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Файл:Ординатура / Офтальмология / Английские материалы / Ophthalmology Secrets in Color_3rd edition_Vander, Gault_2007.pdf
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- •Dedication
- •Contributors
- •Preface
- •Top 100 Secrets
- •To what glands do the lymphatics of the orbit drain?
- •What is the orbital septum?
- •You are preparing to do an argon laser trabeculoplasty. Describe the gonioscopic appearance of the anterior chamber angle.
- •After a filtering procedure, your patient develops choroidal effusions. Explain the distribution of these fluid accumulations based on uveal attachments to the sclera.
- •Which retinal layer is referred to as the fiber layer of Henle in the macular region?
- •What are three clinically recognized remnants of the fetal hyaloid vasculature?
- •Where do branch retinal vein occlusions occur? Which quadrant of the retina is most commonly affected?
- •Describe the location of the visual cortex.
- •What is the most likely anatomic location of pathology associated with downbeat nystagmus?
- •Explain why visual acuity in infants does not reach adult levels until approximately 6 months of age, based on retinal differentiation.
- •A neonate presents with an opacification in her left cornea. What is the differential diagnosis?
- •Describe the innervation of the lens.
- •Describe the innervation of the cornea.
- •What are the three layers of the tear film? Where do they originate?
- •Where is the macula represented in the visual cortex?
- •What is macular hole formation?
- •Describe the stages of macular hole formation as proposed by Gass, as well as the changes in our understanding of the disease process since the development of optical coherence tomography (OCT).
- •Bibliography
- •Less laser power is required for photocoagulation in darkly pigmented fundi. What determines this pigmentation?
- •Orbit
- •Name the bones of the orbit.
- •What are the weak spots of the orbital rim?
- •What is the weakest bone within the orbit?
- •Name the divisions of cranial nerve V that pass through the cavernous sinus.
- •What is the annulus of Zinn?
- •What nerves pass through the superior orbital fissure but outside the annulus of Zinn?
- •Eyelid
- •List the factors responsible for involutional entropion.
- •What are the surgical landmarks in locating the superficial temporal artery during temporal artery biopsies?
- •What is meant by the term lower lid retractors?
- •What structures would be cut in a full-thickness lower-lid laceration 2 mm below the lower tarsus?
- •What structure separates the medial fat pad from the central (also called the preaponeurotic) fat pad in the upper eyelid?
- •Lester Jones divided the orbicularis oculi muscle into three portions. Name them.
- •What portions of the orbicularis oculi muscle are important in the lacrimal pump mechanism?
- •Bibliography
- •What is the primary focal point (f)?
- •What is the far point of an eye?
- •Where is the far point for a myopic eye? A hyperopic eye? An emmetropic eye?
- •How do you determine which lens will correct the refractive error of the eye?
- •What is the near point of an eye?
- •Myopia can be caused in two ways. What are they?
- •The power of a proper corrective lens is altered by switching from a contact lens to a spectacle lens or vice versa. Why?
- •What is the amplitude of accommodation?
- •What is the range of accommodation?
- •How does a diopter relate to meters?
- •What is the critical angle?
- •What happens if the critical angle is exceeded?
- •Give examples of total internal reflection.
- •What is the formula for vergence?
- •What is the vergence of parallel light rays?
- •What is the image point if an object lies 25 cm to the left of a +5.00 lens?
- •How is the power of a prism calculated?
- •Key Points: Alleviation of Symptomatic Anisometropia
- •How can the prismatic effect be alleviated?
- •What is the circle of least confusion?
- •Thick lenses have aberrations. List them.
- •Are red or green light rays refracted more by a plus lens?
- •A myopic patient tilts his glasses to see in the distance. What does this tell you?
- •What measurements are necessary in determining the intraocular lens implant calculation?
- •How does an axial error that is incorrect by 0.1 mm affect the intraocular lens calculation?
- •How does an error in keratometry readings affect the intraocular lens calculation?
- •What is the formula for transverse magnification?
- •What is the formula for axial magnification?
- •What is angular magnification?
- •What is the magnification of a direct ophthalmoscope?
- •Does an astronomic telescope form an upright or an inverted image?
- •Does a Galilean telescope form an upright or an inverted image?
- •What is the magnification formula for a telescope?
- •How do you estimate the strength of plus lens needed to read newspaper print without accommodation?
- •The devices mentioned thus far are for magnifying at near. What is available for distance aids?
- •Do convex mirrors add plus or minus vergence?
- •What is the reflecting power in diopters of a mirror?
- •What instrument uses the reflecting power of the cornea to determine its readings?
- •How much of the cornea is measured with a keratometer?
- •Why does a keratometer use doubling of its images?
- •What is a Geneva lens clock?
- •Do you measure the power of spectacles in a lensmeter with the temples toward you or away from you?
- •What does a pachymeter measure?
- •How does the Hruby lens give an upright or inverted image?
- •Why does the indirect ophthalmoscope provide a larger field of view than the direct ophthalmoscope?
- •What are the wavelengths of the spectrum of visible light?
- •Antireflective coatings on spectacle lenses are based on what principle?
- •What is the most effective pinhole diameter?
- •When is a cycloplegic refraction indicated?
- •Which cycloplegic agent lasts the longest? The shortest?
- •When is it important to measure the vertex distance in prescribing glasses?
- •What is the threshold for prescribing glasses in a child with astigmatism?
- •What may cause monocular diplopia?
- •What do you check when patients complain that their new glasses are not as good as their previous pair?
- •If after repeat refraction the patient suddenly develops more hyperopia than you previously noted, what do you look for?
- •Key Points: Causes of Monocular Diplopia
- •When the Jackson cross is used to define the astigmatic axis, is the handle of the lens parallel to the axis or 45 degrees from it?
- •What instrument is useful to measure the accommodative amplitude?
- •Bibliography
- •What are photons?
- •Describe the physical properties of photons.
- •What is the electromagnetic spectrum?
- •What is the light spectrum?
- •How does a prism break white light into the colors of the rainbow?
- •How do rods differ from cones?
- •What are the visual pigments?
- •Describe the three cone pigments.
- •What if the patient has more myopia than previously noted?
- •What about acquired astigmatism?
- •What does laser stand for?
- •To steepen a contact lens fit, do you increase the diameter of the lens or the radius of curvature?
- •What three attributes are necessary to describe any color?
- •What is hue?
- •What is saturation?
- •What is brightness?
- •What are complementary colors?
- •What is the color wheel?
- •How does the eye differ from the ear?
- •What are the primary colors?
- •Where is the final determination of color made?
- •Why is brown, which is definitely a color, not on the color wheel?
- •What is the Abney effect?
- •What are the relative luminosity curves?
- •Define lateral inhibition.
- •What are afterimages?
- •Why are white flowers white?
- •Why is charcoal black?
- •Why are blue flowers blue?
- •Why does mixing paints yield unpredictable results?
- •Why do colors appear different under fluorescent light as opposed to incandescent lights?
- •Key Points: Color Vision
- •Why is the sky blue?
- •Why is the sunset red?
- •Define trichromats.
- •What is congenital dichromatism?
- •Why do deuteranopes have difficulty in distinguishing red from green?
- •What is anomalous trichromatism?
- •How is abnormal color vision inherited?
- •Website
- •Bibliography
- •What is the electroretinogram?
- •How is an ERG performed?
- •Key Points: Components of the Full-Field ERG
- •What parameters are measured during evaluation of the ERG?
- •How is the ERG amplitude affected in retinal disorders?
- •What does the ERG demonstrate in retinal ganglion cell disease?
- •Describe the clinical situations where the ERG is utilized.
- •List the retinal degenerations in which the ERG can help clarify the diagnosis.
- •What does the ERG reveal in congenital rubella syndrome?
- •What does the ERG demonstrate in a progressive cone dystrophy?
- •Why is the ERG useful in patients with congenitally decreased vision?
- •How can the ERG measure retinal function in the presence of opaque ocular media?
- •List the disorders that may demonstrate an extinguished ERG.
- •What are new variations of the standard ERG?
- •In what retinal location is the EOG response generated?
- •What are the clinical uses for the EOG?
- •What does the EOG demonstrate in pattern dystrophies?
- •How does optic nerve disease affect the EOG?
- •How is the EOG affected by rhegmatogenous retinal detachment?
- •What are the characteristics of dark adaptation?
- •What are the indications for ophthalmic ultrasonography?
- •What frequency is used for standard ophthalmic ultrasonography?
- •What are the principles of ultrasonography?
- •How is the clinical ophthalmic ultrasound displayed?
- •What lesion features are evaluated during the ultrasound examination?
- •How is ultrasound used in preoperative cataract evaluation?
- •How is ultrasound used to assess intraocular tumors?
- •Describe the ultrasound features of a choroidal hemangioma.
- •Describe the ultrasound features of a retinal detachment.
- •What ocular conditions may demonstrate calcification on ultrasound?
- •When is ultrasound used to evaluate ocular trauma?
- •What are the ultrasound findings with an intraocular foreign body?
- •What is ultrasound biomicroscopy?
- •What is required when you order orbital MRI studies?
- •What are paramagnetic agents?
- •What is the strategy in ordering imaging studies in an adult with the diagnosis of intraocular neoplasm?
- •What are the indications for ordering CT orbital studies as a first choice?
- •What are the indications for ordering MRI orbital studies as a first choice?
- •What are the indications for orbital ultrasonography in imaging orbital lesions?
- •Bibliography
- •What are the main types of visual field tests?
- •Where is the physiologic blind spot located?
- •When looking at a visual field, how do you differentiate the right eye from the left eye?
- •What is a scotoma?
- •What are causes of fixation errors? What can be done to decrease them?
- •What are false field defects? What are some of their causes?
- •Key Points: Causes of False-Positive Field Defects
- •What is hemianopia?
- •Describe the visual pathway.
- •What causes binasal hemianopia?
- •Where would you expect the lesion causing an homonymous hemianopia without optic atrophy to be located?
- •Does visual acuity help to locate the cause of a visual-field defect?
- •What is the anatomic explanation for a junctional scotoma?
- •When has the visual field of a person with glaucoma progressed?
- •What is the differential diagnosis of general depression of the field without localized field defects?
- •What clinical findings might mimic a neurologic defect?
- •Key Points: Using Visual Fields to Determine Cause
- •Bibliography
- •Name the main causes of a red eye.
- •What are you looking for on the Gram stain?
- •How should the patient be treated?
- •What may cause superficial punctate keratopathy (SPK)?
- •What else is in the differential diagnosis of a red eye in a contact lens wearer?
- •Key Points: Causes of Red Eye in a Contact Lens Wearer
- •A car mechanic complains of a painful red eye. He was fixing a muffler at the time of the onset of pain. What are your concerns?
- •What do you do now?
- •How do you proceed if, instead of a potential ruptured globe, you find a superficial metallic foreign body at 4:00 on the cornea?
- •An unfortunate victim of domestic abuse had lye thrown in his face. What should you do?
- •What is his prognosis?
- •A young boy presents with purulent discharge over the past few days. His mother thinks that he needs antibiotics. Do you agree?
- •What are the common organisms responsible for bacterial conjunctivitis in children? How should you treat?
- •How do you proceed?
- •How do you diagnose the other causes of chronic conjunctivitis?
- •How else may scleritis present?
- •What percentage of patients with scleritis have systemic disease? What diseases are associated with scleritis?
- •What workup is appropriate for a patient with scleritis?
- •How should you treat the patient?
- •What about topical steroids or a subconjunctival steroid injection?
- •Key Points: Diseases That May Mimic Uveitis
- •Bibliography
- •What is a corneal ulcer?
- •What clinical features distinguish an infectious corneal ulcer?
- •What clinical features distinguish a sterile corneal ulcer?
- •What conditions predispose to corneal infections?
- •How can a contact lens wearer reduce the risk of infection?
- •How does the presence of a hypopyon affect the management of infectious keratitis?
- •When should an anterior chamber and/or vitreous tap be performed?
- •When should patients with corneal ulcers be hospitalized?
- •When are systemic medications indicated?
- •Other than antibiotics, what adjunctive therapy may be necessary in the treatment of corneal ulcers?
- •What steps should be taken when a corneal ulcer does not respond to empirical therapy?
- •When should a corneal biopsy be considered?
- •What is the role of topical corticosteroids in the treatment of corneal ulcers?
- •What is appropriate therapy for small peripheral infiltrates in a contact lens wearer?
- •Key Points: Corneal Ulcers
- •Why do herpetic infections occur?
- •Why is herpes a recurrent disease?
- •Give some nonocular signs suggestive of a herpetic corneal infection.
- •What are the noninfectious manifestations of a herpetic keratitis?
- •How should these infections be treated?
- •What is the role of topical corticosteroids in herpes simplex keratitis?
- •Key Points: Herpetic Keratitis
- •When should oral acyclovir be used in herpes simplex keratitis?
- •What other conditions can be mistaken for a corneal infection after LASIK?
- •Which clinical features help to distinguish DLK from an infectious process after LASIK?
- •Key Points: LASIK Infections
- •How does ophthalmia neonatorum typically present?
- •What is the usual means of transmission for neonatal conjunctivitis?
- •What is the most common cause of neonatal conjunctivitis in the United States?
- •Which type of neonatal conjunctivitis is associated with the most severe complications to the eye?
- •Key Points: Most Common Causes of Neonatal Conjunctivitis
- •What other diagnostic tool is used to differentiate the various causes of neonatal conjunctivitis?
- •Is a follicular reaction in the conjunctiva more indicative of a chlamydial or gonococcal infection?
- •Why is Crede prophylaxis (2% silver nitrate drops) no longer the standard agent of choice for routine neonatal conjunctivitis prevention?
- •What is currently used for neonatal prophylaxis?
- •What is the differential diagnosis of neonatal conjunctivitis?
- •When is systemic treatment indicated for neonatal conjunctivitis? Why?
- •What is the treatment for chlamydial conjunctivitis?
- •Key Points: Potential Systemic Complications of Neonatal Conjunctivitis
- •What is the treatment for gonococcal conjunctivitis?
- •What is the treatment for bacterial conjunctivitis?
- •Key Points: Potential Ocular Complications of Neonatal Conjunctivitis
- •What is the treatment for herpes simplex viral conjunctivitis?
- •How can the incidence of ophthalmia neonatorum be reduced in future generations?
- •Website
- •Bibliography
- •You are an antibiotic or steroid eyedrop just placed in the conjunctival fornix. Discuss the barriers to your journey into the eye.
- •Given the above barriers, how would you increase delivery of topical antibiotics or steroids to the desired site of action?
- •Key Points: Corneal Ulcers
- •How do topical steroids work?
- •Since steroids are not cures, what general categories of disorders warrant ophthalmic use of topical steroids?
- •The physician with the residual corneal scar wants to minimize his corneal scar but is concerned about potential side effects of topical steroids. How do you advise him?
- •The patient also requests that the most potent steroid be used with rapid taper so that the overall course may be shortened. Which steroid do you choose?
- •Two days later, only marginal improvement is noted, but intraocular pressure is 35 mmHg. What happened?
- •Bibliography
- •What is the definition of dry eye?
- •Describe the normal tear film.
- •What are the components of the tear film?
- •What is the function of the outer lipid layer?
- •What causes dysfunction of the outer lipid layer?
- •What is the function of the aqueous middle layer?
- •What is the function of the inner mucin layer?
- •What diseases of the conjunctiva can cause dry eye?
- •What is necessary for the normal resurfacing of the tear film?
- •What are the types of dry eye?
- •What are the symptoms of dry eye?
- •What are the most common signs of dry eye?
- •Who gets dry eye?
- •What are the treatments for dry eye patients?
- •What if this is still not enough?
- •Key Points: Severe Dry Eye
- •Is there any treatment to increase tear production?
- •What is the role of acetylcysteine?
- •What medications may be a cause of dry eye?
- •Bibliography
- •What are corneal dystrophies?
- •How do degenerations differ from dystrophies?
- •Discuss the general anatomic classification of corneal dystrophies.
- •Describe the inheritance patterns of anterior membrane dystrophies.
- •Which is the most common anterior membrane dystrophy? Which is strictly epithelial?
- •What are the most common presenting symptoms of anterior membrane dystrophies?
- •Discuss treatment options for recurrent corneal erosions associated with anterior membrane dystrophies.
- •Key Points: Recurrent Corneal Erosions
- •Discuss the role of surgery in the treatment of anterior membrane dystrophies.
- •Do lasers have a role?
- •Describe the inheritance patterns of the stromal dystrophies.
- •Describe the clinical features of the three major stromal dystrophies.
- •Is lattice dystrophy associated with systemic amyloidosis?
- •What characterizes Avellino dystrophy?
- •How are stromal dystrophies treated?
- •Is penetrating keratoplasty a definitive treatment?
- •Key Points: Penetrating Keratoplasty
- •Name the three posterior membrane dystrophies.
- •What is their common clinical manifestation?
- •Describe the inheritance patterns of the three posterior membrane dystrophies.
- •Describe the main clinical characteristics of the three posterior membrane dystrophies.
- •What is unique about the CHED cornea?
- •Can PPMD recur in the graft?
- •List some interesting trivia about corneal dystrophy.
- •Websites
- •Bibliography
- •What is keratoconus?
- •Who gets keratoconus?
- •What is the cause of keratoconus?
- •Is keratoconus hereditary?
- •What systemic conditions are associated with keratoconus?
- •What ocular conditions are associated with keratoconus?
- •What are the symptoms of keratoconus?
- •How is the diagnosis of keratoconus made?
- •Key Points: Diagnosis of Keratoconus
- •What are the topographic signs of keratoconus?
- •How does keratoconus progress?
- •What is acute hydrops?
- •What is the histopathology of keratoconus?
- •How is keratoconus treated?
- •What types of contact lenses are used to treat keratoconus?
- •What are the surgical options for treating keratoconus?
- •What are the results of corneal transplant in patients with keratoconus?
- •Website
- •Bibliography
- •What are the refractive components of the eye?
- •What are the different types of refractive errors?
- •How is myopia related to age?
- •What are the goals of refractive surgery?
- •What features characterize a good candidate for refractive surgery? Are there any contraindications?
- •How is corneal topography used in the evaluation of patients undergoing refractive surgery?
- •What are the major options for the surgical treatment of myopia?
- •How does RK reduce myopia?
- •What are the various RK techniques?
- •What results have been achieved with RK? What about complications?
- •How does PRK reduce myopia?
- •What results have been achieved with PRK? What about complications?
- •What is LASIK?
- •How have advancements in the LASIK procedure helped to improve results?
- •What is the range of myopia recommended for correction with LASIK?
- •How do the surgical results of LASIK compare with those of PRK?
- •Name the important potential complications of LASIK.
- •What is diffuse lamellar keratitis (DLK)? How is it treated?
- •What is the femtosecond laser? What are its potential advantages?
- •What is progressive corneal ectasia?
- •What are intracorneal ring segments?
- •How much myopia do Intacs treat?
- •What are the refractive results of Intacs for myopia?
- •List the potential complications of Intacs.
- •Is the Intacs procedure reversible?
- •What are phakic IOL implants?
- •What is the effect of the Verisyse phakic IOL implant on endothelial cell count?
- •What are accommodative IOLs?
- •Are there any other surgical options for the treatment of myopia?
- •What are the treatment options for astigmatism?
- •What can be done about astigmatism after a corneal transplant?
- •What about procedures for hyperopia?
- •What are the effects of refractive surgical procedures on corneal endothelial cells?
- •What is the role of drugs in refractive surgery?
- •What is glaucoma?
- •How is glaucoma classified?
- •How prevalent is glaucoma?
- •What is the pathogenesis of glaucoma?
- •What is normal intraocular pressure (IOP)?
- •True or false: Loss of peripheral vision is a warning sign of early glaucoma.
- •Key Points: Common Visual-Field Defects Found in Glaucoma
- •What is a glaucoma suspect?
- •In examination of the optic nerve, what findings could be consistent with a diagnosis of glaucoma or suspicion of glaucoma?
- •Key Points: Common Optic Nerve Findings in Glaucoma
- •How does intraocular pressure (IOP) fluctuate in glaucoma patients?
- •What role does central corneal thickness play in the evaluation of glaucoma?
- •Name factors that affect the measurement of intraocular pressure.
- •What is the primary goal of treatment of patients with glaucoma?
- •What factors help determine which option to try?
- •Are eyedrops safer than oral medications?
- •Are some optic nerves more resistant to intraocular pressure damage than others?
- •What disease entities can mimic LTG?
- •What landmarks are seen in the anterior chamber (AC) angle?
- •Why is a goniolens necessary to visualize the AC angle?
- •What are the different kinds of goniolenses? How do they differ?
- •How is gonioscopy performed?
- •What are the different gonioscopic anterior chamber angle classification systems?
- •How do I know if I can safely dilate a patient, with or without a slit lamp?
- •How is angle closure classified?
- •Primary Angle Closure (Relative Pupillary Block)
- •Key Points: Common Signs of Acute Primary Angle-Closure Glaucoma
- •How does subacute or intermittent angle closure present clinically?
- •How does chronic angle closure present clinically?
- •What are the anatomic characteristics of eyes with primary angle closure?
- •What is the pathophysiologic mechanism of relative pupillary block?
- •What nonmedical maneuver may help to lower IOP even before medicating the patient?
- •How would you treat the involved eye medically?
- •Key Points: Basic Treatment of Acute Primary Angle-Closure Glaucoma
- •How would you treat the involved eye with laser?
- •What are the most common complications of laser PI?
- •What are the indications for surgical intervention? What are the surgical options?
- •What would you recommend for the fellow eye?
- •Plateau Iris
- •Describe the epidemiology of plateau iris.
- •How does it present clinically?
- •What is plateau iris configuration (PIC)?
- •What is plateau iris syndrome?
- •How is plateau iris treated?
- •Aqueous Misdirection Syndrome (Malignant/Ciliary Block Glaucoma)
- •What is aqueous misdirection syndrome?
- •How is aqueous misdirection treated medically?
- •How can aqueous misdirection be treated with laser if it is unresponsive to medication?
- •How can aqueous misdirection be treated surgically if refractory to medical therapy and/or laser?
- •Neovascular Glaucoma
- •What typically causes neovascular glaucoma (NVG)?
- •How is neovascular glaucoma treated?
- •Miscellaneous
- •What are the different mechanisms of producing angle closure secondary to inflammation?
- •Describe nanophthalmos.
- •Websites
- •Bibliography
- •What should you look for to make a diagnosis of pseudoexfoliation glaucoma?
- •Is the condition cured after cataract extraction?
- •What is true exfoliative glaucoma?
- •Key Points: Pseudoexfoliation Glaucoma
- •What does a Krukenberg spindle look like? What does it mean?
- •How is pigmentary dispersion treated?
- •What else can cause postoperative glaucoma?
- •How can raised episcleral venous pressure cause glaucoma?
- •Key Points: Causes of Raised Episcleral Venous Pressure
- •Bibliography
- •What classes of medications are used to treat glaucoma?
- •How do these medications work?
- •Any hints for prescribing prostaglandin analogs?
- •Any tips on prescribing adrenergic agonists?
- •Any tips on prescribing carbonic anhydrase inhibitors (CAIs)?
- •Key Points: Glaucoma Topical Medications
- •How many eyedrops can be used?
- •What are the general rules for using eyedrops?
- •In a patient with an ocular allergy secondary to topical medication, which is the most likely offender?
- •Are any of the glaucoma medications safe for use in pregnant women? In children?
- •Is there any evidence that current glaucoma medications are neuroprotective?
- •Are there any glaucoma medications that are not designed to lower eye pressure?
- •Key Points: Common Side Effects of Topical Glaucoma Medications
- •Website
- •What are the indications for trabeculectomy surgery?
- •What is the goal of glaucoma surgery?
- •How do we inform patients about the risks of trabeculectomy surgery?
- •Describe the factors associated with failure of glaucoma filtering surgery.
- •What medications should be stopped before filtration surgery?
- •What are the choices of anesthesia?
- •Does a triangular versus a rectangular flap affect outcome?
- •Does the size of the internal block affect outcome?
- •How tight should I make the scleral flap?
- •Are releasable sutures necessary?
- •Does it matter how far I dissect the scleral flap anteriorly?
- •Should atropine be used during the procedure?
- •How often are steroids used in the postoperative period?
- •How can you avoid a flat anterior chamber after trabeculectomy?
- •What do you do when a wound leak occurs in the immediate postoperative period?
- •Key Points: How to Avoid Complications of Trabeculectomy
- •What do you do if there is vitreous loss at the time of the trabeculectomy?
- •Which ocular conditions may predispose to vitreous loss during trabeculectomy surgery?
- •Are antimetabolites indicated in primary filtering procedures?
- •What do you do when the iris blocks the trabeculectomy site in the immediate postoperative period?
- •What do you do if the bleb starts to fail?
- •Key Points: How to Improve Your Success Rate
- •What is the technique of bleb needling?
- •What is the differential diagnosis for a flat anterior chamber?
- •How urgent is the management of a flat anterior chamber?
- •What are the indications to drain a choroidal detachment?
- •What is a hyphema?
- •List the causes of a hyphema.
- •What is the most common cause of a traumatic hyphema?
- •Describe the pathophysiology of a traumatic hyphema.
- •List the anterior segment structures that may split or tear in response to blunt ocular injury.
- •When a patient presents with a hyphema due to blunt ocular trauma, which anterior segment structure is the most likely source of the hemorrhage?
- •What ocular injuries may be associated with a traumatic hyphema?
- •Describe an appropriate approach toward the workup of a patient with a hyphema.
- •Key Points: Traumatic Hyphema
- •What are pertinent questions to ask a patient who presents with a traumatic hyphema? Why?
- •How are hyphemas managed?
- •Explain the rationale for the use of antifibrinolytic agents in the treatment of hyphema.
- •Name the most common adverse effects associated with aminocaproic acid treatment.
- •In what setting is aminocaproic acid contraindicated?
- •Why are patients with sickle cell disease or sickle cell trait at a particularly high risk for developing complications from a hyphema?
- •What level of intraocular pressure is considered medically uncontrolled?
- •List the indications for surgical intervention in the management of a hyphema.
- •Name the major complications associated with a hyphema.
- •What is corneal blood staining?
- •What percent of patients with a hyphema develop corneal blood staining?
- •In which setting is corneal blood staining most likely to occur?
- •In the setting of a traumatic hyphema, when is a patient at greatest risk for developing a recurrent hemorrhage?
- •How common is a recurrent hemorrhage?
- •What is the significance of a recurrent hemorrhage? Why is it important to try to prevent it?
- •List the risk factors that may be associated with an increased risk of developing a recurrent hemorrhage.
- •What types of surgical techniques can be used to evacuate a hyphema?
- •List the types of secondary glaucoma associated with a traumatic hyphema.
- •Is the chance of developing secondary glaucoma related to the size of the hyphema?
- •Given a history of ocular trauma, how can one make the diagnosis of angle recession on gonioscopic examination?
- •Once a cyclodialysis cleft is suspected, how can it be diagnosed?
- •Bibliography
- •Explain the derivation of the word cataract.
- •What is the leading cause of blindness worldwide?
- •What is a nuclear sclerotic cataract?
- •What produces the brown color seen in cataracts?
- •What are the typical symptoms of nuclear sclerotic cataracts?
- •What are posterior subcapsular cataracts?
- •What are the symptoms of posterior subcapsular cataracts?
- •What are the associated systemic findings in patients with cataracts?
- •What are the major potential causes of cataracts in infants?
- •What is a morgagnian cataract?
- •What is phacolytic glaucoma?
- •What is phacomorphic glaucoma?
- •What is pseudoexfoliation? What is its relationship to cataracts?
- •What is true exfoliation syndrome as opposed to pseudoexfoliation syndrome?
- •What systemic syndromes should be considered in a patient with a spontaneously dislocated natural lens?
- •What other clinical findings are common in patients with a traumatic cataract?
- •What are the indications for cataract surgery?
- •What is aphakia? What are aphakic spectacles? What is pseudophakia?
- •How is the IOL power determined? What is the most commonly used IOL power?
- •What are multifocal IOLs? How do multifocal IOLs work?
- •What is IFIS? What is a flomax pupil?
- •What is posterior capsular opacification? What is a secondary membrane? Can a cataract grow back?
- •What is a YAG capsulotomy?
- •What is the origin of the term laser?
- •What is couching?
- •Bibliography
- •What are the indications for cataract surgery?
- •What are two nonsurgical methods of managing a cataract?
- •What preoperative tests are used to gauge visual impairment?
- •Key Points: Tests of Visual Impairment
- •What are the basic steps in removing a cataract?
- •How is the eye anesthetized for surgery?
- •What are the disadvantages of topical anesthesia for cataract surgery?
- •What is couching?
- •What are the two most common ways to remove a cataract?
- •What is phacoemulsification?
- •How does the phacoemulsification machine work?
- •How is a capsulotomy performed?
- •Are lasers used to remove cataracts?
- •Once a cataract is removed (aphakia), what are the options to restore vision?
- •Who invented intraocular lenses?
- •Of what are implants made?
- •What are the most common positions of IOLs?
- •Is an implant indicated in every aphakic patient?
- •How is the power of an IOL determined?
- •How is the surgical wound closed?
- •How should patients be managed postoperatively?
- •What are the most significant trends in cataract surgery?
- •What does the future hold for cataract surgery?
- •Bibliography
- •What complications may result from local anesthesia for cataract surgery?
- •How do you treat a retrobulbar hemorrhage?
- •Key Points: Most Common Intraoperative Complications of Cataract Surgery
- •What are the common complications related to the cataract wound?
- •What is iris prolapse? How is it treated?
- •What types of intraocular hemorrhage may occur during or after cataract surgery?
- •What is the incidence of posterior capsule rupture for an experienced surgeon during cataract surgery?
- •What are the possible consequences of posterior capsule rupture?
- •Key Points: Postoperative Cataract Surgery Complications
- •What are the causes of postoperative inflammation?
- •How does infectious endophthalmitis present? When does it usually occur?
- •What are the common organisms cultured from the vitreous of endophthalmitis patients?
- •What are the causes of corneal edema after cataract surgery?
- •What is the incidence of retinal detachment after cataract surgery? Which patients are at greater risk?
- •What is cystoid macular edema?
- •What patients are likely to suffer from CME? How is it treated?
- •What is a secondary membrane?
- •When does a secondary membrane develop? How frequently does it occur?
- •How is a secondary membrane treated? What complications may occur?
- •What are the most common complications related to IOLs?
- •Why are patients with diabetes at greater risk when undergoing cataract surgery?
- •What medication is associated with intraoperative floppy iris syndrome?
- •What are the indications for capsular tension rings?
- •What is amblyopia?
- •How is amblyopia generally classified?
- •How does strabismus cause amblyopia?
- •How prevalent is amblyopia?
- •What factors place children at increased risk for amblyopia?
- •What anatomic changes have been shown to occur in amblyopia?
- •How early should children be screened for amblyopia?
- •What are some clinical techniques to check for amblyopia in nonverbal children?
- •Besides visual acuity, what other aspects of visual function may be affected in amblyopia?
- •How does anisometropia cause amblyopia?
- •Key Points: Amblyopia Fundamentals
- •What steps should be taken before patching or penalization?
- •What are some alternative treatments to patching?
- •At what point can amblyopia treatment be discontinued?
- •What are some of the factors affecting the success of amblyopia treatment?
- •Can the vision of an amblyopic eye ever improve in adulthood?
- •Is color vision affected in amblyopia?
- •Does amblyopia cause a relative afferent pupillary defect?
- •In which of the following conditions is amblyopia most likely to occur: Congenital esotropia, Accommodative esotropia, Intermittent exotropia, or Constant exotropia?
- •What is the effect of neutral density filters on the vision of an amblyopic eye compared with a normal eye?
- •What is the crowding phenomenon? What is its significance in amblyopia?
- •What is eccentric fixation?
- •Can refractive surgery be used to treat anisometropic amblyopia in children?
- •Key Points: Amblyopia Treatment Guidelines
- •What is the upper age limit for treatment of amblyopia?
- •Should anisometropia be corrected if amblyopia is not present?
- •When should strabismus surgery be performed in a patient with amblyopia?
- •What is an esodeviation?
- •What are the different types of esodeviations?
- •How common is strabismus in infants?
- •What is pseudoesotropia?
- •What is congenital esotropia?
- •What are the characteristics of congenital esotropia?
- •Why do some children with congenital esotropia appear to have an abduction deficit?
- •How can a pseudoabduction deficit be distinguished from a true abduction deficit?
- •What is the differential diagnosis of an infant with esotropia?
- •How is vision evaluated in a child with congenital esotropia?
- •How common is amblyopia in congenital esotropia?
- •What are the goals in the treatment of congenital esotropia?
- •What level of binocular vision can develop in children with congenital esotropia?
- •When is congenital esotropia treated?
- •Why is it important to treat amblyopia before surgical correction of congenital esotropia?
- •What other motility disorders are often associated with congenital esotropia?
- •What is accommodative esotropia?
- •At what age does accommodative esotropia develop?
- •What are the three types of accommodative esotropia?
- •What three factors influence the development of refractive accommodative esotropia?
- •How do the aforementioned three factors lead to accommodative esotropia?
- •What is the AC:A ratio?
- •How can the AC:A ratio be measured?
- •How can refractive accommodative esotropia be treated?
- •Why are spectacles a better option than miotics in the treatment of refractive accommodative esotropia?
- •Key Points: Esotropia
- •What is nonrefractive accommodative esotropia?
- •How can nonrefractive accommodative esotropia be treated?
- •What is partial or decompensated accommodative esotropia?
- •How is partial or decompensated accommodative esotropia treated?
- •What are the characteristics of the nystagmus blockage syndrome?
- •What is cyclic esotropia?
- •What are the characteristics of acute acquired comitant esotropia (AACE)?
- •How should patients with AACE be managed?
- •What is the differential diagnosis of exotropia?
- •Some patients have the opposite problem: esotropia that is worse at distance than near. What is this condition called?
- •What is the differential diagnosis of hypertropia?
- •What other evaluations are important?
- •What other diseases may be associated with CPEO?
- •What is congenital ocular motor apraxia?
- •Describe the presentation of a patient with internuclear ophthalmoplegia.
- •Where is the causative lesion?
- •Bibliography
- •How are forced ductions performed?
- •Why perform forced ductions?
- •When correcting a horizontal or vertical strabismus, how do you decide how many muscles to recess or resect?
- •What type of needle is used to suture the muscle to the sclera?
- •What is an adjustable suture?
- •When should an adjustable suture be used?
- •What is a transposition procedure?
- •When is a transposition procedure performed?
- •Key Points: Most Common Complications of Strabismus Surgery
- •What are the signs of infection after strabismus surgery?
- •What should you do if you suspect that you perforated the globe when passing the scleral suture?
- •What is a slipped muscle?
- •How is a slipped muscle prevented?
- •What is the adherence syndrome?
- •How can strabismus surgery cause anterior segment ischemia?
- •How is anterior segment ischemia avoided?
- •What is nystagmus?
- •List the major types of nystagmus.
- •What is the natural history of IIN?
- •What is the null zone of IIN?
- •Is the null zone the same for each eye?
- •What are the subtypes of IIN?
- •Do patients with poor vision also have the same natural history of the nystagmus waveform evolution?
- •Is a distinctive nystagmus associated with specific ocular pathology?
- •Does IIN ever disappear spontaneously?
- •What is the hallmark of spasmus nutans?
- •Does nystagmus mean that the patient is blind?
- •Are some types of nystagmus present at birth?
- •You often hear of nystagmus associated with untreated congenital cataracts. Is it distinctive?
- •Does a patient need vision to have nystagmus?
- •If one sees what seems to be the natural history of IIN, should an MRI be obtained?
- •Do patients with torsional IIN exhibit a head tilt in respect to torsion?
- •Is the pivot of the torsion always on the visual axis?
- •Do patients develop torsional nystagmus late in childhood or later in life?
- •What is alternating in periodic alternating nystagmus?
- •What is the time cycle of period alternating nystagmus?
- •Is congenital periodic alternating nystagmus commonly associated with any other ocular problem?
- •Does acquired periodic alternating nystagmus imply central nervous system pathology?
- •Does acquired periodic alternating nystagmus respond to pharmacologic treatment?
- •Does congenital periodic alternating nystagmus respond to any drug?
- •Key Points: Glasses for Nystagmus
- •What is the danger of missing the diagnosis of periodic alternating nystagmus?
- •What is the surgical treatment of periodic alternating nystagmus?
- •Most patients with IIN have vision that is better at near than at distance. Why?
- •Because convergence improves vision, should minus lenses be used to stimulate accommodative convergence?
- •Are bifocals helpful to a teenage patient with IIN?
- •Is photophobia common with IIN?
- •Do patients with albinism have photophobia?
- •You may have heard that contact lenses lessen nystagmus. Do they help?
- •Aside from using a full screen of letters, what should one do when checking the visual acuity of a nystagmus patient with unexpected poor vision?
- •Clinically, how do you distinguish manifest latent nystagmus (MLN) from IIN?
- •Bibliography
- •What muscles control the size of the pupil? Describe their innervation.
- •Trace the pathway of the parasympathetic innervation of the pupil.
- •Trace the pathway of the sympathetic innervation of the pupil.
- •Trace the pathway of the pupillary light reflex.
- •What is an afferent pupillary defect? How should you examine for it?
- •A lesion in which anatomic areas may cause an afferent pupillary defect?
- •What is anisocoria? How should one examine a patient with anisocoria?
- •What is the differential diagnosis of a unilateral dilated, poorly reactive pupil?
- •Key Points: Management of Third-Nerve Palsy
- •What is light/near dissociation? What are its possible causes?
- •Bibliography
- •What is diplopia?
- •List the causes of monocular diplopia.
- •What are the causes of binocular diplopia?
- •What are some causes of intermittent diplopia?
- •Why do aneurysms involve the pupil in oculomotor nerve palsies, whereas infarctions generally do not?
- •What are the causes of isolated cranial neuropathies?
- •How do you test for trochlear nerve palsy in the presence of oculomotor nerve palsy?
- •What else should you know about trochlear nerve palsy?
- •List the major causes of abduction deficit other than cranial neuropathy.
- •How do you treat an unresolved abducens nerve palsy?
- •What else should you know about abducens nerve palsy?
- •What are the localizing symptom complexes of nerve palsy?
- •What is internuclear ophthalmoplegia (INO)?
- •Key Points: Oculomotor Palsy
- •What is ocular myasthenia gravis?
- •How is the Tensilon test performed?
- •Key Points: Myasthenia Gravis
- •What is convergence insufficiency?
- •What is skew deviation?
- •What other supranuclear conditions commonly produce diplopia?
- •Explain divergence paresis.
- •What is the ice test?
- •Bibliography
- •What is optic neuritis?
- •Which systemic diseases are associated with optic neuritis?
- •Who most commonly gets optic neuritis?
- •What are the typical clinical findings in optic neuritis?
- •Which clinical test is most sensitive for patients with optic neuritis?
- •How common is pain on eye movement in patients with optic neuritis?
- •What visual field defects are found in patients with optic neuritis?
- •What is the natural history of optic neuritis?
- •What is the expected visual outcome for patients with optic neuritis?
- •Are there any predictors of poor visual outcome?
- •What were the objectives of the ONTT?
- •What were the conclusions of the ONTT regarding treatment of optic neuritis?
- •What was the strongest predictor for the development of MS?
- •What were the other predictors for developing MS?
- •Key Points: Optic Neuritis
- •Are there any other medications that may influence the risk of developing MS?
- •Bibliography
- •What may simulate a bitemporal field defect?
- •Key Points: Differential Diagnosis of Chiasmal Visual Defects
- •What visual field is often seen in a toxic or metabolic optic neuropathy?
- •What may cause a constricted visual field?
- •Should the biopsy be done before the steroids are started in order to ensure that the diagnosis can be made?
- •What biopsy finding makes the diagnosis?
- •What if the temporal artery biopsy is normal?
- •What else may herald giant cell arteritis?
- •INO can be bilateral or unilateral. What might you find in bilateral disease?
- •What causes INO?
- •What do you do after the evaluation?
- •How should the patient be treated?
- •Key Points: Causes of Pseudotumor Cerebri
- •Why did the patient have double vision?
- •What other symptoms may the patient have?
- •What else may the patient experience?
- •Bibliography
- •What are the causes of tearing?
- •Key Points: Primary Causes of Tearing
- •Describe the normal path of tear drainage in the eyelids.
- •Where do tears go after leaving the eyelids?
- •What is the tear pump?
- •How does lower eyelid laxity affect tear drainage?
- •How can you tell if a patient has lower eyelid laxity?
- •How do you correct lower eyelid laxity?
- •Why do patients with dry eyes complain of tearing?
- •Of what are tears composed?
- •How can you determine if a patient produces enough tears?
- •How do you know if the tear composition is inadequate?
- •Key Points: Tests for Patients with Tearing
- •What causes obstructions of the punctum, canaliculus, or lacrimal sac?
- •What causes nasolacrimal duct obstructions?
- •How do I evaluate the lacrimal system for obstructions?
- •What is a dye disappearance test?
- •What is a primary Jones dye test?
- •What is a secondary Jones dye test?
- •How do you treat obstructions of the eyelid portion of the lacrimal system?
- •How do you treat obstructions of the nasolacrimal duct?
- •Describe acute dacryocystitis.
- •What is the appropriate treatment for acute dacryocystitis?
- •What are the signs of congenital nasolacrimal duct obstructions?
- •Key Points: Treatment of Congenital Epiphora
- •How are congenital obstructions first managed?
- •What if the tearing is still present after a probing?
- •Bibliography
- •What is proptosis?
- •How is proptosis diagnosed?
- •List common problems associated with proptosis.
- •What is the most common cause of unilateral proptosis?
- •What is the most common cause of bilateral proptosis?
- •What are other causes of proptosis?
- •List the causes of pseudoproptosis.
- •Which neuroimaging test is best to evaluate the etiology of proptosis?
- •What should be done for persistent proptosis or progression of infection despite adequate antibiotic treatment in a case of orbital cellulitis?
- •Which clinical entity is characterized by a child younger than 6 years of age with gradual, painless, progressive, unilateral axial proptosis with visual loss?
- •What is the most common benign orbital tumor in adults that causes unilateral proptosis?
- •Of the various orbital tumors causing proptosis, list those tumors that are encapsulated or appear well circumscribed on neuroimaging.
- •Bibliography
- •Who develops TRO?
- •Is everyone with TRO hyperthyroid?
- •What causes TRO?
- •Do environmental factors affect TRO?
- •Does TRO improve when the systemic thyroid imbalance is treated?
- •Should all patients who receive radioactive iodine be treated with systemic steroids?
- •What are the early signs of TRO?
- •Which patients require orbital imaging?
- •What findings are present on orbital imaging?
- •Does everyone with proptosis have TRO?
- •How do the tissues of the orbit change in TRO?
- •How long does the disease last?
- •Is everyone who develops TRO affected in the same way?
- •What can be done to treat TRO?
- •When are systemic steroids used?
- •Is orbital irradiation standard treatment for TRO?
- •How does orbital irradiation affect TRO?
- •Does orbital irradiation work immediately?
- •Which patients are candidates for orbital irradiation?
- •Which patients require surgery?
- •What kinds of surgery are done in patients with TRO?
- •What is orbital decompression?
- •Which patients require orbital decompression?
- •What is optic nerve compression?
- •What are the complications of orbital decompression?
- •When do patients require muscle surgery?
- •Key Points: Thyroid-related Ophthalmopathy
- •What are the alternatives to muscle surgery?
- •What type of muscle surgery is required?
- •Does eye muscle surgery affect the eyelids?
- •What kind of eyelid surgery is done?
- •How many surgeries do patients with TRO require?
- •What is inflammation?
- •How does inflammation affect the orbit?
- •What are the best terms to describe orbital inflammation?
- •What is specific orbital inflammation?
- •How is nonspecific orbital inflammation (NSOI) different?
- •What, then, is the etiology of NSOI?
- •Describe a typical clinical presentation of NSOI.
- •Is NSOI always acute in onset?
- •Is the symptom of pain necessary to make the diagnosis?
- •How is NSOI in children different?
- •Name the five most common anatomic patterns of NSOI.
- •How is the diagnosis of NSOI made?
- •What is the best imaging technique for NSOI?
- •What blood tests can be ordered to evaluate NSOI?
- •When should an orbital biopsy be performed?
- •What is the histopathology of NSOI?
- •Name two subtypes of orbital inflammation.
- •How is NSOI treated?
- •What if a patient fails to respond to or is intolerant of steroids?
- •Key Points: Nonspecific Orbital Inflammation
- •What is the most common specific orbital inflammation?
- •What infections can occur in the orbit?
- •Name the most common source of orbital cellulites.
- •In adults, what pathogens usually cause orbital cellulitis?
- •How is orbital cellulitis treated?
- •When should surgery be undertaken?
- •What are the major categories of orbital vasculitis?
- •How is ptosis classified?
- •What is the most common cause of acquired ptosis?
- •What clinical findings help to differentiate congenital ptosis from acquired aponeurotic ptosis?
- •Key Points: Features of Aponeurotic Ptosis
- •What are the features of congenital ptosis?
- •What causes pseudoptosis?
- •What is the primary cause of ptosis after intraocular surgery?
- •What is the anatomic cause for the eyelid crease?
- •What neurologic conditions are associated with ptosis?
- •What are the myogenic causes of ptosis?
- •What are the features of blepharophimosis syndrome?
- •Key Points: Features of Ocular Myasthenia gravis
- •What measurements should be taken during the preoperative examination of patients with ptosis?
- •What is the Neosynephrine test?
- •What are the complications of ptosis surgery?
- •Name some useful tests for diagnosing myasthenia gravis.
- •Name some causes of acquired ptosis in young adults.
- •What clues are helpful in determining whether an eyelid lesion is benign or malignant?
- •What eyelid lesion is associated with a chronic follicular conjunctivitis?
- •What is a keratoacanthoma? What malignancy does it simulate?
- •What is the most common malignant eyelid tumor?
- •What are its two clinical presentations?
- •In order of frequency, where do basal cell carcinomas present?
- •Do basal cell carcinomas metastasize?
- •How do you treat tumors with a suspicious lesion?
- •How do you treat a recurrent tumor that has limited the extraocular motility from invasion of the orbit?
- •Describe basal cell nevus syndrome.
- •What are the complications of radiation to the area around the eye?
- •Where do squamous cell carcinomas usually present around the eye?
- •How are patients with squamous cell carcinomas treated?
- •How is the biopsy performed? How is the specimen sent to the lab? What stains should be requested?
- •How are patients with sebaceous cell carcinoma treated?
- •What is the most common type of malignant melanoma of the eyelid?
- •How do you follow a patient who has had an eyelid malignancy?
- •Bibliography
- •Uveitis in the Immunocompetent Patient
- •What is uveitis?
- •How is granulomatous uveitis distinguished from nongranulomatous uveitis?
- •What are the distinctive clinical features of granulomatous anterior uveitis?
- •What are the clinical features of nongranulomatous anterior uveitis (NGAU)?
- •Can iris nodules occur in nongranulomatous anterior uveitis?
- •Is the distribution of KP helpful in narrowing a differential diagnosis?
- •Is dilated fundus examination indicated in all patients with anterior uveitis?
- •What is the most common cause of NGAU?
- •What other conditions are in the differential diagnosis of acute NGAU?
- •Discuss the most common cause of uveitis in children.
- •Which condition may produce spontaneous hyphema in a child?
- •What studies should be ordered?
- •When are ocular tests helpful?
- •What may confound interpretation of serology for infectious agents?
- •What is the most common cause of intermediate uveitis?
- •What are the causes of visual loss in pars planitis?
- •What are the indications for treatment in pars planitis?
- •Describe the most common causes of posterior uveitis.
- •How is the diagnosis of ocular toxoplasmosis made?
- •How is ocular toxoplasmosis managed?
- •What serious side effects may occur with oral antibiotic therapy for toxoplasmosis?
- •What are the features of ocular sarcoidosis?
- •How does the presentation of sarcoidosis differ with age?
- •What testing may be helpful in making the diagnosis of sarcoidosis?
- •Key Points: Most Common Forms of Uveitis
- •What are the features of ocular syphilis?
- •Which diagnostic tests are used to assess for syphilitic uveitis?
- •How is syphilitic uveitis treated?
- •What are the most common features of ocular histoplasmosis?
- •What is sympathetic ophthalmia?
- •Describe acute retinal necrosis (ARN) syndrome.
- •What other types of retinitis may have a similar clinical presentation?
- •Describe the ocular features of Lyme disease.
- •Describe the most common features of ocular tuberculosis.
- •What form of uveitis may present with enlarged lymph glands?
- •Why do patients with uveitis develop glaucoma?
- •Name the uveitis entities that are associated with an acute elevation in intraocular pressure (IOP).
- •What is the approach to the treatment for uveitis?
- •What should be the general approach to the use of steroids to treat uveitis?
- •When are alternate immunosuppressives indicated to treat autoimmune uveitis?
- •In which conditions with uveitis or scleritis are immunosuppressive agents indicated?
- •Name major categories of alternate immunosuppressives.
- •Masquerade Syndromes
- •Define masquerade syndrome.
- •Key Points: Common Masquerade Syndromes
- •In what age groups should one have the highest suspicion for masquerade syndromes?
- •Describe the clinical features of retinoblastoma.
- •Describe the ocular findings associated with leukemia.
- •How can a malignant melanoma produce inflammatory signs?
- •Describe other entities that may simulate anterior and/or posterior uveitis.
- •Ocular Manifestations Of Acquired Immune Deficiency Syndrome (AIDS)
- •What is the most common ocular manifestation of AIDS?
- •What is the most common ocular opportunistic infection in patients with AIDS?
- •Describe the early symptoms of CMV retinitis.
- •How does CMV retinitis present clinically?
- •What are the more common entities in the differential diagnosis of CMV retinitis?
- •How is the diagnosis of CMV retinitis made?
- •What is the initial treatment strategy for CMV retinitis?
- •What is the strategy in the event of a relapse?
- •Does resistance to antiviral medication develop?
- •What is clinical resistance? How is it managed?
- •How long should treatment be continued in patients with CMV retinitis?
- •Name the main toxicities of the antiviral therapies.
- •What is progressive outer retinal necrosis?
- •Why do retinal detachments develop in cases of infectious retinitis? Who is at risk?
- •Describe the unique characteristics of ocular syphilis in patients with AIDS.
- •Key Points: Ocular Manifestations of AIDS
- •What is papillitis?
- •What is the most common malignancy in the periocular region in AIDS patients?
- •What other periocular malignancies may develop?
- •Which medications may be associated with ocular toxicity?
- •Describe the clinical features of chloroquine retinopathy.
- •What management is advised for chloroquine retinopathy?
- •Key Points: Chloroquine/Hydroxychloroquine Toxicity
- •How may thioridazine affect the retina?
- •What other phenothiazines cause retinopathy?
- •How may quinine sulphate cause retinopathy?
- •What are the retinal toxic effects of sildenafil (Viagra)?
- •How does cocaine abuse affect the retina?
- •What is vigabatrin retinotoxcity?
- •How does fetal alcohol syndrome affect the retina?
- •What is unusual about cystoid macular edema caused by nicotinic acid?
- •Name the substances that may cause crystalline retinopathy.
- •What is the mechanism of the retinopathy caused by talc?
- •How should talc retinopathy be managed?
- •What effects may iron overload have on the retina?
- •What drugs can cause retinal thromboembolic events?
- •What chelating agents may cause maculopathy?
- •Bibliography
- •What is Coats disease?
- •List the clinical characteristics of Coats disease.
- •What is the incidence in women?
- •What is the most common age at which Coats disease becomes apparent?
- •What percentage of cases are unilateral versus bilateral?
- •Are the retinal vascular changes easy to detect?
- •Do we know the etiology of Coats disease?
- •Are there any conditions with which Coats disease can be confused?
- •What is xanthopsia? Which drug may cause it?
- •What are the clinical features of tamoxifen retinopathy? How much drug is necessary to cause symptoms?
- •Can intraocular injection of antibiotics cause retinopathy?
- •What is interferon retinopathy?
- •Can conditions other than retinoblastoma simulate Coats disease?
- •Key Points: Differential Diagnosis of Coats Disease
- •Other than fluorescein angiography, what may be helpful in confirming the diagnosis?
- •Is it advisable to obtain a computed tomographic (CT) scan?
- •Can aspiration of subretinal exudates aid in diagnosis?
- •How is Coats disease managed?
- •How long does it take for the exudate to disappear?
- •Is more than one treatment necessary?
- •Once the abnormal vessels are gone, is the patient considered cured?
- •Can this condition be managed once the retina has detached?
- •If left untreated, what is the outcome?
- •When should an eye with Coats disease be enucleated?
- •Can Coats disease occur with any other retinal conditions?
- •Bibliography
- •What are the mechanisms of injury to the fundus in blunt trauma?
- •What clinical entity is caused by the contrecoup mechanism?
- •Name the five types of retinal breaks seen in fundus trauma.
- •Where are retinal dialyses most commonly seen?
- •When do retinal detachments occur with dialyses?
- •What is the prognosis for repair of a retinal detachment associated with a dialysis?
- •Describe the clinical features of a choroidal rupture.
- •Can orbital adnexal trauma result in fundus abnormalities?
- •Key Points: Retinal Breaks in Blunt Trauma
- •What are the signs of a scleral rupture?
- •Why is the initial exam of a severely traumatized eye important?
- •Where is the most likely place for a globe to rupture?
- •Outline the goals of managing a ruptured globe.
- •Key Points: Globe Ruptures
- •What ultrasound artifacts are important to recognize in evaluation of the traumatized globe?
- •Do all intraocular foreign bodies need to be removed immediately? Which ones require early vitrectomy for removal?
- •Which metals are toxic to the eye?
- •List the clinical findings in siderosis bulbi.
- •Do all copper foreign bodies cause chalcosis?
- •Key Points: Intraocular Foreign Bodies
- •Which organisms most commonly cause posttraumatic endophthalmitis?
- •Outline the role of prophylactic antibiotics.
- •What regimen of antibiotics is used to treat posttraumatic endophthalmitis?
- •Does injury to one eye place the other eye at risk for visual loss?
- •Can trauma elsewhere in the body cause fundus abnormalities?
- •Who develops ARMD?
- •Why will ARMD become such an enormous challenge in the next 25 years?
- •Describe etiologic factors involved in the development of ARMD.
- •Name common visual symptoms in ARMD patients.
- •What is dry or nonexudative ARMD?
- •What is wet or exudative ARMD?
- •Key Points: Clinical Findings Associated with ARMD
- •What is fluorescein angiography?
- •What is optical coherence tomography (OCT)?
- •Name proven therapies for exudative ARMD.
- •What is the Macular Photocoagulation Study (MPS)?
- •How does conventional laser treatment affect exudative ARMD?
- •What percentage of patients with exudative ARMD can be effectively treated with laser photocoagulation?
- •What is the role of additional nutritional supplements in ARMD therapy?
- •What is photodynamic therapy? How does it differ from laser photocoagulation?
- •What is the role of surgery in ARMD?
- •What is macular translocation?
- •What is the role of pharmacologic management in ARMD?
- •What is combination therapy?
- •Name the three processes necessary for choroidal neovascular membrane development.
- •What are low vision AIDS?
- •What is retinopathy of prematurity?
- •Who gets retinopathy of prematurity?
- •Who should be screened for ROP?
- •How is ROP classified?
- •What is plus disease?
- •When should acute ROP be treated?
- •How do you treat acute ROP?
- •How is cryotherapy applied?
- •Does posterior ROP respond to treatment?
- •What is the expected result after laser treatment for ROP?
- •Key Points: Indications for Laser Treatment of ROP
- •What can be done for more advanced stages of ROP?
- •What are some of the late complications of ROP?
- •Bibliography
- •How is diabetic retinopathy classified? What fundus features are characteristic of each category?
- •Who is at risk for the development of diabetic retinopathy?
- •Key Points: Mechanisms of Vision Loss in Diabetes
- •What is the recommendation for screening patients with diabetes?
- •What is the definition of clinically significant macular edema (CSME)?
- •Key Points: Clinical Features of Clinically Significant Macular Edema
- •What are the results of the ETDRS concerning treatment of diabetic macular edema?
- •What other findings did the ETDRS report?
- •Key Points: DRS High-Risk Characteristics
- •What are the side effects of PRP?
- •Do all patients treated with PRP show resolution of HRC?
- •What is the role of supplemental PRP?
- •What are the indications for fluorescein angiography in diabetic retinopathy?
- •What are the possible uses of optical coherence tomography (OCT) in the management of diabetic retinopathy?
- •What is the differential diagnosis of diabetic retinopathy?
- •What is the significance of neovascularization of iris (NVI) in diabetes?
- •What are the indications for vitrectomy in diabetic retinopathy?
- •What are the complications of vitrectomy for diabetes?
- •Are there any other options for the treatment of diabetic macular edema beyond laser and, occasionally, vitrectomy?
- •Bibliography
- •What types of retinal arterial obstructions can occur?
- •What causes a retinal artery to become blocked?
- •Describe the typical symptoms of a retinal arterial obstruction.
- •What do you see on examination when a retinal arterial obstruction has occurred?
- •Is there any ancillary testing that can be done to confirm the diagnosis?
- •Which systemic diseases are associated with retinal arterial obstruction?
- •Do you always have to test for giant cell arteritis?
- •Which patients are at risk to get a retinal arterial obstruction?
- •Can any prophylactic treatment be given?
- •What is the incidence of bilateral retinal arterial obstructions?
- •Is there any proven treatment for retinal arterial obstruction?
- •Key Points: Retinal Arterial Obstruction
- •Why is the retina so sensitive to arterial inflow problems?
- •How do you tell a retinal arterial obstruction from a retinal venous obstruction?
- •Is acute obstruction of a retinal artery an emergency?
- •What does the retina look like months or years after an arterial obstruction?
- •Are there any other late complications after retinal arterial obstructions?
- •Bibliography
- •Branch Retinal Vein Occlusion
- •What are the symptoms of a branch retinal vein occlusion (BRVO)?
- •What are the clinical signs of a BRVO?
- •Are there systemic associations in patients with a BRVO?
- •Where does a BRVO most commonly occur?
- •Key Points: Common Characteristics of a Branch Retinal Vein Occlusion
- •How is a BRVO categorized?
- •What are the complications of a BRVO?
- •What is the treatment for an uncomplicated BRVO?
- •What were the results of the Branch Vein Occlusion Study in the treatment of macular edema?
- •What is the treatment for a patient with an ischemic BRVO before the development of neovascularization?
- •What is the treatment for a patient with an ischemic BRVO after the development of neovascularization?
- •Key Points: Medical Evaluation of Patients with BRVO
- •What are emerging therapies for a branch retinal vein occlusion?
- •Central Retinal Vein Occlusion
- •What are the symptoms of a central retinal vein occlusion (CRVO)?
- •What are the clinical signs of a CRVO?
- •Key Points: Common Characteristics of a Central Retinal Vein Occlusion
- •What are the risk factors for a CRVO?
- •How is a CRVO categorized?
- •What are the complications of a CRVO?
- •What is the treatment for an uncomplicated CRVO?
- •Key Points: Medical Evaluation of Patients with CRVO
- •Are there emerging therapies for macular edema from a central retinal vein occlusion?
- •What is the recommended treatment for a patient with an ischemic CRVO?
- •What is retinal detachment?
- •What are the major characteristics of each type of retinal detachment?
- •What are the major causes of exudative retinal detachments?
- •How does the retina remain attached?
- •What are the major predisposing factors for RRDs?
- •What are the types of retinal breaks?
- •What are the signs of a chronic RRD?
- •What is degenerative retinoschisis?
- •What are the options for repair of retinal detachment?
- •Which patients are the best candidates for pneumatic retinopexy?
- •Which patients are poor candidates for pneumatic retinopexy?
- •What intraoperative findings should be confirmed at the time of scleral buckle placement?
- •What three factors should be confirmed with indirect ophthalmoscopy at the conclusion of scleral buckling surgery?
- •How should cases of RRD be approached if pars plana vitrectomy is the chosen treatment?
- •Which gases may be used inside the eye? In what concentrations?
- •What are the primary causes of failure of initial RD repair?
- •What are the major objectives in repair of tractional retinal detachment?
- •Bibliography
- •What is retinoblastoma?
- •How common is retinoblastoma?
- •What causes retinoblastoma?
- •On what chromosome is the genetic mutation associated with retinoblastoma?
- •What syndrome is associated with retinoblastoma?
- •What is the laterality of retinoblastoma?
- •What is germline mutation retinoblastoma?
- •Who manifests germline mutation retinoblastoma?
- •What is somatic mutation retinoblastoma?
- •Who manifests somatic mutation retinoblastoma?
- •What are the most common presenting findings of retinoblastoma?
- •What are the most common lesions simulating retinoblastoma?
- •At what age does retinoblastoma typically present?
- •What is trilateral retinoblastoma?
- •When is pinealoblastoma diagnosed?
- •What second cancers are associated with retinoblastoma?
- •How often do eyes with retinoblastoma present with glaucoma?
- •How often does retinoblastoma invade the optic nerve?
- •What is the survival rate with retinoblastoma?
- •What are the growth patterns of retinoblastoma?
- •What is the differential diagnosis of endophytic retinoblastoma?
- •What is the differential diagnosis of exophytic retinoblastoma?
- •Can retinoblastoma spontaneously regress?
- •List the options for management of an eye with intraocular retinoblastoma.
- •What are the conservative options for management of a small retinoblastoma posterior to the equator of the eye?
- •What are the chances that future offspring of a child with bilateral retinoblastoma will develop retinoblastoma?
- •What is the most used classification scheme for retinoblastoma?
- •What is the International Classification of Retinoblastoma?
- •How does retinoblastoma appear on ultrasound?
- •How does retinoblastoma appear on computed tomography?
- •How does retinoblastoma appear on magnetic resonance imaging?
- •Should pars plana vitrectomy be performed to obtain tissue for confirming the diagnosis of retinoblastoma?
- •Key Points: Management of Retinoblastoma
- •Bibliography
- •What is the main differential diagnosis of a relatively flat pigmented fundus lesion?
- •What is the main differential diagnosis of an elevated pigmented fundus lesion?
- •What is the most practical ancillary test for differentiating melanoma from subretinal blood?
- •What is the most reliable way to diagnose choroidal melanoma?
- •Key Points: Risk Factors for Choroid Nevus Becoming Malignant
- •What clinical signs suggest that a small, suspicious pigmented fundus lesion may eventually metastasize?
- •What congenital ocular conditions are clearly associated with a higher incidence of uveal melanoma?
- •Does uveal melanoma have a predilection for gender, age, or race?
- •What external ocular sign strongly suggests the presence of an underlying ciliary body or peripheral choroidal melanoma?
- •What is the main route of distant spread of uveal melanoma?
- •What is a melanocytoma?
- •What is the most common treatment for a melanoma that occupies 2 clock hours of the ciliary body?
- •Bibliography
- •What is the most common malignant intraocular neoplasm?
- •What is the characteristic shape of choroidal malignant melanoma?
- •Is a mushroom configuration pathognomonic for choroidal melanoma?
- •Key Points: Prognostic Factors in Uveal Melanoma
- •What is the Callender classification?
- •What is the most common cell type?
- •How are melanoma cell types distinguished histopathologically?
- •Which cell type has the worst prognosis?
- •What is the most common site of metastatic uveal melanoma?
- •Does enucleation of uveal melanoma increase tumor deaths by disseminating tumor cells?
- •What was the main consequence of the Zimmerman hypothesis?
- •What is the Collaborative Ocular Melanoma Study?
- •What did the COMS results reveal?
- •How are most uveal melanomas treated?
- •How effective is treatment of posterior uveal melanoma?
- •What clinical features suggest that a small pigmented choroidal tumor is a melanoma?
- •Do melanomas of the iris behave differently?
- •What clinical features suggest that a uveal tumor is a metastasis?
- •What is the most common site of uveal metastasis?
- •What primary tumors are responsible for most uveal metastases?
- •What type of hemangiomas occur in the choroid?
- •If choroidal hemangiomas are benign, why are they treated?
- •What is the typical clinical presentation of retinoblastoma in the United States?
- •How old are patients when diagnosed with retinoblastoma?
- •What does retinoblastoma look like grossly?
- •What is an exophytic retinoblastoma?
- •What do rosettes signify in retinoblastoma?
- •What are fleurettes?
- •What are the most important prognostic features of retinoblastoma?
- •How does retinoblastoma become fatal?
- •The retinoblastoma gene is located on what chromosome?
- •How is the retinoblastoma gene classified?
- •What does bilateral retinoblastoma signify clinically?
- •Can a child with a unilateral retinoblastoma have hereditary disease?
- •Are most retinoblastomas familial?
- •Are patients with hereditary retinoblastomas at risk for other nonocular tumors?
- •Key Points: Retinoblastoma
- •Name the three diseases that are most often confused with retinoblastoma clinically.
- •How does Coats disease differ from retinoblastoma?
- •What are the characteristic features of persistent hyperplastic primary vitreous (persistent fetal vasculature)?
- •What is the second most common primary intraocular tumor of childhood?
- •Where are most medulloepitheliomas located?
- •What is a teratoid medulloepithelioma?
- •Should all orbital capillary hemangiomas be excised?
- •What orbital tumors can mimic orbital cellulitis?
- •What are the most common causes of childhood proptosis?
- •What about orbital schwannoma?
- •How does one order orbital computed tomography?
- •How does one order orbital magnetic resonance imaging (MRI)?
- •Discuss the histologic classification of orbital rhabdomyosarcoma.
- •How is orbital RMS best treated? What is the prognosis?
- •Key Points: Imaging in Orbital Processes
- •What are the important facts about orbital lymphoproliferative lesions?
- •Index
332UVEITIS
51.Name major categories of alternate immunosuppressives.
&Antimetabolites (e.g., methotrexate): Often used for their steroid-sparing effect
&T-cell inhibitors (e.g., cyclosporine)
&Alkylating agents (e.g., cyclophosphamide): Typically reserved for severe, sight-threatening uveitis not adequately responsive to aforementioned agents
&Biologicals (e.g., infliximab): Tumor necrosis factor (TNF) inhibitors are one example of this expanding arsenal of immunosuppressant and anti-inflammatory agents
Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol 130:492–513, 2000.
MASQUERADE SYNDROMES
52.Define masquerade syndrome.
The term masquerade syndrome refers to ophthalmic disorders that are not primarily inflammatory in nature but may present clinically as either anterior or posterior uveitis
(Table 39-5). These entities may be mistaken for, or masquerade as, primary uveitis. Extensive evaluation is often initiated because patients manifest with atypical features, recurrent episodes of uveitis, or uveitis that is unresponsive to standard therapy.
KEY POINTS: COMMON MASQUERADE SYNDROMES
1.Retinoblastoma in children
2.Leukemia in children
3.Primary intraocular lymphoma in the elderly
4.Ocular ischemic syndrome in the elderly
5.Peripheral retinal detachment in any age group
53.In what age groups should one have the highest suspicion for masquerade syndromes?
In the very young and in the elderly.
54.Describe the clinical features of retinoblastoma.
Retinoblastoma is the most common primary intraocular malignancy in
children, usually presenting before age |
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||
2. The most common signs are |
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||
leukocoria (white pupillary reflex) and |
|
||
strabismus. Occasionally, tumor |
|
||
necrosis may produce significant |
|
||
inflammation. Tumor cells layered in the |
|
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anterior chamber may produce a |
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|
|
|
pseudohypopyon (Fig. 39-2). |
Figure 39-2. Pseudohypopyon caused by seeding |
||
Retinoblastoma cells may enter the |
|||
of retinoblastoma cells in the anterior chamber. |
|||
vitreous, as vitreous seeds, and |
|||
(From Shields JA, Shields CL: Intraocular Tumors: |
|||
simulate vitritis. Calcification on |
A Text and Atlas. Philadelphia, W.B. Saunders, |
||
ultrasonography and CT scan may help |
1992.) |
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TABLE 39-5. M O S T C O M M O N M A S Q U E R A D E S Y N D R O M E S T H A T M A Y M I M I C U V E I T I S
Disease |
Location |
Age (yr) |
Signs of Inflammation |
Diagnostic Tests |
|
|
|
|
|
Retinoblastoma |
Anterior |
<15 |
Flare, cells, pseudohypopyon |
Aqueous tap for LDH levels and cytology |
Leukemia |
Anterior |
<15 |
Flare, cells, heterochromia |
Bone marrow, peripheral blood smear, aqueous cytology |
Intraocular foreign body |
Anterior |
Any age |
Flare, cells |
X-ray, ultrasound, CT scan |
Malignant melanoma |
Anterior |
Any age |
Flare, cells |
Angiography (fluorescein, ICG), ultrasound, MRI |
Ocular ischemic |
Anterior |
50þ |
Cell, flare, redness |
IVFA, carotid Doppler |
syndrome |
|
|
|
|
Peripheral retinal |
Anterior |
Any age |
Flare, cells |
Ophthalmoscopy, ultrasound |
detachment |
|
|
|
|
Retinitis pigmentosa |
Posterior |
Any age |
Cells in vitreous |
ERG, EOG, visual fields |
Primary intraocular |
Posterior |
15þ |
Vitreous cells, retinal |
Cytology of aqueous/vitreous fluid |
lymphoma |
|
|
hemorrhage or exudates, |
|
|
|
|
RPE infiltrates |
|
Lymphoma |
Posterior |
15þ |
Retinal hemorrhage, exudates, |
Biopsy of lymph node/bone marrow, physical examination |
|
|
|
vitreous cells |
|
Retinoblastoma |
Posterior |
<15 |
Vitreous cells, retinal exudate |
Ultrasound, aqueous tap |
Malignant melanoma |
Posterior |
15þ |
Vitreous cells |
Fluorescein ultrasound |
CT ¼ computed tomography, ERG ¼ electroretinogram, EOG ¼ electro-oculogram, ICG ¼ indocyanine green, IVFA ¼ fluorescein angiography, LDH ¼ lactate dehydrogenase, MRI ¼ magnetic resonance imaging, RPE ¼ retinal pigment epithelium.
Adapted from American Academy of Ophthalmology: Ophthalmology Basic and Clinical Science Course, Section 6. San Francisco, American Academy of Ophthalmology, 1997.
UVEITIS
333
Figure 39-4. Leukemic infiltration of the optic nerve head, retina, and choroid in an 8-year-old child. (From Shields JA, Shields CL: Intraocular Tumors: A Text and Atlas. Philadelphia, W.B. Saunders, 1992.)
Figure 39-3. Yellow-white chorioretinal infiltrates in intraocular lymphoma. (From Shields JA, Shields CL: Intraocular Tumors: A Text and Atlas. Philadelphia, W.B. Saunders, 1992.)
334 UVEITIS
to differentiate retinoblastoma from various forms of childhood uveitis, including toxoplasmosis, toxocariasis, cysticercosis, and pars planitis.
Shields JA, Augsburger JJ: Current approaches to the diagnosis and management of retinoblastoma. Surv Ophthalmol 25:347–372, 1981.
55.What may present with chronic steroid-resistant panuveitis in a patient older than age 50?
Primary intraocular lymphoma, formerly known as reticulum cell sarcoma (Fig. 39-3). Elderly individuals may present with bilateral vitreous cells, anterior chamber reaction, and retinal and choroidal infiltrates. The retinal infiltrates may be patchy and
associated with hemorrhage and exudate. Dense vitritis may be the only presenting sign. Most patients eventually develop some form of CNS involvement. CT or magnetic resonance imaging (MRI) may demonstrate CNS
tumors. Vitreous aspirate or lumbar puncture may establish the diagnosis. Therapy may include ocular and CNS irradiation combined with intrathecal chemotherapy.
Char DH, Ljung BM, Miller T, Phillips T: Primary intraocular lymphoma (ocular reticulum cell sarcoma): Diagnosis and management. Ophthalmology 95:625–630, 1988.
56.Describe the ocular findings associated with leukemia.
Clinically, the retina is the most commonly affected (Fig. 39-4). Retinal vascular dilation and tortuosity, hemorrhages, cotton-wool spots, and peripheral neovascularization occur. Roth spots are hemorrhages with white centers composed of leukemic cells or platelet-fibrin aggregates. Histopathologically, the choroid is the most commonly involved and may cause exudative retinal detachment. IVFA demonstrates multiple areas of hyperfluorescence similar to that found
in VKH syndrome. Anterior segment findings include conjunctival mass, iris heterochromia, anterior chamber cell and flare, pseudohypopyon, spontaneous hyphema, and elevated
intraocular pressure. Optic nerve infiltration and orbital involvement are common.
Kincaid MC, Green WR: Ocular and orbital involvement in leukemia. Surv Ophthalmol 27:211–232, 1983.
57.How can a malignant melanoma produce inflammatory signs?
Necrotic tumors may elicit an intense inflammatory response associated with seeding of tumor cells into the vitreous cavity and anterior segment. Occasionally, melanophages or tumor cells that contain melanin produce a brown pseudohypopyon. Blockage of the
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