Ophthal

1. progressive bilateral blurring of vision- cataracts likely

painless, glare, halos around lights at night

red reflex is lost as cataract progresses

tx- lens extraction w/ artificial lens implantation

atrophic macular degeneration -dry- usually associated scotoma, one or both eyes, slow progressive

exudative/ neovascular macular degen- wet- unilateral, aggressive vision loss, often starts with straight line distortion; central scotoma

open angle glaucoma- insidious gradual loss of peripheral vision, no halos

acute angle closure glaucoma- severe eye pain, conjunctival redness, poorly reactive mid-dilated pupil

2. open-angle glaucoma - typically has elevated intraocular pressure- atrophy of the optic nerve head eg optic disc rim thinning, increased cup/disc ratio

irreversible

lower IOP-

1st line topical prostaglandin eg latanoprost- increasing drainage of aqueous humour through uveoscleral pathway

topical b blockers eg timolol [caution w/ asthma]

sx eg laser trabeculoplasty

ophthalmic atropine- dilate pupil- contra in OAG because dilation can lead to angle narrowing --> acute angle closure glaucoma

systemic carbonic anhydrase inhibitors use acutely for angle-closure glaucoma

3. eye trauma- high velocity- corneal abrasion, open globe laceration

fluorescein drops

rule out OGL before saline irrigation

4. retinal detachment- flashes of light + floaters; 'curtain coming down over my eyes'; grey elevated retina

laser tx

choroidal rupture- blunt ocular trauma, central scotoma, retinal edema, hemorrhagic detachment of the macula, subretinal haemorrhage, cresent-shaped streak

CRAO- sudden painless loss of vision in one eye; cherry red fovea pale optic disc, boxcar segmentation of blood in retinal veins

proliferative diabetic retinopathy- neovascularization; vitreous hemorrhage, macular oedema, retinal detachment

5. ocular manifestations of HIV-

cataracts

CMV retinitis- fluffly or granular retinal lesions, unilateral

herpes simplex keratitis- branching/ dendritic corneal ulcers, pain redness tearing, unilat

uveitis

neuroophthalmic complications- optic neuropathy, motor palsies

cataracts- hiv, DM, ocular trauma, glucocorticoid use, external radiation exposure

6. lens dislocation - ectopia lentis- vibration of the iris during left and right movement, painless vision loss, lens displacement on siltlamp; blunt trauma or genetic condition eg marfan and homocystinuria

echocardiogram- marfans

7. ocular chemical burn

alkali eg bleach- cause liquefactive necrosis- deeper penetration

restore neutral pH- copious irrigation

8. chronic blepharitis- common contributors seborrheic dermatitis rosacea allergies bacterial esp staph viral eg HSV and demodex mite

burning or itching lids, discharge, foreign body sensation

hordeolum ie style- erythematous nodule at the lid margin

preseptal cellulitis- acute unilateral eyelid swelling and erythema

9. contact-lens associated keratitis- gram neg eg pseudomonas and serratia

can lead to corneal perforation scarring and permanent vision loss

10. macular degeneration- grid test screening

11. allergic conjunctivitis- IgE mediated acute hypersensitivity- bilateral, watery, ocular pruritus

viral- watery/ mucoid discharge, 1-2weeks

bacterial- purulent discharge unremitting

12. strabismus- tx strengthen the deviated eye eg patch unaffected eye cycloplegic drops eg atropine to blur unaffected eye, correct refractive errors ie glasses, surgery

cover test- normal eye maintains the same position without moving

red reflex more intense in the deviated eye; also asymmetric corneal light reflex

13. neurofibromatosis type 1 w/ optic pathway glioma- large compress the optic nerve causing decreased visual acuity altered colour vision optic nerve atrophy and proptosis; axillary freckling cafe au lait mononuclear eye proptosis; chromosome 17 neurofibromin nf1 gene suppressor gene

14. optic nerve injury- indirect shearing forces rom facial trauma or direct penetrating eye trauma; acute vision loss, decreased colour vision, afferent pupillary defect; normal ed reflex; ct orbit; ophthal referral +/- surgical decompression

poor initial visual acuity associated with worse prognosis

vitrous haemorrhage- bleeding- decreased VA, RAPD, and abnormal red reflex

15. neonatal conjunctivitis

chemical- <24hrs- after silver nitrate prophylaxis mild irritation and tearing- tx w/ eye lubricant

gonococcal- 2-5days- marked eyelid swelling purulent discharge corneal edema/ ulceration- single IM 3rd gen cephalosporin

chlamydial- 5-14days- mild eyelid swelling, watery or mucopurulent discharge- oral erythromycin

duct obstruction- dacryostenosis- unilateral tearing and minimal conjunctival injection

16. open globe injury- extrusion of vitreous, eccentric or teardrop pupil, decreased VA, RAPD, decreasded intraocular pressure; opthal referral, eye shield ct eye, iv antibiotics tetanus

hypopyon- layering of inflamm cells in the dependent portion of the anterior chamber

perilimbal injection- ciliary flush- dilation of the vasculature at the junction of the sclera and cornea

17. subconjunctival haemorrhage- observation; disappear in 24-48hrs

18. strabismus

dilated fundoscopic examination to assess for secondary causes such as retinoblastoma [nodular cream-coloured retinal mass; leukocoria, esotropia]

optic neuritis- eye pain worse with movement- visual evoked potential

19. dacrocystitis- infection of the lacrimal sac; pain and redness in medial canthal region, purulent discharge from punctum; staph aureus and b-hemolytic strep; systemic abx

chalazion- hard painless lid nodule; chronic granulomatous inflamm of the meibomian gland

20. open-angle glaucoma- enlarged cup with cup/disc ratio >0.6, increased cup size over time, thinning of disc rim, pale disc [optic nerve atrophy]

21. congenital dacryostenosis- complications dacryocystocele dacrocystitis

22. amblyopia- functional reduction in VA; unilat most common- 2+ line difference in vision between the eyes, bilat- vision worse than 2-/4- at age 4+;

aetiology- strabismus, asymmetric refractive error, vision deprivation er cataracts ptosis

corrective lenses, use of amblyopic eye, surgery

23. acute angle closure glaucoma- raised IOP; triggered by pupillary dilation or certain meds eg decongestants

nonreactive and mid-dilated pupil, conjunctival redness, corneal opacification; eye pain headache nausea diminished vision halos

ophthal consult, tonometry

24. routine VA testing at age 4; Snellen chart gold standard

VA worse than 20/40 at age 4 or 20/30 at 5+, pupillary asymm 1+mm, nystagmus, ptosis - refer

autism screening- 18mths 2yrs

25. age-related macular degeneration- maintained peripheral vision; atropy of the central retina [macula], retinal pigment epithelium, Bruch's membrane, and choriocapillaries

26. acute angle closure glaucoma; laser peripheral iridotomy

27. traumatic hyphema; complications- rebleeding, intraocular HTN, permanent vision loss

28. trachoma- chlamydia trachomatis serotypes A B C- conjunctival injection, tarsal inflammation, pale follicles

active- follicular conjunctivitis

chronic- scarring of the eyelids and inversion of the eyelashes [trichiasis]- lashes rub on the eye and cause ulcerations and blindness

giemsa stain; oral azithromycin

29. Graves disease- eyes lid lag proptosis diplopia; TSH receptor autoantibodies stimulate adipocytes + T cell activation and stimulation of orbital fibroblasts ---> orbital tissue expansion and lymphocytic infiltration

30. vitreous haemorrage- sudden loss of vision, floaters; most common cause DM; difficult to visualize fondus;

conservative treatment- upright position during sleep enhances settling of the haemorrhage

31. advanced HIV- CMV retinitis- cd4 <100; blurred vision floaters photopsia; yellow-white fluffy haemorrhagic lesions adjacent to the fovea and retinal vessels

oral antivirals eg valganciclovir; intravitreal injections to reduce risk of blindness and retinal detachment due to retinal scarring for lesions near the fovea

initiate ARVs - usually 2 weeks after beginning CMV treatment

32. infectious keratitis- HSV has branched dendritic ulcerations deceased corneal sensation watery discharge and recurrent episodes- immunocompromised

bacterial- staph pseudomonas- improper contact lens use corneal trauma foreign body- central round ulcer, stromal abscess, mucopurulent discharge, acute presentation

fungi- immunocompromised with corneal injury involving contaminated soil- ulcerations with feathery margins and satellite lesions, mucopurulent discharge, indolent course

33. allergic conjunctivitis

34. herpes zoster ophthalmicus- VZV, vesicular rash; first division of the trigeminal nerve; conjunctivitis and corneal ulcers; involvement of the tip of the nose- Hutchinson sign

dendriform corneal ulcers; high dose acyclovir

35. orbital compartment syndrome- increased IOP; risk factors trauma coagulopathy infection surgery; acute eye pain diplopia vision loss; periorbital swelling ecchymosis and tightness proptosis diffuse subconjunctival haemorrhage limited extraocular movements RAPD; emergency surgical decompression

36. Sjogren syndrome- keratoconjunctivitis sicca- chronic dry eye- discomfort grittiness foreign body sensation

decreased tear volume --> hyperosmolar state on eye surface, inflammation; complications- decreased VA, superficial infection, corneal ulceration, corneal perforation. tx artificial tears, humidifiers, eyeglasses with occlusive barriers

37. postoperative endophthalmitis- within 6weeks of sx; bacterial or fungal; pain and decreased VA, swollen eyelids and conjunctiva, hypopyon, corneal edema and infection; intravitral abx injection or victrectomy

38. central retinal vein occlusion- painless loss of vision; venous dilation and tortuosity due to venous occlusion, blood and thunder appearance due to diffuse haemorrhages, cotton wool spots, disc swelling, scattered and diffuse haemorrhages due to backup of blood and increased resistance leading to ischaemic damage;

fluorescein angiography; significant- intravitreal injection of VEGFi

amaurosis fugax- atheroemboli from carotid arteries- temporary vision loss- sometimes swelling of the optic disc

39. steroid-induced open angle glaucoma; tonometry

40. neonatal gonococcal conjunctivitis

1. acute angle closure glaucoma- headache ocular pain nausea decreased visual acuity, conjunctival redness corneal opacity fixed mid-dilatd pupil

dx- tonometry measure IOP, gonioscopy measure corneal angle

tx systemic acetazolamide [consider mannitol], topical multidrug topical therapy eg timolol pilocarpine apraclonidine; laser iridotomy

2. myopia- increased axial length of the eye or corneal protrusion, refracted image focused anterior to the retina

complications- retinal detachment, macular degeneration

3. presbyopia- loss of elasticity in the lens

nonspherical cornea- astigmatism

4. orbital cellulitis- pain with eye movements proptosis ophthalmoplegia visual changes' sinusitis most common risk factor esp ethmoid or maxillary; CT orbits and sinuses, iv antibiotics

5. anterior uveitis- ocular pain photophobia decreased VA, ciliary flush pupillary constriction hypopyon; herpes toxo syphilis, sarcoidosis, spondylarthritis, IBD; slit-lamp, HLA-B27 pelvis/ spine xray CXR HIV syphilis; dilating eye drops, topical glucocorticoids

6. sympathetic ophthalmia- autoimmune- t-cells recognize self-antigens as foreign- inflamm response against both eyes

7. photokeratitis- UV light cause desquamation of corneal epithelium; dx punctate corneal staining with fluorescein dye; prevention with UV protective eyewear; eye pain and photophobia 6-12hrs after exposure, foreign body sensation in the eye, decreased vision, conjunctival erythema chemosis tearing

8. viral conjunctivitis- most cases adenovirus; warm or cold compresses +/- antihistamine/ decongestant drops

9. anterior uveitis

10. Leukocoria- retinoblastoma

11. diabetic retinopathy

background- microaneurysms hemorrhages exudates retinal edema

pre-proliferative- cotton wool spots

proliferative or malignant- newly formed vessels

12.herpes simplex keratitis- dendritic ulcerations

13. external hordeolum [style]- often staph aureus but can be sterile- warm compresses- persistent or large chalazion then can add incision and curettage

preseptal cellulitis- eyelid anterior to the orbital septum- oral antibiotics eg doxycycline