Patient with Eye Problems - Golub (DCM)
Terms in this set (87)
Hot do we take a history of someone who is complaining about their eyes/vision?
HPI (opthalmic problem)
Past ophthalmic hx
Current and Past medical problems inculding meds
What would you do on physical examination for a patient with ophthalmic problems?
Inspect and palpate
Vital signs (visual acuity, pupil size, reaction to light and accommodation, tonometry)
Visual fields (confrontation)
Eye Movements (diplopia ad strabismus)
What is this?
Sterile pus (Hypopyon) and blood (Hyphema) in the Anterior Chamber
What is this?
Xanthelasma; yellow plaque with cholesterol. What might be an underlying pathology? (flip card)
primary biliary sclerosis --> we must investigate thoroughly
What is this? Pathogenesis? Acute or chronic? Is it painful?
Hordeolum aka "sty"; infection of an eyelash follicle and/associated sebaceous gland, small acute, painful and self-limited
What is this? Pathogenesis? Is it acute or chronic? Is it painful? What can we do to treat it?
Chalazion; obstruction and rupture of Meibomian glands with accumulation of lipids and following inflammation, large, chronic, painless; can use warm-compress, anti-inflammatory drugs, can also incise and curettage
What is this? What might have caused it?
Blepharitis; Chronic inlammation of the eyelid (can recur after treatment), can be caused by staphylococcus or other parasites
hyperemia, flaking, crusting
What is this? Pathogenesis? Treatment?
Angioedema; could be an allergic reaction or pseudoallergic reaction (NSAIDs like Aspirin), could be hereditary or idiopathic, could be caused by infectious mononucleosis, SVC obstruction, hypothyroidism
What is this?
Entropion aka "Trichiasis"; inward rolling or the lower eyelid, cornea can be scarred by lashes --> blindness
What is this?
Ectropion; outward rolling of the lower eyelid, can be due to weakening of tissues, this is a benign condition
What are some conditions that can present with Red Eye or Painful Eye?
iritis and iridocyclitis
acute angle closure glaucoma (AACG)
What is this? What causes it?
Episcleritis / Scleritis; episclera is the loose connective tissue between sclera and conjunctiva. Episcleritis is usually
or may accompany an autoimmune disease (RA, SLE, etc)
Is Episcleritis painful? How do we treat it?
severe pain and occular tenderness. Treatment is anti-inflammatory drugs such as NSAIDS or glucocorticoids
CAREFUL: must differentiate between herpes simplex virus in which case, NSAIDS and glucocorticoids are contraindicated
What is this? What causes it? Is it painful? What are some associated symptoms?
Subconjuctival Hemorrhage; spontaneous or after trauma or coughing, No eye pain, no photophobia
must rule out other bleeding disorders. no need to treat, resolves in a week
What are these?
B. Bacterial (pain, purulent, eyelash matting)
C. Viral (hyperemia, lymphadenopathy)
D. HSV with Corneal Ulceration
What is this? What causes it? Is it painful? Can we treat with steroids?
Keratitis, can be bacterial, fungi, protozoal or viral
Corneal ulceration seen under Fluoroscein can be caused by HSV 1, avoid treating with steroids
What is Uveitis?
Inflammation of the iris and ciliary body
What are some manifestations of uveitis?
severe photophobia, blurry vision, intraoccular pain, congestion of ciliary blood vessels near the cornea
What is this?
What is the difference between a "closed angle
and an "open angle"?
What are some etiologies of Acute Angle Closure Glaucoma (AACG)?
- shallow anterior chamber
- hypermetropia (shorter optic axis)
- thinner or thicker iris (angle can close by thick iris due to increased sympathetic tone with pupil dilation, drugs, reading long hours in dim light)
- anteriorly situated and thicker lens
What are the criteria for diagnosis of AACG?
At least 2 of the following symptoms
- Ocular pain
- A history of interminent blurring of vision with halos (due to
+ At least 3 of the following signs
- Conjuncitval injection
- Mid-dilated nonreactive pupil
- Shallower anterior chamber
- Corneal edema (haziness)
- Intraocular pressure (IOP) > 21 mmHg
What do people with AACG see when they look at light?
Halos around light
What does a "shadow sign" indicate?
What is the management for AACG?
This is an emergency, the patient should be brought to the hospital.
Reduce IOP and restore anterior chamber angle
. Give analgesics for pain and antiemetics for nausea and vomiting (extra ocular manifestations). Definite treatment is Laser Peripheral Iridotomy and Anterior Chamber Paracenthesis
What is Visual Impairment?
vision loss, can be sudden or transient
What is Refractive Error? What are four types of Refractive Error?
Refractive Error is poor visual acuity correctable with lens.
Myopia (near sightedness)
Hypermetropia (hyperopia, far sightedness)
What is the first step in examination of a patient with visual loss?
Rule out refractive error
Which type of refractive error results from light rays focusing BEFORE the retina?
Which type of refractive error results from light rays focused BEHIND the retina?
Which type of refractive error results from stiffening of the lens?
Which type of refractive error results from light rays propagating in two different planes and focus at different areas?
What is the problem in Presbyopia that results in poor vision?
Because the lenses are stiff, the patient cannot accomodate for near objects.
In Myopia, are the eyeballs too long or too short?
How do you correct Myopia?
In Hypermetropia, is the eyeball too long or too short?
How do you correct Hypermetropia?
How do you correct Presbyopia?
How is Astigmatism corrected?
If your patient does poorly on the Snellen chart, they most likely have which refractive error?
If your patient performs poorly on a reading chart, they most likely have which refractive error?
What are some EYE DISORDERS that causes transient / sudden loss of vision?
Retinal artery Occlusion
(central and branch)
- Retinal Vein occlusion
- Hypertensive Retinopathy (crisis)
- Optic Neuritis
- Retinal Detachment
What are some CNS DISORDERS that causes ransient / sudden loss of vision?
- classic migrane
- transient ischemic attack
- factitious (functional) vision loss
What is Amaurosis Fugax and what might cause it?
It is a transient, painless monocular blindness. It "looks" like a curtain descending on one eye. It can be caused by an embolus in the central retinal artery or its branch. It can progress to retinal infarct
embolus can be made up of cholesterol (Hollenhorst plaque), calcium, platelet and fibrin debris
Where is the main source of the embolus that can cause Amaurosis Fugax?
atherosclerotic plaque in the carotid artery or aorta
What is this?
Amaurosis Fugax Hollenhorst Plaque
What are some causes of chronic visual loss?
Primary Open Angle Glaucoma
Age-related Macular Degeneration
What is Primary Open Angle Glaucoma?
It is a slow progressive, painless loss of peripheral vision. The patient is often unaware.
It is an optic nueropathy that leads to the loss of ganglionic cells and their axons and a
of the optic disk
How do we screen for and diagnose Glaucoma?
1. History non-informative: no complaints (spared foveal acuity)
2. Visual acuity: normal
3. Visual fields by confrontation: peripheral visual field defects
4. Slit lump examination with tonometry: increased IOP
5. Automated perimetry testing: arcuate scotomas of Turkish scimitar shape
6. Fundoscopy: optic disk cupping in advance cases
• Screening is necessary because pressure lowering prevents progression, but doesn't reverse the vision loss
What is this?
Pathological Cupping in Glaucoma
What is the leading cause of severe visual loss in adults over age 50?
Age-related Macular Degeneration (AMD)
A 63 year old woman comes into your office complaining off blurry vision and that she sees dark or empty areas in the center of her visual field. She also complains that straight lines look wavy or crooked. You determine that this patient might be suffering from which pathology?
Dr. Golub's Practice Questions and Answers:
What are the three "vital signs of ophthalmology" that you measure with every patient?
Vision, pupil, and pressure.
It's important to check these signs prior to dilation as dilating drops will affect these measurements.
What is glaucoma?
Glaucoma is gradual death of the optic nerve. The optic nerve damage arises from pressure, stretching, sheer forces, or vascular compromise.
What is a Marcus Gunn pupil?
This is an APD (afferent pupillary defect) that usually occurs with optic nerve/tract lesions or infarcts.
You have a patient who appears to have a shallow anterior chambers and occludable angles. Would you use pilocarpine?
Pilocarpine will constrict the pupils — by flattening the iris you potentially open up the drainage angle next to the trabecular meshwork. Pilocarpine will also decrease pressure in the eye by affecting aqueous production.
What's the difference between open-angle and closed-angle glaucoma? How about chronic versus acute glaucoma?
Open angle is a common, chronic condition where aqueous drainage is impaired.
Closed-angle glaucoma is caused by acute closure of the irido-corneal angle leading to blockage of ALL aqueous drainage - an ophthalmologic emergency that can quickly lead to blindness.
What are the risk factors for developing primary open-angle glaucoma?
•High intraocular pressure
•Race (Asians, African American and Hispanics)
•Suspicious optic nerve appearance (large vertical cupping)
•Thin central corneal thickness
What's a normal eye pressure? Does a patient with pressure of 14 have glaucoma?
About 8 to 21 mmHg
Glaucoma is classically associated with high intraocular pressure. There are some patients with glaucoma with normal pressure. Pressure fluctuates throughout the day
What are the three kinds of conjunctivitis? How do you differentiate them on history and physical exam?
The cause of conjunctivitis is not always obvious. Generally you'll see the following classic findings:
: watery discharge, follicles on palpebral conjunctiva, enlarged lymph nodes, typically unilateral
: mucous discharge, often unilateral
: bilateral itching and swelling
List the eight structures/areas that we check on the slit-lamp exam.
Working our way from the front to the back of the eye, structures that we document within our notes include:
•EXT (external structures)
•LL (lids and lacrimation)
•CS (conjunctiva and sclera)
•AC (anterior chamber)
What kind of vision loss occurs with glaucoma?
Typically loss of eyesight occurs in the periphery first where the loss is less noticeable. Scotomas (visual field loss areas) in glaucoma tend to follow certain patterns that start in the mid-periphery (arcuate scotoma). Many patients don't notice visual symptoms until the disease is far progressed. Generally, the central vision is spared until very late stages of glaucoma (Tunnel vision).
What retina findings do you see with glaucoma?
You see increased cupping of the optic disk, usually in a vertical and undermining of the blood vessels as they exit the disk.
What is the flow-pathway for aqueous fluid?
Aqueous is first produced by the ciliary body. It then flows forward through the pupil into the anterior chamber. Finally, aqueous drains through the trabecular meshwork and back into the venous system via the canal of Schlemm
What does it mean to have a phakic eye or an aphakic eye?
Phakic means that the patient has their original lens. Pseudophakic means that they have an intraocular lens implant. Aphakic means that their lens was removed, but no replacement lens was placed.
What is the uvea?
The uvea comprises the iris, ciliary body, and the choroid.
How many chambers are there in the eyeball?
Three. The anterior chamber sits in front of the iris, the posterior chamber between the iris and the lens, and the vitreous chamber lies behind the lens filling most of the eye.
How many layers are there in the cornea?
There are five: the superficial Epithelium, Bowman's layer, Stroma, Decemet's membrane, and the inner Endothelium
A patient comes into your office in great distress because their eye looks incredibly red. On exam, you see they have a spot of hemorrhage under the conjunctiva. Is this a problem?
Subconjunctival hemorrhage occurs when a conjunctival blood vessel "pops," usually after a Valsalva, or when sneezing and coughing. This is generally benign. If the hemorrhage is recurrent, think about bleeding disorders.
Patient is present with chronically irritated, grainy-feeling eyes with stinging and occasional watering. What is your diagnosis?