Board Review Ophthalmology

1. Board ReviewOphthalmology By Stacey Singer-Leshinsky R-PAC

2. 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

3. 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

4. Terms • Miosis: constriction • Mydriasis: dilation: sympathetic • Anisocoria: unequal: • Adies tonic pupil: poor light reaction • Argyll robertson: small irregular. Syphilis • Convergence • Divergence

5. 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.

6. 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

7. Eyelids/conjunctiva/Lacrimal Gland • Pterygium • Complications: • blockage of vision as grows onto cornea • Management: • Eye drops to moisten eyes and decrease inflammation. Surgical excision

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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.

21. 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

22. 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

23. 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

24. Eyelids/Conjunctiva/Lacrimal Gland • 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

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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

31. Orbit • Blow out fracture • Associated with trauma to orbit • Examine facial bones, sinuses, eyes • EOMs • Orbital films • Optho referral.

32. 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). • .

33. 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

34. Globe • Iritis • Diagnostics: • Slit-lamp examination (keratitic precipitates WBC on epithelium) • Management • Ophthalmologist consult • Mydriatics • Corticosteroids • Complications: loss of vision

35. 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

36. 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

37. Globe • Diabetic Retinopathy • Clinical manifestations: • Decreased visual acuity/color vision • retinal hemorrhage • retinal edema • Neovascularization • macular exudate

38. 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

39. Globe • Retinopathy • Management: • Type II diabetes need annual follow up • Treatment is surgery- laser photocoagulation and vitrectomy.

40. 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

41. 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

42. Globe • Retinal Artery Occlusion • Diagnostics • Look for other reasons for emboli • Management: • Ophthalmologist consult immediately • Ocular massage • Need cardiac workup • Thrombolysis

43. 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

44. 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.

45. 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

46. 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.

47. 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

48. 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

49. 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.

50. Globe • Strabismus • Types: • Convergent: esotropia • Divergent: exotropia • Hypertropia: upward deviation • Hypotropia: downward deviation • Management: Exercise or surgery.