How to use this
Every condition in the Exam 2 ophthalmology block that needs ophthalmology sooner than a routine clinic slot — 57 of them — sorted by how fast, with the finding that identifies it and the first thing to do. The tiers are the ones Professor Jaquith uses on the disposition slide, not a scheme invented for this page.
Checked slide by slide against all five decks. Where a lecture states an urgency, that is the tier. Where it says only “refer” and never says how fast, the row says so rather than inventing an interval — and where a deck gives two different answers in two places, both are printed. There are two of those, and they are the ones worth knowing about.
The order matters more than the list. Sections 1.1 to 1.4 are a triage sequence the lecture asks you to complete before naming a diagnosis; the condition tables are what that sequence sorts into. If you are revising against the clock, section 6 is the one that changes what you do at the bedside.
1 · Triage before diagnosis
Lecture 10 closes on six slides of pure triage. They are worth more than any single condition on this page, because they work on the red eye you cannot name yet.
1.1 · The first 60 seconds
Complete all of it before naming the diagnosis.
Visual acuity in each eyewith correction
Pupilsshape, reactivity, afferent defect
Extraocular movementsnote pain or restriction
Corneaclarity, and fluorescein staining
Injection and dischargethe pattern of each
The history that changes everythingcontact lenses, trauma, surgery, steroids
Reduced vision or an abnormal pupil is a red flag — and the whole list is meant to be completed before naming the diagnosis.
1.2 · Danger signs — this is not simple conjunctivitis
Any one of these means immediate or same-day evaluation.
- Moderate to severe pain, or consensual photophobia
- Reduced visual acuity, a relative afferent pupillary defect, or an abnormal pupil
- Corneal opacity, infiltrate, ulcer or dendrite
- Ciliary flush, hypopyon, or markedly elevated intraocular pressure
- Proptosis, diplopia, or painful or restricted eye movement
- Chemical exposure, penetrating trauma, or recent eye surgery
- A contact lens wearer with pain or photophobia
1.3 · Localize by pattern
| Where | What you see |
|---|---|
| Conjunctiva | Itch or discharge · diffuse injection · vision preserved |
| Cornea | Pain and photophobia · fluorescein defect, infiltrate or opacity |
| Anterior chamber | Consensual photophobia · ciliary flush · irregular pupil |
| Sclera or orbit | Deep pain, or painful eye movement · violaceous sclera, proptosis, restriction |
| Angle closure | Pain and headache with halos and nausea · cloudy cornea · mid-dilated pupil |
1.4 · The disposition ladder
The deck's own four tiers, and the examples it gives for each.
| Tier | When | Examples given |
|---|---|---|
| EMERGENT | now | Chemical injury (irrigate first), open globe, angle closure, orbital cellulitis, endophthalmitis |
| SAME DAY | today | Keratitis or corneal ulcer, anterior uveitis, scleritis, ocular herpes zoster |
| URGENT | within 24–48 hours | Unexplained decreased vision, persistent pain or photophobia, an atypical or worsening red eye |
| ROUTINE | in clinic | Uncomplicated conjunctivitis, or chronic eyelid and ocular-surface disease |
Common Ophthalmological Disorders, slides 66–70
2 · EMERGENT — now
25 conditions. These do not wait for a clinic list, and several of them are lost in minutes to hours: the central retinal artery is irreversible after 90 minutes, and hyphema rebleeds hardest in the first 72 hours.
| Condition | What gives it away | First move | Slides |
|---|---|---|---|
| Gonococcal conjunctivitisL10 | SEVERE purulent discharge WITH a palpable preauricular node · neonate | Newborn: hospitalize, systemic ceftriaxone once, specialty consultation. Untreated risk is corneal perforation. | Slides 40–41 |
| Post-septal (orbital) cellulitisL10 | THE EYE ITSELF IS RED · PROPTOSIS · painful restricted eye movement · diplopia · reduced vision | Hospitalize. Broad-spectrum intravenous antibiotics for 48–72 hours, then oral for at least a week. | Slides 51–53 |
| Corneal ulcerL10 | Patient RESISTS OPENING the eye · white spot on the cornea · contact lens wearer · ciliary flush | Broad-spectrum topical fourth-generation fluoroquinolone to start; agent-specific therapy then follows from ophthalmology.Slide 61 says emergent referral; the disposition slide groups “keratitis/corneal ulcer” under same day. The deck says both. | Slides 60–61 |
| Acute angle-closure glaucomaL12 | Severe pain + headache + vomiting · colored halos · hazy cornea | Topical pilocarpine or timolol, intravenous acetazolamide, then mannitol or isosorbide. Laser peripheral iridotomy 1–2 days after onset. | Slides 9, 13–14, 16–17, 20 |
| Retinal detachmentL12 | Flashes and floaters, then a curtain that STAYS · painless | Refer immediately. Surgery urgently, or within a week, depending on type. | Slides 25–30 |
| Central retinal artery occlusion (CRAO)L12 | Painless profound loss over SECONDS · CHERRY-RED SPOT | High-concentration inhaled oxygen and digital massage, intravenous acetazolamide, anterior chamber paracentesis; thrombolytic within 8 hours. Irreversible after 90 minutes. | Slides 36–40 |
| Branch retinal artery occlusion (BRAO)L12 | Painless loss of a WEDGE of field · sectoral pallor | As for the central form — the management does not change, only the size of the field lost. | Slides 41 |
| Arteritic AION (giant cell arteritis)L12 | Over 55 · NEW temporal headache · scalp tenderness, jaw claudication | Intravenous methylprednisolone for 3 days, then a slow oral taper. Do not wait for the biopsy. | Slides 47, 49–51 |
| PapilledemaL12 | BILATERAL swollen discs · headache, nausea, vomiting · INTRACRANIAL pressure | Neuroimaging first to exclude a mass, then lumbar puncture; treat the cause. The raised pressure is intracranial, not intraocular. | Slides 42–46 |
| Horner syndromeL11 | Ptosis + MIOSIS + anhidrosis · DILATION LAG | Treat the cause — but with neck pain, trauma or focal neurology it is carotid dissection until proven otherwise. | Slides 13, 15, 27–30 |
| Cranial nerve III palsyL11 | Ptosis + MYDRIASIS · impaired movement · pupil involved = STAT | A pupil-involving third is STAT — image for a posterior communicating artery aneurysm. | Slides 39–41 |
| Cataract — pediatricL13 | Zonular is commonest · leukocoria · may have nystagmus | Surgery is not deferred in a neonate — it is done early to prevent amblyopia. | Slides 36, 38 |
| RetinoblastomaL13 | LEUKOCORIA in a young child · white pupil in photographs | Ocular oncology, multimodal therapy, genetic counseling. An absent red reflex in a newborn is this or congenital cataract until proven otherwise. | Slides 41–42 |
| Open globe injuryL14 | Pupil pulled toward a wound · soft eye · massive hemorrhagic chemosis | Rigid shield taped over the eye, ophthalmology called immediately. Antiemetics and analgesia so the patient does not strain; tetanus. | Slides 14 |
| Full-thickness eye wall lacerationL14 | Sharp object or high-velocity projectile · entry ± exit wound | Shield and ophthalmology. Surgical repair — and posterior-segment foreign bodies are deliberately left alone at first. | Slides 15–16 |
| Globe ruptureL14 | Blunt trauma — airbag, fist, baseball · soft eye | Shield, ophthalmology immediately, antiemetics, analgesia, tetanus. Immediate surgical repair with wound exploration. | Slides 17 |
| HyphemaL14 | Blood layered in the anterior chamber after blunt trauma | Bed rest with the head elevated, antiemetics, ocular hypotensives, cycloplegic drops and oral aminocaproic acid. Rebleeding peaks in the first 72 hours. | Slides 24–25 |
| Lid lacerationL14 | Cut at the lid margin or within 6–8 mm of the medial canthus | Ophthalmology for margin involvement, within 6–8 mm of the medial canthus, the lacrimal system, the inner lid surface, ptosis, tarsal plate or levator.A partial-thickness laceration meeting none of those criteria can be repaired in the emergency department, with ophthalmology in 2–3 days. | Slides 26–27 |
| Periorbital hematomaL14 | Bleeding within the orbit · not always traumatic | Canthotomy with cantholysis — release the lateral canthal tendon and cut its inferior branch to let the blood out. | Slides 33 |
| Retinal detachment — rhegmatogenousL14 | Curtain descending · flashes and floaters · commonest type | Ophthalmology STAT and seen within 24 hours. Pain control, antiemetics, head of bed at 30–40 degrees. | Slides 35–36 |
| Retinal detachment — tractionL14 | Proliferative diabetic retinopathy · concave and localized | Surgical — and the diabetic control conversation that should have come years earlier. | Slides 39 |
| Orbital floor (blowout) fractureL14 | Diplopia on UPWARD gaze · infraorbital numbness · fist or ball | True blowout → ophthalmology, because 30% have a significant globe injury. Entrapment → facial trauma surgeon.Without eye injury or entrapment this is not emergent — ice, analgesia and follow-up in 2–3 days. Only a true blowout or entrapment escalates. | Slides 40–43 |
| Basilar skull fractureL14 | Raccoon eyes · Battle sign · clear or pink rhinorrhea | Cerebrospinal fluid leak → neurosurgery consult and admission. | Slides 44, 47 |
| Chemical injury | Any chemical exposure · the disposition slide lists it FIRST | Irrigate first — before acuity, before examination, before the referral call. | Slide 70 |
| Endophthalmitis | Inflammation of the WHOLE eye · what undertreated keratitis becomes | Ophthalmology now. It is what undertreated keratitis becomes, and it can cost the eye. | Slides 5, 56, 70 |
3 · SAME DAY
6 conditions — the deck names four of these on the disposition slide itself: keratitis or corneal ulcer, anterior uveitis, scleritis and ocular herpes zoster.
| Condition | What gives it away | First move | Slides |
|---|---|---|---|
| ScleritisL10 | SEVERE BORING pain, WORSE AT NIGHT, radiating to the face · VIOLACEOUS hue · vessels do NOT move | Systemic anti-inflammatories to begin; corticosteroids and immunomodulators for severe, necrotising, posterior or refractory disease. The sclera can perforate.Slide 50 says urgent referral; the disposition slide puts scleritis in same day. The deck says both. | Slides 49–50 |
| KeratitisL10 | Contact lens overwear · corneal opacification · “broken up” corneal light reflection · CILIARY FLUSH | Referral within 24 hours for slit lamp with fluorescein, and treat the underlying cause before it scars. | Slides 54–56 |
| Herpes simplex keratitisL10 | TRUE DENDRITE — tree-branching, elevated edges, TERMINAL END BULBS · younger patient · rash not dermatomal | Oral antivirals for 10 days. | Slides 57–59 |
| Herpes zoster keratitisL10 | PSEUDOdendrite — no branch pattern, no elevated edges, no end bulbs · older patient · dermatomal V1 rash respecting the midline | Oral antivirals for 10 days, ideally within 72 hours of the rash appearing. | Slides 57–59 |
| Anterior uveitis (iritis, iridocyclitis)L10 | CONSENSUAL photophobia · ciliary flush · irregular pupil stuck to lens or cornea · cells in the anterior chamber | Within 24 hours, because delay may cost vision. Non-infectious → topical corticosteroids. | Slides 62–63 |
| Age-related macular degeneration — wetL13 | Sudden worsening of a central blur · neovascular | Intravitreal anti-VEGF; thermal laser photocoagulation or photodynamic therapy. | Slides 11, 14 |
4 · URGENT — within 24–48 hours
26 conditions. The generic trigger, for anything not named below, is unexplained decreased vision, persistent pain or photophobia, or an atypical or worsening red eye.
Every neuro-ophthalmology condition follows the same pathway: History and physical examination → labs and imaging (head computed tomography or magnetic resonance imaging of the brain) if indicated → ophthalmology referral → the appropriate specialist: neurology, vascular surgery or neurosurgery.
| Condition | What gives it away | First move | Slides |
|---|---|---|---|
| DacryoadenitisL10 | Swelling over the LATERAL ONE THIRD of the UPPER lid · ipsilateral preauricular node | Inflammatory → corticosteroids. Cause unclear → empiric oral antibiotics, reassessed at 24 hours. | Slides 22–23 |
| DacryocystitisL10 | Swelling over the NASAL aspect of the LOWER lid, BELOW the medial canthal tendon · pus from the punctum | Well and afebrile → oral antibiotics 10 days. Febrile or ill → admit for intravenous therapy 48–72 hours. | Slides 24–25 |
| ChemosisL10 | Swelling of the conjunctiva itself · a sign, not a diagnosis | Treat the cause — but proptosis, restricted movement, reduced vision or an afferent defect alongside it makes this urgent. | Slides 31 |
| Chlamydial conjunctivitis — neonatalL10 | Neonate · maternal cervical infection · may also have pneumonia | Erythromycin 50 mg/kg/day in four divided doses for 14 days. | Slides 44 |
| TrachomaL10 | Poor sanitation · repeated childhood infections · scarred upper lid · lashes turned in | Azithromycin 1 g orally as a single dose. Trichiasis requires surgery. | Slides 45–46 |
| Pre-septal (periorbital) cellulitisL10 | Swollen red lid but THE EYE ITSELF IS WHITE · movements full and painless · vision normal | Mild → oral antibiotics 10–14 days. Admit if moderate-severe or toxic, unreliable, a child of 5 or under, or not improving. | Slides 51–53 |
| Posterior uveitis (choroiditis, retinitis)L10 | NO PAIN · floaters, scotomas, metamorphopsia · cells in the posterior vitreous · vitreous haze | Does not respond to topical treatment — may need an intraocular corticosteroid injection.The slide says only “refer to ophthalmology” — no interval — and notes it develops far more slowly than anterior uveitis. | Slides 64–65 |
| Amaurosis fugaxL12 | Transient monocular curtain · seconds to minutes · then full recovery | Treat it as a transient ischemic attack of the eye: stroke workup, carotid imaging, cardiac assessment, antiplatelets. | Slides 4–8 |
| Optic neuritisL12 | PAINFUL EYE MOVEMENT · loss of color vision · young woman | Corticosteroids if a demyelinating cause is found; two or more lesions → neurology or neuro-ophthalmology.The slide says “REFER to Optho” without stating how fast. | Slides 22–24 |
| Central retinal vein occlusion (CRVO)L12 | Painless loss · “BLOOD AND THUNDER” fundus | Urgent referral to restore flow, and evaluate the underlying disorder — hypertension, diabetes, hyperviscosity. | Slides 31–34 |
| Branch retinal vein occlusion (BRVO)L12 | Painless loss of PART of the field · sectoral hemorrhage | As for the central form, and treat the underlying disorder. | Slides 35 |
| Non-arteritic AIONL12 | 40–60 · painless · “disc at risk” · normal markers | Observation and cardiovascular risk factor modification — but the workup is identical to the arteritic form, because that must be excluded. | Slides 47–48, 50, 52 |
| Relative afferent pupillary defect (Marcus Gunn)L11 | Swinging flashlight → BOTH pupils DILATE on the bad eye | A sign, not a diagnosis — find the retinal or optic nerve disease behind it. | Slides 25–26 |
| Argyll Robertson pupilL11 | Small BILATERAL pupils · no light, brisk near | Treat the underlying syphilis. | Slides 19, 31–33 |
| Cranial nerve IV palsyL11 | VERTICAL binocular diplopia · head tilt AWAY from the bad eye | Traumatic: observe about 6 months before corrective treatment, patching one eye meanwhile. | Slides 42–43, 46 |
| Cranial nerve VI palsyL11 | HORIZONTAL binocular diplopia · failure of abduction | Traumatic: observe about 6 months, patching one eye in the interim. | Slides 44–46 |
| NystagmusL11 | Involuntary rhythmic oscillation · named for the FAST beat | Complete ophthalmic examination, then imaging, then labs. The etiology must be addressed.Who to refer, explicitly: infants and young children; nystagmus acquired in adolescence or adulthood; and non-physiologic nystagmus in adults — upbeat, monocular or asymmetric, or non-physiologic horizontal. | Slides 3–5 |
| Idiopathic intracranial hypertensionL13 | Overweight woman of childbearing age · pulsatile tinnitus · transient greyouts | Acetazolamide promptly, with a supervised weight reduction program. Surgery only if medical therapy fails.The referral carries no stated interval; it is the acetazolamide the slide says to start promptly. | Slides 4–5 |
| StrabismusL13 | Binocular diplopia — gone when either eye is covered | Ophthalmology, and treat the cause — untreated in a child it causes amblyopia. | Slides 25, 29 |
| AmblyopiaL13 | Commonest cause of vision loss in children · unequal eyes | Patch or atropinise the good eye to force the weaker one to work. Treatment works less well as visual maturity approaches. | Slides 30, 32–33 |
| Uveal melanomaL13 | Commonest eye cancer in adults · feeder vessel · usually found incidentally | Radiation therapy is now the commonest treatment; enucleation is needed less often. | Slides 44–46 |
| Conjunctival melanomaL13 | Raised and vascular pigmented conjunctival lesion | Specialist management under ocular oncology. | Slides 52–54 |
| Corneal abrasionL14 | Fingernail or contact lens · severe foreign body sensation | Topical broad-spectrum antibacterial, and periodic re-examination to confirm healing and exclude infection. | Slides 18 |
| Corneal or conjunctival foreign bodyL14 | Grinding or striking metal · vertical linear corneal scratches | Topical anesthetic, then a sterile 27-gauge needle. A rust ring comes out with a burr.Consult immediately instead if there is any concern the object passed through the cornea. | Slides 21–22 |
| Orbital contusionL14 | Peri-orbital swelling without hemorrhage | Supportive, through to surgery depending on the patient's condition. | Slides 31 |
| Retinal detachment — exudativeL14 | No break and no traction · systemic disease or a tumor behind it | Treat the underlying condition — this one is not primarily a surgical problem. | Slides 39 |
5 · Routine, until it is not
These are managed in clinic — until one of these triggers fires, and then they are not. This table is the one that catches people out, because the diagnosis does not change; only the disposition does.
| Condition | What changes it | Becomes | Slides |
|---|---|---|---|
| Bacterial conjunctivitis | Immunocompromised · contact lens wearer · recent eye surgery · foreign body · corneal opacity or suspicion of keratitis · no improvement in 24 hours | Urgent | Slide 41 |
| Bacterial conjunctivitis — newborn | Suspected gonococcal infection in a newborn — untreated risk is corneal perforation | EMERGENT | Slide 41 |
| Viral conjunctivitis | Longer than 3 weeks · photophobia or vision loss appearing after onset | Refer | Slides 36–37 |
| Episcleritis | No response in 2 days | Refer | Slides 47–48 |
| Chemosis | Proptosis · restricted movement · reduced vision · an afferent pupillary defect | URGENT | Slide 31 |
| Pterygium | Growing, or vision affected | Refer | Slides 27–28 |
| Chalazion / hordeolum | Chalazion recurrent, or persisting more than 2–3 months — refer to rule out sebaceous carcinoma · hordeolum not improving in 2 weeks · associated pre-septal cellulitis | Refer | Slide 21 |
| Blepharitis / meibomitis | Symptoms not improving after several weeks of lid hygiene | Refer | Slides 18–19 |
| Allergic conjunctivitis | Not settling as allergen levels fall — the disease may be unusually severe, or the diagnosis may be wrong | Refer | Slide 35 |
| Iris nevus | Any concerning feature — refer to rule out melanoma; ophthalmology may pass it to ocular oncology | Refer | Slide 49 |
| Pre-septal cellulitis | Moderate-severe or toxic · poor compliance · child aged 5 or under · no improvement on oral antibiotics | Admit | Slides 51–53 |
6 · Never do these
Every one of these is stated outright in a lecture, and every one of them is a way of making the eye worse while meaning to help.
Never dilate an eye when ocular trauma is suspected.The deck puts an exclamation mark on this one.Ocular Trauma, slide 6
Do not remove a penetrating object.Ensure tetanus is up to date, image, and leave it where it is.Ocular Trauma, slide 6
Computed tomography of the orbit without contrast — and no MRI.Metallic foreign bodies and magnets do not mix.Ocular Trauma, slide 6
Do not measure intraocular pressure if a penetrating globe injury is suspected.Pressing on an open eye can extrude its contents.Ocular Trauma, slide 25
Do not patch the contact lens wearer with a corneal defect.Remove the lenses, keep them if a culture is wanted, and arrange same-day review.Common Ophthalmological Disorders, slide 71
No take-home topical anesthetic, and no take-home corticosteroid.Repeated anesthetic is toxic to the epithelium and delays healing; steroids can worsen an infection that has not been identified yet.Common Ophthalmological Disorders, slide 71; Ocular Trauma, slide 18
Leave posterior-segment foreign bodies alone at the first evaluation.Going after one early risks more damage than the object itself.Ocular Trauma, slide 16
Do not wait for the temporal artery biopsy before starting steroids.In arteritic anterior ischemic optic neuropathy the delay costs the second eye.Acute Vision Loss, slides 49–51
7 · Check yourself
1. A contact lens wearer has severe pain, photophobia and blurred vision after sleeping in the lenses. Fluorescein shows a central epithelial defect with a white infiltrate. What are the next steps?
Remove the lenses and do not patch. No take-home topical anesthetic or corticosteroid. Same-day ophthalmology for microbial keratitis. Preserve the lenses and case in case a culture is requested.
2. Which conditions sit in the EMERGENT — now tier?
Five of them: chemical injury (irrigate first), open globe, angle closure, orbital cellulitis and endophthalmitis.
3. A patient over 55 has sudden visual loss, a new temporal headache and jaw claudication. What must not delay treatment?
The temporal artery biopsy. Start intravenous methylprednisolone; untreated, the second eye follows the first.
4. Which two findings on the first-60-seconds list are called red flags in their own right?
Reduced vision, and an abnormal pupil.
5. A child is struck in the eye with a ball and has severe pain, vomiting and bradycardia on attempted upgaze, but the eye looks quiet. What is this?
An orbital floor fracture with inferior rectus entrapment — the white-eyed blowout. The autonomic disturbance is the clue, and it needs a facial trauma surgeon.
6. What separates pre-septal from post-septal cellulitis at the bedside?
In pre-septal disease the eye itself is white, movements are full and painless, and vision is normal. Proptosis, painful or restricted movement, diplopia or reduced vision means post-septal — and that is emergent.