Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

*NOTE: Please study the trances together with the lecture

slide
Part 1: Introduction

I. General Reminders
- Keep calm
- Get template from OPD from different departments
- Focused PE, then proceed with other symptoms
- Put post-itsmarkers/ on books
- Bring personal notes
- PRAY

II. Instruments
- Working penlight
- Millimeter Ruler
- Jaeger (near vision chart)
- Occluder with pinhole

III. History taking and physical examination

A. Establish rapport: Introduce yourself, establish rapport, Distance (Snellen chart, Bailey-Lovie Chart)
ask permission to interview and to examine the patient - SC= without correction
B. General data: Name, age, sex, occupation - PH= pinhole
C. Chief complaint: Blurring of vision, redness, eye - CC= with correction
discomfort Near (Jaeger chart)
D. History of Present Illness: When did it start? Sudden - SC= without correction
or gradual? Character? Precipitating/alleviating factors? - CC= with correction
E. Past Medical History: Hypertension, DM, PTB, thyroid
disease, allergy, glaucoma, autoimmune disease, Amsler Grid
F. Visual Acuity: before any exam, or before shining a - Central 20 degrees of visual field
light on the patient’s eyes. Ask for usage of eye glasses - Normal reading distance (With reading glasses on, if any)
and if it is for far vision or for reading. Do not use reading - Corrected visual acuity for near – READING GLASSES
glasses for corrected vision (CC). - Distortion of the grid: metamorphopsia
G. External Eye Exam, EOMs
H. Fundoscopy: perform in any case as it is part of External Eye Exam
neurologic exam
A. Lids – swelling, masses, ptosis, abnormal position
Visual Acuity B. Lashes – misdirected, extra rows, matting
- Angular measurement of testing distance to the minimal C. Conjunctiva – hyperemic, masses, discoloration
object size resolvable at that distance. D. Sclera – icteric, redness, dilated vessels
- Vital sign of the eyes E. Cornea – clear, hazy, opacities
- 20/50 means (testing distance)/(distance at which a F. Anterior chamber – deep, cells, flare
normal/unimpaired eye can see that line) G. Iris – pigmented, lesions, rubeosis
- Near vision – Jaeger notation H. Pupils – Size, Equal, Reactive to Light, RAPD,
- Error of refraction: corrected by pinhole shape
- Always make sure the other eye not being tested I. Lens – clear, slightly opaque, opaque
is occluded! J. Anterior chamber depth: shadow= shallow on
tangential light
Test Targets K. RAPD – important neurologic exam. In RAPD,
- Optotypes – individual letter/number or picture on a testing Consensual light reflex is greater that direct light
chart reflex : afferent affectation
- “B” – hardest for patients to recognize, misinterpreted as E
or 8 * In measuring direct pupillary response, don't let the light
- C, D, O cross the bridge of the nose. If testing for RAPD, you may
- L – easiest
Fundoscopy
- Pupils are not dilated. You may only visualize little larger
than the optic disc
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

IV. Common Ocular Symptoms - Eye produces an image with multiple focal points/lines
- Abnormalities of vision - Football/almond shaped orbit
- Blurring of vision - The average of two meridians with different focus
- Double vision (Interval of Sturn) results into a circle of least confusion
- Abnormalities of ocular appearance by compensation– results to fatigue of the eye
- Redness
- Fleshy mass on the cornea Presbyopia
- Lesions on the eyelids; discharge
- Abnormalities of ocular sensation
- Pain - Accommodation – eye changes refractive power by
- Discomfort; itching; dryness - altering the shape of its crystalline lens.
- Foreign body - Loss of accommodative ability (stiffening) of crystalline
lens
A. Errors of Refraction - Starts at around age 40 y/o
- Most common OPD cases
- Refractive States of the Eye Management: Error of refraction
- Emmetropia
- Ametropia - Use of lenses to achiever the best possible acuity
- on distance and near vision tests.
A. Myopia (Near sighted) - Subjective
B. Hyperopia (Far sighted) - Objective = retinoscopy
C. Astigmatism - Use of lenses to achiever the best possible acuity
D. Presbyopia - on distance and near vision tests.

Pinhole Acuity Test Types of Lenses

- Pinhole admits only central rays of light, which do
not require refraction by cornea or lens A. Spheres
- If acuity improves by 2 or more lines, patient - Same curvature over its entire surface, same
likely has EOR power in all meridians
- If acuity DOES NOT improve, patient may have B. CONVE(x) = CONVErge = plus (+)
nonrefractive causes for the reduced VA - 1 diopter plus power converges parallel rays of
- No improvement with pinohle: still may be EOR, or
light to focus at 1m from the lens.
macular, nerve, cornea
C. Concave = diverge = minus (-)
- Parallel light rays enter the lens appear to diverge
Causes of Refractive Errors
- Virtual image is considered to appear at a focal
point in front of the lens
A. Eye length
B. Corneal curvature
C. Lens curvature (Least common)

Myopia

- Image of distant objects focuses in front of the retina.

- Eye is longer than the average (Axial Myopia)
- Refractive elements have more refraction than average
(Curvature/Refractive Myopia)
- Patient must move nearer to see clearer

Hyperopia

- Image is focused behind the retina.

- Eye is shorter than average (Axial Hyperopia)
- Refractive elements have less power (Refractive
- Hyperopia)
Astigmatism
B. Cataract
- Any opacity in the lens
- Aggregation or denaturation of lens proteins
- From oxidative damage, ultraviolet light
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

A. Mature – all lens protein are opaque - Wet and protect surface of cornea
B. Immature – has some transparent protein - Inhibit growth of microorganisms, antimicrobial
C. Hypermature – cortical proteins have become liquid enzymes
D. Morgagnian – lens nucleus floats in the capsular bag, - Contains IgA, IgG, IgE
completely liquefied - Corneal nutrition, K, Na, Cl

Causes: Cataract Causes

A – Aging
- Nuclear sclerosis - Hypofunction of lacrimal gland Sjogren’s, Irridation,
- May have improved near vision w/o glasses (second Mumps
sight) - Mucin deficiency – SJS, chemical burns, anti-
- Monocular diplopia muscarinics
B – Blow out (TRAUMA) - Lipid deficiency – lid margin scarring, blepharitis
- Foreign body to the lens; blunt trauma (star-shaped) - Defective spreading of Tear Film – pterygium,
C – Congenital – Pedia (remove part of the PC) decreased blinking (Irregular surface)
- Rubella, disorders of metabolism
D – Diabetes, drugs
- Cortical
- Corticosteroids, phenothiazines

*After-cataract: opacification of posterior capsule

(proliferatingepithelium). Significant problem in almost all
pedia patients

*Recent theory: tear is a homogenous mixture instead of

layers

Signs and symptoms

Treatment: Cataract
- Surgery
- Extracapsular Cataract Extraction
- Phacoemulsification (Replacement of lens)
- MSICS (Manual Small
Incision Cataract Extraction
- Intracapsular Cataract Extraction
- Mechanical irrigation/aspiration handpiece
- Mechanical irrigation- usually for children due to soft lens
- Itchy, sandy, foreign body sensation
- Redness, stinging sensation, pain
- Absent tear meniscus
- Tear Break-up Time
- Dry spots
- >10 seconds = Normal
- Slit lamp : absent meniscus
- Tear break up with fluorescein dye
- Aggravated by electric fan/ air-conditioning
- Severe manifestation in SJS patients

C. Dry Eye Syndrome

- Chosen when there are no other patients
- Tears

- 7-19 um thick, covers corneal and conjunctival

epithelium
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

- What do we rule out?

Signs and Symptoms: Conjunctivitis

- Pruritus, discharge, redness, foreign body sensation,
fullness around the eyes, pain – cornea may be affected
- Hyperemia, lacrimation, papillary
hypertrophy
- Edema of conjunctival stroma
- Hypertrophy of lymphoid layer of stroma

Viral Conjunctivitis
- Most common – usually caused by adenovirus (after
URTI)
- Watery tearing, occasionally mucous discharge.
- Follicles on palpebral conjunctiva
- Preauricular lymph nodes (pathognomonic), submandibular
lymph nodes
Treatment: Dry Eye Syndrome
- Artificial tears Bacterial Conjunctivitis
- Mucopurulent discharge
- Matting of eyelashes, difficulty opening eyes in the morning,
- Carboxymethylcellulose 1gtt 4-6x/day crusts on eyelashes
- Hypromellose - Papillae on palpebral conjunctiva
- Sodium hyaluronate - Staph, Strep, Haemophilus, Chlamydial, Gonoccocal
- Preservative-free artificial tears
Allergic Conjunctivitis
- Ointment/eye gel - Red/pinkish eyes, follicles
- Watery discharge, chemosis
- Bilateral affectation
- TID or ODHS
- History: allergic rhinitis, asthma
- May cause blurring of vision
- For severe dry eyes

- Blepharitis

- Lid hygiene and topical antibiotics

- Severe

- Punctal plugs, electrocautery

- Definitive management

D. Conjunctivitis

A. Viral
B. Bacterial
C. Allergic Management: Conjunctivitis
- Viral
- Measure visual acuity
- Supportive
- –Distance - Antibiotic drops (Prophylaxis for secondary
- –Near bacterial infection)
- –Amsler
- Bacterial
- Slit-Lamp Examination
- Red/Pink Eye - Fluoroquinolones
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

- Aminoglycosides tearing
- 1 drop 4-6 times daily
- Frequent hand hygiene - Cause: Sun, Sand, Wind
- Elastotic degeneration (actinic damage from UV)
Allergic
- Treatment
- Antihistamine
- Cold compress - Pterygium: excision with conjunctival
autograft – reduces recurrence rate to 6-5%
E. Subconjunctival Hemorrhage (vs. 24-89% - bare sclera); alternative
- Bleeding under the conjunctiva amniotic membrane graft
- Generally benign - Pinguecula: lubricants, weak steroids
- Spontaneous (pingueculitis)
- Coughing, sneezing, bending over, vomiting, valsalva
maneuver, lifting heavy objects
- Trauma or surgery
- Recurrent arteriosclerosis (elderly)
- Impaired coagulation (hemophilia, aspirin)

Management: Subconjunctival hemorrhage

- Assurance
- Supportive

- Artificial tears

F. Pterygium vs. Pinguecula

- Pterygium
- Wing-shaped, triangular growth of tissue that extends
from the conjunctiva the cornea, usually on the nasal
side
- Fibrovascular; almost always preceded by pinguecula
- Pigmented iron line at the anterior edge of the
pterygium (Stocker line on slit lamp)
*“Pugita”- vernacular for pterygium
- Pinguecula
- Same, but NOT reaching the corne
- Yellowish nodule temporal/nasal to the cornea
G. Hordeolum
External vs. Internal
- Infection of Zeis and Moll (Stye)
- Infection of Meibomian gland
- Symptoms: pain, erythema, swelling
- Causes: Staph infection
- Treatment:
- Warm compress 10-15 mins, TID-QID
- If no resolution in 48 hours – I&D
- Internal – vertical incision (following the
orientation of Meibomian gland)
- External – horizontal incision (following
the orientation of the Langer’s line)
- Antibiotics – ointment; oral; Co-amox
BID if with preseptal cellulitis

Chalazion
Signs and Symptoms: Pterygium
- Idiopathic, sterile, chronic granulomatous
-Pugita (pterygium), foreign body sensation, redness, itching,
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

inflammation of meibomian gland - Sedation

- Painless swelling - Pediatric lid speculum and portable slit lamp
- Biopsy indicated for recurrent chalazion; meibomian
VII. Ocular Emergencies
gland carcinoma mimics the appearance of chalazion Ocular Trauma
- I&C; vertical incision (conjunctival surface), horizontal
- In life-threatening conditions – CAB: Do not evaluate the
(skin surface)
eyes first!
V. Emergency Equipment - Protective eye shield until patient is stabilized
- Light source (penlight, muscle light)
- Direct ophthalmoscope Corneal Abrasion
- Near vision card - Epithelial defects due to trauma
- Pinhole occluder - Fingernail to eye, contact lens overwear,
- +2.5D lens and +20D lens ultraviolet burns from welding
- Small toys for children - Pain, FB sensation, tearing, blepharospasm, decreased
- Fluorescein strips vision
- Eyelid retractor - Rule out HSV keratitis – corneal sensitivity; which can
- Small ruler (mm) simulate abrasion (Dendritic pattern on fluorescein dye)
- Proparacaine, timolol maleate 0.5%, pilocarpine 2%, - Corneal ulcer vs. abrasion
tropicamide 1%
Treatment: Corneal Abrasion
- Litmus papers for chemical injuries

- Topical anesthetic onto the affected eye

VI. General Evaluation in Emergencies - Rule out a foreign body – fornices
- Cycloplegic agent (eg, cyclopentolate 1%) to relieve
- History – patient’s vision before injury the discomfort caused by ciliary spasm
- Never delay treatment of TRUE OCULAR - Patch/Bandage soft contact lens for abrasions >3-
4mm.
- EMERGENCY (Chemical burn, CRAO) - Reexamine after 24 hours
- Examine contact lens; culture cornea and contact lens
- Tetanus booster – penetrating/perforating trauma to rule out microbial keratitis
- Visual Acuity: If greatly impaired use red/green color test
Corneal Foreign Body
or light projection
- Metal, dirt, wood, vegetable matter, glass,
- Surgical?: Last oral intake
caterpillar hairs
*AACG – no longer true ocular emergency, does not cause
- Evert eyelids
immediate blindness
- Microbial keratitis – scraped, stained,
VII. Pediatric Evaluation
cultured
- Careful observation without touching the child
- Superficial FB – remove in the clinic or ER
- Toys and interesting fixation targets
using syringe
- Restrain child if uncooperative; avoid if globe is open
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

- Deep perforation – rigid fenestrated – Orbital wall fracture

aluminum shield – EOM laceration
Globe Laceration – Embedded FB
- History
- Symptoms Treatment: Eyelid laceration
- Significantly decreased vision - Need not be repaired immediately, done by experienced
- Hypotony ophthalmologist.
- Shallow anterior chamber - May delayed for 12-24 hours
- Altered shape, size or position of the pupil
Blunt Ocular Trauma
- Visible tracks through the crystalline lens or
- Direct blow to the eye by blunt object
vitreous
- Subconjunctival hemorrhage, hyphema, lens dislocation,
- Tracing line of FB (High velocity penetration
globe rupture, orbital wall fractures, iridodialysis, angle
may seal the laceration and mask the trauma)
recession, iris sphincter rupture, traumatic iritis.
- Conjunctival chemosis
- Visual acuity if possible
- Hyphema
- Crepitus on palpations – orbital wall/floor fracture
- Evaluation
- Expose globe; signs of perforation
- Visual Acuity
- Check iris, pupils (RAPD)
- Seidel test: check for leaks of aqueous humor,
- EOMs, posterior segment disorders
shows spots of unstained area
- IOP <10 mmHg – suggestive of rupture
- Vitreous or uveal tissue on ocular surface
- MRI Traumatic Hyphema
- Avoid applying pressure on globe! - Occurs spontaneously
- Intraocular surgery
Treatment: Globe Laceration
- Traumatic injury – blunt ocular trauma
- Antiemetics
- IOP elevated in large hyphemas (monitor)
- Sedatives and analgesics
- CBC, clotting studies, platelet count, liver function tests
- Tetanus prophylaxis
- Hemoglobin electrophoresis in black patients (e.g. sickle
- Rigid shield
cell)
- Prophylactic parenteral antibiotics
- Repair or Enucleation
Eyelid Laceration
- History – object, time and severity of injury
- Examine for concurrent injuries
– Canalicular lacerations
– Occult trauma to globe
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

Treatment: Traumatic hyphema Endophthalmitis

- Infection within the eye; spares the sclera
- Protective eye shield; moderate restriction of physical
- Spontaneous (endogenous source)
activity
- Postoperative (cataract surgery)
- Decrease IOP if elevated - Post traumatic

- Ocular pain, decreased vision, hypopyon,

Ocular Infections vitritis, conjunctival injection
- Ophthalmia neonatorum - Periocular cultures, anterior chamber tap,
vitreous biopsy with cultures and stains
– Conjunctivitis within first few months of life
Treatment:
– Causative agents
• C. trachomatis - Consult with appropriate subspecialists
• S. aureus - Diagnostic/therapeutic vitrectomy
• S. pneumoniae - Intravitreal, topical and IV antibiotics
• N. gonorrhea
• HSV Preseptal and Orbital Cellulitis
– Conjunctival scrapings – Gram satin, Giemsa stain - Preseptal cellulits affects only the eyelids and periorbital
– Treatment: tissues anterior to the orbital septum
• C. Trachomatis – erythromycin 50mkd x 3 - Erythema, swelling, tenderness of the eyelids
weeks + ointment - Does not usually require diagnostic work up Can
Acute Conjunctivitis be treated with oral antibiotics – outpatient
- Red eye, discharge and ocular irritation Orbital cellulitis
- Bacterial - Proptosis, ophthalmoplegia, decreased vision,
• Mucopurulent discharge significant eye pain, abnormal pupillary reflexes
- Viral - Most commonly from teeth, sinuses or lacrimal sac
• Watery or mucoid discharge - In children – commonly arises due to spread from
• Ipsilateral preauricular lymphadenopathy ethmoid sinuses
- Presents with red eye, fever, lethargy, lid swelling,
Treatment: Acute Conjunctivitis conjunctival congestion, chemosis and diplopia
• Bacterial Conjunctivitis Treatment
– Topical antibiotic - Preseptal cellulitis
– Gonococcal – systemic ceftriaxone 25-50 mkd IV x 7 days - Severe – risk for cavernous sinus thrombosis,
• Viral conjunctivitis meningitis and brain abscess
– Supportive treatment - Admitted for broad spectrum IV antibiotics and
– Cold compress topical antibiotics
– Artificial tears -
– Topical antibiotics
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

- Orbital cellulits - Blood column segmentation

- Otolaryngologic evaluation (sinus drainage) - Cherry-red spot at the fovea

- Poor prognosis
VIII. True Ocular Emergencies
*Light perception does not rule out CRAO
A. Ocular Chemical Burn
- Copious irrigation immediately Emergent Treatment

Acid burns - Irreversible retinal damage: 90 mins

- Denature tissue proteins - Treatment: within 24 hours

- Less devastating than alkali burns Goals of treatment

Alkali Burns - Restore retinal blood flow (CRAO to BRAO)

- Do not cause denaturation - Move a potential retinal embolus distally

- Penetrate deeper - Lower intraocular pressure to improve

- More destructive from saponification of the tissues - retinal perfusion
- May cause - Massage the globe digitally or with fundus
- Corneal melting - contact lens
- Blanching of the conjunctiva - Acetazolamide 500 mg/IV
- Severe corneal scarring - Topical timolol 0.5%

Clinical Findings
Arterial dilation
- Conjunctival hyperemia
- Either inhale a combination of 95% oxygen and
- Chemosis
- Corneal epithelial erosions - 5% carbon dioxide or breathe into a paper bag
- Mild haziness
(Effectiveness questionable)
Treatment - Thorough medical evaluation

- Prompt copius irrigation Ø Patients older than 55 years old

- Do not wait for complete history and PE, VA
Ø Measure erythrocyte sedimentation rate to rule out
- Topical cyclopegics
- Antibiotics giant cell arteritis
- Corticosteroid drops
- Patch the eye Ø If ESR suggests temporal arteritis, give high-
Ø dose corticosteroids
Central Retinal Artery Occlusion

- Unilateral, acute, painless, severe loss of vision

Acute Angle Closure Glaucoma
- Embolic episodes
- Carotid or cardiac disease - Iris becomes apposed to the trabecular meshwork,
- Giant cell arteritis
- Collagen vascular disease blocking aqueous humor drainage
- Hypercoagulation disorders
- Afferent pupillary defect - Pupillary block
- Retinal arterial narrowing - More likely to occur when pupil is mid-dilated
 Oral Revalida Review2019

OPHTALMOLOGY
Lecturer: Carlo Miguel B. Galang,MD

Acute Angle Closure Glaucoma

Symptoms

- Headache
- Severe eye pain
- Nausea and Vomiting (from pain)

Signs

- Pupil is mid-dilated and sluggish

- Anterior chamber is shallow
- Aqueous flare and cells
- Chamber angle is closed on gonioscopy

Treatment
1.Attempt to terminate the attack by compressing the central
cornea with a muscle hook or Zeis gonioprism
2. Instill a topical beta blocker
3. Only in phakic patients, instill pilocarpine
4. Instill topical corticosteroid drops
5. Systemic CAI 250 mg PO x 2 or IV
6.Osmotic agents
7. Topical glycerin – reduce corneal edema and swelling
(with anesthetic)
8. Definitive Laser Iridotomy or Surgical Iridectomy: make
passage way from anterior to posterior