Term
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Definition
• Upper eyelid covers portion of iris but not the pupil
• Palpebral fissure is the opening between the eyelids
• Conjunctiva is a clear mucous membrane
• Bulbar conjunctiva covers most of anterior eyeball and adheres loosely to underlying tissue and meets cornea at limbus |
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Term
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Definition
– Lines the eyelids
– Two parts meet in a folded recess permitting movement of the eyeball |
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Term
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Definition
| – Each plate contains parallel row of Meibomian glands which open on lid margins |
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Term
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Definition
– Muscle raises upper lid
– Innervated by oculomotor CN 7
– Smooth muscle innervated by sympathetic nervous system also contributes to lid elevation |
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Term
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Definition
– Protects conjunctiva
– Inhibits bacterial growth
– Gives smooth surface to cornea |
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Term
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Definition
– Clear layer at front and center of eye
– Lies in front of the iris
– Function: helps focus light as it enters the eye |
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Term
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Definition
– White outer coat of eye
– Tough leather like tissue extends around the eye – Gives the eye its shape
– Attaches to the extraocular eye muscles |
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Term
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Definition
| – Layer of blood vessels between the retina and sclera |
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Term
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Definition
| – Colored part of the eye which helps regulate the amount of light entering the eye by opening and closing the pupil (acts like a shutter on a camera) |
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Term
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Definition
– Transparent
– Focuses light on the retina
– “fine tunes” vision
– Deterioration with aging leads to farsightedness
– Intraocular lenses are used to replace lenses clouded by cataracts |
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Term
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Definition
| – Over a million nerve fibers carrying messages from the retina to the brain |
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Term
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Definition
– Nerve layer lining the back of the eye
– Senses light and creates electrical impulses sent through the optic nerve to the brain |
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Term
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Definition
– Lies mostly within the bony orbit and lateral to the eyeball
– Tears drain medially through two tiny hole called lacrimal puncta
• Located on lower lid medially
– Tears then pass into lacrimal sac and into nose through nasolacrimal duct |
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Term
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Definition
spherical
– Focuses light on the retina |
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Term
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Definition
| – Controlled by muscles of the iris |
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Term
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Definition
– Controlled by the ciliary body
• Allows the eye to focus on near or distant objects |
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Term
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Definition
– Clear liquid
– Produced by ciliary body
– Fills anterior and posterior chambers of the eye
– Circulates from posterior chamber through the pupil to the anterior chamber
– Drains out the anterior chamber through the canal of schlemm
– This circulatory system controls pressure inside the eye |
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Term
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Definition
=fundus
– Seen with ophthalmoscope
• Structures of the fundus – Retina
– Choroid
– Fovea
– Macula
– Optic disc
– Retinal vessels
• Optic nerve and retinal vessels enter eyeball posteriorly |
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Term
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Definition
– Point of central vision
– Lateral and slightly inferior to optic disc – Small depression in retina |
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Term
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Definition
| – Small dark circular area circumscribed by the macula |
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Term
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Definition
– Transparent, gelatinous material that fills the eyeball behind the lens
– Helps maintain the shape of the eye |
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Term
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Definition
– Intraocular portion of the optic nerve
– Its margins, color and cup to disc ratio should be noted
– It has sharp borders, yellow-orange to creamy pink
– Round to slightly oval with its long axis vertical |
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Term
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Definition
– Small depression in the center of the optic disc
• The cup is the portion of the disc which is central, lighter in color and penetrated by the retinal vessels
– Horizontal diameter <1/2 the horizontal diameter of the disc
– Cup to disc ratio is expressed as a decimal from 0.1 to 0.9, usual is around 0.5 |
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Term
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Definition
– Area of the retina responsible for fine central vision
– Darker gray in appearance
– Oval depression in center of macula is called a fovea
• The fovea is the center of the retina
– Asking the patient to look directly into the light of the ophthalmoscope will bring the fovea into your view |
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Term
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Definition
– Visible with ophthalmoscope
– Central retinal artery branches at the optic disc into divisions that supply the 4 quadrants of the inner retinal layers
– Veins form a similar pattern to the arteries
– Arteries are smaller in diameter that the veins and lighter in color |
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Term
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Definition
• Entireareaseenbyaneye when it looks at a central point
• Centerofcircle=focusofgaze
• Eachvisualfieldisdividedinto quadrants
• Fieldsextendfarthestonthe temporal sides
• Fieldsrestrictedby-eyebrows, cheeks, nose
• Blindspot=lackofretinal receptors at optic disc
– Located 15 degrees temporal to the line of gaze
• When using both eyes
– The two visual fields overlap in an area of binocular vision
– Laterally vision is monocular
• Visual pathways
– Light reflected from the image must pass through the pupil to be focused on sensory neurons in the retina
– Image projected is upside down and reversed right to left
• An image from the upper nasal visual field strikes the lower temporal quadrant of the retina |
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Term
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Definition
– Nerve impulses stimulated by light
– Are conducted through the retina, optic nerve and optic tract on each side
– Then to the optic radiation that ends in the visual cortex of the brain in the occipital lobe |
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Term
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Definition
– Light enters optic disc and then photosensitive retinal ganglia cells pass info into the optic nerve CN II
– In the midbrain impulses to the Edinger Westphal nucleus whose parasympathetic axons fun along both the left and right oculomotor nerve cause pupillary constriction |
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Term
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Definition
– Motor
– Parasympathetic
– Pupillary constriction |
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Term
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Definition
• Pupils constrict when shifting gaze from a far object to a near object
• Reaction innervated by the oculomotor CN 3 similar to the pupillary reaction
• Convergence also occurs
– This is an extraocular movement
• Accommodation also occurs
– Increased convexity of the lenses caused by contraction of the ciliary muscles (this is difficult to actually see or measure in routine PE) |
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Term
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Definition
• Autonomic Nerve supply to the eyes
– Fibers traveling to the oculomotor nerve and producing pupillary constriction are a part of the parasympathetic nervous system
• Iris is supplied by the sympathetic NS
– When stimulated, the pupils dilate and upper lid rises
a little
– This pathway starts in the hypothalamus through the brainstem and cervical cord
– Then it follows the carotid and or its branches into the orbit |
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Term
| CN Tested During the Eye Exam |
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Definition
• Pupillary reflex: CN 2 and CN 3
• EOM:CN3,CN4,CN6
• Majority ocular muscles are innervated by CN 3
– Also the levator palpebrae which raises the lid (observe for ptosis)
– Parasympathetic pupillary constrictors also run along CN 3
• Superior oblique: CN 4 • Lateral rectus: CN 6 |
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Term
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Definition
• Position the patient 20 feet in front of the Snellen or Rosenbaum eye chart (or hold a pocket card at 14 inch “reading” distance)
• Have the patient cover one eye at a time with the index card
• Ask the patient to read progressively smaller letters until they can go no further
• Record the smallest line the patient reads successfully (20/20, 20/30, 20/40, etc.)
• Repeat with the other eye |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| loss of consensual reflex |
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Term
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Definition
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Term
| on fundoscopic What Are You Looking For? |
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Definition
• Optic cup and disc: The outline of the optic disc should be clear. It should be light yellow with a reddish-pink background. The optic disc represents the optic nerve head. The optic cup is the central portion of the disc. Normally, it should be less than 1⁄2 the diameter of the disc and be flat.
• Abnormalities: Pallor of the optic disc may indicate optic nerve disease.
• Blurred disc margins may indicate hypertensive retinopathy or papilledema.
• Elevated, edematous disc may indicate hypertensive retinopathy or papilledema.
• Enlarged or elevated cup may indicate hypertensive retinopathy, glaucoma, and papilledema.
• Net of new blood vessels growing on disc surface may indicate diabetic retinopathy.
• Retina:Normallyared/orange color; macula is dark and avascular temporally.
• Abnormalities:Prominentflame hemorrhages may indicate hypertensive or diabetic retinopathy, papilledema, neoplasm, increased ICP, trauma.
• Cottonwoolspots: Hypertension, Diabetes, AIDS, blood dyscrasias.
• Vessels: Normally, the arterial- venous ratio is 2:3 (the veins are larger). The arteries appear bright red, the veins a slight purplish color.
• Abnormalities: Dilated vessels, engorged veins, tortuosity, A-V nicking, copper and silver wiring are all associated with long- standing hypertension, diabetic retinopathy. |
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Term
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Definition
| for estropia, exotropia- strabismus |
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Term
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Definition
• Inward turning lid margin
• Lashes irritate cornea
• Causes: congenital, aging, scarring, spasm, eye infection (trachoma), blepharitis |
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Term
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Definition
• Outward turning lid margin exposing palpebral conjunctiva
• More common in elderly
• If punctum of lower lid turns outward, eye drainage is affected
• Causes: stroke, skin cancer, rapid weight loss, aging, Bell’s Palsy, birth defects, growths/tumors, scars, injuries |
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Term
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Definition
• Deviations of the eye toward the nose, which are the most common type of strabismus in children
• In moderate to large esodeviations, the corneal light reflex appears approximately in the center of the fixating eye's pupil and is displaced temporally in the deviated eye
• Causes: accommodative esotropia, idiopathic infantile esotropia, Duane syndrome, abducens palsy, and sensory esotropia
• Constant esotropia in an infant <4 four months old and persistent intermittent or constant esotropia in a child >4 months old are unlikely to resolve spontaneously
• Management: glasses, surgery, optho |
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Term
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Definition
• Outwarddeviationsoftheeye
• Typicallypresentduringthefirstdecadeoflife
• Thecorneallightreflexappearsapproximatelyinthe center of the fixating eye and is displaced nasally in the deviated eye
• Themostcommoncauseofexodeviationinchildren is intermittent exotropia. Other causes include type II Duane syndrome, oculomotor nerve paresis, congenital fibrosis of the extraocular muscles, sensory exotropia, and consecutive exotropia
• Management:visiontherapy,glasses,surgery,optho |
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Term
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Definition
• Also known as exophthalmos
• Seen in Grave’s disease
• The degree is dependent on the depth of the orbit and the degree of enlargement of the retroocular muscles and retroocular fibrous and fatty tissue.
• May be symmetric, but is often asymmetric, and may be accompanied by a sensation of pressure behind eyeballs.
• May be partially masked by periorbital edema, which is a common accompaniment.
• In more severe disease, there may be severe conjunctival inflammation and ulceration from over exposure |
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Term
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Definition
• A benign, yellowish, triangular wedge of fibrovascular conjunctival tissue that typically starts medially on the nasal conjunctiva and extends laterally onto the cornea
• Frequently seen with aging, male sex, and UV light
• Does not interfere with vision unless it approaches visual axis
• Symptoms: redness, itching
• Management: artificial tears, surgery if astigmatism leading to visual impairment, documented growth that is threatening to affect the visual axis, opacity in the visual axis, restriction of eye movement, significant cosmetic impact or intractable irritation |
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Term
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Definition
• Adegenerativeeyeconditionthatis often confused with pterygium
• Yellowish,slightlyraised conjunctival lesion arising at the limbal conjunctiva
• Commononthenasalconjunctiva, temporal conjunctiva, or both.
• Unlikeapterygiumthatarisesfrom the limbus and progresses onto the cornea, a pinguecula arises from the limbus and remains confined to the conjunctiva without corneal involvement
• Management:artificialtears |
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Term
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Definition
• Blood in the anterior chamber; may be from trauma
• Symptoms: Painful, blood visible in front of eye, blurry vision
• The blood may cover most or all of the iris and the pupil, blocking vision partially or completely
• Causes: abnormal blood vessels on iris surface, herpes, blood clotting disorder, cancer, artificial lens implants
• Warrants same-day evaluation by an ophthalmologist as it can be associated with significant trauma, inflammation, or pathologic neovascularization |
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Term
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Definition
• Pus (WBC infiltration) in the anterior chamber
• Warrants same-day evaluation by an ophthalmologist as it can be associated with infectious keratitis or endophthalmitis- endophthalmitis-bacterial or fungal infection within the eye, including involvement of the vitreous and/or aqueous humors |
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Term
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Definition
• Caused by bacteria, viruses, fungi, or parasites
• Symptoms: complain of foreign body sensation and have trouble keeping the involved eye open
• PE: corneal opacity or infiltrate (typically a round white spot) in association with red eye, photophobia, and foreign body sensation. This infiltrate or ulcer (>0.5 mm in size) can be seen with a penlight and does not require a slit lamp for identification. It will stain with fluorescein. Mucopurulent discharge is typically present. Fulminant cases may present with an associated hypopyon
• Improper contact lens wear is the largest risk factor for bacterial keratitis
• Emergent optho |
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Term
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Definition
• Herpessimplexcauses infectious keratitis, characterized by red eye, photophobia, foreign body sensation, and watery discharge.
• Maybeafaintbranchinggrey opacity on penlight exam.
• Thisbranchingopacityisbest visualized with application
of fluorescein.
• Althoughtypicallyaself-limited process, duration of symptoms is reduced with treatment with topical or oral antiviral agents. |
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Term
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Definition
• Slightly raised yellowish, well circumscribed plaques
• Cholesterol-filled, soft, yellow plaques that usually appear on the medial aspects of the eyelids bilaterally
• May accompany hyperlipidemia, biliary cholangitis
• Management: benign, lipid lowering agents, removal can be attempted with surgery, carbon dioxide laser, or topical 100 percent trichloroacetic acid (TCA) |
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Term
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Definition
• Painful, tender red infection in a gland at the margin of the eyelid
• An acute purulent inflammation of the eyelid
• It may be sterile or may show both inflammatory cells and bacteria, most commonly Staphylococcus aureus.
• An internal hordeolum represents inflammation of a meibomian gland just under the conjunctival side of the eyelid.
• An external hordeolum (stye) arises from an eyelash follicle or a lid-margin tear gland
• Management: warm compresses, if turns into chalazion-refer to optho, concurrent preseptal cellulitis, oral antibiotics with Staphylococcal coverage, topical medications and antibiotics (but not proven) |
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Term
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Definition
• Subacute nontender and usually painless nodule involving a Zeis or Meibomian gland becoming obstructed
• May become acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin
• Eyelid swelling and erythema and then evolve into a painless, rubbery, nodular lesion
• An inflamed hordeolum will often calm and scar into a hard chalazion
• Management: hot compresses, ophthalmologist for incision and curettage or direct glucocorticoid injection |
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Term
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Definition
• 85 to 90 percent of all such malignancies
• Sun exposure
• Small, slow-growing, firm, painless, pearly, and indurated, telangiectasias
• Treatment: Moh’s chemosurgery, cryo-surgical |
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Term
| eye Squamous Cell Carcinoma |
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Definition
• Faster growing than BCC • Arise de novo or from AK • Likely to metastasize
• Lower eyelid
• Nodules or plaques with everted edges that crust
• Treatment: biopsy, wide excision |
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Term
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Definition
• Often mistaken for recurrent chalazion or blepharoconjunctivitis
• Highly malignant carcinoma arising from meibomian, Zeis, or sebaceous glands of the skin
• Upper lids of females over 50 y/o
• Treatment: wide surgical excision with frozen section control |
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Term
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Definition
• A rapidly growing hyperkeratotic nodule with a central keratin plug
• Grows in 3-6 weeks
• May occur on either sun- damaged or protected skin
• Treatment: controversial if malignant or benign; they resemble squamous cell carcinomas histologically; excision |
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Term
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Definition
• Most common benign tumor of eyelid
• Caused by HPV
• Frond-like, skin tag
• Simple excision or cryo |
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Term
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Definition
• Greasy, brownish, crust- like lesions, “stuck on” to eyelid
• Elderly
• Shave biopsy |
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Term
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Definition
• Pre-malignant condition
• Predisposes to SCC
• Dry, scaly, flat with erythematous base
• Biopsy, surgical excision, cryo |
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Term
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Definition
• Dark protrusion of packed keratin from the surface of the skin
• Overlies and area of malignancy (BCC or SCC)
• Biopsy |
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Term
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Definition
| pin-point, multiple, firm, white lesions that appear on upper/lower eyelids; therapy consists of puncture of the lesions |
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Term
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Definition
| solitary, slow growing, mobile, firm, round subcutaneous nodule found on upper eyelid; forms after surgery/trauma or congenital; surgical excision of cyst shell |
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Term
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Definition
| found in infancy, often grow in puberty; firm, mobile, found in the lateral brow or upper eyelid region; can extend far back into the orbit; orbital imaging indicated; complete excision without disrupting cyst wall |
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Term
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Definition
• A painful, destructive, and potentially blinding disorder that may also involve the cornea, adjacent episclera, and underlying uveal tract. May be nodular
• Symptoms: severe, constant, boring pain that worsens at night or in the early morning hours and radiates to the face and periorbital region. Additionally, patients may report headache, watering of the eyes, ocular redness, and photophobia.
• Management: Optho urgently; look for rheumatologic and inflammatory disorders; topical & systemic steroids |
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Term
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Definition
• Inflammation of the episcleral vessels that appear salmon pink
• Less painful than scleritis
• Localized ocular redness
• May be nodular
• Management: resolves spontaneously, topical steroids may be used |
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Term
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Definition
• Infectionofthenasolacrimal system
• Acuteinflammationispainful,red, and tender, purulent discharge
• Chronicinflammationassociated with obstruction of the nasolacrimal duct
• Maybeacuteorchronic
• Tearingisprominent
• Pressureonthesacproduces regurgitation of material through the puncta of the eyelids
• Treatment:oralorIVantibiotics;for chronic infections topical antibiotics |
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Term
| Epidemic Keratoconjunctivitis (EKC) |
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Definition
• Form of viral conjunctivitis
• Causes a keratitis (inflammation of the cornea) and a conjunctivitis
• Caused by adenovirus types 8, 19, 37
• The same strain that may cause viral conjunctivitis may cause EKC
• Same symptoms as viral but has a FB sensation and multiple corneal infiltrates barely visible with a penlight, visual acuity degrades by 2-3 lines to 20/40 range
• Vision threatening
• Refer to optho immediately; topical glucocorticoids |
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Term
| Hyperacute Bacterial Conjunctivitis |
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Definition
• N. gonorrhoeae, can cause a hyperacute bacterial conjunctivitis that is severe and sight-threatening, requiring immediate ophthalmologic referral
• Usually transmitted from the genitalia to the hands and then to the eyes.
• Concurrent urethritis is typically present
• Profuse discharge within 12 hours of inoculation, redness, irritation and tender to palpation, tender preauricular adenopathy
• Gram negative diploccoci on Gram stain
• Treatment: admit, systemic antibiotics and topical therapy |
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Term
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Definition
• Trachoma: a public health problem in 41 countries, and is responsible for irreversible blindness or visual impairment of about 1.9 million people
– Treatment: "SAFE": Surgery for advanced disease, Antibiotics to clear C. trachomatis infection, Facial cleanliness and Environmental improvement to reduce transmission
• Adult inclusion conjunctivitis: STI; Chlamydia trachomatis. Concurrent asymptomatic urogenital infection is typically present.
– Giemsa or direct fluorescent antibody (DFA) staining of conjunctival smears or by culture or PCR of swabbed specimens.
– Treat Chlamydia |
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Term
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Definition
• Glaucoma involves a characteristic atrophy of the optic nerve head ("cupping"), often with peripheral vision defects. Angle-closure glaucoma is characterized by narrowing or closure of the anterior chamber angle, leading to increased intraocular pressure (IOP) and damage to the optic nerve
• Drainage of aqueous humor through the anterior angle is blocked by anatomic narrowing of the angle in primary angle-closure glaucoma.
• Acute blockage is an ophthalmic emergency, since vision loss and blindness may occur quickly.
• Patients with chronic angle-closure glaucoma may not develop increased IOP and symptoms, and diagnosis may be delayed resulting in more vision loss than patients with acute angle-closure glaucoma
• Secondary angle-closure is caused by a variety of processes that either push or pull the anterior chamber angle closed. These may include fibrosis and scarring, drug reactions, neovascularization, or mass.
• Symptoms: vision loss, headache, severe eye pain, light halos, nausea, and vomiting.
• PE: Ocular exam reveals a red eye, corneal cloudiness or edema, a shallow anterior chamber, and poorly reactive mid-dilated pupil.
• Management: Urgent referral for ophthalmology; diagnosis via gonioscopy; topical agents to reduce IOP; beta-blocker, an alpha agonist, and an agent to produce miosis. We also suggest systemic medication to decrease IOP, which may include oral or IV acetazolamide, IV mannitol, oral glycerol, or isosorbide
• Once acute attack subsides, laser peripheral iridotomy to provide a small drainage hole through the iris
• Avoid decongestants and anticholinergic medications which may precipitate an attack |
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Term
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Definition
• Anopticneuropathycharacterizedbyprogressive peripheral visual field loss followed by central field loss in a typical pattern.
• Occasionalelevatedintraocularpressure(IOP).
• Increasedaqueousproductionand/ordecreasedoutflow are possible mechanisms for elevation of intraocular pressure
• Leadingcauseofblindnessintheworld
• Riskfactors:age,blackrace,familyhistory,elevated IOP
• Symptoms:rare,detectedincidentally;Somepatients are unaware of field loss even when it has progressed to central "tunnel vision."
• Screening: tonometry
• Glaucoma is diagnosed in patients with characteristic nerve damage on fundus examination and on visual field testing typically in the presence of elevated IOP.
• Some say either characteristic optic nerve change OR visual field defects as sufficient criteria for diagnosis of open-angle glaucoma.
• Treatment: prostaglandins, Bblockers, alpha adrenergic agonists, Systemic carbonic anhydrase inhibitors, laser therapy, surgery |
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Term
| Corneal Arcus/Arcus Senilis |
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Definition
• Thin grayish white arc or circle not quite at the edge of the cornea; an annular yellow-white deposit on the peripheral cornea
• Causes: Deposition of cholesterol esters, cholesterol, and neutral fat in the cornea
• Accompanies normal aging
• Also seen in younger people, especially African Americans
• In young people suggests possible hyperlipoproteinemia
• Usually benign; correlated with younger life spans in one study |
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Term
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Definition
• A difference in the size of two pupils greater than 4mm
• Present in 1/5 of the population
• May be normal or a sign of ocular or neurologic disease
– Should be considered a neurosurgical emergency if a patient has anisocoria with acute onset of third-nerve palsy and associated with headache or trauma
– Symmetrically rapid constriction in pupillary light response indicates that the anisocoria is not due to third nerve palsy
– If the difference in pupil size in both light and dark illumination is constant, then it is called physiologic or essential anisocoria |
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Term
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Definition
is governed by the balance of actions of two opposing muscle groups of the iris: the dilator and sphincter pupillae.
• Regulation of the pupillary size is predominantly achieved by reflex mechanisms in response to the amount of ambient light.
• Other factors influencing pupillary size include patient age, emotional state (adrenergic tone), state of arousal, and intraocular pressure |
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Term
| Pupillary constriction to light and near stimuli |
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Definition
| is mediated via parasympathetic (cholinergic) nerve fibers that travel along the third cranial nerve. The pupillary light reflex pathway is a four neuron pathway |
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Term
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Definition
is mediated
through three- neuron sympathetic (adrenergic) pathways that originate in the hypothalamus |
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Term
| Anisocoria represents either |
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Definition
impaired dilation or constriction of one pupil.
• These are mediated by sympathetic and parasympathetic pathways, respectively.
• PE: Neurologic examination of the pupils notes their size, shape, and symmetry in light and dark conditions as well as the responses to light and near stimuli.
• The abnormal pupil can be identified by examination in light and dark conditions.
• Anisocoria that is greater in the dark identifies the small pupil as abnormal and implies a lesion in the sympathetic pathways.
• Anisocoria that is more pronounced in light conditions identifies the large pupil as abnormal and implies a lesion in the parasympathetic pathways.
• Anisocoria due to sympathetic lesions is usually a feature of Horner syndrome
• Parasympathetic causes of anisocoria include trauma, topical drugs, tonic pupil, and third nerve palsy. |
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Term
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Definition
• The main clinical question in the patient with anisocoria is deciding whether the larger pupil or the smaller pupil is the problem
• The key differentiating signs the pupillary reaction to light, the near response, and the amount of anisocoria in the light and in the dark
• Tonic Pupil (Adie’s pupil)
• Oculomotor CN III Paralysis
• Horner’s syndrome
• Small irregular pupils
• Blind eye
• Marcus Gunn Pupil
• Argyll Robinson Pupil-syphilis |
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Term
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Definition
• Apupilwithparasympatheticdenervationthat constricts poorly to light but reacts better to accommodation (near response), such that the initially larger Adie pupil becomes smaller than its normal fellow and remains tonically constricted, redilating very slowly when exposed to dark.
• Damagetotheparasympatheticciliaryganglionor short ciliary nerves followed by aberrant reinnervation
• Large,irregularpupil
• Usuallyunilateralmydriasiswithslowedorabsent reaction to light
• Slowedaccommodationcausesblurredvision
• The tonic pupil constricts poorly or not at all to light but reacts better to accommodation (near response), such that the initially larger tonic pupil becomes smaller than its normal fellow and remains tonically constricted, redilating very slowly when exposed to dark.
• The key differentiating signs are the pupillary reaction to light, the near response, and the amount of anisocoria in the light and in the dark.
• Causes: idiopathic, local disorders within the orbit affecting the ciliary ganglion including tumor, inflammation, trauma, surgery, or infection
• Management: may use pilocarpine, find underlying cause (unexplained bilateral tonic pupils-test for syphilis and patients with light- near dissociation of the pupils in the setting of a third nerve palsy or other dorsal midbrain signs should undergo neuroimaging
• Most do not need treatment as Adie’s tonic pupil is benign |
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Term
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Definition
• The 3rd nerve controls the movement of 4/6 eye muscles and also controls constriction of the pupil, the position of the upper eyelid and the ability of the eye to focus
• A complete third nerve palsy causes a completely closed eyelid and deviation of the eye outward and downward. The eye cannot move inward or up, and the pupil is typically enlarged and does not react normally to light. A partial third nerve palsy affects, to varying degrees, any of the functions controlled by the third cranial nerve.
• Dilated pupil (6-7mm) is fixed to light and near reaction
• May have associated ptosis and lateral eye deviation, double vision
• May be congenital or acquired: head injury, infection, migraine, brain tumor, aneurysm, diabetes, or high blood pressure
• Management: none for congenital; if acquired may get relief with surgery removal of a tumor or anuerysm, patching the eye may help |
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Term
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Definition
• Caused by a lesion anywhere along the sympathetic pathway that supplies the head, eye, and neck
• Small pupil (miosis) that reacts to light and accommodation (with dim lighting)
• The amount of anisocoria is worse in the dark than in the light, and it is associated with dilation lag of 15 to 20 seconds
• Symptoms: miosis, ptosis, and anhidrosis
• First order-central lesion (anhidrosis)
• Second order-preganglionic lesion (anhidrosis) • Third order-postganglionic lesion
• Neuroimaging to determine location
• Associated neurologic symptoms and signs can be useful in localizing the origin of the Horner syndrome:
• Brainstem signs (diplopia, vertigo, ataxia, lateralized weakness) suggest a brainstem localization
• Myelopathic features (bilateral or ipsilateral weakness, long tract signs, sensory level, bowel and bladder impairment) suggest involvement of the cervicothoracic cord.
• Arm pain and/or hand weakness typical of brachial plexus lesions suggest a lesion in the lung apex.
• Ipsilateral extraocular paresis, particularly a sixth nerve palsy, in the absence of other brainstem signs localize the lesion to the cavernous sinus.
• An isolated Horner syndrome accompanied by neck or head pain suggests an internal carotid dissection.
• Topical administration of one to two drops of 4 to 10 percent cocaine or
Apraclonidine drops (used for glaucoma) may be required to distinguish a Horner syndrome from physiologic anisocoria.
• Apraclonidine reverses Horner’s syndrome
• A normal pupil dilates more than the Horner pupil, increasing the degree of anisocoria, a response not seen in physiologic anisocoria. |
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Term
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Definition
• RelativeAfferentpupillary defect indicating a decreased pupillary response to light in the affected eye
• Mostcommoncauseislesion of optic nerve (distal to the optic chiasm) or severe retinal disease
• Cando“swingingflashlight test” for diagnosis |
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Term
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Definition
• Small, irregular pupil: accommodates but does not react to light
• Seen in tertiary syphilis
• Argyll Robertson pupils are not tonic. They constrict quickly to near and redilate quickly when removed from the near stimulus. |
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Term
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Definition
• Typically, the pupils dilate, or widen, in response to low light so they can collect more light.
• Sometimes pupils will dilate for a reason unrelated to the levels of light in the environment.
• They may stay enlarged even in bright environments-this condition as mydriasis
• Causes: anticholinergics, injury to the eye, increased oxytocin, drug use-such as cocaine, ecstasy, hallucinogenics, and crystal methamphetamine
• Benign episodic unilateral mydriasis (BEUM)
• Cranial nerve neuropathy
• Traumatic brain injury
• Mydriatics
• Management: treat the cause, opaque contact lenses or light-sensitive sunglasses; surgery |
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Term
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Definition
• Pupils that are abnormally small under normal lighting conditions are called pinpoint pupils
• In bright light, your pupils get smaller (constrict) to limit the amount of light that enters. In the dark, your pupils get bigger (dilate). That allows more light in, which improves night vision.
• Impaired far vision
• Causes: opioids, ICH, uncontrolled HTN, Horner’s syndrome, anterior uveitis, nerve agents, prescription drops, oral medications, neuro syphilis
• Management: find the underlying problem |
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Term
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Definition
• Arefractiveerror,meaningitisnot an eye disease or eye health problem; it's simply a problem with how the eye focuses light.
• Causedbyanirregularly shaped cornea; occasionally an irregular lens (lenticular astigmatism)
• Insteadofthecorneabeing shaped like a baseball it is shaped like an American football
• Threetypes:myopic,hyperopic, and mixed |
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Term
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Definition
• Arefractive defect of the eye
• Collimated light produces image focus in front of the retina when accommodation is relaxed
• Squinting, eye strain and headaches
• Occurs when the eyeball is too long
• Caused by
the cornea and/or lens being too curved for the length of the eyeball
• Begins in childhood and you may have a higher risk if your parents are nearsighted
• Management: glasses, contacts, refractive surgery, PRK, LASIK, orthokeratology (special contact lenses at night that reshape the cornea) |
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Term
| Hyperopia: Farsightedness |
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Definition
• Either eyeball is too short or lens cannot become round enough
• Image not focused on the retina
• This is not the same as presbyopia which is the lack of the ability of the lens to accommodate with age |
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Term
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Definition
• Progressively diminished ability to focus on near objects with age
• Etiology:
– Loss of elasticity of the crystalline lens
– Changes in the lens’s curvature from continual growth
– Loss of power of the ciliary muscles (the muscles that bend and straighten the lens) have also been postulated as its cause
• Treatment: glasses, contacts, surgery |
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Term
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Definition
• Uveitis is characterized by inflammation of the uvea, which is the middle portion of the eye; the anterior portion of the uvea includes the iris and ciliary body, and the posterior portion of the uvea is known as the choroid
• Inflammation of the anterior uveal tract, characterized by the presence of leukocytes in the anterior chamber of the eye, is called anterior uveitis and is synonymous with iritis. When the adjacent ciliary body is also inflamed, the process is known as iridocyclitis
• The presence of leukocytes in the vitreous humor and evidence of active chorioretinal inflammation are diagnostic of intermediate uveitis and posterior uveitis, respectively.
• Terms used to describe forms of uveitis posterior to the lens include vitritis, intermediate uveitis, pars planitis, choroiditis, retinitis, chorioretinitis, and retinochoroiditis
• Panuveitis is defined as simultaneous inflammation in the anterior chamber, vitreous humor, and retina or choroid.
• Uveitis occurs in association with other systemic medical conditions, especially infections and inflammatory diseases, but may occur as an isolated process.
• Uveitis symptoms depend on the portion of the uveal tract affected.
• Anterior uveitis may produce pain and redness
• Posterior or intermediate uveitis is more likely to be painless, but is often associated with floaters and/or some degree of visual loss.
• Visual loss may occur with anterior, intermediate, or posterior involvement
• Slit lamp and funduscopic examination are necessary to establish the presence of uveitis. Examination should include scleral depression to assess for inflammation just posterior to the lens (the pars plana of the uveal tract)
• Because of a strong association between uveitis affecting the pars plana (pars planitis) and MS, particular attention should be given to the neurologic history in patients with pars planitis
• Treatment: Treat infectious agent
• Anterior uveitis not due to infection is treated with topical glucocorticoids.
• Dilating ophthalmic drops are indicated if ciliary spasm is causing pain or if there is risk for posterior synechiae.
• Posterior or intermediate uveitis and panuveitis are generally not responsive to topical treatment. Initial management of uveitis posterior to the lens usually includes observation, as well as periocular and, occasionally, intraocular glucocorticoid injections.
• Oral glucocorticoids are frequently recommended for patients with uveitis that is resistant to topical therapy |
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Term
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Definition
• Swelling of the optic disc due to increased intracranial pressure:
– Brain tumor or abscess.
– Head injury.
– Bleeding in the brain.
– Inflammation of the brain (encephalitis) or its tissue coverings (meningitis)
– Idiopathic intracranial hypertension.
– Uncontrolled, life-threatening hypertension
• Unilateral or bilateral
• Asymptomatic or blurry vision, headache, partial or total loss of vision, enlargement of blind spot
– Paton’s lines are radial retinal lines cascading from the optic disc
• On ophthalmoscope exam
– Venous engorgement (usually first sign)
– Loss of venous pulsation
– Hemorrhages over and/or adjacent to the optic disc – Blurring of optic margins
– Elevation of optic disc |
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Term
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Definition
• Backward depression of disc and atrophy • Base of enlarged cup is pale
• Physiologic cup greater than 0.5 |
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Term
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Definition
• Damage of optic nerve
• Disc vessels absent
• Symptoms: blurred vision, difficulties with peripheral (side) vision, difficulties with color vision, a reduction in sharpness of vision
• Causes: glaucoma, stroke of optic nerve, tumor, optic neuritis, MS, congenital |
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Term
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Definition
• Vein appear to stop abruptly on either side of artery
• Causes: hypertension |
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Term
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Definition
• Copper or silver wiring
– Retinal arterioles appear orange or yellow instead of red ("copper wiring")
– Retinal arterioles look white if they have become occluded ("silver wiring")
• Thickening of vessels • Arteriosclerosis, HTN |
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Term
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Definition
• White or greyish, ovoid lesions with irregular “soft” borders
• Usually smaller in size than the disc
• Results from infarcted nerve fibers
• Causes: hypertension, diabetes, HIV, lupus, severe anemia or thrombocytopenia, hypercoagulable states, connective tissue disorders, viruses, Behçet, Purtscher, and many others |
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Term
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Definition
• Dot/Blot hemorrhages
– Rupture of deep capillaries submerged within retina and caused by arteriolar, capillary, or venular incompetence
– Seen in DM
• Flame hemorrhages
– Rupture on retinal nerve fiber layer of superficial pre-capillary arterioles, small veins
– Commonly associated with systemic hypertension, leukemia, severe anemia, thrombocytopenia, retinal vein occlusion, trauma
• Pre-retinal
– Blood in potential spaces between retina and vitreous
– Horizontal line of demarcation
– Seen in intracranial pressure, anemia, thrombocytopenia, trauma, vigorous headshaking in abused infants, retinal vein occlusion
• Subretinal hemorrhages
– Rupture of choroidal vessels under fovea in interface between choroid and retina
– Commonly associated with age- related macular degeneration
• Vitreous hemorrhages
– Rupture of superficial retinal vessels or vessels on fibrovascular stalk extending into vitreous
– Commonly associated with proliferative diabetic retinopathy, hypertension, trauma |
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Term
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Definition
• Tiny, round, red spots often near macular
• Minute dilatations of very small retinal vessels
• Seen in diabetes |
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Term
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Definition
• Yellow flecks made up of lipid residues of serous leakage from damaged capillaries
• Small and round and may coalesce
• Causes: Diabetes main cause, but also neuroretinitis, retinal vein occlusion, Von Hippel-Lindau Disease, other vascular dysplasias, radiation- induced retinal vasculopathy |
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Term
| Retinal Neovascularization |
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Definition
• Formation of new blood vessels
– More numerous and tortuous and narrower than other blood vessels
– Seen in late proliferative stage of DM retinopathy, sickle cell disease, retinopathy of prematurity, retinal vein occlusion, severe carotid stenosis
– Vessels can grow into vitreous and cause retinal detachment or visual loss |
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Term
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Definition
• Yellow-white flecks (retinal Drusen) scattered around macular region; these are "tombstones" of dead retinal pigment epithelium
• Cause is often age-related macular degeneration, poorly understood disorder of aging
• Dry form of age-related macular degeneration makes up 90% of cases, consisting of drusen and atrophic pigment epithelium
• Wet form makes up 10% of cases, consisting of choroidal vessels burrowing into retina to cause bleeding |
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Term
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Definition
• Cotton wool spot surrounded by hemorrhage, representing retinal microinfarct that bled
• Not specific for endocarditis
• Many conditions cause this, including hypertension, diabetes, blood dyscrasia, HIV, bacterial endocarditis, connective tissue diseases, abusive head trauma in infants |
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Term
| Age-Related Macular Degeneration |
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Definition
• The leading cause of adult blindness in industrialized countries
• A degenerative disease of the central portion of the retina (the macula) that results primarily in loss of central vision.
• AMD is classified as dry (atrophic) or wet (neovascular or exudative)
• The risk of AMD increases with age. Smoking is the major modifiable risk factor for AMD.
• A common polymorphism in the complement factor H (CFH) gene appears to explain about 50 percent of cases of AMD. |
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Term
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Definition
• Patients may complain of gradual loss of vision in one or both eyes
• Pathogenesis unclear
• Development of Drusen |
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Term
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Definition
• May present as acute visual distortion or loss of central vision as a result of subretinal hemorrhage or fluid accumulation.
• Symptoms usually appear in one eye, although the disease is often present in both eyes.
• Distortion of straight lines (metamorphopsia) is one of the earliest changes
• Scotoma may be present |
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Term
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Definition
• Aspotinthevisualfieldinwhich vision is absent or deficient.
• Causedbyaprobleminbrain, eye, or optic nerve
• Causes: stroke, tumor, injury, glaucoma or retinal problem, MS or other diseases that can affect the optic nerve, chemicals
• Symptoms:spotinvisionthat can be dark, very light, blurred, or flickering, trouble seeing certain colors, the need for bright light in order to see clearly |
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Term
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Definition
• Retinoblastoma: urgent
• An opacity of the lens (cataract)
• Detached retina (less common): Emergency
• Opacity of the vitreous
• Artificial eye |
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Term
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Definition
• Most common primary intraocular malignancy of childhood and accounts for 10 to 15 percent of cancers within the first year of life
• Diagnose by light examination, presents as leukocoria
• local and systemic chemotherapy, cryotherapy, laser photocoagulation, and enucleation |
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Term
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Definition
• Occurs when the multilayer neurosensory retina separates from the underlying retinal pigment epithelium and choroid.
• This separation can occur passively due to accumulation of fluid between these two layers, or it may occur actively due to vitreous traction on the retina, such as with diabetic traction retinal detachment
• Usually painless |
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Term
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Definition
• Acutepainlessmonocularvisualloss with retinal ischemia visualized on funduscopic examination
• Carotidarteryatherosclerosisisthe most common etiology
• Cardiogenicembolismisthemost likely etiology in young patients. Other causes include clotting disorders, vasculitis, and other vascular diseases, giant cell arteritis
• Maybecentralorabranch
• Management:carotidimagingstudy, ECG |
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Term
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Definition
• Transient monocular visual loss (TMVL) and amaurosis fugax are used interchangeably to describe painless, transient vision loss in one eye, attributed to ischemia or vascular insufficiency and lasting for several seconds to a few minutes
• Patients describe their vision loss as a shade or curtain coming down over their eye.
• Usually occurs in people older than 50 with atherosclerotic risk factors: diabetes, hypertension, and hyperlipidemia, CAD, PVD
• A retinal artery embolus is a common cause, usually seen in retinal arteries (ocular TIA)
• Workup similar to stroke: carotid Doppler, MRA, TEE
• Find the source, lower intraocular pressure by systemic or topical agents, or by anterior chamber paracentesis; ocular massage to dislodge an embolus to the retinal periphery; carbogen (95% oxygen, 5% carbon dioxide) inhalation or paper bag rebreathing to induce retinal artery dilation; hyperbaric oxygen; and thrombolysis |
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Term
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Definition
• Opacitiesofthelensesvisibleinthe pupil
• Mostcommoninoldageorvery young, commonly bilateral
• Canbenuclear(central)or peripheral
• Aleadingcauseofpartialortotal blindness
• Riskfactors:olderage,smoking, poor lifestyle habits, alcohol consumption, sunlight exposure, lower educational status, diabetes mellitus, and systemic and possibly high-dose inhaled corticosteroids
• Symptoms: problems with night driving, reading road signs, or difficulty with fine print, an increase in myopia
• Patient complains of painless progressive decline in vision
• Management: funduscopic exam to check for other causes of diminished vision, surgery |
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Term
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Definition
• Superficial grayish, white opacity in the cornea secondary to an old injury or to inflammation
• Size and shape are variable
• It should not be confused with the opaque lens of a cataract which is visible on a deeper plane and only through the pupil |
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Term
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Definition
| • Periorbital ecchymosis is a sign of basal skull fracture or subgaleal hematoma, a craniotomy that ruptured the meninges, or (rarely) certain cancers. |
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Term
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Definition
-yellowing of the eye
• Toomuchbilirubincauses jaundice. Bilirubin is a yellow chemical in hemoglobin, the substance that carries oxygen in your red blood cells. As red blood cells break down, your body builds new cells to replace them. The old ones are processed by the liver. If the liver cannot handle the blood cells as they break down, bilirubin builds up in the body and your skin may look yellow. |
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Term
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Definition
• Hemianopsia, or hemianopia, is a decreased vision or blindness (anopsia) in half the visual field, usually on one side of the vertical midline.The most common causes of this damage are stroke, brain tumor, and trauma.
• Quadrantanopia, quadrantanopsia, or quadrant anopia refers to an anopia affecting a quarter of the field of vision. It can be associated with a lesion of an optic radiation.
• Binasal hemianopsia (or binasal hemianopia) is the medical description of a type of partial blindness where vision is missing in the inner half of both the right and left visual field. It is associated with certain lesions of the eye and of the central nervous system, such as congenital hydrocephalus.
• Bitemporal hemianopsia, also known
as bitemporal heteronymous hemianopsia or bitemporal hemianopia, is the medical description of a type of partial blindness where vision is missing in the outer half of both the right and left visual field. |
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Term
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Definition
• Abnormaldrynessofthe conjunctiva and cornea of the eye, with inflammation and ridge formation, typically associated with vitamin A deficiency
• Mayleadtolesionsoncornea- Bitot’s spots and blindness
• Riskfactors:povertyandlack of adequate diet, especially a lack of animal products, alcoholism, CF, Celiac disease, cirrhosis
• Treatment:VitaminA |
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