Study Points

Disorders and Injuries of the Eye and Eyelid

Course #90563 - $75 • 15 Hours/Credits

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Study Points

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  1. Describe the normal anatomy and physiology of the eye and eyelid.
  2. Outline the physiology of vision.
  3. Describe vision screening recommendations and barriers to their implementation.
  4. Identify appropriate skills for the clinical examination of adults' eyes.
  5. Describe the components of pediatric eye examinations.
  6. Discuss the assessment of refraction and preparedness for eye examinations in the primary care setting.
  7. Differentially diagnose inflammatory conditions of the eye and eyelid, and describe the pharma- cologic and nonpharmacologic treatment options.
  8. Define the causes, treatment options, and preventive strategies for noninflammatory conditions of the eye and eyelid.
  9. Identify the causes and treatment of mechanical disorders of the eyelid.
  10. Identify the most common causes of eye injuries and sudden loss of vision.
  11. Explain the appropriate diagnosis and treatment for eye emergencies, including interventions for non-English-proficient patients.
  12. Describe eye conditions that commonly occur in children.
  13. Outline the impact of vision impairment in adults and interventions to improve quality of life for vision-impaired individuals.
  14. Describe the ocular manifestations of several chronic diseases and the recommendations for eye follow-up.
  15. Identify ocular side effects that may result with the administration of some common medications and herbal supplements.
  16. Discuss the diagnosis and treatment of malignant conditions of the eye and eyelid.
  1. The middle membrane of the eye is the

    OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE EYE

    Each eye has three primary membranes: the cornea and sclera (external membrane), the uvea (middle membrane), and the retina (innermost membrane).

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  2. "Floaters" are caused by

    OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE EYE

    The vitreous is attached to the lens and occupies the space between the lens and the retina; the attachment is firm in young individuals and becomes weaker with age. This structure represents two-thirds of the volume of the eye and is filled with vitreous fluid, a clear, jelly-like substance made up primarily of water, with approximately 1% to 2% of the components being soluble proteins, salts, and hyaluronic acid [22]. Vitreous fluid has many functions: it transmits light, supports the posterior surface of the lens, helps to hold the retina against the retinal pigment epithelium, and transports nutrients to the cornea. During natural aging, vitreous fluid may shrink or thicken, causing tiny strands or clumps to form, the cause of muscae volitantes or so-called floaters (small spots or threads that appear in the field of vision).

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  3. The central point for focusing of an image is the

    OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE EYE

    The act of vision is made possible by a process that is similar to the function of a camera. The cornea transmits and focuses light into the eye, and the intrinsic muscles of the iris constrict and expand to control the size of the pupil, allowing the appropriate amount of light to enter the eye. The contraction and relaxation of the muscles of the ciliary body change the shape of the lens, helping the eye to focus and allowing for a sharp image to form on the surface of the retina. The central point for focusing of the image (the visual axis) is the fovea.

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  4. Which of the following is responsible for peripheral vision?

    OVERVIEW OF THE ANATOMY AND PHYSIOLOGY OF THE EYE

    The human retina contains approximately 100 million rods and 5 million cones. Rods allow vision in dim light, and cones facilitate vision in bright light (daylight). Cones also provide color perception and high spatial resolution. Rods are responsible for peripheral vision, and the macula provides the central 10 degrees of vision. Most cones are located within the macula. The fovea is made up exclusively of cones and provides for the best visual acuity. In contrast, there are no rods or cones in the area of the retina where the optic nerve leaves the eye; as such, this area is known as the eye's blind spot.

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  5. The most common reason given by pediatricians for the poor rates of vision screening among children is lack of

    CLINICAL EXAMINATION OF THE EYE

    Among children, the rate of appropriate eye examinations is also low, as is the rate of follow-up examinations for children who failed visual acuity screening [33,34]. For example, a survey of pediatricians showed that preschool vision screening was done on 36% of children 3 years of age, 58% of children 4 years of age, and 73% of children 5 years of age [33]. Respondents gave many reasons for the lack of screening, with the most common reasons being that children were not cooperative (39%) and that testing is time-consuming (21%) [33].

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  6. Which of the following may indicate palsy of the third cranial nerve?

    CLINICAL EXAMINATION OF THE EYE

    Pupils should be equal, round, and reactive to light (which is documented as the acronym PERRL). It is fairly common for there to be subtle inequalities (up to 0.4 mm) in the size of the two pupils, but this inequality is normal only if the asymmetry remains constant during changes in ambient light [39]. In assessing anisocoria (unequal pupils), the first two questions should be: Is there a normal light reaction? Is anisocoria worse in darkness or light? If the light reaction is poor in the eye with a larger pupil, the pupillary constrictor of that eye is abnormal; if the light reaction is good in both eyes, the pupillary dilator of the eye with smaller pupil is abnormal [39]. Anisocoria that is worse in light and accompanied by ptosis and paresis of extraocular muscles may be indicative of intracranial aneurysm. Anisocoria may indicate Horner syndrome if ipsilateral ptosis and anhidrosis are also present. Other possible causes of unequal pupils include trauma-related damage to the iris and pupil and palsy of the third cranial nerve. Irregularly shaped pupils are most commonly related to an intraocular problem, such as congenital anomaly, inflammation, or trauma.

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  7. The appropriate distance for testing visual acuity with the Rosenbaum card is

    CLINICAL EXAMINATION OF THE EYE

    Visual acuity is usually measured with a wall-mounted Snellen chart. Patients are asked to cover one eye and read the line of the smallest letters they can at a distance of 20 feet; the test is then repeated with the other eye covered. The lines of letters on the chart correspond to specified visual acuity based on what a person with "normal vision" can see at various distances. A smaller version (to scale) of the Snellen chart is the Rosenbaum card, which can be held 14 inches away from the patient.

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  8. Which of the following is recommended for testing visual acuity in young children?

    CLINICAL EXAMINATION OF THE EYE

    Testing of visual acuity in children who cannot communicate verbally is done by evaluating the ability to fix and follow an object (cross-cover test), and this may be carried out binocularly and monocularly [27,37]. For older children, visual acuity can be assessed with vision testing machines or a variety of picture cards and wall charts (e.g., LEA symbols, Snellen letters or numbers, tumbling E test, or HOTV test) [27,37]. The guideline developed by the AAP in conjunction with other organizations includes detailed information on these tests and how to perform and interpret them [41].

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  9. Which of the following signs in a child warrants urgent referral to an ophthalmologist?

    CLINICAL EXAMINATION OF THE EYE

    FINDINGS IN THE PEDIATRIC PATIENT THAT WARRANT REFERRAL TO AN OPHTHALMOLOGIST

    Sign, Symptom, or ConditionIndication for Referral
    Signs
    AnisocoriaExpedited
    Asymmetry in terms of color, brightness, or size on the red reflex testExpedited
    Poor binocular fixation after 3 months of ageRoutine
    CataractExpedited
    Cloudy or asymmetrically enlarged corneasExpedited
    Corneal opacities (congenital)Expedited
    Corneal ulcerUrgent
    Detection of an eye muscle imbalance on assessment of ocular motilityRoutine
    Movement in or out when shifting the cover on the cross cover testRoutine
    NystagmusWithin few weeks of onset
    Optic disk abnormalitiesUrgent if papilledema is suspected; expedited if associated with decreased vision; routine otherwise
    ProptosisUrgent if orbital cellulitis is suspected; expedited otherwise
    PtosisExpedited if Horner syndrome or palsy of the third cranial nerve is suspected
    Retinal detachment (suspected)Urgent
    Conditions
    BlepharitisIf persistent or resistant to local treatment with lid hygiene and topical antibiotics
    ChalazionIf persistent or resistant to local treatment with lid hygiene and topical antibiotics
    Conjunctivitis (allergic)If severe or persistent after treatment with topical antihistamines or mast-cell stabilizers
    Conjunctivitis (infectious)If severe or persistent after treatment with topical antibiotics
    DacryoceleExpedited
    Herpes simplex virus keratitisUrgent
    IritisExpedited
    Other
    Inability to read letters or lack of verbal skills as appropriate for age (when eye disease is suspected)Expedited
    Presence of congenital or genetic ocular anomalies or infections (e.g., aniridia, toxoplasmosis)Routine
    Presence of systemic syndromes, metabolic disorders, or chromosomal abnormalities with possible ocular involvement (e.g., juvenile rheumatoid arthritis, galactosemia, diabetes mellitus, Marfan syndrome, Down syndrome)Routine
    Suspected abuseUrgent
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  10. Among adults, a high degree of myopia is associated with

    CLINICAL EXAMINATION OF THE EYE

    Approximately 75% of adults older than 40 years of age have ametropia requiring refraction correction [8,43]. However, many refractive errors are not sufficiently corrected and are, as such, the leading cause of mild visual impairment [43]. Among all adults, myopia occurs more frequently than hyperopia (25% vs. 10%), and hyperopia is more common in women than men; both myopia and hyperopia have been found to be more common in white adults than in Hispanic or black adults [43]. A high degree of myopia has been associated with a higher risk of ocular diseases that may lead to vision loss (e.g., glaucoma, cataract, retinal detachment).

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  11. Which of the following instruments should be part of the basic equipment for office preparedness in all primary care settings?

    OFFICE PREPAREDNESS FOR EYE EXAMINATION AND TREATMENT IN THE PRIMARY CARE SETTING

    CONTENTS OF EYE TRAY FOR EMERGENCY TREATMENT

    Eye irrigation system (i.e., intravenous tubing, liter of isotonic saline, and basin)
    Ophthalmic medications (i.e., short-acting mydriatic agent, topical anesthetic, and topical antibiotics)
    Cobalt blue light
    Handheld ophthalmoscope
    Fluorescein dye
    Litmus or pH paper
    Hypodermic needle (18 or 20 gauge)
    Loupe
    Cotton-tipped swabs
    Sterile water
    Diluted sodium hypochlorite spray (for disinfecting work surfaces)
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  12. Which "red-eye" condition is encountered most frequently by primary care clinicians?

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Conjunctivitis is inflammation of the membrane that lines the underneath surface of the eyelids and the exposed surface of the sclera. Of the so-called red-eye-associated conditions, conjunctivitis is encountered most often by primary care clinicians and is one of the most common diagnoses in family practice [52]. The condition is most often caused by the highly contagious adenoviruses; other causes include infectious micro-organisms, chemicals, mechanical eye irritation, allergies, immune-mediated factors, and neoplastic diseases [8]. In general, bacterial conjunctivitis is uncommon, and fungal or parasitic cases are rare. Any ocular chemical irritants, foreign bodies, or trauma can introduce conjunctivitis. These noninfectious agents cause inflammation in only the affected eye. The features and treatment differ according to the type of conjunctivitis. Conjunctivitis rarely causes permanent vision loss or structural damage but is a socioeconomic burden because of lost work or school time and the cost of medical visits and treatment [8].

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  13. Which of the following is the most common type of conjunctivitis?

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Conjunctivitis is inflammation of the membrane that lines the underneath surface of the eyelids and the exposed surface of the sclera. Of the so-called red-eye-associated conditions, conjunctivitis is encountered most often by primary care clinicians and is one of the most common diagnoses in family practice [52]. The condition is most often caused by the highly contagious adenoviruses; other causes include infectious micro-organisms, chemicals, mechanical eye irritation, allergies, immune-mediated factors, and neoplastic diseases [8]. In general, bacterial conjunctivitis is uncommon, and fungal or parasitic cases are rare. Any ocular chemical irritants, foreign bodies, or trauma can introduce conjunctivitis. These noninfectious agents cause inflammation in only the affected eye. The features and treatment differ according to the type of conjunctivitis. Conjunctivitis rarely causes permanent vision loss or structural damage but is a socioeconomic burden because of lost work or school time and the cost of medical visits and treatment [8].

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  14. The primary risk factor for bacterial keratitis is

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    The primary risk factor for bacterial and fungal keratitis is contact lens use; other common risk factors are pre-existing ocular disease and ocular trauma [57,58]. Pseudomonas aeruginosa, Staphylococcus aureus, and other coagulase-negative staphylococci are the most common causative micro-organisms [57,58]. Treatment with topical antibiotic should be empiric, and the eye should not be patched [8,59]. Bacterial keratitis carries a heavy burden: in 2010, 930,000 physician office and outpatient clinic visits and 58,000 emergency department visits were for bacterial keratitis or contact lens disorders [60]. The estimated cost was $175 million in direct healthcare expenditures annually [60]. This burden calls for clinicians to heighten awareness of proper hygiene among their patients who wear contact lenses, emphasizing several points (Table 9).

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  15. One of the most common causes of infectious uveitis is

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Uveitis is inflammation of the uvea, or the iris, ciliary body, and choroid; the condition is categorized by site: anterior, intermediate, and posterior uveitis and panuveitis [59]. The cause of uveitis is usually unclear. It may follow certain acute infections, toxin exposures, or bruising of the eye. Cytomegalovirus (CMV), herpes viruses, Pneumocystis jiroveci, and toxoplasmosis are the most common causes of infectious uveitis [59]. On occasion, uveitis is a "herald sign" of an unrecognized autoimmune disorder or granulomatous disease (e.g., sarcoidosis, tuberculosis, histoplasmosis).

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  16. Which of the following is the most commonly used antibiotic for endogenous endophthalmitis caused by a Gram-positive microbe?

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Patients with endophthalmitis should be referred to an ophthalmologist immediately, as prompt treatment is crucial to preserving vision [62]. Cultures of aspirate from the aqueous and vitreous should be done to determine the causative organism [62]. Treatment of endophthalmitis after cataract surgery usually consists of intravitreal injection of antibiotics, and primary vitrectomy may be done, although its benefit is unclear [69]. Treatment outcomes depend on the causative organism, with outcomes best for cases of Gram-positive coagulase-negative infections, followed by Gram-negative and S. aureus infections [69]. Endogenous endophthalmitis is most often treated with both systemic and intravitreal antibiotics, and vitrectomy is sometimes done [68]. The most commonly used intravitreal antibiotics are vancomycin (for Gram-positive infections) and ceftazidime (for Gram-negative infections) [59,68]. Other potential treatments being investigated for the management of endophthalmitis include perioperative prophylaxis with antibiotics and adjunctive steroid therapy [72,73].

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  17. Optic neuritis is considered to be an early indicator of

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Inflammation of the optic nerve is most often associated with a demyelinating disease, especially multiple sclerosis. In fact, optic neuritis is considered to be an early indicator of multiple sclerosis, with the disease subsequently developing in more than 50% of individuals [76]. Other possible causes include infection (e.g., meningitis, Lyme disease, syphilis, viral infection), tumor metastasis, and chemicals or medications; the cause is often unknown [59]. Optic neuritis occurs most often in individuals 20 to 40 years of age [59].

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  18. Which of the following is the best recommendation for an external hordeolum?

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Treatment with warm compresses will help alleviate the symptoms of an external hordeolum, and the condition usually resolves spontaneously within a few days [62]. No treatment has been found to shorten the time to resolution. An external hordeolum does not grow; if the mass becomes enlarged, the patient should be evaluated for a neoplasm [62]. A systematic review of treatments for acute internal hordeolum showed no evidence for or against a variety of treatments that included warm (or hot) compresses, lid scrubs, antibiotics, or glucocorticoids [85].

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  19. Which of the following is recommended as first-line treatment for patients with mild dry-eye syndrome?

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Dry eye is classified as mild, moderate, severe, and severe and/or disabling, according to several factors, including severity and frequency of discomfort, visual symptoms, conjunctival injection and staining, corneal staining, corneal/tear signs, and lid/meibomian gland abnormalities, as well as the fluorescein tear break-up time and the Schirmer score [8]. The AAO recommends treatment according to the severity of the condition. For mild dry eye, recommendations include environmental modifications (avoidance of dry, drafty environments; use of a humidifier; and avoidance of secondary smoke), discontinuation of offending topical or systemic medications, artificial tears, warm compresses and eyelid scrubs, treatment of contributing ocular conditions (such as blepharitis), and correction of eyelid abnormalities [8]. In addition to these treatments, anti-inflammatory agents, such as topical cyclosporine, lifitegrast, and corticosteroids; systemic omega-3 fatty acids supplements and punctal plugs are options for moderate dry eye [86]. Although omega-3 fatty acid products have been used for treatment of dry eye, a prospective randomized 12-month trial of 3,000 mg omega-3 fatty acids failed to show any clinical benefit over placebo [8]. Punctal occlusion, with either silicone or collagen plugs, may provide relief for severe dry eye [87]. However, in its Choosing Wisely campaign, the AAO notes that punctal plugs should not be used until other options (artificial tears, lubricants, and compresses) have been used [88] Additional options for severe dry eye include systemic cholinergic agonists, systemic anti-inflammatory agents, mucolytic agents, autologous serum tears, contact lenses, and tarsorrhaphy [8].

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  20. The primary symptom associated with entropion is

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Entropion is a condition in which the eyelid margin (usually the lower lid) turns inward so that the eyelashes rub against the cornea and conjunctiva. The primary symptom is irritation of the ocular surface; other signs and symptoms may include redness, excessive tearing, eye discomfort or pain, photophobia, and stringy white mucoid discharge [59].

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  21. The most common cause of eyelid retraction is

    SYMPTOMATIC CONDITIONS OF THE EYE AND EYELID

    Eyelid retraction is symptomatic of many congenital and acquired diseases, and its multifactorial etiology includes neurogenic, myogenic, mechanical, and miscellaneous causes [95]. As the most common cause is thyroid ophthalmopathy, the patient's thyroid status should be evaluated.

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  22. Across all demographics and sites of injury, the most common type of eye injury is a

    EYE INJURIES AND EMERGENCIES

    Eye injuries cover a spectrum of severity, from corneal abrasions caused by minor trauma (e.g., vigorous rubbing or fingernails) to high-velocity penetrating injuries and injuries that cause sudden loss of vision. Nearly half (49%) of all eye injuries in the emergency department are superficial injury of the cornea; other common types of eye injury have been laceration of skin of the eyelid and around the eye, unspecified bruise of the eye, bruise of orbital tissues, and other specified open wound of the ocular adnexa [4]. The rates of eye injury, as well as the causes of injury, vary according to patient demographics. Understanding the populations at greatest risk of injury and the types of injuries incurred in distinct populations can help clinicians and other healthcare professionals to better target education and prevention strategies.

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  23. The most common setting for eye injuries is the

    EYE INJURIES AND EMERGENCIES

    Several causes of eye injury have been identified as occurring most frequently, and the causes vary according to age and the site of injury. Many consumer products cause eye injuries in the home, sports and recreation also cause a large proportion of eye injuries, and occupational hazards cause eye injuries in the work place. The home is the most common setting for eye injuries among adults and children, accounting for approximately 69% to 78% of all eye injuries [103,105,106]. Among children and adolescents, close to 50% of eye injuries occur in sports and recreational activities [107].

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  24. Which of the following sports is associated with the highest risk of eye injury?

    EYE INJURIES AND EMERGENCIES

    CLASSIFICATION OF SPORTS ACCORDING TO RISK OF EYE INJURY

    Level of RiskSport
    Eye safe
    Gymnastics
    Track/field
    Low risk
    Bicycling
    Diving
    Martial arts (noncontact)
    Skiing (snow and water)
    Swimming
    Wrestling
    Moderate risk
    Badminton
    Fishing
    Football
    Golf
    Soccer
    Tennis
    Volleyball
    Water polo
    High risk
    Activities involving small, fast projectiles (paintball guns, air rifles, BB guns)
    Basketball
    Baseball/softball
    Boxing
    Cricket
    Fencing
    Hockey (field and ice)
    Lacrosse
    Martial arts (full-contact)
    Racquetball
    Squash
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  25. The most common mechanism of eye injury in sports is

    EYE INJURIES AND EMERGENCIES

    The most common mechanism of eye injury in sports is blunt trauma, which is defined as an injury that occurs when a blunt object that is larger than the orbital opening exerts force on the floor of the orbit or the medial wall, with resultant fractures of the thin bones [120]. Blunt trauma can cause several different types of injury, such as:

    • Orbital blowout fracture

    • Contusion of the orbit and lid

    • Rupture of the globe

    • Injury to the iris

    • Traumatic iritis

    • Subconjunctival hemorrhage

    • Hyphema (blood in the anterior chamber)

    • Retinal or vitreous hemorrhage

    • Choroidal rupture

    • Retinal tear or detachment

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  26. Evidence has shown that which of the following topical agents is effective in the treatment of an uncomplicated corneal abrasion?

    EYE INJURIES AND EMERGENCIES

    The treatment of corneal abrasions (with or without a foreign body) has simplified over the past several years, with adequate healing achieved with minimal treatment. Most corneal abrasions heal without complications, and relieving pain is the primary concern. Oral analgesics and topical nonsteroidal anti-inflammatory drugs (NSAIDs) may be used, but oral analgesics are more cost-effective [137]. One 2017 systematic review of five topical NSAIDs (i.e., 0.1% indomethacin, 0.03% flurbiprofen, 0.5% ketorolac, 1% indomethacin, 0.1% diclofenac) found no strong evidence to support their use [138]. However, other studies indicate that diclofenac 0.1% is effective [137]. Topical NSAIDs should be used for no more than one or two days [137]. Topical mydriatics and cycloplegics were once used to relieve pain, but they are no longer recommended, as evidence has shown no benefit in cases of uncomplicated corneal abrasion [139,140]. Evidence for the use of topical antibiotics is lacking, but they are often prescribed to prevent infection [137,141,142]. If a topical antibiotic is used, an ointment is preferred to drops because it is more lubricating and soothing; erythromycin 0.5% ophthalmic ointment and sulfacetamide 10% ophthalmic ointment are two recommended options [137]. A systematic review found that patching does not reduce pain; in addition, the use of a patch results in a loss of binocular vision [143]. A tetanus booster is not needed for patients with a superficial corneal abrasion when there is no evidence of perforation, infection, or devitalized tissue [144].

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  27. Which of the following should a primary care clinician refer to an eye specialist for treatment?

    EYE INJURIES AND EMERGENCIES

    Other minor injuries that are encountered in the primary care setting are subconjunctival hemorrhage, small conjunctival lacerations, and minor eyelid lacerations. Subconjunctival hemorrhage is typically a focal, bright red lesion in the underlying white of the sclera. It is usually related to minor trauma or to a contact lens-induced injury [145]. In evaluating the eye, a globe rupture should be ruled out; subconjunctival hemorrhage in the area surrounding the cornea is a sign of globe rupture [135]. In older patients, spontaneous subconjunctival hemorrhage is often associated with hypertension [145]. The condition usually resolves on its own in a few days to a few weeks, and patients should be reassured that the condition is not serious. In infants and children with subconjunctival hemorrhage, nonaccidental trauma should be considered [146].

    Primary care clinicians can treat small conjunctival lacerations (less than 1 cm) that do not involve the underlying sclera with a topical antibiotic and close follow-up [147]. Patients with larger lacerations should be referred to an eye specialist, as sutures may be necessary. Examination with a slit-lamp microscope can help to distinguish a conjunctival laceration from a globe rupture [135].

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  28. Which of the following is the only injury for which treatment should be given without first testing visual acuity?

    EYE INJURIES AND EMERGENCIES

    Exposure of an eye to chemicals (liquid, powder, or gas) represents a true ocular emergency, and it is the only injury for which treatment should not be delayed until visual acuity is tested. The eye should be treated immediately on the basis of the history alone, if necessary [50,51,135]. The severity of an injury caused by exposure to a chemical can range from reversible edema to stromal scarring, calcific band keratopathy, and fibrosis of the iris or ciliary body. Severity will depend on the pH concentration of the chemical, the nature of the chemical, the volume of direct exposure, and the duration of exposure [50,135,149]. An alkali (pH of more than 10) can penetrate the cornea more readily than an acid (pH of less than 4) and thus presents the greater danger; alkali burns are also more common [147,149]. Determining the type of chemical is important, as the mechanism of injury differs between acidic and alkali agents. Examples of alkalis are household cleaning fluids, fertilizer, pesticides, and sparklers and firecrackers [135]. Hydrofluoric acid is the most common cause of acid burns [50,135]. When possible, the patient should be asked to bring in the container or a sample of the chemical. Identification of the chemical can also be obtained from Material Safety Data Sheets, which are required for some occupational sites [51].

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  29. Which of the following is NOT one of the most common signs/symptoms of mechanical globe injury?

    EYE INJURIES AND EMERGENCIES

    Blunt trauma or a high-velocity injury can cause a full-thickness rupture or laceration through the cornea and/or sclera. Because of the high risk of infection and vision loss associated with a mechanical globe injury, it should be considered in every case of eye trauma [51,135]. Blunt trauma to the eye, as from a thrown ball, motor vehicle accident, or assault, can cause a globe rupture, whereas penetrating injury, as from a knife or a small high-velocity projectile, can cause a globe laceration [147]. The most common signs/symptoms are eye pain, redness, tearing, and decreased vision, but a globe injury should be suspected after blunt trauma or a penetrating injury even if these symptoms are absent [147].

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  30. A patient presents with suspected central retinal artery occlusion. Which of the following should be done immediately?

    EYE INJURIES AND EMERGENCIES

    Immediate treatment should be given if the occlusion occurred within the past 24 hours. Because of the need for immediate restoration of blood flow to the retina in order to preserve vision, interventions should be implemented before the patient can be seen by an eye specialist. Digital massage of the closed eyelid should be done immediately (for 15 minutes), as it may dislodge an embolus, allowing it to move to a smaller branch of the artery [59]. In addition, the intraocular pressure should be lowered with either a topical hypotensive drug, such as timolol 0.5%, or acetazolamide (oral or intravenous) [59,155]. However, treatment rarely improves visual acuity, and treatment given 72 hours or more after occlusion is unlikely to improve vision [59]. Systemic corticosteroids should be given to patients who have central retinal artery occlusion caused by temporal arteritis.

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  31. Among children 6 to 72 months of age, the prevalence of strabismus is highest in which of the following racial/ethnic groups?

    COMMON EYE CONDITIONS IN CHILDREN

    In MEPEDS, which included children 6 to 72 months of age in Los Angeles County, the prevalence of strabismus was highest for Asian children (3.6%) and lowest for Hispanic/Latino children (2.4%) (Table 13) [48,49]. Different rates were found in the Vision in Preschoolers (VIP) Study, which included children 3 to 5 years of age in five geographically diverse locations. In this older population, the prevalence of strabismus was highest among non-Hispanic white (4.6%) and lowest among Asian children (1.0%) [46].

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  32. Which of the following types of cataracts is associated with light-blocking spokes extending from the outer rim of the lens to its center?

    VISION IMPAIRMENT IN ADULTS

    Cataracts—opacifications of the eye's crystalline lens—are the leading cause of blindness among adults worldwide and are the second leading cause in North America; they are also the overall leading cause of moderate and severe vision impairment [14]. Cataracts affect more than 24 million people older than 40 years of age in the United States, and by 75 years of age, half of all people have cataracts [5]. Slow, painless vision loss occurs over years in the eye with a cataract. Due to the cataract's opacity, the patient's pupil may appear gray. The different types of adult-onset cataracts are nuclear, cortical, and subcapsular (posterior and anterior), and mixed. Of the three types, nuclear cataracts develop most frequently in older adults [8]. With nuclear cataracts, central opacification and coloration interfere with visual function. Nuclear cataracts affect distance vision more often than near vision [8]. Cortical cataracts are characterized by light-blocking spokes extending from the outer rim of the lens to its center (Image 1), and patients most often report glare. Posterior subcapsular cataracts, granular opacities in the posterior pole of the cortex that develop under the capsule, cause visual impairment in bright light and glare. With posterior subcapsular cataracts, near vision is affected more often than distance vision [8].

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  33. The prevalence of primary open-angle glaucoma is highest among adults in which of the following racial/ethnic groups?

    VISION IMPAIRMENT IN ADULTS

    Glaucoma is the fourth leading cause of blindness and moderate and severe vision impairment in the United States and worldwide [14]. An estimated 2.7 million people older than 40 years of age in the United States have glaucoma, and the number is expected to reach 7.3 million by the year 2050. The prevalence of glaucoma is highest among people 70 to 79 years of age (32%), women (50%), and Hispanics (50%) [213]. It has been estimated that an additional 2.4 million people in the United States have undetected (and untreated) glaucoma [178]. The prevalence of glaucoma increases with age and occurs twice as frequently in the non-Hispanic black population (the highest prevalence) than in the non-Hispanic white population [176]. The rate of undiagnosed glaucoma is higher among minority populations compared with the non-Hispanic white population [178].

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  34. The leading cause of blindness in North America is

    VISION IMPAIRMENT IN ADULTS

    Age-related macular degeneration, the leading cause of blindness in North America, is a degenerative disease that causes loss of central visual acuity by its effects on the Bruch's membrane, choroid, outer neural retina, and retinal pigment epithelium [8]. Age-related macular degeneration is classified into two forms: neovascular (otherwise known as wet or exudative) and non-neovascular (otherwise known as dry or nonexudative). The slowly progressing, atrophic non-neovascular form is more common than the wet form, affecting approximately 80% of people with age-related macular degeneration; however, the neovascular form is responsible for almost 90% of the severe vision loss due to age-related macular degeneration [8]. Age-related macular degeneration is classified as early, intermediate, and advanced, based on the size and extent of drusen (small yellow deposits that form under the macula) [8].

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  35. A strong and consistent association has been found between age-related macular degeneration and

    VISION IMPAIRMENT IN ADULTS

    RISK FACTORS ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION

    Level of Association Risk Factor
    Strong and consistent
    Increasing age
    Current cigarette smoking
    Previous cataract surgery
    Family history of age-related macular degeneration
    Moderate and consistent
    Higher body mass index
    History of cardiovascular disease
    Hypertension
    Higher plasma fibrinogen
    Weaker and inconsistent
    Gender
    Ethnicity
    Diabetes
    Iris color
    History of cerebrovascular disease
    Serum total and HDL cholesterol and triglyceride levels
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  36. A gritty feeling in the eye and blurred vision may be associated with all of the following autoimmune disorders, EXCEPT:

    OCULAR MANIFESTATIONS OF DISEASES AND MEDICATIONS

    MOST COMMON OCULAR DISORDERS

    Autoimmune Disorder Most Common Ocular Manifestation Subjective Symptoms
    Rheumatoid arthritis
    Dry eye
    Scleritis, episcleritis
    Keratitis sicca
    Burning, pain, blurred vision, sensation of foreign body or grittiness, redness, photophobia, ocular tenderness
    Systemic lupus erythematosus (SLE)
    Dry eye
    Scleritis, episcleritis
    Retinal vascular occlusion
    Burning; pain; blurred vision; sensation of foreign body or grittiness; redness; sudden painless loss of vision
    Multiple sclerosis
    Uveitis
    Optic neuritis
    Pain with eye movement, photophobia, vision loss
    Giant cell arteritisIschemic optic neuropathySudden, painless loss of vision; constitutional symptoms
    Graves diseaseProptosis, lid retraction, optic nerve compressionGritty feeling, blurred vision, diplopia, photophobia, dry eye
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  37. How often should patients with HIV infection and CMV retinitis in whom maintenance therapy has been discontinued and whose immune systems have been reconstituted have an ophthalmologic examination?

    OCULAR MANIFESTATIONS OF DISEASES AND MEDICATIONS

    HIV-related CMV retinitis is treated with anti-CMV agents, such as valganciclovir (oral), ganciclovir (intravenous), ganciclovir followed by valganciclovir, foscarnet (intravenous), or cidofovir (intravenous) [228]. In a guideline on the prevention and treatment of HIV-related opportunistic infections, the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America recommend that the choice of treatment should be individualized, based on the location and severity of the lesions and the level of immunosuppression [228]. Ophthalmologic examination is recommended every three months for individuals with CMV retinitis in whom maintenance therapy has been discontinued; examinations may be done annually after immune reconstitution [228].

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  38. A patient is noted to have swelling of the optic disc. Which of the following drugs could cause this?

    OCULAR MANIFESTATIONS OF DISEASES AND MEDICATIONS

    MEDICATIONS WITH OCULAR SIDE EFFECTS

    Drug or SupplementSide EffectsTreatment and Indication for ReferralRecommended Follow-Up
    AmiodaroneBlurred vision, halos, corneal changes, optic neuropathy, loss of eyelashes or eyebrows, photosensitivityRefer promptly to ophthalmologist for vision changes and discontinue drug if optic neuropathy is suspectedBaseline eye examination and every 6 to 12 months (or more frequently depending on findings)
    AnticholinergicsBlurry near visionTell patients about potential difficulty focusing and possible need for glasses
    Angle-closure glaucoma (rare)Refer emergently to ophthalmologist for acute vision loss, eye redness or pain, or cloudy cornea
    Antihistamines (e.g., loratadine, cetirizine)Dry-eye syndrome, keratoconjunctivitis, photosensitivityConsider discontinuation of medication or use of non-drying antihistamine
    Antimalarial drugs (e.g., hydroxychloroquine, chloroquine)Loss of color vision, visual field, visual acuity, corneal deposits, bull's eye appearance of maculaBaseline comprehensive eye examination and annual eye examination beginning 5 years after the start of treatment
    Corticosteroids (oral and inhaled)Cataracts, glare, decreased visual acuity, halos, glaucoma, loss of peripheral visionMaintain close follow-upMeasurement of intraocular pressure every 6 months (by eye specialist)
    COX-2 inhibitorsConjunctivitis, blurred visionEducate patients regarding possible side effects
    DigoxinYellowish-orange or snowy, flickering visionMaintain dose in therapeutic range
    Erectile dysfunction drugsChanges in color perception, blurred vision, sensitivity to lightConsider decreasing dose or discontinuing medication
    EthambutolColor vision changes, visual field defects, optic neuritis (usually bilateral)Discontinue drug for vision changes and refer to ophthalmologistBaseline eye examination and monthly examinations (for patients taking a dose >15 mg/kg/day)
    Nicotinic acid (niacin)Decreased visual acuity, cystoid macular edema, dry eyes, discoloration of eyelids, loss of eyelashes and eyebrows, proptosisDiscontinue medication and refer to ophthalmologist for vision changes
    Phenothiazines (e.g., thioridazine)Blurred vision, changes in color vision, difficulty seeing at nightReduce dose or discontinue medication
    Retinoids (e.g., isotretinoin)Intracranial hypertension, meibomian gland dysfunction, dry-eye syndrome, blepharoconjunctivitisPrompt referral to ophthalmologist for unexplained headache or blurred visionOphthalmic examinations should be performed at least every 6 months.
    TamoxifenRetinopathy, cystoid macular edema, loss of visual acuity, retinal hemorrhage, optic disc swellingBaseline comprehensive eye examination (including testing of color vision) within first year of initiation of therapy and at least every 2 years.
    TopiramateAcute angle-closure glaucoma, blurred vision, conjunctival hyperemia, corneal edema, shallow anterior chamber, cataracts, pupil changes, elevated intraocular pressure, visual field defects, blindnessMaximal medical therapy (oral and topical aqueous suppressants) is needed
    Bisphosphonates
    PamidronateUveitis, episcleritis, and scleritis (rare); conjunctivitisRefer to ophthalmologist for persistent decrease in vision or if patient has ocular pain; topical ocular or systemic medication may be needed to reduce inflammation
    AlendronateBlurred vision, ocular pain, conjunctivitis, uveitis, scleritis
    EtidronateConjunctivitis, blurred vision
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  39. The criterion standard for diagnosis of primary vitreoretinal lymphoma is

    MALIGNANT CONDITIONS OF THE EYE AND EYELID

    The diagnosis of primary vitreoretinal lymphoma includes examination with direct ophthalmoscopy and slit-lamp microscopy. Ancillary studies such as fluorescein angiography and ultrasonography are often useful [254,255]. Cytologic analysis is the criterion standard for diagnosis, and other tests such as immunocytochemistry, flow cytometry, and polymerase chain reaction testing are also useful [256]. A complete medical and neurologic examination should be carried out to determine the presence of central nervous system lymphoma and to rule out other causes of uveitis, such as sarcoidosis, toxoplasmosis, and tuberculosis. Diagnostic testing should include a chest x-ray, laboratory studies (complete blood count, erythrocyte sedimentation, chemistry levels), neuroimaging of the brain and orbits, and a lumbar puncture [257].

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  40. Which of the following is most helpful in distinguishing periocular basal cell carcinoma from squamous cell carcinoma of the eyelid?

    MALIGNANT CONDITIONS OF THE EYE AND EYELID

    The various clinical presentations of basal cell carcinoma make diagnosis a challenge, with the lesion being undetected or misidentified in 20% to 40% of cases [261]. The lesions that are most often confused with basal cell carcinoma include papilloma, nevus, hidrocystoma, epidermal inclusion cyst, and squamous cell carcinoma [265,267]. The clinical features of squamous cell carcinoma also vary widely [258]. Squamous cell carcinoma usually presents as an ulcerated erythematous nodule or superficial erosion on the skin but can also appear as a verrucous papule or plaque. Color also varies, and the lesions may be reddish-brown, pink, or flesh-colored. They typically present as exophytic tumors, ranging in size from a few millimeters to centimeters. Larger lesions may appear crusted, erythematous, or eroded. In contrast to basal cell carcinoma, overlying telangiectasias are uncommon. The margins may be ill defined or well circumscribed [258].

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