TMOD Flashcards

Question

LASIK - flap slip

Answer 1

Frequent AT Send back to the surgeon to reposition the flap, consider suture FU is urgent surgical repositioning then see as directed by surgeon

Answer 2

Prednisolone acetate 1% q1h If severe, it may require lifting the flap and irrigation of the interface FU: daily until improvement noted

Answer 3

Treat if >2mm inside of flap and easily noted on SLE Surgical debridement if dense, flap melt, approaching VA or affecting vision Small pockets may be treated with YAG laser FU is weekly for 1 month to determine stability ** If stable and low grade, see yearly

Answer 4

Offer scleral or RGP contact lens fit Consider referral back to surgeon if patient is interested in enhancement FU weekly for 1 month to determine stability, if stable and low grade, see yearly

Answer 5

Offer scleral or hybrid contact lens fit Consider referral to corneal specialist for corneal cross-linking, INTACS, penetrating keratoplasty FU for scleral lens fit, then every 3-6 months

Answer 6

Treat as dry eye unless reactivation of HSK is suspected Frequent AT Bruder mask Cyclosporine 0.05% BID or lifitegrast 5% BID if persistent Consider autologous serum tears or amniotic membrane if nonhealing if HSK suspected 400 mg A 5x daily for 7-10 days 500 mg V 3x daily for 7-10 days 250 mg F 3x daily for 7-10 days - do not prescribe to patients with HIV AIDs due to TTP risk Ganciclovir 0.15% 5x daily for 7-10 days Trifluridine 1% 9x daily for 7-10 days FU is routine for cataract surgery (1d,1w,1m, 3m) unless HSK is suspected then see back in 2-7 days to monitor tx response

Answer 7

5% NaCl QID with ung QHS Reduce IOP if needed with aqueous suppressants Erythromycin 0.5% ung BID and cyclopentolate 1 % TID for painful ruptured bullae Consdier BCL, anterior stromal micropuncture PKP/DMEK/DSEK if advanced FU every 1-3 days until improvement is noted, then every 5-7 days until healed

Answer 8

Mild subluxation: monitor with dilated exams If symptomatic or significantly displaced/dislocated: refer back to surgeon for repositioning or alternate procedure (ACIOL, pars plana lensectomy, leave aphakic) FU at the recommendation of OMD, worsening symptoms or 1 year

Answer 9

IV vancomycin 1mg/0.1 mL OR ceftazidime 2mg/0.1 mL INTENSIVE prednisolone acetate 1% q1h INTENSIVE fortified antibiotic options - cefazolin 50 mg/mL - ceftazidime 50 mg/mL - tobramycin 15 mg/mL - vancomycin 25 mg/mL Atropine 1% QID Consider hospitalization for observation FU as directed by OMD, see every 12-24 hours early, pt should show improvement by 48 hours ** if subacute consider fungal - IV amphotericin B 10 mcg/0.1 mL - IV voriconazole 100 mcg/0.1 mL ** if fungal is confirmed start natamycin 5% q1h

Answer 10

frequent viscous AT (genteal gel) q2h with ung at night (genteal pm) consider patching or BCL if not a CL wearer consider surgical excision of pterygium/ping if that is the cause FU in 1-7 days if thinning is not too severe and low-risk of perforation

Answer 11

PFAT 4-10 times daily with ung (genteal pm) QHS Blepharitis: erythromycin 0.5% BID-TID Immunosuppressive agents may be used for progressive SD Consider surgical correction of entropion Consider cryotherapy for trichiasis Mucous membrane grafts may be used for reconstruction of fornices FU every 1-2 weeks during acute phase and every 1-6 months during remissions

Answer 12

Best correct with specs, poly lenses medically necessary HYDROPS: 5% NaCl and ung at night, 1% cyclopentolate TID, erythromycin 0.5% ung BID PKP results are suboptimal, generally not recommended FU every 6 months unless acute hydrops develop, then every 1-4 weeks

Answer 13

Avoid eye rubbing Best correct with glasses or SCL in mild cases Consider sceral or RGP in severe cases Corneal transplant, INTACS, and corneal cross-linking may be helpful HYDROPS: 5% NaCl and ung at night, 1% cyclopentolate TID, erythromycin 0.5% ung BID FU every 3-6 months depending on the severity unless acute hydrops develop, then every 1-4 weeks

Answer 14

** Adenovirus subgroup D serotypes 8,19,37 Patient education: condition will get worse for 4-7 days then recover in 2-3 weeks Highly contagious for 2 weeks or if eyes are red and tearing Avoid touching eyes, shaking hands, sharing towels, and restrict work/school PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe Peel any pseudomembranes that form *** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed

Answer 15

Enterovirus 70, coxsackie virus A24, adenovirus serotype 11 Highly contagious for 2 weeks or if eyes are red and tearing Avoid touching eyes, shaking hands, sharing towels, and restrict work/school PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe Peel any pseudomembranes that form *** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed

Answer 16

Adenovirus subgroup D of serotypes 3 and 7 Highly contagious for 2 weeks or if eyes are red and tearing Avoid touching eyes, shaking hands, sharing towels, and restrict work/school PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe Peel any pseudomembranes that form *** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed

Answer 17

Blepharitis: 0.5% erythromycin ung BID WC, lid hygiene, moxifloxacin 0.5% QID, loteprednol 0.5% QID RECURRENT or RESISTANT add doxycycline 100 mg BID x 2 weeks then 100 mg QD x 1 month then 50 mg QD until the disease is well-controlled FU 2-7 days depending on s/s Monitor IOP on steriods Do NOT use steroids without antibiotic coverage Do NOT taper antibiotics

Answer 18

Blepharitis: 0.5% erythromycin ung BID WC, lid hygiene, moxifloxacin 0.5% QID, loteprednol 0.5% QID RECURRENT or RESISTANT add doxycycline 100 mg BID x 2 weeks then 100 mg QD x 1 month then 50 mg QD until the disease is well-controlled FU 2-7 days depending on s/s Monitor IOP on steriods Do NOT use steroids without antibiotic coverage Do NOT taper antibiotics

Answer 19

Order thyroid function tests MILD: aggressive PFAT with ung at night Consider punctal occlusion Treat blepharitis with 0.5% erythromycin ung BID Consider cyclosporine 0.05% BID OU MODERATE/SEVERE: topical tacrolimus 0.03% ung BID acetylcysteine 10% TID for filaments loteprednol 0.5% for exacerbations 0.5% silver nitrate solution on cotton-tipped applicator for 10-20 seconds on superior bulbar conjunctiva followed by irrigation, then erythromycin ung BID x 1 week doxycycline 100 mg BID x 2 weeks then 100 mg QD x 1 month then 50 mg QD until the disease is well-controlled if still symptomatic, refer to oculoplastics for conjunctival cautery, cryotherapy, conjunctival resection FU every 2-4 weeks during exacerbations

Answer 20

MILD: aggressive PFAT with ung at night SEVERE: loteprednol 0.5% or FML 0.1% QID for 4 weeks with slow taper Cyclosporine 0.05% BID may be used as an alternative or adjunct therapy (BCL if necessary) FU weekly during exacerbation, then every 3-6 months

Answer 21

Prophylactic use of antihistamine/MCS combo for2-3 weeks before allergies BEZPOP Shield ulcer treated with polytrim 10,000/mL QID or erythromycin 0.5% ung QID and cyclopentolate 1% TID Consider cyclosporin 0.05% BID if no response to other treatment Cool compresses If atopic dermatitis to the eyelids, consider tacrolimus 0.03-0.01% ung BID to skin FU daily in the presence of a shield ulcer or every 2-3 weeks during exacerbation

Answer 22

Refer to cataract surgeon if symptoms warrant or obstructing view of the posterior pole Best correct vision with glasses

Answer 23

Consider in CL wearer and non-responsive HSK Stain: calcofluor white with KOH wet mount Culture: non-nutrient agar with ecoli overlay TX 1. poly hexamethyl biguanide 0.02% q1h OR chlorhexidine 0.02% q1h 2. propamidine isethionate 0.1 % q1h 3. oral itraconazole 400 mg (one loading dose) then 200 mg daily Discontinue CL wear PAIN: Cyclopentolate 1% TID or oral naproxen 500 mg BID Delay corneal transplant by 6-12 months after treatment due to risk of recurrence FU daily until consistent improvement, then every 1-3 weeks Treat until no inflammation for 3 months

Answer 24

consider in vegetative trauma, poor response to antibiotics, indolent onset Stain: calcofluor white with KPH wet mount Culture: sabouraud (acidic pH inhibits bacterial growth) TX Filamentous fungi: Natamycin 5% q1h around clock Candida: Amphotericin B 0.15% q1h around clock oral itraconazole 400 mg (one loading dose) then 200 mg daily cyclopentolate 1% TID FU daily until improvement, stability is a favorable sign

Answer 25

Stain: Giemsa - shows multinucleated giant cells Culture: Viral transport medium SKIN: 0.5% erythromycin BID CORNEA: Consider Trifluridine 1% 9x/day for 1 week, then 4x/day for 1 week Ganciclovir 0.15% gel 5x/day for 1 week, then 2x/day for 1 week ORAL: Valacyclovir 500 mg TID for 7-10 days ** do not prescribe (F) in patients with HIV due to risk of thrombotic thrombocytopenic purpura (ttp) and hemolytic uremic syndrome Cyclopentolate 1% TID if AC reaction or photophobia Prednisolone acetate 1% q2h-QID for disciform keratitis WITHOUT EPI defect Do not use PGA for IOP reduction FU daily until improvement is noted then every 1-2 weeks

Answer 26

SMALL defect: 0.5% erythromycin QID until resolved PFAT, BCL, and Moxifloxacin 0.5% QID If corneal ulcer is present treat as bacterial keratitis Oral doxycycline 100 mg BID may slow stromal lysis 1g vitamin c/ascorbic acid may help promote collagen synthesis and reduce level of ulceration Oxervate 0.002% 6x/day (2 hours apart) tarsorrhaphy may be necessary FU daily until improvement is noted then every week till resolved

Answer 27

staph: +, cat + strep: +, cat - pseudo: - ** culture if lesion is larger than 1 mm, in visual axis, or unresponsive to treatment, or suspicious history cyclopentolate 1% TID for comfort and to prevent synechia formation NONSTAINING peripheral infiltrate with minimal AC reaction - Moxi 0.5% q1h while awake OR polymyxin B/trimethoprim 10000U/1mg/mL q1h (**** if CL wearer, use both*****) <1.5 mm peripheral infiltrate, epi defect, mild AC, mod discharge - moxi 0.5% q1h with polymyxin B/trimethoprim 10000 U/1g/mL q1h around the clock with loading dose of q5min for 5 doses, then every 3o mins until midnight, then q1h >1.5 mm, in the visual axis, or unresponsive to initial tx - fortified (g) or tobramycin 15 mg/mL q1h ALTERNATING - fortified cefazolin 50 mg/mL or (v) 25mg/mL q1h (** every 30 mins around the clock) Reserve vancomycin 25 mg/mL for patients at risk for MRSA or with penicillin/cephalopsorin allergy If Pseudomonas is suspected: tobramycin 15 mg/mL q30 min with cefazoline 50 mg/mL every hour Loading dose q5h for 5 doses, then every 30 -60 mins around the clock NEVER taper an antibiotic lower than QID Admit to hospital if infection is sight threatening, impending preforation, patient cannot adminiters antibiotics as prescribed/frequency, poor compliance with fu FU daily to measure size and depth of defect and infiltrate, pain, and AC reaction

Answer 28

Stain: will show gram-negative intracellular diplococci Culture: chocolate agar or Thayer-martin cyclopentolate 1% TID for comfort and to prevent synechiae ceftriaxone 1g IV 12-24h PLUS azithromycin 1g PO one time if corneal involvement ** gentamicin 240 mg IM plus 2 mg azithromycin PO if allergic to cephalosporins ceftriaxone 1g IM plus azithromycin 1g PO one time if conjunctival involvement Mox 0.5% q1h around the clock ** these patients should be admitted to the hospital for IV ceftriaxone order infectious disease consultation, sexual partners should be treated as well FU daily until consistent improvement is noted, then every 2-3 days

Answer 29

Consider treating any IOP > than 21-32 in one eye and 24-32 in the other (despite VF damage -- INVOLVE PT IN DECISION) Consider treating all patients with IOP > 32 (cut off of OHTS) TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years , can extend follow up every 6 months

Answer 30

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation Deep sclerotomy iStent trabecular micro-bypass Endocyclophotocoagulation Trabectome trabecular ablation MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 31

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation Deep sclerotomy iStent trabecular micro-bypass Endocyclophotocoagulation Trabectome trabecular ablation MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 32

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation Deep sclerotomy iStent trabecular micro-bypass Endocyclophotocoagulation Trabectome trabecular ablation MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 33

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS *** International Collaborative Exfoliation Syndrome Treatment Study (ICEST): outflow enhancers (latanoprost) are more beneficial than aqueous suppressors (timolol/dorzolamide) for PXE Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation Deep sclerotomy iStent trabecular micro-bypass Endocyclophotocoagulation Trabectome trabecular ablation MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 34

Prednisolone 1% Q1H-Q6H Atropine 1% TID Timolol 0.5% QAM ** Consider Combigan BID or Cosopt BID Brimonidine 0.1% TID Dorzolamide 2% TID ** Consider Simbrinza TID DO NOT US PGA due to risk of increased inflammation Refer to retinal specialist to treat retinal ischemia with PRP and or antiVEGF Surgical options include trabeculectomy tube shunt procedure laser cyclophotocoagulation of CB cyclocryotherapy once neovascular membrane is inactive ** In a painful blind eye, treat with topical steroids and cycloplegics or consider retrobulbar alcohol injection or enucleation if unsuccessful FU in 1-2 days for urgent therapeutic intervention, as angle closure may proceed rapidly if left untreated Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 35

Prednisolone 1% Q1H-Q6H Cyclopentolate 1% TID (if symptomatic) Timolol 0.5% QAM ** Consider Combigan BID or Cosopt BID Brimonidine 0.1% TID Dorzolamide 2% TID ** Consider Simbrinza TID DO NOT US PGA due to risk of increased inflammation Consider oral dorzolamide 250 mg BID or methazolamide 50 mg BD if nonresponsive. If IOP is dangerously high and nonresponsive, consider 1g/kg mannitol IV over 45 minutes.s Surgical options (6) - ALT - SLT - trabeculectomy - tube shunt procedure - laser cyclophotocoagulation of CB - cyclo cryotherapy MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery, include - canaloplasty - deep sclerotomy - iStent trabecular micro bypass - endocyclophotocoagulation - trabectome trabecular ablation FU every 2 days during an attack, then weekly until the episode resolves - monitor in 6 weeks after starting a new drop - follow up every 3 months at the time of diagnosis (rotate VF, gonio, full dilation/scans, and IOP check) - if stable for years, can extend follow-up to every 6 months

Answer 36

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation of CB cyclo therapy ** CONSIDER vitrectomy and AC irrigation if medical management fails ** MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 37

if there is no PI, refer for PI if signs of aqueous misdirection are still present, then begin medical therapy: - Atropine 1% and phenylephrine 2.5% QID - Acetazolamide 2 250 mg tabs PO - Timolol 0.5% BID - Brimonidine 0.2% BID - Mannitol 1g/kg IV over 45 minutes if attack is broken, continue atropine 1% daily indefinitely send for PI of the fellow eye if it is occludable if previous tx is unsuccessful, then refer for surgical intervention to disrupt the anterior hyaloid face (YAG laser disruption or vitrectomy) or argon laser of the ciliary process FU varies at the discretion of the OMD performing PI but should be closely monitored and PI of the other eye should by performed within 1 week

Answer 38

if the wound leaks, then topical aqueous suppressants and bandage CL if not yet, G3 flat chamber (lens, endo, and iris all touching), then atropine 1% TID and prednisolone 1% QID to encourage posterior rotation of the CB If the AC is completely flat or IOP is consistently very low, refer back to the surgeon for wound closure if there is one and drainage of the choroidal detachment with the reformation of the AC with viscoelastic. If starting a steroid, see the patient at least weekly - if there is a wound leak, see daily until improvement or refer back to surgeon

Answer 39

TX options 1. Latanoprost 0.005% QHS ~ CONSIDER Rocklatan 0.02%/0.005% QHS) 2. ADD Timolol 0.05% QAM ~ CONSIDER COMBOS ** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID ** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID 3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID 4. ADD Rhopressa 0.02% QHS Surgical options (9) ALT SLT Trabeculectomy Tube shunt procedure Laser cyclophotocoagulation Cyclocryotherapy MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include - canaloplasty - deep sclerotomy - iStent trabecular micro-bypass - endocyclophotocoagulation - trabectome trabecular ablation Monitor in 6 weeks after starting new drops FU every 3 months at the time of diagnosis ** Rotate VF, gonio, Dilated exam/scans, and IOP checks) If stable for years, can extend follow up every 6 months

Answer 40

If visual acuity is HM or better, IOP reduction is urgent Apply all available topical glaucoma meds if available and not contraindicated - Timolol 0.5% - Brimonidine 0.2% - Latanoprost 0.005% - Dorzolamide 2% (unless sulfa induced angle closure) - Topical drops in 3 rounds each 15 minutes apart Acetazolamide 2 250 mg tabs PO if NOT sulfa-induced angle closure or sulfa allergy Recheck IOP in 1 hour; if still elevated, repeat drops and give IV mannitol 1g/kg over 45 minutes unless patient has heart or renal disease If secondary angle closure, consider cyclopentolate 1% and phenylephrine 2.5% for 4 doses when laser cannot be performed In phacomorphic glaucoma, lens should be removed as soon as the eye is quiet For pupillary block, LPI is indicated within 1-5 days of the attack If IOP is still elevated after 2 courses of max medical therapy, LPI or surgical PI should be performed FU daily until IOP has been reasonably reduced, then weekly The fellow eye has a 40-80% chance of being occluded in 5-10 years Baseline glaucoma testing should be obtained once the attack is controlled Recommended family members have exams due to likelihood of occludable angles

Answer 41

Cataract surgery should be performed within 24-48 hours Cyclopentolate 1% TID Pred 1% Q1H Timolol 0.5% QAM/BID Brimonidine BID-TID Dorzolamide 2% BID-TID Mannitol 1g/kg over 45 mins if no heart disease or kidney disease FU the day after cataract surgery If IOP has returned to normal, see in 1 week

Answer 42

If VA is HM or better, IOP reduction is urgent Apply all available topical glaucoma meds if available and not contraindicated - Timolol 0.5% - Brimonidine 0.2% - Latanoprost 0.005% - Dorzolamide 2% (unless sulfa induced angle closure) - Topical drops in 3 rounds each 15 minutes apart Acetazolamide 2 250 mg tabs PO if NOT sulfa-induced angle closure or sulfa allergy Recheck IOP in 1 hour, if still elevated, repeat drops and give IV mannitol over 45 minutes unless patient has heart disease or renal disease If secondary angle closure, consider cyclopentolate 1% and phenylephrine 2.5% for 4 doses when laser cannot be performed If topiramate or sulfa drug induced angle closure, consider atropine 1% TID to induce posterior rotation of the CB If IOP is still elevated after 2 courses of max medical therapy, LPI or surgical PI should be performed Discuss discontinuing causative medication with prescribing physician FU daily until the IOP has been reasonably reduced, then weekly - the fellow eye has a 40-80% chance of being occluded in 5-10 years - baseline glaucoma testing should be obtained once the attack is controlled Recommend family membrane have exam due to likelihood of occludable angles

Answer 43

careful observation until glaucoma develops 1. Timolol 0.5% QAM - Consider Combigan or Cospot 2. ADD Brimonidine 0.1% BID-TID 3. ADD Dorzolamide 2% BID-TID - Consider Simbrinza Peripheral laser iridotomy to reduce iridozonular contact, SLT with lower energy and 180 degrees treated at a time Consider MIGS, guarded filtration procedures, tube shunt when other therapies fail Monitor in 6 weeks after starting new drop FU every 3 months at the time of diagnosis (rotate VF, gonio, DFE/scans, and IOP check) If stable for years, can extend FU every 6 months

Answer 44

treat elevated IOP after CE with aqueous suppressants - if inflammation is excessive, then increase the steroid Post-op pupillary block - YAG LPI if cornea is clear - Consider cyclopentolate 1% and pred 1% q15 min for 4 doses - Timolol 0.5% - Brimonidine 0.1% - Dorzolamide 2% - Topical aqueous suppressants in 3 rounds separated by 15 minutes each if no contraindications - Acetazolamide 2 250 mg tabs PO - Perform YAG LPI or iridectomy when cornea is clear If elevated IOP after glaucoma filtering procedure - removal or lysis sutures over the scleral flap - topical pilo may pull iris out of the sclerostomy if it is recent onset - if vitrous is blocking the sclerostomy, YAG lysis may be attempted - blood or fibrin blocking the sclerostomy may resolve over time or intracameral tissue plasminogen activator may help dissolve the clot - treated as POAG if no success with the above FU in 6 weeks if starting a new drop - otherwise, FU at OMD recommendations

Answer 45

if there is no PI, refer for PI if signs of aqueous misdirection are still present, then begin medical therapy: - Atropine 1% and phenylephrine 2.5% QID - Acetazolamide 2 250 mg tabs PO - Timolol 0.5% BID - Brimonidine 0.2% BID - Mannitol 1g/kg IV over 45 minutes if attack is broken, continue atropine 1% daily indefinitely send for PI of the fellow eye if it is occludable if previous tx is unsuccessful, then refer for surgical intervention to disrupt the anterior hyaloid face (YAG laser disruption or vitrectomy) or argon laser of the ciliary process FU varies at the discretion of the OMD performing PI but should be closely monitored and PI of the other eye should by performed within 1 week

Answer 46

G1: bleb infection without AC or vitreous involvement - (F) cefazolin 50 mg/mL and (F) tobramycin 15 mg/mL alternating every half hour for the first 24 hours with a loading dose of one drop every 5 minutes for 30 minutes G2: bleb infection with AC involvement with NO vitreous involvement - (F) cefazolin 50 mg/mL and (F) tobramycin 15 mg/mL alternating every half hour for the first 24 hours with a loading dose of one drop every 5 minutes for 30 minutes - ADD cyclopentolate 1% TID and more careful monitoring G3: bleb infection with AC and vitreous involvement ** treat as endophthalmitis ** - AC or vitreous tap with gram stain and culture - IV broad-spectrum antibiotics (vancomycin and ceftazidine) and possible steroid injection depending on severity of inflammation - Pred 1% q1h around the clock - (F) Tobramycin 15 mg/mL q1h around the clock for 2 days - (F) Vancomycin 25 mg/mL q1h around the clock for 2 days - Atropine 1% BID-QID - Vitrectomy if vision is light perception or worse - Consider systemic antibiotics FU in 6-12 hours and again at 12-24 hours to ensure stability - see at least daily until infection is resolving - admission to the hospital may be indicated

Answer 47

Atropine 1% TID Pred 1% QID Ketorolac 0.5% QID Timolol 0.5% BID/QAM Brimonidine 0.1% BID Dorzolamide 2% TID Acetazolamide 500 mg sequels PO BID Surgical repositioning or removal of lens if patient experiences recurrent episodes, formation or PAS, or persistent CME - consider YAG lysis of vitreous strands FU in 1 day if treating in office, or at OMD recommendation if referring

Answer 48

Pred 1% q1h-6h if no active epi defect Cyclopentolate 1% TID Timolol 0.5% BID-QAM Brimonidine 0.1% BID-TID Dorzolamide 2% TID Acetazolamide 500 mg sequels BID PO Mannitol 1g/kg IV over 45 mins AC paracentesis if reduction in IOP is urgent or IOP is refractory to therapy Treat cause of uveitis (HSV, etc) Do NOT use PGA or miotics in inflammatory glaucoma FU daily until improvement is noted, then extend

Answer 49

Refer to neurology if chronic, who may prescribe amitriptyline, venlafaxine or topiramate FU as directed by neurology or yearly

Answer 50

Consider imaging to rule out Horners if persistent Obtain an MRI of the brain when history is atypical or neurologic abnormality is present Avoid alcohol and cigarettes during a cluster cycle Refer to neurologist, who may prescribe oxygen, sumatriptan, calcium channel blockers, oral steroids, or lithium FU in 7-10 days with neurology FU every few weeks if patient is put on oral steroids

Answer 51

New onset migraines after 50 are rare; consider another cause. MRI of the head is indicated for atypical migraines >50 Always on the same side of the head Visual disturbance during or after the headache phase Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy Prophylaxis with beta blockers (metoprolol), CCB (amlodipine) and antidepressants FU with neurology in 4-6 weeks to evaluate therapy

Answer 52

New onset migraines after 50 are rare; consider another cause. MRI of the head is indicated for atypical migraines >50 Always on the same side of the head Visual disturbance during or after the headache phase Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy Prophylaxis with beta blockers (metoprolol, CCB (amlodipine) and antidepressants FU with neurology in 4-6 weeks to evaluate therapy

Answer 53

New onset migraines after 50 are rare; consider another cause. MRI of the head is indicated for atypical migraines >50 Always on the same side of the head Visual disturbance during or after the headache phase Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy Prophylaxis with beta blockers (metoprolol, CCB (amlodipine) and antidepressants FU with neurology in 4-6 weeks to evaluate therapy

Answer 54

Mean 9 months of use before vision loss (VA typically better than 20/40) Insidious onset, nerve swelling persists for months and resolves slowly (months to years) Consult a cardiologist concerning stopping the drug. Vortex keratopathy alone does not require therapy. FU several times in the first year of taking amiodarone, then annually - If active disc edema is present, follow every 3 months

Answer 55

Test for cholinergic hypersensitivity with pilocarpine 0.125% in both eyes, the dilated Adie pupil should constrict while nothing happens to the other pupil If pupil is not hypersensitive in acute onset, retest in 2-3 weeks If any questions about the diagnosis, refer to neruo for work-up Consider pilocarpine 0.125% BID-QID for cosmesis and accommodation If diagnosis is certain, FU annually

Answer 56

Confirm diagnosis with reversal of anisocoria with 1% apraclonidine Confirm the location of the lesion with 1% phenylephrine (if pupil dilates = POST) or 1% hydroxyamphetamine (if pupil dilates = PRE) If transient vision loss, headache/neck/face pain, pulsatile tinnitus, or dysgeusia, then consider ICA dissection Check for thyroid enlargement or neck mass Investigate history of headache, arm pain, stroke, neck surgery, trauma, and neck pain Order CBC with differential. CT of the chest to evaluate the apex of the lung for Pancoast tumor MRI and MRA of the brain and neck Lymph node biopsy if lymphadenopathy is present Treat the underlying disorder with consult to neurology FU is ASAP with neurology for acute Horners, imaging should be performed immediately for dissection Remaining workup should be performed within 2 days FU with optometry in 1 year

Answer 57

Order FTA ABS or MHA TP or VDRL testing to confirm diagnosis of syphilis If diagnosis of syphilis is established, order infectious disease consult for potential lumbar puncture Tx for untreated syphilis: penicillin g 4 million units IV q4h for 10-14 days followed by benzathine penicillin 2.4 units IM weekly for 3 weeks FU within a few days for workup and infectious disease consult Repeat lumbar puncture should be performed every 6 months to 2 years until cell counts normalize

Answer 58

Cause (most common): aneurysm between ICA and pcomm order immediate contrast-enhanced CT and CTA or gadolinium-enhanced MRI and MRA of head and neck if results are equivocal or shows a mass and patient is older than 10, order cerebral angiography Consider ordering CBC with diff in children, ice test if MG is suspected, FBG, HbA1c and BP - ESR and CRP and platelets if GCA is suspected treat underlying abnormality, patch the involved eye if symptomatic of diplopia - strab surgery if condition is stable for years FU urgently with neuro, then at recommendation of neuro

Answer 59

Cause (most common): ischemic microvascular disease (diabetes) microvascular thrid nerve palsies will NOT have aberrant regeneration order immediate contrast-enhanced CT and CTA or gadolinium-enhanced MRI and MRA of head and neck if results are equivocal or shows a mass and patient is older than 10, order cerebral angiography Consider ordering CBC with diff in children, ice test if MG is suspected, FBG, HbA1c and BP - ESR and CRP and platelets if GCA is suspected treat underlying abnormality, patch the involved eye if symptomatic of diplopia - strab surgery if condition is stable for years FU urgently with neuro, then at recommendation of neuro - if secondary to ischemia, function should return in 3 months

Answer 60

If vertical fusional vergence is greater than 6, it is likely congenital. If a double Maddox rod is rotated a total of 10 degrees between the two eyes, then a bilateral SO paresis is likely present. Ice test if MG is suspected - CT of head and orbits if orbital disease is suspected - BP, FBG, A1c if ischemia is suspected - Immediate ESR, CRP, and platelets if GCA is suspected - MRI of the brain, if accompanied by other neurologic abnormalities MRI of the brain for all patients less than 45 without a history of head trauma and all patients 45-55 with no vasculopathy risk factors or trauma Treat underlying disorder - consider patching or prescribing prism if stable Defer strab surgery for at least 6 months after the onset of palsy FU annually if congenital If acquired and workup is negative, presume vascular and see back in 3 months - if it does not resolve in 3 months or neurologic abnormalities develop, order MRI of the brain for possible lesion Return to clinic if any ptosis, worsening double vision, sensory abnormalities or pupil abnormalities

Answer 61

Check carefully for papilledema - check FBG, BP A1c - ESR/CRP/platelets if suspected GCA - Lyme antibody and FTAABS and RPR/VDRL - MRI of the brain in all children with CN6 palsy MRI of brain if younger than 45, no vasculopathic risk factors, severe pain or neurologic signs, history of cancer, bilateral, or papilledema is present Treat underlying condition - patch affected eye - prism for longstanding stable deviations - consider strab surgery after 6 months of stability y FU every 6 weeks after onset of the palsy until resolves MRI is indicated if any new neuro signs develop, abduction deficit increases, or the isolated 6th nerve palsy does not resolve in 6 months

Answer 62

Central: weakness to the lower facial musculature only Peripheral: weakness to upper and lower facial musculature Order CT scan if h/o trauma to r/o basilar skull fracture Order MRI/CT if - neurologic signs - h/o of cancer - duration >3 months - 6th nerve involvement - 8th nerve involvement ORDER CT chest ACE CBC with diff Lyme antibody EBV titer HIV testing FTA-ABS and RPR/VDRL RF ESR ANA ANCA -- h/o of stroke = Carotid ultrasound/ekc -- h/o of primary neoplasm = LP ** Stroke/CPA mass/temporal bone fracture/nerve laceration: Refer to NEUROLOGIST ** Otitis: Refer to ENT ** RH Syndrome - Start Acyclovir 800 mg 5x for 10 days - Refer to ENT - Contraindicated in pregnancy and renal failure ** Guillan Barre: Refer to NEUROLOGIST ** Lyme Disease - Refer to INFECTIOUS DISEASE - Tx oral doxy, pnc, IV ceftriaxone ** Sarcoid - Refer to a NEUROLOGIST if CNS involvement or an internist for systemic elevation - May require Prednisone ** Metastatic Disease - Refer to Oncologist for chemotherapy or radiation ** Bell Palsy (Idiopathic) - 86% resolve completely with observation in 2 months - PT with a facial massage or electrical stimulation - Prednisone 60 mg PO daily for 7 days, followed by 10 mg per day increases likelihood of facial nerve recovery - Treat dry eye/corneal exposure FU 1 moth and 3 months - If not resolved at 3 months, order MRI of the brain to r/o mass lesion

Answer 63

Order immediate ESR, CRP, and platelets if there is any suspicion of GCA or if the patient is older than 55 Confirm with temporal artery biopsy Consult internist to r/o cardiovascular disease Observation, avoid BP meds at night (if possible), treat OSA if present FU monthly to monitor nerve edema (should resolve in 8 weeks) with mild vision improvement over 6 months

Answer 64

Order immediate ESR, CRP, and platelets if there is any suspicion of GCA or if the patient is older than 55 Confirm with temporal artery biopsy Biopsy should be performed within a week of starting systemic steroids IV methylprednisolone 250 mg q6h for 12 doses, then 80-100 mg oral prednisone daily If temporal artery biopsy is (+) for GCA, patient should be on 1 mg/kg prednisone initially Without steroids, contralateral eye may be involved within 1 day New tx options: tocilizumab (IL - 6 blocker) weekly infusions with a shorter (26 week) steroid taper FU as directed by neurology who will manage steroid taper TX should last at least 6-12 months, use the smallest amount of steroid possible to suppress the disease

Answer 65

Current AHA guidelines suggests MRI with diffusion-weighted imaging, urgent carotid and cardiac studies (carotid ultrasound and ekc), and neurology consultation Immediate ESR/CRP/platelets if GCA is suspected Cardiac and carotid auscultation Order CBC with diff, FBG, A1c, and lipid profile The cardiologist may prescribe aspirin 81-325 mg PO daily - consult vascular surgery in patients with high-grade carotid stenosis for stent or endarterectomy - for thrombus, consider hospitalization and heparin therapy FU is immediate diagnostics for possible therapeutic intervention - see at least every 6 months or at recommendation of cardiology

Answer 66

CT/MRI scan of sinuses, orbits, and brain Lumbar puncture for patients with h/o of carcinoma Lymph node biopsy if lymphadenopathy is present Consider CBC with diff, ESR, ANA, RF, and ANCA AV fistula may close spontaneously. Metastasis should be managed by oncology. Intra-cavernous aneurysm/dissection should be managed by neurosurgery. Mucormycosis requires immediate hospitalization with emergent CT scans of the orbit, sinuses, and brain - several consults (ID, neuro, ENT, endocrinology) - tx with amphotericin B IV Pituitary apoplexy needs immediate referral to neurosurgery Cavernous sinus thrombosis: hospitalization for IV antibiotics or anticoagulants Tolosa Hunt Syndrome - Prednisone 60-100 mg daily PO for 2-3 days then gradual taper over 5-6 weeks as pain subsides - Diagnosis of exclusion FU is immediate hospitalization, no matter the cause!

Answer 67

Order gadolinium-enhanced MRI with referral to neurosurgery and oncology If metastatic disease is suspected, a CT of the chest, abdomen, and pelvis will be ordered Treatment may include chemotherapy, radiation, and resection surgically Follow up is immediate referral to neurosurgery and oncology for evaluation

Answer 68

The central macula is represented by the most posterior part of the occipital cortex Have the patient say, “You can’t teach an old dog new tricks.” Have patient smile Have patient close eyes and hold out arms If one of the three is abnormal, there is 72% chance of CVA Call 911 at any sign of a stroke ER will check BP, FBG, A1c, carotid ultrasound, CT/MRI of the head and neck and possibly echocardiogram If ischemic stroke, tissue plasminogen activator may be injected if within 4 hours of symptom onset A carotid stent may be placed or an endarterectomy performed If stroke is hemorrhagic, give drugs to reduce ICP and BP and prevent seizures Surgical clip may be placed, or an aneurysm may be coiled Follow up closely every few hours for the first day after emergency treatment

Answer 69

Midbrain (3,4), Pons (5, 6, 7, 8), Medulla (9, 10, 11, 12) Have patient say, “you can’t teach an old dog new tricks.” Have patient smile Have patient close eyes and hold out arms If one of the three is abnormal, there is 72% chance of CVA Call 911 at any sign of a stroke ER will check BP, FBG, A1c, carotid ultrasound, CT/MRI of the head and neck and possibly echocardiogram If ischemic stroke, tissue plasminogen activator may be injected if within 4 hours of symptom onset A carotid stent may be placed or endarterectomy performed If stroke is hemorrhagic, give drugs to reduce ICP and BP and prevent seizures Surgical clip may be placed, or an aneurysm may be coiled Follow up closely every few hours for the first day after emergency treatment.

Answer 70

Order B scan ultrasound, FAF, fluorescein angiography, CT scan of the orbits, or enhanced depth imaging of the ONH on OCT No treatment is proven to alter the clinical course of drusen Some use brimonidine due to its “potentially neuroprotective properties” Follow up annually once there is no progression noted

Answer 71

If hemifacial spasm is suspected, order MRI of the brain with attention to the posterior fossa and path of CN 7 Consider botulinum toxin injections into the orbicularis muscle every 3-4 weeks if severe Consider surgical excision of the orbicularis muscle from the upper eyelids and brow if botox does not help FL-41 tint has shown to decrease light sensitivity and help some patients with BEB Surgical ablation of the facial nerve has been largely abandoned due to high recurrence and high incidence of facial paralysis Follow up in 1 month after botox injections (90% improvement symptomatically)

Answer 72

In suspected spasmus nutans, order MRI of the brain to rule out an anterior visual pathway lesion - Resolves between 2-8 years. Head nodding, torticollis, and nystagmus In saccadomania/opsoclonus, order abdominal and chest imaging to rule out neuroblastoma or visceral carcinoma Visual field is indicated if seesaw nystagmus is present - Lesion involves parasellar region and chiasm (may have bitemporal hemianopia) Convergence retraction nystagmus in up gaze is likely pineal gland or other dorsal midbrain tumor Downbeat nystagmus: Cerebellar degeneration or lesion at the cervicomedullary junction Periodic alternating nystagmus: Lesion of cervicomedullary junction, posterior fossa, MS - May respond to baclofen (NOT SAFE FOR KIDS) Peripheral vestibular nystagmus: Accompanied by vertigo, deafness, or tinnitus Prescribe prism in glasses to set eyes at null point, consider muscle surgery if large face turn Severe and disabling nystagmus may be treated with retrobulbar botulinum toxin Follow up at recommendation of neurology, at least annually

Answer 73

Convergence may be intact - Brainstem and posterior fossa pathology should be ruled out If skew deviation is present, Park 3 step will not isolate a specific muscle Order MRI of the brainstem, midbrain, and brain If acute stroke is diagnosed, admit to hospital for neurologic evaluation and observation - If concern for demyelinating disease, consider treatment recommendations in optic neuritis section Follow up with neurology as directed, there is no treatment for INO itself - Patients mostly recover within 1 year

Answer 74

Explosive painful onset is the hallmark of IOIS/orbital pseudotumor Bilateral presentation should be a trigger to rule out systemic disease, metastasis, and lymphoma This is a diagnosis of exclusion Orbital CT with contrast may show involvement of the EOM tendons (unlike TED) In atypical cases, order ESR, CBC with diff, ANA, ACE, ANCA, LHD, IgG levels, BUN/creatinine, FBG, HbA1c, chest CT, mammography, or prostate evaluation Incisional biopsy before starting steroid therapy Be suspicious for metastasis in patients with a history of cancer Prednisone 1 mg/kg per day as an initial dose with 40 mg omeprazole po daily May be treated with orbital radiation, cyclophosphamide, or methotrexate as an alternative to steroids Follow up in 1 day Maintained at the initial dose for 3-5 days and a very slow taper is performed to 40mg per day over 2 weeks and to 20 mg per day over several weeks

Answer 75

OCT and FAF of the optic nerves. Evaluate for SVP. Check BP. Emergent MRI with gadolinium and MRV of the head are preferred over CT. If MRI/MRV are unremarkable order lumbar puncture with CSF analysis and opening pressure measurement. Directly treat the cause of the elevated ICP. Follow up with neurology emergently for MRI/MRV and possible lumbar puncture.

Answer 76

MS is unlikely if vision is NLP, no pain is present, disc edema is present, or peripapillary hemes or exudates are present MRI of the brain and orbits with gadolinium and fat suppression in ALL cases Check BP Consider CBC, ESR, ACE, Lyme antibody, FTA-ABS, RPR/VDRL, Chest X-ray or CT, ANA, FBG, and A1c If MRI shows one area of demyelination and patient is NOT diagnosed with MS do the following within 14 days of decreased vision: - IV methylpred 1g/day IV for 3 days - Then pred 1 mg/kg/day po over 11 days - Then taper prednisone over 4 days (20 mg day 1, 10 mg days 2-4) - Omeprazole 20 mg po daily for prophylaxis ONTT found that steroid treatment reduced progression to CDMS for 3 years ONTT found that steroid therapy increases rapidity of visual recovery but does NOT improve final visual outcome ONTT found that using oral pred ONLY without IV methylpred increases risk of recurrence If MRI shows 2+ demyelinating lesions and patient has not been diagnosed with MS, treat as above and refer to neurologist for possible treatment with interferon-beta, fingolimod, etc. - Patients with 1+ lesions on MRI have 72% chance of developing CDMS over 15 years With a negative MRI, the risk of MS is low, repeat MRI at 3-6 months then periodically If patient has a prior diagnosis of MS or optic neuritis, observation is appropriate Follow up in 4-6 weeks after presentation, then every 3-6 months

Answer 77

Junctional scotoma - compression of anterior knee of the chiasm  Bitemporal more dense above - compression from underneath chiasm Bitemporal more dense below or macular bitemporal - compression of posterior chiasm Order formal HVF, order CT/MRI with coronal, sagittal, and axial scans Order endocrine workup with assistance of endocrinologist Surgical debulking may be performed by an ENT or neurosurgeon Prolactinomas may be treated with bromocriptine or cabergoline Consult submitted to endocrinologist Educate patient on symptoms of acute apoplexy - severe headache, nausea, altered consciousness, ophthalmoplegia, facial numbness, vision loss, stroke symptoms - Life threatening complication of pituitary apoplexy is adrenal crisis - May start immediate steroids or emergent surgical decompression Follow annually if there is no compression - After treatment, perform visual field at 3 months and then every 6-12 months after that - Periodic neuroimaging is essential, recurrence is not uncommon

Answer 78

OCT and FAF of the optic nerves Evaluate for SVP Check BP Emergent MRI with gadolinium and MRV of the head are preferred over CT - If MRI/MRV are unremarkable order lumbar puncture with CSF analysis and opening pressure measurement - Opening pressure is often >25cm H2O Visual field is the most important test for monitoring these patients Weight loss of 5-10% is shown to improve symptoms Acetazolamide 250 mg po QID building up to 500-1000mg if tolerated and no sulfa allergy Discontinue any causative meds, neurosurgical shunt may be recommended Optic nerve sheath decompression is effective if vision is threatened Follow up with neurology emergently for MRI/MRV and possible lumbar puncture If acute and no other cause of swelling is determined, then monitor every 3 months in the absence of visual field loss If vision decreases, follow more urgently

Answer 79

MS is unlikely if vision is NLP, no pain is present, disc edema is present, or peripapillary hermes or exudates are present MRI of the brain and orbits with gadolinium and fat suppression in ALL cases Check BP Consider CBC, ESR, ACE, Lyme antibody, FTA-ABS, RPR/VDRL, Chest X-ray or CT, FBG, and A1c If MRI shows one area of demyelination and patient is NOT diagnosed with MS do the following within 14 days of decreased vision: IV methylpred 1g/day IV for 3 days Then pred 1 mg/kg/day po over 11 days Then taper prednisone over 4 days (20 mg day 1, 10 mg days 2-4) Omeprazole 20 mg po daily for prophylaxis ONTT found that steroid treatment reduced progression to CDMS for 3 years ONTT found that steroid therapy increases rapidity of visual recovery but does NOT improve final visual outcome ONTT found that using oral pred ONLY without IV methylpred increases risk of recurrence If MRI shows 2+ demyelinating lesions and patient has not been diagnosed with MS, treat as above and refer to neurologist for possible treatment with interferon-beta, fingolimod, etc.  Patients with 1+ lesions on MRI have 72% chance of developing CDMS over 15 years With a negative MRI, risk of MS is low, repeat MRI at 3-6 months then periodically If patient has a prior diagnosis of MS or optic neuritis, observation is appropriate Follow up in 4-6 weeks after presentation, then every 3-6 months

Answer 80

Etiology includes tobacco/alcohol abuse, severe malnutrition with thiamine (B1) deficiency, pernicious anemia (B12 malabsorption), chloramphenicol, ethambutol, isoniazid, digitalis, streptomycin, chlorpropamide, disulfiram, amiodarone, and lead Order formal HVF Order CBC with diff, serum B1, B12, and folate (B9) levels Consider heavy metal screen If disc is swollen, consider blood test for Leber hereditary optic neuropathy Treat with thiamine 100 mg BID PO, folate 1 mg daily po, multivitamin tablet daily, eliminating the causative agent, or 1000mg B12 IM monthly for pernicious anemia Every month at first then every 6-12 months when stabilized

Answer 81

Check BP of both arms to rule out subclavian steal syndrome CBC to rule out anemia and polycythemia vera Immediate ESR, CRP, platelets if GCA is suspected Electrocardiogram, echocardiogram, and holter monitor to rule out dysrhythmia - Consider carotid ultrasound - Order MRA, CTA, or vertebral artery doppler ultrasound to evaluate posterior cerebral blood flow Coordinate care with internal medicine or neurology with initiation of antiplatelet therapy. Control risk factors of HTN, HLD, DM Follow up with urgent testing, further follow-up is dictated by the underlying condition at the recommendation of neurology/cardiology

Answer 82

1g azithromycin po 1 time OR 100 mg doxycycline BID po x1-2wk Topical erythromycin 0.5% ung BID x2-3 weeks Follow up in 2-3 weeks. Patient and sexual partners should be evaluated by medical doctors for other STIs

Answer 83

(+) HLA-DR4, (+) RF, (+) anti-CCP Episcleritis: Artificial tears if mild - Topical ketorolac 0.5% QID or loteprednol 0.5% QID - Consider oral NSAID ibuprofen 600 mg TID-QID po - Follow up every 2-3 weeks until symptoms resolve then steroid is tapered Scleritis - Omeprazole 20 mg po daily - Naproxen 250-500 mg BID po - If no improvement, prednisone 60-80 mg daily po for 1 week with a taper to 20 mg po over one week then a slower taper ** Calcium and Vitamin D supplementation to reduce osteoporosis - If long term control is not achieved with less than 10 mg per day, immunosuppressive therapy is indicated (cyclophosphamide, methotrexate, cyclosporine, azathioprine) - Eye shield if there is significant thinning and risk of perforation - Referral to rheumatology and uveitis specialist may be indicated - Follow up within 1 week depending on amount of scleral thinning and symptoms Monitor for signs of hydroxychloroquine toxicity, contact prescribing physician if they develop.

Answer 84

(+) ANA, (+/-) antiphospholipid antibodies, (+) anti-dsDNA, meeting 4/17 separate clinical elements for diagnosis Treat discoid skin lesions with 0.5% hydrocortisone ointment - Monitor as needed See every 3 months if retinopathy is present Treat optic neuritis with IV methylpred followed by oral pred as discussed in optic neuritis section - Follow up in 4-6 weeks, then every 3-6 months in chronic stage If optic neuritis develops in SLE, over half of patients have permanent central scotoma and eventual optic atrophy Monitor for signs of hydroxychloroquine toxicity, contact prescribing physician if they develop Follow as indicated for individual condition. Patient should be followed by rheumatology

Answer 85

Artificial tears if mild Topical ketorolac 0.5% QID or loteprednol 0.5% QID Consider oral NSAID ibuprofen 600 mg TID-QID po Follow up every 2-3 weeks until symptoms resolve then steroid is tapered

Answer 86

Stop smoking and refer to an internist or endocrinologist for systemic management Treat dry eye and exposure keratopathy Order T3, T4, TSH Cold compress in the morning and head elevation at night for lid edema Orbital decompression in cases of optic neuropathy, recalcitrant keratopathy, globe luxation, uncontrolled high IOP, or severe proptosis Tepezza: Insulin like growth factor receptor blocker, decreases orbital fibroblast stimulation Order of surgical intervention is always: orbital decompression, strabismus surgery, lid surgery Follow up for immediate treatment of optic nerve compression - See restrictive strabismus patients every 3 months - Minimal exposure and mild proptosis may be seen every 3-6 months - Return immediately with worsening vision or diplopia or significant ocular irritation - Offer smoking cessation resources

Answer 87

Treatment for leukemia includes chemotherapy, immunotherapy, or radiotherapy Acute lymphoblastic leukemia (ALL) treatment includes prednisone Leukapheresis and bone marrow transplant may be necessary Intravitreal methotrexate may show improvement in inflammation and tumor cell infiltration in the eye Coordinate care with neurology/oncology as needed Follow up every 3 months for retinopathy, refer to ophthalmology if neovascularization develops or retinopathy is severe

Answer 88

Intermediate uveitis is the most common form of uveitis in lyme disease (+) borrelia burgdorferi antibody (ELISA), (+) western blot for lyme Doxycycline 100 mg bid x2-3 weeks Amoxicillin 500 mg TID x2-3 weeks Azithromycin 500 mg po QD x2-3 weeks Ceftriaxone 2g IV x2-3 weeks if neuro signs Treat uveitis with topical steroid and cycloplegic Follow up every day until improvement is noted, then weekly until resolved

Answer 89

Beta blockers may be prescribed systemically for aortic root dilation Lens extraction if refraction is not possible, lens dislocation into the vitreous cavity, anterior lens displacement with secondary glaucoma, and cataract formation Follow up annually unless complications develop

Answer 90

(+) acetylcholine receptor autoantibodies, (+) anti-muscle specific kinase antibodies Ice pack test for 2 min relieves ptosis by 2 mm or more Order TSH, T3, T4, CT of chest to rule out a thymoma Refer to neurologist familiar with MG. May consider oral pyridostigmine If patient is having difficulty breathing, hospitalize for plasmapheresis and IV immunoglobulin If systemic steroids are started, patient should be hospitalized for risk of respiratory crisis Azathioprine or cyclosporine may be helpful Follow ocular myasthenia every 6 months If muscular weakness is present, monitor every 1-4 days by neurologist until improved

Answer 91

Carotid ultrasound, IVFA for diagnostic purposes Consider PRP and anti-VEGF if neovascularization is present Perform gonioscopy at each visit Refer to cardiologist Refer to neurosurgeon for carotid endarterectomy or stent placement Follow up for carotid ultrasound urgently

Answer 92

Loss of accommodation, decreased corneal sensitivity, occlusive vascular disorders, aggressive meningioma growth, cavernous sinus syndromes, IIH/pseudotumor cerebri, migraines, worsening of diabetic retinopathy, central serous chorioretinopathy, ocular adnexal chloasma, ptosis, Purtscher-like retinopathy due to complement cascade or emboli after delivery Preeclampsia/eclampsia/HELLP syndrome Preeclampsia-Eclampsia Hypertensive Posterior Encephalopathy Syndrome (PEHPES) Control blood pressure and electrolyte imbalances Prompt delivery is ideal if preeclampsia/eclampsia develops Refer systemic complications to obstetrics/gynecology specialist Follow up as indicated by the ocular condition

Answer 93

Order sagittal/coronal/axial CT of the orbits with contrast before wound exploration Order CBC with diff Admit patient to hospital with consult to infectious disease or ENT Ampicillin-sulbactam 3g IV q6h  Vancomycin 15 mg/kg q12-24h if MRSA suspected Ceftriaxone 2g IV daily and metronidazole 500 mg IV q6h if allergic to penicillin See twice daily in the hospital for the first 48 hours, if condition worsens consider subperiosteal abscess and re-order CT of orbits

Answer 94

Omeprazole 20 mg po daily Naproxen 250-500 mg BID po If no improvement, prednisone 60-80 mg daily po for 1 week with a taper to 20 mg po over one week then a slower taper Calcium and Vitamin D supplementation to reduce osteoporosis If long term control is not achieved with less than 10 mg per day, immunosuppressive therapy is indicated (cyclophosphamide, methotrexate, cyclosporine, azathioprine) Eye shield if there is significant thinning and risk of perforation Referral to rheumatology and uveitis specialist may be indicated Follow up within 1 week depending on amount of scleral thinning and symptoms

Answer 95

Sickle cell retinopathy is most common with HbSC and HbSThal genotypes Order sickledex, hemoglobin electrophoresis, sickle cell preparation Neovascularization with vitreous hemorrhage may be treated with PRP  Retinal detachment and vitreous hemorrhage may be treated with vitrectomy Anti-VEGF may or may not be beneficial Systemic hydroxyurea, L-glutamine, or pain relievers may be prescribed Blood transfusions and stem cell transplants may be considered If no retinopathy, follow annually Follow retinopathy every 3-6 months and refer to ophthalmology if neovascularization is present

Answer 96

Order RF, ANA, SS-A anti-Ro, and SS-B anti-La antibodies Negative serology should be followed by salivary gland biopsy when suspicion is high 3 of 4 of the following should be present: 1. Abnormally low schirmer test with rose bengal or fluorescein staining 2. Objective evidence of decreased salivary gland flow 3. Evidence of lymphocytic infiltration of the salivary glands on biopsy 4. Evidence of systemic autoimmune process by (+) RF, ANA, SSA, or SSB Treat dry eye Systemic treatment may include methotrexate, hydroxychloroquine, or cyclophosphamide Treat filaments with topical acetylcysteine 10% TID x2-3 weeks Follow up every 6 months or sooner if symptoms or signs warrant

Answer 97

Consult with internal medicine and dermatology Hospitalization in a burn unit (hydration, wound care, and systemic antibiotics), remove the inciting factor. Treat dry eyes, iritis, and bacterial keratitis if present. Peel pseudomembranes, symblepharon lysis Possible amniotic membrane therapy Systemic or topical vitamin A and IV immunoglobulin. Follow daily in hospital with infection surveillance, once released, weekly follow-ups

Answer 98

Current AHA guidelines suggest MRI with diffusion weighted imaging, urgent carotid and cardiac studies (carotid ultrasound and echocardiogram), and neuro consult Immediate ESR/CRP/platelets if GCA is suspected Cardiac and carotid auscultation Order CBC with diff, FBG, A1c, and lipid profile Cardiologist may prescribe aspirin 81-325 mg po daily - Consult vascular surgery in patients with high grade carotid stenosis for stent or endarterectomy - For thrombus, consider hospitalization and heparin therapy Follow up is immediate diagnostics for possible therapeutic intervention See at least every 6 months or at recommendation of cardiology