Eye Semiology

Front 1

Definition. Causes.

Back 1

Miosis: Both small <3mm

- narcotic-related

- pontine stroke

- neurosyphilis

- Wernicke's encephalopathy

Front 2

Definition. Causes.

Back 2

Mydriasis: both large >5mm

- sympathomimetic drugs (cocaine) - reactive to light

- medullary stroke = fixed, dilated

- anticholinergic drugs (atropine = fixed, belladonna)

Front 3

Back 3

Aniscoria: > 0.5mm difference (if less = normal)

- anticholinergic drops

- CN3 palsy

- Holmes-Adie syndrome

- Horner's syndrome

- Glaucoma crises

Front 4

What is a Glaucoma Crisis?

Back 4

pain, red, cloudy cornea, external pressure kills the parasympathetic fibers first producing change in pupillary size.

Front 5

Define. Cause.

Back 5

Xanthelasma = hypercholesterolemia

Subcutaneous accumulation of cholesterol around the lacrimal gland.

Front 6

Define. Cause.

Back 6

Periorbital edema = Graves' Disease

Front 7

Define. Cause.

Back 7

Periorbital edema in diffuse edematous state = anasarca (accumulation of albumin)

Nephrotic syndrome.

Front 8

Define. Cause.

Back 8

Lacrimal gland enlargement. Bilateral:

- alcoholism (usu with parotid gland enlargement)

- Sjogren's syndrome

- sarcoidosis

Front 9

Define. Cause.

Back 9

(oculomotor palsy) CN 3 palsy: eye deviated laterally and inferiorly (CN 4 - depression and intorsion; CN 6 - abduction). May also have dilated pupil (loss of parasympathetic innervation). Ptosis (loss of levator).

Nerve infarction occurs from compromised vascular supply (inside out) may spare pupillary function

- diabetes

External Pressure (outside-in) will usually effect pupillary size initially then motor fibers

-Tumor

- uncal herniation (greatest fear)

- aneurysm

- infarct

Front 10

Define. Cause.

Back 10

(abducens palsy) CN 6: failure to abduct due to increased intracranial pressure. Causes include:

- meningeal processes (carcinomatous and infectious meningitis)

- tumor

- cavernous sinus process = carotid artery aneurysm or rhino cerebral mucormycosis

- diabetes (CN VI is the longest and most likely to be involved in neuroapthy)

- vascular disease with focal brainstem ischemia (involving the nucleus in the pons)

- NOT MS: no increase in intracranial pressure and does not involve cranial nerves (limited to white matter) but involvement of nuclei of the nerves does occur

Front 11

Rhinocerebral mucormycosis - definition, exam and treatment

Back 11

- Devastating fungal infection seen in immunocompromised patients and poorly controlled DM

- begins as sinus infection but spreads to involve orbit, palate and brain

- look for necrotic eschar (on palate), CN palsies and facial asymmetry

- management: antifungal and aggressive surgery

Front 12

Define. Causes.

Back 12

intranuclear opthalmoplegia (INO): failure to adduct. Due to involvement of medial longitudinal fasciculus. Causes include:

- brainstem stroke (unilateral)

- multiple sclerosis (bilateral)

- diabetes

Front 13

Define. Causes.

Back 13

Bilateral ptosis: diffuse weakness. Causes include:

- myasthenia gravis = weakness us beginning with muscles of the face (ptosis, EOM weakness, dysphagia)

- Guillain-Barre syndrome (Miller Fisher variant)

- Botulism

Front 14

Define. Causes

Back 14

Unilateral ptosis: CN3 palsy. Causes include:

- uncal herniation

- diabetes

- infarct

Front 15

Define. Causes.

Back 15

Unilateral ptosis: Horner's syndrome. Ipsilateral involvement of sympathetic chain - ptosis, miosis, and anhydrosis. Affected pupil reacts to light. Causes:

- cancer (lung cancer with spinal mets)

- spinal cord disease

- neck mass

- vascular aneurysm/dissection

Front 16

Define. Causes.

Back 16

Bilateral proptosis = Eyes pushed out. Graves' disease - not simply hyperthyroidism, not lid lag.

Front 17

Define. Causes.

Back 17

Unilateral proptosis: causes include:

- retro-ocular tumor

- periorbital infection

- cavernous sinus infection

Front 18

Define. Causes.

Back 18

Scleral icterus/jaundice (yellow): causes include:

- hepatobilliary disease

- brisk hemolysis

- congenital liver disease syndromes: Crippler-Najjar, Rotor, Dubin-Johnson, Wilson's diseaes

- melanoma can metastasize to the liver which may produce jaundice to to functional compromise (also can involve the eye producing therapeutic enucleation with subsequent placement of glass prosthesis)

Front 19

Define. Causes.

Back 19

Blue Sclera: osteogenesis imperfecta

Front 20

Define. Causes.

Back 20

Scleritis/episcleritis = deep inflammation of the sclera and the vessels. Begins with red, inflamed sclera and later may cause scleral thinning with ability to see urea. causes include:

- rhematoid arthritis

- vasculitis

Front 21

Define.

Back 21

Glaucoma crisis with corneal edema = cloudy/steamy

Front 22

Define. Causes.

Back 22

Corneal arcus = arcus senilis. Hyperlipidemia (less than 40 yo)

Front 23

Define. Causes.

Back 23

Keiser-Fleisher ring = Wilson's disease (copper deposition)

Front 24

Define. Causes. What is another thing that this disease can produce?

Back 24

Roth spots = hemorrhage with a white center corresponding to a cotton wool spot. Infectious endocarditis

Infectious endocarditis can also produce endophthalmitis via hematogenous spread of infection (produces a painful, red eye)

Front 25

Define. Causes.

Back 25

Cotton Wool Spots = reflect the edge of a micro-retinal infarct associated with:

- type II DM

- hypertension

- systemic lupus

- venous infarcts

Front 26

Define. Causes.

Back 26

Papilledema = blurring of the optic disk

Increased intracranial pressure

Front 27

Define. Causes.

Back 27

Diabetic retinopathy.

Purple = Flame hemorrhages

green = microaneurysms

dot and blot retinopathy = reflects retinal capillary microanaerysms and intra-retinal hemorrhages

Front 28

Define.

Back 28

Hypertensive retinopathy, grade 4

papiledema

cotton wool spots

A-V nicking

flame hemorrhages

silver wiring

hard exudate = macular starring

Front 29

Define. Cause.

Back 29

Hollenhorst crystal - reflecting cholesterol embolization from atherosclerotic plaque

Front 30

What is Multiple sclerosis?

Back 30

White matter disease caused by autoimmunity directed against myelin.

Front 31

What are the symptoms of MS? What is Lhermitte's sign?

Back 31

Symptoms vary depending on area of involvement including:

- weakness

- sensory deficits

- visual loss- diplopia

- gait disorders

- generalized fatigue

Lhermitte's sign = transient electric shock-like sensation produced by neck flexion, indicating cervical spinal cord pathology

Front 32

What is the Argyll Robertson Pupil? Which nucleus is involved?

Back 32

Involvement of the Edinger-Westphal nucleus. Small, irregular pupils that do not react to light, but do constrict during accommodation.

Front 33

What diseases are associated with an Argyll Robertson pupil?

Back 33

Diagnostic of neurosyphilis (tabes dorsalis) now commonly seen in DM, lyme disease and MS.NOT with myasthenia gravis and ALS which produce muscle weakness (via different mechanisms) but NOT associated with pupillary abnormalities.

Front 34

What is the Marcus Gunn pupil?

Back 34

Abnormality of the swinging light test producing a large pupil. It is an afferent abnormality.

Front 35

What is Holmes-Adie Syndrome? How does it present?

Back 35

Irregular dilated pupil (Aniscoria) - initially unilateral, may progress to bilateral involvement over time.

Delayed constriction to accommodation takes about 5-10 minutes. Reacts to instilled medications. Associated with loss of deep tendon reflexes.

Front 36

Cause.

Back 36

Papilledema from Malignant hypertension. High pressure transmitted through optic nerve due to elevated systemic arterial pressure.

Front 37

Cause.

Back 37

Papilledema from Central retinal vein occlusion. Indicates high pressure transmitted through optic nerve due to venous pressure (eye DVT)

Front 38

Cause.

Back 38

Papilledema from brain tumor. Indicates high pressure transmitted through optic nerve through high intracranial pressure (brain tumor, meningitis)

Front 39

Describe the 4 grades of hypertensive retinopathy evaluated by fundoscopy in terms of vessel appearance, retinal appearance and papilledema.

Back 39

Front 40

What is copper wiring indicative of?

Back 40

Hypertensive retinopathy

Front 41

Back 41

Central Reitnal artery occlusion. Pale and avascular retina.

Front 42

Most common variant of Osteogenesis Imperfecta and its clinical features.

Back 42

Disorder of collagen production. Most common variant (type 1) has AD inheritance. Clinical features include recurrent fractures (usu before puberty) triangular shaped face, blue sclera, hearing loss, scoliosis, loose joints and brittle teeth. Hearing loss, not visual impairment is typical.

Front 43

• Abducens palsy (CN 6)

Back 43

presents as an inability to abduct the involved eye. This nerve has a relatively long course in the subarachnoid space and cavernous sinus, and as such, may be involved by meningeal processes (e.g. infectious meningitis), diseases associated with neuropathy (e.g. diabetes mellitus), cavernous sinus diseases (e.g. carotid artery aneurysm, rhinocerebral mucormycosis) and diseases that cause increased intracranial pressure (e.g. brain tumor).

Front 44

• Arcus senilis

Back 44

white corneal ring associated with hyperlipidemia in patients < 40 years of age (normal finding in older patients).

Front 45

• Argyll Robertson pupil

Back 45

caused by damage to the Edinger-Westphal nucleus, this was originally described in neurosyphilis. The pupils are small and do not react to light but do constrict (if closely examined) to the accommodation maneuver.

Front 46

• Blue sclera

Back 46

although rarely reported in other entities, this finding strongly suggests osteogenesis imperfect, a disease associated with recurrent bone fracture, short stature, scoliosis, hearing loss and skin laxity.

Front 47

• Cotton wool spot

Back 47

white retinal lesion reflecting a micro-infarct, this can be seen in many diseases including diabetes and hypertension.

Front 48

• Diabetic retinopathy

Back 48

as for hypertension, the fundoscopic exam may reveal microvascular complications in diabetes. Potential finding may include microaneurysms and intraretinal microhemorrhages (aka dot and blot changes), cotton wool spots, flame hemorrhages, and vessel proliferation, but diabetes alone should not produce papilledema.

Front 49

• Hollenhorst crystal

Back 49

a small bright lesion in a small retinal artery indicating cholesterol embolization and atherosclerosis.

Front 50

• Holmes-Adie syndrome

Back 50

part of a systemic neurologic syndrome manifested as an irregular dilated pupil that has a delayed constriction to light. Initially unilateral, this frequently progresses to involve both eyes and can be associated with a lack of deep tendon reflexes (areflexia). These pupils respond briskly to instilled medications, underscoring that the pathogenesis involves denervation.

Front 51

• Hypertensive retinopathy

Back 51

the fundoscopic exam allows direct assessment of the microvascular effects of hypertension. The slideshow provides a table showing the grading of hypertensive retinopathy. Papilledema in conjunction with the other findings denotes grade IV.

Front 52

• Intranuclear ophthalmoplegia (INO)

Back 52

this disorder is produced by damage to the medial longitudinal fasciculus running in the brainstem – this is not a cranial nerve palsy! The exam finding is the inability to adduct the involved side – it may be unilateral or bilateral

Hint 52

there may be nystagmus of abducting eye. Multiple sclerosis is the most common cause of INO, but brainstem stroke and rarer pathology can potentially produce this finding.

Front 53

• Marcus Gunn pupil (afferent pupillary abnormality)

Back 53

the involved eye does not react to light directly but does constrict to light directed to the opposite eye (consensual response).

Front 54

• Oculomotor palsy (CN 3)

Back 54

a complete Oculomotor palsy presents with (3) components: 1) a downward and laterally deviated eye, 2) unilateral ptosis and 3) dilated pupil (mydriasis). The parasympathic fibers mediating pupillary constriction tend to run on the outside of the nerve, and the fibers innervating extraocular muscles in the nerve core. As such, partial Oculomotor palsy can occur with nerve core infarction (spares pupillary function) or early in the course of external compression (only a “blown” pupil).

Front 55

• Papilledema

Back 55

blurring of the optic disc margins produced by increased pressure transmitted through the optic nerve. As such, any disorder leading to increased intracranial pressure (ICP) may produce this: hypertensive crisis (aka malignant hypertension), brain tumor or abscess, meningitis – retinal vein occlusion can produce papilledema without increased ICP.

Front 56

• Roth spot

Back 56

representing hemorrhage within a cotton wool spot, this finding was initially described in infective endocarditis, but also can be seen in systemic lupus, diabetes and leukemia (and others).

Front 57

• Xanthelasma

Back 57

yellowish subcutaneous lipid collection adjacent to medial canthus of eye that is indicative of hyperlipidemia.