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Introduction to Clinical Medicine Ophthalmology Review.

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1 Introduction to Clinical Medicine Ophthalmology Review

2 Acknowledgments Chapter 1 – Dina Abdulmannan, R5 Chapter 1 – Dina Abdulmannan, R5 Chapter 2 – Mohammed Al-Abri, R4 Chapter 2 – Mohammed Al-Abri, R4 Chapter 3 – Ahmed Al-Hinai, R5 Chapter 3 – Ahmed Al-Hinai, R5 Chapter 4 – Chantal Ares, R4 Chapter 4 – Chantal Ares, R4 Chapter 5 – Ashjan Bamahfouz, R5 Chapter 5 – Ashjan Bamahfouz, R5 Chapter 6 – Serene Jouhargy, R5 Chapter 6 – Serene Jouhargy, R5 Chapter 7 – David Lederer, R5 Chapter 7 – David Lederer, R5 Chapter 8 – Norman Mainville, R4 Chapter 8 – Norman Mainville, R4 Chapter 9 – Abdulla Naqi, R5 Chapter 9 – Abdulla Naqi, R5 Editors – Kashif Baig, R5 Editors – Kashif Baig, R5 Hady Saheb, R2 Hady Saheb, R2

3 Outline Chapter 1 – The Eye Examination Chapter 1 – The Eye Examination Chapter 2 – Acute Visual Loss Chapter 2 – Acute Visual Loss Chapter 3 – Chronic Visual Loss Chapter 3 – Chronic Visual Loss Chapter 4 – Red Eye Chapter 4 – Red Eye Chapter 5 – Ocular and Orbital Injuries Chapter 5 – Ocular and Orbital Injuries Chapter 6 – Amblyopia & Strabismus Chapter 6 – Amblyopia & Strabismus Chapter 7 – Neuro-Ophthalmology Chapter 7 – Neuro-Ophthalmology Chapter 8 – Ocular Manifestations of Systemic Disease Chapter 8 – Ocular Manifestations of Systemic Disease Chapter 9 – Drugs and the Eye Chapter 9 – Drugs and the Eye Source: Basic Ophthalmology for Medical Students and Primary Care (Cynthia Bradford)

4 The Eye Examination Chapter 1

5 Anatomy

6 Anatomy Extraocular movements Extraocular movements Medial Medial Lateral Lateral Upward Upward Downward Downward

7 Visual Acuity General physical examination should include : General physical examination should include : Visual acuity Visual acuity Pupillary reaction Pupillary reaction Extraocular movement Extraocular movement Direct ophthalmoscope Direct ophthalmoscope Dilated exam (in case of visual loss or retinal pathology) Dilated exam (in case of visual loss or retinal pathology) Distance or Near Distance or Near Distance visual acuity at age 3 Distance visual acuity at age 3 early detection of amblyopia early detection of amblyopia

8 Distance Visual Acuity Testing VA - Visual acuity VA - Visual acuity OD - ocular dexter OD - ocular dexter OS - ocular sinister OS - ocular sinister OU - oculus uterque OU - oculus uterque 20/20 20/20 Distance between the patient and the eye chart Distance between the patient and the eye chart_____________________________________________ Distance at which the letter can be read by a person with normal acuity

9 Distance Visual Acuity Testing Place patient at 20 ft from Snellen chart Place patient at 20 ft from Snellen chart OD then OS OD then OS VA is line in which > ½ letters are read VA is line in which > ½ letters are read Pinhole if < 20/40 Pinhole if < 20/40

10 Snellen eye chart Rosenbaum pocket chart

11 Distance Visual Acuity Testing If VA < 20/400 If VA < 20/400 Reduce the distance between the pt and the chart and record the new distance (eg. 5/400) Reduce the distance between the pt and the chart and record the new distance (eg. 5/400) If < 5/400 If < 5/400 CF (include distance) CF (include distance) HM (include distance) HM (include distance) LP LP NLP NLP

12 Near Visual Acuity Testing Indicated when Indicated when Patient complains about near vision Patient complains about near vision Distance testing difficult/impossible Distance testing difficult/impossible Distance specified on each card (35cm) Distance specified on each card (35cm)

13 Pupillary Examination Direct penlight into eye while patient looking at distance Direct penlight into eye while patient looking at distance Direct Direct Constriction of ipsilateral eye Constriction of ipsilateral eye Consensual Consensual Constriction of contralateral eye Constriction of contralateral eye

14 Ocular Motility Rt superior rectus Lt inferior oblique Lt superior rectus Rt inferior oblique Rt lateral rectus Lt medial rectus Lt lateral rectus Rt medial rectus Rt inferior rectus Lt superior oblique Lt inferior rectus Rt superior oblique

15 Direct Ophthalmoscopy Tropicamide or phenylephrine for dilation Tropicamide or phenylephrine for dilation unless shallow anterior chamber unless shallow anterior chamber unless under neurological evaluation unless under neurological evaluation Use own OD to examine OD Use own OD to examine OD Same for OS Same for OS

16 Intraocular Pressure Measurement Range: Range:

17 Anterior chamber depth assessment Likely shallow if Likely shallow if ≥ 2/3 of nasal iris in shadow ≥ 2/3 of nasal iris in shadow

18 Summary of steps in eye exam Visual Acuity Visual Acuity Pupillary examination Pupillary examination Visual fields by confrontation Visual fields by confrontation Extraocular movements Extraocular movements Inspection of Inspection of lid and surrounding tissue lid and surrounding tissue conjunctiva and sclera conjunctiva and sclera cornea and iris cornea and iris Anterior chamber depth Anterior chamber depth Lens clarity Lens clarity Tonometry Tonometry Fundus examination Fundus examination Disc Disc Macula Macula vessels vessels

19 Acute Visual Loss Chapter 2

20 History Age Age POH & PMH POH & PMH Onset Onset Duration Duration Severity of visual loss compared to baseline Severity of visual loss compared to baseline Monocular vs. binocular ? Monocular vs. binocular ? Any associated symptoms Any associated symptoms Ophtho enquiry Ophtho enquiry Visual acuity assessment Visual fields Pupillary reactions Penlight or slit lamp examination Intraocular pressure Ophthalomoscopy - red reflex - assessment of clarity of media - direct inspection of the fundus Examination

21 Media Opacities Corneal edema : Corneal edema : - ground glass appearance - ground glass appearance - R/O AACG - R/O AACG Corneal abrasion Corneal abrasion Hyphema Hyphema - Traumatic, spontaneous Vitreous hemorrhage Vitreous hemorrhage - darkening of red reflex with clear lens, AC and cornea - darkening of red reflex with clear lens, AC and cornea - traumatic - traumatic - retinal neovascularization - retinal neovascularization

22 Retinal Diseases Retinal detachment Retinal detachment - flashes, floaters, shade over vision - flashes, floaters, shade over vision - RAPD (if extensive RD) - RAPD (if extensive RD) - elevated retina +/- folds - elevated retina +/- folds Macular disease Macular disease - decrease central vision - decrease central vision - metamorphopsia - metamorphopsia

23 Central Retinal Artery Occlusion (CRAO) True ophthalmic emergency! True ophthalmic emergency! Sudden painless and often severe visual loss Sudden painless and often severe visual loss Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow Characteristic “ cherry-red spot ” Characteristic “ cherry-red spot ” No optic disc swelling unless there is ophthalmic or carotid artery occlusion No optic disc swelling unless there is ophthalmic or carotid artery occlusion Months later, pale disc due to death of ganglion cells and their axons Months later, pale disc due to death of ganglion cells and their axons

24 Central Retinal Artery Occlusion (CRAO) treatment Ocular massage: Ocular massage: -To dislodge a small embolus in CRA and restore circulation -To dislodge a small embolus in CRA and restore circulation -Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes -Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes Ocular hypotensives, vasodilators, paracentesis of anterior chamber Ocular hypotensives, vasodilators, paracentesis of anterior chamber R/O giant cell arteritis in elderly patient without a visible embolus R/O giant cell arteritis in elderly patient without a visible embolus

25 Branch Retinal Artery Occlusion (BRAO) Sector of the retina is opacified and vision is partially lost Sector of the retina is opacified and vision is partially lost Most often due to Most often due to embolus embolus Treat as CRAO Treat as CRAO

26 Central Retinal Vein Occlusion (CRVO) Subacute loss of vision Subacute loss of vision Disc swelling, venous engorgement, cotton- wool spots and diffuse retinal hemorrhage. Disc swelling, venous engorgement, cotton- wool spots and diffuse retinal hemorrhage. Risk factors: age, HTN, arteriosclerotic vascular disease, conditions that increase blood viscosity (polycythemia vera, sickle cell disease, lymphoma, leukemia) Risk factors: age, HTN, arteriosclerotic vascular disease, conditions that increase blood viscosity (polycythemia vera, sickle cell disease, lymphoma, leukemia) Needs medical evaluation Needs medical evaluation Long term risk for neovascular glaucoma, so periodic ophtho f/u Long term risk for neovascular glaucoma, so periodic ophtho f/u

27 Optic Nerve Disease Non-Arteritic Ischemic Optic Neuropathy (NAION) Non-Arteritic Ischemic Optic Neuropathy (NAION) - vascular disorder - vascular disorder  pale, swollen disc +/- splinter hemorrhage  pale, swollen disc +/- splinter hemorrhage  loss of VA, VF ( often altitudinal )  loss of VA, VF ( often altitudinal ) Arteritic Ischemic Optic Neuropathy (AION) Arteritic Ischemic Optic Neuropathy (AION) - Symptoms of giant cell arteritis - ESR, CRP, Platelets +/_ TABx - Rx : systemic steroids

28 Optic Nerve Disease Optic neuritis Optic neuritis - idiopathic or associated with multiple sclerosis - idiopathic or associated with multiple sclerosis - young adults - young adults - decreased visual acuity and colour vision - decreased visual acuity and colour vision -RAPD -RAPD -pain with ocular movement -pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal disc) -bulbar (disc swelling) or retrobulbar (normal disc) Traumatic optic neuropathy Traumatic optic neuropathy - direct trauma to optic nerve - direct trauma to optic nerve - indirect : shearing force to the vascular supply - indirect : shearing force to the vascular supply

29 Visual Pathway Disorders Hemianopia Hemianopia - Causes: vascular or tumors - Causes: vascular or tumors Cortical Blindness Cortical Blindness - aka central or cerebral - aka central or cerebral - Extensive bilateral damage to cerebral pathways - Extensive bilateral damage to cerebral pathways - Normal pupillary reactions and fundi - Normal pupillary reactions and fundi

30 Chronic Visual Loss Chapter 3

31 Introduction: 1994: 38 million blind people (age >60 yrs) worldwide 1994: 38 million blind people (age >60 yrs) worldwide 1997: in western countries, leading causes of blindness in people over 50 yrs of age 1997: in western countries, leading causes of blindness in people over 50 yrs of age 1) Age-Related Macular Degeneration 2) Cataract 3) Glaucoma 4) Diabetes

32 Glaucoma  Risk factors: Old ageMyopia African-American raceBlood Hypertension Family HistoryDiabetes Mellitus High IOPSmoking  Classification:  open-angle glaucoma vs. angle-closure glaucoma  primary vs. secondary

33 Glaucoma Evaluation: Evaluation: complete history complete history complete eye examination (including IOP, gonioscopy, optic disc) complete eye examination (including IOP, gonioscopy, optic disc) Perimetry Perimetry normalAbnormal

34 Glaucoma  Treatment Options:  Medical:  drops to decrease aqueous secretion or increase aqueous outflow  systemic medications (PO or IV)  Laser:  Iridotomy  Iridoplasty  Trabeculoplasty  Surgical:  Filtration Surgery (e.g. Trabeculectomy)  Tube shunt  Cyclodestructive procedures

35 Cataract  congenital vs. acquired  often age-related  different forms (nuclear, cortical, PSCC)  reversible  very successful surgery

36 Cataract Evaluation: Evaluation: History History Ocular Examination Ocular Examination Others: A-scan, ± B-scan, ± PAM Others: A-scan, ± B-scan, ± PAM Treatment: Treatment: Surgical Surgical IOL implantation IOL implantation

37 Age-Related Macular Degeneration  Types: 1) Dry:- drusen, RPE changes (atrophy, hyperplasia) 2) Wet:- choroidal neovascularization drusen RPE atrophy CNV

38 Age-Related Macular Degeneration Fluorescein Angiography

39 Age-Related Macular Degeneration Treatment: Treatment: micronutrient supply micronutrient supply vit C & E, β-carotene, minerals (cupric oxide, zinc oxide) vit C & E, β-carotene, minerals (cupric oxide, zinc oxide) treat wet ARMD treat wet ARMD lasers lasers intra-vitreal injections of anti-VEGF intra-vitreal injections of anti-VEGF surgery surgery low vision aids low vision aids

40 The Red Eye Chapter 4

41 DDx Red Eye Acute angle closure glaucoma Acute angle closure glaucoma Iritis or iridocyclitis Iritis or iridocyclitis Herpes simplex keratitis Herpes simplex keratitis Conjunctivitis (bacterial, viral, allergic, irritative) Conjunctivitis (bacterial, viral, allergic, irritative) Episcleritis Episcleritis Soft contact lens associated Soft contact lens associated Scleritis Scleritis Adnexal Disease (dacryocystitis, stye, blepharitis, lid lesions, thyroid..) Adnexal Disease (dacryocystitis, stye, blepharitis, lid lesions, thyroid..) Subconjunctival hemorrhage Subconjunctival hemorrhage Pterygium Pterygium Keratoconjunctivitis sicca Keratoconjunctivitis sicca Abrasions or foreign bodies Abrasions or foreign bodies Corneal ulcer Corneal ulcer 2’ to abnormal lid function 2’ to abnormal lid function THINK Anatomy “front to back” Acute vs. chronic Visually threatening?

42 History Onset? Sudden? Progressive? Constant? Onset? Sudden? Progressive? Constant? Family/friends with red eye? Family/friends with red eye? Using meds in eye? Using meds in eye? Trauma? Trauma? Recent eye surgery? Recent eye surgery? Contact lens wearer? Contact lens wearer? Recent URTI? Recent URTI? Decreased VA? Pain? Discharge? Itching? Photophobia? Eye rubbing? Decreased VA? Pain? Discharge? Itching? Photophobia? Eye rubbing? Other symptoms? Other symptoms?

43 Red Eye: Symptoms *Decreased VA (i nflamed cornea, iridocyclitis, acute glaucoma) *Decreased VA (i nflamed cornea, iridocyclitis, acute glaucoma) *Pain (k eratitis, ulcer, iridocyclitis, acute glaucoma) *Pain (k eratitis, ulcer, iridocyclitis, acute glaucoma) *Photophobia ( iritis) *Photophobia ( iritis) *Colored halos ( acute glaucoma) *Colored halos ( acute glaucoma) Discharge ( conj. or lid inflammation, corneal ulcer) Discharge ( conj. or lid inflammation, corneal ulcer) Purulent/mucopurulent: Bacterial Purulent/mucopurulent: Bacterial Watery: Viral Watery: Viral Scant, white, stringy: allergy, dry eyes Scant, white, stringy: allergy, dry eyes Itching ( allergy) Itching ( allergy) * can indicate serious ocular disease

44 Physical Exam Vision Vision Pupil asymmetry or irregularity Pupil asymmetry or irregularity Inspect: Inspect: pattern of redness (heme, injection, ciliary flush) pattern of redness (heme, injection, ciliary flush) Amount & type of discharge Amount & type of discharge Corneal opacities or irregularities Corneal opacities or irregularities AC shallow? Hypopyon? Hyphema? AC shallow? Hypopyon? Hyphema? Fluorescein staining Fluorescein staining IOP IOP Proptosis? Lid abnormality? Limitation EOM? Proptosis? Lid abnormality? Limitation EOM?

45 Red Eye: Signs *Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) *Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) Conjuctival hyperemia (nonspecific sign) Conjuctival hyperemia (nonspecific sign) *Corneal opacification (iritis, corneal edema, acute glaucoma, keratitis, ulcer) *Corneal opacification (iritis, corneal edema, acute glaucoma, keratitis, ulcer) *Corneal epithelial disruption (corneal inflammation, abrasion) *Corneal epithelial disruption (corneal inflammation, abrasion) *Pupil abnormality ( iridocyclitis, acute glaucoma) *Pupil abnormality ( iridocyclitis, acute glaucoma) *Shallow AC ( acute angle closure glaucoma) *Shallow AC ( acute angle closure glaucoma) *Elevated IOP (iritis, acute glaucoma) *Elevated IOP (iritis, acute glaucoma) *Proptosis (thyroid disease, orbital or cavernous sinus mass, infection) *Proptosis (thyroid disease, orbital or cavernous sinus mass, infection) Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular syndrome) Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular syndrome) * can indicate serious ocular disease

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49 Red eye management for 1° care physicians Blepharitis: Blepharitis: Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction) Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction) Stye: Stye: Warm compresses (refer if still present after 1 month) Warm compresses (refer if still present after 1 month) Subconj heme: Subconj heme: Will resolve in days Will resolve in days Viral conjunctivitis Viral conjunctivitis Cool compresses, tears, contact precautions Cool compresses, tears, contact precautions Bacterial conjunctivitis Bacterial conjunctivitis Cool compresses, antibiotic drop/ointment Cool compresses, antibiotic drop/ointment

50 Important Side Effects Important Side Effects Topical anesthetics: Topical anesthetics: Not to be used except for aiding in exam Not to be used except for aiding in exam Inhibits growth & healing of corneal epithelium Inhibits growth & healing of corneal epithelium Possible severe allergic reaction Possible severe allergic reaction Decrease blink reflex: exposure to dehydration, injury, infection Decrease blink reflex: exposure to dehydration, injury, infection Topical corticosteroids: Topical corticosteroids: Can potentiate growth of herpes simplex, fungus Can potentiate growth of herpes simplex, fungus Can mask symptoms Can mask symptoms Cataract formation Cataract formation Elevated IOP Elevated IOP

51 Ocular & Orbital Injuries Chapter 5

52 Anatomy & Function Bony orbit Bony orbit Globe, EOM, vessels, nerves Globe, EOM, vessels, nerves Rim protective Rim protective “Blow out” fracture “Blow out” fracture Medial fracture -> subQ emphysema of eyelids Medial fracture -> subQ emphysema of eyelids

53 Anatomy & Function Eyelids Eyelids Reflex closing when eyes threatened Reflex closing when eyes threatened Blinking rewets the cornea Blinking rewets the cornea Tear drainage Tear drainage CN VII palsy -> exposure keratopathy CN VII palsy -> exposure keratopathy Lacrimal apparatus Lacrimal apparatus Tear drainage occurs at medial canthus Tear drainage occurs at medial canthus Obstruction -> chronic tearing (epiphora) Obstruction -> chronic tearing (epiphora)

54 Anatomy & Function Conjunctiva & cornea Conjunctiva & cornea Quick reepitheliization post-abrasion Quick reepitheliization post-abrasion Iris & ciliary body Iris & ciliary body Blunt trauma -> pupil margin nick (tear) Blunt trauma -> pupil margin nick (tear) Blunt trauma -> hyphema Blunt trauma -> hyphema Blunt trauma -> iritis Blunt trauma -> iritis (pain, redness, photophobia, miosis)

55 Anatomy & Function Lens Lens Cataract Cataract Lens dislocation (ectopia lentis) Lens dislocation (ectopia lentis) Vitreous humor Vitreous humor Decreased transparency Decreased transparency (hemorrhage, inflammation, infection) Retina Retina Hemorrhage Hemorrhage Macular damage (reduce visual acuity) Macular damage (reduce visual acuity)

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57 Management or Referral Chemical burn Chemical burn Alkali>Acid b/c more rapid penetration Alkali>Acid b/c more rapid penetration OPHTHALMIC EMERGENCY OPHTHALMIC EMERGENCY ALL chemical burns require immediate and perfuse irrigation, THEN ophtho referral ALL chemical burns require immediate and perfuse irrigation, THEN ophtho referral

58 Urgent Situations Penetrating injuries of the globe Penetrating injuries of the globe Conjunctival or corneal foreign bodies Conjunctival or corneal foreign bodies Hyphema Hyphema Lid laceration (sutured if not deep and neither the lid margin nor the canaliculi are involved) Lid laceration (sutured if not deep and neither the lid margin nor the canaliculi are involved) Traumatic optic neuropathy Traumatic optic neuropathy Radiant energy burns (snow blindness or welder’s burn) Radiant energy burns (snow blindness or welder’s burn) Corneal abrasion Corneal abrasion

59 Semi-urgent Situation Orbital fracture Orbital fracture Subconjuctival hemorrhage in blunt trauma Subconjuctival hemorrhage in blunt trauma Refer patient within 1-2 days Refer patient within 1-2 days

60 Treatment Skills Ocular irrigation Ocular irrigation Foreign body removal Foreign body removal Eye meds (cycloplegics, antibiotic ointment, anesthetic drops and ointment) Eye meds (cycloplegics, antibiotic ointment, anesthetic drops and ointment) Patching (pressure patch, shield) Patching (pressure patch, shield) Suturing for simple eyelid skin laceration Suturing for simple eyelid skin laceration

61 Take-home Points Teardrop-shaped pupil & flat anterior chamber in trauma are associated with perforating injury Teardrop-shaped pupil & flat anterior chamber in trauma are associated with perforating injury Avoid digital palpation of the globe in perforating injury Avoid digital palpation of the globe in perforating injury In chemical burn patient immediate irrigation is crucial as soon as possible In chemical burn patient immediate irrigation is crucial as soon as possible Traumatic abrasions are located in the center or inferior cornea due to Bell’s phenomenon Traumatic abrasions are located in the center or inferior cornea due to Bell’s phenomenon Know and respect your limits Know and respect your limits

62 Chapter 6 Amblyopia & Strabismus

63 Amblyopia Definition Definition loss of VA not correctable by glasses in otherwise healthy eye loss of VA not correctable by glasses in otherwise healthy eye 2% in US 2% in US Strabismic(50%) > refractive > deprivation Strabismic(50%) > refractive > deprivation The brain selects the better image and suppresses the blurred or conflicting image The brain selects the better image and suppresses the blurred or conflicting image Cortical suppression of sensory input interrupts the normal development of vision Cortical suppression of sensory input interrupts the normal development of vision

64 Strabismus Misalignment of the two eyes Misalignment of the two eyes Absence of binocular vision Absence of binocular vision Concomitant: angle of deviation equal in all direction Concomitant: angle of deviation equal in all direction EOM: normal EOM: normal Onset: childhood Onset: childhood Rarely caused by neurological disease <6 years Rarely caused by neurological disease <6 years Can be due to sensory deprivation Can be due to sensory deprivation Incomitant: angle of deviation varies with direction of gaze Incomitant: angle of deviation varies with direction of gaze EOM : abnormal EOM : abnormal **Paralytic : CN, MG ** **Paralytic : CN, MG ** Restrictive: orbital disease, trauma Restrictive: orbital disease, trauma

65 Strabismus Phoria: latent deviation Phoria: latent deviation Tropia: manifest deviation Tropia: manifest deviation

66 Corneal Light Reflex

67 Cover Test

68 Treatment Refractive correction (glasses) Refractive correction (glasses) Patching Patching Surgery Surgery

69 Chapter 7 **35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits neuro-ophthalmic signs or symptoms** Neuro-Ophthalmology

70 The Neuro-Ophthalmic Exam Visual acuity Visual acuity Confrontation visual fields Confrontation visual fields Pupil size and reaction Pupil size and reaction (Efferent vs Afferent (Marcus Gunn) problem) Ocular motility for strabismus, limitation and nystagmus Ocular motility for strabismus, limitation and nystagmus Fundus exam (optic nerve swelling and venous pulsations) Fundus exam (optic nerve swelling and venous pulsations)

71 Parasympathetic Parasympathetic

72 Sympathetic

73 Efferent vs Afferent defect

74 Selected Pupillary Disorders Mydriasis Mydriasis CN III palsy CN III palsy Herniation of temporal lobe or Aneurysm Herniation of temporal lobe or Aneurysm Adie’s Tonic Pupil Adie’s Tonic Pupil Young women, unilateral, sensitive to dilute pilocarpine, benign Young women, unilateral, sensitive to dilute pilocarpine, benign Miosis Miosis Physiologic Physiologic Horner’s Syndrome Horner’s Syndrome Etiologic localization (cocaine and hydroxyamphetamine) Etiologic localization (cocaine and hydroxyamphetamine) Argyll Robertson Pupil of tertiary syphilis Argyll Robertson Pupil of tertiary syphilis small, irregular, reacts to near stimulus only small, irregular, reacts to near stimulus only

75 Selected Motility Disorders True diplopia is a binocular phenomenon True diplopia is a binocular phenomenon Etiologies of monocular diplopia? Etiologies of monocular diplopia? Do not forget to check ALL cranial nerves (especially 5/7/8) Do not forget to check ALL cranial nerves (especially 5/7/8) CN IV CN IV Vertical diplopia, head tilt toward OPPOSITE side Vertical diplopia, head tilt toward OPPOSITE side Think closed head trauma or small vessel disease Think closed head trauma or small vessel disease Myasthenia Gravis Myasthenia Gravis Chronic autoimmune condition affecting skeletal muscle neuromuscular transmission (verify with Tensilon test) Chronic autoimmune condition affecting skeletal muscle neuromuscular transmission (verify with Tensilon test) Can mimic any nerve palsy and often associated with ptosis Can mimic any nerve palsy and often associated with ptosis NEVER affects pupil NEVER affects pupil

76 CN III Palsy Think: PCOM Aneurysm, Brain Tumor, Trauma Think: Trauma, Elevated ICP, HTN, Diabetes and viral infections CN VI Palsy

77 Internuclear Ophthalmoplegia (INO) Think: Elderly-small vessel disease Young Adult-MS Child-Pontine Glioma

78 Nystagmus - selected types May be benign or indicate ocular and/or central nervous system disease May be benign or indicate ocular and/or central nervous system disease Definition according to fast phase Definition according to fast phase End-point Nystagmus End-point Nystagmus seen only in extreme positions of eye movement seen only in extreme positions of eye movement Drug-induced Nystagmus Drug-induced Nystagmus Anticonvulsants, Barbiturates/Other sedatives Anticonvulsants, Barbiturates/Other sedatives Searching/Pendular Nystagmus Searching/Pendular Nystagmus common with congenital severe visual impairment common with congenital severe visual impairment Nystagmus associated with INO Nystagmus associated with INO

79 Selected Optic Nerve Disease Congenital Anomalous Disc Elevation Congenital Anomalous Disc Elevation absence of edema, hemorrhage and presence of SVP absence of edema, hemorrhage and presence of SVP Think: optic disc drusen and hyperopia Think: optic disc drusen and hyperopia Papilledema (def?) Papilledema (def?) Presence of bil edema, hemorrhage and absence of SVP Presence of bil edema, hemorrhage and absence of SVP Think: hypertension (must check BP) and Think: hypertension (must check BP) and brain tumor Papillitis/Anterior Optic Neuritis Papillitis/Anterior Optic Neuritis unil edema, hemorrhage unil edema, hemorrhage Think: inflammatory Think: inflammatory

80 Selected Optic Nerve Disease Ischemic Optic Neuropathy Ischemic Optic Neuropathy Pallor, swelling, hemorrhage Pallor, swelling, hemorrhage altitudinal visual field loss altitudinal visual field loss Optic Atrophy Optic Atrophy Think: previous optic neuritis or ischemic optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, glaucoma Think: previous optic neuritis or ischemic optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, glaucoma

81 Selected Visual Field Defects

82 Ocular Manifestations of Systemic Disease Chapter 8

83 Systemic Diseases Many systemic diseases have ocular manifestations and sequelae Many systemic diseases have ocular manifestations and sequelae Exam may aid with diagnosis, assessment of disease activity, prognosis Exam may aid with diagnosis, assessment of disease activity, prognosis Common conditions Common conditions Diabetes Diabetes Hypertension Hypertension Pregnancy Pregnancy Sickle cell anemia Sickle cell anemia Thyroid disease Thyroid disease Sarcoidosis and inflammatory/autoimmune Sarcoidosis and inflammatory/autoimmune Malignancy Malignancy Aids Aids Syphilis Syphilis Systemic infection Systemic infection

84 Diabetes Leading cause of vision loss (18-64 yrs) Leading cause of vision loss (18-64 yrs) Intensive glycemic control reduced risk of development and progression of retinopathy (DCCT) Intensive glycemic control reduced risk of development and progression of retinopathy (DCCT) Risk of developing retinopathy  with duration of disease (type 1 5 yrs, 15 yrs, rates lower for type 2) Risk of developing retinopathy  with duration of disease (type 1 5 yrs, 15 yrs, rates lower for type 2) Non-proliferative changes (NPDR) Non-proliferative changes (NPDR) Mild - Moderate Mild - Moderate Microaneurysms Microaneurysms Dot-blot hemorrhages Dot-blot hemorrhages Hard exudates Hard exudates Macular edema (most common cause of mild-mod V A loss) Macular edema (most common cause of mild-mod V A loss) Severe Severe Venous beading Venous beading Intraretinal microvascular abnormalities (IRMA) Intraretinal microvascular abnormalities (IRMA) Nerve fiber layer infarcts – cotton wool spots Nerve fiber layer infarcts – cotton wool spots

85 Diabetes Proliferative (PDR) Proliferative (PDR) Responsible for most of the profound visual loss Responsible for most of the profound visual loss Neovascularization in response to ischemia Neovascularization in response to ischemia Disc, retina, iris Disc, retina, iris If untreated → vitreous hemorrhage, tractional retinal detachment If untreated → vitreous hemorrhage, tractional retinal detachment Management Management Frequency of exams Frequency of exams Type 1 – initial exam when post-pubertal and within 5 yrs of Dx Type 1 – initial exam when post-pubertal and within 5 yrs of Dx Type 2 – exam at time of Dx Type 2 – exam at time of Dx All patients – generally examine q1yr unless poor glycemic control, HTN, anemia, proteinuria, mod-severe NPDR or PDR which require more freq F/U All patients – generally examine q1yr unless poor glycemic control, HTN, anemia, proteinuria, mod-severe NPDR or PDR which require more freq F/U Pregnant + type I – first trimester + q3months Pregnant + type I – first trimester + q3months Treatment Treatment Focal laser Focal laser Panretinal photocoagulation Panretinal photocoagulation Vitrectomy with laser Vitrectomy with laser

86 Hypertension Arteriolar Sclerosis Arteriolar Sclerosis Extent relates to duration + severity of HTN Extent relates to duration + severity of HTN Thickening and sclerosis of arterioles Thickening and sclerosis of arterioles  light reflex width (copper  silver wire)  light reflex width (copper  silver wire) A-V nicking A-V nicking May predispose to BRVO if severe May predispose to BRVO if severe Acute BP elevation Acute BP elevation Fibrinoid necrosis  exudates, CWS, flame hemorrhages, optic disc swelling Fibrinoid necrosis  exudates, CWS, flame hemorrhages, optic disc swelling

87 Hypertension Diagnosis Diagnosis Classification Classification Grade 0 – no changes Grade 0 – no changes Grade 1 – barely detectable arterial narrowing Grade 1 – barely detectable arterial narrowing Grade 2 – obvious arterial narrowing with focal irregularities Grade 2 – obvious arterial narrowing with focal irregularities Grade 3 – gr 2 + retinal hemorrhages or exudate Grade 3 – gr 2 + retinal hemorrhages or exudate Grade 4 – gr 3 + disc swelling Grade 4 – gr 3 + disc swelling Management Management Control BP Control BP Avoid nocturnal hypotension – ischemic optic neuropathy, glaucomatous field loss Avoid nocturnal hypotension – ischemic optic neuropathy, glaucomatous field loss

88 Pregnancy Physiologic Δs Physiologic Δs  IOP,  corneal sensitivity,  accommodation, dry eye, Δ in refraction  IOP,  corneal sensitivity,  accommodation, dry eye, Δ in refraction Avoid changing glasses, contacts, refractive surgery Avoid changing glasses, contacts, refractive surgery Pathologic Δs Pathologic Δs  risk of CSR, uveal melanoma  risk of CSR, uveal melanoma Pre-eclampsia/eclampsia Pre-eclampsia/eclampsia Scotoma, diplopia, dimness Scotoma, diplopia, dimness Vascular Δs Vascular Δs Hemorrhages, exudates, retinal edema, disc swelling Hemorrhages, exudates, retinal edema, disc swelling Serous exudative RD in 10% of eclampsia Serous exudative RD in 10% of eclampsia Diabetes – exacerbated retinopathy Diabetes – exacerbated retinopathy

89 Sickle Cell Anemia SC and S Thal more likely to have eye involved SC and S Thal more likely to have eye involved Arteriolar occlusion Arteriolar occlusion intravasc sickling  hemolysis  hemostasis  thrombosis  capillary non-perfusion intravasc sickling  hemolysis  hemostasis  thrombosis  capillary non-perfusion Similar to diabetes – poor perfusion = retinal ischemia  neovascularization Similar to diabetes – poor perfusion = retinal ischemia  neovascularization Laser Tx – can prevent vision loss Laser Tx – can prevent vision loss

90 Thyroid disease Graves Graves Autoimmune Autoimmune Signs Signs **Retraction of upper + lower lids** **Retraction of upper + lower lids** Upper lid lag in  gaze Upper lid lag in  gaze Most common cause of unil & bil proptosis in adults Most common cause of unil & bil proptosis in adults Eyelid swelling, conj vascular congestion Eyelid swelling, conj vascular congestion Symptoms Symptoms Exposure related – lubricate frequently Exposure related – lubricate frequently Treatment Treatment Surgery for severe proptosis, diplopia 2° EOM involvement, optic nerve decompression Surgery for severe proptosis, diplopia 2° EOM involvement, optic nerve decompression Radiation for inflammatory swelling Radiation for inflammatory swelling

91 Sarcoidosis Sarcoidosis Sarcoidosis Focal non-caseating granulomas Focal non-caseating granulomas Most common African-American females 20 – 40 yrs Most common African-American females 20 – 40 yrs  Ca++,  ACE, abnormal CXR  Ca++,  ACE, abnormal CXR Ocular involvement Ocular involvement Conj, lacrimal gland – dry eye Conj, lacrimal gland – dry eye Anterior or posterior uveitis Anterior or posterior uveitis Retinal perivasculitis, hemorrhages, neovascularization Retinal perivasculitis, hemorrhages, neovascularization More likely to have CNS involvement if retina affected More likely to have CNS involvement if retina affected Early topical or systemic steroids may prevent complications Early topical or systemic steroids may prevent complications Cataract, glaucoma, iris to lens adhesion Cataract, glaucoma, iris to lens adhesion

92 Autoimmune Dry eye Dry eye Sarcoidosis, SLE, Rheumatoid arthritis Sarcoidosis, SLE, Rheumatoid arthritis Healthy pts > 40yrs Healthy pts > 40yrs Symptoms Symptoms Burning, grittiness esp in PM Burning, grittiness esp in PM crusting in AM crusting in AM tearing tearing Treatment Treatment lubrication lubrication Anterior uveitis Anterior uveitis Ankylosing spondylitis, Reiter, Behcet Ankylosing spondylitis, Reiter, Behcet Juvenile RA – esp pauciarticular (asymptomatic) Juvenile RA – esp pauciarticular (asymptomatic) Needs close F/U Needs close F/U

93 Malignancy Primary ocular malignancy rare Primary ocular malignancy rare Metastasis Metastasis Breast, lung most common Breast, lung most common Usually localize to choroid but EOMs, optic nerve can be affected Usually localize to choroid but EOMs, optic nerve can be affected Lymphoma, leukemia Lymphoma, leukemia Radiation complications Radiation complications Cornea – keratitis / dryness Cornea – keratitis / dryness Lens – cataract Lens – cataract Optic nerve – neuropathy Optic nerve – neuropathy Retina – vasculopathy Retina – vasculopathy Chemo Chemo Carmustine – retinal artery occlusion Carmustine – retinal artery occlusion

94 AIDS Common Common AIDS retinopathy AIDS retinopathy Cotton wool spots Cotton wool spots CMV retinitis CMV retinitis Leading cause of visual loss in AIDS Leading cause of visual loss in AIDS Hemorrhagic necrosis of retina Hemorrhagic necrosis of retina More common if CD4<50 More common if CD4<50 Kaposi’s sarcoma Kaposi’s sarcoma Less common Less common Herpes zoster, simplex, toxoplasmosis Herpes zoster, simplex, toxoplasmosis Oculomotor dysfcn 2° CNS involvement Oculomotor dysfcn 2° CNS involvement

95 Syphilis Can cause permanent visual loss if dx and tx are delayed Can cause permanent visual loss if dx and tx are delayed Congenital vs acquired Congenital vs acquired Acute interstitial keratitis Acute interstitial keratitis Bilateral vs unilateral Bilateral vs unilateral Age 5 – 25 yrs Age 5 – 25 yrs Pain + photophobia Pain + photophobia Diffusely opaque cornea with  V A Diffusely opaque cornea with  V A Late – ghost vessels + opacities Late – ghost vessels + opacities Secondary Secondary Pain, redness, photophobia, blurred vision, floaters Pain, redness, photophobia, blurred vision, floaters Iritis, choroiditis, and/or exudates around disc + vessels Iritis, choroiditis, and/or exudates around disc + vessels Tertiary Tertiary Chorioretinitis and/or diffuse neuroretinitis and vascular sheathing Chorioretinitis and/or diffuse neuroretinitis and vascular sheathing

96 Others Candidiasis Candidiasis Fluffy white-yellow superficial retinal infiltrate, vitritis Fluffy white-yellow superficial retinal infiltrate, vitritis Systemic ± intravitreal ampho B Systemic ± intravitreal ampho B Herpes zoster Herpes zoster Varicella zoster virus – reactivation in CN V Varicella zoster virus – reactivation in CN V Hutchinson sign Hutchinson sign Ocular signs Ocular signs Keratitis Keratitis Uveitis Uveitis Decreased corneal sensation Decreased corneal sensation Rare – optic neuritis, nerve palsies involving motility limitation and diplopia Rare – optic neuritis, nerve palsies involving motility limitation and diplopia Post-herpetic neuralgia Post-herpetic neuralgia

97 Drugs & The Eye Chapter 8

98 Topical Drugs Used for Diagnosis: Fluorescin Dye Fluorescein strip: Fluorescein strip: water soluble water soluble No systemic complications No systemic complications Beware of contact lens staining Beware of contact lens staining Cobalt blue light Orange becomes green Orange yellow dye Eye with corneal ulcer

99 Anesthetics Example: Example: Propracaine Hydrochloride 0.5% (Alcaine) Propracaine Hydrochloride 0.5% (Alcaine) Tetracaine 0.5% Tetracaine 0.5% Uses: Uses: Anesthetize cornea within 15 sec, last 10 mins Anesthetize cornea within 15 sec, last 10 mins Remove corneal foreign bodies Remove corneal foreign bodies Perform tonometry Perform tonometry Examine damaged corneal surface Examine damaged corneal surface Side effects: Side effects: Allergy: local or systemic Allergy: local or systemic Toxic to corneal epithelium ( inhibit mitosis, migration) Toxic to corneal epithelium ( inhibit mitosis, migration)

100 Mydriatics (pupil dilation) Two classes: Two classes: 1. Cholinergic-blocking ( parasympatholytic) 2. Adrenergic-stimulating (sympathomimetic) Iris sphincter constrict pupil Pupillary dilator muscles

101 Cholinergic-Blocking drugs Action Action Dilate by paralyzing iris sphincter muscle Dilate by paralyzing iris sphincter muscle Cycloplegia by paralyzing ciliary body muscles Cycloplegia by paralyzing ciliary body muscles TropicamideCyclopentolate TropicamideCyclopentolate Max pupil dilatation 30 minComplete Cycloplegia Max pupil dilatation 30 minComplete Cycloplegia Effect diminishes 4-5 hrsUsed for refracting children Effect diminishes 4-5 hrsUsed for refracting children Side effects: Side effects: Rare Rare Nausea / vomiting Nausea / vomiting Pallor vasomotor collapse Pallor vasomotor collapse Other examples: Other examples: 1. Homatropine hydrobromide 1% or 2% 2. Atropine sulfate 0.5% or 1% 3. Scopolamine hydrobromide 0.25% or 5% (last 1-2 wks)

102 Adrenergic Stimulating Drugs Phenylephrine 2.5% or 10% Phenylephrine 2.5% or 10% Dilates in 30 mins, no effect on accommodation Dilates in 30 mins, no effect on accommodation Pupil remains reactive to light Pupil remains reactive to light Combine with Tropicamide for maximal dilatation Combine with Tropicamide for maximal dilatation Infants combine Cyclopentolate 0.2% & Phenylephrine 1% Infants combine Cyclopentolate 0.2% & Phenylephrine 1% Side effects: Side effects: acute hypertension or MI (with 10%) acute hypertension or MI (with 10%)

103 Topical Therapeutic Drugs Decongestants: Decongestants: Over the counter weak adrenergic-stimulating drugs Over the counter weak adrenergic-stimulating drugs Vasoconstriction = white eyes temporarily Vasoconstriction = white eyes temporarily E.g. Naphazoline 0.012% Phenylephrine 0.12% Tetrahdrozaline0.05% E.g. Naphazoline 0.012% Phenylephrine 0.12% Tetrahdrozaline0.05% Side effect Side effect rebound vasodilatation, common rebound vasodilatation, common acute angle closure glaucoma, rare acute angle closure glaucoma, rare Anti-allergics Combination naphazoline+antazoline Decongestant+antihistamine Mast cell stabilizers Anti-inflammatory Topical steroids should NEVER be prescribed by primary care physician Non steroidals: e.g. diclofenac Uses : ocular itch, macular edema, prevent pupil constriction during cataract Sx

104 Systemic Side Effects of Glaucoma Meds Beta blockers Beta blockers Timolol, levobunolol, metapranolol, carteolol Timolol, levobunolol, metapranolol, carteolol Nonselective Nonselective ↓ Aqueous production ↓ Aqueous production Bronchospasm  Ø Asthma, COPD Bronchospasm  Ø Asthma, COPD Bradycardia  Precipitate or worsen cardiac failure Bradycardia  Precipitate or worsen cardiac failure Betaxolol Betaxolol Cardio selective  avoids pulm. side effects Cardio selective  avoids pulm. side effects Cholinergic-stimulating drugs Pilocarpine ↑aqueous outflow Side effects Miosis Headache Systemic: lacrimation, N/V, diarrhea Echothiophate Long acting anticholinestrase Inactivates plasma cholinestrase,  pt more susceptible to effect of succinylcholine Prolonged apnea or death reported

105 Systemic Side Effects of Glaucoma Meds Alpha-2 adrenoceptor agonist Alpha-2 adrenoceptor agonist Brimonidine: (Alphagan) Brimonidine: (Alphagan) ↓ aqueous production, ↑uveoscleral outflow ↓ aqueous production, ↑uveoscleral outflow Hypotension & apnea in infants Hypotension & apnea in infants Local allergic conjunctivitis Local allergic conjunctivitis Dry mouth, fatigue, headache Dry mouth, fatigue, headache Apraclonidine: (Iopidine) Apraclonidine: (Iopidine) Used against pressure spikes after iris laser Used against pressure spikes after iris laser Orthostatic hypotension Orthostatic hypotension High allergic conjunctivitis High allergic conjunctivitis Adrenergic-stimulating drugs: (Epinephrine, Dipivefrin) Adrenergic-stimulating drugs: (Epinephrine, Dipivefrin) Arrhythmias, HTN, Arrhythmias, HTN, Prostaglandin analog Latanoprost (Xalatan) PGF2α ↑ uveoscleral outflow Iris darkening Elongation of eye lashes CME Carbonic anhydrase inhibitors Oral Acetazolammide (Diamox) Sulfur allergy Parasthesia, anorexia, metallic taste, renal calculi Topical Dorzolamide (Trusopt) Same side effects but lower

106 Ocular side effects of systemic drugs SteroidsAnti-inflammatoryPSCC, Steroid induced glaucoma Chloroquine Rx of RA, SLE Corneal deposits Bull’s eye maculopathy 250mg qd, or 300g total Digitalis (Digoxin) Atrial Fibrillation Yellow vision most common sign of intoxication Amiodarone Cardiac arrhythmias Cornea verticillata (whorls) DiphenylhydantoinSeizure Horizontal nystagmus in lateral gaze, vertical nystagmus in up gaze Ethambutol TB chemotherapy Optic neuropathy ChlorpromazineSchizophrenia Punctate Corneal epithelial opacities Thioridazinepsychosis Pigmentary retinopathy

107 Good Luck!


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