Myopia is a known risk factor - Pt presents w/ Glaucoma (open angle) - Characteristics include:---1) IRREVERSIBLE blindness ---2) Loss of peripheral vision is a LATE manifestation ---3) RF------Myopia ------AA race ------Increasing age (> 40)------Genetics (First degree family member)
A 45-year-old man with a history of type 2 diabetes mellitus and hypertension is referred to an ophthalmologist because of abnormalities seen on funduscopic examination. He has not had any changes in vision or eye pain. He last saw an ophthalmologist approximately five years ago when he was diagnosed with diabetes, but has not returned for annual examinations. His medications include hydrochlorothiazide, metformin, and pioglitazone. He has no medication allergies. He smokes a pack of cigarettes daily and drinks beer socially on the weekends. On physical examination, pupils are equally round and reactive to light and accommodation. There is no afferent pupillary defect. Peripheral vision is decreased bilaterally. Visual acuity is 20/40 in his right eye and 20/60 in his left eye. Funduscopic examination reveals a large cup to disc ratio bilaterally. Tonometry reveals ocular pressures of 35 mmHg on the right and 30 mmHg on the left. Which of the following is true of this patient's condition?(Blindness associated w/ it is reversibleORLoss of peripheral vision is early manifestation ORMyopia is a known risk factor)
S.Aureus-*Most cases of adult conjunctivitis are caused by S.aureus* → can present w/:1) Can present in one or both eyes ---(or can start in one eye & progress to both eyes) 2) Erythema & discharge → w/an often *Stuck shut* eye when waking*Chlamydia trachomatis -Can cause bacterial conjunctivitis but*much more less common than S.aureus*-Also, most cases are marked w/long standing symptoms *(weeks-to-months)* & *concurrent urogenital infections*SIDE NOTE: Differentiation of discharge between bacterial & viral:----------------------Bacterial---------------------------------- --*Thick purulent discharge that continues through the day & night*--Usually in the corners of the eye & *re-accumulates w/in mins after wiping*--------------------------Viral----------------------------------- --Stringy, watery discharge that causes a gritty sensation in the eye --Frequently associated w/ URTI's
A 24F, presents d/t 3 days of left eye redness & discharge, w/ crusting of the eyelid & difficulty opening in the morning. Today, the pt's right eye also become red. She has had no pain, itching, photophobia, or visual difficulty. Her bf has had similar symptoms. The pt has no chronic conditions & takes no meds. PE shows bilateral conjunctiva erythema. There is thick, yellowish discharge at the corner of the eyes that quickly re-accumulates after wiping. The cornea is normal, & no ocular tenderness is present. Which of the following pathogens is the most likely responsible for this pts condition? (Chlamydia trachomatisORStaph aureus)
Optic neuritis -Pt has optic neuritis → which presents w/:--1) *Primarily in young women 20-40 (pt is 26)* → associated w/ *MS*--2) Usually presents w/ *mono-ocular* vision loss → begins centrally then moves peripherally --3) *Pain w/ eye mvmt*--4) Washed out colors Key exam findings -1) Afferent pupillary defect → *(paradoxical pupillary dilation on affected eye)*-2) Fundoscopy → *central scotoma/unremarkableRetinal detachment -Presentation includes:--1) Floaters or bright flashes of light --2) Dense shadow that starts peripherally & moves centrally -------(pts vision abnormalities began centrally) --3) Pt would describe vision loss as a "curtain/veil" -------(pt describes it as "smudge" & blurry vision)--4) Funduscopic exam → floaters would be seen ----(pt has an UNREMARKABLE exam)
A 26F, presents d/t blurry vision in her left eye. She first noticed a "smudge" in the center of her left vision 2 days ago. The pt has been using the computer more than normal to study for an exam & thought that this might be the cause. She ceased using the computer, but the smudge gradually enlarged to involve most of the entire left visual field. She also reports that colors appear "washed out." The pt has mild left ocular discomfort w/ eye mvmt. She has no sig PMHx. Temp 98F, BP 124/82, pulse 78/min. Visual acuity is 20/200 in the left eye & 20/20 in the right. When light is moved from the right eye to the left, the left pupil dilates. Muscle strength, deep tendon reflexes, & sensation are normal. Fundoscopic exam is unremarkable. Which of the following is the most likely Dx?(Optic neuritis ORRetinal detachment)
Cool, moist compress-Pt most likely has VIRAL conjunctivitis → which presents w/:--1) Conjunctival inflammation & watery discharge in the setting to URTI---Mild symptoms (low fever, mild sore throat, rhinorrhea) --2) Mild injection & granular appearance + gritty sensationErythromycin ointment -Would be used in cases of bacterial conjunctivitis-However, pt would have a grossly purulent eye discharge (more severe onset & symptoms)Olopatadine eyedrops - Antihistamine → Would be Used for TMT of allergic rhinitis- Allergic rhinitis presents w/ itchy red eyes & no discharge
A 28F, complains of gritty sensation & discharge from the right eye for 3-days. She also has rhinorrhea, mild sore throat, & low-grade fever of 100.3F. The symptoms began a week after classes started in the fall. PMHx is sig for genital herpes & endometriosis. Eye exam shows mild injection & granular appearance of the tarsal conjunctiva of the right eye w/profuse watery discharge. Nasal mucosa is normal, & the pharynx has mild erythema w/out exudates. Which of the following is the most appropriate next step in MGMT?(Cool, moist compressORErythromycin ophthalmic ointmentOROlopatadine eyedrops)
Age-related exocrine gland atrophy-Pt presents w/ age-related sicca syndrome → characterized by:-1) Presents in older women-2) Presents w/Dry, gritty sensation in eyes & mouth----(Sensation of dust/sand in eyes ± decreased visual acuity)----(presence of dental caries indicates dry mouth)-3) Etiology ---(decreased blink rates, oxidative damage, excessive evaporation of tears (d/t meibomian dysfunction) ---use of anticholinergics also contribute to eye dryness)Autoimmune destruction of exocrine glands-Usually presents in middle aged females---(pt is 73) -Majority of pts have a positive anti-nuclear antibody assay--(pts has negative assay)
A 73F, presents d/t dry eyes. For the last year, she has had mild burning discomfort associated w/ a sensation of dust or sand in the eyes. Recently, the pt has had difficulty reading small-print books d/t decreed visual acuity. She uses OTC eye drops to relieve the discomfort. PMHx is sig for hypothyroid & OA of the knees. which are treated w/ levothyroxine & acetaminophen. She drinks a glass of wine nightly & does not smoke. Vitals are normal. On exam, the pupils are symmetrically round & reactive to light. The conjunctivae are normal bilaterally, & funduscopic exam is normal. Oropharyngeal exam shows dry mucosa w/mild dental caries. Neuro exam is unremarkable. Serum chem panel, CBC, & TSH are normal. Serum anti-nuclear antibody assay is neg. Which of the following is the most likely cause of this pts symptoms?(Age-related exocrine gland atrophy ORAutoimmune destruction of exocrine glands)
Blepharitis -Characterized by inflammation of the eyelid margin- usually most prominent at the opening of the meibomian glands -Burning/itching of the eyelids (diffuse, bilateral)-Discharge (leading to crusting/gritty sensation of eyelids in the morning) -Foreign body sensation in eye -Associated w/:--1) Seborrheic dermatitis --2) Rosacea--3) Allergies --4) Bacterial infection (staph)--5) Viral infections (HSV)--6) Demodex (mite infection)TMT-Supportive (wash compresses, gentle scrub, eyelid massage) Hordeolum -This is a stye- Presents w/ acute FOCAL inflammation of the eyelash follicle or tear gland - Presents as tender, erythematous nodule in the lid marginTMT-Supportive → Warm compress
Compare/contrast the presentation of the eye conditions blepharitis Vs hordeolum?
Emergency surgical decompression - Pt presents w/orbital compartment syndrome - Presentation includes:-1)RF---a) Trauma ---b) Coagulopathy ---c) Infection ---d) Surgery -2) Presentation ---a) Acute eye pain ---b) Diplopia; vision loss -3) Exam findings---a) Rock hard eye → (d/t periorbital swelling, ecchymosis & tightness) ---b)Proptosis ---c) Diffuse subjunctive hemorrhage ---d) Limited ROM of eye mvmts ---e) Afferent pupillary defect MGMT-1) Emergency surgical decompression → (symptoms arise d/t swelling in a confined space, which uses rapidly increased intra-orbital pressure leading to nerve & globe ischemia Dilated funduscopic exam -1) Can be used AFTER surgical decompression to assess the extent of damage
A 16 year old boy is brought to the ED d/t an eye injury. About an hour ago, he was playing paintball & was shot in the face by an opponent. The pt was not wearing eye protection. He felt immediate pain & had difficulty seeing. He has no chronic conditions. Temp is 99.5. Exam shows periorbital edema & ecchymosis w/ proptosis of the left eye. Palpation over the left eye-lid reveals rock-hard induration. Visual acuity is 20/100 in the left eye & 20/20 in the right eye. There is a relative afferent pupillary defect in the left eye. Which of the following is the best next step?(Dilated funduscopic examOREmergency surgical decompression)
Retinal detachment - Pt presents w/ nearsightedness ("Myopia" → caused by increased anterior/posterior diameter of the eye)-A) Complications include:---1) Retinal detachment ---2) Macular degeneration -B) MGMT includes---1) Antimuscarinic drops (atropine) ---2) Orthokeratology (rigid contact lens)-----(both used to slow myopia progression)Pterygium development - A wedge-shaped proliferation of conjunctival tissue that expands from the lateral aspect of the eye toward the cornea. - Usually associated w/ chronic UV light exposure
A 16F, is brought to clinic for vision follow up. The pt has myopia that was Dx'd at age 8. She wears corrective lenses and her prescription has progressed yearly. She has no other chronic med conditions. Vitals are normal. Exam shows equal pupillary reflexes; visual acuity is 20/50 bilaterally, with current lenses. Refraction testing results in a lens prescription that is -9 diopters sphere in the right eye & -8.75 diopter spheres in the left eye. The pt is at increased risk for which condition?(Retinal detachmentORPterygium development)
Open-angle glaucoma-A) Presentation includes:----1) Decreased visual acuity & difficulty reading------(pt is said to "Having to change reading glasses often")----2) Progressive vision loss in otherwise ASYMPTOMATIC pt --B) Funduscopy findings ----1) increased optic disc pressure → causing pallor -------(pts is 0.7 & 0.9 → N = 0.1-0.4)Age-related macular degeneration - MOST common cause of vision loss in ages >65 - However, the presentation is different, including:---a) Progressive loss of vision → Initially centrally, then spreading peripherally ---b) scotomas ---c) Blurred vision---d) Distortion of straight lines ------[pt has NONE of these symptoms]---B) Funduscopic finddings include:------1) Drusen → (small discreet, yellow-white spots in macula ------2) NORMAL Cup-to-disc pressure
A 64-year-old woman comes to the physician for a follow-up examination. She has had difficulty reading for the past 6 months. She tried using multiple over-the-counter glasses with different strengths, but they have not helped. She has hypertension and type 2 diabetes mellitus. Current medications include insulin and enalapril. Her temperature is 37.1°C (98.8°F), pulse is 80/min, and blood pressure is 126/84 mm Hg. The pupils are round and react sluggishly to light. Visual acuity in the left eye is 6/60 and in the right eye counting fingers at 6 feet. Fundoscopy shows pallor of the optic disc bilaterally. The cup-to-disk ratio is 0.7 in the left eye and 0.9 in the right eye (N = 0.3).Which of the following is the most likely diagnosis?(Open angle glaucoma ORAge-Related macular degeneration)
Epinephrine- Pt presents w/ closed angle glaucoma → -A) presentation includes:----1) Unilateral, red, Hard, severely painful eye on palpation----2) mid-dilated non-reactive pupil----3) Frontal headaches +/- vomiting & nausea-B) MGMT----1) First line → pilocarpine, timolol, apraclonidine----2) acetazolamide, mannitol---CONTRAINDICATED------ Epinephrine (can lead to increased pressure)
A 50-year-old man comes to the emergency department because of a severely painful right eye. The pain started an hour ago and is accompanied by frontal headache and nausea. The patient has vomited twice since the onset of the pain. He has type 2 diabetes mellitus. He immigrated to the US from China 10 years ago. He works as an engineer at a local company and has been under a great deal of stress lately. His only medication is metformin. Vital signs are within normal limits. The right eye is red and is hard on palpation. The right pupil is mid-dilated and nonreactive to light. The left pupil is round and reactive to light and accommodation.Which of the following agents is contraindicated in this patient?(Pilocarpine OREpinephrine)
CRAO- Key Funduscopic findings of CRAO include:--a) Retinal pallor → (pale, white retina)--b) Cherry-red spot in fovea--c) Narrow retinal vessels w/ a cattle-truck (segmented) appearance--d) Normal appearing optic disc --e) Soft & hard exudates in the superior & nasal retinal quadrants regionCRVO-Key Funduscopy findings:---1) Hemorrhages → would be seen as "red" color in RETINA------[pt has "pale, white retina"]---2) Cotton wool spots ---3) Dilated retinal blood vessels ---4) Edema -B) Presentation includes:----1) Graying of vision ----2) Painless vision loss----3) Blurring of vision Anterior ischemic optic neuropathy- Also presents w/ painless vision loss- Key funduscopic findings are:----1) Hyperemic/edematous optic disc +/- splinter hemorrhages in optic disc------[pt has NORMAL optic disc]----2) NO retinal & NO macular changes-------[pts has "pale, white retina" & a bright red area in macula]
A 62-year-old woman is brought to the emergency department because of sudden loss of vision in her right eye that occurred 50 minutes ago. She does not have eye pain. She had several episodes of loss of vision in the past, but her vision improved following treatment with glucocorticoids. She has coronary artery disease, hypertension, type 2 diabetes mellitus, and multiple sclerosis. She underwent a left carotid endarterectomy 3 years ago. She had a myocardial infarction 5 years ago. Current medications include aspirin, metoprolol, lisinopril, atorvastatin, metformin, glipizide, and weekly intramuscular beta-interferon injections. Her temperature is 36.8°C (98.2°F), pulse is 80/min, and blood pressure is 155/88 mm Hg. Examination shows 20/50 vision in the left eye and no perception of light in the right eye. The direct pupillary reflex is brisk in the left eye and absent in the right eye. The indirect pupillary reflex is brisk in the right eye but absent in the left eye. Intraocular pressure is 18 mm Hg in the right eye and 16 mm Hg in the left eye. A white, 1-mm ring is seen around the circumference of the cornea in both eyes. Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula. The optic disc appears normal. Fundoscopic examination of the left eye shows a few soft and hard exudates in the superior and nasal retinal quadrants.The optic disc and macula appear normal. Which of the following is the most likely diagnosis?(Anterior ischemic optic neuropathy ORCVAOORCRAO
Vitreous hemorrhage-A) Presentation → Can present TWO ways:---1) Painless Obscuration w/ floaters or haze---2) Painless loss of vision-B) Etiology---1) Associated w/ DM-C) Funduscopic findings---1) Obscured & difficult to visualize---2) No red reflex (d/t opacification of blood in vitreous)Retinal detachment- Also presents w/ painless loss of vision & floaters & is associated w/ DM → the key to making a differentiation is in the Funduscopic findings -A) Funduscopic findings ---1) SOMETIMES presents w/ absent red reflex---2) KEY → pale area of detached retina w/ either subtle or marked elevation-----[no changes on retina are observed in this pt]Cataracts- Also causes painless vision loss & is associated w/ DM-A) Funduscopic findings:---1) Can present w/ absent red reflex---2) Obscuration & difficult to visualize fundus-B) Presentation →KEY DIFFERENTIATING FACTOR----1) Cataracts is NOT ACUTE-----------(pt presents in one night)
A 63-year-old woman comes to the emergency department because of a 1-day history of progressive blurring and darkening of her vision in the right eye. Upon waking up in the morning, she suddenly started seeing multiple dark streaks. She has migraines and type 2 diabetes mellitus diagnosed at her last health maintenance examination 20 years ago. She has smoked one pack of cigarettes daily for 40 years. Her only medication is sumatriptan. Her vitals are within normal limits. Ophthalmologic examination shows visual acuity of 20/40 in the left eye and 20/100 in the right eye. The fundus is obscured and difficult to visualize on funduscopic examination of the right eye. The red reflex is diminished on the right.Which of the following is the most likely diagnosis?Retinal detachment ORCataracts ORVitreous hemorrhage
Ketotifen drops- Pt presents w/ seasonal allergies-A) MGMT includes an antihistamine-----1) First line → Ketotifen (antihistamine)-----2) Second line → Low dose corticosteroids (Fluorometholone)Fluorometholone - Pt presents w/ allergy-like symptoms - Allergies will almost never be treated w/ a steroid as first-line (-olone is a steroid derivative)
A 35-year-old man comes to the physician because of itchy, watery eyes for the past week. He has also been sneezing multiple times a day during this period. He had a similar episode 1 year ago around springtime. He has iron deficiency anemia and ankylosing spondylitis. Current medications include ferrous sulfate, artificial tear drops, and indomethacin. He works as an elementary school teacher. His vital signs are within normal limits. Visual acuity is 20/20 without correction. Physical examination shows bilateral conjunctival injection with watery discharge. The pupils are 3 mm, equal, and reactive to light. Examination of the anterior chamber of the eye is unremarkable.Which of the following is the most appropriate treatment?(Fluorometholone drops ORKetotifen drops)
Perform Gonioscopy- Pt presents w/ acute angle closure glaucoma - A) MGMT includes:-----a) Diagnostic testing:-----------1) Gonioscopy → (allows for direct visualization of anterior chamber of eye)-----b) TMT----------1) Acute symptoms relief → Any glaucoma meds (timolol, pilocarpine,acetazolamide)-----------2) Definitive TMT → peripheral IridectomyAtropine - This is CI in acute angle closure glaucoma
A 57-year-old woman comes to the emergency department because of severe pain around her right eye, blurred vision in the same eye, and a headache for the past 4 hours. She is nauseous but has not vomited. She can see colored bright circles when she looks at a light source. She is currently being treated for a urinary tract infection with trimethoprim-sulfamethoxazole. She appears uncomfortable. Vital signs are within normal limits. Examination shows visual acuity of 20/20 in the left eye and counting fingers at 5 feet in the right eye. The right eye shows conjunctival injection and edemaof the cornea. The right pupil is dilated and fixed. Intravenous analgesia and antiemetics are administered.Which of the following is the most appropriate next step in management?(Atropine ORPerform gonioscopy)
Supportive- Pt presents w/ non-complicated keratoconjunctivitis --a) TMT is based on severity of symptoms----Non-complicated = SupportiveTopical moxifloxacin- Used to Treat COMPLICATED epidemic keratoconjunctivitis, presents w/:--1) Erythematous conjunctiva------[pt not described to have "erythematous" conjunctiva]2) Purulent discharge------[pt does not have]3) Upper lid papillae (on slit lamp)------[pt's slit lamp findings are: follicular reaction & diffuse, fine epithelial keratitis]4) Fever & lymphadenopathy
A 6-year-old girl is brought to the physician because of a 4-day history of irritation and redness in both eyes. Her symptoms initially started in the left eye and progressed to involve both eyes within 24 hours. She presents with profuse tearing and reports that her eyes are sticky and difficult to open in the morning. She was diagnosed with asthma 2 years ago and has been admitted to the hospital for acute exacerbations 3 times since then. Current medications include inhaled beclomethasone, inhaled albuterol, and montelukast. Her temperature is 38.2 °C (100.8°F). Physical examination reveals a tender left preauricular lymph node. There is chemosis and diffuse erythema of the bulbar conjunctiva bilaterally. Slit lamp examination reveals a follicular reaction in both palpebral conjunctivae and diffuse, fine epithelial keratitis of both corneas. Corneal sensation is normal.Which of the following is the most appropriate next step in management?(Supportive ORTopical moxifloxacin)
Topical Ofloxacin- Pt presents w/ severe bacterial keratitis-A) Presentation includes:---1) Unilateral eye pain → (can be progressive) ---2) Impaired vision ---3) Discharge → (excess tearing)-B) Associated RFs---1) Contact lenses-C) Funduscopy findings:---1) Round, corneal infiltrate → (conjunctival injection & edematous cornea w/ whitish exudate in anterior chamber)---2) Hypopyon → (round corneal infiltrate on Fluorescein stain)-D) MGMT---1) (First-line) → Ofloxacin (broad spectrum antibiotics)Topical pilocarpine & timolol- Used in Acute-angle closure glaucoma- Also presents w/ sudden-onset, unilateral eye pain, ocular inflammation, & blurry vision- However, the presentation of acute-angle closure glaucoma typically presents w/: ----1) Frontal headaches +/- nausea & vomiting-------[pt does not have these symptoms]----2) Rock Hard pupil → (on palpation)-B) Funduscopy findings ----1) Mid-dilated, non-reactive pupil
A 51-year-old man comes to the physician because of a 1-day history of progressive pain, excessive tearing, and blurry vision of his right eye. He first noticed his symptoms last evening while he was watching a movie at a theater. His left eye is asymptomatic. He wears contact lenses. He has atopic dermatitis treated with topical hydrocortisone. His temperature is 37°C (98.6°F), pulse is 85/min, and blood pressure is 135/75 mm Hg. Examination shows a visual acuity in the left eye of 20/25 and 20/40 in the right eye. The right eye shows conjunctival injection and an edematous cornea with a whitish exudate at the bottom of the anterior chamber. Fluorescein staining shows a round corneal infiltrate.Which of the following is the most appropriate pharmacotherapy?(Topical pilocarpine & timolol ORTopical Ofloxacin)
Topical erythromycin- Pt most likely has BACTERIAL conjunctivitis-A) MGMT includes:---1) First line → TOPICAL ErythromycinOral erythromycin- Used to treat Chlamydial (VIRAL) conjunctivitis-A) Presentation includes:---1) Follicular conjunctivitis w/ follicles & a cobblestone appearance of palpebral conjunctiva------[pt has edema of both eyelids, bilateral conjunctival injection, & a thin purulent discharge)---2) Cornea findings → (Pannus) corneal haziness w/ neovascularization-------[pt has a normal cornea]---3) Usually coincides w/ STD infection (chlamydia)-------[pt has no signs of STD infection]---4) Persists for weeks/months w/ no/partial response to topical antibiotic therapy-B) MGMT1) ORAL erythromycin2) Doxy/AZ
A 26-year-old woman comes to the physician because of a 3-day history of redness, foreign body sensation, and discharge of both eyes. She reports that her eyes feel "stuck together" with yellow crusts every morning. She has a 3-year history of nasal allergies; her sister has allergic rhinitis. She is sexually active with 2 male partners and uses an oral contraceptive; they do not use condoms. Vital signs are within normal limits. Visual acuity is 20/20 in both eyes. Ophthalmic examination shows edema of both eyelids, bilateral conjunctival injection, and a thin purulent discharge. Examination of the cornea, anterior chamber, and fundus is unremarkable. The remainder of the examination shows no abnormalities.Which of the following is the most appropriate pharmacotherapy?(Topical erythromycin OROral erythromycin)
CT scan of chest- Pt most likely presents w/ Horners syndrome most likely d/t a pancoast tumor-A) Presentation incldues:---1) Key symptom → Chronic Unilateral upper arm & shoulder pain-B) Associated RF ----1) heavy smoker → leading to (HTN, CAD)-C) Eye manifestations---1) Ptosis (Drooping eyelid)---2) Aniscoria (unequal pupil size)---3) KEY → application of apraclonidine leads to- Mydriasis of affect pupil (reversal aniscoria)-D) other symptoms:---1) Anhydrosis----(pt does not have)-E) MGMT---1) CT scan of chest → (associated w/ lung cancer)Applanation Tonometry- Used if Glaucoma is suspected- Presentation of glaucoma DOES NOT INCLUDE arm pain, ptosis, and aniscoria
A 68-year-old man comes to the physician for a routine health maintenance examination. His wife has noticed that his left eye looks smaller than his right eye. He has had left shoulder and arm pain for 3 months. He has hypertension and coronary artery disease. Current medications include enalapril, metoprolol, aspirin, and atorvastatin. His medical history is significant for gonorrhea, for which he was treated in his 30's. He has smoked two packs of cigarettes daily for 35 years. He does not drink alcohol. His temperature is 37°C (98.6°F), pulse is 71/min, and blood pressure is 126/84 mm Hg. The pupils are unequal; when measured in dim light, the left pupil is 3 mm and the right pupil is 5 mm. There is drooping of the left eyelid. The remainder of the examination shows no abnormalities. Application of apraclonidine drops in both eyes results in a left pupil size of 5 mm and a right pupil size of 4 mm.Which of the following is the most appropriate next step in management?(Applanation tonometry ORCT scan of chest)
Oral erythromycin- Pt presents w/ Neonatal Conjunctivitis → TMT is dependent on what the causeof it is:1) Chemical2) Gonococcal (Neisseria)3) Chlamydial**HINT IN QUESTION → PCR is used to detect viruses → The pt has a POSITIVE PCR so we know it is VIRAL → ORAL erythromycin is used to treat VIRAL conjunctivitis -----(In contrast, TOPICAL erythromycin is used to treat BACTERIAL) Chemical1) Onset:< 24 hours after birth2) Symptoms:- Mild conjunctival irritation & tearing after silver nitrate prophylaxis3) TMT:- Eye lubricantGonococcal (Neisseria)1) Onset:2-5 days2) Symptoms- Marked eye swelling- Profuse purulent discharge- Corneal edema/ulceration3) TMT- Single IM dose of 3rd gen cephalosporinChlamydial1) Onset- 5-14 days2) Symptoms- Mild eyelid swelling- Watery, serosanguineous/mucopurulent discharge3) TMT- PO macrolide
A 2-week-old female newborn is brought to the physician for the evaluation of red eyes with discharge for 2 days. She was born at 39 weeks' gestation to a 22-year-old woman. Pregnancy and delivery were uncomplicated. The mother received irregular prenatal care during the second half of the pregnancy. The newborn weighed 3700 g (8 lb 2.5 oz) at birth, and no congenital anomalies were noted. She currently weighs 4000 g (8 lb 13 oz). Examination of the newborn shows pink skin. The lungs are clear to auscultation. There is mucopurulent discharge in both eyes and mild eyelid swelling.Polymerase chain reaction assay of conjunctival scraping confirms the diagnosis.Which of the following is the most appropriate next step in management?(Topical erythromycin OROral erythromycin)
Herpes simplex keratitis- Both present similarly- KEY DIFFERENCE → (SLIT LAMP FINDINGS)---1) Dendritic ulcer → (ulcer that looks like a tree branch on superior portion of eye)Pseudomonas keratitis- Common in pts that where contact lenses & immunosuppressed- Presents similarly to Herpes simplex keratitis w/ ocular pain, photophobia, epiphora (watering of eyes), & decreased visual acuity- KEY DIFFERENCE (SLIT LAMP FINDINGS)----1) central, white corneal ulcer often accompanied by hypopyon → (sedimentation of leukocytes at bottom of anterior chamber)-----[pt has tree-like branching ulcer]
A 36-year-old woman with HIV comes to the physician because of a 3-day history of pain and watery discharge in her left eye. She also has blurry vision and noticed that she is more sensitive to light. Her right eye is asymptomatic. She had an episode of shingles 7 years ago. She was diagnosed with HIV 5 years ago. She admits that she takes her medication inconsistently. She wears contact lenses. Current medications include abacavir, lamivudine, efavirenz, and a nutritional supplement. Her temperature is 37°C (98.6°F), pulse is 89/min, and blood pressure is 110/70 mm Hg. Examination shows conjunctival injection of the left eye. Visual acuity is 20/20 in the right eye and 20/80 in the left eye. Extraocular movements are normal. Her CD4+ T-lymphocyte count is 90/mm3. A photograph of the left eye after fluorescein administration is shown.Which of the following is the most likely Dx?(Pseudomonas keratitis ORHerpes simplex keratitis)
Age related macular degeneration-A) Symptoms ---1) Gradual blurring vision-B) Ampler grid findings:---1) Wavy & bent lines when looking at center of grid---2) Blurring of central vision--Both indicate metamorphosia-C) Funduscopy findings:---1) Multiple areas of discoloration seen at macula---2) Upper temporal vascular arch (bubble) -------(Vascular arch → Confirms the Dx of age related macular degeneration)Diabetic retinipoathy- Can present w/ Hard yellow-pale exudates, blurring vision, central metamorphosia- However, pt would have other Funduscopic findings including:1) Cotton-wool spots (retina)2) Microaneurysms (retina)3) Dot-and-blot hemorrhages (retina)----[pt does not have these on retinopathy]Hypertensive retinopathy- Can present w/ Hard/soft yellow-pale exudates, blurring vision, central metamorphosia- Other key Funduscopic findings include:1) Flame-shaped hemorrhages2) Focal attenuation of arterioles3) AV nicking------[pt has none of these]
A 62-year-old woman comes to the physician because of increasing blurring of vision in both eyes. She says that the blurring has made it difficult to read, although she has noticed that she can read a little better if she holds the book below or above eye level. She also requires a bright light to look at objects. She reports that her symptoms began 8 years ago and have gradually gotten worse over time. She has hypertension and type 2 diabetes mellitus. Current medications include glyburide and lisinopril. When looking at an Amsler grid, she says that the lines in the center appear wavy and bent. An image of her retina, as viewed through funduscopy is shown.Which of the following is the most likely diagnosis?(Hypertensive retinopathy ORDiabetic retinopathy ORAge related macular degeneration)
Ranibizumab- Pt presents w/ age -related macular degeneration → Presentation includes:-A) Signs & symptoms ---1) Progressive vision loss, initially centrally, than spreading peripherally --------Pt has "Acute ON chronic vision loss" → (pt has sudden vision loss but has noticed bilateral loss of central vision over the last year) ---2)Scotomas ---3) Blurred vision---4) Distortion of straight lines -B) Associated RFs---1) Age > 50 ---2) Smoking---3) CVD ---4) FMHx---5) Aspirin use -C) Diagnostic tests & results:---1) Tonometry → Increased pressure -------Leaking of serous fluid & blood behind retina ---2) Slit-lamp → ------a) Sub-retinal fluid ------b) Small hemorrhages w/ grayish -green discoloration in the macula ------c) Drusen w/ retinal pigment changes -D) TMT---1) Intra-ocular VEGF inhibitors → (Ranibizumab/bevacizumab) ---2) Photocoagulation --------2nd-line TMT---3) Vitamin cocktails → (β-carotene)
A 70 year-old man comes to the emergency department for sudden loss of vision in the right eye over the last 24 hours. He has noticed progressive bilateral loss of central vision over the last year. He has had difficulty reading his newspaper and watching his television. He has smoked 1 pack daily for 50 years. Ophthalmologic examination shows visual acuity of 20/60 in the left eye and 20/200 in the right eye. The pupils are equal and reactive to light. Tonometry reveals an intraocular pressure of 18 mm Hg in the right eye and 20 mm Hg in the left eye. Anterior segment examination is unremarkable. Slit-lamp examination shows subretinal fluid and small hemorrhage with grayish-green discoloration in the macular area in the right eye, and multiple drusen in the left eye with retinal pigment epithelial changes. Which of the following is the most appropriate initial treatment for the patient's illness?(Thermal laser photocoagulationORRanibizumab)
Oral Amox-clauvulanate- Pt presents w/ acute dacrocystitis -A) Signs/Symptoms include:---1) Pain, erythema, swelling below the medial canthus of the eye ---2) Purulent drainage from lacrimal punctum -B) Etiology ---1) Most caused by Gm(+) bacteria → (Staph/Strep)-C) TMT---1) Oral antibiotics Nasolacrimal duct probing - CI in acute dacrocystitis to avoid spreading infection
A 44-year-old woman comes to the physician because of pain and swelling below her left eye for 3 days. She has also had excessive watering from her eyes during this period. She has no history of serious illness and takes no medications. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye. There is purulent discharge from the lower lacrimal punctum on palpation of the swelling. The remainder of the examination shows no abnormalities. The discharge is sent for cultures. Which of the following is the most appropriate next step in management?(Nasolacrimal duct probingOROral Amox-clauvulanate)
Retinitis Pigmentosa- Presentation includes:-A) Etiology ---1) Most pts become symptomatic in EARLY adulthood -B) Signs & symptoms ---1) Progressive visual field loss → (mid periphery) ---2) Night blindness---3) Decreased visual acuity → (late findings) -C) Funduscopic findings ---1) Retinal vessel attenuation ---2) Optic disc pallor---3) Abnormal retinal pigmentation → (focal areas of discoloration bilaterally) Vit. A deficiency - Can cause xerophthalmia → characterized by excessive dryness of the cornea & conjunctiva & night blindness - However, the pt has NORMAL APPEARING CORNEA & CONJUNCTIVA- Also, the pt is vegetarian and much of Vit A from diet comes from veggies
A 17F, presents d/t vision changes. Over the past 2 months, the pt has had difficulty seeing at night while driving. Last week, she was almost involved in a MVC b/c she did not see a car approaching at an intersection. The pt is strict vegan & eats a variety of plant products. She takes no daily meds. Temp is 98.8F. Visual acuity is 20/20 bilaterally. Bilateral lashes, conjunctivae, & cornea appear unremarkable. Pupils are equal & reactive, & extra-ocular muscles are intact. The pt has a visual field defect in the mid periphery in both eyes. Red reflex is equal bilaterally. Funduscopic exam reveals optic disc pallor & attenuation of retinal vessels w/ focal areas of discoloration bilaterally. Which of the following is the most likely cause of this pts presentation?(Retinitis pigmentosaORVit A deficiency)
Optic nerve injury - Presentation includes:-A) Etiology ---1) Indirect → shearing forces from facial trauma---2) Direct → penetrating eye trauma -B) Signs/symptoms ---1) Acute vision loss---2) Decreased color vision---3) Afferent pupillary defect -C) Diagnostic test ---1) CT scan of orbit -D) TMT---1) Urgent ophthalmology referral ---2) ± Surgical decompression Lens dislocation - Can also present w/ acute vision loss after trauma - However, :---a) It is commonly associated w/ iris tremulousness ---b) DOES NOT CAUSE relative afferent pupillary defect
A 9B, presents to the ED following a bicycling accident. The pt was riding downhill when he hit a rock & lost control. He was thrown off his bike & hit his handlebars before tumbling onto the pavement. The pt was not wearing a helmet but did not lose consciousness. BP is 118/80, & pulse is 140/min. Exam shows ecchymosis over the right superior orbit w/ underlying tenderness & a few scalp abrasions. Visual acuity is 20/20 in the left eye. Using the Right eye, the pt is unable to read the largest letter on the visual acuity chart & is only able to perceive light. There is a relative afferent pupillary defect in the right eye. Extra-ocular mvmts are normal, & the red reflex is symmetric bilaterally. Fluorescein dye testing is unremarkable. Which of the following is the most likely Dx?(Optic nerve injury ORLens dislocation)
Entrapment of inferior rectus - Inferior rectus is located below the eye and is responsible for pulling the eyeball DOWNWARDEntrapment of superior rectus- Superior rectus is located above the eye & is responsible for pulling the eye UPWARD
A 21-year-old man comes to the emergency department complaining of double vision. Two nights ago he was involved in a bar fight and was struck in the head several times. He did not lose consciousness. Since the fight he has been very tender over his right cheek. He has experienced double vision, particularly when looking downward. He denies any change in acuity or floaters in visual fields. He is otherwise healthy. He has no previous history of ocular problems. On examination he has a large ecchymosis over his right cheek. Sclerae are white. There is no blood in the anterior chamber. Fundoscopy is normal. While testing eye movements, it is noticed that his right eye is unable to track downwards. Extraocular movements are intact in his left eye.Which of the following explains these findings?(Entrapment of inferior rectus VSEntrapment of superior rectus)
Loss of red reflex - Pt presents w/ signs & RFs concerning for cataracts -A) RF-----1) Age (>60)-----2) Chronic sunlight exposure -----3) DM → HIGH RISK-----4) Glucocorticoids use-----5) Smoking -----6) HIV -B) Signs/Symptoms-----1) Gradual loss of visual acuity -----2) Excessive glare w/ halos around bright lights -----3) Myopic shift --------(presbyopia → difficulty in close vision) -----4) Muted color vision-C) PE findings -----1) Loss of red reflex -----2) Opacification of lens -----3) Decrease acuity in BOTH central & peripheral vision Drusen deposits in macula - Seen in age-related macula degeneration- Also presents w/ decreased visual acuity & increased difficulty reading in the day & night in pts >60- However, key differences include:---1) SPREAD OF VISION LOSS → macular degeneration presents w/ CENTRAL-to-PERIPHERAL spread of vision loss -------[pt has gradual loss of BOTH central & peripheral vision]---2) OTHER KEY SYMPTOMS ------1) Scotomas ------2) Distortion of straight lines & Blurred visionIncreased cup:disc ratio- Seen in glaucoma - Also presents w/ vision loss in pts >65- However, key differences include:---1) DOES NOT present w/ glare, halos, or difficulty w/ night driving ---2) AREA OF VISION LOSS → typically presents w/ loss of PERIPHERAL vision -------[pt has gradual loss of BOTH central & peripheral vision]
A 67F, presents d/t difficulty driving at night for the past several months. She sees halos around streetlights & excessive glare from the headlights of oncoming cars. The pt also has difficulty driving in bright sunlight. Interior daytime vision is fine, & she has needed her reading glasses less often, but reading at night has been worse. PMHx is notable for HTN & DM II. She has a 20-p/y smoking Hx but quit 10-years ago. Which of the following exam findings is most associated w/ the cause of this pts symptoms?(Loss of red reflex VSIncreased cup:disc ratioVSDrusen deposits in macula)
Retinal embolism - Pt most likely presents w/ Amaurosis fugax -A) Etiology -----1) Retinal ischemia d/t atherosclerotic emboli → MOST COMMONVascular spasm- Describes the pathophys of a MIGRAINE
A 67F, presents to the ED d/t an episode of vision loss in the right eye. The pt was at a movie theater when her right eye vision suddenly became "dim" for approximately 10-mins. Her vision has now recovered but she remains very concerned about the episode. The pt has never hd similar symptoms in the past but does report occasional headaches. She has had no focal weakness or numbness. PMHx is sig for CAD, HTN, & DM II. BP is 130/85, & pulse is 65/min & regular. There is a right-sided carotid bruit. Neuro & funduscopic exams are unremarkable. Which of the following is the most likely cause of this pts symptoms?(Retinal embolism VSVascular spasm)
Laser photocoagulation - Pt has Signs & RFs suspicious for proliferative diabetic retinopathy -A) Funduscopic signs ----1) Neovascularization of the optic disc & retinal vessels ----2) Decreased visual acuity -B) RF----1) Long Hx of diabetes -C) Signs/Symptoms ----1) Chronic Blurring of vision -------a) Can be both eyes -D) MGMT - BASED ON PROLIFERATIVE VS NON-PROLIFERATIVE DX ----a) Dx tests -------1) Fluorescein angiography ----------a) PROLIFERATIVE findings --------------1) Vitreous hemorrhages --------------2) Neovascularization --------------3) Retinal detachment -----b) TMT----------1) Pan-retinal laser photocoagulation ----------2) VEGF inhibitors --------------a) Ranibizumab, Pegaptanib------------------aa) Adjunct to photocoagulation ----------b) NON-proliferative findings --------------1) Dot & Blot hemorrhages --------------2) Hard exudates --------------3) Micro-infarcts ("cotton-wool" spots) --------------4) Microaneurysms -----b) TMT----------1) Tight glycemic & BP control----------2) Laser photocoagulation
A 55-year-old woman comes to the physician because of increased blurring of vision in both eyes for the past 4 months. She has tried using over-the-counter reading glasses, but they have not helped. She has a history of hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Current medications include lisinopril, insulin, metformin, and a fluticasone-vilanterol inhaler. Vital signs are within normal limits. Examination shows visual acuity of 20/70 in each eye. A photograph of the fundoscopic examination of the right eye is shown. Which of the following is the most appropriate next step in management?(Laser photocoagulation VSVEGF inhibitors)