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SECTION

8

Ophthalmology
Conjunctivitis

Bilateral

Unilateral

Watery discharge

Purulent, thick discharge

Easily transmissible

Poorly transmissible

Normal vision

Normal vision

Itchy

Not itchy

Preauricular adenopathy

No adenopathy

No specific therapy

Topical antibiotics

.... T IP
The "must know" subjects in ophthalmology are:



The red eye (emergencies)
Diabetic retinopathy
Artery and vein occlusion
Retinal detachment

497

Treat with medications to decrease the production of aqueous humor or to increase its drainage. pilocarpine. metipranolol. betaxolol. beta blockers. Walking into a dark room can precipitate pain because of pupilary dilation. • Prostaglandin analogues: latanoprost. and apraclonidine to constrict the pupil and enhance drainage • Laser iridotomy 498 . The diagnosis is confirmed with tonometry.3. Confirmation is with tonometry indicating extremely elevated intraocular pressure.I Master the Boards: USMLE Step 2 CK I I J The Red Eye (Ophthalmologic Emergencies) Presentation Itchy eyes. The cup-to-disc ratio is greater than the normal 0. brinzolamide • Alpha-2 agonists: apraclonidine • Pilocarpine • Laser trabeculoplasty: performed if medical therapy is inadequate Acute Angle-Closure Glaucoma / Look for the sudden onset of an extremely painful. red eye that is hard to palpation. mannitol. or levobunolol • Topical carbonic anhydrase inhibitors: dorzolamide. carteolol. discharge Autoimmune diseases Pain Trauma Eye findings Normal pupils Photophobia Fixed midpoint pupil Feels like sand in eyes Most accurate test Clinical diagnosis Slit lamp examination Tonometry Fluorescein stain Best initial therapy Topical antibiotics Topical steroids Acetazolamide. The cornea is described as "steamy" and the pupil does not react to light because it is stuck. laser trabeculoplasty No specific therapy. Treat with: • Intravenous acetazolamide • Intravenous mannitol to act as an osmotic draw of fluid out of the eye • Pilocarpine. patch not clearly beneficial Glaucoma Chronic Glaucoma Chronic glaucoma is most often asymptomatic on presentation and is diagnosed by routine screening. travoprost. bimatoprost • Topical beta blockers: timolol.

or valacyclovir. Treat with oral acyclovir. Early cataracts are diagnosed with an ophthalmoscope or slit lamp exam. Cataracts There is no medical therapy for cataracts. Proliferative retinopathy is treated with laser photocoagulation. Steroids markedly increase the production of the virus. Nonproliferative or "background" retinopathy is managed by controlling glucose level. The new lens may automatically have a bifocal capability. and painful. Surgically remove the lens and replace with a new intraocular lens. Advanced cataracts are visible on examination. Vascular endothelial growth factor inhibitors (VEGF) are injected in some patients to control neovascularization. Vitrectomy may be necessary to remove a vitreal hemorrhage obstructing vision. Source: Conrad Fischer.J Ophthalmology I I Herpes Keratitis Keratitis is an infection of the cornea. famciclovir. 499 . Topical antiherpetic treatment is trifluridine and idoxuridine. Diabetic Retinopathy Annual screening exams should detect retinopathy before serious visual loss has occurred. but do not use steroids. Steroids make the condition worse. Beware of steroid use for herpes keratitis. The eye may be very red. The most accurate test is fluorescein angiography. Figure 19. swollen.1: New blood vessel formation obscures vision. MD. Fluorescein staining of the eye helps confirm the dendritic pattern seen on examination.

. Figure 19. ocular massage. acetazolamide. There is no conclusive therapy for either condition. MD. The maculq.3: Retinal vein occlusion leads to extravasation of blood into the retina. and thrombolytics. or anterior chamber paracentesis to decrease intraocular pressure. Try ranibizumab for vein occlusion.Master the Boards: USMLE Step 2 CK Retinal Artery and Vein Occlusion Both conditions present with the sudden onset of monocular visual loss. 500 . MD. You cannot make the diagnosis without retinal examination. Source: Conrad Fischer. is described as "cherry red" in artery occlusion because the rest of the retina is pale. Figure 19. Treatment of artery occlusion is attempted with 100% oxygen. 2: Retinal artery occlusion presents with sudden loss of vision and a pale retina and dark macula. Source: Conrad Fischer.

cryotherapy. Macular Degeneration Macular degeneration is now the most common cause of blindness in older persons in the United States.J Ophthalmology I I Retinal Detachment Risks include trauma to the eye." Reattachment is attempted with a number of mechanical methods such as surgery. The neovascular or wet type causes 90% of permanent blindness from macular degeneration.4: Sudden. Detachment presents with the sudden onset of painless. painless loss of vision "like a curtain coming down. and diabetic retinopathy. and the injection of an expansile gas that pushes the retina back up against the globe of the eye. laser. Atrophic macular degeneration has no proven effective therapy. MD. extreme myopia that changes the shape of the eye. unilateral loss of vision that is described as "a curtain coming down. There is an atrophic (dry) type and a neovascular (wet) type. Figure 19." Source: Conrad Fischer. Anything that pulls on the retina can detach it. 501 . The cause is unknown. Visual loss in macular degeneration: • Far more common in older patients • • Normal external appearance of the eye • Loss of central vision Neovascular disease is more rapid and more severe. New vessels grow between the retina and the underlying Bruch membrane.

They are injected directly into the vitreous chamber every 4 to 8 weeks. Over 90% of patients will experience a halt of progression.Master the Boards: USMLE Step 2 CK Figure 19. Source: Conrad Fischer. and one-third of patients will have improvement in vision. MD. I 502 . or aflibercept. The best initial therapy for neovascular disease is a VEGF inhibitor such as ranibizumab. bevacizumab.5: Macular degeneration can be diagnosed only by visualization of the retina.