Transcript Ophthalmology Review for Year 4 Med Students

Dr. S. Chan
Dr. M. Abtahi
Dr. Paul Yan

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

Vision
Intraocular Pressure
Pupils
Extraocular movements
Trauma
And red eye
When a patient arrives at the ER with a
supposed alkali chemical burn to the eye,
what is your first action,
a)
b)
c)
d)
Check vision
Check pupils for afferent pupillary defect
Irrigate eye with normal saline
Check PH of the conjunctival fornix
When a patient arrives at the ER with a
supposed alkali chemical burn to the eye,
what is your first action,
a)
b)
c)
d)
Check vision
Check pupils for afferent pupillary defect
Irrigate eye with normal saline
Check PH of the conjunctival fornix
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


Chemical burn :
Acid , coagulate proteins and inhibit further
corneal penetration
Alkali worse prognosis
never try to neutralize
If a ruptured globe is suspected, the first
action to take is to:
a)
b)
c)
d)
Shield the eye
Patch the eye
Give topical or systemic antibiotics
Assess the division
If a ruptured globe is suspected, the first
action to take is to:
a)
b)
c)
d)
Shield the eye
Patch the eye
Give topical or systemic antibiotics
Assess the globe
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R/O intraocular foreign body with orbital CT
scan, especially if “metal on metal”
mechanism
NPO
IV antibiotic
Tetanus status

REMEMBER THE VITALS!
 Decreased vision
 Decreased pressure
 Abnormal pupil
 Decreased extraocular movements

On slit lamp exam:
 360 subconjunctival hemorrhage
 Shallow anterior chamber
 Hyphema
 Obvious leak (check with fluorescein
The best study to evaluate a patient with
intraocular foreign body is
a)
b)
c)
d)
Orbital ultrasound
MRI scan of the orbits
CT scan of the orbits
Plain film of the skull
The best study to evaluate a patient with
intraocular foreign body is,
a)
b)
c)
d)
Orbital ultrasound
MRI scan of the orbits
CT scan of the orbits
Plain film of the skull
7. Management of orbital floor fracture
Is a surgical emergency that requires immediate
repair
b) Includes surgical repair only for persistent diplopia
add/or cosmetic issues.
c) Does not require ophthalmology consultation
because associated ocular damage is rare
d) Always include topical and systemic antibiotics
a)
7. Management of an orbital floor fracture in an
adult:
Is a surgical emergency that requires immediate
repair
b) Includes surgical repair only for persistent
diplopia add/or cosmesic issues.
c) Does not require ophthalmology consultation
because associated ocular damage is rare
d) Always include topical and systemic antibiotics
a)
Treatment:
No coughing , no nose blowing!!
Systemic Abx, if sinusitis
Surgery if # more than 50% of the floor,
diplopia not improving
Enophthalmos more than 2 mm,
There might be a picture of a kid with a
white eye, who can’t look up., blow out
fracture  Emergency!!
In the case of the contact lens wearer with a
corneal abrasion
a) Instills antibiotics, patch the eye, and reexamine
in 24 hours
b) Antibiotic coverage for gram-positive organism
is important.
c) refer to an ophthalmologist only if the case is
complicated by a corneal infiltrate.
d) The risk of ulceration is significantly higher than
in non –contact lens wearers
In the case of the contact lens wearer with a
corneal abrasion
a) Instills antibiotics, patch the eye, and reexamine
in 24 hours
b) Antibiotic coverage for gram-positive organism
is important.
c) refer to an ophthalmologist only if the case is
complicated by a corneal infiltrate.
d) The risk of ulceration is significantly higher
than in non–contact lens wearers
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No patching in contact lens induced
abrasions  risk of pseudomonas ulcer
No patch for simple abrasion less than 10mm
(In real life, just don’t patch)
Never prescribe topical anesthetics!
All of the following conditions may cause
exposure keratitis except
a)
b)
c)
d)
Thyroid exophthalmos
Cranial nerve 7 palsy
Scarred or malposition lid
Episcleritis
All of the following conditions may cause
exposure keratitis except
a)
b)
c)
d)
Thyroid exophthalmos
Cranial nerve 7 palsy,
Scarred or malposition lid
Episcleritis
Proper treatment for a corneal abrasion
includes which of the following?
a)
b)
c)
d)
Topical corticosteroids
A tight patch over the eye for 48 to 72 hours
Topical anesthetic for less then 12 hours
only
Oral analgesic if necessary
Proper treatment for a corneal abrasion
includes which of the following?
a)
b)
c)
d)
Topical corticosteroids
A tight patch over the eye for 48 to 72 hours
Topical anesthetic for less then 12 hours
only
Oral analgesic if necessary
Conjunctival injection with discharge
a)
b)
c)
d)
Should always be treated with a topical
antibiotic
Can be treated with a topical steroid initially if
the inflammation is significant.
Should be treated with parenteral antibiotic if
highly purulent
Is probably of viral origin in the presence of
prominent itching symptoms.
Conjunctival injection with discharge
a)
b)
c)
d)
Should always be treated with a topical
antibiotic
Can be treated with a topical steroid initially if
the inflammation is significant.
Should be treated with parenteral antibiotic
if highly purulent (think Gonococcal!)
Is probably of viral origin in the presence of
prominent itching symptoms.
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Papillae
 Allergic conjunctivitis
 Bacterial conjunctivitis

Follicles
 Viral conjunctivitis
 Chlamydial conjunctivitis
Remember:
Gonococcal conjunctivitis should be treated
with parenteral antibiotic.
Why?
Risk of corneal perforation
10. which of the following is not characteristic
of acute angle closure glaucoma
a)
b)
c)
d)
High IOP
Mild eye pain
Decreased vision
A fixed and dilated pupil
10. which of the following is not characteristic
of acute angle closure glaucoma
a)
b)
c)
d)
High IOP
Mild eye pain
Decreased vision
A fixed and dilated pupil
Primary angle closure glaucoma, risk factors
 Hyperopia
 Age>70
 Female
 Family history
 Asian, Inuit people
 Mature cataract
 Shallow anterior chamber
 Pupil dilation
What is your next plan:
 Refer to ophthalmologist for laser iridotomy
What would be the next plan
 Laser iridotomy
 Aqueous suppression with drops
 Miotics to reverse the pupillary block
11. The finding that best distinguishes orbital
cellulitis from preseptal cellulitis is,
a)
b)
c)
d)
Profound skin erythema with swelling
extending above the eyebrow
Limited extraocular movements
Fever
Pain around the eye
11. The finding that best distinguishes orbital
cellulitis from preseptal cellulitis is,
a)
b)
c)
d)
Profound skin erythema with swelling
extending above the eyebrow
Limited extraocular movements
Fever
Pain around the eye
All of the following are part of the evaluation
and management of orbital cellulitis except
a)
b)
c)
d)
Ophthalmologic consultation
Orbital CT scan
Blood culture
Outpatient administration of oral antibiotics
in an immunocompetent patient
All of the following are part of the evaluation
and management of orbital cellulitis except
a)
b)
c)
d)
Ophthalmologic consultation
Orbital CT scan
Blood culture
Outpatient administration of oral
antibiotics in an immunocompetent
patient
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
Request stat ophthalmology and ENT
consultations to rule out a life–threatening
fungal infection (mucoromycosis)
Diabetic patient with ketoacidosis
 Frozen globe, + RAPD
12. which of the following is least consistent
with the diagnoses of temporal arteritis?
a)
b)
c)
d)
Jaw claudication
diabetes mellitus
age over 65 years
Scalp or forehead tenderness
12. which of the following is least consistent
with the diagnoses of temporal arteritis?
a)
b)
c)
d)
Jaw claudication
diabetes mellitus
age over 65 years
Scalp or forehead tenderness
In a patient who presents with unilateral visual
loss with scalp tenderness
a)
b)
c)
d)
A temporal artery biopsy should be
performed before steroids are started.
An erythrocyte sedimentation rate(ESR)
should be obtained immediately.
Involvement off the second eye is rare.
Temporal arteritis is unlikely if the patient is
older than 65.
In a patient who presents with unilateral visual
loss with scalp tenderness
a)
b)
c)
d)
A temporal artery biopsy should be
performed before steroids are started.
An erythrocyte sedimentation rate(ESR)
should be obtained immediately.
Involvement off the second eye is rare.
Temporal arteritis is unlikely if the patient is
older than 65.
In giant cell arteritis all of the following are true
except
A low or normal sedimentation rate does not
exclude the diagnoses
b) The most common cranial nerve paralysis that
occur involves the third cranial nerve.
c) A deficit in choroidal circulation is typically
seen on fluorescein angiography.
d) This condition typically affects people under
age 60.
a)
In giant cell arteritis all of the following are true
except
A low or normal sedimentation rate does not
exclude the diagnoses
b) The most common cranial nerve paralysis that
occur involves the third cranial nerve.
c) A deficit in choroidal circulation is typically
seen on fluorescein angiography.
d) This condition typically affects people under
age 60.
a)
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Epidemiology:
 F
 > 60 y/o
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Signs:
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Abrupt monocular loss of vision
Jaw Claudication
Headache or Pain over temporal artery
Scalp tenderness
PMR symptoms
Constitutional symptoms
Management
 Treatment with high dose steroid immediately
 Temporal Artery Biopsy within 2 weeks
13. Possible causes for sudden Visual loss
include all of following except
a)
b)
c)
d)
Temporal arteritis
Retinal detachment
Open Angle Glaucoma
Nonarteritic optic neuropathy
13. Possible causes for sudden Visual loss
include all of following except
a)
b)
c)
d)
Temporal arteritis
Retinal detachment
Open Angle Glaucoma
Nonarteritic optic neuropathy
. The best method for evaluating a 50-year-old
patient for best-corrected vision without his
or her glasses is,
a)
b)
c)
d)
Near card
Distance chart with pinhole
Distance chart with both eye open
Magazine or newspaper
. The best method for evaluating a 50-year-old
patient for best-corrected vision without his
or her glasses is,
a)
b)
c)
d)
Near card
Distance chart with pinhole
Distance chart with both eye open
Magazine or newspaper
What mechanism of action do cycloplegics
use to relieve pain?
a)
b)
c)
d)
Topical anesthetic
Paralysis of pupillary dilation
Paralysis of ciliary spasm
Decrease production of inflammatory cells
in anterior chamber
What mechanism of action do cycloplegics
use to relieve pain?
a)
b)
c)
d)
Topical anesthetic
Paralysis of pupillary dilation
Paralysis of ciliary spasm
Decrease production of inflammatory cells
in anterior chamber

Indications in
 Iritis
 Very large or painful corneal abrasion
This patient presents with sudden unilateral
vision loss. All of the following are treatment
options except
a)
b)
c)
a)
Continuous digital massage of the globe to
dislodge an embolus
Topical beta blockers
AC paracentesis by an
ophthalmologist
Re-breathing CO2
This patient presents with sudden unilateral
vision loss. All of the following are treatment
options except
a)
b)
c)
a)
Continuous digital massage of the globe to
dislodge an embolus
Topical beta blockers
AC paracenthesis by an
ophthalmologist
Re-breathing CO2
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Emboli from carotid a. or heart, arrhythmia,
valvular, endocarditis
Thrombosis
Giant Cell Arteritis
In the elderly the most common source of
emboli to ophthalmic or retinal arterioles is
a)
b)
c)
d)
Fibrin or cholesterol from an ulcerated
carotid plaque.
A calcified heart valve
Fibrin -platelet emboli from mitral valve
prolapse
Fibrin- platelet emboli from the aorta
In the elderly the most common source of
emboli to ophthalmic or retinal arterioles is
a)
b)
c)
d)
Fibrin or cholesterol from an ulcerated
carotid plaque.
A calcified heart valve
Fibrin -platelet emboli from mitral valve
prolapse
Fibrin- platelet emboli from the aorta
All of the following statements
regarding this trauma case are
true except
a)
b)
c)
d)
It is the result of a tear in an iris vessel.
It is associated with other ocular injuries in
25% of patients.
It is treated with antibiotics and routine
activities.
It should be referred to ophthalmologist.
All of the following statements
regarding this trauma case are
true except
a)
b)
c)
d)
It is the result of a tear in an iris vessel.
It is associated with other ocular injuries in
25% of patients.
It is treated with antibiotics and routine
activities.
It should be referred to ophthalmologist.
Risk of re-bleed highest on days 2-5 , resulting in
 Increased IOP, corneal staining, iris necrosis,
 Management:
 No Aspirin
 No Valsalva or bending over  Couch potato!
Herpes zoster involving the ophthalmic
division of cranial nerve V is more likely to
have ocular involvements if
a)
b)
c)
d)
The tip of the nose is involved
The upper lid is involved
The lower lid is involved
Either lid margin is involved
Herpes zoster involving the ophthalmic
devision of cranial nerve V is more likely to
have ocular involvements if
a)
b)
c)
d)
The tip of the nose is involved
The upper lid is involved
The lower lid is involved
Either lid margin is involved
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
In presence of Hutchinson sign there is a 70%
risk of eye involvement.
Management:
 Oral antiviral
 In cases of conjunctival involvement,
erythromycin
 Refer to ophthalmologist
A 30 y/o M, presents with
redness, pain photophobia and
decreased vision. If this is the
photo of his eye,the next step is
Patch the eye and give assurance of
spontaneous resolution
b) Prescribe a topical corticosteroid
c) Prescribe a topical antibiotic ointment
d) Referral to an ophthalmologist
a)
A 30 y/o M, presents with
redness, pain photophobia and
decreased vision. If this is the
photo of his eye,the next step is
Patch the eye and give assurance of
spontaneous resolution
b) Prescribe a topical corticosteroid
c) Prescribe a topical antibiotic ointment
d) Referral to an ophthalmologist
a)
What we do:
 Antiviral preferably oral
 Topical Steroids if indicated
Lid laceration repair should include
a)
b)
c)
d)
Assessment of possible canalicular injury
Foreign body removal
Tetanus prophylaxis
All of the above
Lid laceration repair should include
a)
b)
c)
d)
Assessment of possible canalicular injury
Foreign body removal
Tetanus prophylaxis
All of the above
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
Lid margin laceration
Medial lid laceration with canalicular involvement
Sunconjunctival hemorrhages
a)
b)
c)
d)
Are usually a sign of underlying
hematologic or coagulation abnormalities,
even in the absence of retinal
hemorrhages that require extensive
Systemic workup.
Are sometimes associated with severe
pain and or loss of vision.
Require cessation of any NSAID or
Systemic anticoagulant for resolution.
Resolve spontaneously in 2-3 weeks.
Sunconjunctival hemorrhages
a)
b)
c)
d)
Are usually a sign of underlying
hematologic or coagulation abnormalities,
even in the absence of retinal
hemorrhages that require extensive
Systemic workup.
Are sometimes associated with severe
pain and or loss of vision.
Require cessation of any NSAID or
Systemic anticoagulant for resolution.
Resolve spontaneously in 2-3 weeks.
Prolonged use of topical ophthalmic
anesthetics can cause
a)
b)
c)
d)
Iritis
Corneal damage
Open-angle glaucoma
Reactivation of a latent herpes simplex virus
infection
Prolonged use of topical ophthalmic
anesthetics can cause
a)
b)
c)
d)
Iritis
Corneal damage
Open-angle glaucoma
Reactivation of a latent herpes simplex virus
infection
Side effects of topical steroid
 Corneal fungal ulcers
 Cataracts
 Open-angle glaucoma
 Progression of herpes keratitis, dendrites
Treatment of a chalazion , which presents as
an acute tender swelling of the lid usually
a)
b)
c)
d)
Requires incision and drainage
Requires topical antibiotics
Requires a short course of systemic
antibiotics
Includes warm compresses and lid hygiene
for 2 weeks
Treatment of a chalazion , which presents as
an acute tender swelling of the lid usually
a)
b)
c)
d)
Requires incision and drainage
Requires topical antibiotics
Requires a short course of systemic
antibiotics
Includes warm compresses and lid hygiene
for 2 weeks
Still a chalazion
Neonatal Chlamydial conjunctivitis
a)
b)
c)
d)
Has become rare the advent of silver nitrate
prophylaxis
Occurs only after 21 days of age
Maybe treated with topical erythromycin
alone
Requires two weeks of systemic
erythromycin for effective treatment
Neonatal Chlamydial conjunctivitis
a)
b)
c)
d)
Has become rare the advent of silver nitrate
prophylaxis
Occurs only after 21 days of age
Maybe treated with topical erythromycin
alone
Requires two weeks of systemic
erythromycin for effective treatment

Toxic
 1-2 days
 Silver nitrate or erythromycin
 No treatment needed

Gonococcal
 3-5 days
 Most serious threat


Chlamydial
Herpes simplex after 2-3 weeks
Manifestations
of systemic diseases
All of the following are true regarding
intracranial hypertension except
The most common ocular manifestation is
optic disc edema.
b) Visual deficits that occur during presentation
are usually severe.
c) The most common visual symptoms are
transient visual obscurations.
d) Idiopathic intracranial hypertension can be
associated with vitamin A or D toxicity,
tetracycline therapy, and steroid withdrawal.
a)
All of the following are true regarding
intracranial hypertension except
The most common ocular manifestation is
optic disc edema.
b) Visual deficits that occur during presentation
are usually severe.
c) The most common visual symptoms are
transient visual obscurations.
d) Idiopathic intracranial hypertension can be
associated with vitamin A or D toxicity,
tetracycline therapy, and steroid withdrawal.
a)






Papilledema , bilateral disc swelling
Nausea/Vomiting/Headache
Transient visual obscuration
Pulsatile tinnitus
Normal visual acuity
Transient blurry vision
Patients with episcleritis
a)
b)
c)
d)
Usually complain of severe deep pain.
Are very likely to have a systemic connective
tissue disease
Have engorged superficial vessels overlying
the sclera below the conjunctiva.
Can develop necrosis and melting of the
sclera with perforation.
Patients with episcleritis
a)
b)
c)
d)
Usually complain of severe deep pain.
Are very likely to have a systemic connective
tissue disease
Have engorged superficial vessels
overlying the sclera below the
conjunctiva.
Can develop necrosis and melting of the
sclera with perforation.

To differentiate:
 Place a drop of Phenyephrine 2.5%
 Re-examine after 10-15 min, should be white!

Scleritis
 SEVERE PAIN
 Bluish
Retinopathy the most common ocular
manifestation of HTN.
Key features of chronic HTN: AV nicking, blot
hemorrhages, cotton wool spots,
microaneurysm
All of the following statements about optic
neuritis are false except




It is painless.
It always spontaneously resolves.
It may be initial manifestation of multiple
sclerosis
It usually results in permanent visual loss
All of the following statements about optic
neuritis are false except




It is painless.
It always spontaneously resolves.
It may be initial manifestation of multiple
sclerosis
It usually results in permanent visual loss
* In MS diplopia can be 2º to internuclear ophthlmoplegia (INO)
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




Young female
Blurred vision
Decreased color vision, 2º to optic neuritis
RAPD
Diplopia 2º to internuclear ophthalmoplegia
In optic neuritis, treatment with oral steroid
will increase the risk of MS
Glaucoma
POAG
PACG
Common 95%
 Chronic
 Painless
 Moderate IOP
 Normal cornea , pupil
 No symptom






Rare 5%
Acute onset
Painful red eye
Extremely IOP
Haze cornea, middilated
pupil , N/V, halo around
light
Risk factor for open-angle glaucoma include
each of the following except
a)
b)
c)
d)
African racial heritage
gender
Age greater than 60 years
Positive family history for glaucoma
Risk factor for open-angle glaucoma include
each of the following except
a)
b)
c)
d)
African racial heritage
gender
Age greater than 60 years
Positive family history for glaucoma
Remember IOP is a risk factor not a definition
 Remember myopia is a risk factor not a cause
, (even a minor risk factor )


Central Retinal Vein Occlusion
 Blood and thunder
 Second most common retinopathy
after Diabetes

Risk factor





Hypertension
Glaucoma
Diabetes
Other
 arteriosclerotic vascular disease,
hyperviscosity, (PV, OCP, sickle cell,
lymphoma, leukemia,
Treatment
 None
 Treat underlying disease
Posterior vitreous detachment may be
associated with which of the following?
a)
b)
c)
d)
Darkness in the central division
Retinal tear or detachments
Athersclerosis
Temporal arteritis
Posterior vitreous detachment may be
associated with which of the following?
a)
b)
c)
d)
Darkness in the central division
Retinal tear or detachments
Athersclerosis
Temporal arteritis

Posterior vitreous detachment
 Normal aging of vitreous liquefaction


Floater , flashes
However, can cause a retinal tear or
detachment
 Be very suspicious if “curtain effect”

Refer to ophthalmologist for a dilated exam
Patient with type 2 diabetes should be
evaluated by an ophthalmologist
a)
b)
c)
d)
Beginning five years after diagnoses
Every two years after diagnoses
At the time of diagnoses
Not before puberty
Patient with type 2 diabetes should be
evaluated by an ophthalmologist
a)
b)
c)
d)
Beginning five years after diagnoses
Every two years after diagnoses
At the time of diagnoses
Not before puberty


Reduction of best corrected visual acuity due
to cortical suppression of sensory input
Etiologies
 Strabismus
 Refractive
 Deprivation

Treatment
 Occlusion of the good eye
Ptosis
Miosis
Anhydrosis
Heterochromia

DDx







DDx
Retinoblastoma
Cataract
Retinal
coloboma
ROP
Toxocariasis
Retinal
detachment

Kawasaki disease
No to steroid
Yes Aspirin

REMEMBER THE VITALS
 VISION
 PRESSURE
 PUPILS
 EXTRAOCULAR MOVEMENTS


Angle Closure Glaucoma
Giant Cell Arteritis