0
Q
Shafer’s sign
A
Suspended pigment particles floating in the anterior vitreous
described as “tobacco dust,”
pathognomonic for a retinal tear
1
Q
combination of flashing lights and floaters should be considered…
A
…a retinal detachment until proven otherwise
2
Q
Finding cotton wool spots in a healthy patient without DM or hypertension…
A
…consider HIV testing
3
Q
What antibiotic would you use for a small corneal ulcer in a contact lens wearer?
A
While most small ulcers can be treated with erythromycin, you must worry about pseudomonas in contact lens wearers. Treat all CL wearers with ciprofloxacin or moxifloxacin. If the ulcer is large, jump right to fortified antibiotics like vancomycin and tobramycin
4
Q
The major types of penetrating
eye injury are:
A
eye lid lacerations
corneal lacerations
scleral lacerations
perforating trauma (+/- an exit wound) including occult foreign body penetration (e.g. when metal strikes metal)
There may also be associated injuries to:
intraocular structures — e.g. lens, iris, retina
extraocular structures — e.g. lids, extra-ocular muscles, orbital bones, optic nerve and brain
5
Q
Marcus-Gunn pupil
A
Relative afferent pupillary defect
6
Q
Optic neuritis - papillitis causes
A
- multiple sclerosis
- familial
- idiopathic
- inflammation
+ viral — e.g. infectious mononucleosis, herpes zoster, viral encephalitis
+ childhood infections or vaccinations — e.g. measles, mumps, chickenpox
+ Granulomatous inflammations — e.g. tuberculosis, syphilis, sarcoidosis, cryptococcus
+ Contiguous inflammation of the meninges, orbit, or sinuses.
7
Q
What are the Pulfrich phenomenon and Uhthoff sign?
A
Both of these are occassionally present in optic neuritis:
Pulfrich phenomenon — altered perception of moving objects
Uhthoff sign — worsening of symptoms with exercise or increase in body temperature
8
Q
Possible underlying causes of papilloedema
A
- intracranial
space-occupying lesions (e.g. neoplasms, trauma, infection, and vascular causes)
benign intracranial hypertension (trauma, drugs, idiopathic, Addisons, sinus thrombosis)
central venous sinus thrombosis
meningoencephalitis - CSF
hydrocephalus – obstructive, communicating (production vs. absorption of CSF)
high CSF protein — e.g. Guillain-Barre Syndrome - extracranial
central retinal vein occlusion (CRVO)
retro-orbital mass
hypertension (grade IV)
9
Q
Causes of optic atrophy
A
Optic atrophy may be the end stage of:
chronic papiloedema chronic optic neuritis glaucoma optic neuropathies (e.g. toxic, metabolic, ischemic and compressive) familial, e.g. retinitis pigmentosa
10
Q
Compare expected examination findings: optic neuritis and papilloedema
A
Papillitis (optic neuritis):
pupilary reaction — RAPD present visual acuity — reduced colour vision — red desaturation visual fields — large central scotoma pain on eye movement — present localisation — usually unilateral fundoscopy — blurred disc margins
Papilloedema:
pupilary reaction — normal
visual acuity — normal (transient loss)
colour vision — normal
visual fields — large blind spot, peripheral constriction
pain on eye movement — present
localisation — usually bilateral
fundoscopy — blurred disc margins, no venous pulsation
11
Q
Oculomotor (III) nerve palsy
A
The eyes are “down and out” with a droopy eyelid.
The majority of the extraocular muscles are innervated by CN3, so when knocked-out the eye deviates down and out because of the still functioning abducens and superior oblique muscles. In addition, the levator palpebrae (the main lid retractor) is innervated by CN3 and its paralysis gives you a severe eyelid ptosis. Finally, the parasympathetic pupil-constrictor fibers from the Edinger-Westphal nucleus travel within CN3, and their loss gives you a “blown pupil.”
Compressive lesions usually affect the parasympathetic nerve component: a blown pupil is a potential emergency. Whenever you have pupillary involvement, you need an MRI and angiography to rule out a dangerous aneurysm or tumor.
12
Q
Trochlearis (IV) nerve palsy
A
- upward deviation of the affected eye
- “cyclotorsion” twisting of the eye -> tilting of the head away from the lesion.
- causes: 1/3rd Trauma
1/3rd Congenital
1/3rd Ischemic (diabetic)
1/3rd Tumor
13
Q
Abducens paresis (VI)
A
Crossed eye. Consider increased intracranial pressure.
(Something about this abrupt turn makes the 6th nerve especially susceptible to high intracranial pressure. Patients with high ICP from pseudotumor cerebri commonly have their 6th nerve(s) knocked out – abducens palsy is actually incorporated into the Dandy criteria for diagnosing PTC.)
14
Q
if the patient has MG, check …
A
them up for a thymoma and check their thyroid levels
15
Q
if a patient complains of a painful Horners …
A
… think of a carotid dissection and move quickly to rule out this diagnosis.
16
Q
Szem mekkora
A
Kb. 24 mm átmérőjű, felülről lefelé kb 0.5 mm-el összelapított
17
Q
Sclera milyen vastag
A
N. opticus belépése körül 1-2 mm, előrefele folyamatosan vékonyodik, legvékonyabb az equator előtt közvetlenül a szemizmok tapadása mögött ( 0,3 mm), előre újra vastagabb, különösen a szemizmok tapadásának megfelelően (0,6 mm)
18
Q
Sclerát mik fúrják át
A
- n. opticus (hátsó pólustól 3 mm medial fele)
- aa. ciliares posteriores breves et longi, nn ciliares breves et longi (n. opticus kilépése körül)
- vv vorticosae (equator tájékán)
- aa ciliares anteriores (szemizmok tapadása tájékán)
19
Q
Cornea rétegei elölről hátrafele
A
- Hám (epithelium anterius corneae)
- Lamina limitans anterior (Bowman-hártya)
- Substantia propria corneae
- Lamina limitans posterior (Descemet-hártya)
- Endothelium camerae anterioris
20
Q
Cornea mérete, vastagsága
A
13 mm átmérő, kívülről nézve haránt irányban 12 mm, függőlegesen 11 mm
Középen 0,8-0,9 ?! mm, szélein 1,1 mm
21
Q
M. ciliaris részei kívülről befele
A
- medialis irányú rostok (Brücke-féle izom)
- radialis irányú rostok
- circularis irányú rostok
22
Q
Iris rétegei elölről hátra
A
- Endothelium
- Stroma iridis
- M. dilatator pupillae
- Stratum pigmenti iridis = pars iridica retinae
23
Q
Choroidea rétegei kívülről befele
A
- Lamina suprachoroidea
- Lamina vasculosa
- Lamina chorocapillaris
- Lamina basalis (Bruch féle hártya)
24
Tunica vasculosa erei
- aa ciliares posteriores breves -> sp. perichoroidale -> oszlik a choroideában és a corpus ciliare hátsó részében -> vv vorticosae
- aa ciliares posteriores longi (nas et temp) -> sp. perichoroidale -> corpus ciliare és iris határán kettéoszolva egymással anast -> circulus arteriosus iridis major [~iris külső + c ciliare elülső] {+ aa ciliares anteriores}
- circulus arteriosus iridis minor [~ iris belső] 1. Orbiculus ciliaris meridonalis erei -> chiroidea venái 2. Corneoscleralis határ -> episcleralis venahálózat
25
Tunica vasculosa idegei
- nn ciliares breves {psy rostok ggl ciliaréból + sy postgangl rostok gg cercicale superius}
- nn ciliares longi {n nasociliarisból leváló somatosensoros ágak}
Belépés->sp. perichoroidale -> c ciliare: sűrű fonat -> leváló ágak:
+ tisztán érző: szaruhártyában l propriát es elülső hámréteget
+ psy postggl: c ciliarehoz, m ciliarist idegzik be
+ érző és vegetatív motoros rostokat tart ágak -> iris ->
> m sphincter pupillae (ggl ciliareból postggl)
> m dilatator pupillae (ggl cervicale superiorból postggl)
> stroma (n nasociliarishoz tartozó érzőrostok)
26
Retina fejlődéstanilag miből alakult ki
Prosencephalon -> diencephalon
27
Retina milyen vastag
Hátul 0,4 mm, ora serrata közelében 0,1 mm
28
Vakfolt mérete
1,6 mm
29
Sárgafolt mérete, helye
Discus nevinopticu közepétől lateral fele 4 mm-re (kb 15fok), 2mm átmérőjű ellipsis
30
Retina erei
A et v centralis retinae -> a et v papillaris superior et inferior -> arteriola et venula temporalis retinae superior, temporalis retinae inferior, nasalis retinae superior, nasalis retinae inferior
Macula luteához: arteriola et venula macularis superior et inferior
31
Retina rétegei
Szemgolyó központjára vonatakoztatva
1. Pigmenthám (str pigmenti retinae)
2. Csapok és pálcikák
3. Membrana limitans externa
4. Str granulosum externum
5. Str plexiforme externum
6. Str granulosum internum
7. Str plexiforme internum
8. Str ganglionare
9. Opticusrostok rétege
10. Membrana limitans interna
32
Seidel test corneal laceration
Wipe a strip of fluorescein paper over the wound, if the dye flows down the corneal surface -> aqueous leakage
33
Converting Cylinder
You can convert a glass prescription from +/- cylinder format by the following method:
a. add the cylinder to the sphere (you remember how to add negatives, don’t you?)
b. change the sign of the cylinder
c. change the axis by 90 degrees
Thus: +2.00 +3.00 at 170 converts to
+5.00 –3.00 at 080
34
Szemlencse alakja, mérete
Bikonvex lencséhez hasonló, facies anterior laposabb, facies posterior domborúbb, 9 mm átmérő
Újszülöttön majdnem gömb alakú, d=4,5 mm
35
Csarnokvíz összetevői
Kevés fehérje, szőlőcukor, karbamid, hialuronsav
36
Csarnokvíz keringése
Processus ciliares érfonatai -> hátsó szemcsarnok -> lencse elülső és iris hátsó felszíne közti kapillárisrésen át sugárirányban pupilla -> elülső szemcsarnok -> spatia anguli iridocornealis -> spongiosa sclerae rései -> sinus venosus sclerae -> vv aqueosae -> vv episclerales
37
The two major causes of hereditary lens dislocation
Marfan's syndrome and homocystinurea
38
By what mechanisms can patients with diabetic retinopathy lose vision?
- macular edema – leaking vessels near the fovea/macula can cause localized swelling that can affect best corrected vision. This is very common, and ophthalmologists watch for this and can treat the area with focal laser therapy if the swelling falls within treatment criteria
- vitreous hemorrhage (from leaking neovascular vessels
- tractional retinal detachment from fibrosing/contracting areas of neovascularization.
- acute glaucoma (from neovascularization of the iris/angle).
- cataract formation (often PSC cataracts on the back of the lens).
39
What are the “three vital signs” of ophthalmology?
Vision, pupil, pressure
40
Egyenes szemizmok eredése és tapadása
- Részben a canalis opticus felső csontos peremén, részben anulus tendineus communis (itt m rectus bulbi inferior, medialis, lateralis
- equatornál lapos ínba mennek át, szemgolyóra simulnak, 6-8 mm-re a szaruhártya mögött tapadnak az ínhártyában.
41
M obliquus bulbi superior lefutása
Canalis opticus csontos pereme -> homlokcsont pars orbitalis: trochlea -> lefele, lateral, hátra -> külső felső hátsó octanson tap
42
M obliquus bulbi inferior eredése és tapadása
Maxilla crista lactimalis posterior alsó vége mellett -> külső alsó hátsó octans
43
Küslő szemizmok beidegzése
- n oculomotorius: m rectus bulbi sup, med, inf; m obliquus bulbi inf
- n trochlearis: m obliquus bulbi sup
- n abducens: m rectus bulbi lat
44
Könny elvezetése
Gl lacrimalis pars orbitalis, pars palpebralis) -> ductuli exteriorii -> fornix conj sup elülső fala -> lacus lacrimalis -> puncta lacrimalia -> canaliculi lacrimales -> saccus lacrimalis -> ductus nasolacrimalis -> alsó orrjárat
45
Fénytörés mitől függ
- törésmutatók különbsége
| - határfelületbgeometriai adottságai (sík v görbült felület
46
Causes of optic atrophy
Optic atrophy may be the end stage of:
- chronic papiloedema
- chronic optic neuritis
- glaucoma
- optic neuropathies (e.g. toxic, metabolic, ischemic and compressive)
- familial, e.g. retinitis pigmentosa
47
What is pseudopapilloedema
Pseudopapilledema mimics papilloedema and may result from the presence of optic disc drusen or a congenitally anomalous disc.
The optic disc is not truly swollen — the characteristic findings include:
- Vessels overlying the disc are not obscured
- the disc is not hyperemic
- surrounding nerve fiber layer is normal.
- spontaneous venous pulsations are usually present.
Further investigation may still be required to rule out raised intracranial pressure.
48
Goldmann equation
The Goldmann equation states:
Po = (F/C) + Pv ; Po is the IOP in millimeters of mercury (mmHg), F is the rate of aqueous formation, C is the facility of outflow, and Pv is the episcleral venous pressure.
49
B1 vitamin hiány szemtünetek
- szemmozgató idegek bénulása
- látóideg-gyulladás
- színtévesztés
- látótérkiesések
50
B2 vitamin hiány szemtünetek
- blepharo-conjunctivitis
- keratitis
- cornea-ereződés
- retinavérzések
51
B3 vit hiány szemtünetek
- conjunctivitis
- keratitis
- papillaoedema
- fénykerülés
- hemeralopia
52
B12-hiány szemtünetek
- látóideg-károsodás
| - retinavérzések
53
C vitamin hiány szemtünetek
- a szem különböző részeinek bevérzései
- cornea fekély
- szemizombénulás
54
A-vit hiány szemtünetek
Xerophtalmia -> fertőzés -> cornea fekélyek, farkasvakság, a szemfehérjén habos, ún. Bitot-foltok jelennek meg
55
D-vit-hiány szemtünetek
- cataracta zonularis
- orbita csontosodási zavar
- látóideg sorvadás
- keratitis phlyctenosa
56
E-vit hiány szemtünetek
- keratitis
| - cataracta
57
K-vit hiány szemtünetek
szemfenéki vérzések
58
Stadgardt disease
~ macular dystrophy, fundus flavimaculatus
- au rec (10% dom - st like ELOVL 4 gene)
- begins at late childhood, leading to legal blindness
- 1/10000 children
- lipid rich deposits in RPE
- ABCA4 gene
- napszemuveg lassithatja
59
Vistagan
Levobunolol
5 mg/ml (levobunolol hidroklorid)
Vistagan Liquifilm 5 ml
max 25C-on tarolni
60
Ganfort
Bimatoprost, timolol (0,3 mg/ml, 5mg/ml, ami megfelel 6,8 mg/ml timolol maleátnak)
3ml kisz.
61
Uveitis anatomiai beosztasa
Anatomic classifications include:
- anterior uveitis (iritis)
- intermediate uveitis (iridocyclitis, cyclitis, Fuch's heterochromic iridocyclitis, phacogenic uveitis, pars planitis, and peripheral uveitis)
- posterior uveitis (focal, multifocal, or diffuse choroiditis; chorioretinitis; retinochoroiditis; retinal vasculitis; neuroretinitis); and
- panuveitis (inflammation of all 3 regions of the uvea)
62
Uveitis etiologiaja
traumatic, immunologic, infectious, and masquerade forms
63
Mydriatic and Cycloplegic Agents in uveitis
- useful in the treatment of anterior uveitis.
- prevent the formation of posterior synechiae
- relieve photophobia
- alleviate pain due to ciliary spasm
- promote relaxation of the anterior segment, which may lead to earlier recovery from inflammation.
- In addition to promoting improved vision, these agents also enhance the physician’s ability to evaluate the posterior segment of the eye -
- and have the long-term benefit of reducing intraocular pressure (IOP)
- and the risk of permanent structural damage.
64
Periocular corticosteroid (sub-tenon, transseptal) risks and complications
- risks of ocular hypertension and cataract development.
- Complications include
+ globe perforation
+ ptosis
+ subdermal fat atrophy
+ extraocular muscle paresis
+ optic nerve injury
+ retinal and choroidal vascular occlusion
+ cutaneous hypopigmentation
65
Intravitreal corticosteroid duration of efficacy
Up to 3 months
66
Kenalog® hatóanyag
Triamcinolone acetonide
67
Triesence® hatóanyag
Triamcinolone acetonide
68
Systemic steroid in uveitis
- vision-threatening uveitis, when topical administration is insufficient
- a systemic disease also requires steroid treatment (ie, Behcet’s disease).
- In severe cases of intermediate uveitis or panuveitis pulsed infusion of methylprednisolone may be useful at a rate of 1 gram/day infused over 1 hour.
- The standard of care with prednisone is a dose of 1 mg/kg/day with a weekly taper of 5 to 10 mg.
- If surgical intervention is necessary, the prednisone dose may be increased to prevent postsurgical complications including uveitis exacerbation and cystoid macular edema. - -
- Administration of corticosteroids for longer than 3 months or at a dose higher than 5 mg/day should be accompanied by IMT and bone preservation therapy as the risk of fracture and bone loss is a concern with extended administration.
69
NSAID in uveitis
- topical and oral NSAIDs are used to manage inflammation via the inhibition of cyclooxygenase and the reduction of prostaglandin synthesis.
- Topical NSAIDs may be used to reduce postsurgical inflammation and cystoid macular edema
- oral treatment is useful in the treatment of
+ recurrent nongranulomatous; idiopathic or HLA-B27-associated acute anterior uveitis
+ and recurrent, acute, or chronic iridocyclitis.
70
Leggyakoribb antimetabolitok nem inf. eredetű uveitis kezelésében
Methotrexate, mycophenolate mofetil (MMF), and azathioprine
71
Methotrexate routes of administration in non-infectious uveitis
- orally, the starting methotrexate dose is 7.5 to 15 mg/week with a possible increase of up to 20 to 25 mg/week.
- intramuscularly, the dose may be increased to up to 50 mg/week.
- subcutaneously
- Intramuscular or subcutaneous administration is indicated for doses higher than 20 mg/week due to improved bioavailability and for patients who experience GI upset with oral administration.
- Intravenous and intravitreal administration are usually reserved for cases of severe disease at doses of 100 to 200 mg weekly and 400 µg/0.1 mL, respectively.
- During the course of treatment, folic acid supplementation is indicated at a dose of 1 mg daily (except on the days of methotrexate administration).
72
Azathioprine and MMF in non-inf uveitis - routes of administration
administered orally at starting doses of 75 to 100 mg daily and 1 to 2 g daily, respectively.
Genotyping or testing for thiopurine methyltransferase activity should be done prior to dosing as some patients may be poor metabolizers
73
Potential mechanisms for post-LASIK dry eye
| occurring in nearly all patients and resolving in the vast majority
- LASIK causes corneal denervation and subsequently decreases corneal sensation, a primary stimulus for tear production.
- Corneal hypoesthesia changes the ocular surface-lacrimal gland functional unit, leading to tear film hyperosmolarity and inflammation of the ocular surface.
- Additional potential mechanisms for post-LASIK dry eye include loss of neurotrophic effect, goblet cell damage, and altered corneal shape.
74
Isotretionin ocular side effects
abnormal meibomian gland function and atrophy, blepharoconjunctivitis, increased tear osmolarity, tear instability, ocular discomfort, and photophobia
75
Lacrimal function unit (LFU)
- maintains the homeostasis of the ocular surface
| - cornea, conjunctiva, lacrimal and meibomian glands, lacrimal drainage system, and the connecting neural pathways.
76
The proposed American College of Rheumatology diagnostic criteria for Sjögren syndrome
2 of 3 objective findings:
• Keratoconjunctivitis sicca with ocular staining score ≥ 3
• Serum autoantibodies (positive Sjögren syndrome-associated antibodies A or B [SS-A or SS-B] or antinuclear antibody and rheumatoid factor)
• Positive labial salivary gland biopsy
77
Brvo leggykoribb helye
Superotemporalis r.
78
Hol tünetmentes gyakran a brvo
Nasal
79
Brvo major complications
macular edema and retinal neovascularization
80
?has been shown to be a key molecular player in the pathogenesis of the major complications of a BRVO
VEGF
81
Taleum® hatóanyag
sodium cromoglycate
82
Causes of spontaneous hyphema (rare)
Diabetes mellitus, clotting disorder, eye tumor, or, in children, child abuse
83
Partial biometry IOL: if only AL is given
Ks=74.56-1.317xAL
84
Partial biometry IOL: if Ks or nothing is given
Mean IOL power for that population
85
IOL formula - how to choose
26 mm: SRK/T or Haigis
| >27 mm: H1 AL = 0.8814xIOL Master AL + 2.8701 (adjust AL and use Holladay 1)
86
IOL formula - don'ts
- no SRK-II
| - no SRK/T for steep corneas
87
Cystoif macular edema after cataract surgery
- most common compl?
- 6-10 weeks after surgery
- increased perifoveolar capillary permeability
- intraocular vascular ibstability
- increased prostaglandin production (anterior uvea)
- cystloid spaces and lacunar cavities in the outer plexiform layer of Henle
+ thick layer absorb large quantities of fluid
+ avascular with limited capillary absorption of fluid
+ thin fovea and ILM with increased susceptibility to inflammatory exsudates and toxic products through the vitreous
88
Cystoid macular edema after cataract surgery - risk factors
- Preoperative
+ ERM
+ Hypertension
+ Diabetes mellitus
+ Uveitis (active or history)
+ history of CME (including on the ci tralat eye)
- Intraoperative
+ type of cat surgery (ICCE vs ECCE vs phaco)
+ vitreomacular traction
+ ultraviolet light exposure
+ posterior capsular rupture
+ vitreous loss (incarceration to the wound or adhesion to iris)
+ iris prolapse
+ IOL type (iris-supported/closed-loop ACIOL
- Postoperative
+ medications (epinephrine, dipivefrin, prostaglandin analogs)
+ Inlflanmation
+ Hypotony
89
Terson syndrome
Intraocular hemorrhage associated with intracranial hemorrhage and elevated intracranial pressures
Med
flashcards
Decks in class (11)
# Cards
