Board Review Ophthalmology By Stacey Singer-Leshinsky R-PAC

Board ReviewOphthalmology

ByStacey 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


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


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/ConjunctivaLacrimal Gland Blepharitis

S Aureus: Itching, lacrimation,

tearing, burning, photophobia

Seborrheic: lid margin erythema, dry

flakes, oily secretions on lid margins, associated dandruff

Diagnostics: none

Eyelids/ConjunctivaLacrimal 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


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


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


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/GonococcalConjunctivitis 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/GonococcalConjunctivitis

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/GonococcalConjunctivitis 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.


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


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


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


Conjunctival Foreign bodies Trauma to conjunctiva Clinical manifestations:

Acute pain, foreign body sensation Redness, tearing Visual acuity might be affected

Diagnostics: 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.


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.

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Board Review Ophthalmology By Stacey Singer-Leshinsky R-PAC