Ophthalmology Disorders Part 1

What is appropriate treatment fo viral conjunctivitis?

topical ganciclovir and/or acyclovir, valacyclovir

6 y/o child presents to the clinic with copius watery discharge of the eyes and also has preauricular adenopathy. He has been swimming in the country club pool about 3 times a week. What is the most likely diagnosis? How would you treat this?

Viral conjunctivitis: topical ganciclovir and/or acyclovir, valacyclovir

What virus is usually responsible for viral conjunctivitis?

Adenovirus

27 y/o adult presents to clinic with purulent eye discharge and lid crusting. He states that he wears contact lens. What is the preferred treatment for this patient?

Topical fluoroquinolone (ofloxacin or ciprofloxacin)

What is the treatment for trachoma?

Azithromycin

What is the treatment for inclusion conjunctivitis?

Doxycyline

What is the treatment for gonococcal conjunctivitis?

Ceftriaxone and/or topical abx such as erythromycin or bacitracin

What diagnostic test is used for dry eye?

epithelial keratopathy stain with fluorescein

What diagnostic test is used keratojunctivitis sicca?

Schirmer test

33 y/o male presents to clinic with painful red eye, photophobia, and foreign body sensation of the eye. He states he occasionally wears his contact lens overnight. During diagnostic exams, large yellow infiltrates (> 1mm) were found. Cornea has epithelial defect and an underlying opacity via slit lamp examination. Based on these findings, what is first line treatment for this patient?

topical fluoroquinolones such as levofloxacin, ofloxacin, norfloxacin, ciprofloxacin (tx for bacterial keratitis)

Branching of the corneal ulcer is the most characteristic manifestation of what disorder?

Herpes Simplex Keratitis

63 y/o patient presents to clinic with blurred vision that has gradually worsen over the few days. Patient has no pain or redness of the eyes. What is the most likely diagnosis?

Cataracts

Patient presents to clinic with painful red eye, photophobia, and foreign body sensation. On physcial exam, she has pustular rash with crusting around the eyes and eyelid. What is the most likely diagnosis? How would you treat it?

Herpes Zoster Ophthalmicus; acyclovir, valacyclovir, famciclovir within 72 hours of onset of rash

Where is the abscess located when a patient has internal hordeolum?

meibomian gland of the eyelid

Where is the abscess located when a patient has external hordeolum?

gland of Zeis

What is the distinct clinical presentation between a hordeolum and chalazion?

A hordeolum presents as a painful, red, swollen lump on the eyelid, while a chalazion is typically a painless, firm lump resulting from blocked meibomian glands.

What is the treatment for anterior blepharitis?

Treatment typically includes warm compresses, eyelid hygiene, and topical abx ointment (bacitracin or erythromycin) for acute cases

What is the treatment for posterior blepharitis?

warm compress for mild cases, long-term low-dose oral abx (-cycline class) for inflammation of conjunctiva and cornea, short term topical corticosteroids (prednisone) may be indicated, and ciprofloxacin ophthalmic solution

Patient presents to clinic with pain, photophobia, reduced vision, and purulent discharge. Hypopyon found in the anterior chamber, and a ring-shaped corneal infiltrate was also found. What is the most likely diagnosis?

Corneal Ulcer (could also be bacterial keratitis)

Patient presents to clinic with acute painful red eye with reduced vision loss. Patient is diagnosed with a corneal ucler. How do you treat this patient?

Refer to an ophthalmologist for urgent evaluation and management

A 45-year-old woman presents to the clinic with complaints of pain, swelling, and redness in the inner corner of her left eye. She reports that the symptoms have progressively worsened over the past 3 days. The patient also notes a yellowish discharge from the corner of her eye, especially when pressing on the area. She has no significant medical history but mentions occasional dry eyes and a history of frequent sinus infections.

On examination, the patient has a tender, swollen mass over the lacrimal sac area, with erythema and warmth over the skin. There is purulent discharge from the punctum of the left eye when gentle pressure is applied. The visual acuity is unaffected, and there is no evidence of proptosis or chemosis.

Based on the clinical findings, what is the most likely diagnosis for this patient, and what are the appropriate next steps in management?

This patient likely has dacryocystitis, an infection of the lacrimal sac. Management includes warm compresses, and if symptoms persist or worsen, antibiotic therapy may be necessary, possibly with referral to an ophthalmologist if complications arise.

A 47 y/o female with a medical history of diabetes presents to clinic with vision loss. What would you expect to find during her funduscopic exam?

cotton wool spots, intraretinal hemorrhages (flamed shaped), and hard exudates

A 50 y/o male with history of diabetes presents to clinic with vision loss. Cotton wool spots, intraretinal hemorrhages (flamed shaped), and hard exudates were found during his funduscopic exam. Based on these findings, how do you treat this patient?

Treatment involves controlling blood sugar levels, monitoring for progression, and considering laser photocoagulation therapy or intravitreal anti VEGF injections if necessary.

A 36 y/o male presents to clinic and reports initial sxs of seeing floaters and reduced peripheral vision. However, the patient has experienced unitateral vision loss after a few hours. Patient denies pain. Based on these findings, what would you diagnose this patient?

retinal detachment

72 y/o female presents to the clinic with a complaint of gradual vision loss in her right eye over the past 6 months. She reports difficulty reading, especially small print, and has noticed that colors appear less vibrant. On funduscopic exam, macula shows bright yellow deposits in retinal layers. Based on these findings, what does the patient have?

This presentation is consistent with dry age-related macular degeneration (AMD), characterized by gradual vision loss and yellow deposits known as drusen deposits.

How would you treat wet AMD?

intravitreal injections of anti-VEGF agents, such as ranibizumab or aflibercept, to reduce fluid buildup and prevent vision loss

photodynamic therapy laser treatment to eradicate neovascular tissue

What is the most common type of retinal detachment?

rhgematogenous retinal detachment

A 65-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department complaining of sudden, painless loss of vision in his left eye. The patient reports that the vision loss occurred over the course of a few minutes and is associated with the sensation of a "shadow" in his central visual field. He denies any trauma or recent headaches.

On examination, his visual acuity in the left eye is 20/200, and he has a relative afferent pupillary defect (RAPD) in the left eye. Fundus examination reveals a pale retina with a "cherry-red spot" at the macula, and there is no evidence of retinal hemorrhage or exudates.

What is the most likely diagnosis, and what is the treatment for this patient?

The most likely diagnosis is central retinal artery occlusion (CRAO). Intra-arterial revascularization by local thrombolytic injection via angiography if performed within a few hours of symptom onset.

A 65-year-old woman presents to the emergency department with severe right eye pain, headache, nausea, and blurred vision. She reports seeing halos around lights and has a history of intermittent eye pain over the past few weeks. On examination, her right eye appears red, the cornea is slightly hazy, and the pupil is mid-dilated and non-reactive to light. Intraocular pressure (IOP) is significantly elevated at 50 mmHg. What is the likely diagnosis and treatment for this patient?

acute angle-closure glaucoma; decrease intraocular pressure IV acetazolamide and topical medications (timolol) to lower the IOP, followed by peripheral iridotomy as definitive tx

72-year-old man with a history of hypertension and diabetes presents for a routine eye exam. He denies any eye pain or vision disturbances. Fundoscopic examination reveals optic nerve cupping and retinal nerve fiber layer thinning. Tonometry shows an IOP of 24 mmHg, and visual field testing reveals peripheral vision loss. What is the likely diagnosis and treatment?

Chronic open-angle glaucoma; topical medications to lower intraocular pressure (IOP), such as prostaglandin analogs eye drops and beta-blockers (timolol), or surgical options if necessary.

What is the difference between pathophysiology of chronic open-angle glaucoma and chronic angle-closure glaucoma?

COAG: IOP is increased due to reduced drainage of aqeous fluid through the trabecular meshwork

CAAG: IOP is increased due to reduced drainage of aqeous fluid through the anterior chamber

A 35-year-old man presents to the clinic with right ear pain, itching, and a sensation of fullness that has worsened over the past three days. He recently returned from a beach vacation, where he frequently swam in the ocean. He denies fever, hearing loss, or upper respiratory symptoms. On physical examination, the external ear is tender to palpation, and the ear canal appears swollen and erythematous with serous discharge. The tympanic membrane is partially obscured but appears intact.

CIPRODEX drops (topical abx and corticosteroid ear drops)

A 72-year-old man with a history of type 2 diabetes mellitus presents to the emergency department with severe right ear pain and drainage that has persisted for the past two weeks. He reports worsening hearing in the affected ear and pain that radiates to his jaw. He has been using over-the-counter ear drops, but his symptoms have not improved. On physical examination, the external ear appears erythematous and swollen, with purulent discharge in the external auditory canal. Granulation tissue is noted at the bony-cartilaginous junction of the external canal. He has tenderness over the mastoid and along the jawline. His temperature is 38.3°C (100.9°F). Which of the following is the most appropriate next step in management for this patient?

Admission to the hospital and IV ciprofloxacin

A 2-year-old boy is brought to the pediatric clinic by his parents due to fever, ear tugging, and irritability for the past two days. His parents report that he recently had a cold. On examination, his temperature is 38.5°C (101.3°F), and otoscopic examination reveals a bulging, erythematous tympanic membrane with reduced mobility on pneumatic otoscopy. What is the most appropriate initial treatment for this patient?

oral amoxicillin

What is the hallmark clinical presentation of chronic otitis media?

purulent otorrhea and often painless, varying degrees of conducive hearing loss, and perforation or retraction of the TM

What would you expect to find regarding the tympanic membrane on a patient with acute otitis media?

A bulging, erythematous tympanic membrane with reduced mobility on examination.

Asymptomatic effusion + no signs or symptoms of inflammation with a TM that is dull and hypomobile is most likely what diagnosis?

Serous otitis media

What is first line treatment for chronic otitis media?

topical fluoroquinolones (ofloflaxacin or ciproflaxacin); definitive treatment is tympanoplasty

What would you expect to find regarding the tympanic membrane on a patient with chronic otitis media?

A retracted or perforated TM.

A 32-year-old man presents to the ENT clinic with chronic foul-smelling ear drainage from his left ear for the past six months. He denies fever but reports progressive hearing loss in the affected ear. He has a history of recurrent ear infections but has not experienced significant ear pain. On otoscopic examination, there is a retraction pocket in the pars flaccida with white debris accumulation. The tympanic membrane appears perforated, and there is no acute inflammation. What is the most likely diagnosis?

Cholesteatoma

What is the clinical hallmark presentation for otosclerosis?

A slowly progressive conductive hearing loss often bilaterally and asymmetrically, often accompanied by tinnitus.

How would you treat otosclerosis?

NaF therapy, biphosphonate, and/or surgical stapedectomy.

A 50-year-old man presents to the clinic with progressive hearing loss in his right ear over the past year. He also reports occasional episodes of unsteadiness but denies vertigo, tinnitus, or ear pain. He has no history of ear infections or head trauma. On physical examination, Weber’s test lateralizes to the left ear, and Rinne’s test shows air conduction greater than bone conduction bilaterally. Neurological examination is unremarkable. What is the most appropriate next step in evaluation of this patient?

This patient has symptoms suggestive of an acoustic neuroma (vestibular schwannoma), a benign tumor of the vestibulocochlear nerve (cranial nerve VIII). The classic presentation includes gradual unilateral sensorineural hearing loss and imbalance due to compression of the cochlear and vestibular portions of CN VIII. MRI with contrast is the gold standard for diagnosis.

What is the distinct clinical presentation between vestibular neuritis and labyrinthitis?

Vestibular neuritis typically presents with acute, severe vertigo without auditory symptoms, while labyrinthitis involves both vertigo and hearing loss due to inflammation of the inner ear structures.

A 40-year-old woman presents to the emergency department with a sudden onset of severe dizziness that started this morning. She describes the sensation as if the room is spinning and notes associated nausea and vomiting. She denies hearing loss, tinnitus, ear pain, or recent head trauma. She recently recovered from an upper respiratory infection a week ago. On physical examination, she has horizontal unidirectional nystagmus that worsens when she looks toward the unaffected side. The Dix-Hallpike maneuver is negative for positional vertigo, but the head impulse test is positive on the affected side. What is the likely diagnosis?

This patient likely has vestibular neuritis, a viral inflammation of the vestibular nerve, often following a respiratory infection.

What results would you expect on the Weber test and Rinne test on a patient with sensorineural hearing loss?

The Weber test would lateralize to the unaffected ear, while the Rinne test would show air conduction greater than bone conduction on the affected side.

What results would you expect on the Weber test and Rinne test on a patient with conductive hearing loss?

The Weber test would lateralize to the affected ear, while the Rinne test would show bone conduction greater than air conduction on the affected side.

A 45-year-old man presents to the clinic with recurrent episodes of vertigo over the past several months. He describes the episodes as a spinning sensation lasting 30 minutes to a few hours, often associated with nausea and vomiting. He also reports intermittent hearing loss, a feeling of fullness in his left ear, and tinnitus. He denies recent infections, head trauma, or use of ototoxic medications. Physical examination is unremarkable, but audiometry reveals low-frequency sensorineural hearing loss in the left ear. What is the most likely underlying pathophysiology of this condition?

This patient likely has Meniere's disease, which is characterized by increased endolymphatic fluid pressure in the inner ear. This condition results in episodic vertigo, fluctuating hearing loss, tinnitus, and a sensation of ear fullness.

What is the classic triad of symptoms for Meniere disease?

Episodic vertigo, tinnitus, (unilateral) hearing loss.

A 60-year-old woman presents to the clinic with episodic dizziness for the past two weeks. She describes a spinning sensation that lasts for less than a minute and occurs when she turns her head or gets out of bed in the morning. She denies hearing loss, tinnitus, or ear pain. There is no history of recent infections, head trauma, or neurological symptoms. On physical examination, the Dix-Hallpike maneuver triggers rotatory nystagmus and vertigo when her head is turned to the right. What is the most appropriate initial treatment for this patient?

This patient likely has Benign Paroxysmal Positional Vertigo (BPPV). The most appropriate initial treatment is the Epley maneuver, a series of head movements designed to reposition displaced otoliths in the inner ear.

What pathogen is most commonly involved with acute pharyngotonsillitis?

Group A Streptococcus pyogenes

A 14-year-old boy presents to the clinic with sore throat, fever, and difficulty swallowing for the past three days. He denies cough, runny nose, or conjunctivitis. On examination, his temperature is 38.9°C (102°F). His oropharynx is erythematous with bilateral tonsillar swelling, exudates, and tender anterior cervical lymphadenopathy. What is the appropriate next step in management?

Perform a rapid antigen test for Group A Streptococcus to confirm the diagnosis of acute pharyngotonsillitis.

What is the antibiotic therapy for GAS pharyngitis?

PCN V potassium or cefuroxime axetil

If a patient has a history of ARF, what antibiotics can be given if there are some concerns with compliance of treatment?

Long-acting penicillin injections (such as benzathine penicillin G) can be administered to ensure adherence and effective prevention of rheumatic fever recurrence. Erythromycin or azithromycin if there is a PCN allergy

What are the typical signs of peritonsillar abscess?

drooling, trismus, dysphagia, “hot potato” voice, and deviation of the uvula from affected side

What are the non-suppurative complications of GAS infection?

ARF and scarlet fever

A 12-year-old girl presents to the emergency department with fever, joint pain, and fatigue for the past week. Her mother reports that she had a sore throat about three weeks ago that resolved without treatment. On examination, her temperature is 38.5°C (101.3°F), and she has swelling and redness in her knees and ankles, with pain that seems to migrate from one joint to another. A cardiac exam reveals a new holosystolic murmur at the apex. A non-pruritic, erythematous rash with a serpiginous border is noted on her trunk. Laboratory tests show elevated ESR and CRP, and an anti-streptolysin O (ASO) titer is positive. What is the most appropriate treatment for this patient?

Antimicrobial prophylaxis with PCN V or erythromycin and anti-inflammatory medications such as NSAIDS or corticosteroids to manage symptoms and prevent further complications. IM PCN G benzathine may be used for long-term prophylaxis against rheumatic fever.

What are the 5 major criteria for Revised Jones Criteria for diagnosis of ARF?

carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.

What are the 4 minor criteria for Revised Jones Criteria for diagnosis of ARF?

fever, polyarthralgia, elevated acute phase reactants, and prolonged PR interval.