Transcript Board Review Ophthalmology

Board Review
Ophthalmology
By
Stacey Singer-Leshinsky R-PAC
Vision








Image focused by cornea and lens onto retina
Light absorbed by photoreceptors in retina
(rods and cones)
Macula: cones only. Detailed vision
Fovea: cones dense. Best visual acuity
Choroid: provides nutrition to retina
Cornea: covers iris, pupil, anterior chamber
Palpebra: protect globe
Cathus: where lids meet
Terms








Ptosis: drooping of eyelid
Ectropion: lower lid outward
Entropion: lower lid inward
Proptosis: exophthalmos
Visual acuity
Visual fields: scotomas
Direct pupillary response
Consensual pupil response
Terms







Miosis: constriction
Mydriasis: dilation: sympathetic
Anisocoria: unequal:
Adies tonic pupil: poor light reaction
Argyll robertson: small irregular. Syphilis
Convergence
Divergence
Terms




Emmetropia: light focused on retina perfect
Myopia: near sighted. Need lens for distance.
Globe long
Hyperopia: Far sighted. Need lens for near.
Globe short
Presbyopia: lens cannot accommodate for
near objects. Can’t increase refractive power.
Eyelids/conjunctiva/Lacrimal
Gland

Pterygium



Conjunctiva begins to
grow onto cornea
Etiology is UV sunlight
and dry conditions
Clinical:



Blurred vision
Eye irritation-Itching,
burning
During growth appears
swollen and red
Eyelids/conjunctiva/Lacrimal
Gland

Pterygium

Complications:


blockage of vision as
grows onto cornea
Management:

Eye drops to moisten
eyes and decrease
inflammation. Surgical
excision
Eyelids/Conjunctiva/Lacrimal
Gland

Hordeolum


Acute localized infection or
inflammation of eyelid margin to hair
follicles of eyelash or meibomian
glands. Blockage or infection with
staph
Clinical manifestations:




Tender, red, swollen, pain
Vision acuity normal
Diagnostics- none
Management: resolves spontaneously,
topical antibiotic, warm compresses,
might need I/D
Eyelids/Conjunctiva/Lacrimal
Gland

Entropion



Lower eyelid inward
Etiology: older, weakness of muscle
surrounding lower part of the eye
Clinical manifestations:




Redness, light sensitivity, dryness
Increased lacrimation, foreign body
sensation. Lashes scratch cornea
Diagnostics none
Management: Artificial tears,
epilation of eyelashes, botox,
surgery
Eyelids/Conjunctiva/Lacrimal
Gland

Ectropion:



Lower eyelid outward exposing
palpebral conjunctiva
Etiology: Older , 7th nerve palsy.
Obicularis oculi muscle relaxation
Clinical manifestations:





Excessive lacrimation
Drooping eyelid
Redness, photophobia, dryness, foreign
body sensation
Diagnostics: none
Management: Artificial tears, surgery
Eyelids/Conjunctiva/Lacrimal
Gland

Blepharitis:



Inflammation of eyelids (lid margins).
Etiology: S. aureus (ulcerative) or a chronic skin
condition(non-ulcerative).
Two forms:


Anterior: affects outside lids where eyelashes attach.
Caused by bacteria or seborrheic
Posterior: Inner eyelid. Caused by problems with
meibomian glands in eyelid (gland plugging). Caused by
acne Rosacea or seborrheic
Eyelids/Conjunctiva
Lacrimal Gland

Blepharitis

S Aureus:


Seborrheic:


Itching, lacrimation,
tearing, burning,
photophobia
lid margin erythema, dry
flakes, oily secretions on lid
margins, associated
dandruff
Diagnostics: none
Eyelids/Conjunctiva
Lacrimal Gland

Blepharitis-Management

Anterior:


Hygiene. Remove scales with baby shampoo.
Apply Bacitracin or or erythromycin
Posterior:

Expression of meibomian gland on regular
basis. If corneal inflammation need oral
antibiotic. Artificial tears, cool compresses
Eyelids/Conjunctiva/Lacrimal
Gland

Chalazion:



Localized sterile swelling of upper or lower
eyelid due to blockage of meibomian gland
If ruptures, granulation tissue results.
Secondary to hordeolum
Risks: Blepharitis, acne rosacea
Eyelids/Conjunctiva/Lacrimal
Gland

Chalazion






Hard non-tender swelling
Painless, present for weeks to months
Conjunctiva red and elevated near lesion
May distort vision if near cornea
Diagnostics: none, biopsy
Management:



Warm compresses
Injection or corticosteroid or I/D if no
improvement
Sugery
Eyelids/Conjunctiva/Lacrimal
Gland

Conjunctivitis: Viral


Inflamed palpebral and bulbar conjunctiva.
Etiology: Viral: Adenovirus type 3
Clinical
Unilateral or bilateral edema and hyperemia of
conjunctiva
 Watery discharge
 Ipsilateral preauricular lymphadenopathy.
 May be associated with pharyngitis, fever,
malaise
Management:
 Warm compresses
 Sulfonamide drops to prevent secondary
bacterial infection, topical vasoconstrictors


Eyelids/Conjunctiva/Lacrimal
Gland

Bacterial Conjunctivitis

Etiology:



S.pneunoniae, S. aureus, moraxella
Transmission is direct contact
Clinical manifestations:





Copious purulent discharge from both
eyes (yellow/green)
Mild discomfort/sticky eyes
Complications: corneal ulcer
Diagnosis: gram stain
Management: topical antibiotics such
as polytrim, fluoroquinolones
Chlamydial/Gonococcal
Conjunctivitis



Serotypes A, B, Ba and C
cause trachoma, and
serotypes D through K
produce adult inclusion
conjunctivitis
Chlamydial (inclusion)
conjunctivitis is found in
sexually active young adults.
Diagnosis can be difficult.
Look for systemic signs of
STD.
Chlamydial/Gonococcal
Conjunctivitis







Eye infection greater than 3 weeks
not responding to antibiotics.
Mucopurulent discharge
Conjunctival injection
Corneal involvement uveitis
possible
Preauricular lymphadenopathy
Conjunctival papillae
Chemosis: membranes that line
eyelids and surface of the eye
(conjunctiva) are swollen.
Conjunctival papillae
Chlamydial/Gonococcal
Conjunctivitis


Diagnosis:
 Fluorescent antibody stain, enzyme
immunoassay tests
 Giemsa stain: Intracytoplasmic inclusion
bodies in epithelial cells,
polymorphonuclear leukocytes and
lymphocytes.
Management:
 Oral: Tetracycline, Azithromycin,
Amoxicillin and erythromycin
 Topical:
erythromycin, tetracycline or
sulfacetamide
 Gonococcal: ceftriaxone 1g IM, and then
1gm IV 12-24 hours later.
Eyelids/Conjunctiva/Lacrimal
Gland

Allergic conjunctivitis



Etiology: allergen.
Release of inflammatory mediators leading
to vascular permeability and vasodilation
Clinical






Itching /Tearing /Redness
stringy discharge
photophobia and visual loss
Hypertrophic palpebral conjunctiva with
cobblestone papillae
No preauricular nodes
Management: Topical antihistamines, topical
vasoconstrictors, mast cell degranulation
inhibitors, topical steroids
Eyelids/Conjunctiva/Lacrimal
Gland

Dacryocystitis


Nasolacrimal obstruction leading to
sac infection
Etiology: Acute:



S. aureus, B-hemolytic strep.
Chronic: S. epidermidis, candida
Chronic Dacryocystitis etiology:

mucosal degeneration, ductile stenosis,
stagnant tears, bacterial overgrowth
Eyelids/Conjunctiva/Lacrimal
Gland

Dacryocystitis

Clinical manifestations:




Pain, redness, swelling to tear sac
Purulent discharge from sac
Diagnostics: none , CT for
etiology
Management:



Children: Oral Augmentin, antibiotic
drops
Adults: Keflex/Augmentin, topical
antibiotic drops
Warm compresses
Eyelids/Conjunctiva/Lacrimal
Gland

Conjunctival Foreign bodies


Trauma to conjunctiva
Clinical manifestations:




Diagnostics:




Acute pain, foreign body sensation
Redness, tearing
Visual acuity might be affected
Visual acuity
Fluorescein staining
Evert eyelids
Management:




Local anesthetic
Normal saline flush/ sterile cotton tip applicator
Antibiotic ointment
Referral if not healing
Eyelids/Conjunctiva/Lacrimal
Gland

Periorbital/ Orbital Cellulitis



Orbital septum: is a membranous sheet in the
upper eyelid attached to the edge of the orbit,
where it is continuous with the periosteum.
Etiology is hordeolum, chalazion, conjunctivitis,
dacryocystitis.
Periorbital cellulitis: Remains anterior to orbital
septum. Limited to the eyelids
Orbital cellulitis: Posterior to orbital septum in
orbit. Unilateral/ young. Risk is sinus infection or
entrance through ethmoid bone. Treat
aggressively to avoid extension to meninges and
brain via cavernous sinus.
Eyelids/Conjunctiva/Lacrimal
Gland

Periorbital/ Orbital cellulitis




Periorbital cellulitis: conjunctival injection, fever,
edematous erythematous periorbital soft tissue,
EOM nontender, normal IOP, normal visual
acuity, normal sensation.
Orbital cellulitis: little conjunctival injection,
fever, edematous erythematous periorbital soft
tissue, tenderness with EOM, elevated IOP,
impaired visual acuity, sensation can be
impaired.
Diagnosis: CT soft tissue orbital infiltration,
cultures
Management: Admission, broad spectrum
antibiotics, surgery.
Cornea

Corneal Abrasion


Superficial irregularity from trauma or
foreign body, contact lens
Clinical manifestations:







Severe pain
Redness/photophobia
Excessive tearing
Foreign body sensation
Decreased visual acuity
Eye usually closed
Rust ring if metallic object
Cornea

Corneal Abrasion

Diagnostics



Fluorescein staining
Evert lids, check for foreign body
Management:





Remove foreign body
Antibiotic ointment
Eye patch with pressure
Oral pain meds
Follow up
Cornea

Corneal Foreign body



Trauma to cornea. Inflammatory response.
Rule out intraocular foreign bodies.
Clinical manifestations:






Pain/photophobia/redness
Foreign body sensation
Blurred vision
History of trauma
Eye closed
Ring infiltrate surrounding site if >24 hours
Cornea
Corneal Foreign body

Diagnostics:





Visual acuity
Fluorescein stain
Evert eyelids
CT/MRI
Management:





Topical anesthetic
Antibiotic ophthalmic ointment
Eye patch
Oral pain medication
Follow up


Orbit

Blow out fracture





Associated with
trauma to orbit
Examine facial bones,
sinuses, eyes
EOMs
Orbital films
Optho referral.
Hyphema



Blood in anterior chamber between iris and cornea due to
torn blood vessels within the iris and ciliary body
Etiology: Spontaneous or post trauma.
Clinical manifestations:






History: blunt trauma
eye pain,
decreased vision, photophobia,
evaluate for globe rupture.
Management: Head elevated, decreased eye ROM,
analgesics, mydriatic, topical steroids, eye shield.
Complications: rebleeding, reduced vision, glaucoma
(increased IOP due to obstructed drainage of aqueous
humor).
Globe

Iritis



Acute anterior uveitis.
Intraocular inflammation of iris and
ciliary body.
Clinical manifestations:




Circumcorneal injection (redness around
cornea): ciliary flush
Moderate deep aching pain/photophobia
Blurred vision
Small irrregular non reactive pupil
Globe

Iritis

Diagnostics:


Slit-lamp examination
(keratitic precipitates
WBC on epithelium)
Management




Ophthalmologist consult
Mydriatics
Corticosteroids
Complications: loss of
vision
Globe

Optic Neuritis



Inflammation of optic nerve
Associated with multiple sclerosis, viral infections
Clinical manifestations:






Unilateral acute visual loss
Improves in 2-3 weeks
Pain with eye movement
Color vision loss
Marcus gunn pupil (when light is applied to affected eye,
it fails to constrict completely. However when light is
shown in consensual eye, both constrict)
Refer to ophthalmologist
Globe

Diabetic retinopathy


Leading cause of blindness in
adults in USA
Abnormal growth of retinal
blood vessels secondary to
ischemia.

Nonproliferative: confined to
retina.




Capillary micro aneurysms
Dilated veins
Flame shaped hemorrhages
Proliferative


Neovascularization
Can lead to retinal detachment
Globe

Diabetic Retinopathy

Clinical manifestations:





Decreased visual acuity/color vision
retinal hemorrhage
retinal edema
Neovascularization
macular exudate
Globe

Hypertensive Retinopathy


Atherosclerosis.
Vasoconstriction and
ischemia due to hypertension
Clinical manifestations:


Decreased visual acuity
Retinal hemorrhage, retinal
edema, cotton wool exudates,
copper/silver wiring, A/V
nicking, optic disc swelling
Globe

Retinopathy

Management:


Type II diabetes need annual follow up
Treatment is surgery- laser photocoagulation
and vitrectomy.
Globe

Retinal Detachment



Leakage of vitreous fluid leads to
detachment
Spontaneously or second to trauma
Clinical manifestations:




Visual loss
Floaters/flashing lights as initial
symptoms
Retinal tear on fundoscopic exam
Management: Ophthalmology
consult and laser surgery
Globe

Retinal Artery Occlusion



Occlusion of the central retinal
artery by embolus leading to
visual loss
Common in elderly with
hypertension, Diabetes, giant
cell arteritis
Clinical manifestations:





Painless loss of vision.
Cherry red spot on fovea
Swelling of the retina
Optic nerve is pale
Cotton wool spots to area affected
Globe

Retinal Artery Occlusion

Diagnostics


Look for other reasons for
emboli
Management:




Ophthalmologist consult
immediately
Ocular massage
Need cardiac workup
Thrombolysis
Globe

Cataract:


Opacities of the lens.
Clinical manifestations:



Hazy, blurred distorted
vision. Loss of color
vision.
Opaque lens on
examination. Pupil white,
fundus reflection is
absent.
Management is surgery
Globe

Macular degeneration




Loss of central vision due
to degeneration of cells in
macular.
Risk factors include age,
sun exposure.
Gradual loss of central
vision, blurred vision,
scotoma. Peripheral vision
preserved.
Management: No
effective treatment, Might
respond to laser therapy.
Globe

Glaucoma




Eye emergency
Disease of optic nerve. Abnormal drainage
of aqueous from the trabecular meshwork
Leads to increased ocular pressure,
ischemia, degeneration of optic nerve,
blindness.
African Americans at risk, Diabetics,
migraine, older age group
Globe

Open-Angle Glaucoma


Poor drainage of the aqueous through the
trabecular meshwork causing damage to optic
nerve and visual loss. Narrow angle.
Clinical manifestations:




Asymptomatic until late
Slow progressive peripheral field visual loss
Increased cup: disc ratio
Management: Miotic drops such as pilocarpine to
reduce amount of aqueous humor produced and
increase the outflow.
Globe

Angle Closure Glaucoma


Closure of preexisting
narrow anterior chamber
Clinical manifestations:






Ocular pain/decreased vision
Halos around lights
Conjunctiva injected/cornea
cloudy
Pupil mid-dilated
N/V
Visual field defects/ enlarged
optic disk with pallor
Globe

Angle Closure Glaucoma

Diagnostics:



Tonometry
Field testing
Management:


Open Angle Glaucoma: B Adrenergic blocking eye drops
(timolol, levobunolol), epinephrine eye drops, alpha 2
agonists, surgery
Closed Angle: Decrease IOP by laser. Iridotomy, systemic
acetazolamide, osmotic diuretics, pilocarpine
Globe

Strabismus



Cannot align both eyes simultaneously.
Leads to diplopia. May occur in one or both eyes.
Types

Non paralytic


Short length or improper insertion of extraocular muscles.
Deviation is constant in all directions of gaze.
Paralytic

Weakness of extraocular muscles.
Deviation varies depending on the direction of gaze.
Globe

Strabismus

Types:

Convergent: esotropia

Divergent: exotropia



Hypertropia: upward deviation
Hypotropia: downward deviation
Management: Exercise or surgery.
Globe

Strabismus

Clinical manifestations:





Esotropia or exotropia
Both eyes can not align simultaneously
One eye wanders when patient tired, eventually eyes
turn outward constantly
Diagnostics: Cover/uncover test
Management:




Check visual acuity if Amblyopia patch good eye
Surgery
Corrective lenses.
Can lead to amblyopia and blindness if not corrected.