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Eye Balls on Parade (2011)

Eye Balls on Parade (2011)

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Published by Kyle Michael

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Published by: Kyle Michael on Mar 27, 2012
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1
EyeBalls on Parade
Lecture 1 - Essentials of Anatomy & Physiology
-3 leading causes of blindness in US are: 1)DM, 2)Glaucoma, and 3)Macular degeneration-CN VII closes eye (orbicularis oculi), III opens eye (levator palpebrae)-Levator Palpebrae +
Mueller‟s muscle
 /Superior Tarsal (sympathetic) opens eyelid-Orbicularis closes eye
 
Canal/Fissure Structures running throughOptic Canal
Optic nerve + meningeal sleeveOphthalmic artery + sympathetic complex
Superior Orbital Fissure
Lacrimal nerveFrontal nerveSuperior Ophthalmic VeinTrochlear nerveOculomotor nerveNasociliary nerveAbducent nerve
Inferior Orbital Fissure
Maxillary nerveInfraorbital nerveZygomatic nervePterygopalatine ganglion branchesInferior ophthalmic vein-Orbital fracture usually in lamina papyracea (orbital floor)-When injured, Endothelium does NOT proliferate --- Epithelium does-
Cataract
is a normal aging process; just thickening of the lens with age-
Scotoma
= reduced/absent vision
; “blind spot”
; may look like
a “cracked mirror” or “heat off pavement” to the pt
 -
Hemianopia
= loss of ½ visual field-
Homonymous
= loss of right or left visual field-
Lesions
!-Anterior to chiasm = monocular loss-Chiasmal = bitemporal hemianopia-Posterior to chiasm = homonymous hemianopia-Cupping is out-pouching of optic disc-Macula --- 1:1 rods to cones, avascular; where fine vision is from-
Metabolism
is very important for transparency, mainly in lens epithelium-Anaerobic glycolysis, TCA, Hexose monophosphate shunt, and
Sorbitol pathway
; utilizes every type of metabolism
we‟ve learned about!
 -Glucose enters through the aqueous humor and is rapidly metabolized-
Sorbitol Pathway:
Usually only 5% of glucose metabolism, but with hyperglycemia (DM), it gets shunted down thispathway utilizing
 Aldose Reductase
 -
Lens swells and blurs vision…cataracts
 -
Sorbitol CANNOT diffuse out of lens…osmotic
influx of H20 = edema, separation of lens fibers, loss of transparency, refractive changes. Chronically this process leads to cell lysis w/release of cellular contents andearly cataract development.-
Sorbitol → Fructose (CAN diffuse out of lens) but takes 6 weeks for vision to go back to normal
 -
Reactive surface of eye
 
= Cornea (2/3) and Lens (1/3)…if different, then
Astigmatism
; cornea =
“point and shoot”
 
lens = “focus”
 -
Astigmatism
 
 – 
uneven curvature of the cornea; causes separate areas of focus and consequent blurring-
Accommodation
= ability of ciliary muscle to contract for lens to focus; look near, pupils will constrict and eyes converge-
Hyperopia
 
= Farsighted…axial length short
 
 – 
you can see far; images focus behind the retina-
Myopia
 
= Nearsighted…axial length long
 
 – 
you can see near; images focus in front of the retina-
Presbyopia
= loss of accommodation (focusing) w/ age (early
40‟s)…CANNOT be halted w/ refractive surgery
 -
Photophobia
= Iritis until proven otherwise-
Visual Acuity
= best corrected monocular vision (distance, near, color, Amsler grid)-20/200 = Legal Blindness-Corrective Surgery: See notepool if you really want to
 
2
Lecture 2 -The Ocular Exam
-Visual Acuity
1
st
(except in chemical burns)-Best corrected monocular vision
 – 
Distance (Snellen), Near (Rosenbaum)-Color with pseudochromatic plates -
red/blue/green…defect usually x
-linked but can be acquired d/t drugs or O.N.damage-Amsler Grid -
testing macula for scotoma/metamorphopsia…10 degrees
from fixation of central vision-Visual Fields
 – 
Confrontation; check for scotomas and any other visual defects/lesions-External Exam
 – 
lids, eyebrows, eyelids, eyelashes, lacrimal glands, lymph nodes, proptosis/exophthalmos-Top 3 Complaints Seen in Ophthalmology:1) Disturbance of vision
 – 
diplopia, reading problems, blurred vision, color changes, etc.-**
anytime you hear “floaters” and “photopsia” (flashes of light) you MUST think 
 retinal detachment**
 
2) Pain or discomfort in/about eyes
 – 
foreign body sensation, burning, headaches, etc.-Itching = allergies; photophobia = iritis3) Abnormal eye secretions-Purulent
 – 
bacterial- Mucus
 – 
allergy-Serous - viral-Cornea: Cornea Sensitivity = CN V-
Fluroescein Staining of Cornea…detects epithelial defects (visualize w/ cobalt blue filter)
 -Corneal abrasions are VERY painful (worse than childbirth?)
-Arcus Cornea
 
 – 
corneal degeneration which could be d/t dyslipidemia-Anterior Chamber Assessment of Depth with Side Penlight Test
 – 
normal = deep; if shallow think glaucoma-
Refer cataracts when decreased vision interferes w/ ADL‟s (patient decides if they need surgery, not physician)
 -Pupillary Testing: DO NOT USE PERRLA!!-Direct
 – 
size (mm), equal,
anisocoria
(unequal size of pupils), reactive to light-Consensual-Swinging - detects afferent reflex (II in / III out); most important; RAPD = Relative Afferent Pupillary Defect-Pupillary Defects:-
CN III defect
 
 – 
dilated pupil (pupil sparing), EOM paresis/palsy (eye will be aBducted), ptosis-
Adie’s Tonic Pupil
= usually post-viral syndrome involving ciliary ganglion leading to blurred vision (esp. near),periocular discomfort, and decreased depth perception. D/t pupil that barely moves and is not completely round-
Pharmacologic Pupil
= often medical personnel or medications; allergy, cold, or motion sickness-
Horner’s Syndrome
= SNS pathway lesion leading to: Ptosis, Miosis, Anhydrosis (lack of sweating)-
Argyll Robertson Pupil
 
(Prostitute‟s Pupil )
= pupils accommodate but do not react to light, are irregular and small.Associated w/DM, EtOH, and Syphilis-Cover-Uncover test
 – 
checking for strabismus; best for checking EOM alignment-EOM tests
 – 
especially when c/o of diplopia
Right + Up
-Right superior rectus-Left inferior oblique
Lest + Up
-Left superior rectus-Right inferior obliquee
Right
-Right lateral rectus-Left medial rectus
Left
-Left lateral rectus-Right medial rectus
Right and Down
-Right inferior rectus-Left superior oblique
Left and Down
-Left inferior rectus-Right superior oblique-Opthalmoscopy
 – 
red reflex, cup:disc ratio, circulation, macula, etc.-
Nystagmus
 
 – 
spontaneous back-and-forth movement of the eye(s); can be d/t drugs, CNS lesions, physiologic, tumors, etc.-Common causes of diplopia = III/IV/VI Palsy, Myasthenia Gravis, Graves, Blowout fracture-Do NOT dilate if shallow chamber, neurological pt, iris supported lens-
Schiotz Tonometry…normal 10P 10
-21 mmHg, anesthetize w/ proparacaine, separate lids w/out pressure-Record and
 convert to IOP
 -***Eye Exam Steps Summary (
KNOW THIS!!)***
-Measure best corrected monocular VA, Perform VF via confrontation, Inspect external (lid, lashes, lymph nodes), Inspectconjunctiva & sclera, Test EOM, Pupillary testing, Inspect cornea & iris, Assess A/C depth, Assess lens clarity, Fundus exam(C/D, A/V, macula), Perform tonometry if indicated-
 Refer if…*** 
 
-VA <20/20 if visual complaints-VA <20/40 even in absence of complaints-VA asymmetry --- difference of 2 lines or more-Fundus abnormality-Shallow A/C or IOP > 22 mmHg
 
3
Lecture 3 - Acute Visual Loss I
-Disease Etiologies: PD VITAMIN C (Psychiatric/functional, Drugs, Vascular, Infectious, Trauma, Autoimmune/Allergy,Metabolic, Idiopathic/Iatrogenic, Neoplasm, Congenital)-Onset < 72 hours-
**Herpetic eye disease is the leading cause of INFECTIOUS corneal blindness in the US
 -1
st
refractive surface of eye = Tear Film; then cornea, anterior chamber, lens, vitreous, and retina-
Corneal Edema
= most common cause of increased intraocular pressure (IOP)
-Mostly by acute angle closure glaucoma; becomes dull ground glass appearance-
Acute Angle Closure Glaucoma
 -Acute onset, severe pain,
mid-dilated fixed pupil
 
… could be irregular, “ground glass” appearance
 /cloudy, push on eye =rock hard, blurred vision, haloes around the lights, headache, nausea/vomit, IOP rises, shallow anterior chambers-Treatment = Pilocarpine 2% (muscarinic agonist), Acetazolamide (carbonic anhydrase inhibitor), Glycerine/Isosorbide,
 IV  Mannitol 
(osmotic diuretic)-Also do a laser iridotomy to create a hole in the ciliary body to allow fluid to drain again-Treat both eyes
at same time…prophylactic iridotomy if chamber is narrow
; drugs are NOT substitutes for iridotomy-
Hyphema
 
= Blood in anterior chamber…most commonly caused by
blunt trauma
-Decreased VA dependent on % hyphema-
Hospitalize if > 2% hyphema/visible…re
-bleed in 3-5 days.-sitting pt up leads to blood pooling in base of anterior chamber with a clear meniscus-
Vitreous Hemorrhage
 
= bleeding into vitreous…like a hyphema,
but resolves slower-Looks like cobwebs/blobs; like blood in clear jelly-Most commonly caused by
diabetic retinopathy + neovascularization
…then by retinal detachment
 -Dx made through dilated pupil-
Vitreous Detachment
= vitreous separates from retina w
ith aging…the gel liquefies/shrinks/becomes opaque
 -Nearsighted (myopia) > Farsighted (hypermyopia)-
When it pulls away, it makes specks/clumps…these reflect shadows into retina
 -
FLOATERS!
-Etiologies =
Myopia
, Cataract surgery (YAG), Inflammatory disease-
Retinal Detachment
 
=
 Photopsia + Floaters
 -Hole in the eye, Fireworks in the eye
flashes of light
-Followed by shade in visual field, slow loss of peripheral vision-Begins peripherally and dissects posteriorly-Dx through dilated pupil by ophthalmologist-
Macular Disease
…poor vision, generally NOT RAPD
(
relative afferent pupillary defect)
 -
DRUSEN BODIES!
 -Young pts = central serous retinopathy-Old pts = macular degeneration; dry vs wet-Sudden loss of vision if wet disciform-90% will
have chronic form…10% have sudden hemorrhage in choroid
 -Use Amsler Grid to help Dx-
Amaurosis Fugax
= sudden complete loss of vision lasting seconds to minutes; monocular dimming of vision-Temporary arterial obstruction; mini stroke/TIA of the eye-Evaluation: Cardiovascular, Cerebrovascular, Ophthalmologic, Migraine (ECHO, Holter monitor, etc.)-
Scintillating Scotoma ( 
a spot of flickering light near or in the center of the visual fields, which preventsvision within the scotoma
)mostly from Migraine
- heat waves/cracked mirror visual symptoms-
Can‟t prevent
 -Like going into the fog-
Migraine
 - Scintillating scotoma
 – 
see above- Amaurosis fugax- Ransient cortical blindness- Homonymous hemianopsia- Classic or opthalmic

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