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Ophthalmology Back to Basics Review. March 29, 2011 Dr. Andrew Toren. MCC Objectives. Eye Redness Pupil Abnormalities Amblyopia / Strabismus Acute / Chronic Visual Loss. Pupil Abnormalities. Rationale

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ophthalmology back to basics review
OphthalmologyBack to Basics Review
  • March 29, 2011
  • Dr. Andrew Toren
mcc objectives
MCC Objectives
  • Eye Redness
  • Pupil Abnormalities
  • Amblyopia / Strabismus
  • Acute / Chronic Visual Loss
pupil abnormalities
Pupil Abnormalities
  • Rationale
  • Pupillary disorders of changing degree are in general of little clinical importance. If only one pupil is fixed to light, it is suspicious of the effect of mydriatics. However, pupillary disorders with neurological symptoms may be of significance.
  • -Causal Conditions
  • Local disorder of iris
  • Anisocoria (unequal/asymmetric pupils)
  • Post eye surgery
  • Impaired pupil constriction (third nerve palsy, tonic pupil, mydriatics)
  • Impaired pupil dilatation (Horner syndrome) (hypothalamus/brain stem/spinal cord lesions)
  • Impairment of pupil constriction (without anisocoria)
  • Unilateral (optic nerve or retinal lesion)
  • Bilateral (diabetes, syphilis, midbrain lesion, hydrocephalus, factitious)
  • -Key Objectives
  • Determine whether there has been previous ocular inflammation, trauma, loss of vision, or eye pain in order to begin ruling out local disorders.
  • -Objectives
  • Through efficient, focused, data gathering:
  • Differentiate clinically between the various mechanisms of pupil abnormalities.
  • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:
  • Select patients in need of referral for further investigation.
  • Conduct an effective plan of management for a patient with pupil abnormalities:
  • Select patients in need of referral for management.
  • Applied Scientific Concepts
  • Outline function of cranial nerves and demonstrate how to examine them.
  • Describe the mechanism of pupillary constriction
eye redness
Eye Redness
  • Rationale
  • Red eye is a very common complaint. Despite the rather lengthy list of causal conditions, three problems make up the vast majority of causes: conjunctivitis (most common), foreign body, and iritis. Other types of injury are relatively less common, but important because excessive manipulation may cause further damage or even loss of vision.
  • -Causal Conditions
  • Lids/Lashes/Orbits/Lacrimal system
  • Blepharitis (infectious, allergic)
  • Hordeolum (stye)/Chalazion
  • Foreign body
  • Cellulitis (pre-septal, orbital)
  • Naso-lacrimal duct obstruction
  • Conjunctiva/Sclera
  • Conjunctivitis (viral, bacterial, chlamydial, allergic, also neonatal)
  • Subconjunctival hemorrhage
  • Episcleritis/Scleritis
  • Pinguecula/Pterygium
  • Cornea (corneal abrasions, contact lens overwear)
  • Keratitis, infectious
  • Foreign body (refer if not better in 24 hours)
  • Anterior chamber/Iris
  • Iritis/Iridocyclitis/Uveitis
  • Glaucoma, acute
  • Hypopyon
  • Hyphema
  • -Key Objectives
  • Determine whether the condition requires prompt referral.
  • -Objectives
  • Through efficient, focused, data gathering:
  • Differentiate causal conditions that are benign from those that require prompt referral.
  • Determine if vision is affected (reading with affected eye), is there foreign body sensation (inability to open and keep eye open is objective evidence), photophobia, trauma, discharge persisting throughout the day, headache and malaise, nausea and vomiting.
  • Determine visual acuity first, then if there is corneal opacity or infiltrate, aversion to light in uninvolved eye, pupil light reaction (not fixed or pin-point), purulent discharge, redness pattern, WBC or RBC in anterior chamber.
  • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:
  • Select investigations for diagnosis and required prior to initiation of therapy.
  • Conduct an effective plan of management for a patient with eye redness:
  • Outline management for two of the three most common causes of eye redness, conjunctivitis and foreign body.
  • Select patients in need of referral.
acute visual loss
Acute Visual Loss
  • Rationale
  • Loss of vision is a frightening symptom that demands prompt attention; most patients require an urgent ophthalmologic opinion.
  • -Causal Conditions
  • Glaucoma (acute angle closure)
  • Haemorrhage (diabetic retinopathy, may be traumatic, penetrating, hyphema)
  • Nervous system/Vascular
  • Retinal artery/Vein occlusion (TIA/CVA)
  • Migraine
  • Occipital infarction/Haemorrhage (TIA/CVA)
  • Trauma
  • Blunt (global rupture, corneal abrasion, choroidal rupture, lens dislocation)
  • Penetrating (globe penetration ( intra-ocular foreign body, corneal/lens perforation, optic nerve injury)
  • Haemorrhage (may be traumatic, penetrating)
  • Other (carotid-cavernous sinus fistula, chemical splash)
  • Retinal/Macular/Optic disc problems
  • Optic neuritis/Optic nerve injury
  • Retinal detachment (may be traumatic)
  • Anterior ischemic optic neuropathy/temporal arteritis
  • Acute macular lesion
  • Infectious/Inflammatory
  • Other (drug toxicity, functional visual loss)
  • -Key Objectives
  • Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely).
  • Examine the eye with external, direct ophthalmoscope, visual fields, and pupils.
  • -
acute visual loss1
Acute Visual Loss
  • Objectives
  • Through efficient, focused, data gathering:
    • Determine whether the loss is monocular or binocular, and if binocular, is it hemianopic, any exposure to agents or trauma.
    • Determine character of visual loss, since important associated systemic conditions (diabetes, hypertension, temporal arteritis) or similar past events may suggest cause.
    • Differentiate causes of visual loss by examination of cornea, pupil, lens, retina, optic disc, and visual fields (listen for murmurs, carotid bruits).
    • Determine the presence of a foreign body, abnormal extraocular musculature, pupillary reflex.
  • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:
    • Since vast majority of cases will be referred urgently, all tests will be arranged by specialist.
  • Conduct an effective plan of management for a patient with acute loss of vision:
    • Select patients in need of specialized care.
chronic visual loss
Chronic Visual Loss
  • CHRONIC VISUAL DISTURBANCE/LOSS
  • -Rationale
  • Loss of vision is a frightening symptom that demands prompt attention on the part of the physician.
  • -Causal Conditions
  • Pre-retinal conditions
  • Corneal disorders (dystrophy, scarring, edema)
  • Lens disorders (age related, traumatic, steroid-induced)
  • Glaucoma (primary, secondary)
  • Retinal dysfunction
  • Diabetic (retinal edema, retinopathy)
  • Vascular insufficiency
  • Tumors
  • Macular degeneration or dystrophy
  • Post-retinal lesions
  • Optic chiasm lesions (pituitary adenoma)
  • Lesions anterior to the optic chiasm (optic nerve/monocular)
    • Compressive optic neuropathy
      • Intracranial (masses)
      • Orbital (thyroid disease)
    • Toxic/Nutritional (nutritional deficiencies, tobacco-alcohol amblyopia, methanol)
    • Hereditary optic neuropathies
  • -Key Objectives
  • Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely).
  • Perform direct ophthalmoscope examination of the eye.
  • -Objectives
  • Through efficient, focused, data gathering:
  • Determine whether the visual loss is monocular or binocular.
  • Differentiate causes of visual loss by examination of cornea, lens, retina, and optic disc.
  • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:
  • Perform visual acuity and field-testing.
  • List indications for fluorescein angiography.
  • Conduct an effective plan of management for a patient with chronic visual loss:
  • Select patients in need of specialized care.
  • -Applied Scientific Concepts
  • Back to Top
  • Outline the anatomical pathways involved in vision (pre-retinal structures, retina, optic nerve and its pathway through the chiasm, occipital optic cortex).
  • Explain potential visual field defects with lesions at various areas in this pathway
key objectives
Key Objectives
  • Acute / Chronic Visual Loss
    • Know how to examine the eye & common causes
  • Eye Redness
    • Know how to manage and when to refer the patient
  • Pupil Abnormalities
    • Know the main causes of pupil abnormalities
  • Amblyopia / Strabismus
    • Know what amblyopia is / know the differential and treatment for misaligned eyes
resources
Resources
  • Basic Ophthalmology, American Academy of Ophthalmology , Cynthia A. Bradford; MD
  • http://www.ophthobook.com/
eye redness1
Eye redness
  • by the end of this lecture students will be able to:
    • know a differential diagnosis for a red eye
    • be able to differentiate between serious vision threatening, benign, and non urgent causes of a red eye
examination of the eye
examination of the eye

HOW TO EXAMINE THE EYE FOR DUMMIES

  • Topical Anesthesia
  • Light Source
  • iPhone/Eye Chart
  • Paper Clips (plastic coated)
  • visual acuity - don’t forget pinhole!
  • pupils
  • conjunctiva: pattern of injection
  • discharge
  • evert lids: papillae or follicles?
  • lymph node
slit lamp examination
slit lamp examination
  • cornea: fluorscein staining (abrasions, dendrites), opacities
  • anterior chamber: depth, cells
  • intraocular pressure
history
history
  • timing
  • visual changes
  • pain, photophobia, tearing
  • discharge
  • other risk factors: prior episodes, contact lens use, medical comorbidities
the usual suspects
the usual suspects
  • blepharitis
  • conjunctivitis
    • viral
    • allergic
    • bacterial
  • subconjunctival hemorrhage
  • foreign body
  • pterygium
the red eye
the red eye
  • Non-Traumatic
  • Traumatic
blepharitis
blepharitis
  • Inflammation of the lid margin (crusting/redness of lids)
  • Causes ‘gritty’/foreign body sensation, often concomitant with other ocular surface disease
  • Associated with recurrent hordeolum (styes) or chalazia
  • Improvement with warm compresses/lid hygeine, artificial tears, tetracycline
the usual suspects1
the usual suspects
  • herpes simplex keratitis
  • herpes zoster
  • bacterial keratitis
  • corneal ulcer
  • iritis / episcleritis / scleritis
conjunctivitis
conjunctivitis
  • Bacterial - most common in children
  • Viral - most common in adults
  • Allergic - bilateral, frequently c/o ‘itch’
bacterial conjunctivitis
bacterial conjunctivitis
  • Signs:
    • Discharge - purulent vs mucopurulent
question
Question
  • What type of neonatal conjunctivitis occurs on the first day?
pitfalls adult conjunctivitis
Pitfalls: Adult Conjunctivitis
  • Adult Hyperacute Conjunctivitis
    • Gonococcus
    • Signs/symptoms of severe infection
    • Rapid onset
  • Chlamydial Conjunctivitis
    • Sexually active adolescents/adults
    • Unilateral, Follicular reaction
    • Chronic (>3 weeks)
    • Microtrak
    • Oral Tetracyclin
bacterial conjunctivitis1
bacterial conjunctivitis
  • Usually self limited
  • Treatment necessary?
    • Limits spread
    • Shortens course
    • Patient comfort
    • Prevents recurrence
    • Prevents chronic staph conjunctivitis
bacterial conjunctivitis therapy
bacterial conjunctivitis therapy
  • Choice of antibiotic depends on other factors:
    • Polysporin
      • no prescription required
    • Polytrim
      • Low cost
      • Well tolerated
    • Fucithalmic
      • BID dosing
pitfalls in treatment
Pitfalls in Treatment
  • Avoid
    • Gentamicin
      • Epithelial toxicity
    • Steroid containing solutions
        • Garasone
        • Tobradex
        • Blephamide
      • Increase IOP, Cataract
      • Geographic Herpes
      • Worsen Infection
      • Corneal Spread
    • Frequent switching of drops
viral conjunctivitis
Viral Conjunctivitis
  • History: Infectious Contacts, URTI, Drops/Drugs
  • Etiology: Adenovirus
  • Treatment: No specific therapy
    • Cool compresses, artificial tears, infectious precautions
allergic conjunctivitis
Allergic Conjunctivitis
  • Symptoms: ITCHING
  • Signs: mild redness, conjunctival chemosis, watery discharge, papillary hypertrophy
  • Treatment: cold compress, antihistamines, non-steroidal drops, mast cell stabilizers, topical corticosteroids
subconjunctival hg
Subconjunctival Hg
  • What is the appropriate management of a large subconjunctival hemorrhage
    • A) Stop any anticoagulation and observe for improvement
    • B) Observe. If no resolution in 1-2 weeks refer to ophthalmology
    • C) Observation only
    • D) If large, refer to ophthalmology
bacterial keratitis
bacterial keratitis
  • much less common
  • pain, reduced vision
  • management:
    • Large/Central Ulcer: Culture, Fortified antibiotics, urgent referral
    • Small Ulcer: topical gtts, refer
herpes simplex keratitis
Herpes Simplex Keratitis
  • Unilateral, often have previous history
  • Pain -variable, photophobia,
  • Dendrites, Follicular conjunctivitis
  • Management:
    • Topical trifluridine 1% (Viroptic) 9X/day ± cycloplegia, refer
    • NO STEROIDS!
iritis episcleritis scleritis
Iritis/Episcleritis/Scleritis

Necrotizing Scleritis

Nodular Scleritis

Increasing Ocular Inflammation

Diffuse Scleritis

Localized Scleritis

Episcleritis

Increasing Systemic Complications

Pingeculitis

episcleritis
Episcleritis
  • Symptoms: Often asymptomatic, Mild irritation and/or photophobia
  • Signs: Sectoral Redness, superficial injection, localized tenderness
  • Systemic Associations: RA, SLE, Seronegative spondyloarthropathies
  • Treatment: Tears, Topical/Oral NSAIDS
scleritis
Scleritis
  • Symptoms: Pain (Dull, Achy, Deep, Boring), Photophobia, Tearing
  • Signs: Bluish red injection, deeper structures, nodules, necrosis
  • Systemic Association in 50%, high 5 yr mortality - needs investigation
    • Collagen Vascular
    • Rheumatoid arthritis
    • Lupus
    • Wegner’s
  • Treatment: Topical/Oral Steroid/NSAIDS/Immune suppression
angle closure glaucoma aka pupillary block
Angle Closure Glaucoma (aka Pupillary Block)
  • Symptoms: dramatic presentation, significant pain, ocular headache, nausea and vomiting, decreased vision, colored haloes
  • Signs: fixed mid-dilated pupil, steamy cornea, shallow anterior chamber, ELEVATED IOP
angle closure
Angle Closure
  • Treatment:
    • Pilocarpine 1%
    • Pressure lowering medication:
      • Topical / IV / PO
      • Definitive Management: Laser Iridotomy
traumatic red eye
Traumatic Red Eye
  • Red Flags
    • Loss of vision
    • Loss of red reflex
    • Flat anterior chamber
    • Tear shaped pupil
    • Uveal prolapse
the usual suspects2
the usual suspects
  • blepharitis - warm compresses, lid hygeine, artificial tears
  • conjunctivitis
    • viral - cool compresses, contact precautions, observe
    • allergic - avoidance, antihistamine, allergy gtts
    • bacterial - broad spectrum antibiotic gtts
  • subconjunctival hemorrhage -observe
  • foreign body
  • pterygium
the usual suspects3
the usual suspects
  • herpes simplex keratitis - refer
  • herpes zoster - refer
  • bacterial keratitis - broad spectrum antibiotics, refer if no improvement
  • corneal ulcer - broad spectrum Abx, refer
  • iritis / episcleritis / scleritis - dilate, refer
  • angle closure glaucoma - refer urgently
trauma
Trauma
  • Hyphema
    • Gross (visible) or micro (visible only on slit lamp exam)
    • Rx - Cylcoplegia, rest, refer
  • Traumatic Mydriasis
  • Orbital Fracture - CT scan, refer (repair ~1 week), no nose blowing, beware in children of White Eye-Blow Out Fracture
when to refer
when to refer
  • vision changes
  • pain, severe headache, nausea/vomitting
  • corneal abnormalities or opacities
  • fluorescein staining
  • shallow anterior chamber
  • increased IOP
  • marked purulent discharge
  • trauma
  • proptosis
urgent referral time sensitive
Urgent referral - time sensitive
  • acute angle closure glaucoma
  • corneal ulcers
  • trauma - eg ruptured globe
  • endophthalmitis
urgent referral 48hrs
Urgent referral <48hrs
  • acute anterior uveitis (iritis)
  • scleritis
  • nasolacrimal infections
anatomy pupillary response
Anatomy - Pupillary Response
  • Afferent Pathway - CNII
  • Efferent Pathway - CNIII parasympathetic, sympathetic
irregular pupil
Irregular Pupil
  • Mechanism: damage to compliance of iris or iris musculature
  • Trauma – visible tears in margin or sphincter
  • Iridodialysis – outer edge of iris is torn away from its ciliary attachment
  • Synechiae – can result from intraocular inflammation causing adherence to lens or cornea
  • Neovascularization – can distort & impair reactivity
  • Malformations: coloboma, aniridia
  • Cataract surgery!
anisocoria
Anisocoria
  • Inequality in diameter of the 2 pupils
  • Efferent disturbances of pupil size usually unilateral
slide64
Degree of anisocoria greater in:
    • Dim light – weakness in dilator muscle (or physiologic) of smaller pupil
      • Small Pupil
    • Bright light – weakness of sphincter of bigger pupil
      • Large Pupil
dim light small pupil
Dim Light / Small Pupil
  • Physiologic: <2mm
  • Horner’s
  • Pharmacologic: cholinergic - stimulation of parasympathetic efferent pathway
    • Eg Pilocarpine
features
Features
  • Miosis
  • Ptosis -2-3 mm
    • upside-down ptosis (1-2 mm) of the lower lid
      • Leads to pseudoenophthalmos
  • Anhydrosis
  • Other features:
    • transient dilation of conjunctival vessels, increased accomodation
    • In longstanding cases heterochromia of the iris may occur (the affected side being less pigmented)
horner s
Horner’s
  • Tests:
    • Cocaine - Is Horner’s present or absent?
      • Blocks re-uptake of norepinephrine in the neuromuscular junction
      • NB: apraclonidine (alpha-agonist)
    • Hydroxyamphetamine - Is1st/2nd vs 3rd order Horner’s?
      • Causes release of norepinephrine

AAO, Neuro-Ophthalmology

bright light large pupil
Bright Light / Large Pupil
  • Damage to parasympathetic outflow to iris sphincter muscle
    • Oculomotor nerve (CNIII) paresis
    • Tonic Pupil
    • Intermittent dilation of one pupil caused by inhibition of parasympathetic pathway
  • Trauma to sphincter
  • Pharmacologic stimulation: Anti-cholinergics
cn iii palsy
CN III Palsy
  • Pupil Involvement?
    • Assume to be aneurysm!
  • Complete vs Incomplete?
  • Young vs Vasculopathy & Diabetic?
  • Needs urgent neuroimaging - CTA MRI/MRA, angiography

AAO, Neuro-Ophthalmology

large pupil others
Large Pupil: Others
  • Tonic Pupil
    • Longstanding
    • Aberrant regeneration
    • Light-near disassociation
  • Pharmacologic
    • Red cap drops, Anticholinergics eg scopolamine
    • Test with Pilocarpine
  • Traumatic Mydriasis
extraocular muscles
Extraocular Muscles

AAO, Neuro-Ophthalmology

important questions
Important Questions
  • Does the diplopia resolve when 1 eye is covered? (i.e. monocular vs. binocular)
  • Is it the same in all fields gaze (comitant) or does it vary with gaze direction (incomitant)?
  • Is it horizontal, vertical, or oblique?
  • Is it constant, intermittent, or variable?
4th nerve palsy
4th Nerve Palsy
  • Congenital
    • Asymptomatic until 40-60yo (↓ fusional amplitudes)
    • Chronic head tilt – check old photographs
  • Ischemic
    • Patients older than 50yo with ischemic risk factors
    • Expect resolution within 3 months
  • Others: Trauma; MS, tumour, hydrocephalus, aneurysn, Idiopathic, Graves and Myasthenia
  • Neuroimaging: little diagnositc value initially
  • Medical Work-up & Observe
cn iii palsy1
CN III Palsy

AAO, Neuro-Ophthalmology

6th nerve palsy
6th Nerve Palsy
  • Causes esodeviation
  • Ischemic – most common
    • Patients older than 50yo with ischemic risk factors
    • Expect resolution within 3 months
  • Other important causes: Tumours, Trauma, raised ICP, demyelinating disease
  • Investigations:
    • Adults > 50yo
      • Medical work-up (BP, fasting BG, lipid profile)
      • Lack of recovery after 3 months --> MRI
    • Patients < 50yo
      • Rarely ischemic --> must image (MRI/FLAIR)
      • Consider LP, Tensilon test

AAO, Neuro-Ophthalmology

slide78
INO
  • Internuclear Ophthalmoplegia
  • Ipsilateral Impaired ADduction
  • Contralateral ABducting nystagmus
  • See most often in demyelinating disease
  • Mneumonic: INO = Insufficient Nasal Output
diplopia summary
Diplopia Summary
  • Remember the 4 questions
  • Determine onset and course
  • Check pupils in CN3 palsy
  • Pupil-involving needs imaging (CTA or MRI)
  • Other indications for imaging
  • Non-resolving (presumed ischemic) CN palsy
  • Younger patients (< 50yo)
  • Value of a Tensilon test in MG
  • In older patients, consider GCA (ESR, CRP)
amblyopia
Amblyopia
  • Decreased vision in eye from disuse of eye during development (~before age 8)
  • Causes include:
    • Refractive error
    • Strabismus
  • Early detection is key
strabismus
Strabismus
  • Disruption of binocular vision
  • Binocular fusion develops <4-6months
  • Most common cause is accommodation from hyperopia
    • Rx with glasses
    • Rx amblyopia with patching if necessary
cover uncover
Cover/UnCover
  • Tropia : the eyes are turned all the time.
    • Hyper/Hypo/Exo/Eso
  • Phorias: eye deviations that are only present some of the time eg .stress, illness, fatigue, or when binocular vision is interrupted.
acute chronic visual loss
Acute / Chronic Visual Loss
  • Red Eye
  • Pupil Abnormalities
  • Diplopia
  • Amblyopia
causes of acute visual loss
Causes of Acute Visual Loss
  • Cornea:
    • Surface disorders - eg. exposure kerathopathy, dry eye
    • Corneal Edema (Acute ACG, other corneal diseases)
  • Anterior Chamber:
    • Hemorrhage - eg. Neovascularization in Ischemia/Diabetes
  • Vitreous:
    • Hemorrhage from Ischemia/Diabetes
  • Retina:
    • Vascular-occlusive disease, macular degeneration, hemorrhage, retinal detachment
  • Optic Nerve:
    • Temporal Arteritis / Giant Cell Arteritis vs non-arteritic anterior ischemic optic neuropathy (NAION); Optic Neuritis; compressive lesions
chronic visual loss1
Chronic Visual Loss
  • Glaucoma
  • Diabetic Retinopathy
  • Age Related Macular Degeneration
  • Cataract
case 1
Case 1
  • 28y.o. day care worker with 3 days of red eye
  • Vision 20/25 OU
  • Pupils normal
  • Conjunctiva injected
  • Discharge clear
  • Cornea clear
  • AC deep and quiet
  • IOP 18
  • Preauricular node palpable
  • Hx: no contact lens use, recent URTI
case 2
Case 2
  • 9 y.o. female complains of red eye for 1 week
  • Vision 20/60 OD, 20/20 OSPupils smallConjunctiva: ciliary injectionDischarge wateryCornea clearAC cellsIOP 14
  • no preauricular node
  • Hx: photophobia, recent limp
case 3
Case 3
  • 68yo. male c/o of burning, foreign body sensation in both eyes (OS>OD)
  • vision: 20/25 OD, 20/30 OS
  • conjunctival: injected
  • discharge: tearing, discharge in the am
  • cornea: debris on cornea, no fluorescein staining
  • AC / IOP / lymph nodes: unremarkable
  • Hx: worse with new eye gtts recently
case 4
Case 4
  • A 43 female presents with 5 days of pain and redness in her left eye. She has no discharge and conjunctival chemosis. She has a history of rheumatoid arthritis. Which of the following tests would you order next:
  • Conjunctival swabs
  • Corneal swabs
  • CBC, ANA, RF, ACE, and CXR
  • Ophthalmic slit lamp assessment
case 5
Case 5
  • A 42 female presents with 3 days of pain and redness in her left eye. She reports halos in her vision and a dull pain. Which of the following would be the next appropriate steps:
  • Visual acuity
  • Slit lamp examination for the presence of anterior chamber cell
  • Conjunctival swabs
  • Systemic investigations for connective tissues and rheumatologic diseases
  • Intraocular pressure measurement
  • Dilated fundus examination
case 6
Case 6
  • A 44 male presents with 7 days of foreign body irritation and blurry vision in his left eye following an unknown foreign body in eye while working in machine shop. Which of the following would be the next appropriate steps:
  • Visual acuity
  • Slit lamp examination
  • Eversion of the upper eyelid
  • Conjunctival swab
  • CT orbits
  • Intraocular pressure measurement
  • Dilated fundus examination
case 7
Case 7
  • A 44 female with a history of 2 days of severe boring pain in her right eye. presents with a red eye to the clinic. She has a history of 5 days of discomfort in both eyes. Vision is unaffected. On exam her eye looks as follows. What is the appropriate initial treatment:
  • Oral steroids
  • Topical lubrication
  • Indomethacin 50mg po tid
  • Topical bacitracin and polymyxin B
  • Homatropine 1% 1 gtt tid
  • Topical antihistamines drops
case 8
Case 8
  • A 42 male presents with halos, intraocular pain and an IOP of 65 with corneal edema. The next steps in management of his condition would include which of the following:
  • Slit lamp examination and fundoscopy
  • IV Mannitol
  • Topical levobunolol 0.5%
  • Topical pilocarpine 4%
  • Oral acetazolamide 500 bid for 7 days
  • Urgent ophthalmology referral
  • Topical prostaglandins drops
case 9
Case 9
  • A 43 male presents with a history of rheumatoid arthritis presents with a red eye for 5 days self medicated with topical steroids. Slit lamp examination shows a corneal dendritic lesion with terminal bulbs and mild anterior chamber inflammation. Treatment would include the following:
  • Topical levobunolol 0.5%
  • Immediate ophthalmic referral
  • Topical steroid drops
  • Trifluoridine 1% 1gtt q2h
  • Valtrex 1g po tid
case 10
Case 10
  • A 45 male with presents with 7 days of foreign body irritation and redness in her left eye following foreign body in eye while working in machine shop. Which of the following would be the next appropriate steps:
  • Visual acuity
  • Slit lamp examination
  • Eversion of the upper eyelid
  • Conjunctival swab
  • CT orbits
  • Intraocular pressure measurement
  • Dilated fundus examination
case 11
Case 11
  • A 4 day old male with presents profuse mucopurulent discharge in both eyes. What is the management of this patient?
  • Urgent ophthalmology consultation
  • Topical silver nitrate
  • Conjunctival gram stain
  • Conjunctival culture
  • Blood cultures
  • Cefotaxime 100–150 mg/kg/day IV or IM, 12 hourly
  • Dilated fundus examination
case 12
Case 12
  • A 64 year old male with a diffuse red eye, mild discharge and pain in his right eye. His pupil is newly dilated and fixed at 6mm and unresponsive to pilocarpine 2%. What is the management of this patient?
  • Urgent Ophthalmology Consultation
  • Measurement of intraocular pressure
  • CT Angiogram or MRA/MRV of the head
  • ESR, CRP, and CBC
  • Dilated fundus examination
case 13
Case 13
  • An 76 year old male presents with complaint of double vision. History of diabetes and high blood pressure. His pupil are reactive and IOP is normal. What is the next step in management of this patient?
  • Urgent CT head scan
  • Measurement of blood glucose, triglycerides, and cholesterol
  • CT Angiogram or MRA/MRV of the head
  • ESR, CRP, and CBC
  • Patch affected eye
case 14
Case 14
  • A 2 month old child is noted to have a significantly large esotropia. What is the most important next step the physician should perform?
  • Detailed family history for strabismus or neoplasm
  • Doll’s eye manoeuvre
  • MRI of head +/- abdomen
  • Genetic testing
  • Examine old photo graphs
  • Reassurance