Introduction to Clinical Medicine

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Introduction to Clinical Medicine. Ophthalmology Review. Acknowledgments. Chapter 1 – Dina Abdulmannan, R5 Chapter 2 – Mohammed Al-Abri, R4 Chapter 3 – Ahmed Al-Hinai, R5 Chapter 4 – Chantal Ares, R4 Chapter 5 – Ashjan Bamahfouz, R5 Chapter 6 – Serene Jouhargy, R5
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Introduction to Clinical MedicineOphthalmology ReviewAcknowledgments
  • Chapter 1 – Dina Abdulmannan, R5
  • Chapter 2 – Mohammed Al-Abri, R4
  • Chapter 3 – Ahmed Al-Hinai, R5
  • Chapter 4 – Chantal Ares, R4
  • Chapter 5 – Ashjan Bamahfouz, R5
  • Chapter 6 – Serene Jouhargy, R5
  • Chapter 7 – David Lederer, R5
  • Chapter 8 – Norman Mainville, R4
  • Chapter 9 – Abdulla Naqi, R5
  • Editors – Kashif Baig, R5
  • Hady Saheb, R2Outline
  • Chapter 1 – The Eye Examination
  • Chapter 2 – Acute Visual Loss
  • Chapter 3 – Chronic Visual Loss
  • Chapter 4 – Red Eye
  • Chapter 5 – Ocular and Orbital Injuries
  • Chapter 6 – Amblyopia & Strabismus
  • Chapter 7 – Neuro-Ophthalmology
  • Chapter 8 – Ocular Manifestations of Systemic Disease
  • Chapter 9 – Drugs and the Eye
  • Source: Basic Ophthalmology for Medical Students and Primary Care (Cynthia Bradford)The Eye Examination Chapter 1AnatomyExtraocular movements MedialLateralUpward DownwardAnatomyVisual Acuity
  • General physical examination should include :
  • Visual acuity
  • Pupillary reaction
  • Extraocular movement
  • Direct ophthalmoscope
  • Dilated exam (in case of visual loss or retinal pathology)
  • Distance or Near
  • Distance visual acuity at age 3
  • early detection of amblyopia
  • Distance Visual Acuity Testing
  • VA - Visual acuity
  • OD - ocular dexter
  • OS - ocular sinister
  • OU - oculus uterque
  • 20/20
  • Distance between the patient and the eye chart
  • _____________________________________________ Distance at which the letter can be read by a person with normal acuity Distance Visual Acuity Testing
  • Place patient at 20 ft from Snellen chart
  • OD then OS
  • VA is line in which > ½ letters are read
  • Pinhole if < 20/40
  • Rosenbaum pocket chart Snellen eye chart Distance Visual Acuity Testing
  • If VA < 20/400
  • Reduce the distance between the pt and the chart and record the new distance (eg. 5/400)
  • If < 5/400
  • CF (include distance)
  • HM (include distance)
  • LP
  • NLP
  • Near Visual Acuity Testing
  • Indicated when
  • Patient complains about near vision
  • Distance testing difficult/impossible
  • Distance specified on each card (35cm)
  • Pupillary Examination
  • Direct penlight into eye while patient looking at distance
  • Direct
  • Constriction of ipsilateral eye
  • Consensual
  • Constriction of contralateral eye
  • Ocular Motility Direct Ophthalmoscopy
  • Tropicamide or phenylephrine for dilation
  • unless shallow anterior chamber
  • unless under neurological evaluation
  • Use own OD to examine OD
  • Same for OS
  • Intraocular Pressure Measurement
  • Range: 10 - 22
  • Likely shallow if ≥ 2/3 of nasal iris in shadowAnterior chamber depth assessment Summary of steps in eye exam
  • Visual Acuity
  • Pupillary examination
  • Visual fields by confrontation
  • Extraocular movements
  • Inspection of
  • lid and surrounding tissue
  • conjunctiva and sclera
  • cornea and iris
  • Anterior chamber depth
  • Lens clarity
  • Tonometry
  • Fundus examination
  • Disc
  • Macula
  • vessels
  • Acute Visual LossChapter 2AgePOH & PMHOnsetDurationSeverity of visual loss compared to baselineMonocular vs. binocular ?Any associated symptoms Ophtho enquiryVisual acuity assessmentVisual fieldsPupillary reactions Penlight or slit lamp examinationIntraocular pressureOphthalomoscopy - red reflex - assessment of clarity of media - direct inspection of the fundusHistoryExaminationMedia Opacities
  • Corneal edema:
  • - ground glass appearance - R/O AACG
  • Corneal abrasion
  • Hyphema
  • - Traumatic, spontaneous
  • Vitreous hemorrhage
  • - darkening of red reflex with clear lens, AC and cornea - traumatic - retinal neovascularizationRetinal Diseases
  • Retinal detachment
  • - flashes, floaters, shade over vision - RAPD (if extensive RD) - elevated retina +/- folds
  • Macular disease
  • - decrease central vision - metamorphopsiaCentral Retinal Artery Occlusion (CRAO)
  • True ophthalmic emergency!
  • Sudden painless and often severe visual loss
  • Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow
  • Characteristic “ cherry-red spot ”
  • No optic disc swelling unless there is ophthalmic or carotid artery occlusion
  • Months later, pale disc due to death of ganglion cells and their axons
  • Central Retinal Artery Occlusion (CRAO) treatment
  • Ocular massage:
  • -To dislodge a small embolus in CRA and restore circulation -Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes
  • Ocular hypotensives, vasodilators, paracentesis of anterior chamber
  • R/O giant cell arteritis in elderly patient without a visible embolus
  • Branch Retinal Artery Occlusion (BRAO)
  • Sector of the retina is opacified and vision is partially lost
  • Most often due to
  • embolus
  • Treat as CRAO
  • Central Retinal Vein Occlusion (CRVO)
  • Subacute loss of vision
  • Disc swelling, venous engorgement, cotton-wool spots and diffuse retinal hemorrhage.
  • Risk factors: age, HTN, arteriosclerotic vascular disease, conditions that increase blood viscosity (polycythemia vera, sickle cell disease, lymphoma , leukemia)
  • Needs medical evaluation
  • Long term risk for neovascular glaucoma, so periodic ophtho f/u
  • Optic Nerve Disease
  • Non-Arteritic Ischemic Optic Neuropathy (NAION)
  • - vascular disorderpale, swollen disc +/- splinter hemorrhage loss of VA , VF ( often altitudinal )
  • Arteritic Ischemic Optic Neuropathy (AION)
  • Symptoms of giant cell arteritis
  • ESR, CRP, Platelets +/_ TABx
  • Rx : systemic steroids
  • Optic Nerve Disease
  • Optic neuritis
  • - idiopathic or associated with multiple sclerosis - young adults - decreased visual acuity and colour vision -RAPD -pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal disc)
  • Traumatic optic neuropathy
  • - direct trauma to optic nerve - indirect : shearing force to the vascular supply Visual Pathway DisordersHemianopia - Causes: vascular or tumorsCortical Blindness - aka central or cerebral - Extensive bilateral damage to cerebral pathways - Normal pupillary reactions and fundiChronic Visual LossChapter 31994: 38 million blind people (age >60 yrs) worldwide1997: in western countries, leading causes of blindness in people over 50 yrs of ageAge-Related Macular Degeneration CataractGlaucomaDiabetesIntroduction:Glaucoma
  • Risk factors:
  • Old age Myopia African-American race Blood Hypertension Family History Diabetes Mellitus High IOP Smoking
  • Classification:
  • open-angle glaucoma vs. angle-closure glaucoma
  • primary vs. secondary
  • Glaucoma
  • Evaluation:
  • complete history
  • complete eye examination (including IOP, gonioscopy, optic disc)
  • Perimetry
  • normalAbnormalGlaucoma
  • Treatment Options:
  • Medical:
  • drops to decrease aqueous secretion or increase aqueous outflow
  • systemic medications (PO or IV)
  • Laser:
  • Iridotomy
  • Iridoplasty
  • Trabeculoplasty
  • Surgical:
  • Filtration Surgery (e.g. Trabeculectomy)
  • Tube shunt
  • Cyclodestructive procedures
  • Cataract
  • congenital vs. acquired
  • often age-related
  • different forms (nuclear, cortical, PSCC)
  • reversible
  • very successful surgery
  • Cataract
  • Evaluation:
  • History
  • Ocular Examination
  • Others: A-scan, ± B-scan , ± PAM
  • Treatment:
  • Surgical
  • IOL implantation
  • Age-Related Macular Degeneration
  • Types:
  • 1) Dry: - drusen, RPE changes (atrophy, hyperplasia) 2) Wet: - choroidal neovascularizationdrusenCNVRPE atrophyAge-Related Macular DegenerationFluorescein AngiographyAge-Related Macular Degeneration
  • Treatment:
  • micronutrient supply
  • vit C & E, β-carotene, minerals (cupric oxide, zinc oxide)
  • treat wet ARMD
  • lasers
  • intra-vitreal injections of anti-VEGF
  • surgery
  • low vision aids
  • The Red EyeChapter 4Acute angle closure glaucomaIritis or iridocyclitisHerpes simplex keratitisConjunctivitis (bacterial, viral, allergic, irritative)EpiscleritisSoft contact lens associatedScleritisAdnexal Disease (dacryocystitis, stye, blepharitis, lid lesions, thyroid..)Subconjunctival hemorrhagePterygiumKeratoconjunctivitis siccaAbrasions or foreign bodiesCorneal ulcer2’ to abnormal lid functionTHINKAnatomy “front to back”Acute vs. chronicVisually threatening?DDx Red EyeHistory
  • Onset? Sudden? Progressive? Constant?
  • Family/friends with red eye?
  • Using meds in eye?
  • Trauma?
  • Recent eye surgery?
  • Contact lens wearer?
  • Recent URTI?
  • Decreased VA? Pain? Discharge? Itching? Photophobia? Eye rubbing?
  • Other symptoms?
  • Red Eye: Symptoms
  • *Decreased VA (inflamed cornea, iridocyclitis, acute glaucoma)
  • *Pain (keratitis, ulcer, iridocyclitis, acute glaucoma)
  • *Photophobia (iritis)
  • *Colored halos (acute glaucoma)
  • Discharge (conj. or lid inflammation, corneal ulcer)
  • Purulent/mucopurulent: Bacterial
  • Watery: Viral
  • Scant, white, stringy: allergy, dry eyes
  • Itching (allergy)
  • * can indicate serious ocular diseasePhysical Exam
  • Vision
  • Pupil asymmetry or irregularity
  • Inspect:
  • pattern of redness (heme, injection, ciliary flush)
  • Amount & type of discharge
  • Corneal opacities or irregularities
  • AC shallow? Hypopyon? Hyphema?
  • Fluorescein staining
  • IOP
  • Proptosis? Lid abnormality? Limitation EOM?
  • Red Eye: Signs
  • *Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma)
  • Conjuctival hyperemia (nonspecific sign)
  • *Corneal opacification (iritis, corneal edema, acute glaucoma, keratitis, ulcer)
  • *Corneal epithelial disruption (corneal inflammation, abrasion)
  • *Pupil abnormality (iridocyclitis, acute glaucoma)
  • *Shallow AC (acute angle closure glaucoma)
  • *Elevated IOP (iritis, acute glaucoma)
  • *Proptosis (thyroid disease, orbital or cavernous sinus mass, infection)
  • Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular syndrome)
  • * can indicate serious ocular diseaseScleritisEpiscleritisHSV KeratitisCorneal Ulcer with hypopyonSubconj hemorrhageHyphemaCorneal abrasion with & without fluoresceinBlepharitisIritisConjunctivitisAcute angle closure glaucomaRed eye management for 1° care physicians
  • Blepharitis:
  • Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction)
  • Stye:
  • Warm compresses (refer if still present after 1 month)
  • Subconj heme:
  • Will resolve in 10-14 days
  • Viral conjunctivitis
  • Cool compresses, tears, contact precautions
  • Bacterial conjunctivitis
  • Cool compresses, antibiotic drop/ointment
  • Important Side Effects
  • Topical anesthetics:
  • Not to be used except for aiding in exam
  • Inhibits growth & healing of corneal epithelium
  • Possible severe allergic reaction
  • Decrease blink reflex: exposure to dehydration, injury, infection
  • Topical corticosteroids:
  • Can potentiate growth of herpes simplex, fungus
  • Can mask symptoms
  • Cataract formation
  • Elevated IOP
  • Ocular & Orbital InjuriesChapter 5Anatomy & Function
  • Bony orbit
  • Globe, EOM, vessels, nerves
  • Rim protective
  • “Blow out” fracture
  • Medial fracture -> subQ emphysema of eyelids
  • Anatomy & Function
  • Eyelids
  • Reflex closing when eyes threatened
  • Blinking rewets the cornea
  • Tear drainage
  • CN VII palsy -> exposure keratopathy
  • Lacrimal apparatus
  • Tear drainage occurs at medial canthus
  • Obstruction -> chronic tearing (epiphora)
  • Anatomy & Function
  • Conjunctiva & cornea
  • Quick reepitheliization post-abrasion
  • Iris & ciliary body
  • Blunt trauma -> pupil margin nick (tear)
  • Blunt trauma -> hyphema
  • Blunt trauma -> iritis
  • (pain, redness, photophobia, miosis)Anatomy & Function
  • Lens
  • Cataract
  • Lens dislocation (ectopia lentis)
  • Vitreous humor
  • Decreased transparency
  • (hemorrhage, inflammation, infection)
  • Retina
  • Hemorrhage
  • Macular damage (reduce visual acuity)
  • Ruptured GlobeHyphemaDislocated lensManagement or Referral
  • Chemical burn
  • Alkali>Acid b/c more rapid penetration
  • OPHTHALMIC EMERGENCY
  • ALL chemical burns require immediate and perfuse irrigation, THEN ophtho referral
  • Urgent Situations
  • Penetrating injuries of the globe
  • Conjunctival or corneal foreign bodies
  • Hyphema
  • Lid laceration (sutured if not deep and neither the lid margin nor the canaliculi are involved)
  • Traumatic optic neuropathy
  • Radiant energy burns (snow blindness or welder’s burn)
  • Corneal abrasion
  • Semi-urgent Situation
  • Orbital fracture
  • Subconjuctival hemorrhage in blunt trauma
  • Refer patient within 1-2 days
  • Treatment Skills
  • Ocular irrigation
  • Foreign body removal
  • Eye meds (cycloplegics, antibiotic ointment, anesthetic drops and ointment)
  • Patching (pressure patch, shield)
  • Suturing for simple eyelid skin laceration
  • Take-home Points
  • Teardrop-shaped pupil & flat anterior chamber in trauma are associated with perforating injury
  • Avoid digital palpation of the globe in perforating injury
  • In chemical burn patient immediate irrigation is crucial as soon as possible
  • Traumatic abrasions are located in the center or inferior cornea due to Bell’s phenomenon
  • Know and respect your limits
  • Amblyopia & StrabismusChapter 6Amblyopia
  • Definition
  • loss of VA not correctable by glasses in otherwise healthy eye
  • 2% in US
  • Strabismic(50%) > refractive > deprivation
  • The brain selects the better image and suppresses the blurred or conflicting image
  • Cortical suppression of sensory input interrupts the normal development of vision
  • Strabismus
  • Misalignment of the two eyes
  • Absence of binocular vision
  • Concomitant: angle of deviation equal in all direction
  • EOM: normal
  • Onset: childhood
  • Rarely caused by neurological disease <6 years
  • Can be due to sensory deprivation
  • Incomitant: angle of deviation varies with direction of gaze
  • EOM : abnormal
  • **Paralytic : CN, MG **
  • Restrictive: orbital disease, trauma
  • Strabismus
  • Phoria: latent deviation
  • Tropia: manifest deviation
  • Corneal Light ReflexCover TestTreatment
  • Refractive correction (glasses)
  • Patching
  • Surgery
  • Neuro-OphthalmologyChapter 7**35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits neuro-ophthalmic signs or symptoms**The Neuro-Ophthalmic Exam
  • Visual acuity
  • Confrontation visual fields
  • Pupil size and reaction
  • (Efferent vs Afferent (Marcus Gunn) problem)
  • Ocular motility for strabismus, limitation and nystagmus
  • Fundus exam (optic nerve swelling and venous pulsations)
  • ParasympatheticSympatheticEfferent vs Afferent defectSelected Pupillary Disorders
  • Mydriasis
  • CN III palsy
  • Herniation of temporal lobe or Aneurysm
  • Adie’s Tonic Pupil
  • Young women, unilateral, sensitive to dilute pilocarpine, benign
  • Miosis
  • Physiologic
  • Horner’s Syndrome
  • Etiologic localization (cocaine and hydroxyamphetamine)
  • Argyll Robertson Pupil of tertiary syphilis
  • small, irregular, reacts to near stimulus only
  • Selected Motility Disorders
  • True diplopia is a binocular phenomenon
  • Etiologies of monocular diplopia?
  • Do not forget to check ALL cranial nerves (especially 5/7/8)
  • CN IV
  • Vertical diplopia, head tilt toward OPPOSITE side
  • Think closed head trauma or small vessel disease
  • Myasthenia Gravis
  • Chronic autoimmune condition affecting skeletal muscle neuromuscular transmission (verify with Tensilon test)
  • Can mimic any nerve palsy and often associated with ptosis
  • NEVER affects pupil
  • CN III PalsyCN VI PalsyThink: PCOM Aneurysm, Brain Tumor, Trauma Think: Trauma, Elevated ICP, HTN, Diabetes and viral infections Internuclear Ophthalmoplegia (INO)Think: Elderly-small vessel diseaseYoung Adult-MSChild-Pontine GliomaNystagmus - selected types
  • May be benign or indicate ocular and/or central nervous system disease
  • Definition according to fast phase
  • End-point Nystagmus
  • seen only in extreme positions of eye movement
  • Drug-induced Nystagmus
  • Anticonvulsants, Barbiturates/Other sedatives
  • Searching/Pendular Nystagmus
  • common with congenital severe visual impairment
  • Nystagmus associated with INO
  • Selected Optic Nerve Disease
  • Congenital Anomalous Disc Elevation
  • absence of edema, hemorrhage and presence of SVP
  • Think: optic disc drusen and hyperopia
  • Papilledema (def?)
  • Presence of bil edema, hemorrhage and absence of SVP
  • Think: hypertension (must check BP) and
  • brain tumor
  • Papillitis/Anterior Optic Neuritis
  • unil edema, hemorrhage
  • Think: inflammatory
  • Selected Optic Nerve Disease
  • Ischemic Optic Neuropathy
  • Pallor, swelling, hemorrhage
  • altitudinal visual field loss
  • Optic Atrophy
  • Think: previous optic neuritis or ischemic optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, glaucoma
  • Selected Visual Field DefectsOcular Manifestations of Systemic DiseaseChapter 8Systemic Diseases
  • Many systemic diseases have ocular manifestations and sequelae
  • Exam may aid with diagnosis, assessment of disease activity, prognosis
  • Common conditions
  • Diabetes
  • Hypertension
  • Pregnancy
  • Sickle cell anemia
  • Thyroid disease
  • Sarcoidosis and inflammatory/autoimmune
  • Malignancy
  • Aids
  • Syphilis
  • Systemic infection
  • Diabetes
  • Leading cause of vision loss (18-64 yrs)
  • Intensive glycemic control reduced risk of development and progression of retinopathy (DCCT)
  • Risk of developing retinopathy  with duration of disease (type 1 23% @ 5 yrs, 80% @ 15 yrs, rates lower for type 2)
  • Non-proliferative changes (NPDR)
  • Mild - Moderate
  • Microaneurysms
  • Dot-blot hemorrhages
  • Hard exudates
  • Macular edema (most common cause of mild-mod VA loss)
  • Severe
  • Venous beading
  • Intraretinal microvascular abnormalities (IRMA)
  • Nerve fiber layer infarcts – cotton wool spots
  • Diabetes
  • Proliferative (PDR)
  • Responsible for most of the profound visual loss
  • Neovascularization in response to ischemia
  • Disc, retina, iris
  • If untreated → vitreous hemorrhage, tractional retinal detachment
  • Management
  • Frequency of exams
  • Type 1 – initial exam when post-pubertal and within 5 yrs of Dx
  • Type 2 – exam at time of Dx
  • All patients – generally examine q1yr unless poor glycemic control, HTN, anemia, proteinuria, mod-severe NPDR or PDR which require more freq F/U
  • Pregnant + type I – first trimester + q3months
  • Treatment
  • Focal laser
  • Panretinal phot
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