Ophthalmology block — everything that has to be recallable cold
| Term | What you need to know |
|---|---|
| What she said, verbatim | “My recommendation to you guys for those is again, use your resources, MAKE A CHART — which ones cause PAIN, which ones don’t cause pain? Which ones are UNILATERAL, which ones are BILATERAL? Which ones will cause which PHYSICAL EXAM ABNORMALITIES, like FIXED PUPILS, for example. That’s how you’re gonna differentiate these.” |
| How hard she committed to it | “Particularly your PINK EYE — know the difference and how to differentiate those. That’s a thousand percent on the exam because that’s on your boards. So that’s definitely gonna be on your exam. AT LEAST TWO QUESTIONS MINIMUM. Haven’t made those questions yet, but I guarantee you those are gonna be on the exam.” |
| PAINLESS | ENTROPION · ECTROPION · DERMATOCHALASIS · XANTHELASMA · BLEPHARITIS / MEIBOMITIS · CHALAZION · PINGUECULA · PTERYGIUM · SUBCONJUNCTIVAL HEMORRHAGE · ALLERGIC CONJUNCTIVITIS · VIRAL CONJUNCTIVITIS · CHLAMYDIAL CONJUNCTIVITIS - ADULT INCLUSION · TRACHOMA · AUTOIMMUNE CONJUNCTIVITIS · POSTERIOR UVEITIS. |
| PAINFUL | HORDEOLUM · DACRYOADENITIS · DACRYOCYSTITIS · GONOCOCCAL CONJUNCTIVITIS · EPISCLERITIS · SCLERITIS · PRE-SEPTAL CELLULITIS · POST-SEPTAL CELLULITIS · KERATITIS · HERPES SIMPLEX KERATITIS · HERPES ZOSTER KERATITIS · CORNEAL ULCER · ANTERIOR UVEITIS. Note EPISCLERITIS is MILD pain and SCLERITIS is SEVERE, BORING and WORSE AT NIGHT — that contrast is the whole point of the pair. POST-SEPTAL cellulitis adds PAIN ON EYE MOVEMENT. |
| PAIN VARIES / depends | CHEMOSIS · BACTERIAL CONJUNCTIVITIS. BACTERIAL conjunctivitis is soreness rather than true pain; CHEMOSIS depends entirely on its cause. |
| BILATERAL | DERMATOCHALASIS · XANTHELASMA · BLEPHARITIS / MEIBOMITIS · ALLERGIC CONJUNCTIVITIS · VIRAL CONJUNCTIVITIS · CHLAMYDIAL CONJUNCTIVITIS - NEONATAL · TRACHOMA · AUTOIMMUNE CONJUNCTIVITIS. VIRAL starts in ONE eye and spreads to the other — do not let the first day fool you. |
| UNILATERAL | CHALAZION · HORDEOLUM · DACRYOADENITIS · DACRYOCYSTITIS · SUBCONJUNCTIVAL HEMORRHAGE · BACTERIAL CONJUNCTIVITIS · CHLAMYDIAL CONJUNCTIVITIS - ADULT INCLUSION · EPISCLERITIS · SCLERITIS · PRE-SEPTAL CELLULITIS · POST-SEPTAL CELLULITIS · KERATITIS · HERPES SIMPLEX KERATITIS · HERPES ZOSTER KERATITIS · CORNEAL ULCER · ANTERIOR UVEITIS. DACRYOADENITIS is unilateral EXCEPT the viral form, which is usually bilateral. |
| EITHER / not defined by side | ENTROPION · ECTROPION · PINGUECULA · PTERYGIUM · CHEMOSIS · GONOCOCCAL CONJUNCTIVITIS · POSTERIOR UVEITIS. |
| PUPIL abnormalities — she named these | ANTERIOR UVEITIS: pupil small and IRREGULAR, may be stuck to lens or cornea. POST-SEPTAL CELLULITIS: possible AFFERENT PUPILLARY DEFECT. ACUTE GLAUCOMA (on the red-eye chart): DILATED and FIXED. Everything else on the list leaves the pupil alone — and that is itself the discriminator. |
| PINK EYE — the one she guaranteed | ALLERGIC: ITCH, bilateral, watery/stringy, PAPILLAE (“looks like a strawberry”), NO node. VIRAL: adenovirus, profuse WATERY, FOLLICLES, TENDER preauricular node, one eye then the other. BACTERIAL: thick YELLOW/WHITE, often UNILATERAL, PAPILLAE, usually NO node. GONOCOCCAL: SEVERE purulent WITH a palpable node. CHLAMYDIAL: CHRONIC >1 month, stringy mucoid, FOLLICLES, failed topicals. |
| Findings are SUGGESTIVE, not definitive | Her caveat about papillae and follicles: “There are some findings that could be suggestive, but they’re NOT DEFINITIVE.” |
| Term | What you need to know |
|---|---|
| Almost all vignettes | “Pretty much all clinical vignettes… recognize conditions by the vignette.” Read for the DEFINING FEATURE, not the disease name. |
| What the lead-in asks | “SOME diagnosis, but A LOT are next management plan, first line treatment, patient education.” The lead-in decides the answer — read it before the options. |
| Pictures | “Way more non-pictures than pictures.” Do not bank on recognizing a photograph. |
| Which half is this? | CMS = MANAGEMENT. Clin Path I Lecture 4 = MECHANISM, on the same condition list. If the question asks WHY the tissue fails, that is the other course. |
| Term | What you need to know |
|---|---|
| The first 60 seconds | VISUAL ACUITY each eye with correction · PUPILS (shape, reactivity, afferent defect) · EXTRAOCULAR MOVEMENTS (pain? restriction?) · CORNEAL CLARITY + FLUORESCEIN · pattern of INJECTION and DISCHARGE · history of CONTACT LENS, TRAUMA, SURGERY, STEROIDS. |
| THE TWO RED FLAGS | REDUCED VISION or an ABNORMAL PUPIL. “Do not let obvious redness substitute for an eye examination.” |
| Danger signs — NOT conjunctivitis | Moderate-severe pain or CONSENSUAL PHOTOPHOBIA · reduced acuity/RAPD/abnormal pupil · corneal opacity, infiltrate, ulcer or DENDRITE · CILIARY FLUSH, hypopyon, high pressure · proptosis, diplopia, painful restricted movement · chemical or penetrating injury, recent surgery · CONTACT LENS WEARER WITH PAIN. |
| Localize by pattern | CONJUNCTIVA: itch/discharge, diffuse, VISION PRESERVED. CORNEA: pain/photophobia, fluorescein defect. ANTERIOR CHAMBER: CONSENSUAL photophobia, ciliary flush, irregular pupil. SCLERA/ORBIT: deep pain or painful movement, violaceous, proptosis. ANGLE CLOSURE: pain+headache+halos+nausea, cloudy cornea, MID-DILATED pupil. |
| TWO EXCEPTIONS TO THE SEQUENCE | CHEMICAL — IRRIGATE FIRST, before history or exam, then check pH normalized. OPEN GLOBE — rigid shield, NO pressure, NO TONOMETRY, nil by mouth, emergency consult. |
| Referral timing | EMERGENT NOW: chemical injury, open globe, angle closure, ORBITAL cellulitis, endophthalmitis. SAME DAY: keratitis/corneal ulcer, ANTERIOR UVEITIS, SCLERITIS, ocular herpes zoster. URGENT 24–48h: unexplained vision loss, persistent pain/photophobia, atypical red eye. ROUTINE: uncomplicated conjunctivitis, chronic lid disease. |
| Term | What you need to know |
|---|---|
| ENTROPION vs ECTROPION | ENTROPION turns IN → foreign body sensation → TRICHIASIS → corneal abrasion. ECTROPION turns OUT → tearing → EXPOSURE KERATOPATHY. CN VII palsy causes ECTROPION only. SURGERY IS DEFINITIVE for both. |
| DERMATOCHALASIS | Excess loose skin + orbital fat prolapse, from AGING. “Heaviness,” “looking through lashes.” EXAMINE VISUAL FIELDS — a deficit is what gets BLEPHAROPLASTY covered by insurance. |
| XANTHELASMA | Oval YELLOWISH plaques, asymptomatic. WORK UP THE METABOLISM: lipid profile + fasting glucose/HbA1C + liver function. Treat the underlying issue. Local: cryotherapy, laser, peel, excision. RECURRENCES ARE COMMON. Caveat: many patients have NORMAL lipids. |
| BLEPHARITIS / MEIBOMITIS | ROSACEA · SEBORRHEIC DERMATITIS · STAPH AUREUS. Crusting/scaling at LASH BASES, thick TOOTHPASTE-LIKE meibomian secretion, decreased or frothy tear film. LID HYGIENE FIRST → if no better at 2 WEEKS, topical abx → then oral. CHRONIC: CONTROLLED, NOT CURED. |
| CHALAZION vs HORDEOLUM | CHALAZION: STERILE meibomian obstruction, days–weeks, NON-TENDER. HORDEOLUM: acute INFECTION (staph), 24h/overnight, TENDER. Both: warm compresses + massage. |
| When to refer a lid lump | HORDEOLUM: no better in 2 WEEKS → ophtho for I&D. CHALAZION: no resolution → ophtho for steroid injection or curettage; IMPROVEMENT MAY TAKE MONTHS. RECURRENT, or persisting >2–3 MONTHS → REFER TO RULE OUT SEBACEOUS CARCINOMA. |
| Term | What you need to know |
|---|---|
| DACRYOADENITIS = GLAND | LATERAL ⅓ of the UPPER lid. INFLAMMATORY MOST COMMON (bacterial rare, viral usually bilateral). ± ipsilateral PREAURICULAR node, temporal injection, fever, leukocytosis. Inflammatory → CORTICOSTEROIDS, response in 48h. |
| DACRYOCYSTITIS = SAC | NASAL aspect of the LOWER lid, BELOW the medial canthal tendon. From NASOLACRIMAL DUCT OBSTRUCTION. Mucoid/purulent discharge EXPRESSIBLE FROM THE LOWER PUNCTUM. |
| A mass ABOVE the tendon | NOT dacryocystitis — suspect a LACRIMAL SAC TUMOR (rare). |
| Dacryocystitis management | Afebrile, well, reliable → OUTPATIENT ORAL ABX ×10 DAYS. Febrile, ill, unreliable → ADMIT, IV 48–72h then oral to complete 10–14 days. Improvement expected 24–48h. Afterwards: PROBING AND IRRIGATION often needed, may need surgery. |
| THE HEDGES | Imaging is NOT automatic for either — reserve CT for severe disease, orbital findings, chronicity, atypical presentation, suspected abscess/mass, or failure to improve. DO NOT START STEROIDS until infection is reasonably excluded. |
| Term | What you need to know |
|---|---|
| PINGUECULA vs PTERYGIUM | Both from SUN and WIND, almost always at 3 or 9 O’CLOCK. PTERYGIUM EXTENDS ONTO THE CORNEA; PINGUECULA DOES NOT. “Pterodactyls fly (into cornea), penguins can’t.” |
| Pterygium management | Sun/dust/wind protection + lubricating drops — but CONSERVATIVE MANAGEMENT WILL NOT RESOLVE IT. NON-URGENT referral if GROWING or VISION AFFECTED. Surgery if distorting vision. |
| SUBCONJUNCTIVAL HEMORRHAGE | VALSALVA · bleeding disorder · ANTIPLATELET/ANTICOAGULANT · HYPERTENSION. Painless, vision/pupil/cornea NORMAL. HISTORY IS THE WORKUP — CHECK THE BP if unexplained. Reassurance; resolves 2–4 WEEKS. |
| Recurrent hemorrhage — the hedge | NOT automatic hematology referral. Medication review, blood pressure, TARGETED evaluation for hematologic disease. |
| CHEMOSIS | Conjunctival SWELLING — a SIGN, not a diagnosis. Allergy, infection, thyroid eye disease, angioedema, trauma, orbital cellulitis, impaired venous drainage. URGENT if with PROPTOSIS, RESTRICTED MOVEMENT, REDUCED VISION or an AFFERENT PUPILLARY DEFECT. |
| Term | What you need to know |
|---|---|
| Acute vs chronic | ACUTE ≤ 4 WEEKS. CHRONIC > 4 WEEKS. |
| PAPILLAE vs FOLLICLES | PAPILLAE: RED at surface, PALER at base → BACTERIAL (except chlamydia) and ALLERGIC. FOLLICLES: PALE at surface, REDDER at base → CHLAMYDIAL and VIRAL. PREAURICULAR NODE → chlamydial, GONOCOCCAL, viral. |
| ALLERGIC | ITCH · bilateral · watery/stringy · chemosis · papillae · NO NODE · vision preserved. Avoid allergen, cool compresses, artificial tears, topical H1 ± mast cell stabilizer — OLOPATADINE DOES BOTH — plus systemic H1. |
| VIRAL | ADENOVIRUS. Profuse WATERY discharge, FOLLICLES, TENDER PREAURICULAR NODE, starts one eye then the other, recent URI. Cool compresses, artificial tears, CONTAGIOUS PRECAUTIONS. Often WORSE OVER WEEK ONE, resolves 2–3 WEEKS. Refer if >3 wks, or photophobia/vision loss after onset. |
| BACTERIAL | THICK YELLOW/WHITE discharge, often UNILATERAL, papillae, usually NO node. Immunocompetent adult → TOPICAL BROAD-SPECTRUM (fluoroquinolone) + contagious precautions. |
| URGENT REFERRAL in bacterial | Immunocompromised · CONTACT LENS WEARER · recent eye surgery · foreign body · corneal opacity or suspected keratitis · NO IMPROVEMENT IN 24 HOURS. |
| GONOCOCCAL — the exception | SEVERE purulent discharge WITH a PALPABLE PREAURICULAR NODE. NEWBORN = EMERGENCY: hospitalize, SYSTEMIC CEFTRIAXONE, cultures + Gram stain, test for chlamydia and dissemination. Untreated → CORNEAL PERFORATION. |
| CHLAMYDIAL — adult | Serotypes D–K. CHRONIC (a month+), stringy mucoid, FOLLICLES, UNRESPONSIVE TO TOPICALS. Confirm: conjunctival NAAT or DFA. DOXYCYCLINE 100 mg BD × 7 DAYS. Avoid sun, full glass of water, stay upright, separate from antacids/iron/calcium/magnesium. EVALUATE FOR OTHER STIs, NOTIFY PARTNERS. |
| CHLAMYDIAL — neonate | ERYTHROMYCIN 50 mg/kg/day divided QID × 14 DAYS. MONITOR UNDER 6 WEEKS FOR INFANTILE HYPERTROPHIC PYLORIC STENOSIS — erythromycin is a MOTILIN RECEPTOR AGONIST. Often admitted because of concomitant PNEUMONIA. |
| TRACHOMA | Serotypes A, B, C. ***LEADING INFECTIOUS CAUSE OF BLINDNESS WORLDWIDE. Most active cases ASYMPTOMATIC. MDA: AZITHROMYCIN 1 g PO SINGLE DOSE where prevalence ≥5%. CHAIN: inflammation → LID SCARRING → ENTROPION → TRICHIASIS → blindness. TRICHIASIS NEEDS SURGERY. |
| AUTOIMMUNE | Recurrent/chronic hyperemia, MINIMAL PAIN, NO DISCHARGE, systemic complaints. Pemphigoid, Stevens–Johnson, Sjögren, GVHD. ROUTINE ophtho referral. |
| Term | What you need to know |
|---|---|
| EPISCLERITIS | Often IDIOPATHIC. MILD acute pain, FOCAL/SECTORAL redness, NO discharge, NO photophobia. Vessels CAN be moved with a cotton tip. |
| THE TEST | 2.5% PHENYLEPHRINE, WAIT 15 MINUTES → EPISCLERAL VESSELS BLANCH. |
| Episcleritis treatment | Artificial tears + ORAL NSAID TAKEN WITH FOOD. No response in 2 DAYS → refer. Usually self-limited; may recur in either eye. |
| SCLERITIS | Often SYSTEMIC AUTOIMMUNE. SEVERE BORING PAIN, WORSE AT NIGHT, radiating to face. VIOLACEOUS HUE = choroid through THINNED sclera. Vessels CANNOT be moved. Pain WITH EYE MOVEMENT. |
| Scleritis management | URGENT REFERRAL — SCLERA AT RISK OF PERFORATION, may need a surgical patch. Slit lamp + fundoscopy, work up the systemic cause. |
| THE FIRST SIGN OF RESPONSE | DECREASED PAIN — even if the inflammation looks unchanged. |
| The hedges | Non-infectious ANTERIOR scleritis commonly BEGINS with systemic NSAIDs; steroids/immunomodulators for severe, NECROTISING, posterior or refractory disease. PERFORATION RISK IS GREATEST IN NECROTISING DISEASE, not uniformly. |
| Term | What you need to know |
|---|---|
| CILIARY FLUSH | Ring of red vessels from the LIMBUS around the cornea (anterior ciliary arteries). Means inflammation of CORNEA, IRIS or CILIARY BODY. Seen in: CORNEAL INFLAMMATION (ulcer, keratitis) · ANTERIOR UVEITIS · ACUTE GLAUCOMA. It RULES OUT simple conjunctivitis. |
| KERATITIS | Risks: corneal trauma, DRY EYES, CONTACT LENS OVERWEAR, topical ocular STEROIDS. Signs: corneal OPACIFICATION, “BROKEN UP” corneal light reflection, CILIARY FLUSH. URGENT REFERRAL WITHIN 24h for slit lamp + fluorescein. |
| The ring infiltrate | ACANTHAMOEBA — contact lens wearers with POOR HYGIENE, e.g. RINSING LENSES IN TAP WATER. |
| Undertreated keratitis | CORNEAL SCARRING or PERFORATION → ENDOPHTHALMITIS → POSSIBLE REMOVAL OF THE EYE. Bacterial prognosis: good for small–moderate, POOR for severe, WORSE INSIDE THE VISUAL AXIS. |
| HSV vs HZV keratitis | SIMPLEX: TRUE DENDRITE — tree-branching, ELEVATED EDGES, TERMINAL END BULBS. PATHOGNOMONIC. Younger. Skin NOT dermatomal, may cross midline. ZOSTER: PSEUDODENDRITE — lacks all three. Older. DERMATOMAL, usually V1, RESPECTS THE MIDLINE, often spares lower lid. |
| HUTCHINSON SIGN | Vesicle on the TIP OF THE NOSE = NASOCILIARY branch = HIGHER RISK OF OCULAR INVOLVEMENT. |
| Herpetic treatment | ORAL ANTIVIRALS (aciclovir/valaciclovir/famciclovir) ×10 DAYS, ideally within 72h of rash onset. IV aciclovir for severe, disseminated, orbital, retinal, CNS or significantly immunocompromised. NO TOPICAL GLUCOCORTICOIDS BY THE PCP IN ACTIVE HSV EPITHELIAL DISEASE. |
| CORNEAL ULCER | CONTACT LENS USE = MAJOR RISK. Patient RESISTS OPENING THE EYE. Ciliary flush + corneal defect. EMERGENT REFERRAL — a step above keratitis. Swab central/large ulcers. Start BROAD-SPECTRUM TOPICAL (4th-gen fluoroquinolone). STEROIDS CAN WORSEN INFECTION IF STARTED TOO EARLY, especially FUNGAL or HERPETIC — leave to ophtho. NEXT-DAY follow-up; most heal 2–3 WEEKS. |
| The contact lens case | REMOVE LENSES, DO NOT PATCH · NO take-home ANESTHETIC (delays healing, masks progression) · NO empiric STEROID · SAME-DAY ophthalmology · PRESERVE LENSES AND CASE for culture. Do NOT delay treatment solely to obtain a culture. |
| Term | What you need to know |
|---|---|
| ANTERIOR (iritis/iridocyclitis) | PAIN, photophobia, redness AT THE CORNEAL EDGE, VISION OFTEN PRESERVED. CELLS IN THE ANTERIOR CHAMBER, CONSENSUAL PHOTOPHOBIA, CILIARY FLUSH, variable IOP, IRREGULAR PUPIL stuck to lens/cornea, KERATIC PRECIPITATES (WBC on the corneal endothelium). |
| Anterior management | URGENT REFERRAL WITHIN 24h for slit lamp + dilated fundoscopy — DELAY MAY COST VISION. Infectious → treat organism. Non-infectious → TOPICAL CORTICOSTEROIDS. Recurrent or systemic features → THOROUGH SYSTEMIC EVALUATION. |
| POSTERIOR (choroiditis/retinitis) | Blurred vision, FLOATERS, SCOTOMAS, METAMORPHOPSIA — and NO PAIN if isolated. CELLS IN THE POSTERIOR VITREOUS, vitreous haze. Idiopathic, autoimmune, INFECTIOUS: TOXOPLASMOSIS, CMV. |
| Posterior management — THE DIFFERENCE | DOES NOT RESPOND TO TOPICAL TREATMENT — may need an INTRAOCULAR CORTICOSTEROID INJECTION. Fluorescein angiography helps separate ACTIVE from INACTIVE lesions. Develops far more slowly, may last YEARS. INFECTION MUST BE EXCLUDED BEFORE IMMUNOSUPPRESSION. |
| Term | What you need to know |
|---|---|
| Both forms | DIRECT EXTENSION from bacterial SINUS, SKIN or DENTAL infection. In DIABETIC/ELDERLY/IMMUNOCOMPROMISED consider FUNGUS — ASPERGILLOSIS, MUCORMYCOSIS. |
| THE GIVEAWAY | PRE-SEPTAL: THE EYE ITSELF IS WHITE, movements FULL and PAINLESS, vision normal. POST-SEPTAL: eye RED, PROPTOSIS, PAINFUL RESTRICTED MOVEMENT, DIPLOPIA, reduced vision, possible AFFERENT PUPILLARY DEFECT. |
| Workup | CT ORBITS + PARANASAL SINUSES WITH CONTRAST · complete ocular exam with fundoscopy · Gram stain and culture of drainage · CBC with differential · BLOOD CULTURES. |
| Management | MILD PRE-SEPTAL → outpatient ORAL abx 10–14 DAYS vs STAPH (±MRSA) and STREP. ADMIT + IV 48–72h then oral ≥1 week if: moderate-severe/toxic, poor compliance, CHILD ≤5 YEARS, no improvement on orals — AND ALL POST-SEPTAL. |
| Untreated | INTRACRANIAL SPREAD → MENINGITIS or CAVERNOUS SINUS THROMBOSIS. Expect improvement 24–48h. May need ENT, OMFS, and/or ID consults. |
| The hedge | MILD, CLEARLY PRE-SEPTAL disease with normal vision, pupils and painless full movements may be managed CLINICALLY WITHOUT ROUTINE CT. |
| The four modalities | SLIT LAMP: anterior — lids, cornea, conjunctiva, sclera, iris. OPHTHALMOSCOPY: direct / indirect / SLIT-LAMP (most common). FLUORESCEIN EXAM: dye INSTILLED, Wood's lamp — abrasions, ulcers, foreign bodies. FLUORESCEIN ANGIOGRAPHY: dye INJECTED, reaches eye in 10–15 SEC, blue flash, NO IODINE — retina and choroid blood flow. |
| Term | What you need to know |
|---|---|
| SUDDEN VISION LOSS | IS A STROKE UNTIL PROVEN OTHERWISE. You can have a stroke with NO other symptom. EVERYONE GETS AN MRA (magnetic resonance angiography). |
| The four questions | ONE EYE OR BOTH? · SUDDEN OR GRADUAL? · CENTRAL OR PERIPHERAL? · PAINFUL OR PAINLESS? These four decide the diagnosis, not the fundus. |
| PAINFUL | ACUTE ANGLE-CLOSURE GLAUCOMA (severe, at rest) · OPTIC NEURITIS (on eye MOVEMENT). Everything else here is PAINLESS. |
| BOTH EYES | PAPILLEDEMA, or a lesion at/behind the CHIASM. Everything else is MONOCULAR. |
| “CURTAIN” = TWO DIAGNOSES | AMAUROSIS FUGAX — curtain LIFTS in seconds to minutes. RETINAL DETACHMENT — curtain STAYS and advances over days. DURATION separates them. |
| Refer emergently | ANY patient OVER 50 with SUDDEN VISUAL LOSS. |
| Term | What you need to know |
|---|---|
| What | TRANSIENT MONOCULAR vision loss. “FLEETING BLINDNESS.” SECONDS TO MINUTES. PAINLESS. |
| IF IT LASTED HOURS | IT IS NOT A TIA (transient ischemic attack). Duration is the first filter. |
| Cause | Retinal emboli, CAROTID or CARDIAC. Most commonly a TIA (transient ischemic attack). Also RETINAL VASCULAR SPASM. |
| Risks | Older age, DM (diabetes mellitus), HTN (hypertension), ATHEROSCLEROSIS, cardiac VALVE disease, IVDU (intravenous drug use), SICKLE CELL, coagulation disorders, RAYNAUD’S. |
| Workup | CAROTID DOPPLER if carotid suspected · ECHO (echocardiogram) if cardiac · MRA for everyone. |
| Treatment | TREAT THE UNDERLYING CAUSE. Stroke risk → ASA (aspirin) + CLOPIDOGREL. Carotid emboli → ENDARTERECTOMY. Raynaud’s/spasm → CALCIUM CHANNEL BLOCKERS. |
| Prognosis | ~85% FULL RECOVERY. The rest PROGRESS TO CRAO (central retinal artery occlusion). |
| Term | What you need to know |
|---|---|
| ACUTE = CLOSED ANGLE | IRIS BLOCKS THE DRAINAGE CIRCUIT. SEVERE SUDDEN EYE PAIN, HEADACHE, NAUSEA/VOMITING, COLORED HALOS, decreased vision. HAZY CORNEA, pupillary dilation, narrow/occluded angle. |
| THE PRESSURE | 40–80 mmHg on TONOMETRY or GONIOSCOPY. |
| Acute treatment | TOPICAL PILOCARPINE (alpha-blocker) or TIMOLOL (beta-blocker) · IV ACETAZOLAMIDE then MANNITOL or ISOSORBIDE. DEFINITIVE = LASER PERIPHERAL IRIDOTOMY, 1–2 DAYS AFTER ONSET. |
| Acute RISK FACTORS | SYSTEMIC ANTICHOLINERGICS (atropine) · NEBULIZED BRONCHODILATORS · prior ANTERIOR UVEITIS · lens dislocation · AFRICAN AMERICAN RACE. Obstruction from TUMOR or SCARRING. |
| CHRONIC = OPEN ANGLE | TRABECULAR MESHWORK abnormality by the CANAL OF SCHLEMM, from AGING. MUCH MORE COMMON. ASYMPTOMATIC in most. PAINLESS. |
| Chronic field loss | PERIPHERAL FIRST → patients say “TUNNEL VISION” → then blindness. |
| THE CLASSIC SIGN | OPTIC NERVE CUPPING — increased CUP-TO-DISC RATIO. Also RIM PITTING, BAYONETING (vessels with narrow angulations), SPLINTER HEMORRHAGES, rim thinning. |
| Chronic pressure | MAY BE NORMAL OR ELEVATED — nerve damage occurs either way. |
| Chronic risks | AFRICAN AMERICAN race, HISPANIC, ADULTS OVER 40, DM, age, FAMILY HISTORY, HTN, MYOPIA. |
| Chronic treatment | FIRST-LINE: LATANOPROST · TAFLUPROST · TIMOLOL drops. Refractory/advanced → LASER TRABECULOPLASTY. SURGERY IS DEFINITIVE FOR BOTH FORMS. |
| The missed case | An INTRACTABLE HEADACHE LOCALIZED BEHIND THE EYE with a RED EYE. Glaucoma is a LEADING CAUSE OF BLINDNESS WORLDWIDE. |
| Term | What you need to know |
|---|---|
| Who | 18–45 YEARS OLD, 75% FEMALE. A much YOUNGER group than everything else here. |
| Cause | MULTIPLE SCLEROSIS, autoimmune, POSTVIRAL, or idiopathic. |
| Symptoms | UNILATERAL loss over HOURS TO SEVERAL DAYS · PAINFUL EYE MOVEMENT · central vision loss · LOSS OF COLOR VISION. |
| Signs | Often a NORMAL-APPEARING DISC. RELATIVE AFFERENT PUPILLARY DEFECT (MARCUS GUNN). |
| Workup | REFER TO OPHTHALMOLOGY. Slit lamp, dilated fundoscopy, COLOR VISION + neuro exam. MRI (magnetic resonance imaging) BRAIN AND ORBITS, WITH AND WITHOUT CONTRAST. |
| THE THRESHOLD | ≥2 CHARACTERISTIC DEMYELINATING LESIONS → treat and refer to NEUROLOGY / NEURO-OPHTHALMOLOGY. |
| Treatment & prognosis | CORTICOSTEROIDS if demyelinating. SPONTANEOUS RECOVERY IS THE RULE — improves within WEEKS, usually NORMAL WITHIN A YEAR. |
| Education | RECURRENCE = GREATER RISK OF MS (multiple sclerosis). Find the cause; do not just treat the episode. |
| Term | What you need to know |
|---|---|
| What | Traction detachment, commonly AFTER A RETINAL TEAR OR HOLE. Types: RHEGMATOGENOUS, TRACTION, SEROUS/EXUDATIVE. |
| Who | MOST COMMON AFTER AGE 50 — the vitreous SHRINKS with age. |
| Risks | MYOPIA, TRAUMA, CATARACT EXTRACTION, DM, tumor, CONNECTIVE TISSUE DISEASE, family history. |
| FLASHES & FLOATERS | REPRESENT THE TEAR, not the detachment. |
| Then | GRAY OR BLACK SHADOWS peripherally, may cover the WHOLE EYE WITHIN DAYS. “CURTAIN or DARK CLOUD.” PAINLESS. |
| MACULA INVOLVED | → SUDDEN LOSS OF VISION in that eye. |
| Odd but useful | VISION CHANGES WITH HEAD POSITION — the retina is floating loose. |
| Fundus | ELEVATED GRAY retina WITH FOLDS · PIGMENTED WELL-DEMARCATED area · TEARS ARE ORANGE AND CRESCENT SHAPED. ULTRASOUND IS MORE SENSITIVE THAN FUNDOSCOPY and types it. |
| Treatment | EMERGENCY — REFER IMMEDIATELY. Surgery urgently or within a week by type: LASER PHOTOCOAGULATION · CRYOTHERAPY · PNEUMATIC RETINOPEXY · VITRECTOMY · SCLERAL BUCKLE. |
| Term | What you need to know |
|---|---|
| CRAO — CENTRAL RETINAL ARTERY OCCLUSION | EMBOLUS. A STROKE IN THE EYE. IRREVERSIBLE DAMAGE AFTER 90 MINUTES. |
| CRAO presentation | PAINLESS PROFOUND LOSS OVER SECONDS. Acuity COUNTING FINGERS TO LIGHT PERCEPTION. “ISLAND” OF VISION IN THE TEMPORAL FIELD. |
| CRAO PUPIL — the clue | SLOW TO DIRECT LIGHT, BUT BRISK WHEN THE OTHER EYE IS ILLUMINATED. |
| CRAO fundus | PALE SWELLING of the posterior segment + CHERRY-RED SPOT AT THE FOVEA. Emboli in the central artery. |
| CRAO treatment | HIGH-CONCENTRATION INHALED O₂ + DIGITAL MASSAGE OVER THE EYELID · IV ACETAZOLAMIDE · ANTERIOR CHAMBER PARACENTESIS · THROMBOLYTIC INTO THE OPHTHALMIC ARTERY WITHIN 8 HOURS. |
| CRAO systemic | STROKE RISK RISES AT ONSET — if plaque reached a tiny retinal artery, there is far more in that carotid. |
| CRVO — CENTRAL RETINAL VEIN OCCLUSION | THROMBUS. MORE COMMON THAN CRAO. SUDDEN PAINLESS loss; sometimes GRADUAL OVER DAYS TO WEEKS. |
| CRVO fundus | “BLOOD AND THUNDER” — DISC SWELLING, VENOUS DILATION, COTTON WOOL SPOTS, RETINAL HEMORRHAGES. |
| CRVO treatment | URGENT OPHTHALMOLOGY REFERRAL TO RESTORE BLOOD FLOW. Evaluate and treat the underlying disorders. |
| Shared risks | HTN · DM · HLD (hyperlipidemia) · RAYNAUD’S · AGE >50 · HYPERCOAGULABLE · GIANT CELL ARTERITIS · ENDOCARDITIS · ATRIAL MYXOMA · OBESITY. CRAO adds ATRIAL FIBRILLATION. |
| Shared later | NEOVASCULARIZATION WEEKS TO MONTHS AFTER the occlusion, in both. |
| Shared confirmatory | COLOR FUNDUS PHOTOGRAPHY + FLUORESCEIN ANGIOGRAPHY. |
| BRAO and BRVO — the BRANCH forms | SAME DISEASE, SMALLER VESSEL. A BRANCH is blocked, not the trunk → ONLY PART OF THE RETINA affected, PARTIAL field loss. Everything else identical. |
| Term | What you need to know |
|---|---|
| THE DISTINCTION | INTRACRANIAL pressure, NOT INTRAOCULAR. Every other condition here is pressure inside the GLOBE. |
| Causes | TUMOR · TRAUMA · INTRACRANIAL INFECTION (meningitis) · HEMORRHAGE · VITAMIN A TOXICITY. |
| Visual symptoms | NON-SPECIFIC: FLICKERING, BLURRY, DOUBLE VISION. |
| Systemic symptoms | Signs of raised ICP (intracranial pressure): NAUSEA, VOMITING, HEADACHE. |
| Fundus | ENGORGED RETINAL VEINS · SWOLLEN OPTIC DISC · ± retinal hemorrhages. BILATERAL. |
| Phases | ACUTE may have HEMORRHAGES and COTTON WOOL SPOTS. CHRONIC = elevation + blurred margins, NO hemorrhage or cotton wool spots. ATROPHIC = the AXONS HAVE DIED. |
| Workup | MRI and/or CT (computed tomography) HEAD to rule out a MASS, then LUMBAR PUNCTURE — INCREASED OPENING PRESSURE CONFIRMS. TREAT THE UNDERLYING DISORDER. |
| vs GLAUCOMA | PAPILLEDEMA PUSHES THE DISC OUT. GLAUCOMA CUPS IT IN. |
| Term | What you need to know |
|---|---|
| Both forms | SUDDEN PAINLESS loss of SIDE OR CENTRAL vision · SWELLING AND PALENESS of the optic nerve head · ONE EYE FIRST, SECOND EYE AT RISK. |
| NAION — NON-arteritic | 90–95% OF CASES. AGE 40–60. Linked to a SMALL STRUCTURAL OPTIC DISC = “DISC AT RISK.” HTN, DM, HIGH CHOLESTEROL, SLEEP APNEA. |
| NAION workup | A DIAGNOSIS OF EXCLUSION. WORKUP IS IDENTICAL TO ARTERITIC — make sure there is no GCA. Then evaluate HTN, DM, ANEMIA; neuroimaging if unclear. |
| NAION management | OBSERVATION + CARDIOVASCULAR RISK MODIFICATION. Consider AVOIDING ANTIHYPERTENSIVES AT BEDTIME — NOCTURNAL HYPOTENSION worsens it. |
| AAION — ARTERITIC | Caused by GIANT CELL (TEMPORAL) ARTERITIS. AGE 55+. Usually ELDERLY, CAUCASIAN WOMEN. A MEDICAL EMERGENCY. |
| AAION systemic | MALAISE, WEIGHT LOSS, FEVER · HEADACHE in the TEMPORAL or OCCIPITAL region · SCALP TENDERNESS on combing the hair · JAW CLAUDICATION on chewing. NO prior headache history → new temporal headache = the warning sign. |
| AAION workup | ESR (erythrocyte sedimentation rate) + CRP (C-reactive protein) rule GCA in or out. TEMPORAL ARTERY BIOPSY IS THE GOLD STANDARD — but DO NOT WAIT FOR IT. |
| AAION treatment | IV METHYLPREDNISOLONE ×3 DAYS, then SLOW ORAL TAPER to the lowest suppressive dose — TYPICALLY 6 TO 12 MONTHS. Add FAMOTIDINE for GI ULCER PROPHYLAXIS. |
| AAION prognosis | Depends on DURATION and WHEN STEROIDS STARTED. Untreated → BLINDNESS. |
| Her boundary | She will NOT test GCA as a disease in its own right — learn it as THE CAUSE OF ARTERITIC AION. |
| Term | What you need to know |
|---|---|
| The principle | The efferent limb is BILATERAL, so both pupils get the same command. UNEQUAL means an EFFERENT PATHWAY IS BROKEN. |
| WORSE IN THE DARK | The SMALL pupil is abnormal — it is failing to DILATE. HORNER, opioids, Argyll Robertson. |
| WORSE IN THE LIGHT | The LARGE pupil is abnormal — it is failing to CONSTRICT. CN III PALSY, ADIE, pharmacologic mydriasis. |
| EQUAL IN BOTH | PHYSIOLOGIC ANISOCORIA — the MOST COMMON cause, usually UNDER 0.4 mm. |
| Pupil size rule | Set by the AVERAGE ILLUMINATION DETECTED BY EACH EYE. Cover one eye and the other DILATES. |
| MARCUS GUNN (RAPD) | AFFERENT defect at the RETINA or OPTIC NERVE. Swing the light to the affected eye and BOTH PUPILS DILATE. |
| HORNER SYNDROME | PTOSIS + MIOSIS + ANHIDROSIS (anhidrosis may be ABSENT by lesion level). TEST = DILUTE APRACLONIDINE — no effect on a normal pupil, DILATES the Horner pupil. |
| HORNER HALLMARK | DILATION LAG. Anisocoria most evident in the FIRST 4–5 SECONDS after dimming. After 10–15 s it dilates a little — that is PASSIVE, not sympathetic recovery. |
| HORNER LOCALIZATION | 1st ORDER: brainstem stroke/tumor, cord lesion ABOVE T1. 2nd ORDER: PANCOAST TUMOR, thyroid cancer. 3rd ORDER: CAROTID DISSECTION, cavernous sinus. OFTEN IDIOPATHIC. |
| ARGYLL ROBERTSON | BILATERAL MIOSIS. NO light reaction, BRISK near reaction — LIGHT-NEAR DISSOCIATION. TERTIARY SYPHILIS, with TABES DORSALIS. Lesion in the DORSAL MIDBRAIN. |
| ADIE TONIC PUPIL | MYDRIASIS with POOR light response, SLOW TONIC near response. Ciliary ganglion damage then ABERRANT REINNERVATION. WOMEN IN THEIR 30s, often UNILATERAL. SECTOR PARALYSIS on slit lamp, ABSENT ACHILLES/PATELLAR REFLEXES. |
| Term | What you need to know |
|---|---|
| CN (cranial nerve) III | SUPERIOR division: LEVATOR + SUPERIOR RECTUS. INFERIOR division: INFERIOR + MEDIAL RECTUS, INFERIOR OBLIQUE, and PARASYMPATHETICS. |
| CN III causes | MOST COMMON: MICROVASCULAR (DM, HTN). MOST DREADED: COMPRESSION BY AN ENLARGING ANEURYSM, usually POSTERIOR COMMUNICATING ARTERY — RUPTURE WITHIN HOURS TO DAYS. |
| THE CN III DECISION | PUPIL INVOLVED → STAT CTA (computed tomography angiography) HEAD / MRA BRAIN. PUPIL SPARED → reassurance and imaging, but NOT STAT. |
| CN IV | SUPERIOR OBLIQUE — INTORTS and DEPRESSES. The ONLY nerve from the DORSAL brainstem, and it CROSSES. VERTICAL BINOCULAR DIPLOPIA; patient TILTS THE HEAD AWAY from the bad eye. Isolated = usually CONGENITAL, even in adults. |
| CN VI | LATERAL RECTUS — ABDUCTS. HORIZONTAL BINOCULAR DIPLOPIA. CHILDREN: INTRACRANIAL TUMORS. ADULTS: MICROVASCULAR, or major trauma/skull base fracture. |
| CN IV / VI workup | Isolated atraumatic → MRI BRAIN WITH AND WITHOUT CONTRAST + HbA1C (hemoglobin A1C) if at risk. TRAUMATIC → OBSERVE ~6 MONTHS, PATCH ONE EYE meanwhile. |
| PTOSIS — three muscles | LEVATOR PALPEBRAE = CN III. MÜLLER’S = SYMPATHETIC, worth 1–2 mm. ORBICULARIS OCULI = CN VII, CLOSES the lid. |
| PTOSIS — tell them apart | CN III PALSY: REDUCED levator + MYDRIASIS. HORNER: NORMAL levator + MIOSIS. MYASTHENIA: REDUCED levator, uni- OR bilateral, VARIABLE THROUGH THE DAY. |
| The one-liner | PTOSIS + SMALL PUPIL = HORNER. PTOSIS + LARGE PUPIL = CN III PALSY. |
| NYSTAGMUS | INVOLUNTARY, BIPHASIC, RHYTHMIC oscillation. Congenital or acquired. SYMPTOMATIC UNLESS ACQUIRED BEFORE AGE 8. VERTIGO is often the primary symptom; also OSCILLOPSIA, blurring, compensatory head position. |
| JERK NYSTAGMUS | Named for the FAST beat. INCREASES WITH GAZE TOWARD THE FAST PHASE. HORIZONTAL IS THE MOST COMMON FORM. |
| FIELD DEFECTS | MONOCULAR total loss = OPTIC NERVE = PRE-CHIASM. BITEMPORAL = CHIASM. HOMONYMOUS = POST-CHIASM: tract → homonymous hemianopsia; radiation → SUPERIOR QUADRANTANOPIA; STRIATE CORTEX → homonymous hemianopsia WITH MACULAR SPARING. |
| Term | What you need to know |
|---|---|
| Vision loss in CHILDREN | AMBLYOPIA. 3–5% of kids. |
| EYE CANCER in ADULTS | UVEAL MELANOMA — melanocytes of CHOROID, CILIARY BODY or IRIS. |
| Form of GLAUCOMA | PRIMARY OPEN-ANGLE. |
| PEDIATRIC cataract type | ZONULAR. |
| Metastatic site for OCULAR MELANOMA | THE LIVER. |
| Treatment for uveal melanoma | RADIATION THERAPY — enucleation is now less common. |
| AMD split | 80% DRY · 20% WET. |
| Term | What you need to know |
|---|---|
| NUCLEAR | BROWN central lens. Distance worse than near — a MYOPIC SHIFT, so they may read without glasses again. |
| CORTICAL | SPOKE-like opacities from the PERIPHERY. Silent until central, then GLARE is the commonest complaint. |
| POSTERIOR SUBCAPSULAR | Plate-like, BEHIND the lens. Faster onset, classically UNDER 50, on CORTICOSTEROIDS or DIABETIC. Symptoms BETTER after dilation. |
| PEDIATRIC — ZONULAR | COMMONEST pediatric type. White opacity round the nucleus. |
| PEDIATRIC — POLAR | Less common but CENTRAL, so caught earlier. |
| The rule | A CATARACT ALONE NEVER CAUSES A RELATIVE AFFERENT PUPILLARY DEFECT. If there is one, something else is wrong. |
| Advanced sign | LOSS OF RED REFLEX · leukocoria · pupil looks gray or white. |
| Treatment | SURGERY ONLY. Deferred until it interferes with daily life — EXCEPT a NEONATE, operated early to prevent AMBLYOPIA. |
| Clouds again years later | POSTERIOR CAPSULE OPACIFICATION. Treated with YAG LASER. The lens cannot regrow. |
| Term | What you need to know |
|---|---|
| Where the vision goes | CENTRAL, with DISTORTION. Glaucoma takes the PERIPHERY — that is the split. |
| DRY (non-exudative) | 80%. DRUSEN, pigmentary change, atrophy. |
| WET (exudative) | 20%. CHOROIDAL NEOVASCULARIZATION bleeds into retina → DISCIFORM SCAR. |
| Home monitoring | AMSLER GRID. |
| Confirming wet | FLUORESCEIN ANGIOGRAPHY · OPTICAL COHERENCE TOMOGRAPHY. |
| Dry treatment | STOP SMOKING. AREDS2: vitamins C and E, zinc, copper, lutein, zeaxanthin. |
| Why not beta carotene | Original AREDS used it; dropped because it RAISED LUNG CANCER RISK IN SMOKERS. |
| Wet treatment | INTRAVITREAL ANTI-VEGF · laser · photodynamic therapy. |
| Prognosis | SLOWS progression. Does NOT reverse loss. |
| Term | What you need to know |
|---|---|
| Amblyopia in one line | Brain FAVORS one eye; the other never develops. |
| Three routes in | STRABISMUS · ANISOMETROPIA (unequal refraction) · DEPRIVATION (cataract, ptosis, corneal opacity). |
| Occlusion objection test | Child OBJECTS when the GOOD eye is covered. Calm when the BAD eye is covered. |
| Numeric definition | TWO LINES or more difference on best corrected acuity. |
| Screening | ALL children UNDER 5. |
| Treatment | PATCH or ATROPINISE THE GOOD EYE. Never the weak one. |
| Timing | Good before 7, BETTER BEFORE 5. |
| Treated late | Acuity can recover; STEREO VISION DOES NOT. They struggle with 3D and judging distance. |
| Strabismus giveaway | BINOCULAR diplopia — GONE when either eye is covered. |
| Test | COVER TEST · displaced CORNEAL LIGHT REFLEX in larger deviations. |
| Term | What you need to know |
|---|---|
| RETINOBLASTOMA giveaway | LEUKOCORIA — white pupil, classically noticed in a PHOTOGRAPH. |
| Who | Young children, almost exclusively. Genetic mutation, often RECESSIVE so family history misleads. |
| NO BIOPSY | Risks SEEDING the tumor. Diagnosis is EXAM + IMAGING. |
| Primary care job | RED REFLEX at every well-child check. |
| Family history | Seen by an experienced ophthalmologist WITHIN THE FIRST 8 WEEKS OF LIFE. |
| Prognosis | UNTREATED close to 100% FATAL. TREATED >95% five-year survival. NO RECURRENCE AT 5 YEARS = CURED. |
| UVEAL MELANOMA | Commonest ADULT eye cancer. Choroid, ciliary body or iris. Usually found INCIDENTALLY. |
| Melanoma vs freckle | FEEDER VESSEL. A cancer builds its own blood supply; a freckle has none. Plus >3 mm base, >1 mm deep, GROWING. |
| Fine needle aspiration | For MOLECULAR PROGNOSTIC TESTING, not to make the diagnosis. |
| Spread | LIVER. Ten-year mortality ~32% overall; IRIS melanoma only 4–10% because it is VISIBLE and found early. |
| IRIS NEVUS | FLAT, under 3 mm, AVASCULAR, inferior iris, stable. Low transformation risk but still monitored. |
| LISCH NODULES | Tan, bilateral, multifocal — NEUROFIBROMATOSIS TYPE 1. |
| CONJUNCTIVAL MELANOMA | RAISED and VASCULAR. A conjunctival NEVUS is FLAT with CLEAR CYSTS. |
| Term | What you need to know |
|---|---|
| Who | OVERWEIGHT WOMAN OF CHILDBEARING AGE. |
| Symptoms | Intractable HEADACHE · PULSATILE TINNITUS · TRANSIENT visual obscuration · pain behind the eyes. |
| Signs | PAPILLEDEMA · visual field loss · CN6 (ABDUCENS) PALSY. |
| Order first | MRI BRAIN + MR VENOGRAPHY — exclude a mass AND a venous sinus thrombosis. |
| Then | LUMBAR PUNCTURE: ELEVATED OPENING PRESSURE. That is the confirmation. |
| Not the same as | SYSTEMIC hypertension. Blood pressure may be normal. |
| Treatment | ACETAZOLAMIDE promptly + WEIGHT REDUCTION program. |
| The durable fix | WEIGHT LOSS. Everything else buys time. |
| Last resort | CSF diversion — optic nerve sheath fenestration or shunt. |
| Term | What you need to know |
|---|---|
| MYOPIA | LONG eyeball. Focus IN FRONT of retina. CONCAVE (negative) lens. |
| HYPEROPIA | SHORT eyeball. Focus BEHIND retina. CONVEX (positive) lens. |
| ASTIGMATISM | UNEVEN curvature → MULTIPLE focal points. TORIC lens. |
| Who to refer to | Isolated refractive error → OPTOMETRY. Medical eye disease → OPHTHALMOLOGY. |
| Corneal opacity vs cataract | OPACITY is on the CORNEA; CATARACT is the LENS. |
| Refractive vs everything else | Refractive blur CORRECTS FULLY WITH LENSES. Nothing else here does. |
| The color clue | OPTIC NEUROPATHY is the one that takes COLOR VISION. Think of it first if colors look washed out. |
| Functional visual loss | NORMAL exam, NORMAL pressure, CLEAR lens, symptoms that do not fit anatomy. |
| Term | What you need to know |
|---|---|
| DO NOT remove a penetrating object | It may be TAMPONADING the wound. Removal can extrude intraocular contents. |
| DO NOT order MRI | CT ORBIT. A magnet moves a METALLIC fragment through the eye. |
| DO NOT dilate the eye | NEVER, when ocular trauma is suspected. It costs you the pupil exam. |
| DO NOT send home topical anesthetic | Delays healing, MASKS worsening symptoms, can cause a CORNEAL ULCER. |
| ALWAYS | ABCs FIRST. Then tetanus status for any metal or organic penetration. |
| Automatic CT without contrast | Loss of consciousness, alcohol, confusion, TACHYPNEA, apneic breathing, ANTICOAGULANTS, or eye penetration. |
| Epidemiology | Leading cause of MONOCULAR BLINDNESS in YOUNG ADULT MEN in the US. Usually arrives with MAJOR BRAIN TRAUMA. |
| Term | What you need to know |
|---|---|
| Definition | FULL-THICKNESS defect in cornea and/or sclera. Compartments open to the outside. |
| THE SIGNS | PUPIL DISTORTED TOWARD THE WOUND · FLAT anterior chamber · uveal tissue protruding · massive hemorrhagic CHEMOSIS · SOFT EYE · deep lid laceration · hyphema or vitreous hemorrhage. |
| Two forms | FULL-THICKNESS EYE WALL LACERATION (sharp / high velocity) vs GLOBE RUPTURE (blunt). |
| Globe rupture — where | At a WEAK POINT: posterior to the EOM insertions (esp SUPERONASAL), OLD SURGICAL INCISIONS, LAMINA CRIBROSA. |
| Globe rupture — suspect when | Blunt trauma + MASSIVE HEMORRHAGIC CHEMOSIS or a SOFT EYE. |
| THE MOMENT you suspect it | RIGID SHIELD taped over the eye + OPHTHO IMMEDIATELY + ANTIEMETIC + analgesia + tetanus. Then SURGICAL REPAIR. |
| Cut lens capsule | Lens becomes HYDRATED, EDEMATOUS, OPAQUE. LENSECTOMY required but often DEFERRED. |
| Posterior segment foreign body | LEAVE IT ALONE at initial evaluation — going after it does more damage. |
| Term | What you need to know |
|---|---|
| Corneal abrasion — history | FINGERNAIL or CONTACT LENS handling. One of the COMMONEST ocular injuries. |
| Corneal abrasion — symptoms | SEVERE foreign body sensation, tearing, photophobia, blurred vision. |
| Corneal abrasion — diagnosis | SLIT LAMP with FLUORESCEIN — stains the exposed BASEMENT MEMBRANE. |
| Corneal abrasion — treatment | TOPICAL BROAD-SPECTRUM ANTIBACTERIAL. NO PATCH (slide says it may ease pain; it does not). Re-examine. |
| Foreign body — history | GRINDING or STRIKING METAL. |
| THE LOCALIZING SIGN | LINEAR VERTICAL corneal defects = object in the TARSAL CONJUNCTIVA of the UPPER LID. EVERT THE LID. |
| Foreign body — removal | Topical anesthetic → slit lamp → STERILE 27-GAUGE NEEDLE. RUST RING (iron/copper) → battery BURR. |
| When to refer | Any concern the object passed THROUGH the cornea — that is an OPEN GLOBE. |
| Term | What you need to know |
|---|---|
| What | Blood in the ANTERIOR CHAMBER from injured vessels. Blunt or penetrating. CAN BE A SIGN OF OPEN GLOBE. |
| Symptoms | Blurred vision, eye pain, photophobia. |
| Measure the pressure | YES — UNLESS penetrating globe injury is suspected. |
| Whole goal of management | PREVENT A REBLEED. |
| Management | BED REST head elevated · ANTIEMETICS · ocular hypotensives · topical or oral CORTICOSTEROIDS · CYCLOPLEGIC drops (atropine, homatropine, scopolamine) · ORAL AMINOCAPROIC ACID (antifibrinolytic, slows clot breakdown). |
| THE TIMING FACT | MOST REBLEEDING IS IN THE FIRST 72 HOURS. Secondary hemorrhage is what causes PERMANENT visual loss. |
| Avoid | ASPIRIN and ANTIPLATELETS. Increased risk in SICKLE CELL DISEASE. |
| Raised pressure treated with | Beta blockers, PILOCARPINE, ACETAZOLAMIDE, osmotic agents if needed. |
| Term | What you need to know |
|---|---|
| Lid laceration — CONSULT OPHTHO IF | LID MARGIN · within 6–8 mm of the MEDIAL CANTHUS · LACRIMAL duct or sac · INNER lid surface · associated PTOSIS · TARSAL PLATE or LEVATOR. |
| Full-thickness lid laceration | Comes with a corneal laceration or GLOBE RUPTURE in about TWO THIRDS of cases. |
| Partial-thickness | Repair in the ED, ophtho follow-up in 2–3 days. |
| Medial third laceration | May transect the CANALICULAR system → CHRONIC TEARING FOR LIFE if not repaired properly. |
| Facial lacerations | May be left OPEN 24 HOURS before closure — the face is highly vascular. |
| ORBITAL CONTUSION | Swelling WITHOUT hemorrhage. Held IN FRONT of the septum by the tarsal plate and septal margin → PRESEPTAL ecchymosis. Supportive to surgery. RULE OUT BRAIN TRAUMA. |
| PERIORBITAL HEMATOMA | Bleeding WITHIN the orbit. NOT ALWAYS TRAUMATIC — eye surgery, peribulbar injections, orbital VARICES, lymphangiomas/AVM, ANTICOAGULANTS, SICKLE CELL, orbital pseudotumour, idiopathic. |
| Periorbital hematoma — treatment | CANTHOTOMY with CANTHOLYSIS — expose the lateral canthal tendon, cut its INFERIOR branch, let the blood out. |
| Term | What you need to know |
|---|---|
| Presentation (all) | CURTAIN or shadow descending · cloudy/smoky vision · FLOATERS · momentary FLASHES · monocular field defect · acuity drops when the MACULA goes. |
| Diagnosis & timing | History + DILATED EYE EXAM. Must be seen by ophtho WITHIN 24 HOURS. |
| RHEGMATOGENOUS | MOST COMMON. FULL-THICKNESS BREAKS + vitreous traction + liquefied vitreous into the subretinal space. Preceded by POSTERIOR VITREOUS DETACHMENT. → SURGICAL. |
| Rhegmatogenous — brought forward by | MYOPIA, CATARACT SURGERY, OCULAR TRAUMA. |
| TRACTION | Most commonly PROLIFERATIVE DIABETIC RETINOPATHY. More LOCALIZED and CONCAVE. → SURGICAL. |
| EXUDATIVE (serous) | NO break, NO traction. Systemic vascular/inflammatory disease or INTRAOCULAR TUMOR. → TREAT THE UNDERLYING CONDITION. |
| Acute management | Ophtho STAT, pain control, antiemetics, HEAD OF BED 30–40 DEGREES. |
| Term | What you need to know |
|---|---|
| Mechanism 1 — true blowout | Blunt object raises ORBITAL PRESSURE, blowing out the FLOOR (most often) or MEDIAL WALL. Fist or ball. |
| Mechanism 2 | Force to the INFRAORBITAL RIM buckles the floor. |
| THE GAZE RULE | DIPLOPIA ON UPWARD GAZE = INFERIOR RECTUS entrapment. DIPLOPIA ON LATERAL GAZE = MEDIAL RECTUS. |
| Other findings | Periorbital ecchymosis, lid edema, chemosis, subconjunctival hemorrhage, INFRAORBITAL NUMBNESS (infraorbital nerve), subcutaneous EMPHYSEMA, enophthalmos, proptosis. |
| Entrapment also gives | SEVERE PAIN + AUTONOMIC disturbance: BRADYCARDIA and VOMITING on attempted eye movement. |
| THE PEDIATRIC TRAP | “WHITE-EYED BLOWOUT” — entrapment with NO orbital soft tissue signs at all. A quiet-looking eye does not exclude it. |
| Diagnosis | CT of ORBITS and MIDFACE. |
| Management ladder | No injury/entrapment → ICE + analgesia, review 2–3 days. Blood in MAXILLARY SINUS → ANTIBIOTICS. True blowout → OPHTHO (30% have a significant globe injury). ENTRAPMENT → FACIAL TRAUMA SURGEON STAT (muscle NECROSIS). |
| WHY antibiotics for blood in the sinus | PROPHYLACTIC, not treatment. The eye is STERILE; blood in the sinus means the sinus is DISRUPTED and now has a PORTAL OF ENTRY. |
| WHY the CT includes the MIDFACE | To catch ADDITIONAL FRACTURES. Finding the orbital floor is not the same as excluding everything else. |
| Surgical timing | Often DELAYED 1–2 WEEKS to let swelling settle. Already-damaged optic nerve is unlikely to improve and surgery may worsen it. |
| Term | What you need to know |
|---|---|
| What | LINEAR fracture of the skull base: CRIBRIFORM PLATE of ethmoid, orbital plate of FRONTAL, PETROUS/SQUAMOUS TEMPORAL, SPHENOID, OCCIPITAL. |
| The catch | Trauma there often has NO SYMPTOMS of its own — you find it on INDIRECT SIGNS. |
| INDIRECT SIGNS | RACCOON EYES · BATTLE SIGN · HEMOTYMPANUM · bleeding into middle ear or sphenoid sinus · CSF LEAK with CLEAR or PINK RHINORRHEA. |
| TWO BEDSIDE TESTS FOR CSF | DEXTROSE STICK may be positive. Fluid on FILTER PAPER or the BEDSHEET shows a HALO / DOUBLE RING SIGN — INNER ring of BLOOD, OUTER ring of CSF. |
| HOW to do the halo test | Hold a BEDSHEET, paper or tissue under the nostril, let the drip fall, and watch it DRY. Two rings appear. She called this “very classic” and a sign NOT TO MISS. |
| Diagnosis | CT ORBITS — but the fracture is NOT ALWAYS EVIDENT. |
| Management | CSF present → NEUROSURGERY CONSULT and ADMISSION. Otherwise admission depends on clinical condition, associated injuries, brain injury on CT. |
| Antibiotics for a CSF leak | CONTROVERSIAL — risk of selecting RESISTANT organisms. |
| Term | What you need to know |
|---|---|
| FIBROUS (outer) | CORNEA — most of the FOCUSING POWER. SCLERA — shape + muscle attachment. |
| VASCULAR / UVEA (middle) | IRIS — controls pupil size. CILIARY BODY — makes AQUEOUS + accommodation. CHOROID — NOURISHES THE RETINA. |
| NEURAL (inner) | RETINA — rods and cones. MACULA — central vision. FOVEA — highest acuity. OPTIC DISC — blind spot. |
| Why the layer matters | UVEITIS is MIDDLE-layer, which is why it takes iris + ciliary body + choroid together. Scleritis/episcleritis OUTER. Occlusions and detachments INNER. |
| Term | What you need to know |
|---|---|
| JERK | SLOW phase + FAST phase. Named for the FAST beat. INCREASES with gaze TOWARD the fast phase. |
| Most common jerk form | HORIZONTAL — slow drift one way, quick snap back. |
| Horizontal jerk SUBTYPES | Normal PHYSIOLOGIC GAZE-EVOKED · INFANTILE · SPASMUS NUTANS · LATENT. |
| PENDULAR | BOTH phases EQUAL velocity and amplitude — NO fast phase. Most often HORIZONTAL. |
| Pendular context | CONGENITAL, or after PROLONGED BILATERAL BLINDNESS beginning in CHILDHOOD. |
| UPBEAT — the alarm | ALWAYS ABNORMAL. CEREBELLAR or MEDULLARY lesion; less commonly DRUG INTOXICATION. Present only on UPWARD gaze. |
| Term | What you need to know |
|---|---|
| MACULAR DYSTROPHIES mimicking AMD | STARGARDT (yellow-white FLECKS) · SORSBY (AUTOSOMAL DOMINANT, CNV like wet AMD) · NORTH CAROLINA (congenital, NON-progressive) · BEST / VITELLIFORM (LIPOFUSCIN mimics drusen). |
| The tell for all four | INHERITED, and they present YOUNGER than age-related degeneration. |
| LEUKOCORIA besides retinoblastoma | COATS' (retinal TELANGIECTASIA with exudation) · PERSISTENT FETAL VASCULATURE · TOXOCARIASIS (granulomatous) · RETINAL ASTROCYTOMA (glial, TUBEROUS SCLEROSIS) · MEDULLOEPITHELIOMA (nonpigmented ciliary epithelium) · CONGENITAL CATARACT · OCULAR TOXOPLASMOSIS. |
| UVEAL MELANOMA by site | IRIS (melanotic OR partly AMELANOTIC) · CILIARY BODY · CHOROID. |
| Two ciliary body signs | SENTINEL VESSEL (dilated episcleral vessel over the tumor) and EXTRASCLERAL EXTENSION. |
| IRIS NEVUS | INFERIOR half · does NOT typically grow · FLAT / under 1 mm · not vascular · may cause CORECTOPIA. Apparent around PUBERTY, ASYMPTOMATIC. |
| PIGMENTED IRIS differential | FRECKLE (flat, no stromal involvement) · LISCH NODULES (NF1) · MELANOCYTOMA (granular; secondary glaucoma from PIGMENT DISPERSION) · MELANOCYTOSIS (congenital, RAISES melanoma risk) · COGAN-REESE / ICE (corneal ENDOTHELIAL abnormality) · IRIS MELANOMA · METASTATIC CARCINOMA. |
| Pushes an iris lesion toward MELANOMA | INFERIOR location · DIFFUSE configuration · BLOOD in the anterior chamber. |
| NON-PIGMENTED CONJUNCTIVAL lesions | SQUAMOUS CELL CARCINOMA (gelatinous/LEUKOPLAKIC; mistaken for AMELANOTIC melanoma) · LYMPHOMA (SALMON-PINK, painless, fornix) · KAPOSI SARCOMA (reddish-purple, HIV/AIDS) · PYOGENIC GRANULOMA (rapidly growing red, after TRAUMA or SURGERY). |