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PD Lec 4-Eyes
| Question | Answer |
|---|---|
| opening btw eyelids | palpebral fissue |
| clear mucous membrane | conjunctive |
| covers most of anterior eyeball and adheres loosely to underlying tissue- meets cornea at limbus | bulbar conjunctiva |
| conjunctiva that lines the eyelids- two parts meet in a folded recess permitting movement of eyeball | palpebral conjunctiva |
| firm strips of CT in the eyelid- plates contain parallel row of meibomian glands that open lid margina | tarsal plates |
| eye muscle that raises the upper lid- innervation my oculomotor nerve- smooth muscle innervated by sympathetic ns, also contributes to lid elevation | levator palpebrae |
| protects conjunctiva, inhibits bacterial growth, gives smooth surface to cornea | tear fluid |
| clear layer at front and ctr of eye, lies in fron of iris- fxns to help focus light as it enters the eye | cornea |
| white outer coat of the eye, tough, leather like tissue extends around the eye, gives eye shape and attaches to the extraocular eye muscles | sclera |
| layer of blood vessels btw retina and sclera | choroid |
| colored part of the eye that helps reg amt of light entering eye by opening and closing the pupil (acts like shutter on camera) | iris |
| transparent, crystalline- focuses light on the retuna, fine tunes vision, deterioration w/ ageing leads to farsightedness- intraocular lenses are used to replace lenses clouded by cataracts | lens |
| over a mill nerve fibers carrying messages from retina to the brain | optic nerve |
| nerve layer lining the back of the eye - senses light and creates electrical impulses sent through the optic nerve to the brain | retina |
| gland that lies mostly w/in bony orbit/lateral to the eyeball-tears drain medially through two tiny holes (lacrima puncta) located on the lower lid medially- tear pass into lacrimal sac and into nose through nasolacrimal duct | lacrimal gland |
| sphericle and focuses light on the retina | eyeball |
| controlled by the muscles of the iris | pupilary size |
| controlled by the ciliary body- allows eye to focus on near or distant objects | thickness of the lens |
| clear liquid-produced by ciliary body, fills ant and post chambers of eye- circulates from posterior chamber through pupil to the anterior chamber -drains out of ant chamber through canal of schlemm | aqueous humor |
| what controls pressure inside the eye | circulatory system that circulates aq humor from posterior chaber through ant chamber |
| aqueous humor drains out of the anterior chamber through here | canal of schlemm |
| posterior eye, seen with opthalmoscope - structures are retina, choroid, fovea, macula, optic disc, retinal vessels | fundus |
| optic nerve and retinal vessels enter the eyeball from which direction | posteriorly |
| point of central vision, lateral and slightly inf to optic disc, small depression in retina | macula |
| small dark circ area circumscribed by the macula | fovea |
| transparent gelatinous material that fills the eyeball behind the lens, helps maintain shape of the eye | vitreous body |
| intraocular portion of optic nerve- margins, color and cup to disc ratio should be determined- sharp borders, yellow orange to creamy pink- round to slightly oval with long axis vertical | optic disc |
| small depression in the ctr of the optic disc- portion that is lighter in color and penetrated by retinal vessels - diameter is less than 1/2 horizonal diameter of optic disc | physiologic cup |
| what is a normal physiologic cup to optic disc ratio | 0.1-0.9 (usually written as <0.5 in normal subject) |
| area of retinal responsible for fine central vision- darker grey appearance, oval depression with fovea in the center | macula |
| center of the retina- ask patient to look directly into light to bring this into view | fovea |
| branches at the optic disc into divisions that supply the 4 quadrants of the inner retinal layers | central retinal artery |
| how can you tell the difference btw the arteries and veins you are viewing with an opthalmoscope | arteries are smaller in diameter than the veins and lighter in color |
| entire area seen by an eye when it looks at a central point- ctr of circule- focus of gaze- each vis field is divided into quadrants- fields extend farthest on the temporal sides, fields restricted by, eyebrows, cheeks, nose | visual fields |
| lack of retinal receptors at the optac disc- located 15 degrees temporal to the line of gaze in the visual field | blind spot |
| an enlarged blind spot occurs in conditions that affect the optic nerve such as: | glaucoma, papilledema and optic neuritis |
| two visual fields overlap in this area | binocular vision |
| lateraly vision | monocular vision |
| light reflected from the image must pass through pupil to be focues on sensory neurons in the retina- image projected upside down and reversed from R to L- image from upper nasal visual field strikes lower temporal quadrant of the retina | visual pathway |
| nerve impulses are stimulated by | light |
| where are nerve impulses conducted through | the retina, optic nerve and optic tract on each side |
| where does the visual pathway go from the optic tract on each site | optic radiation that ends in visual cortex of the brain in the occipital lobe |
| pupillary size changes in response to light and effort of focusing on a near object | pupillary rxn |
| light shining directly onto the retina | direct light rxn |
| opposite eye response in the light rxn | consensual |
| what nerve does the pupillary rxn go in and go out | in CNII (afferent limb) -optic nerve out CNIII (efferent limb) oculomotor nerve |
| light enters optic disc and then photosensitive retinal ganglia cells pass info to this nerve -afferent limb | CN II optic |
| in the midbrain, impulses get sent here during pupillary rxn whose parasympathetic axons run along both the L and R oculomotor nerve caused pupillary constriction | edinger westphal nucleus |
| efferent limb of the pupillary rxn, motor, parasympathetic, pupillary constriction | CN III- oculomotor nerve |
| pupils constric when shifting gaze from a far object to a near object- rxn innervated by CN3 - convergence occurs , accomodation occurs | near rxn |
| extraocular movement of your eyes inward to look at a near object | convergence |
| increased convexity of the lenses caused by contraction of the ciliary muscles (diff to actually see or measure in routine physical exam) | accomodation |
| part of the ns that supplies the iris - when stimulated, pupils dilate and upper lid rises a little, pathway starts in hypothalamus through brainstem and cervical cord- follows carotid a. or its brances to the orbit | sympathetic ns |
| fibers traveling to the oculomotor nerve and producing pupillary constriction are part of the what ns | parasypathetic ns |
| (sensory) relays information from the eye to the brain, senses light and vision. It is the afferent (toward the brain – sensory) nerve of pupillary action | CN II optic nerve |
| (motor): innervates the most of the eye muscles as well as being the efferent limb of pupillary action. Raises the eyelid | CN III: Oculomotor |
| (motor): innervates the superior oblique muscle which is responsible for downward, inward movement of the eye | CN IV: Trochlear |
| (motor): innervates the lateral rectus, which moves the eye laterally | CN VI: Abducens |
| movements of each eye coordinated by 6 muscles (4 rectus, 2 oblique) with 6 cardinal directions - all CN3 besides lr6 and so4 | extraocular movements |
| controlled by the abducens nerve | lateral rectus |
| controlled by the trochlear nerve | superior oblique |
| seeing two diff images on the same object- monocular or binocular, | diplopia |
| double vision that is only a refractive problem in the front of the eye most commonly caused by astigmatism | monocular diplopia |
| abnormal curvature of the corneal surface | astigmatism |
| occurs when eyes do not move in synchrony with each other, CN lesion (3,4,6), EOM abnormalities (muscle fibroses seen in graves), derangements neuromuscular junction (myasthenia gravis) | binocular diplopia |
| drooping of the upper lid- causes include myasthenia gravis, damage to CN3, damage to symp nerve supply (Horners syndrome)- weakened muscle, relaxed tissues and weight of herniated fat, can be congenital | ptosis |
| can be caused by weakened muscle, relaxed tissues and weight of herniated fat of eyelid | senile ptosis |
| inward turning of the lid margin- more common in elderly, lashes irritate the cornia | entropion |
| outward turning lid margin exposing palpebral conjunctiva- if punctum of lower lid turns eye out, eye drainage is affected, more common in elderly | ectropion |
| can see rim of sclera btw upper lid and iris- wide eyed stare- assoc w/ lid lag suggests hyperthyroidism | lid retraction |
| eye protrudes forward, bilateral suggests infiltrative opthalmopathy of graves disease- may have assoc edema of eyelids and conjunctival injection- unilateral can be graves, tumor or inflammation of orbit | exopthalmus |
| benign yellowish triangular nodule on bulbar conjunctiva on either side - freq seen with aging, often first seen on nasal side, doesnt interfere with vision | pinguecula |
| triangular thickening bulbar conjunctiva grows slowly across outer surface of cornea, usually on nasal side, reddening may occur, can encroach upon pupil and interfere with vision "surfers eye" | pterygium |
| blood in the anterior chamber of the eye | hyphema |
| pus (WBC infiltration) in the anterior chamber | hypopyon |
| inflammation of episcleral vessels that appear salmon pink, localized ocular redness, may be nodular | episclerities |
| slightly raised yellowish, well circumscribed plaques, appear along nasal portion one or both lids, may accompany lipid disorder | xanthelasma |
| painful, tender red infection in a gland at the margin of the eyelid | stye/ hordeolum |
| subacute nontender and usually painless nodule involving a meibomian gland- may become acutely inflamed but unlike a sty, usually points inside the lid rather than on the lid margin | chalazion |
| swelling btw the lower eyelid and nose- acute inflammation is painful red and tender, chronic inflammation is assoc w/ obstruction of the nasolacrimal duct- prominent tearing, pressure on sac produces regurgitation of material through puncta of eyelids | dacrocystitits/ stenosis |
| diffuse dilatation of conjunctival vesselsl with redness that tends to be maximal peripherally, no affect on vision or pupil- watery mucoid or mucopulrulent discharge, bacterial, viral, parasitic irritation or allergic | conjunctivitis |
| leakage of blood outside vessels, producing homogenous, sharply demarcated, red area that fades over days to hellow, then disappears- not painful, no affect on vision, pupil or cornea, resolves spontaneously, trauma cough sneeze bleeding disorder | subconjunctival hemorrhage |
| dilation of deeper vessels that are visible as radiating vessels or a reddish violet flush around the limbus- important signs in injury/infection, acutre iritis, glaucoma | ciliary injection |
| red eye with moderate/ severe pain, decreased vision, watery/purulent ocular discharge, pupil unaffected, cornea affected depending on cause, typically from abrasions, or a viral or bacterial infection | corneal infection injury |
| red eye w/ mod/ achy/ deep pain accompanied by decreased vision, no ocular discharged, pupil is very small and irregular with time, cornea is clear/ slightly clouded, associated with systemic ocular disorders | acute iritis |
| red eye w/ severe/ achy/ deep pain, decreased vision, no ocular discharge, dilated/ fixed pupils, steamy/ cloudy cornea, acute increase iop - emergency | glaucoma |
| thin grayish white arc or circle not quite at the edge of the cornea, accompanies normal aging, also seen in younger ppl, esp african americans- in young ppl suggests poss hyperlipoproteinemia, usually benign | corneal arcus/ arcus senilis |
| opacities of lenses visible through the pupil, most common in old age, can be nuclear (central) or peripheral | cataracts |
| superficial grayish white opacity in the cornea, secondary to an old injury or to inflammation- size and shape are variable- shouldnt be confused w/ opaque lens of a cataract which is visible on deeper plane and only through pupil | corneal scars |
| progressively diminished ability to focus on near onjects w/ age- loss of elasticity of the crystalline lens, changes in lens curvature from continual growth- loss of power of the ciliary muscles (muscles that bend and straighten the lens) | presbyopia |
| impaired far vision | myopia |
| pupils of different sizes >4mm- present in 1/5 of pop- can be normal or a sign of ocular or neurologic disease | anisocoria |
| very small pupils | miosis |
| very large pupils | mydriasis |
| pupil disorder seen in syphilis | argyll robinson pupil |
| difference in pupil size in both light and dark illumination is constant | physiologic or essential anisocoria |
| when is anisocoria considered a neurosurgical emergency | if it comes w/ acute onset of third nerve palsy and assoc w/ headache or trauma |
| this indicates that anisocoria is not due to third nerve palsy | symmetrically rapid constriction in pupillary light response |
| large, irregular pupils, usually unilateral, slowed or absent rxn to light, slowed accomodation causes blurred vision | adies tonic |
| dilated pupil (6-7mm) fixed to light and near rxn- may have associated ptosis and lateral eye deviation (EX: right pupil non reactive, complete prosis, hypoexotropia, impaired adduction, elevation and depression in the right eye) | cn III palsy |
| damage to sns- small pupil (miosis) that reacts to light and accomodation (with dim lighting)- ptosis present- loss of sweating on forehead- hydropigmentation of an eye | horners syndrome |
| loss of sweating on the forehead | anhydrosis |
| small irregular pupil, accomodates but do not react to light- seen in tertiary syphilis | argyll robertson pupil |
| indicates a decreased pupillary response to light in the affected eye | relative afferent pupillary defect (RAPD) |
| relative afferent pupillary defect (RAPD) iindicating decreased pupillary response to light in the effected eye, msot common cause is lesion of optic nerve (distal to optic chiasm) or several retinal disease- can do sweinging flashlight test for diagnosis | marcus gunn pupil |
| caused by imbalance in ocular muscle tone, often heredetary, causes gaze deviation classificed acc to direction, cover/ uncover test | developmental disorders |
| eye deviated medially | esotropia |
| eye deviated laterally | exotropia |
| new onset dysconjugate gaze caused by nerve injury, lesions, trauma, ms, syphilis and others- left eye cannot look down when turned inward, deviation is max in this direction | left cranial nerve 4 paralysis |
| new onset dysconjugate gaze caused by nerve injury, lesions, trauma, ms, syphilis and others-eye is pulled outward by action of the 6th nerve- upward, downward and inward movements are impaired or lost, ptosis and pupillary dilation may be associated | left cranial nerve iii paralysis |
| fine, rhythmic, oscillation of the eye- vertical, horizontal or rotatory- few beats on extreme gaze is normal | nystagmus |
| venous stasis leads to engorgement/ swelling- disc swollen w/ margins blurred- physiologic cup not visible - swelling due to increased ICP, uni/ bilateral - asymptomatic or headache, blurry vision, loss of vis, enlargement of blind spot, patons lines | papilledema |
| backward depression of disc and atrophy- base of enlarged cup is pale- physiologic cup >0.5 | glaucomatous cupping |
| death of optic nerve, disc vessels absent | optic atrophy |
| abnormalities of this include AV nicking, cotton wool patches (soft exudate), flame shaped hemorrhages and deep retinal hemorrhages, microaneurysms, hard exudates, papilledema | optic disc abnormalities |
| vein appears to stop abruptly on either side of the artery | av nicking |
| white or greayish, ovoid lesions with irregular, soft borders- usually smaller in size than the disc, results from infarcted nerve fibers | cotton wool patches |
| hemorrhage- small, linear, flame shaped red streaks in the fundi- seen in severe htn, papilledema, retinal vein occlusion | superficial hemorrhages |
| small, rounded, slightly irregular red spots, occur in deep retinal layers, seen in diabetes | deep hemorrhage |
| blood in potential space btw retina and vitreous, horizontal line of demarcation | preretinal hemorrhage |
| tiny, round, red spots often enar macular- minute dilitations of very small, retinal vessels, seen in diabetes | microaneurysms |
| formation of new blood vessels, more numerous and tortous and narrower than other blood vessels, seen in late proliferative stage of DM retinopathy, vessels can grow into vitreous and cause retinal detachment or visual loss | neovascularization |
| creamy or yellowish often bright lesions with well defined hard borders, small and round and amy coalesce- seen in DM and HTN | hard exudates |
| small, tiny, yellow, round spots- appear in normal aging, may accompany age related macular degeneration | drusen |
| what are the 4 grades of diabetic retinopathy -- national standards | -nonproliferative, moderately severe - nonproliferative, severe - proliferative retinopathy with neovascularization - proliferative retinopathy advanced |
| soft exudates of hypertensive retinopathy | soft exudates |
| increased light reflex from arteries (copper wiring), venous tapering at the AV crossing (AV nicking), soft and hard exudates, flame shaped hemorrhages | hypertensive retinopathy |
| radial retinal lines cascading from the optic disc | patons lines |
| what should you see during an opthalmoscopic exam if a patient has papilledema | venous engorgement, loss of venous pulsation, hemorrhages over and or adj to the optic disc, blurring of optic margins, elevation of optic disc, associated w/ elevated ICP |
| leading cause of blindness in west. countries, loss of central vision, dry (debris) and wet (vessels) btw retina and choroid lead to retinal detachment- forms, risk with age >50, current smoking, previous cataract surg, FH, | age related macular degeneration |
| clouding of the lens | cataracts |
| mottling, retinal pigmentation, retinal exudate/ hemorrhage | macular degeneration(MD) |
| change in size optic cup | glaucoma |
| what are common changes in vision errors seen in healthy/ young people | refractive errors |
| what are common changes in vision/ errors seen in over 65 | cataracts, MD, glaucoma |
| leading cause of blindness in african americans, 2nd leading cause of blindness overall, graduall loss of vision w/ damage to optic nerve - loss of vis fields (periphery 1st), pallor and increasing size optic cup (>.5), elevated intraocular pressure (IOP) | glaucoma |
| what are the risk factors of glaucoma | age >65, DM, FH, myopia, ocular HTN (>21 mmHg) |
| nearsightedness, refractive defect of the eye, collimated light produces image focus in front of retina when acoomodation is relaxed | myopia |
| farsightedness- either eyeball is too short or lens cant become round enough so the image isnt focused on the retina, this isnt same as presbyopia which is lack of ability of lens to accomodate with age | hyperopia |
| what are some things included in the eye exam | inspection, visual acuity, corneal reflections, pupillary rxns (light and accom), visual fields, extraocular movements, opthalmoscopic exam, special tests (upper eyelid eversion), alignment, eyebrow dist, lacrimal apparatis, conjunctiva and sclara, iris, |
| scaliness of eyebrows | seborrheic dermatitis |
| lateral sparseness of eyebrows can be caused by this endocrine disease | hypothyroidism |
| how should you look at the conjunctiva and sclera (noting color, vasc pattern, nodules or swelling) | have patient look up and depress both lower lids w/ thumbs |
| what are 4 things to look forn on the cornea and lens | corneal arcus, cataract, pterygium, scarring |
| should there be a shadow when you shine light on the iris | no |
| what does it suggest if you see a crescent shadow on the iris | narrow angle due to bowing of the iris, increases risk of acute narrow- angle glaucoma |
| using a snellen or rosenbaum chart of appropriate distance, test with glasses on, expressed as two numbers (distance in ft/ distance normal eye can recognize) (20/20) | visual acuity |
| what does VA stand for | visual acuity |
| what does OD stand for | ocular dexterity |
| what does OS stand for | ocular sinister |
| what does OU stand for | oculus uterque |
| in the US, when is a person considered legally blind | when vision in the better eye with correction is 20/200 or less or a constricted field of vision of 20 degrees or less |
| constriction of the pupil | miosis |
| dilation of the pupil | mydriasis |
| what is the normal size shape and symmetry of the pupil | round, 3-5mm |
| what is a direct pupillary reaction | direct |
| what is a consensual pupillary reaction | consensual |
| what is the pupillary response when equal pupils and one blind eye with normal neuro | blind eye has consensual light reflex, good eye doesnt |
| how do you test for visual fields and what do you do if a defect is found | first test both eyes at the same time, start in temporal fields bc most detects are here, if a defect is found, test one eye at a time |
| 6 cardinal directions of gaze, observe for normal conjugate movements, nystagmus, lid lag and convergence | extraocular movement |
| have patient follow finger or pencil as you move towards nose, this eye will follow object within range , can be poor in hyperthyroidism | convergence testing |
| what endocrine condition can cause lid lag where the rim of sclera is visible with downward gase | hyperthyroidism |
| used to determine if ocular alignment is normal--> temproal light reflection on here suggests nasal deviation of that eye | corneal light reflection |
| when would you do a cover, uncover test | when the cornal light reflections are asymmetrics, shows deviation of eyes separately |
| how do you test for upper palpebral conjunctiva | flipping the upper lid |
| assessment of protruding eyes- stand behind seated patients and inspect from above, exophthalmeter measures distance btw lateral angle of the orbit and imaginery line across, most anterior part of the cornia <20mm white americans, <22 african americans | exopthalmus (proptosis) |
| observation for fluid regurgitating out of the puncta to the eye- press on lower lid close tot he medial canthess to compress the lacrimal sac, have patient look up | nasolacrimal duct obstruction |
| should be done to R/O foreign body, have patient lookd own, grasp upper eyelashes and pul down and forward, cotton swab or tongue blade above lid margin, push down on stick as you raise edge turning inside out, secure upper lashes against eyebrow to obs | upper palpebral conjunctiva |
| what does it mean when the red relfex is absent when using your opthalmascope | opacity of lens (cataract), opacity of vitreous, detached retina, retinoblastoma |
| what is PERRLA | pupils equal round reactive to light and accomodation |
| used to measure the power of a lens | diopters |
| what cranial nerves are tested in the pupillary reflex | CN II and CN III |
| what cranial nerves are tested when testing EOMs | III, IV, VI |
Created by:
mhartz