Board Review Ophthalmology

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Board ReviewOphthalmology

• By
• Stacey Singer-Leshinsky R-PAC

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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

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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

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Terms

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

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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. Cant increase refractive power.

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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

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Eyelids/conjunctiva/Lacrimal Gland

• Pterygium
• Complications
• blockage of vision as grows onto cornea
• Management
• Eye drops to moisten eyes and decrease
  inflammation. Surgical excision

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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
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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.

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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

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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

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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

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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

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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.

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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.

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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

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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

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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 gt24 hours

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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

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Orbit

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

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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).
• .

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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

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Globe

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

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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

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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

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Globe

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

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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

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Globe

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

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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

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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

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Globe

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

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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

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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.

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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

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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.

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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

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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

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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.

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Globe

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

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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.