Ophthalmology Topic Review Flashcards
(83 cards)
1
Q
Amblyopia definition
A
reduced vision in the absence of ocular disease, which occurs when the brain does not recognize input from that eye
2
Q
Most common causes of amblyopia
A
strabismus and a difference in refractive error
3
Q
Strabismus defintion
A
misalignment of the eye in any direction; may be constant or intermittent
4
Q
Normal visual development landmarks
A
Face follow: birth to 4 weeks of age
Visual following: 3 months of age
Visual acuity measurable with appropriate chart: 3.5yr
5
Q
At what age should ocular alignment for strabismus be examined
A
6 – 12 months
6
Q
At what age can you do the cover-uncover test
A
> 12 months
7
Q
When should you start screening for visual acuity?
A
3 – 5 years
8
Q
What is glaucoma?
A
damage to the optic nerve with visual field loss caused by or related to elevated pressure within the eye.
This high pressure leads to:
- Abnormal eye growth—large eye(s)
- Cloudy cornea with photophobia and tearing
Beware the infant with “big, beautiful eyes” who only opens eyes in dim light!
9
Q
Triad of glaucoma
A
- epiphora (tearing)
- photophobia
- blepharospasm (eyelid squeezing in response to light)
due to corneal irritation
only 30% have all 3
10
Q
Pathophysiology of glaucoma
A
abnormal fetal development of angle structures leading to elevated IOP and optic nerve damage
11
Q
Syndromes associated with glaucoma
A
Sturge Weber Syndrome
NF-1
Stickler Syndrome
Oculocerebrorenal (Lowe) Syndrome
Rieger Syndrome
Hepatocerebrorenal Syndrome
Marfan syndrome
Rubinstein-Taybi Syndrome
12
Q
Risk Factors for glaucoma
A
Previous cataracts (25% in those who had surgery)
Uveitis
Steroid use (topical or systemic)
family history of pediatric glaucoma/vision loss in young family members
13
Q
Cause of vision loss in glaucoma
A
Amblyopia
Vision is reduced secondary to glaucomatous optic nerve damage and corneal scarring but amblyopia is the most common cause of loss of vision in these children
14
Q
Treatment of Infantile Glaucoma (< 5 years)
A
Surgery
- establish a more normal anterior chamber angle (goniotomy and trabeculotomy)
- allow for aqueous fluid to exit the eye (trabeculectomy and seton surgery)
- reduce aqueous fluid production (cyclocryotherapy and cyclophotocoagulation)
if untreated => blindness
15
Q
Treatment of Juvenile Glaucoma
A
eye drops: beta blocker, carbonic anhydrase inhibitor
oral acetazolamide
if untreated => blindness
16
Q
Strains of adenovirus that cause keratoconjunctivitis
A
serotype 8, 19 or 37
17
Q
Management of Adenovirus Keratoconjunctivitis
A
supportive management, should resolve on its own
topical steroid can be used in severe cases - does not reduce recovery time and can actually prolong immune clearance
emphasis on prevention of spread by direct contact
18
Q
Transmission of Epidemic Ketatoconjunctivitis
A
direct contact
19
Q
risk factors for bacterial keratitis
A
- contact lens wear - most important risk factor!
- previous topical steroid use
- ocular surface disease
- ocular trauma
- previous keratitis
- prior surgery
- corneal disease
20
Q
Indications to collect corneal smear and/or culture
A
- central or large corneal infiltrate and/or associated with significant stromal involvement or melting
- chronic or unresponsive infection to broad spectrum antibiotic therapy
- history of corneal surgeries
- atypical clinical features suggesting fungal, amoebic or mycobacterial keratitis
- multiple infiltrates in the cornea
21
Q
Management of infectious keratitis
A
Culture
empiric antibiotics (fluoroquinolones like moxifloxacin)
cycloplegic agents (atropine) to decrease synechiae formation and reduce eye pain
surgical intervention if severe
22
Q
Cause of hyperacute bacterial conjunctivitis
A
Neisseria gonorrhoeae (gonococcal) or
Neisseria meningiditis (meningococcal) infection
23
Q
How to treat blepharitis?
A
Daily cleansing of the lid margins with a cloth or moistened cotton applicator to remove scales and crusts
Staphylococcal blepharitis is treated with an anti-staphylococcal antibiotic applied directly to the lid margins
24
Q
How does optic neuritis present?
A
Visual dysfunction / progressive vision loss over hours to days
Can have abnormal colour vision, visual field loss, RAPD
Periocular pain or pain with EOM is common
May have headache
25
What is the most important diagnosis to rule out in a child presenting with optic neuritis?
MS
ON is high risk for MS
26
What presentation of optic neuritis is most common in young children?
Bilateral optic neuritis
Preceding viral infection
27
What two investigations can help predict risk of MS in a patient with optic neuritis?
LP
MRI
28
Treatment of optic neuritis?
Pulse steroids
Not IVIG **
29
Epidemic Ketatoconjunctivitis presentation
Foreign body sensation
blurred vision (due to corneal involvement)
chemosis
photophobia
30
What is a cataract? When characteristics make it 'visually significant'?
Cataract = Opacification of the lens. Cataracts are deemed visually significant if >3mm and centrally located
31
Bilateral cataracts are more commonly found with syndromic, metabolic, or infectious etiologies.
What are some common METABOLIC syndromes that can present with cataracts?
Galactosemia (can be reversible if remove galactose from diet immediately)
Galactokinase deficiency
Fabry disease (alpha-galactosidase deficiency)
Niemann-Pick disease
Wilson disease
Homocystinuria
Zellweger syndrome
32
Bilateral cataracts are more commonly found with syndromic, metabolic, or infectious etiologies.
What are some common SYNDROMIC ASSOCIATIONS that can present with cataracts?
Trisomies (13, 18, 21)
Turner syndrome
WAGR Syndrome
(Wilms tumour + Aniridia + Genital abnormalities + Retardation)
NF-2
(neurofibromas, vestibular schwannomas, meningiomas, cataracts)
CHARGE
(Coloboma + Heart defects + Choanal atresia + Retardation of growth + Genital abnormalities + Ear abnormalities)
Alport syndrome
(Renal failure, SNHL, Anterior Lenticonus)
Sturge Weber Syndrome
Marfan syndrome
Myotonic dystrophy
Smith-Lemli-Opitz syndrome
(Toe Syndactyly, hypospadias, mental retardation)
33
Bilateral cataracts are more commonly found with syndromic, metabolic, or infectious etiologies.
What are some common INFECTIOUS etiologies that can present with cataracts?
Toxoplasmosis
CMV
HSV
Varicella
Measles
Rubella
Syphilis
Polio
Influenza
34
Unilateral cataracts are more commonly found with intraocular processses.
What are some common INTRAOCULAR causes of cataracts?
Ocular Trauma
Uveitis
Micro-opthalmos
Aniridia
Coloboma
Anterior segment dysgenesis
Posterior lenticonus
ROP
Retinal detachment
Retinitis pigmentosa
Persistent hyperplastic primary vitreous
35
How would cataracts present?
Red Reflex Exam:
- Abnormal red reflex (white reflex, dark spots in reflex)
Bruckner Exam:
- Asymmetric red reflex suggesting amblyopia
+/- structural abnormalities (Ex: irregular asymmetric pupils, coloboma) depending on syndrome
36
Cataracts are deemed 'visually significant' if >3mm and centrally located. Children with cataracts have a high chance of developing amblyopia due to this visual obstruction.
When should children be referred to ophthalmologist?
- Abnormal red reflex
- Asymmetric bruckners exam
- Structural abnormalities or irregular asymmetric pupils
- After 3mo of age = if abnormal fixing & following, nystagmus, squinting
37
A child has been diagnosed with a congenital cataract.
- What is the timing of their surgery for cataract extraction?
- Is it different if it is unilateral vs bilateral cataract?
Cataracts are deemed 'visually significant' if >3mm and centrally located. As children with cataracts have a high chance of developing amblyopia due to visual obstruction, they undergo surgery quite quickly.
If unilateral cataracts = Surgery by 6 weeks
If bilateral cataracts = Surgery by 12 weeks
38
What are the complications to monitor for post-cataract extraction surgery?
- Visual axis opacifications
- Glaucoma
- Retinal detachment
- Strabismus
39
What causes hyphema?
Almost always due to trauma
If no trauma history, think:
- NAT
- bleeding disorder eg vWD
- sickle cell disease
- Warfarin
40
How to treat hyphema?
Urgent ophtho consult
Rule out globe rupture
Measure and treat IOP
Topical cycloplegic and steroid drops
Bed rest
HOB > 45 degrees
Shield to protect eye
41
What is the period of time recurrent hemorrhage and secondary glaucoma are most likely to occur in hyphema?
In the first 3-5 days
42
What is uveitis?
Inflammation of uvea (iris, ciliary body, and choroid)
can be traumatic, inflammatory, infectious and malignant causes
43
symptoms of anterior uveitis?
asymptomatic/insidious if JIA
if acute uveitis: red eye, pain, photophobia and tearing
44
symptoms of posterior uveitis?
- Worsening vision
- Visual field changes
45
etiologies of anterior uveitis?
JIA (HLA-B27+)
Crohn's/Ulcerative Colitis
Kawasaki, MISC
Trauma
TB
Syphilis, leptospirosis
46
etiologies of posterior uveitis?
Toxoplasmosis
Cat scratch disease
TB
Histoplasmosis
Rubella, CMV
(don't worry about memorizing this, no questions related to this and pretty specific)
47
etiologies of panuveitis?
Behcets
Sarcoidosis
Lyme disease
48
Treatment of uveitis?
topical corticosteroid (prednisone) and cycloplegics (atropine)
if autoimmune, oral steroids + immunomodulatory therapy (avoid topical steroids if autoimmune as it increases risk of glaucoma, cataract and blindness)
Info from Nelsons, Nelson board review and Hamilton lecture
49
What is this?
retinal hemorrhage
50
Etiologies of retinal hemorrhage?
vaginal delivery (resolves within weeks)
Non-accidental injury (shaking)
rare: leukemia, vasculitis, meningitis, cyanotic congenital heart disease, endocarditis, sepsis, thrombocytopenia
51
List at least 3 ophthalmologic findings of abusive head trauma?
retinal hemorrhages
retinal folds
retinoschisis (splitting of the retina- STRONGLY suggestive of child abuse)
vitreous hemorrhage
papilledema
optic nerve sheath hemorrhage, optic atrophy
52
what is this? Other features?
Tay-Sachs (RC photo): eye cherry red spot
presents in Infancy, myoclonus, seizures, spasticity, progressive blindness/deafness, developmental regression
death by 3-4yrs by pneumonia
53
What is this? Other features?
Sturge Weber (RC photo)
typical triad:
- facial capillary malformation (port wine stain or nevus flammeus)
- ipsilateral vascular anomaly in the brain (leptomeningeal hemangioma)
- ocular hemangioma
Can also present with glaucoma
54
How would a Horner Syndrome present compared with CN III palsy?
HINT: Think about degree of ptosis, pupil size, eye position.
Horner syndrome
Ptosis + Miosis + Normal Eye Movements
CN III palsy
Severe Ptosis + Mydriasis + "Down and out" eye (can't look up or medially)
CN III can be seen in brain tumors
55
what is periorbital (preseptal) cellulitis?
infection of the anterior portion of the eyelid, not involving the orbit or other ocular structures.
56
what is orbital cellulitis?
infection of the contents of the orbit
orbit = bony cavity in the skull containing globe of the eye (eyeball), extraocular muscles, lacrimal gland, and blood vessels/nerves
57
symptoms of preseptal cellulitis?
Eyelid swelling and erythema
58
symptoms of orbital cellulitis?
painful eye movements
visual impairment, diplopia
Proptosis (eye bulging out)
Severe headaches, vomiting and signs of intracranial involvement (ie frontal osteomyelitis, cavernous sinus venous thrombosis)
Chemosis (= conjunctiva appear swollen and gelatinous)
59
Complications of orbital cellulitis?
Vision loss
Intracranial infection (epidural or subdural abscess; meningitis)
Subperiosteal Abscess + Frontal Bone Osteomyelitis = Potts Puffy Tumor
Venous sinus thrombosis --> prevents drainage --> Hemorrhage --> Stroke
lateral gaze palsy
systemically unwell, fever
60
Empiric antibiotics for orbital cellulitis?
Ceftriaxone, Vancomycin
Add metronidazole if infection from sinuses (which is usually is)
61
Empiric antibiotics for preseptal cellulitis?
Amox-Clav x 7d as outpatient
only need to admit if not getting better
(vs orbital cellulitis we always admit)
62
Complications of orbital cellulitis?
Subperiosteal abscess or orbital abscess
Cavernous sinus thrombosis
Intracranial infections: subdural empyema, intracranial abscess, meningitis: present with HA, emesis
Septic emboli of optic nerve or ischemia due to compression visual loss
63
Management of orbital cellulitis?
Admit
Keep NPO until need for surgery clarified
ENT and Ophthalmology consults urgently
if visual, sensory or CNS sx --> contrast CT scan of orbits, sinuses + brain urgently (only image if signs of complications)
CBC and blood culture
*LP contraindicated due to risk of raised ICP secondary to possible intracranial extension
Ceftriaxone, Vancomycin +/- metronidazole (should improve in 72hr)
Treat underlying sinus disease: nasal decongestants, nasal steroids (often guided by ENT)
Drain if abscesses found on CT
64
presentation of nasolacrimal duct obstruction?
infants <12mo
recurrent mild eye discharge, worse with waking, no conjunctival inj
crusted eyelids
tearing - worse with URTI and outdoors
becomes evident when normal tear production develops (ie not usually at birth)
65
complication of nasolacrimal duct obstruction?
dacryocystitis = Rare acute infection of nasolacrimal sac with inflammation of eye and nose
usually <1mo old
66
management of dacrocystitis?
Emergency referral
Nasolacrimal massage
Systemic antibiotics
Consider surgical management if: respiratory compromise, acute infection, no resolution with medical management
67
Treatment of nasolacrimal duct obstruction?
Massage several times per day
Clean crusted lids with moist cloth
If mucopurulent drainage, add topical abx (Nelson’s recommendation)
Majority resolve spontaneously by 1 year of age;
if persistent, refer to ophtho for surgical probing
68
A baby has a blueish discoloration just medial to her eyeball - what is it? how to treat?
congenital dacryocystocele (mucocele)
= nonpatent nasolacrimal sac that is obstructed on both sides
Seen at birth (or shortly after) as bluish subcutaneous mass
tx: massage
69
complication of dacryocystocele ?
respiratory distress
bc the intranasal portion of the nasolacrimal duct is distended into the nose (remember babies are obligate nose breathers)
70
you see a Kayser-Fleischer ring - what do you do?
slit lamp
this is deposition of copper into the cornea from Wilson disease
usually a teenager with psych sx
71
you see a posterior embryotoxin - what do you do?
slit lamp
this is a prominent white line on internal edge of cornea near sclera in neonate with jaundice
patient has Alagille syndrome
72
How to differentiate viral vs bacterial conjunctivitis?
bacterial =purulent eye discharge (viral = clear)
bacterial more common <5yrs (viral is more teens)
bacterial more common during resp season (fall, winter, early spring) (vs viral more common in summer)
both can have lid swelling, red eyes, can be uni or bilateral
both usually have sick contacts, assoc'd with otitis media, pharyngitis
can see PSEUDOMEMBRANES or true membranes in viral
73
Pathogens causing bacterial conjunctivitis?
H flu (60-80%; assoc’d with otitis media)
strep pneumo (20%)
staph aureus (10%)
H aegyptius, moraxella catarrhalis
74
treatment of bacterial conjunctivitis?
Ix: Conjunctival smear and culture
Per Nelsons:
Topical antibiotic drops (shortens the duration and hastens return to school) + warm compresses
If neisseria gonorrhoaee or H flu: IV ceftriaxone
75
examples of topical antibiotics for bacterial conjunctivitis?
fusidic acid
polymyxin B sulfate
moxifloxacin
Ofloxacin
76
when to refer to ophthalmology in bacterial conjunctivitis?
vision loss
severe purulent discharge or severe pain
severe photophobia
contact lens wearer (DON'T MISS KERATITIS which can threaten vision)
not improving in 72hr
77
differentiate keratitis from conjunctivitis
keratitis = infection of cornea, transparent covering of the iris and pupil
conjunctivitis = infection of he conjunctiva, the thin membrane that covers the white part of the eye and the inside of the eyelids.
**keratitis can threaten vision and often requires urgent ophthalmologic referral, whereas conjunctivitis is usually benign and self-limited**
78
what causes viral conjunctivitis?
usually adenovirus (then we call it "epidemic keratoconjunctivitis") - can be associated with pharyngitis and fever
coxsackie and enterovirus can cause "acute hemorrhagic conjunctivitis" = PINK EYE
79
Treatment of viral conjunctivitis?
educate families that pink eye is HIGHLY CONTAGIOUS
keep out of school 48hr
self-limited 7-14 d course
wash hands often
artificial tears and cool compresses
if membranes/pseudomembranes --> peeling +/- topical steroids
if HERPES SIMPLEX VIRUS = tx with Acyclovir
80
DDX of conjunctivitis?
bacterial - H flu, strep pneumo, staph aureus
viral - usually adenovirus, don't miss herpes simplex virus),
allergic (pruritis)
ophthalmia neonatorum
- thick discharge within 4 d of birth, think GONORRHEA
- 5d-3wk +/- ass'd with pneumonia, think CHLAMYDIA
81
Contact lens wearers are at increased risk for what?
bacterial conjunctivitis with gonorrhea or pseudomonas
corneal ulcer
bacterial keratitis (infected cornea -> VISION threatening --> antibiotics + URGENT OPTHO REFERAL)
82
symptoms of keratitis?
foreign body sensation, difficulty keeping eyelid open (active corneal process), +/- decreased visual acuity, pain, photophobia, discharge
83
what is epidemic ketatoconjunctivitis?
highly contagious and virulent viral conjunctivitis with corneal infection (keratitis) that has reduced visual acuity due to corneal involvement
keratitis can threaten vision and often requires urgent ophthalmologic referral
caused by adenovirus susually
