Other Ocular Conditions Flashcards
(88 cards)
1
Q
Inward turning of the lower eyelid
A
Entropion
2
Q
Entropion is usually seen in who? why?
A
elderly
Maybe from degeneration of the lid fascia or scarring of the conjunctiva and tarsus
3
Q
when is surgery indicated for entropion
A
lashes rub on the cornea
4
Q
tx for entropion (temporary)
A
botox
5
Q
Outward turning of the lower eyelid
A
Ectropion
6
Q
Ectropion is usually seen in who?
A
elderly
7
Q
when is surgery needed with Ectropion?
A
excessive tearing
exposure keratitis
cosmetic problem
8
Q
Abnormal contraction of eyelid muscle
A
Blepharospasm
9
Q
causes of Blepharospasm
A
Stress, tiredness, neurological condition
10
Q
tx for Blepharospasm
A
- Alleviate stress, decrease caffeine
- Botulinum toxin injections
11
Q
Drooping of the eyelid is what condition?
A
Ptosis
12
Q
causes of Ptosis
A
- Usually due to eyelid disease
- Neurological disease
- Horner’s syndrome
- Third nerve palsy
- Myasthenia gravis
— Fluctuating ptosis that worsens late in the day - Congenital
- Dysgenesis of the levator palpebrae superioris
- Abnormal insertion of it’s aponeurosis into the eyelid - Acquired
- Trauma, eye surgery, systemic symptoms, family history, contact lense use, diplopia - Mechanical
- Stretching and redundancy of eyelid skin and subcutaneous fat
- Enlargement or deformation of the eyelid from infection, tumor, trauma or inflammation - Aponeurotic
- Dehiscence or stretching of the aponeurotic tendon
- Elderly - loss of connective tissue elasticity
- Sequelae of eyelid swelling
13
Q
Any proptosis
Eyelid masses or deformity
Inflammation
Pupil inequality
Limitation of movement
Width of palpebral fissures = quantitate the degree of condition
are presentations of what condition?
A
ptosis
14
Q
tx for ptosis
A
- Nonsurgical: Oxymetazoline eye drops
- Stimulates alpha-adrenergic receptors in the superior tarsal muscle (Muller’s muscle) of the eye lid - maintains elevation of the upper lid - Surgery
- reserved for obscured visual field
- Can be cosmetic reasons
- Muller muscle resection
- Levator muscle resection or advancement
15
Q
Fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea
Become inflamed and may grow
A
Pterygium
16
Q
what condition is usually due to prolonged exposure to wind, sun, sand and dust
A
Pterygium
17
Q
tx for Pterygium
A
- Artificial tears
- NSAIDS or weak corticosteroids
- Surgery if severe or impairs vision or severe ocular irritation
- Recurrence is often and more aggressive
18
Q
- Yellowish-orange, slightly raised conjunctival lesion
- Arises from the limbus and stays confined to the conjunctiva, not crossing over onto the cornea like a pterygium
- Can occur on nasal or temporal sides of the conjunctiva
A
Pinguecula
19
Q
what is benign and thought to occur due to exposure to dust
A
Pinguecula
20
Q
dry eye prevalence increases with ___
A
age
21
Q
risk factors of dry eye
A
- Age
- Female gender
- Hormonal changes
- Systemic diseases
- Contact lense wearers
- Systemic medications
- Ocular medications
- Nutritional deficiencies
- Vit A Def - Decreased corneal sensation
- Ophthalmic surgery - especially corneal refractive surgery
- Low humidity environments
22
Q
dry eye can be a result from ?
A
- Any disease associated with the tear film components
- Aqueous - hypofunction of the lacrimal glands
- Mucin
- Lipid - Lid surface abnormalities
- Epithelial abnormalities
23
Q
2 pathophys of dry eye
A
defective spreading of tear film
1. Eyelid abnormalities
- Ectropion or entropion
- Decreased or absent blinking
— Neurologic disorders
— Hyperthyroidism
— Contact lens use
— Drugs
— Herpes simplex keratitis
2. Conjunctival abnormalities
- Pterygium
3. Proptosis
Increased evaporative loss
1. Environmental factors
- Dry, hot, windy climate
2. Meibomian gland function - posterior blepharitis
3. Ocular allergy
24
Q
s/s of dry eye
A
Dryness
redness
FB sensation
excessive mucus secretion
itching
light sensitivity
blurred vision
25
during a slit lamp exam you see:
- Absence of tear meniscus at lower lid margin
- Yellowish mucus strands in lower conjunctival fornix
- Bulbar conjunctiva loses its normal luster and may be thickened, edematous and hyperemic
what is the condition?
dry eye
26
fluorescein staining for dry eye would show what
Defects in the corneal epithelium
27
Rose Bengal and Lissamine Green Staining of dry eye would show what?
Defects in the corneal and conjunctival epithelial cells
28
Schirmer’s test is for what?
Measures tear production by wetting of a filter paper for dry eye
29
Tear Break up Time shows what?
Estimates mucin content
30
complications with dry eye?
1. Impaired vision
2. Extreme discomfort
3. Corneal ulceration
4. Corneal thinning
5. Perforation
6. Infection
7. Corneal scarring and vascularization
31
tx for dry eye
1. **Artificial Tears**
2. Ointment
- Useful for prolonged lubrication (ex. sleeping)
3. Cyclosporine (Restasis)
- Increases tear production d/t inflammation reduction
4. Environmental strategies
- Humidified, moisture chamber glasses, swim goggles
5. punctal plugs - retain lacrimal secretions
- Blocks drainage--increases eyes’ tear films and retains moisture
32
artificial tears contains what?
1. Cellulose - maintain viscosity
2. Polyethylene glycol or polyvinyl alcohol - a spreading agent that prevents evaporation
3. Preservative - prevent contamination
33
- Polycyclic peptide that inhibits both cellular and humoral immune responses by inhibiting IL-2 (needed for T-cell activity)
- Main use is to prevent organ rejection following transplant
Cyclosporine (Restasis)
34
Opacity of the crystalline lens
May cause blurred/distorted vision and blindness
Cataracts
35
what is the leading cause of blindness WW? second?
Cataracts
glaucoma
36
risk factors of Cataracts
1. _Age related_ - MC and #1 cause
- _Degenerative effects of aging on cell structure_
2. Exposure to UVB light
3. Glaucoma
4. Smoking and Alcohol use
5. Congenital
- Intrauterine infections - Rubella, CMV
- Inborn errors of metabolism - galactosemia
6. Traumatic
7. Secondary to systemic disease - DM, myotonic dystrophy, atopic dermatitis
8. Corticosteroids and radiation therapy
9. Uveitis
37
- _Progressive blurring of vision, usually gradual_
- Glare, especially in bright light or when driving at night
- Development of nearsightedness
- Monocular double vision
- Cloudy lens
cataracts
38
early vs late/progresses cataracts
1. Early - Can be seen through a dilated pupil
2. Late / Progresses - Retina becomes more difficult to visualize until fundus reflection is absent and pupil is white
39
tx for cataracts
1. Refer to ophthalmologist
2. _Surgery_
- Visual impairment is criteria: increase falls, effects on daily activity
- Procedure done with local anesthesia, outpatient
- surgically remove and replace the opacified lens from the eye to restore transparency of the visual axis
40
Leading cause of adult blindness in developed countries
Macular Degeneration
41
Loss of central vision; usually bilaterally
Peripheral vision maintained
Macular Degeneration
42
risk factors for Macular Degeneration
Age
White race
Sex - slight female predominance
Family history, hypertension, hyperlipidemia
Cigarette smoking
43
2 classifications of macular degeneration
1. Atrophic - “dry” or “non-exudative”
2. Neovascular - “wet” or “exudative”
44
which macular regeneration has Retinal drusen
atrophic (dry)
45
Hard - discrete, yellow, retinal deposits made from extracellular lipids/proteins
seen in macular degeneration
Retinal drusen
46
what happens with neovascular macular degeneration
1. New vessels grow between the retina or retinal pigment epithelium and Bruch’s membrane (innermost layer of choroid)
- VEGF released
- These abnormal vessels leak
- Accumulation of serous fluid, hemorrhage and fibrosis
2. More rapid and severe vision loss
47
tx for macular degeneration
1. Refer to ophthalmologist
- **VEGF inhibitors**
--- Reverse choroidal neovascularization - stabilization or improvement in vision in _neovascular (wet/exudative)_
--- Administered into the vitreous
--- Tight BP control
- **No tx for _atrophic_**
2. Quit smoking
3. Antioxidants
- Vit C and E
- Zinc
- Copper
- Carotenoids - Reduce risk of disease progression in patients with maculopathy
48
a signal protein produced by cells that stimulates vasculogenesis and angiogenesis.
Vascular endothelial growth factor (VEGF)
49
an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for _draining the aqueous humor from the eye via the anterior chamber_
trabecular meshwork
50
2 types of glaucoma
1. Narrow Angle
- aka closed angle or Acute angle closure glaucoma
2. Open Angle
- Chronic glaucoma
51
A group of eye diseases characterized by _neuropathy to the optic nerve, with or without elevation in intraocular pressure_
Glaucoma
52
during ophthalmologic examination of glaucoma what would you see?
Cupping of the optic disk
53
Leading cause of glaucoma blindness
Acute angle/narrow Glaucoma
54
causes of acute glaucoma
Development abnormality, congenital, scar tissue from trauma or infection, advanced age, farsightedness
55
pathophys of acute glaucoma
1. Angle between the cornea and iris in the anterior chamber is decreased
- lens is located too far forward and presses against the iris
2. Blocks outflow of aqueous humor when the pupil is dilated and the iris thickens and fills in the narrow angle
3. **_Sudden_ increase of intraocular pressure causing damage to the optic nerve**
- normal pressure = 8-21 mmhg
56
risk factors for acute glaucoma
1. Asian descent
- less trabecular meshwork exposed
2. Family hx
3. Female
4. Age 40-50 years
5. Hyperopia (farsightedness)
6. Certain medications
57
pathogenesis of Narrow Angle/Angle Closure Glaucoma
1. Primary angle closure
- Lens located too far forward anatomically and rests against the iris
2. Secondary angle closure
- Anterior angle chamber becomes occluded as a result of:
--- Conditions that PUSH the ciliary body forward
--- Conditions that deform the iris so that it is retracted into the angle (PULLING)
58
s/s of acute glaucoma
1. typically _appear at night_ d/t lower light causing mydriasis (dilation of pupil)
- Vision loss or decreased vision
- _Halos around lights_
- Headache
- Severe eye pain
- N/V
2. Conjunctival redness
3. _Corneal edema or cloudiness
- “Red, steamy cornea”_
4. Shallow anterior chamber
5. Mid-dilated pupil (4 to 6 mm) that reacts to light poorly _if at all_
6. IOP often over 50mmg, leading to a hard eye on palpation
59
ddx for angle closure glaucoma
Iritis
Trauma
Hyphema
Subconjunctival hemorrhage
Corneal abrasion
Infectious keratitis
60
how to diganose angle closure glaucoma
1. _Immediate referral to an ophthalmologist_
- Visual acuity
- Evaluation of the pupils
- IOP
- Slit lamp exam of ant segments
- Visual field testing
- Undilated fundus exam
2. **Gonioscopy** is the _gold standard_ for diagnosis
- Views the iridocorneal angle
61
This technique involves using a special lens for the slit lamp, which allows the ophthalmologist to visualize the angle and diagnose angle-closure.
Gonioscopy
62
helps to determine the severity and chronicity of the angle-closure by measuring the extent of scarring was produced
Indentation gonioscopy
- putting posterior pressure on the eyeball with the lens used for gonioscopy
- The pressure will widen the angle if it is not scarred completely closed
63
tx for angle closure glaucoma
1. Emergent ophthalmologic referral
2. _PLACE PATIENT SUPINE_
3. Systemic medications 1st
- First line: **Acetazolamide**
4. When IOP drops:
- **Pilocarpine**
- can add acetazolamide
5. Other topical agents
- Latanoprost (Prostaglandin)
- Timolol (Beta blocker)
- Apraclonidine (Alpha adrenergic agonist)
6. **_definitive_: Laser peripheral iridotomy**
*recheck IOP every 30-60 min*
64
what angle closure glaucoma tx Decreases production of aqueous humor
Acetazolamide
65
what angle closure glaucoma tx
Increases outflow of aqueous humor/decreases resistance, causes miosis
Pilocarpine- cholinergic agonist
66
A laser is used to create a hole in the peripheral iris to relieve pupillary block, allowing aqueous humor to traverse directly from the posterior to anterior chamber
Laser peripheral iridotomy
67
INITIAL tx for acute glaucoma (waiting for ambulance)
1. EMERGENT REFERRAL TO OPHTHALMOLOGY
2. WHILE WAITING ON AMBULANCE
- LIE ON THEIR BACK
- ACETAZOLAMIDE 500MG PO or IV
- PILOCARPINE 2% EYE DROPS
- ANALGESIA
- ANTIEMETIC
68
how does open/chronic glaucoma happen?
- Angle between the cornea and iris is open
- they have degeneration and slow blockage of trabecular meshwork = slowly reduces the outflow of aqueous humor
- Gradual increase of intraocular pressure which may come and go
- Progressive _peripheral vision loss_ leading to central vision loss
69
risk factors of open angle glaucoma
1. Age
- > 50 y/o
--- Incidence increases with age - 4% after age 40
2. Race
- > Caucasian and African ancestry
--- Leading cause of blindness among African Americans
3. Family hx
4. Elevated intraocular pressure
5. HTN
6. DM
7. CVD
8. Hypothyroid
70
s/s of open angle glaucoma
1. decreased quality of life
2. Difficulty with daily functions
3. _High levels of IOP_ (> 40mmHg) cause *no symptoms in these patients*
4. Gradual _peripheral visual field loss_ (no loss of visual acuity) leading to central vision loss (loss of visual acuity)
- Irreversible
71
what is the Screening Recommendations from American Academy of Ophthalmology
1. _Comprehensive Eye Exam_ - rather than individual tests
2. For adult patients without risk factors for eye disease:
- every 5 to 10 years in patients <40
- every two to four years in patients 40 to 54 years
- every one to three years in patients 55 to 64 years
- every one to two years in patients ≥65 years.
3. For patients with risk factors for glaucoma:
- every one to two years in patients <40 and ≥55 years
- every one to three years in patients age 40 to 54 years
4. Referral for any patient with cupping on fundoscopic exam
72
why is a comprehensive eye exam more recommended than individual tests?
will likely fail to detect many cases of glaucoma, which is defined as an optic neuropathy rather than a disease of high pressure alone.
73
how do you diagnose open angle glaucoma
1. Ophthalmologist
- Fundoscopic Exam
--- Cupping diameter of >50% of the vertical diameter
- Visual Field testing
- Intraocular pressure - tonometry
---Schiotz tonometry - handheld device
74
what ranges of IOP do you need referral
1. IOP >40 mmHg - emergent referral
2. IOP 30-40 mmHg - urgent referral (within 24 hours)
3. IOP 25-29 mmHg - evaluation within 1 week
4. IOP 23-24 mmHg - repeat and/or refer for comprehensive exam
75
tx for open angel glaucoma
1. **Topical Prostaglandins**
- _initial therapy_
- Latanoprost (Xalatan) - generic
- Tafluprost (Zioptan) - no preservatives
- Bimatoprost (Latisse) - lengthens eyelashes
2. **Topical Beta Blockers**
3. **Topical Alpha-2 Adrenergic Agonists**
- Apraclonidine
4. Cholinergic Agonists
- pilocarpine
- Mitotic
5. Topical Carbonic Anhydrase Inhibitors (not effective)
- Acetazolamide (Diamox)
76
SE of Topical Prostaglandins
conjunctival hyperemia, eye irritation, increase in number and length of eyelashes, changes in iris and lash pigmentation, FB sensation
77
what medication is a selective agonist of prostaglandin receptor; increase the outflow of aqueous humor, dropping IOP
Exact mechanism unknown
Topical Prostaglandins
78
what med reduce IOP by interfering with cyclic adenosine monophosphate (cAMP), (cAMP is used to produce aqueous humor in the ciliary process of the eye)
Topical Beta Blockers
79
SE of Topical Beta Blockers
1. Systemic - more common with non-selective BB
- Timoptic (timolol) - bradycardia, hypotension
- Long-term use - bronchospasm
2. Ocular - burning and stinging upon application
80
interactions with Topical Beta Blockers
Don’t give systemic BB - additive effect
81
what med causes mydriasis, decreasing congestion in the blood vessels of the conjunctiva leading to reduction in IOP by reducing the production of aqueous humor
Topical Alpha-2 Adrenergic Agonists
Similarly effective to BB in reducing IOP
82
SE of Topical Alpha-2 Adrenergic Agonists
allergic conjunctivitis, hyperemia, ocular pruritus
83
DDI of Topical Alpha-2 Adrenergic Agonists
1. MAOIs
2. Tricyclics
3. CNS depressants, alcohol, BB, cardiac glycosides, or other antihypertensives
84
what med Causes the pupil to constrict
_Cholinergic Agonists_ - mitotic
constricted = ciliary muscles attached to trabecular meshwork are contracted = opening up Schlemm’s canal = increasing outflow of aqueous humor = decreasing IOP
Deactivated cholinesterase which permits acetylcholine to continue miosis
85
SE of Cholinergic Agonists
Fewer SE than BB
Abd cramps, diarrhea, watery mouth, sweating
Ocular - fixed, small pupils, myopia, visual disturbance,
HA due to ciliary spasm
86
what med slows the action of the enzyme carbonic anhydrase (directly inhibits the production), leading to decreased production of aqueous humor and lowering IOP
_Topical Carbonic Anhydrase Inhibitors_
not as effective
use as a diuretic; can be used as an adjunct in open angle glaucoma
87
CI of Topical Carbonic Anhydrase Inhibitors
Allergy to sulfonamides
88
surgical option for open angle glaucoma
**Laser peripheral iridotomy**
- Creates a hole in the peripheral iris
- Aqueous fluid bypasses the blockage
