

benign conditions that appears during late childhood, may be seasonal, perennial or contact allergy
S&S - itchy, tearing, redness, stringy mucoid discharge, conjunctival hyperemia and edema, occasionally photophobia and vision loss
dx - clinical
tx - symptom relief
1st line - topical H1 receptor antagonist QID for several days
more sever - topical mast cell stabilizer - cromolyn sodium or lodoxamide
topical vasoconstrictor/antihistamine combo, systemic antihistamines - loratidine, systemic corticosteriods

Question 15

vernal keratoconjunctivitis

Answer 15

teens and young adults, seasonal
S&S - b/l conjunctival inflammation, photophobia, intense itchy, systemic atophy
PE - large cobblestone papillae on upper tarsal conjunctiva, corneal involvement frequent incl. refractory ulceration
tx - topical steroids, allergic onjunctivitis tx and cooler climate

Question 16

atopic keratoconjunctivitis

Answer 16

chronic disorder in adulthood
potential staphylococcal blepharitis
corneal involvement frequent
complicated by herpes simplex keratitis

Question 17

dacryoadenitis

Answer 17

inflammation or lacrimal glands
acute - infection
chronic - inflammatory disorders - thyroid disease, orbital swelling, sarcoidosis

Question 18

keratoconjunctivitis sicca

Answer 18

dry mouth, eyes, mucous membrane w/o connective tissue disorder
risks - elderly women, sjogren’s syndrome, rheumatoid arthritis, stevens-johnson syndrome, systemic meds and environmental conditions

Question 19

schirmer test

Answer 19

basal and reflex lacrimal gland function

Question 20

tear deficiency states

Answer 20

tears - lubricate, bacteriostatic
s7s - burning, foreign body sensation, reflex tearing
tx - artificial tears usual TID, QID (preferably without preservatives), lubricating ointmenta hs, more sever - anti-inflammatory or punctal occlusion

Question 21

keratitis

Answer 21

inflammation of cornea
secondary to infection, foreign body causing abrasion, exposure
s&S - pain photophobia, tearing, reduced vision, red eye, circumcorneal injection, purulent or watery discharge, hypopyon (bacterial s&s)

Question 22

bacterial keratitis

Answer 22

usually after corneal injury
p. aeruginosa, pneumococcus, moraxella, staphy.
gram stain and culture with empiric fluoroquinolone
change rx - to high conc. topical antibiotics
gram + - cephalosporine
gram - aminoglycoside or fluoroquinolone
for contact lens wearers - pain and tearing in early AM due to corneal edema, risk for pseudomonas species or acanthamoeba species
education - don’t swim while wearing contacts

Question 23

topical steroids and eye side effects

Answer 23

advance corneal penetration by herpesvirus, elevates IOP -> steroid-induced glaucoma
risk for cataracts

Question 24

exposure keratitis

Answer 24

bell’s palsy, proptosis
etiology - incomplete lid closure - leads to drying out
tx - lubricating solutions and ointments, tape lids shut at night
NO patching -> improperly done, gauze can scratch cornea

Question 25

actinic keratitis

Answer 25

UV light damages cornea due to exposure with symptoms 6-12 hrs later risk - lack of eye protection - welder's arc, sunlamps, snow blindness

Question 26

herpes simplex virus

Answer 26

can cause conjunctivitis, keratitis, blepharitis tx - oral acyclovir topical acyclovir or ganciclovir antivirals with topical steroids to reduce corneal opacity worst case - corneal grafting risk of recurrences so prophylaxis for immunocompromised pts

Question 27

herpes zoster ophthalmicus

Answer 27

infection of the ophthalmic division of CN V etiology - varicella zoster virus presentation - malaise, fever, HA, periorbital burning and itching, rash develops 1-2 days post sxs - vesicles, pustules, crusting dx - fluorescin stain - dendritic ulcer - braches ending in knobs tx - check HIV status if needed, REFER - oral antivirals at high does - 72 hrs of rash onset - acyclovir, valacyclovir, famciclovir posterior uveitis - topical steriods okay - no corneal involvement if over 60 and not immunocompromised, shingles vaccination indicated intraocular involvement suspicion - tip of nose or eyelid margins have vesicles

Question 28

scleritis

Answer 28

inflammation of the sclera mostly anterior, sometimes in isolation, 50% with systemic disease s&s - deep boring pain that may radiate - deep vessels non-blanchable, violaceous injection, systemic disease - connective tissue disorder may involve cornea, adjacent episclear and underlying uveal tract 2/3 rquire high dose glucocorticoids plus possibly immunosuppresive agent or risk of blindness due to destruction

Question 29

episcleritis

Answer 29

abrupt onset of inflammation of episclera, mild and isolated, self-limited or responds to topical therapies, non vision threatening, mostly healthy adult females

Question 30

orbital cellultitis

Answer 30

rapid onset, external - redness and welling, EOM impaired and painful, possible proptosis or optic nerve affected - decr. vision, afferent pupillary defect, disc edema tx - hospitalize, eye consult, blood cultures, CT scan, IV empiric antibiotics vs. staph, strep, h. influenzae ASAP surgical debridement -fungal, no improvement, subperiosteal abscess complications - cavernous sinus thrombosis, meningitis

Question 31

perioribital cellulitis

Answer 31

no proptosis, normal EOMS and vision, skin disruption - trauma, bites, etc.

Question 32

hordeolum

Answer 32

aka sy suppurative inflammation of gland of hair follice of eyelid etiology - blockage prevents normal drainage leading to bacteria entrapment normally of staph aureus risks- poor hygiene, chronic illness, previous hordeola internal- points onto conjunctival surface and can lead to generalized eyelid cellulitis s&s - redness, swelling, pain, tenderness, tearing, blurred vision, foreign body sensation tx - warm compresses, antibiotic ointment, I&D if no improvement in 48 hrs

Question 33

chalazion

Answer 33

chronic inflammatory granuloma of a meibomian gland/ tarsal gland hard, nontender swelling of eyelid with associated redness and swelling of conjunctiva tx- I&D, steroid injections may develop following internal hordeolum

Question 34

blepharitis

Answer 34

common, chronic b/o inflammatory condition of lid margins anterior- skin, lashes, glands posterior - meibomian glands common cause of recurrent conjunctivitis tx - keep lid margins, eyebrows, scalp clean antibiotic eye ointments - bacitracin, erythromycin longterm, lose dose systemic for some posterior cases, short-term topical corticosteroids if indicated

Question 35

entropion

Answer 35

inward turning of lower lid, risk - age due to degeneration of lid fascia, scarring of conjunctiva or tarsus surgery if risk of corneal abrasion

Question 36

ectropion

Answer 36

outward turning of lower eyelid common with advancing age | surgery for excessive tearing, keratitis, cosmeticerior cham

Question 37

acute angle-closure glaucoma

Answer 37

s&s - severe eye pain w/ rapid onset and frontal HA - blurred vision w/halos around lights - abd pain and nausea PE - red eye, cornea steamy; pupil moderately dilated and non-reactive to light - IOP markedly elevation - crescent shadow of anterior chamber - gonioscopy by ophthalmologists to visualize angle - if untreated w/in 2-5 days of symptoms, permanent and severe vision loss

Question 38

primary acute angle-closure glaucoma | tx

Answer 38

-previously narrow anterior chamber angle closes tx - initial acetazolamide mg IV follow by PO acetazolamide QID - no success -> osmotic diuresis, laser therapy or anterior chamber paracentesis to lower IOP Once IOP starts to lower - topical pilocarpine to reverse angle closure surgical tx - iridotomy or iridectomy

Question 39

secondary acute angle-closure glaucoma | tx

Answer 39

seen w/ anterior uveitis, lens dislocation, topiramate therapy systemic acetazolamide maybe with osmotic agents, tx underlying cause

Question 40

chronic glaucoma

Answer 40

chronically elevated IOP s&s- progressive loss of peripheral vision with visual acuity preserved PE - optic disc cupping or asymmetry of cup:disc ratio - central vision good preventative - screen pts >40 Q2-5 years - screen DM of +FH annually tx - PG analogs of topical beta-adrenergic blocking agents with or w/o alpha-agonist agents - medical failure to tx - laser or surgery if untreated can cause complete blindness in 15-20 yrs

Question 41

hypertnesive retinopathy

Answer 41

- excessively high bp can cause small retinal blood vessels to leak, bulge, thicken and become damaged leading to hemorrhages, hard and soft exudates and edema - if choroidal circulation is affected - vasoconstriction, ischemia, retinal infarcts, retinal detachments - venous compression at arteriovenous crossing- AV nicking - AV nicking can predispose for branch retinal vein occulsions and retinal bleeds - graded 1-4 with only 6% survival of pts with grade 4 after 3 yrs OR mild - severe grading - presents w/o visual symptoms - tx - steady, consistent BP control - if acute BP elevations cause HTN retinopathy don't treat too rapidly or aggressively

Question 42

diabetic retinopathy

Answer 42

types: 1. non-proliferative - dilated veins, small aneurysms, bleeding, edema, hard exudates in retina 2. background retinopathy - mild retinal abnormalities 3. maculopathy - macular edema, exudates, ischemia, most common cause of legal blindness in type II DM 4. proliferative- retinal neovascularization, proliferations into vitreous bv can cause retinal detachment, w/o tx bad prognosis compared to non-proliferative, laser surgery tx prevention: 1. Type 1 DM - 5 yrs after dx 2. Type 2 DM - at dx 3. women with DM and pregnant - early and Q2-3 months 4. tx - DM, HTN, lipid level control with good renal fcn

Question 43

retinal detachment

Answer 43

separation of neurosensory layer from retinal pigment epithelium, sub-retinal fluid accumulates under neurosensory layer risks - myopia, cataract surgery hx, ocular trauma, fhx, 50 yo+ s&s - new onset floaters or incr. in floaters, phtopsia - curtain spreading vision loss or sudden unilateral vision loss in periphery - no pain or erythema PE- check visual acuity, visual fields, pupils, trauma signs - ophthalmoscopic exam - retina hanging like a cloud, one+ tears tx - ocular emergency, refer, cover eye and void pressure - goal: close tears and adhere neurosensory and epithelium of retinea to choroid via laser photocoagulation or cryotherapy, with injection of expansile gas into vitreos cavity possibly first prognosis - 90% cases cured w/ one operation unless incr. duration of detachment or macular detachment, w/o tx - loss of vision

Question 44

rhegmatogenous

Answer 44

most common type of retinal detachment due to a tear | often spontaneous and related to changes in the vitreous as we age

Question 45

traction retinal detachment

Answer 45

- pre-retinal fibrosis due to diabetic retinopathy or retinal vein occulsion

Question 46

serous or exudative retinal detachment

Answer 46

accumulation of fluid beneath retina causes partial break or tear neovascular ARMD or choroidal tumors can cause this