SECTION

Ophthalmology
Conjunctivitis

Bilateral

Unilateral

Watery discharge

Purulent, thick discharge

Easily transmissible

Poorly transmissible

Normal vision

Normal vision

Itchy

Not itchy

Preauricular adenopathy

No adenopathy

No specific therapy

Topical antibiotics

.... T IP
The "must know" subjects in ophthalmology are:

The red eye (emergencies)

Diabetic retinopathy
Artery and vein occlusion
Retinal detachment

497

Master the Boards: USMLE Step 2 CK

The Red Eye (Ophthalmologic Emergencies)

Presentation

Itchy eyes,
discharge

Autoimmune
diseases

Pain

Trauma

Eye findings

Normal pupils

Photophobia

Fixed midpoint pupil

Feels like sand in eyes

Most accurate test

Clinical diagnosis

Slit lamp
examination

Tonometry

Fluorescein stain

Best initial therapy

Topical antibiotics Topical

steroids

Acetazolamide,
mannitol,
pilocarpine, laser
trabeculoplasty

No specific therapy;
patch not clearly
beneficial

Glaucoma
Chronic Glaucoma

Chronic glaucoma is most often asymptomatic on presentation and is diagnosed by routine screening. Confirmation is with tonometry indicating
extremely elevated intraocular pressure. Treat with medications to decrease the
production of aqueous humor or to increase its drainage.
Prostaglandin analogues: latanoprost, travoprost, bimatoprost
Topical beta blockers: timolol, carteolol, metipranolol, betaxolol, or
levobunolol
Topical carbonic anhydrase inhibitors: dorzolamide, brinzolamide
Alpha-2 agonists: apraclonidine
Pilocarpine
Laser trabeculoplasty: performed if medical therapy is inadequate
Acute Angle-Closure Glaucoma

Look for the sudden onset of an extremely painful, red eye that is hard to
palpation. Walking into a dark room can precipitate pain because of pupilary
dilation. The cornea is described as "steamy" and the pupil does not react to
light because it is stuck. The cup-to-disc ratio is greater than the normal 0.3.
The diagnosis is confirmed with tonometry. Treat with:
Intravenous acetazolamide
Intravenous mannitol to act as an osmotic draw of fluid out of the eye
Pilocarpine, beta blockers, and apraclonidine to constrict the pupil and
enhance drainage
Laser iridotomy

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Ophthalmology

Herpes Keratitis
Keratitis is an infection of the cornea. The eye may be very red, swollen, and
painful, but do not use steroids. Fluorescein staining of the eye helps confirm
the dendritic pattern seen on examination. Steroids markedly increase the
production of the virus.
Treat with oral acyclovir, famciclovir, or valacyclovir. Topical antiherpetic
treatment is trifluridine and idoxuridine.

Beware of steroid use

for herpes keratitis.
Steroids make the
condition worse.

Cataracts
There is no medical therapy for cataracts. Surgically remove the lens and
replace with a new intraocular lens. The new lens may automatically have a
bifocal capability. Early cataracts are diagnosed with an ophthalmoscope or
slit lamp exam. Advanced cataracts are visible on examination.

Diabetic Retinopathy
Annual screening exams should detect retinopathy before serious visual loss
has occurred. Nonproliferative or "background" retinopathy is managed by
controlling glucose level. The most accurate test is fluorescein angiography.
Proliferative retinopathy is treated with laser photocoagulation. Vascular
endothelial growth factor inhibitors (VEGF) are injected in some patients to
control neovascularization.
Vitrectomy may be necessary to remove a vitreal hemorrhage obstructing
vision.

Figure 19.1: New blood vessel formation obscures vision.

Source: Conrad Fischer, MD.

499

Master the Boards: USMLE Step 2 CK

Retinal Artery and Vein Occlusion

Both conditions present with the sudden onset of monocular visual loss. You
cannot make the diagnosis without retinal examination. There is no conclusive
therapy for either condition.

Figure 19. 2: Retinal artery occlusion presents with sudden loss of vision
and a pale retina and dark macula. Source: Conrad Fischer, MD.

The maculq,. is described

as "cherry red" in artery
occlusion because the rest
of the retina is pale.

Figure 19.3: Retinal vein occlusion leads to extravasation of blood

into the retina. Source: Conrad Fischer, MD.

Treatment of artery occlusion is attempted with 100% oxygen, ocular massage,

acetazolamide, or anterior chamber paracentesis to decrease intraocular pressure, and thrombolytics.
Try ranibizumab for vein occlusion.

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Ophthalmology

Retinal Detachment
Risks include trauma to the eye, extreme myopia that changes the shape of the
eye, and diabetic retinopathy. Anything that pulls on the retina can detach it.
Detachment presents with the sudden onset of painless, unilateral loss of
vision that is described as "a curtain coming down."
Reattachment is attempted with a number of mechanical methods such as
surgery, laser, cryotherapy, and the injection of an expansile gas that pushes
the retina back up against the globe of the eye.

Figure 19.4: Sudden, painless loss of vision "like a curtain coming down."
Source: Conrad Fischer, MD.

Macular Degeneration
Macular degeneration is now the most common cause of blindness in older
persons in the United States. The cause is unknown. There is an atrophic (dry)
type and a neovascular (wet) type.
Visual loss in macular degeneration:
Far more common in older patients

Normal external appearance of the eye

Loss of central vision
Neovascular disease is more rapid and more severe. New vessels grow between
the retina and the underlying Bruch membrane. The neovascular or wet type
causes 90% of permanent blindness from macular degeneration.

Atrophic macular
degeneration has no
proven effective therapy.

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Master the Boards: USMLE Step 2 CK

Figure 19.5: Macular degeneration can be diagnosed only by

visualization of the retina. Source: Conrad Fischer, MD.

The best initial therapy for neovascular disease is a VEGF inhibitor such as
ranibizumab, bevacizumab, or aflibercept. They are injected directly into the
vitreous chamber every 4 to 8 weeks. Over 90% of patients will experience a
halt of progression, and one-third of patients will have improvement in vision.

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