A

A 60
60 year
year old
old male
male tool
tool &
& die
die maker,
maker, who
who often
often
neglects
neglects to
to wear
wear eye
eye protection,
protection, was
was hammering
hammering aa
piece
piece of
of hardened
hardened steel
steel when
when he
he felt something
something hit
hit
his
his right
right eye.
eye. He
He had
had no
no visual
visual complaints,
complaints, but
but
his
his co-workers
co-workers noticed
noticed that
that below. His eye was
red,
red, so
so he
he came
came to
to see
see you.
you.
Examination
Examination revealed
revealed visual
visual acuity
acuity of
of 20/20
20/20 OU,
OU,
normal
normal visual
visual fields
fields to
to confrontation,
confrontation, pupils
equally
equally round and reactive, and normal
extraocular
extraocular movements.
movements. The
The cornea
cornea was
was stained
stained
with
with fluoroscein and no defect was seen. The
globe
globe showed
showed no
no evidence
evidence of a wound, but
but had
had the
the
appearance
appearance Dilated
Dilated ophthalmoscopic
ophthalmoscopic exam was
normal.
normal.

Hyphema
Conjunctivitis
Subconjunctival hemorrhage
None of the above

Hyphema is a term used to describe bleeding in the

anterior chamber (the space between the cornea and the
iris) of the eye. It occurs when blood vessels in the iris
bleed and leak into the clear aqueous fluid.

Conjunctivitis, commonly known as

pink eye, is an infection of the conjunctiva
(the outer-most layer of the eye that covers
the sclera). The three most common types
of conjunctivitis are: viral, allergic, and
bacterial.

Answer is :
Subconjunctival hemorrhage.

What would you do in this case?

X ray.

Ophthalmology referral.

Antibiotic ointment & pressure patch.

Pressure patch.

None of the above.

Answer is: X-RAY.

An
An x-ray
x-ray of
of the
the orbits
orbits is
is imperative
imperative if
if there
there is
is any
any
suspicion
suspicion of an
an intraocular
intraocular foreign
foreign body
body (IOFB).
(IOFB).
An
An entry
entry wound
wound is not always easily seen. When the
history
history involves metal hammering
hammering metal,
metal, as
as in
in this
this
case,
case, an
an IOFB
IOFB should always be suspected and an xray
ray should be done.
This
This CT
CT scan
scan clearly
clearly demonstrates aa metallic
metallic IOFB
in
in the
the right eye.
eye.

A 75 year old male complains of a

gradual onset of a "dark spot" in
the centre of his vision making it
difficult for him to read the paper.

What is the commonest cause of legal blindness

(visual acuity < 20/200) over the age of 65?

Cataract
Diabetic
Retinopathy
Macular Degeneration
Glaucoma

Age-Related Macular Degeneration (ARMD) is the

commonest cause of blindness over the age of 65.
Besides seeing a "dark spot", symptoms may include
distortion of vision (metamorphopsia), where objects
appear distorted in shape. An Amsler Grid (shown
below) tests for macular dysfunction. Tell the patient to
cover one eye and look at the dot in the centre and ask if
there are any wavy lines (metamorphopsia), or dark
spots (scotoma). Shown below is metamorphopsia due
to macular disease.
Examination
Examination revealed
revealed visual
visual acuity
acuity of 20/60 OU with
his
his glasses.
glasses. Visual field testing was normal to
confrontation.
confrontation. Amsler
Amsler Grid testing revealed a "dark
spot".
spot". Pupils
Pupils were
were equal
equal in
in size
size and
and reactivity
reactivity to
to
penlight.
penlight. Fundoscopy, which was similar bilaterally, is
shown:
shown:

A 64 year old, healthy female comes to the

emergency room complaining of a sudden,
painless loss of vision in her right eye (OD).
Physical examination revealed acuity of 20/20
OS, and 20/200 OD, visual field loss
superiorly, normal extraocular movements,
pupils of equal size but with a relative afferent
pupillary defect (RAPD) OD. Funduscopy
was normal OS, but showed a pale, swollen
disc OD (below).

What is the next step in this patient's

management?
Fluoroscein angiography
Erythrocyte sedimentation rate
Complete blood count
Immediate ophthalmology consult
All of the above
None of the above

Erythrocyte sedimentation rate

(ESR) - is the correct next step.
An ESR needs to be done urgently in any patient over the
age of 50 with sudden visual loss. Ophthalmology needs
to be consulted, but it is imperative that an ESR be
ordered immediately.
If the ESR is elevated what is your diagnosis?

Ischemic optic neuropathy

Optic neuritis
Central retinal artery occlusion
None of the above

Ischemic optic neuropathy (ION) - is the correct diagnosis.

The
The ION
ION in
in this
this case
case is
is a result of temporal arteritis
because
because the
the ESR is elevated.
elevated. If
If the ESR was normal, the
ION
ION is
is called
called anterior
anterior ischemic
ischemic optic
optic neuropathy
neuropathy
(AION).
(AION). Both
Both of
of these
these conditions
conditions lead
lead to
to aa pale,
pale, swollen
swollen
disc.
disc. Temporal
Temporal arteritis
arteritis is
is often
often preceded by polymyalgia
rheumatica
rheumatica (shoulder
(shoulder & pelvic
pelvic girdle
girdle pain,
pain, morning
morning
stiffness,
stiffness, fatigue,
fatigue, and
and elevated
elevated ESR).
ESR).
Twenty
Twenty percent of patients with
with polymyalgia
polymyalgia rheumatica
rheumatica
will
will go
go on
on to
to develop temporal arteritis (temporal
headache,
headache, tender
tender scalp,
scalp, jaw
jaw pain
pain when
when chewing,
chewing, and
and
elevated
elevated ESR).
ESR).
The
The symptoms
symptoms of
of temporal
temporal arteritis may
may not
not always
always be
be
present,
present, so
so an
an ESR
ESR should
should be
be done
done in
in all
all cases
cases of
of acute
visual
visual loss
loss in
in patients
patients over
over 50.
50. Temporal
Temporal arteritis is
unlikely
unlikely to occur in persons younger than 50.

A
A 35
35 year
year old
old female
female nursery
nursery school
school teacher
teacher comes
comes to
to
your
your office complaining of red, irritated eyes with
profuse
profuse watery
watery discharge
discharge of
of about
about 44 days
days duration.
duration.
Examination
Examination reveals
reveals visual
visual acuity
acuity of 20/20 OU, normal
visual
visual fields
fields to confrontation, equally round and
reactive
reactive pupils,
pupils, normal
normal extraocular movements,
movements, and
normal
normal appearing
appearing fundi
fundi OU.
OU.
On
On external
external exam
exam the conjunctiva is diffusely red
red and
and
follicles
follicles are
are noted
noted on
on the
the palpebral
palpebral conjunctiva
conjunctiva OU.
OU.

What is the likely diagnosis?

Allergic conjunctivitis
Bacterial conjunctivitis
Viral conjunctivitis
Acute glaucoma
Iritis

Conjunctivitis
Conjunctivitis is
is inflammation
inflammation of
of the
the transparent layer
(the
(the conjunctiva)
conjunctiva) that
that covers
covers the
the white
white of
of the
the eye.
eye. It
It can
can
cause
cause redness,
redness, discharge
discharge from
from the
the eye,
eye, swelling
swelling of
of the
the
eyelid,
eyelid, and sore or itchy eyes.
Allergic
Allergic conjunctivitis
conjunctivitis usually affects both eyes
eyes at
at the
the
same
same time,
time, and
and often
often causes
causes itchiness or a feeling
feeling of
of
grittiness
grittiness or burning.
burning.
Bacterial
Bacterial conjunctivitis usually begins in one eye
eye and
and
often
often spreads
spreads to
to the
the other. If a bacterial
bacterial infection
infection is the
cause,
cause, there
there may
may be
be some
some yellow
yellow pus-like
pus-like discharge
discharge
from
from the
the eye.
eye.
Viral
Viral conjunctivitis
conjunctivitis is
is more
more likely to cause a watery discharge that can be crusty in
the
the morning
morning but
but is
is not
not pus-like.
pus-like. Viral
Viral conjunctivitis
conjunctivitis usually begins in one eye then
then
affects
affects the
the other
other eye
eye within
within 24-48
24-48 hours.
hours. There
There may
may also
also be
be cold-like
cold-like symptoms,
symptoms,
such
such as
as fever
fever and
and aa sore
sore throat.
throat. Like
Like colds,
colds, the
the symptoms
symptoms tend
tend to
to get
get worse
worse over
over
the
the first
first few
few days,
days, and
and then
then gradually
gradually improve
improve over
over the
the next
next two
two to
to three
three weeks
weeks

Viral conjunctivitis - is correct.

Viral
Viral conjunctivitis
conjunctivitis is
is very
very contagious,
contagious, and
and is
is often
often
bilateral
bilateral because
because of its
its easy
easy spread.
spread. It
It is
is usually caused by
adenovirus,
adenovirus, and
and therefore
therefore is often preceded by fever and
pharyngitis.
pharyngitis.
Viral
Viral infections
infections of
of the
the external
external eye are often associated
with
with preauricular
preauricular adenopathy, which should be checked
for
for routinely
routinely in
in cases
cases of
of red
red eye.
eye. There
There is
is no
no viable
viable
medical
medical treatment.
Because
Because this
this condition
condition is
is so
so contagious,
contagious, the patient
patient should
should
be
be advised
advised to stay away from work
work for
for one week after
after the
the
onset
onset of symptoms. At home,
home, careful
careful hand
hand washing
washing
should
should be
be aa priority,
priority, and
and towels
towels should
should not
not be
be shared.
shared.
Antibiotics
Antibiotics are
are not
not appropriate
appropriate against
against aa viral
viral infection.
infection. In
In any
any case
case of "red
"red eye"
eye"
steroids
steroids should
should never
never be
be prescribed
prescribed without
without the
the advice
advice of
of an ophthalmologist
ophthalmologist
because
because of
of the
the serious,
serious, vision-threatening
vision-threatening side effects.

A 29 year old female aerobics instructor presents to

your office complaining of minor left eye (OS)
redness and discomfort. She says that there is no
significant discharge to speak of.
Her visual acuity is 20/20 OU, normal visual fields to
confrontation, normal extraocular movements, pupils
equally round & reactive, and fundi looked normal.
External exam demonstrated slight limbal redness
OS.

What is your diagnosis?

Corneal Abrasion
Keratoconjunctivitis sicca (dry eye)
Corneal ulceration
Herpes simplex keratitis
None of the above

Herpes simplex keratitis - is correct.

Herpes simplex keratitis can be confidently
diagnosed when a branching (dendritic) ulcer is
seen upon fluoroscein staining of the cornea.
Herpes simplex keratitis is a serious condition,
which if neglected can lead to permanent visual
loss. Therefore topical antiviral therapy
(acyclovir, or trifluridine/viroptic) should be
started early and the patient should be followed
by an ophthalmologist due to the threat to
vision.
The dendritic ulcer can advance to become confluent (amoeboid
ulceration). Deeper layers of the cornea can become involved and
lead to corneal edema (disciform keratitis). Deeper invasion may
also lead to uveitis (kerato-uveitis).

Blindness in art

'La Celestina' - by Pablo Picasso - towards the end of his

blue period (1901-1904). Celestina was a notorious
procuress from a 15th century Spanish play.

A 10 year old boy presents to you with a 3

day history of lid redness.
Examination reveals acuity of 20/20 OU,
pupils equally round and reactive, normal
visual fields, normal extraocular movements
and normal fundoscopy.

What is the likely diagnosis?

Orbital tumor
Bacterial conjunctivitis
Orbital cellulitis
Preseptal (lid) cellulitis
None of the above

The
The infection
infection is confined to the eyelids because the
orbital
orbital septum
septum prevents
prevents the
the infection
infection from
from moving back
back
into
into the
the orbit (hence, preseptal cellulitis). The
The orbital
septum
septum is
is aa barrier,
barrier, which separates
separates the lid structures
structures
from
from the
the posterior
posterior orbit.
orbit.
This
This CT
CT scan,
scan, which
which is
is not routinely
routinely done
done in these cases,
demonstrates
demonstrates only
only swelling
swelling of
of the
the left
left lid,
lid, with
with no
no
proptosis
proptosis or
or orbital involvement.
involvement.

The
The following
following table compares orbital cellulitis & preseptal cellulitis:
cellulitis:
ORBITAL
ORBITAL CELLULITIS
CELLULITIS
Location
Location
Proptosis
Proptosis
Eye
Eye movements
Visual
Visual acuity
acuity
Orbital
Orbital pain
pain

orbit
orbit
present
present
decreased
possibly
possibly decreased
present
present

PRESEPTAL
PRESEPTAL CELLULITIS
CELLULITIS
eyelids
absent
normal
normal
normal
absent

Preseptal cellulitis -is correct

Oral antibiotics are used for preseptal
cellulitis
Oral antibiotics can be used on an outpatient
basis, since the orbit is not involved.
However, close follow-up is important to see
that it is resolving, and also because early in
the infection it is sometimes difficult to
distinguish preseptal cellulitis from orbital
cellulitis.

A
A 52 year
year old
old healthy
healthy female
female presents
presents to
to your
your office
office
with
with a 4 day history
history of
of flashing
flashing lights
lights (photopsia)
(photopsia)
and
and floaters
floaters in
in her
her left
left eye
eye (OS).
(OS). She
She also
also
complains
complains of
of aa curtain-like
curtain-like defect
defect in
in her
her field
field of
of
vision
vision OS.
OS.
On
On examination
examination her visual acuity is 20/20
bilaterally.
bilaterally. Visual
Visual field
field testing by confrontation
confrontation
was
was normal
normal OD,
OD, but there was a nasal defect OS.
Pupils
Pupils were of equal size and constricted equally to
light.
light. Funduscopy
Funduscopy was
was normal
normal OD
OD and
and had
had the
the
following
following appearance
appearance OS.
OS.

What is your diagnosis in this case?

scintillating scotoma of migraine
vitreous detachment
retinal detachment
none of the above

A
A posterior vitreous detachment (PVD) is a condition of
the
the eye
eye in
in which
which the
the vitreous
vitreous humor
humor separates
separates from
from the
the
retina.
retina.
The
The vitreous
vitreous humor
humor fills
fills the
the eye
eye behind
behind the
the lens.
lens. At
At birth
birth
itit is
is attached
attached to
to the
the retina.
retina. At
At some
some stage
stage the
the vitreous
vitreous
may
may peel away from the retina.
retina. This
This is usually
usually aa sudden
sudden
event.
event. When
When this
this occurs
occurs there
there is
is aa characteristic
characteristic pattern
pattern
of
of symptoms:
symptoms: flashes of light (photopsia) a sudden
dramatic
dramatic increase in the number of floaters a ring of
floaters
floaters or
or hairs
hairs just
just to the temporal side of the
the central
central
vision
vision aa slight
slight feeling
feeling of
of heaviness
heaviness in
in the
the eye
eye sometimes
sometimes
accompanied
accompanied by slight nausea similar to very mild shock
..

Floaters
Floaters are
are deposits
deposits of
of various
various size,
size, shape,
shape,
consistency,
consistency, refractive index, and motility within the
eye's
eye's normally
normally transparent
transparent vitreous humor.
humor. They
They may
be
be of
of embryonic
embryonic origin
origin or
or acquired
acquired due
due to
to
degenerative
degenerative changes
changes of
of the
the vitreous
vitreous humour
humour or
or retina.
retina.

The
The typical
typical history
history for
for retinal
retinal detachment
detachment includes
flashing
flashing lights
lights (phtotopsia), dark specks (floaters) and a
curtain-like
curtain-like visual
visual defect.
defect. If
If the
the detachment
detachment involves
involves
the
the macula,
macula, visual
visual acuity
acuity will be reduced with a relative
afferent
afferent pupillary defect (RAPD).
In
In retinal
retinal detachment the retina appears elevated, or
ballooning
ballooning forward,
forward, sometimes
sometimes with
with obvious
obvious folds.
folds.
Because
Because of
of this elevation, you will not be able to
simultaneously
simultaneously focus
focus clearly
clearly on
on the
the vessels
vessels of
of both
both the
the
attached
attached &
& detached retina (as can be clearly seen
above).
above).
A
A retinal
retinal detachment
detachment actually
actually represents
represents the
the separation
separation
of
of the
the sensory retina from the underlying
underlying retinal
retinal
pigment
pigment epithelium (RPE). Fluid accumulates
accumulates in
in the
potential
potential space
space between these
these two
two layers.
layers.

Retinal detachment- is correct.

Most detachments are associated with a defect
in the retina. This retinal hole/tear allows fluid
to pass between the sensory retina and the
RPE. These holes are usually the result of
vitreous traction, where shifting of the vitreous
causes a tear in the delicate sensory retina. An
example of a classic horseshoe-shaped tear is
seen below.
Retinal detachments secondary to a retinal
hole/tear are termed rhegmatogenous (rhegma =
hole in Greek) detachments.
Nonrhegmatogenous detachments are less
common and can result from tumors (e.g.
malignant melanoma, metastatic from breast &
lung), or eye inflammation (e.g. scleritis).

You are called to see a 63 year old hypertensive,

type II diabetic male, who complains that he has
been progressively losing vision in his left eye
(OS) over the past 2 days.
His visual loss is completely painless. On
examination his visual acuity is 20/20 OD and
20/200 OS (pinhole). Funduscopy appeared
normal OD, but had the following appearance
OS:

What is your diagnosis?

Background diabetic retinopathy

Proliferative diabetic retinopathy
Central retinal vein occlusion
Central retinal artery occlusion
None of the above

Presentation of CRV occlusion is with a

profound, but gradual, visual loss over hours
to days. CRV occlusion typically occurs in
older individuals, who have a history of
hypertension, and/or diabetes, and/or
generalized atherosclerotic vascular disease.
The mechanism of the occlusion is usually
thought to be due to compression of the central
retinal vein secondary to adjacent arterial
disease.
The fundoscopic appearance is sometimes described as "blood and
thunder" or "ketchup" retina. You can see widespread retinal
hemorrhages, dilated retinal veins, cotton-wool spots, and disc
swelling.

CRA occlusion presents as a painless,

monocular visual loss that occurs suddenly (as
opposed to CRV occlusion, where visual loss
occurs more gradually).
As in this case, the retina typically appears pale
with a cherry-red spot in the foveal area. Pallor
occurs because ischemia causes the nerve fiber
layer of the retina to become edematous making
it difficult to see the underlying colour of the
retinal pigment epithelium and the choroid.
The cherry-red spot is present because the
retina is thinnest over the fovea (remember the
fovea is a pit) and the underlying choroidal
circulation is, therefore, still visible.

Central retinal vein (CRV)

occlusion - is correct.
Emergency referral to an ophthalmologist is not
appropriate because there is nothing that an
ophthalmologist can do to speed recovery. Time will
allow hemorrhages and disc swelling to resolve and
recovery of sight may be complete.
Every case should undergo a future (1) medical
screening, and (2) ophthalmologic assessment.
The
The purpose
purpose of
of the
the medical
medical screening
screening is
is to
to diagnose and
and establish
establish control
control over
over
factors
factors that
that can
can lead to CRV occlusion, such as hypertension, diabetes,
hypercholesterolemia,
hypercholesterolemia, atherosclerosis,
atherosclerosis, or
or various conditions that lead to altered
altered blood
blood
viscosity
viscosity (polycythemia
(polycythemia rubra vera, sickle cell anemia, malignancy, etc.).
The
The purpose
purpose of
of the
the ophthalmologic
ophthalmologic assessment
assessment is
is primarily
primarily intended
intended to
to rule
rule out
out aa
late
late complication
complication of
of CRV
CRV occlusion,
occlusion, which
which occurs
occurs about
about 33 months
months after
after presentation.
presentation.

Sketches by Leonardo da Vinci showing projection of the eye to

the brain (note the inaccuracy of showing eye being connected
to the ventricles).

A 33 year old mother came to your office

complaining that her eye has been painful, light
sensitive, and tearing ever since her baby poked her
in the eye with his finger.
To properly examine the eye, you had to instill a
drop of topical anesthetic (proparacaine 0.5%)
because of blepharospasm. Visual acuity was 20/20
OU. Visual fields, pupil exam, extraocular
movements, and funduscopic exam were all normal.
External exam with fluoroscein is shown here.

What is your diagnosis?

Herpes simplex keratitis
Corneal abrasion
Corneal ulcer
Conjunctivitis

The abrasion can be seen

extending from the centre of the
pupil to about the 1:00 position
on the cornea.

Corneal abrasion - is correct.

A 40 year old with a history of type I diabetes

and hypertension comes to your office for a
regular checkup.

His visual acuity is 20/50 OU. His

funduscopic examination, which is similar
bilaterally, is pictured here.
What is your diagnosis based on the
funduscopic appearance?
Hypertensive retinopathy
Malignant hypertension (papilledema)
Optic neuritis
Non-proliferative diabetic retinopathy
Proliferative diabetic retinopathy

Symptoms of diabetic retinopathy

may include:
"Spiders," "cobwebs" or tiny specks
floating in your vision. Dark streaks
or a red film that blocks vision.
Vision loss or blurred vision. A dark
or empty spot in the center of your
vision. Poor night vision. Difficulty
adjusting from bright light to dim
light.

Nonproliferative diabetic retinopathy (NPDR). This

type, also called background diabetic retinopathy, is an
early stage of the disease. It's the most common type of
retinopathy, and symptoms are often mild or
nonexistent.
In NPDR the walls of blood vessels in the retina
weaken. Tiny bulges called microaneurysms protrude
from the walls of the small vessels in the retina.
Clinically
Clinically significant
significant macular
macular edema
edema (CSME)
(CSME) is
is aa condition
condition of
of swelling
swelling of
of the
the
macula
macula related
related to the development of leaky capillaries and microaneurysms. This
condition
condition may
may or
or may
may not
not be
be associated
associated with
with reduced
reduced or
or distorted
distorted vision.
vision.
Ophthalmologists
Ophthalmologists use
use rather strict
strict criteria
criteria to
to determine
determine whether
whether aa patient
patient should
should
be
be treated
treated with
with focal
focal laser
laser photocoagulation
photocoagulation for
for this condition. These criteria
were
were set
set forth
forth by
by the
the studies
studies mentioned
mentioned above.
above.

Proliferative diabetic retinopathy (PDR)

carries the greatest risk of visual loss of
the conditions discussed thus far. The
condition is characterized by the
development of neovascularization (new,
abnormal vessel growth) on or adjacent to
the optic nerve and vitreous or pre-retinal
hemorrhage (hemorrhage in the vitreous
humor or in front of the retina).
The neovascular vessels are abnormal and have a tendency to break
and bleed into the vitreous humor of the eye. In addition to sudden
vision loss, this may lead to more permanent complications, such as
tractional retinal detachment and neovascular glaucoma

Proliferative diabetic
retinopathy - is correct.

Urgent ophthalmology referral is required

The ophthalmologist will perform
panretinal laser photocoagulation to
reduce the oxygen requirements of the
retina, thereby removing the stimulus for
further neovascular growth.

A patient with a history of chronic bacterial

sinusitis presents to the emergency department
with a very severe headache. While waiting to
be seen, he develops a generalized grand mal
seizure. Physical examination, after the seizure
is over, demonstrates high fever, exophthalmos,
papilledema, and nerve palsies of the VI and III
cranial nerves on one side.
Which of the following is the most appropriate next step?
Admit
Admit to
to the
the medical
medical floor for
for monitoring of progression of symptoms.
Emergency
Emergency CT
CT scan.
scan.
Emergency
Emergency exploratory
exploratory surgery.
Emergency
Emergency ultrasound.
ultrasound.
Keep
Keep in
in emergency
emergency department
department for
for monitoring
monitoring of
of progression
progression of
of symptoms.
symptoms.

The correct answer is - Emergency

CT scan.
This
This is
is the
the way
way that
that cavernous
cavernous sinus
sinus thrombosis
thrombosis presents.
presents.
This
This condition
condition is
is due
due to
to aa septic
septic thrombosis
thrombosis that can
can
complicate
complicate chronic
chronic bacterial
bacterial sinusitis.
sinusitis. Meningitis
Meningitis is
is
another
another significant
significant possibility.
possibility. Lumbar
Lumbar puncture
puncture is
is
dangerous
dangerous in
in aa patient
patient with increased
increased intracranial
intracranial pressure,
pressure,
as
as indicated
indicated by
by the
the papilledema.
papilledema. Emergency
Emergency CT scan of
the
the cavernous
cavernous sinus, air sinuses, orbit, and brain is
warranted.
warranted. Additionally, cultures
cultures of
of blood
blood and
and any
any nasal
nasal
discharge
discharge are warranted; Gram's stain
stain of
of the
the nasal
nasal
discharge
discharge may give a preliminary indication
indication of
of the
causative
causative organism. High dose intravenous antibiotics
antibiotics are
are
started,
started, and
and then
then altered,
altered, if
if necessary, when culture results
are
are reported.
reported. Cavernous
Cavernous sinus
sinus thrombosis
thrombosis has
has aa 30%
30%
mortality
mortality rate, even when prompt, appropriate medical
care
care is
is given.
given.

A
A young mother is
is at
at the
the pediatrician's
pediatrician's office
office for
for a
routine
routine well-baby
well-baby visit for her 18-month-old son. It is
immediately
immediately noticed
noticed that
that one
one of
of the
the baby's pupils is
white,
white, while
while the
the other
other one is black. When asked about
it,
it, the
the mother
mother relates
relates that
that she saw that
that curious
curious
situation
situation for the first time 1 week ago,
ago, but
but since
since the
the
baby
baby was
was otherwise
otherwise asymptomatic,
asymptomatic, she did not think
itit merited
merited special
special attention. Which of the following is
the
the most
most appropriate
appropriate course
course of
of action?
action?

A. Do nothing, this is a normal anatomic variant.

B. Inquire if the father is an albino, and do appropriate genetic
counseling.
C. Seek an ophthalmologic consultation for suspected congenital
cataract.
D. Seek an emergency ophthalmologic consultation for possible
retinoblastoma.
E. Treat the child with antibacterial eye drops and re-check in 2 weeks.

The
The correct
correct answer
answer is:
is: Seek an emergency
emergency
ophthalmologic
ophthalmologic consultation
consultation for
for possible
possible
retinoblastoma.
retinoblastoma.
A newly
newly developed
developed white
white pupil in a child raises the
possibility
possibility of
of retinoblastoma.
retinoblastoma. This
This tumor
tumor is so deadly that
immediate
immediate diagnosis
diagnosis and
and treatment
treatment are
are imperative.
imperative.
Ignoring
Ignoring the
the finding
finding (choice
(choice A)
A) could prove to
to be
be lethal,
lethal,
and
and the
the same
same can be said for any delays caused by
pursuing
pursuing bizarre
bizarre considerations,
considerations, such
such as
as looking
looking for
for
albinos
albinos in
in the family
family (choice
(choice B)
B) or
or treating
treating for
for an
an eye
eye
infection
infection that
that is
is not
not there (choice E). It could be argued
that
that if
if an
an ophthalmologic
ophthalmologic consultation
consultation is
is obtained,
obtained, even
even if
if
itit is
is for aa wrong
wrong diagnosis
diagnosis (choice
(choice C),
C), the
the true
true nature
nature of
of
the
the problem
problem will
will eventually be
be recognized.
recognized. But
But an
an
appointment
appointment to check for cataracts
cataracts (which
(which would
would have
have
been
been present
present since birth) will not be made with the same
urgency
urgency that
that the situation requires.

Ocular examination is performed on a patient

during a routine medical check up. Retinal
examination demonstrates a generalized
retinal arteriolar constriction. The light reflex
on the arterioles is broad and dull. Two areas
of flame-shaped hemorrhages and multiple
cotton wool spots are also seen. These
findings are most suggestive of which of the
following?
A. Central retinal artery occlusion
B. Central retinal vein occlusion
C. Hypertensive retinopathy
D. Non-proliferative diabetic retinopathy
E. Proliferative diabetic retinopathy

The
The correct
correct answer is:
is: The
The changes
changes
illustrated
illustrated are
are those of hypertensive
retinopathy,
retinopathy, and
and may
may additionally
additionally include
include
yellow
yellow hard
hard exudates
exudates (due
(due to
to lipid
lipid deposition
deposition
in
in the
the retina)
retina) and
and a
a congested
congested and
and edematous
edematous
optic
optic disk.
disk. Basically,
Basically, what
what happens
happens is
is that
that the
the
eye
eye tries to
to protect
protect itself
itself from
from the
the
hypertension
hypertension first with arteriolar constriction,
and
and then
then with
with time,
time, thickening
thickening of
of the
the arteriolar
arteriolar
walls
walls (producing
(producing the
the broad
broad light
light reflex).
reflex). The
The
cotton
cotton wool
wool spots
spots are actually small,
superficial
superficial foci of retinal ischemia, which
which occur
occur
when
when the
the arterioles
arterioles squeeze
squeeze down
down too
too hard.
hard.
The
The hemorrhage
hemorrhage and
and deposits
deposits occur
occur because
because
of
of vessel
vessel damage
damage with
with leakage
leakage of
of contents.
Hypertensive
Hypertensive retinopathy
retinopathy can be seen in
chronic
chronic essential
essential hypertension,
hypertension, malignant
hypertension,
hypertension, and toxemia of pregnancy.
Treatment
Treatment of
of the
the retinopathy
retinopathy is
is with
with control
control of
of
the
the hypertension.
hypertension. (Practically, progression can
can
be
be stopped
stopped and the hemorrhages will
will resolve,
resolve,
but the vessel changes remain.)

A 73-year-old obese woman comes to the

emergency department because of a painful
right eye. The pain came on suddenly as she
was preparing dinner, and was accompanied by
severely blurred vision, nausea, and one episode
of vomiting. Examination shows an extremely
tender eye with a hazy cornea and a partially
dilated and fixed pupil. The left eye is normal.
Which of the following is the most likely
diagnosis?
A. Acute conjunctivitis.
B. Acute glaucoma.
C. Optic neuritis.
D. Pseudotumor cerebri.
E. Retinal detachment.

Optic
Optic neuritis
neuritis is
is an
an inflammatory
inflammatory disease
disease of
of the
the
optic
optic nerve.
nerve.
The
The typical
typical patient
patient is aa young
young woman
woman with
with aa rapid
rapid
onset
onset of
of painful
painful loss
loss of vision.
Papilledema
Papilledema is
is present.
present. Many
Many patients
patients later
later
develop
develop multiple
multiple sclerosis.
Pseudotumor
Pseudotumor cerebri is characterized by papilledema caused by
idiopathic
idiopathic intracranial
intracranial hypertension.
hypertension. Most
Most patients
patients are
are young,
young,
obese
obese females with severe headaches and vomiting. The treatment
is
is carbonic
carbonic anhydrase
anhydrase inhibitors.
inhibitors. The
The worst
worst complication
complication is
is
blindness.
blindness.
Retinal
Retinal detachment
detachment is a characterized by a unilateral, painless loss
of
of vision.
vision. It
It is
is often described as a "curtain" coming
coming down
down over
over one
one
eye.
eye. Funduscopic examination reveals a gray retina "floating"
within
within the
the vitreous
vitreous humor. This is described as a gray cloud.

This
This patient
patient has acute glaucoma,
glaucoma, which
which is
is an
an emergency
emergency
brought
brought on
on by
by increased
increased intraocular
intraocular pressure.
pressure. It
It is
is
characterized
characterized by a rapid onset of severe pain and blurry
vision
vision in
in one
one eye.
eye.
"Halos"
"Halos" are
are often seen around lights, and
and nausea
nausea and
and
vomiting
vomiting may
may be
be present.
present. A
A "steamy"-appearing
"steamy"-appearing cornea
cornea
and
and aa dilated
dilated and
and nonreactive
nonreactive pupil are seen. The eye is
tender
tender and "hard" when palpated.
Emergency
Emergency treatment
treatment includes
includes carbonic
carbonic anhydrase
anhydrase
inhibitors
inhibitors or
or mannitol in conjunction with topical beta
blockers
blockers to
to reduce
reduce intraocular
intraocular pressure.
Laser
Laser iridectomy
iridectomy is
is performed
performed when intraocular
intraocular pressure
pressure
is
is under control. The
The worst
worst complication
complication of
of glaucoma
glaucoma is
is
blindness.
blindness.

Glaucoma
Glaucoma is
is aa group
group of
of diseases
diseases that
that can
can damage the eye's
optic
optic nerve
nerve and
and result
result in
in vision
vision loss
loss and
and blindness.
blindness.
Glaucoma
Glaucoma occurs
occurs when
when the normal fluid
fluid pressure
pressure inside
inside
the
the eyes
eyes slowly rises.

Open-angle
Open-angle glaucoma is
is the most common form. Some people
have
have other types of the disease.
Low-tension
Low-tension or
or normal-tension
normal-tension glaucoma. Optic nerve damage
and
and narrowed side vision occur in people with normal eye
pressure.
pressure. Lowering eye pressure at least 30 percent through
medicines
medicines slows
slows the
the disease
disease in
in some
some people.
people. Glaucoma
Glaucoma may
may
worsen
worsen in
in others
others despite
despite low
low pressures.
pressures.
Angle-closure
Angle-closure glaucoma.
glaucoma. The
The fluid
fluid at
at the
the front
front of the
the eye
eye cannot
cannot
reach
reach the
the angle
angle and
and leave
leave the
the eye.
eye. The
The angle
angle gets
gets blocked
blocked by
by
part
part of the iris. People with this type of glaucoma have a
sudden
sudden increase
increase in
in eye
eye pressure.
pressure. Symptoms
Symptoms include
include severe
pain
pain and
and nausea,
nausea, as
as well
well as
as redness
redness of
of the
the eye
eye and
and blurred
blurred
vision.
vision. If
If you
you have
have these
these symptoms,
symptoms, you need to seek
treatment
treatment immediately.

Congenital glaucoma. Children are born with a defect in the

angle of the eye that slows the normal drainage of fluid. These
children usually have obvious symptoms, such as cloudy
eyes, sensitivity to light, and excessive tearing. Conventional
surgery typically is the suggested treatment, because
medicines may have unknown effects in infants and be difficult
to administer. Surgery is safe and effective. If surgery is done
promptly, these children usually have an excellent chance of
having good vision.
Secondary glaucomas. These can develop as complications
of other medical conditions. These types of glaucomas are
sometimes associated with eye surgery or advanced
cataracts, eye injuries, certain eye tumors, or uveitis (eye
inflammation).
Pigmentary glaucoma occurs when pigment from the iris
flakes off and blocks the meshwork, slowing fluid drainage. A
severe form, called neovascular glaucoma, is linked to
diabetes. Corticosteroid drugs used to treat eye inflammations
and other diseases can trigger glaucoma in some people.
Treatment includes medicines, laser surgery, or conventional
surgery.

Some
Some people
people with
with glaucoma
glaucoma use
use marijuana
marijuana because
because
research
research has
has found
found that
that itit has
has aa small
small effect
effect in
lowering
lowering intraocular
intraocular pressure.
pressure. However,
However, no
no research
research
has
has found
found that
that marijuana
marijuana is anywhere
anywhere near
near as effective
as
as legal
legal glaucoma
glaucoma medications,
medications, and
and the
the American
American
Academy
Academy of Ophthalmology,
Ophthalmology, among
among others,
others, says
says the
the
risky
risky side
side effects
effects of
of marijuana
marijuana far
far outweigh
outweigh any
benefit.
benefit.
Popular
Popular opinion
opinion persistently
persistently exaggerates the benefit of
of
marijuana
marijuana for
for glaucoma,
glaucoma, which
which is
is unfortunate
unfortunate because
because
people
people who use
use marijuana
marijuana instead
instead of
of their
their prescribed
prescribed
glaucoma
glaucoma medication
medication run a big risk of losing their
vision.
vision.

One
One week
week after
after an upper
upper respiratory infection,
infection, an
an adult
adult
develops
develops conjunctival
conjunctival hyperemia,
hyperemia, watery discharge, and
ocular
ocular irritation. While both eyes are involved by the
time
time aa physician
physician was
was consulted,
consulted, the
the symptoms
symptoms began
began in
in
one
one eye.
eye. On
On the
the morning
morning of
of the
the doctor's
doctor's visit,
visit, the
the patient
patient
had
had difficulty opening
opening his
his eyelids
eyelids on
on awakening
awakening as
as they
were
were "glued
"glued shut".
shut". Physical
Physical examination
examination demonstrates
demonstrates
hyperemic
hyperemic bulbar
bulbar and tarsal conjunctivae.
conjunctivae. No
No purulent
purulent
fluid
fluid is seen.
seen. The
The preauricular
preauricular lymph
lymph node
node on
on one
one side
side is
is
enlarged.
enlarged.

Which of the following pathogens would be

most likely to cause these symptoms?
A. Adenovirus.
B. Herpes simplex I.
C. Herpes simplex II.
D. Neisseria gonorrhoeae.
E. Staphylococcus aureus.

Herpes virus can cause corneal ulceration,

hyperkeratosis, or scarring.
Neisseria gonorrhoeae can cause conjunctivitis
in both adults and neonates, and produces a
purulent, rather than a watery discharge.
Staphylococcus aureus is a common cause of
bacterial conjunctivitis, and produces a
purulent, rather than a watery discharge.

This
This is
is viral
viral conjunctivitis, which is an acute conjunctival
inflammation
inflammation most
most often
often caused
caused by
by adenovirus.
adenovirus. Most
Most of
of
the
the patients
patients with
with this
this condition have either been recently
exposed
exposed to
to someone with
with viral
viral conjunctivitis
conjunctivitis or
or have
have
recently
recently had
had aa viral upper respiratory infection.
The
The presentation
presentation illustrated
illustrated in
in the
the question
question stem
stem is
is typical.
typical.
Severe
Severe cases
cases also
also additionally
additionally have
have photophobia
photophobia and
and aa
foreign
foreign body
body sensation.
sensation. Pseudomembranes of fibrin and
inflammatory
inflammatory cells
cells on
on the
the conjunctival
conjunctival surfaces
surfaces can
can occur.
occur.
Corneal
Corneal involvement
involvement can
can leave
leave residual
residual scarring visible by
by
slit
slit lamp
lamp for up to 2 years after a severe case. Cases are
self-limited
self-limited but tend to be extremely contagious, so care
should
should be
be taken
taken to have both the patient and the physician
physician
wash
wash their
their hands
hands very
very thoroughly
thoroughly after
after touching
touching the
the face.
face.

Bacterial.

In
In general
general use
use antibiotic
antibiotic therapy
therapy
Trimethroprim/polymyxin
Trimethroprim/polymyxin 44 times
times aa day
day
Ciprofloxacin
Ciprofloxacin drops 4 times a day
Erythromycin
Erythromycin ointment 4 times aa day
day for
for 55 to 7 days.
days.

Viral (most
(most common is adenovirus)

Artificial
Artificial tears
tears 4-8
4-8 times
times aa day
day
Cool
Cool compresses
Frequent
Frequent hand
hand washing
washing
Very
Very contagious
contagious isolate
isolate for
for 10-12
10-12 days
days

Herpes simplex

Antiviral
Antiviral therapy
therapy trifluorothymidine 1 % drops 5
times
times aa day
day
Cool
Cool compresses

THE END