| Ophthalmology |
●Embryology: surface ectoderm: lens, corneal epithelium.... neural ectoderm: retina, iris, miosis/mydriasis m. mesoderm: cornea, sclera.... ☉5 y/o: VA 1.0 ●Myopia: 1. Axial 2. Refractive Tx: PRK: photorefractive keratectomy(10um→1D) ☉Pseudomyopia: ciliary m. hypertension Tx: atropin 4-6 months ☉Snellen's chart: 20 feet, 6 meter ☉IOP: applanation tonometer, most acurate ☉Pathological myopes may present with decreased visual acuity, an unusually large exophoria, strabismus (typically exotropia), open angle glaucoma, premature lenticular opacification and increased axial length (26.5-33.5mm). Dilated fundus examination may unveil any of these signs: flat, obliquely inserted discs, posterior staphyloma, a myopic crescent, patchy choroidal atrophy within the posterior pole, vitreous syneresis, breaks in Bruch's membrane with accompanying choroidal atrophy known as lacquer cracks, ★subretinal neovascular membrane with overlying retinal pigment epithelial hyperplasia (Fuch's spot), subretinal neovascularization without Fuch's spot (subretinal scarring, bleeding, exudate), and retinal breaks or detachments. (http://www.revoptom.com/handbook/oct02_sec5_3.htm) ●Hemianopia: 1.homonymous: after chiasm （兩眼左側視野→兩眼右側網膜→視交叉內側交換→右側皮質） 2.bitemporal hemianopsia: chiasm 內側(★hypophyseal tumor) （兩岸不交通，視野就不廣） 3.binasal hemiaopsia: chiasm 外側(internal carotid a.)（外力壓迫，就只注意外力） 4.quadrianopsia: optic radiata 5.central scotoma: central retinitis ●Eyelid dz: 1.Chalazion霰粒腫: Meibomian gl. obstruction, no pain, common in acne rosacea & seborrhoic dermatitis 2.Hordeolum麥粒腫: Staphylococcus, 3.Strawberry navus: < 6mo. 4.BCC: most common: 90%, no meta 5.SCC: 6.Sebaceous gl. ca. 7.Malignant melanoma 8.Kaposi's sarcoma 9.Ptosis ●Orbital dz: 1.Graves' dz: eyelid retraction, soft tissue invasion, proptosis, optic neuropathy, restrictive myopathy, 2.Cellulitis: ethmoidal 3.Capillary/cavernous haemangioma, rhabdomyosarcoma 4.Orbital fracture: floor most common, Water's view ●Conjunctival dz: 1. Follicular rxn: (LN)viral, chlamydial 2. Papillary rxn: (Cell)Bacterial, contact glass 3. LAP: (1) anteauricular (2) submandibular 4. Acute supurative conjunctivitis: Neisseria 5. Acute catarrhal conjunctivitis: S.pneumoniae, Hemophilus 6. Adenoviral keratoconjunctivitis: →Epidemic keratoconjunctivitis (EKC): 8,19 type →Pharyngoconjunctival fever(PCF): 3,7 type, in children →sudden onset of acute follicular conjunctivitis with watery discharge, hyperemia, chemosis and ★ipsilateral preauricular lymphadenopathy. Both membranes and pseudomembranes can occur in EKC with a distinguishing corneal involvement that ranges from diffuse, fine, superficial keratitis to epithelial defects to subepithelial opacities. →the virus (adenovirus type 19) remains viable for 5 weeks →Treatment is mostly symptomatic (cold compresses and artificial tears). In severe cases, mild topical corticosteroids can be used, especially for the subepithelial opacities. 7. Aute hemorrhagic conjunctivitis: enterovirus 70 8. Chlamydial conjunctivitis: →TRIC: Adult inclusion body, Giemsa stain, Tx: Doxycycline →Trachoma: Herbert's pits 9. Neonatal 10. Allergic: severe itch, eosinophil (1) Seasonal allergic conjunctivitis (2) Vernal Keratoconjunctivitis(VKC): Spring catarrh, Tx: corticosteroid (3) Giant papillary conjunctivitis: contact lens 11. Autoimmune: (1) Cicatrical pemphigoid (2) Stevens- Johnson syndrome 12. Pinguecula瞼裂斑 13. Pterygium翳性贅片: Stocker's line: Fe, Triangular 14. Keratoconjunctivitis sicca乾眼症: →filaments, tear film break-up time, rose bengal staining, Shirmer's: 5 min, normal >15mm, ab <5mm →3 layers of tear: lipid(Meibomian, Zeis), aqueous(Main, Kraus, Wolfring), mucin(Goblet, Henle, Manz) ●Corneal dz: →5 layers: Epithelium(V1), Bowman's(No cell)（No man）, Stroma(90%), Descement's(Regeneration)（Degeneration＆）, Endothelium(keep dehydration) 1.Bacterial keratitis: contact lens: pseudomonas, ground glass appearance 2.Fungal keratitis: 3.Viral keratitis: HSV 4.Corneal degeneration: →Band keratopathy: Ca deposit between epithelium and Bowman's, due to chronic iritis 5.Corneal dystrophy: →Stromal: lattice, granular, macular →Ectatic漲大性: keratoconus 6.Metabolic keratopathy: →MPS:AR →Wilson's dz: Ceruloplasmin ↓, Cu ↑, Kayser-Fleischer ring: Descement's membrane 7. Peripheral corneal dz: →Marginal: catarrhal ulcer →Rosacea ●Lens dz:Cataract →Senile: (1) subcapsular (2) nuclear: second sight of the aged →Traumatic: →Metabolic: (1) DM, (2) galactosemia: oil droplet (3)fabry's dz →Steroid: →Complicated: ant. uveitis most common →Down syndrome →Congenital: Rubella →Tx: extracapsular cataract extraction(ECCE): common, Phacoemulsification →Extracapsular extraction(ECCE), the anterior capsule is cut and removed, the hard nucleus extracted, and the lens cortex removed (this is either via a large incision at the limbus, or after phacoemulsification (emulsifying the lens via ultrasound) via a smaller incision). The posterior capsule is left behind to support the implanted artificial lens. →Comparison of standard extracapsular surgery and extracapsular extraction with phacoemulsification: 1.visual recovery is slower after standard extracapsular surgery than following phacoemulsification 2.extracapsular surgery with phacoemulsification results in less induced astigmatism 3.the numbers of patients who achieve a corrected visual acuity of better than 6/12 after 3 months is similar for the two procedures →Intracapsular extraction(ICCE), alpha chymotrypsin is injected into the posterior chamber to digest the suspensory ligament and then the lens is removed in it's entirety with the aid of a forceps or a cryoprobe.（必須進去夾） ●Glaucoma →aqueous fluid: produced by ciliary epithelial cell, Trabecular route(90%)(Schlemm's canal→vessel of sclera), Uveoscleral route(10%) 1.Primary open angle glaucoma (POAG) →without apparent cause, IOP dysregulation, >21 mmHg →Risk factor: high myopia, RD, negro →Symptoms: optic nerve injury, arcuate scotoma(Grade 2)（弓形視野缺損）, Tx: beta blocker 2.Normal tension glaucoma (NTG) 3.Primary angleclosure glaucoma (PACG) →iris causing aqueous fluid obstruction →Risk factor: DM, >40 y/o, family hx, chinese, female (no HTN) →Symptoms: ant. chamber narrowing, mydriasis, ciliary congestion, halo, acute blurness, headache, pain 4.Secondary glaucoma (1)Pseudoexfoliative glaucoma (PEG): Sampaolesis line（三寶飯沒青菜） (2)Pigmentary glaucoma: 色素散亂症候群, Krukenberg's spindle (3)Neovascular glaucoma (NVG): chronic retinal ischemia causing fiber accumulation 5.Congenital glaucoma (1)Primary congenital glaucoma: buophthalmos牛眼 (2)Iridocorneal dysgenesis: combine Wilms' tumor, chr 11 →Tx: b-blocker(decrease secretion, esp in POAG), sympathetics(alpha: increase excretion, beta: decrease secretion), miotics (contraindicated in PACG), Carbonic anhydrase inhibitors( decrease secretion, Acetazolamide/Diamox), hyperosmotics →Tx: (1)Argon laser trabeculoplasty (ALT) in POAG (2)Nd: YAG laser iridotomy/iridectomy(?) in PACG ●Uveitis 1.Sarcoidosis: candle-wax exudate 2.Behcet's disease: →aphthous ulcer, genital ulcer, 30-40 y/o male, HLA-B51 →It is characterized by oral aphthae and by at least 2 of the following: (1) genital aphthae, (2) synovitis, (3) posterior uveitis, (4) cutaneous pustular vasculitis, (5) meningoencephalitis, (6) recurrent genital ulcers, and (7) uveitis in the absence of inflammatory bowel disease or collagen vascular disease. 3.Vogt-Koyanagl-Harada(VKH): HLA DR4, DW 15, albism of eyelash 4.Viral: VZV(Hutchinson's sign, nasociliarty body invasion), HSV, Acute retinal necrosis (ARN), Rubella 5.Toxoplasmosis 6.Fuch's uveitis syndrome: Non- granulomatous 7.Sympathetic ophthalmitis (SO): Granulomatous →Koeppe nodules, mutton fat Kps, Dalen-Fuchs' nodule →after trauma →→Keratic precipitates, inflammatory cells in anterior chamber or vitreous, →→Synechiae (fibrous tissue scarring between iris and lens), macular edema, perivasculitis of retinal vessels →→Aqueous flare: Tyndall phenomenon observed in the fluid of the anterior chamber of the eye. ●Vitreous dz: 1.posterior vitreous detachment(PVD): vitreous floaters 2.vitreous hemorrhage ●Retinal dz: 1.Retinal detachment: RPE(retinal pigment epithelium) ＆ rods and cones cell layer (1)Leak: PVD, lattice(40%), snailtrack degeneration, acquired →flightening, floaters, peripheral eyefield loss (2)Tractional: DM, trauma (3)Exudative: →Tx: (1)Scleral buckling: for fish mouthing (2)Subretinal fluid drainage (3)Pneumatic retinopexy: 眼底上2/3 (4)Pars plana vitrectomy(PPVT) 2.Retinovascular dz: →Frourescein fundus angiography(FAG): normal: balck →Electroretinography(ERG), Electrooculgraphy(EOG)FOR RPE, Visual evoked potential(VEP) (1)Diabetic retinopathy →simple background: Microaneurysm（最早出現的病變）, flame-like bleeding(★Nerve fiber layer), hard exudate, edema →preproliferative: cotton wool spots（因為缺血而神經水腫）(★Outer plexiform layer) →proliferative: IDDM, neovascularization, vitreous detachment, hemorrhage →macular edema: major cause of DM's visual defect (2)Retinal vein occlusion (RVO) →Branch: BRVO →Central: CRVO a.non-ischemic: most common b.ischemic: ★cotton wool spots, neovascular glaucoma(NVG) c.pappilophlebitis →Tx: photocoagulation (3)Retinal arterial occlusion (RAO) →Branch: emboli →Central: atheroma, ★cherry-red spot (4)Hypertensive retinopathy →vasoconstriction →leakage: macular star →atheroiosclerosis: AV crossings →Sheie Classification: Grade 1: light reflex Grade 2: Salus' sign靜脈歪斜 Grade 3: Bennet's sign: Copper-wiring, Gunn's sign:靜脈直角, flame-like bleeding, cotton wool spots Grade 4: Silver-wiring, optic disc swelling (5)Angiopathy →Sickle cell dz: salmon patch →Anemia: Roth's spots: whitish fibrous center →Leukemia: leopard spot retina (6)Retinopathy of prematurity (ROP) ●Neural dz: →Argyll-Robertson pupil: light reflex(-), Accommodation(+) →Foster Kenedy synd: ●Strabismus: →SO: intorsion, IO: extorsion →Tests: (1)Hirschberg's test: corneal, 15(pupil), 45(limbus) (2)Krimsky test: (3)Cover test: (4)Prism-cover test: 1. Esotropias內斜: most common →Paretic: CN VI palsy →Non-paretic: Infantile esotropia(<6mo),Acommodative esotropia(6mo-7y/o) →→abnormal retinal respondence in small angle 2. Exotropias外斜: →Intermittent →Congenital ☉By ★Hering law, yoke muscles receive equal and simultaneous innervation, the magnitude of which is determined by the fixing eye. Since the magnitude of innervation to yoke muscles is determined by the fixing eye, the angle of deviation between eyes (strabismus) may vary depending on which eye is fixing. The primary deviation is misalignment with the normal eye fixing. When the cause of deviation is acquired muscle paresis, as the paretic eye fixates, the ensuing secondary deviation is typically larger than the primary deviation. When the cause of deviation is congenital strabismus, the primary and secondary deviations are typically about the same.(Emedicine)（第二次比第一次角度大）
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