What is strabismus ?

When is strabismus normal, if ever?

Eye misalignment (crossed eye or deviated eye)

It is normal in the first few months of life, if it is intermittent

Is presbyopia a normal or

abnormal finding?

Normal after age 40

(can’t see well close-up)

What is presbyopia ?

Lack of ability to accommodate that impairs near vision (caused by lens inflexibility, mainly)

What position does the eye end up in with a third cranial nerve palsy?

Down & out (like an intern)

(some prefer a third-year med student to remember CN3 – they’re down & out because they’re just getting started)

How does a cranial nerve 6 lesion present?

No lateral gaze (in the affected eye) –

Causes double vision & crossed eyes, depending on direction of gaze

What does a fourth cranial nerve palsy look like?

Why?

• Can’t look down your nose! (you can’t look down when your eye is medial – a fourth-year medical student can’t look down his nose, because he or she isn’t a doctor yet!)

• The superior oblique is

paralyzed

(their superiority muscle is paralyzed!)

Which autonomic system is responsible for constricting the pupil ?

Parasympathetic

Mydriatics dilate the eyes. What class of medications do they generally belong to?

Sympathomimetics

What is the classic example of a mydriatic ?

Atropine or homatropine

(homatropine lasts up to 3 days, and atropine up to 2 weeks!)

What is the medical term for constricting the pupil?

Miosis

What causes central retinal artery occlusion?

Usually emboli from the heart or carotid, but sometimes emboli that develop due to vasculitis

How does central retinal artery occlusion present?

How is it treated?

• Sudden, painless, unilateral

loss of vision

• Emergently! – must be treated within 90 min.

You can try:

1. Thrombolysis or pressure on the eyeball for a few seconds with sudden release (in an effort to move the obstruction)

2. Anterior chamber paracentesis (remove fluid to drop pressure suddenly – same idea as above)

3. Surgical intra-arterial thrombolysis

What is the official name for a “stye ?”

A hordeolum

What is the difference

between a hordeolum and a chalazion ?

How are they treated?

• Hordeolum – painful, red, at lid margin (a “whore” wearing red with painful lesions)

• Chalazion – painless lump, not at margin

Treatment is warm compresses (chalazions may sometimes be treated with I & D)

What is the main

principle in treating chemical exposures of the eye?

Irrigate the heck out of it!!

(confirm success with pH paper – you are done when the conjunctiva is at neutral pH)

Which is worse in the eye,

acid or alkali?

Why?

• Alkali

• Acid burns, but alkali melts

the cornea

What is preseptal cellulitis (also known as periorbital cellulitis)?

Infection of the skin and subcutaneous tissues anterior to the septal plate in the eyelid

How is orbital cellulitis different from preseptal or periorbital cellulitis?

It is still an infection of the soft tissues or the orbit, but posterior to the eyelid’s septal plate

How common is loss of vision, in an eye with an orbital cellulitis infection?

Around 10 % is properly treated

What are the most

common bugs to cause orbital cellulitis?

With trauma history – gram-negative rods

Without trauma history – Staph & Strep bacteria + & H. flu type B

( H. flu is less common now)

Which fungi are sometimes involved in orbital cellulitis, and mainly in which patient group?

Mucormycosis (faster course) & aspergillus (slower course)

Immunocompromised patients

What are the most common bugs to cause preseptal (aka preorbital or periorbital) cellulitis?

Staph & Strep +

H. influenza in children who are not immunized against it

How is herpes

keratitis (corneal herpes)

treated?

What is the associated buzzword?

• Topical antivirals (meds that

end in “idine”) OR oral

acyclovir

(Cycloplegics are also used in some cases to reduce pain, as in other corneal disorders)

• Dendritic keratitis

(dendritic = looks like a tree on

fluorescein exam)

In addition to topical

antivirals and oral acyclovir, is there anything else

you should do for a patient with herpes keratitis?

REFER TO OPHTHO!!!!!!!!

Patients with orbital cellulitis should always have what diagnostic performed, if possible?

CT to evaluate extent and location of infection and abscesses

How is orbital cellulitis

treated?

Inpatient IV antibiotics

(surgical treatment is used only in certain cases, including failure to respond to antibiotic treatment)

What physical findings suggest orbital cellulitis?

(5)

1. Restriction of eye

movements

2. Proptosis

3. Decreased visual acuity

4. Severe pain on attempted eye

movement

5. Afferent pupillary defect

(Marcus Gunn pupil)

(all signs need not be present)

What are the complications

of orbital cellulitis?

(3)

Meningitis

Venous thrombosis

Blindness

(MVB, like MVP – in this case it’s Most Valuable Bat, because you’ll be blind as a bat with orbital cellulitis)

How is preseptal

cellulitis treated?

Outpatient antibiotics

What is proliferative diabetic retinopathy?

When does this typically develop?

• New vessel growth on the retina

• Typically develops after many years of DM

What are the typical changes of hypertensive retinopathy ?

(5)

1. Arteriolar narrowing

2. Copper or silver wiring (vessel looks like wiring)

3. Cotton-wool spots

(cotton-wool spots also go with CMV retinitis)

4. A-V nicking (arteriovenous nicking, like one vessel has squished the other a bit, when you see it through the ophthalmoscope)

5. Flame-shaped hemorrhages

Papilledema in a patient with hypertension (HTN) suggests what problem?

Hypertensive emergency

(the papilledema shows that the blood pressure is affecting the CNS, because the optic nerve is a cranial nerve)

Arteriolar narrowing, “copper wiring” of retinal vessels, and A-V nicking are all retinal signs of what systemic problem?

Hypertension

(Retinal arteries are narrow, or may have the appearance of “copper wires”

A-V nicking means that the vessels look acutely narrowed where they cross – as if the high-pressure artery “squished” the vein)

If a patient has hypertension, are there retinal signs of HTN that don’t directly involve vessels?

Yes, but they are nonspecific

(cotton-wool spots & small hemorrhages)

What is glaucoma ?

What are the two ways it occurs?

Which is more common?

• Increased intraocular pressure

• Open angle and closed angle

• Open angle is much more common

How is (regular) glaucoma treated?

(4)

Mainly with topical eye drops

1. β-Blockers (may have systemic effects)

2. α-Agonists

3. Sometimes acetazolamide or other carbonic anhydrase inhibitors

4. Sometimes surgery

(miotic agents like pilocarpine are

also effective, but rarely used due

to side effects)

How does regular (open-angle) glaucoma present?

(3)

1. Painless elevation of intraocular pressure

2. Enlargement of optic cup

3. Slow loss of visual field

Most commonly, cataracts in a neonate suggest what

kind of general problem?

TORCH infection

T toxo & treponema

O other

R rubella

C cytomegalovirus

H herpes viruses

What is the most common

cause of slow, painless,

loss of vision?

Cataracts

What pediatric

rheumatologic condition

is commonly associated

with uveitis?

Juvenile RA

(rheumatoid arthritis)

What is UV keratitis ?

Corneal inflammation due to ultraviolet exposure – looks like numerous tiny corneal abrasions on fluorescein exam

How do you get UV keratitis?

• Welding

• Tanning (in a sunbed)

• Snow-skiing

How do you treat a corneal abrasion of any type?

(4)

1. Topical antibiotics

(infection prevention)

2. Pain management

(either PO, or a cycloplegic eye

drop)

3. Tetanus immunization, if not

up to date (an area of

controversy – some do not give

it)

Is eye patching helpful for the comfort or healing of a corneal abrasion?

Generally not –

Patching should be avoided due to problems resulting from the patch, especially in kids <9 years old

Are there any situations in which you should

prescribe steroid drops for the eyes?

NO

(Leave this to an ophthalmologist

in your real-life practice,

  &

don’t do it on the exam)

What eye complications

do you see with

steroid use?

(2)

1. Glaucoma

2. Cataracts

(topical, inhaled, and systemic steroids can all cause these)

What does a corneal ulcer with a “dendritic” pattern

mean?

Herpes keratitis

(big deal – can cause blindness)

How can you tell

whether someone is

susceptible to an attack of acute angle-closure glaucoma?

Flat angles

(the cornea does not rise very

steeply from the limbus, relative to the plane of the iris)

What are the two typical

histories for someone

presenting with angle-closure glaucoma?

1. Just came from a dimly lit area (e.g., movie theater)

2. Anticholinergic medication use

What are the hallmarks of viral conjunctivitis?

(3)

1. Preauricular lymphadenopathy

2. Clear, watery discharge

3. Highly contagious

(healthcare workers, teachers, etc. should be quarantined for 14 days)

How does chlamydial

conjunctivitis present?

Conjunctivitis without purulent discharge, 1–2 weeks after birth

(discharge may be mucoid, or just tear-like)

What are the signs

of an acute angle-closure glaucoma attack?

(4)

1. Red eye

2. “hazy cornea” (due to water

being forced into the corneal

layers by the pressure)

3. Nausea & vomiting

4. Fixed and mid-dilated pupil on

one side only (a trick reason

for why a pupil might be “nonreactive” – it’s stuck!)

In what situation might a patient be admitted to surgery for abdominal pain, then turn out to have an eye problem?