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Ophthalmology Secrets in Color, 3e
Cover
Front matter
Copyright 0323034691
Dedication
Contributors
Preface
Top 100 Secrets
Section I - General
1. Clinical Anatomy of the Eye
Name the seven bones that make up the bony orbit & describe which location is most prone to damage in an orbital blow-out fracture.
Which nerves & vessels pass through the superior orbital fissure? Which motor nerve to the eye lies outside the annulus of Zinn, leaving it unaffected by retrobulbar injection of anesthetic?
A 3-year-old is referred for evaluation of consecutive exotropia after initial bimedial rectus recessions for esotropia performed elsewhere. Review of the operative notes discloses...
What is the most common cause of both unilateral & bilateral proptosis in adults?
You have just begun a ptosis procedure. A lid crease incision was made & the orbital septum has been isolated & opened horizontally. What important landmark should be readily apparent?...
To what glands do the lymphatics of the orbit drain?
What is the orbital septum?
A 70-year-old patient presents with herpes zoster lesions in the trigeminal nerve distribution. Classic lesions on the side & tip of the nose increase your concern about ocular...
Where is the sclera the thinnest? Where are globe ruptures after blunt trauma most likely to occur?
Describe the surgical limbus & Schwalbe's line.
You are preparing to do an argon laser trabeculoplasty. Describe the gonioscopic appearance of the anterior chamber angle.
After a filtering procedure, your patient develops choroidal effusions. Explain the distribution of these fluid accumulations based on uveal attachments to the sclera.
Describe the structure of Bruch's membrane. Name two conditions in which defects develop in this structure spontaneously.
Key Points: Bruch's Membrane
Less laser power is required for photocoagulation in darkly pigmented fundi. What determines this pigmentation?
What is the blood-retinal barrier?
Name the 10 classically described anatomic layers of the retina & the cells that make up the retina.
Which retinal layer is referred to as the fiber layer of Henle in the macular region?
What are three clinically recognized remnants of the fetal hyaloid vasculature?
A patient presents with a central retinal artery occlusion & 20/20 visual acuity. How do you explain this finding?
Where do branch retinal vein occlusions occur? Which quadrant of the retina is most commonly affected?
Discuss the organization of crossed & uncrossed fibers in the optic chiasm.
Describe the location of the visual cortex.
What is the most likely anatomic location of pathology associated with downbeat nystagmus?
A patient presents with a chief complaint of tearing & ocular irritation. As she dumps the plethora of eye drops from her purse, she explains that she has seen seven different doctors & none...
During orbital surgery, a patient's lacrimal gland is removed. Afterward, there is no evidence of tear deficiency. Why not?
Describe the anatomy of the macula & fovea.
Fluorescein angiography typically shows perfusion of the choroid & any cilioretinal arteries prior to visualization of the dye in the retinal circulation. Why?
Explain why visual acuity in infants does not reach adult levels until approximately 6 months of age, based on retinal differentiation.
A neonate presents with an opacification in her left cornea. What is the differential diagnosis?
Describe the innervation of the lens.
Describe the innervation of the cornea.
What are the three layers of the tear film? Where do they originate?
What are the differences in the structure of the central retinal artery & retinal arterioles?
Where is the macula represented in the visual cortex?
What is macular hole formation?
Describe the stages of macular hole formation as proposed by Gass, as well as the changes in our understanding of the disease process since the development of optical coherence tomography (OCT).
Bibliography
2. Anatomy of the Orbit & Eyelid
Orbit
Name the bones of the orbit.
What are the weak spots of the orbital rim?
Describe the most common location of blow-out fractures.
What is the weakest bone within the orbit?
Name the divisions of cranial nerve V that pass through the cavernous sinus.
What is the annulus of Zinn?
What nerves pass through the superior orbital fissure but outside the annulus of Zinn?
Eyelid
List the factors responsible for involutional entropion.
Describe the sensory nerve supply to the upper & lower eyelids.
What are the surgical landmarks in locating the superficial temporal artery during temporal artery biopsies?
What structures would you pass through during a transverse blepharotomy 3 mm above the upper eyelid margin?
What is meant by the term lower lid retractors?
What structures would be cut in a full-thickness lower-lid laceration 2 mm below the lower tarsus?
What structures would be cut in a full-thickness lower-lid laceration 6 mm below the lower tarsus?
Discuss the bony attachments of Whitnall's superior suspensory ligament.
What structure separates the medial fat pad from the central (also called the preaponeurotic) fat pad in the upper eyelid?
Lester Jones divided the orbicularis oculi muscle into three portions. Name them.
What portions of the orbicularis oculi muscle are important in the lacrimal pump mechanism?
Bibliography
3. Optics & Refraction
What is the primary focal point (f)?
What is the secondary focal point (f')?
Where is the secondary focal point for a myopic eye? Ahyperopic eye? An emmetropic eye?
What is the far point of an eye?
Where is the far point for a myopic eye? A hyperopic eye? An emmetropic eye?
How do you determine which lens will correct the refractive error of the eye?
What is the near point of an eye?
Myopia can be caused in two ways. What are they?
The power of a proper corrective lens is altered by switching from a contact lens to a spectacle lens or vice versa. Why?
What is the amplitude of accommodation?
What is the range of accommodation?
How does a diopter relate to meters?
What is the near point of a 4-D hyperope with an amplitude of accommodation of 8?
What is the near point of a 4-D myope with an amplitude of accommodation of 8?
When a light ray passes from a medium with a lower refractive index (n) to a medium with a higher refractive index (n'), is it bent toward or away from the normal?
What is the critical angle?
What happens if the critical angle is exceeded?
Give examples of total internal reflection.
What is the formula for vergence?
What is the vergence of parallel light rays?
What is the image point if an object lies 25 cm to the left of a +5.00 lens?
Draw the schematic eye with power (P), nodal point (np), principal plane, primary (f) & secondary (f') focal points, refractive indices (n, n') & respective distances labeled.
How is the power of a prism calculated?
What is Prentice's rule?
How is Prentice's rule used in real life?
Key Points: Alleviation of Symptomatic Anisometropia
How can the prismatic effect be alleviated?
How does Prentice's rule affect the measurement of strabismic deviations when the patient is wearing glasses?
Bifocals can cause significant problems induced by prismatic effect. What is the difference between image jump & image displacement?
Should a hyperope use a round-top or flat-top reading lens?
Should a myope use a flat-top or round-top reading lens?
What is the circle of least confusion?
What is the spherical equivalent of -3.00 + 2.00 x 125?
Change the following plus cylinder refraction to minus cylinder form: -5.00 + 3.00 x 90.
After cataract surgery, a patient has the following refraction: +1.00 + 3.00 x 100. Does the patient have with-the-rule or against-the-rule astigmatism?
How should you proceed with the patient's care?
What if a postoperative patient has a refraction of +2.00 - 2.00 x 90? Where should you cut the suture?
Thick lenses have aberrations. List them.
Are red or green light rays refracted more by a plus lens?
A myopic patient tilts his glasses to see in the distance. What does this tell you?
What measurements are necessary in determining the intraocular lens implant calculation?
How does an axial error that is incorrect by 0.1 mm affect the intraocular lens calculation?
How does an error in keratometry readings affect the intraocular lens calculation?
What is the formula for transverse magnification?
What is the formula for axial magnification?
What is the effect of axial magnification on accommodative requirements for a given near-viewing distance?
What is angular magnification?
What is the magnification of a direct ophthalmoscope?
Does an astronomic telescope form an upright or an inverted image?
Does a Galilean telescope form an upright or an inverted image?
What is the magnification formula for a telescope?
When using the direct ophthalmoscope, which patient provides the larger image of the retina-the hyperope or the myope?
What do you need to determine the best low-vision aid for a patient?
What are the advantages & disadvantages of using a high add in a bifocal for a low-vision aid?
What are the advantages & disadvantages of using a high-power single-vision lens as a low-vision aid?
How do you estimate the strength of plus lens needed to read newspaper print without accommodation?
What adjustment is necessary when a binocular high-power single-vision lens is used?
What are the advantages & disadvantages of hand-held magnifiers for low-vision aids?
What are the advantages & disadvantages of using loupes as a low-vision aid?
The devices mentioned thus far are for magnifying at near. What is available for distance aids?
Do convex mirrors add plus or minus vergence?
What is the reflecting power in diopters of a mirror?
What instrument uses the reflecting power of the cornea to determine its readings?
How much of the cornea is measured with a keratometer?
Why does a keratometer use doubling of its images?
What is a Geneva lens clock?
Do you measure the power of spectacles in a lensmeter with the temples toward you or away from you?
If you obtain "with" movement during retinoscopy, is the far point of the patient in front of the peephole, at the peephole, or beyond the peephole?
What does a pachymeter measure?
How does the Hruby lens give an upright or inverted image?
Why does the indirect ophthalmoscope provide a larger field of view than the direct ophthalmoscope?
What are the wavelengths of the spectrum of visible light?
Antireflective coatings on spectacle lenses are based on what principle?
What is the most effective pinhole diameter?
When is a cycloplegic refraction indicated?
Which cycloplegic agent lasts the longest? The shortest?
What are the signs & symptoms of systemic intoxication from cycloplegic medications? How are they treated?
When is it important to measure the vertex distance in prescribing glasses?
What is the threshold for prescribing glasses in a child with astigmatism?
What may cause monocular diplopia?
What conditions may give a false-positive reading with a potential acuity meter?
What do you check when patients complain that their new glasses are not as good as their previous pair?
If after repeat refraction the patient suddenly develops more hyperopia than you previously noted, what do you look for?
Key Points: Causes of Monocular Diplopia
What if the patient has more myopia than previously noted?
What about acquired astigmatism?
If the astigmatism has changed & the patient has difficulty with tolerating the new prescription, what are the options?
What does laser stand for?
To steepen a contact lens fit, do you increase the diameter of the lens or the radius of curvature?
How many seconds of arc does the "E" on the 20/20 line of the Snellen eye chart subtend?
When the Jackson cross is used to define the astigmatic axis, is the handle of the lens parallel to the axis or 45 degrees from it?
A 25-year-old patient has a manifest refraction of +0.50 OU & complains of asthenopia. What do you do?
What instrument is useful to measure the accommodative amplitude?
A 35-year-old man has 20/40 uncorrected vision. With +0.50 glasses, he is 20/20. He will remain 20/20 with a +1.50 manifest refraction. With cycloplegia, he has a refraction of +4.00. Define absolute...
Bibliography
4. Color Vision
What are photons?
Describe the physical properties of photons.
What is the electromagnetic spectrum?
Why can we "see" light, but not other types of electromagnetic energy?
What is the light spectrum?
How does a prism break white light into the colors of the rainbow?
How do rods differ from cones?
What are the visual pigments?
Describe the three cone pigments.
How does the sensation of light get to the brain?
What three attributes are necessary to describe any color?
What is hue?
What is saturation?
What is brightness?
What are complementary colors?
What is the color wheel?
How does the eye differ from the ear?
What are the primary colors?
Where is the final determination of color made?
Why is brown, which is definitely a color, not on the color wheel?
Describe the Bezold-Brucke phenomenon.
What is the Abney effect?
What are the relative luminosity curves?
Define lateral inhibition.
What are afterimages?
Why are white flowers white?
Why is charcoal black?
Why are blue flowers blue?
Why does mixing red & blue-green lights result in white, but mixing red & green paint results in brown?
Why does mixing paints yield unpredictable results?
Why do colors appear different under fluorescent light as opposed to incandescent lights?
Key Points: Color Vision
Why is the sky blue?
Why is the sunset red?
Define trichromats.
What is congenital dichromatism?
Why do deuteranopes have difficulty in distinguishing red from green?
What is anomalous trichromatism?
How is abnormal color vision inherited?
What is Kollner's rule?
Website
Bibliography
5. Ophthalmic & Orbital Testing
What is the electroretinogram?
How is an ERG performed?
Key Points: Components of the Full-Field ERG
What parameters are measured during evaluation of the ERG?
How is the ERG amplitude affected in retinal disorders?
Describe different stimulus conditions & the associated photoreceptor response.
What five responses are evaluated during a standard full-field ERG?
How is the ERG affected in age-related macular degeneration?
What does the ERG demonstrate in retinal ganglion cell disease?
Describe the clinical situations where the ERG is utilized.
List the retinal degenerations in which the ERG can help clarify the diagnosis.
What are the clinical & ERG features of retinitis pigmentosa?
What does the ERG demonstrate in female carriers of X-linked retinitis pigmentosa?
What does the ERG reveal in congenital rubella syndrome?
Describe the ERG in X-linked retinoschisis.
What does the ERG demonstrate in a progressive cone dystrophy?
Why is the ERG useful in patients with congenitally decreased vision?
How can the ERG measure retinal function in the presence of opaque ocular media?
List the disorders that may demonstrate an extinguished ERG.
List the disorders that may demonstrate normal a-wave & reduced b-wave amplitude.
List the disorders characterized by an abnormal photopic ERG & a normal scotopic ERG.
What are new variations of the standard ERG?
What is an electro-oculogram?
In what retinal location is the EOG response generated?
What are the clinical uses for the EOG?
What does the EOG demonstrate in pattern dystrophies?
How does optic nerve disease affect the EOG?
How is the EOG affected by rhegmatogenous retinal detachment?
How are the ERG & EOG affected by chloroquine & hydroxychloroquine?
What are the characteristics of dark adaptation?
What are the indications for ophthalmic ultrasonography?
What frequency is used for standard ophthalmic ultrasonography?
What are the principles of ultrasonography?
How is the clinical ophthalmic ultrasound displayed?
What lesion features are evaluated during the ultrasound examination?
The dynamic features of or within a lesion can be detected on the B-scan.
How is ultrasound used in preoperative cataract evaluation?
How is ultrasound used to assess intraocular tumors?
What are the characteristic features of a choroidal melanoma on ultrasound?
Describe the ultrasound patterns in the differential diagnosis of choroidal melanoma.
Describe the ultrasound features of a choroidal hemangioma.
Describe the ultrasound features of a retinal detachment.
Describe the ultrasound features that differentiate retinal detachment, posterior vitreous detachment & choroidal detachment.
What ocular conditions may demonstrate calcification on ultrasound?
When is ultrasound used to evaluate ocular trauma?
What are the ultrasound findings with an intraocular foreign body?
What is ultrasound biomicroscopy?
How is color-Doppler ultrasonography used in ophthalmologic evaluation?
What is required when you order orbital MRI studies?
What are paramagnetic agents?
Which ocular & orbital tissues do not normally enhance on postcontrast MRI studies?
Which ocular & orbital tissues do normally enhance on postcontrast MRI studies?
What is the strategy in ordering imaging studies in a child with leukocoria & total retinal detachment?
What is the strategy in ordering imaging studies in an adult with the diagnosis of intraocular neoplasm?
In which clinical situation are contrast-enhanced MRI studies most helpful in the evaluation of a child with leukocoria?
In which clinical situations are contrast-enhanced MRI studies most helpful in the evaluation of an adult with vitreous hemorrhage?
What are the indications for ordering CT orbital studies as a first choice?
What are the indications for ordering MRI orbital studies as a first choice?
Key Points: Summary of Modalities for Ophthalmic Imaging
Name the most common orbital lesions showing a well-circumscribed & sharply delineated appearance on CT & MRI.
Name the most common orbital lesions showing an ill-defined appearance on CT & MRI.
In which clinical situations are contrast-enhanced MRI studies most helpful in the evaluation of a patient with proptosis?
What are the indications for orbital ultrasonography in imaging orbital lesions?
What are the indications for MRI angiography & carotid angiography in imaging orbital lesions?
How can you differentiate optic nerve lesions from optic nerve sheath lesions with CT & MRI studies?
Summarize the MRI features of normal ocular & orbital tissues.
Bibliography
6. Visual Fields
What are the main types of visual field tests?
What is full-threshold testing?
You order a Goldmann visual field & the isopters are labeled with notations such as I2e & V4e. What do these notations mean?
Where is the physiologic blind spot located?
When looking at a visual field, how do you differentiate the right eye from the left eye?
What is a scotoma?
What are causes of fixation errors? What can be done to decrease them?
What are false-negative errors?
What are false-positive errors?
What are false field defects? What are some of their causes?
Key Points: Causes of False-Positive Field Defects
What is hemianopia?
Define the terms homonymous & congruous in relation to visual-field defects.
How do you describe a visual-field defect?
Describe the visual pathway.
What visual-field defects are characteristically seen in neuro-ophthalmologic disorders?
Describe the visual-field defect in Fig. 6-7. What are its major causes?
What causes binasal hemianopia?
Where would you expect the lesion causing an homonymous hemianopia without optic atrophy to be located?
Does visual acuity help to locate the cause of a visual-field defect?
Describe the visual-field defect in Fig. 6-8. What causes this?
Describe the visual-field defect in Fig. 6-9. Where is the lesion? Are there any coexistent symptoms?
Describe the visual-field defect in Fig. 6-10. Where is the lesion? Are there any coexistent symptoms?
Describe the visual-field defect seen in Fig. 6-11.
What is the anatomic explanation for a junctional scotoma?
What is an optic-tract syndrome?
What are the most common visual-field findings in glaucoma?
When has the visual field of a person with glaucoma progressed?
Describe the visual field in Fig. 6-15. What is your differential diagnosis?
What is the differential diagnosis of general depression of the field without localized field defects?
What clinical findings might mimic a neurologic defect?
Key Points: Using Visual Fields to Determine Cause
What does the future hold for visual-field testing?
Bibliography
Section II - Cornea & External Diseases
7. The Red Eye
Name the main causes of a red eye.
A 40-year-old woman complains of watery, itchy eyes with swollen lids. How should you proceed?
What might you expect to see in a patient with "pink eye?"
A 25-year-old man states that his eyes have been dripping with discharge over the past 8 hours. You notice significant purulent discharge, a preauricular node & marked chemosis. What...
What are you looking for on the Gram stain?
How should the patient be treated?
A 35-year-old man complains of pain in his left eye for several days, watery discharge & blurred vision. He thinks he has had the same symptoms before. He admits to stress on the...
An 80-year-old woman complains of red eyes that constantly tear & burn. She also feels foreign-body sensation & reports that her vision is not as clear as before. The...
What may cause superficial punctate keratopathy (SPK)?
An 83-year-old man has crusty lids & red eyes & complains of "sand in my eyes." What is your diagnosis?
A 45-year-old man with red, weepy eyes complains of foreign-body sensation, which has been occurring for a while. Of note, you realize he has a bulbous nose...
An 18-year-old contact lens wearer presents with her hand over her right eye. She noticed that her eye was somewhat red & irritated 2 days ago but believes...
What else is in the differential diagnosis of a red eye in a contact lens wearer?
A young mother enters with her infant child. Her left eye is tearing profusely & she has trouble keeping it open. She states that she was changing the...
Key Points: Causes of Red Eye in a Contact Lens Wearer
The same woman returns 3 months later complaining that she awoke in the morning with severe pain, redness & tearing in the left eye. It feels like the original...
A car mechanic complains of a painful red eye. He was fixing a muffler at the time of the onset of pain. What are your concerns?
What do you do now?
How do you proceed if, instead of a potential ruptured globe, you find a superficial metallic foreign body at 4:00 on the cornea?
A lifeguard states that his eye has been red for a long time. He has a wing-shaped fold of fibrovascular tissue nasally in both eyes that extends onto the cornea. Should...
An unfortunate victim of domestic abuse had lye thrown in his face. What should you do?
What is his prognosis?
A young boy presents with purulent discharge over the past few days. His mother thinks that he needs antibiotics. Do you agree?
What are the common organisms responsible for bacterial conjunctivitis in children? How should you treat?
A 27-year-old woman complains of red, irritated eyes with watery discharge over the past 6 weeks. A follicular conjunctivitis & palpable preauricular node are present...
How do you proceed?
How do you diagnose the other causes of chronic conjunctivitis?
A 40-year-old woman presents with a bright red eye that she noticed on awakening in the morning. On examination, she has a subconjunctival hemorrhage. What questions are important to ask?
She answers no to the above questions & states that this is her first episode. Should she be worried?
With further thought, she remembers two other hemorrhages in her left eye & reports that her menses have been much heavier recently. What now?
A 60-year-old woman complains that her eyes have been red & burning over the past several weeks. She also has some tearing & photophobia. On exam, you notice mild conjunctival...
A 22-year-old woman presents with mild redness in the temporal quadrant of her left eye for about 1 week. She notices no discomfort. On exam, she has normal vision. Large episcleral...
The same patient returns 2 months later. Her left eye is still red, but it is now diffuse. She denies arthritis, rash, venereal disease, tick exposure, or other medical problems...
A 65-year-old woman with rheumatoid arthritis states that her left eye has been red & painful for a couple of weeks. The pain is severe & radiates to her forehead & jaw & has...
How else may scleritis present?
What percentage of patients with scleritis have systemic disease? What diseases are associated with scleritis?
What workup is appropriate for a patient with scleritis?
How should you treat the patient?
What about topical steroids or a subconjunctival steroid injection?
A 35-year-old man presents with severe photophobia, pain & decreased vision in his right eye for two days. This condition has occurred several times before. He says that it is...
A 68-year-old Asian American woman presents with an acutely painful red left eye that developed after a recent anxiety attack. She has blurred vision & sees halos around...
Key Points: Diseases That May Mimic Uveitis
Bibliography
8. Corneal Infections
What is a corneal ulcer?
What clinical features distinguish an infectious corneal ulcer?
What clinical features distinguish a sterile corneal ulcer?
What conditions predispose to corneal infections?
How can a contact lens wearer reduce the risk of infection?
Describe classic presentations & associations of various types of corneal infections (e.g., bacterial, viral, fungal).
When should smears & cultures be performed?
How should smears & cultures be performed?
What smears & cultures should be obtained? What culture plates should be used?
What is the diagnostic yield for smears & cultures performed prior to the initiation of therapy?
What is the recommended initial therapy for suspected infectious ulcers? How does one determine whether single-agent, broad-spectrum antibiotics or combination...
How does the presence of a hypopyon affect the management of infectious keratitis?
When should an anterior chamber and/or vitreous tap be performed?
When should patients with corneal ulcers be hospitalized?
When are systemic medications indicated?
Other than antibiotics, what adjunctive therapy may be necessary in the treatment of corneal ulcers?
How should the smear & culture results be used to modify treatment?
What are the important immediate & delayed sequelae of corneal ulcers?
How should impending & frank corneal perforations be managed?
What steps should be taken when a corneal ulcer does not respond to empirical therapy?
When should a corneal biopsy be considered?
What is the role of topical corticosteroids in the treatment of corneal ulcers?
How are staphylococcal hypersensitivity infiltrates diagnosed & managed?
What is appropriate therapy for small peripheral infiltrates in a contact lens wearer?
When should a gonococcal infection be suspected? What additional workup & treatment should be initiated?
Key Points: Corneal Ulcers
Why do herpetic infections occur?
Why is herpes a recurrent disease?
Give some nonocular signs suggestive of a herpetic corneal infection.
Are there differences between corneal infections caused by herpes simplex & herpes zoster viruses?
What are the noninfectious manifestations of a herpetic keratitis?
How should these infections be treated?
What is the role of topical corticosteroids in herpes simplex keratitis?
Key Points: Herpetic Keratitis
When should oral acyclovir be used in herpes simplex keratitis?
Are corneal infections common after refractive surgical procedures such as laser in-situ keratomileusis (LASIK)?
What other conditions can be mistaken for a corneal infection after LASIK?
Which clinical features help to distinguish DLK from an infectious process after LASIK?
Key Points: LASIK Infections
How should corneal infections after LASIK be prevented & managed?
9. Ophthalmia Neonatorum
How does ophthalmia neonatorum typically present?
What is the usual means of transmission for neonatal conjunctivitis?
What is the most common cause of neonatal conjunctivitis in the United States?
List the common causes of ophthalmia neonatorum, their usual clinical presentations & their approximate times of onset after birth.
Which type of neonatal conjunctivitis is associated with the most severe complications to the eye?
Key Points: Most Common Causes of Neonatal Conjunctivitis
What other diagnostic tool is used to differentiate the various causes of neonatal conjunctivitis?
Is a follicular reaction in the conjunctiva more indicative of a chlamydial or gonococcal infection?
Why is Crede prophylaxis (2% silver nitrate drops) no longer the standard agent of choice for routine neonatal conjunctivitis prevention?
What is currently used for neonatal prophylaxis?
What is the differential diagnosis of neonatal conjunctivitis?
When is systemic treatment indicated for neonatal conjunctivitis? Why?
List the potential ocular & systemic sequelae of untreated neonatal conjunctivitis.
What is the treatment for chlamydial conjunctivitis?
Key Points: Potential Systemic Complications of Neonatal Conjunctivitis
What is the treatment for gonococcal conjunctivitis?
What is the treatment for bacterial conjunctivitis?
Key Points: Potential Ocular Complications of Neonatal Conjunctivitis
What is the treatment for herpes simplex viral conjunctivitis?
How can the incidence of ophthalmia neonatorum be reduced in future generations?
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Bibliography
10. Topical Antibiotics & Steroids
You are an antibiotic or steroid eyedrop just placed in the conjunctival fornix. Discuss the barriers to your journey into the eye.
Given the above barriers, how would you increase delivery of topical antibiotics or steroids to the desired site of action?
Name the three different formulations of topical medications & the advantages & the disadvantages of each.
Key Points: Strategies to Increase the Penetration of Topical Medications
A 60-year-old man complains of crusting of the eyelids in the morning & chronic foreign-body sensation. Examination reveals moderate blepharitis with...
A 30-year-old woman with "cold" symptoms presents with redness & mucous discharge in both eyes. The ocular symptoms began in the...
A 55-year-old woman complains of discharge & redness of her right eye for 4 weeks. Her family physician told her that she had "pink eye" & prescribed...
A 25-year-old man holding a towel over his right eye complains of copious discharge that began in the morning. Examination reveals diffuse...
A 26-year-old physician in a general surgery residency with a doctorate in pharmacology presents with foreign-body sensation & photophobia in both eyes...
After corneal cultures are done, the patient is instructed to take ciprofloxacin every hour around the clock. Next day, he is in worse pain, and...
The patient now prefers a "proven" treatment regimen with a long history & requests topical fortified antibiotic. However, he recalls that minimal...
The patient reminds you that he is penicillin-allergic & does not enjoy anaphylaxis. What antibiotics should you choose? How do you...
Next morning the ulcer looks worse with 4 mm corneal infiltrate & purulent material overlying the ulcer. The corneal culture confirms Pseudomonas aeruginosa. Why...
Next day, the ulcer looks stable, but the patient complains of persistent & perhaps worsening pain. Examination reveals diffuse punctate corneal epithelial defects...
The patient slowly improves, but significant corneal scar remains. He would like binocular vision for his surgical career & asks you to get rid of his corneal scar. How do you respond?
Key Points: Corneal Ulcers
Review the currently available topical antibiotics in generic & brand names.
How do topical steroids work?
Since steroids are not cures, what general categories of disorders warrant ophthalmic use of topical steroids?
The physician with the residual corneal scar wants to minimize his corneal scar but is concerned about potential side effects of topical steroids. How do you advise him?
After a lengthy discussion, the patient agrees to try topical steroids. However, given his interest in pharmacology, he requests a brief discussion of the pharmacokinetics of...
The patient also requests that the most potent steroid be used with rapid taper so that the overall course may be shortened. Which steroid do you choose?
The patient is started on 1% prednisolone acetate 4 times/day. His scar is beginning to recede, but he returns 2 days later with complaints of a white precipitate...
On day 10 of steroid therapy, the corneal scar is receding rapidly, but the patient complains of foreign-body sensation. Examination reveals large corneal epithelial dendrites. What should you do?
Fortunately, the dendrite heals rapidly & the previous corneal scar has faded significantly with return to 20/20 vision in that eye. Four years have passed & the patient is...
Two days later, only marginal improvement is noted, but intraocular pressure is 35 mmHg. What happened?
The frequency of prednisolone acetate administration was increased to every 3 hours while awake & timolol, 2 times/day, was added. One week later intraocular pressure...
Review the commonly available topical steroids & their generic & brand names.
Bibliography
11. Dry Eyes
What is the definition of dry eye?
Describe the normal tear film.
What are the components of the tear film?
What is the function of the outer lipid layer?
What causes dysfunction of the outer lipid layer?
What is the function of the aqueous middle layer?
What is the function of the inner mucin layer?
What diseases of the conjunctiva can cause dry eye?
What is necessary for the normal resurfacing of the tear film?
What are the types of dry eye?
What are the symptoms of dry eye?
What are the most common signs of dry eye?
What is Sjoumlgren's syndrome?
Who gets dry eye?
What is the difference between fluorescein & rose bengal stains?
How do you measure a tear break-up time (TBUT)?
What is Schirmer's test?
What are the treatments for dry eye patients?
What if the patient uses tears six to eight times a day & returns with red, painful eyes & more superficial punctate keratitis?
What if this is still not enough?
Key Points: Severe Dry Eye
A patient with punctal occlusion returns with more irritation & burning since the procedure was done. The tear film meniscus is greatly improved. What happened?
Is there any treatment to increase tear production?
What is the role of acetylcysteine?
What medications may be a cause of dry eye?
Bibliography
12. Corneal Dystrophies
What are corneal dystrophies?
How do degenerations differ from dystrophies?
Discuss the general anatomic classification of corneal dystrophies.
Key Points: Differences Between Corneal Dystrophies & Degenerations
Describe the inheritance patterns of anterior membrane dystrophies.
Which is the most common anterior membrane dystrophy? Which is strictly epithelial?
What are the most common presenting symptoms of anterior membrane dystrophies?
Discuss treatment options for recurrent corneal erosions associated with anterior membrane dystrophies.
Key Points: Recurrent Corneal Erosions
Discuss the role of surgery in the treatment of anterior membrane dystrophies.
Do lasers have a role?
What controversy surrounds the dystrophies affecting Bowman's layer?
Describe the inheritance patterns of the stromal dystrophies.
Match the stromal dystrophy with the histochemical stain for the accumulated substance.
Describe the clinical features of the three major stromal dystrophies.
Is lattice dystrophy associated with systemic amyloidosis?
What is the differential diagnosis of corneal stromal crystals? What systemic findings are associated with Schnyder's crystalline dystrophy?
How does central cloudy dystrophy of Franccedilois differ from posterior crocodile shagreen?
What characterizes Avellino dystrophy?
How are stromal dystrophies treated?
Is penetrating keratoplasty a definitive treatment?
Key Points: Penetrating Keratoplasty
Name the three posterior membrane dystrophies.
What is their common clinical manifestation?
Describe the inheritance patterns of the three posterior membrane dystrophies.
Describe the main clinical characteristics of the three posterior membrane dystrophies.
How does Fuchs' dystrophy differ from cornea guttata?
Describe the workup of a patient with Fuchs' dystrophy.
What overlapping features are seen in PPMD & ICE syndromes?
What is unique about the CHED cornea?
Discuss management & prognosis of posterior membrane dystrophies.
Can PPMD recur in the graft?
Discuss considerations for combined cataract extraction & corneal transplantation in patients with Fuchs' dystrophy.
List some interesting trivia about corneal dystrophy.
Websites
Bibliography
13. Keratoconus
What is keratoconus?
Who gets keratoconus?
What is the cause of keratoconus?
What is the relationship between contact lens wear & keratoconus?
Is keratoconus hereditary?
What systemic conditions are associated with keratoconus?
What ocular conditions are associated with keratoconus?
What are the symptoms of keratoconus?
How is the diagnosis of keratoconus made?
Key Points: Diagnosis of Keratoconus
What are the topographic signs of keratoconus?
What are the slit-lamp findings of keratoconus?
How does keratoconus progress?
What is acute hydrops?
What is the histopathology of keratoconus?
How is keratoconus treated?
What types of contact lenses are used to treat keratoconus?
What are the surgical options for treating keratoconus?
What are the results of corneal transplant in patients with keratoconus?
Website
Bibliography
14. Refractive Surgery
What are the refractive components of the eye?
What are the different types of refractive errors?
How is myopia related to age?
What are the goals of refractive surgery?
What features characterize a good candidate for refractive surgery? Are there any contraindications?
How is corneal topography used in the evaluation of patients undergoing refractive surgery?
What are the major options for the surgical treatment of myopia?
How does RK reduce myopia?
What are the various RK techniques?
What results have been achieved with RK? What about complications?
How does PRK reduce myopia?
What results have been achieved with PRK? What about complications?
Discuss the major advantages & disadvantages of PRK versus RK.
What is LASIK?
How have advancements in the LASIK procedure helped to improve results?
What is the range of myopia recommended for correction with LASIK?
What are the advantages & disadvantages of LASIK versus RK & PRK?
How do the surgical results of LASIK compare with those of PRK?
What is "wavefront?" Are wavefront ablations any better than standard LASIK?
Name the important potential complications of LASIK.
Key Points: Common Potential Contraindications to LASIK
What is diffuse lamellar keratitis (DLK)? How is it treated?
What is Epi-LASIK? What are the potential advantages?
What is the femtosecond laser? What are its potential advantages?
What is progressive corneal ectasia?
What are intracorneal ring segments?
How much myopia do Intacs treat?
What are the refractive results of Intacs for myopia?
List the potential complications of Intacs.
Is the Intacs procedure reversible?
What are phakic IOL implants?
What is the effect of the Verisyse phakic IOL implant on endothelial cell count?
What are accommodative IOLs?
Are there any other surgical options for the treatment of myopia?
What are the treatment options for astigmatism?
What can be done about astigmatism after a corneal transplant?
A 40-year-old Olympic ski coach desires refractive surgery so that he may see distance clearly. His refraction is -3.00 x -2.00 at 180 in both eyes. The surgeon performs...
What about procedures for hyperopia?
What are the effects of refractive surgical procedures on corneal endothelial cells?
What is the role of drugs in refractive surgery?
Section III - Glaucoma
15. Glaucoma
What is glaucoma?
How is glaucoma classified?
How prevalent is glaucoma?
Name risk factors for the development of primary open-angle glaucoma (POAG).
Discuss the genetics of primary open-angle glaucoma (POAG).
What is the pathogenesis of glaucoma?
What is the clinical presentation of primary open-angle glaucoma?
What is normal intraocular pressure (IOP)?
True or false: Loss of peripheral vision is a warning sign of early glaucoma.
Key Points: Common Visual-Field Defects Found in Glaucoma
What is a glaucoma suspect?
In examination of the optic nerve, what findings could be consistent with a diagnosis of glaucoma or suspicion of glaucoma?
Key Points: Common Optic Nerve Findings in Glaucoma
A patient presents with optic nerve damage in one eye as pictured in Fig. 15-1. The other eye has lower pressures & a healthier optic nerve with a normal visual field. What...
A 74-year-old African American female presents for a routine eye examination. She has not been to an ophthalmolo in 10 years. Her intraocular pressures are 26 mmHg in the right eye...
If the patient in question 13 had been to another ophthalmologist several times a year & was presenting for the first time in your office, what information would be important to obtain?
True or false: If the patient in question 13 had a normal visual field, she would be unlikely to have glaucoma.
True or false: If the patient in question 13 had intraocular pressures of 19 mmHg OD & 18 mmHg OS, then she would be unlikely to have glaucoma.
How does intraocular pressure (IOP) fluctuate in glaucoma patients?
What role does central corneal thickness play in the evaluation of glaucoma?
Name factors that affect the measurement of intraocular pressure.
What is the primary goal of treatment of patients with glaucoma?
Name different initial treatment options for primary open-angle glaucoma.
What factors help determine which option to try?
Are eyedrops safer than oral medications?
Are some optic nerves more resistant to intraocular pressure damage than others?
A patient being treated for glaucoma presents for a follow-up examination with an optic nerve appearance as shown in Fig 15-3. Discuss the findings.
Name five potential causes of disc hemorrhages.
What is low-tension glaucoma (LTG)?
What disease entities can mimic LTG?
What tests should be considered in the workup of a patient with glaucomatous-appearing optic nerves & visual fields without elevated intraocular pressure?
How is average-pressure glaucoma treated?
16. Angle-Closure Glaucoma
What landmarks are seen in the anterior chamber (AC) angle?
Why is a goniolens necessary to visualize the AC angle?
What are the different kinds of goniolenses? How do they differ?
Which goniolens is preferred by most glaucoma specialists & why?
How is gonioscopy performed?
How can I determine which patients may have narrow angles & need gonioscopy?
What are the different gonioscopic anterior chamber angle classification systems?
How do I know if I can safely dilate a patient, with or without a slit lamp?
How is angle closure classified?
Primary Angle Closure (Relative Pupillary Block)
What is the epidemiology of primary angle-closure glaucoma?
What are the symptoms of acute angle-closure glaucoma?
Describe the signs or exam findings seen in primary acute angle-closure glaucoma.
Key Points: Common Signs of Acute Primary Angle-Closure Glaucoma
How does subacute or intermittent angle closure present clinically?
How does chronic angle closure present clinically?
What are the anatomic characteristics of eyes with primary angle closure?
What is the pathophysiologic mechanism of relative pupillary block?
What nonmedical maneuver may help to lower IOP even before medicating the patient?
How would you treat the involved eye medically?
Key Points: Basic Treatment of Acute Primary Angle-Closure Glaucoma
How would you treat the involved eye with laser?
What are the most common complications of laser PI?
What are the indications for surgical intervention? What are the surgical options?
When can you consider an attack to be completely "broken?"
What are the chances of the same thing happening to the fellow eye?
What would you recommend for the fellow eye?
Describe the short- & long-term sequelae to the various structures of the eye after an acute angle-closure attack.
What types of medications are contraindicated in narrow-angle glaucoma?
Key Points: Long-term Sequelae of Acute Angle-Closure Glaucoma Attack
List some possible causes for persistent or recurrent IOP elevation after a successful PI.
Plateau Iris
Describe the epidemiology of plateau iris.
How does it present clinically?
What is plateau iris configuration (PIC)?
How can plateau iris be distinguished from relative pupillary block (primary) angle closure on slit-lamp examination?
What is plateau iris syndrome?
How is plateau iris treated?
Aqueous Misdirection Syndrome (Malignant/Ciliary Block Glaucoma)
What is aqueous misdirection syndrome?
How is aqueous misdirection treated medically?
How can aqueous misdirection be treated with laser if it is unresponsive to medication?
How can aqueous misdirection be treated surgically if refractory to medical therapy and/or laser?
Neovascular Glaucoma
What typically causes neovascular glaucoma (NVG)?
How is neovascular glaucoma treated?
Miscellaneous
What are the different mechanisms of producing angle closure secondary to inflammation?
Describe nanophthalmos.
List one systemic medication that can cause angle closure by producing ciliochoroidal effusions & the principles for manage
Websites
Bibliography
17. Secondary Open-Angle Glaucoma
A 72-year-old man presents for a routine exam. He states that vision in the left eye is getting bad. On exam, he has vision of 20/30...
What should you look for to make a diagnosis of pseudoexfoliation glaucoma?
Is the condition cured after cataract extraction?
What is true exfoliative glaucoma?
Key Points: Pseudoexfoliation Glaucoma
A 24-year-old man with sarcoidosis presents with an intraocular pressure of 35 mmHg in the right eye & 32 mmHg in the left...
The same patient returns 14 days later with pressures of 40 mmHg & 45 mmHg in the right & left eye, respectively. Exam...
What does a Krukenberg spindle look like? What does it mean?
How is pigmentary dispersion treated?
A 95-year-old woman presents with a markedly red, painful right eye of 2 days' duration. Her vision is hand motions at 1 foot & 20/400...
A 64-year-old woman who had cataract surgery in the left eye 1 week ago presents to the emergency department complaining that the...
What other type of open-angle glaucoma can be caused by the lens?
What is Posner-Schlossman syndrome? Who gets it?
What is the classic triad of Fuchs' heterochromic iridocyclitis?
A patient reports for postoperative check-up 1 day after cataract surgery. The pressure in the operated eye is 40 mmHg & the...
What else can cause postoperative glaucoma?
A patient had cataract surgery 1 year ago but continues to have episodes of anterior chamber cell & flare with increased intraocular...
How can raised episcleral venous pressure cause glaucoma?
Key Points: Causes of Raised Episcleral Venous Pressure
A patient with long-standing diabetes has had recurrent vitreous hemorrhage. While you are observing him waiting for the condition to clear,...
What other conditions may cause open-angle glaucoma?
What types of secondary open-angle glaucoma occur in children?
Bibliography
18. Medical Treatment of Glaucoma
What classes of medications are used to treat glaucoma?
How do these medications work?
For patients in good health with primary open-angle glaucoma, what is the first drug to try?
What medicine should be used as second-line therapy? Third-line therapy?
Are there any hints for prescribing beta-blockers?
How does one choose among the five nonselective beta-blockers?
Any hints for prescribing prostaglandin analogs?
Any tips on prescribing adrenergic agonists?
Any tips on prescribing carbonic anhydrase inhibitors (CAIs)?
Key Points: Glaucoma Topical Medications
How many eyedrops can be used?
What are the general rules for using eyedrops?
Pilocarpine is often used in the treatment of angle-closure glaucoma. What is its effect on the anterior chamber?
If a patient does not show an expected response to a topical glaucoma medication, what should the ophthalmologist consider as
Many patients taking topical medications complain of dry or irritated eyes. What should the treating ophthalmologist include as a routine...
In a patient with an ocular allergy secondary to topical medication, which is the most likely offender?
Are any of the glaucoma medications safe for use in pregnant women? In children?
Is there any evidence that current glaucoma medications are neuroprotective?
Are there any glaucoma medications that are not designed to lower eye pressure?
Key Points: Common Side Effects of Topical Glaucoma Medications
Website
19. Trabeculectomy Surgery
What are the indications for trabeculectomy surgery?
What is the goal of glaucoma surgery?
How do we inform patients about the risks of trabeculectomy surgery?
Describe the factors associated with failure of glaucoma filtering surgery.
Does a fornix versus a limbal-conjunctival approach affect outcome?
What medications should be stopped before filtration surgery?
What are the choices of anesthesia?
Does a triangular versus a rectangular flap affect outcome?
Does the size of the internal block affect outcome?
Are iridectomy & paracentesis always necessary during filtration surgery?
How tight should I make the scleral flap?
Are releasable sutures necessary?
Does it matter how far I dissect the scleral flap anteriorly?
Should atropine be used during the procedure?
How often are steroids used in the postoperative period?
How can you avoid a flat anterior chamber after trabeculectomy?
What do you do when a wound leak occurs in the immediate postoperative period?
Key Points: How to Avoid Complications of Trabeculectomy
What do you do if there is vitreous loss at the time of the trabeculectomy?
Which ocular conditions may predispose to vitreous loss during trabeculectomy surgery?
Describe the indications of antimetabolites in trabeculectomy surgery.
How does 5-fluorouracil differ from mitomycin C?
Are antimetabolites indicated in primary filtering procedures?
What do you do when the iris blocks the trabeculectomy site in the immediate postoperative period?
What if the ciliary processes roll anteriorly & block the trabeculectomy site during surgery?
When is it necessary to give postoperative 5-FU injections?
What do you do if the bleb starts to fail?
Key Points: How to Improve Your Success Rate
What is the technique of bleb needling?
What is the differential diagnosis for a flat anterior chamber?
How urgent is the management of a flat anterior chamber?
What are the indications to drain a choroidal detachment?
20. Traumatic Glaucoma & Hyphema
What is a hyphema?
List the causes of a hyphema.
What is the most common cause of a traumatic hyphema?
Describe the pathophysiology of a traumatic hyphema.
List the anterior segment structures that may split or tear in response to blunt ocular injury.
When a patient presents with a hyphema due to blunt ocular trauma, which anterior segment structure is the most likely source of the hemorrhage?
What ocular injuries may be associated with a traumatic hyphema?
Describe an appropriate approach toward the workup of a patient with a hyphema.
Key Points: Traumatic Hyphema
What are pertinent questions to ask a patient who presents with a traumatic hyphema? Why?
How are hyphemas managed?
Explain the rationale for the use of antifibrinolytic agents in the treatment of hyphema.
Name the most common adverse effects associated with aminocaproic acid treatment.
In what setting is aminocaproic acid contraindicated?
Why are patients with sickle cell disease or sickle cell trait at a particularly high risk for developing complications from a hyphema?
Key Points: Traumatic Hyphema & Sickle Cell Disease
What level of intraocular pressure is considered medically uncontrolled?
List the indications for surgical intervention in the management of a hyphema.
Name the major complications associated with a hyphema.
What is corneal blood staining?
What percent of patients with a hyphema develop corneal blood staining?
In which setting is corneal blood staining most likely to occur?
What is the differential diagnosis of the appearance of bright red blood in the anterior chamber within the first 5 days after
In the setting of a traumatic hyphema, when is a patient at greatest risk for developing a recurrent hemorrhage?
How common is a recurrent hemorrhage?
What is the significance of a recurrent hemorrhage? Why is it important to try to prevent it?
List the risk factors that may be associated with an increased risk of developing a recurrent hemorrhage.
What is an eight-ball hyphema?
How is an eight-ball hyphema different from a total or 100% hyphema?
What is the prognosis for an eight-ball hyphema?
When is the optimal time to remove a clotted or eight-ball hyphema? Why?
What types of surgical techniques can be used to evacuate a hyphema?
List the types of secondary glaucoma associated with a traumatic hyphema.
Is the chance of developing secondary glaucoma related to the size of the hyphema?
Why & when is it important to perform gonioscopy on patients who have suffered a hyphema?
Given a history of ocular trauma, how can one make the diagnosis of angle recession on gonioscopic examination?
Explain the difference between a cyclodialysis & an angle recession.
Once a cyclodialysis cleft is suspected, how can it be diagnosed?
How long after a traumatic hyphema is a patient at risk for developing angle-recession glaucoma?
Explain the pathophysiology of angle-recession glaucoma. Is it a direct result of injury to the ciliary body?
Describe treatment for angle-recession glaucoma.
Bibliography
Section IV - Cataracts
21. Cataracts
Explain the derivation of the word cataract.
What is the leading cause of blindness worldwide?
What is a nuclear sclerotic cataract?
What produces the brown color seen in cataracts?
What is "second sight?" How is it associated with nuclear sclerotic cataracts?
What are the typical symptoms of nuclear sclerotic cataracts?
What are posterior subcapsular cataracts?
What are the symptoms of posterior subcapsular cataracts?
What are the associated systemic findings in patients with cataracts?
What are the major potential causes of cataracts in infants?
What is a morgagnian cataract?
What is phacolytic glaucoma?
What is phacomorphic glaucoma?
What is pseudoexfoliation? What is its relationship to cataracts?
A patient underwent successful & uncomplicated cataract surgery & years after their surgery, the IOL completely dislocated. What...
What is true exfoliation syndrome as opposed to pseudoexfoliation syndrome?
What systemic syndromes should be considered in a patient with a spontaneously dislocated natural lens?
Key Points: Dislocated & Subluxated Lenses
What other clinical findings are common in patients with a traumatic cataract?
What are the indications for cataract surgery?
Does a cataract need to be "ripe"?
What is aphakia? What are aphakic spectacles? What is pseudophakia?
How is the IOL power determined? What is the most commonly used IOL power?
What are multifocal IOLs? How do multifocal IOLs work?
What is IFIS? What is a flomax pupil?
What is the difference between an anterior chamber lens & a posterior chamber lens? What is "the capsular bag"?
What is posterior capsular opacification? What is a secondary membrane? Can a cataract grow back?
What is a YAG capsulotomy?
What is the origin of the term laser?
What is the difference between an "intracap" & an "extracap?"