DIP Episode 36 - USMLE Ophthalmology

Okay, welcome. My name is Divine. I am a Guess a PGY one at this point. You just graduated from med school Welcome to the 36th episode of the Divine intervention podcasts Today we're going to be talking about ophthalmology as relevant to the USMLE I would say this is definitely higher for people taking like a medicine shelf or Pediatrics shelf or step 2c cure most likely step 3 as well So let's begin. So the first question says we have a 71 year old male with central not peripheral central scotomas Straight lines appear wavy and blurred when he tries to read So what's the diagnosis? Well, I hope you're thinking about a Makula degeneration, okay, AR MD age relief it Makula generation Makula degeneration and There are actually two types of this disease, right? So there's the wet kind and there's the dry kind and It so happens that the wet kind is the more rapidly progressive kind although Even if it's more rapidly progressive We actually have many more treatment options for wet age relief at Makula degeneration as compared with dry age relief at Makula degeneration Now for you exams the big risk factors you want to think about right? I mean obviously it's in fact It's the most common cause of vision loss in the developed world right so like an industrialized country like the US for example But the biggest factors you want to keep in mind for exams are people that smoke okay?

Smoke one is a very big risk factor and another usual risk factor that me creep its way into exams is the use of aspirin Aspirin like chronic use of aspirin has actually been associated with the development of age relief that Makula degeneration and Some big things you also want to keep in mind right so Makula degeneration people tend to lose their central vision first Before they then begin to lose peripheral vision, okay?

So central vision is lost first in Makula degeneration before peripheral vision Because the macula right the macula is very helpful with central vision Contrast that will block home where people tend to lose their peripheral vision first and then they lose their central vision in the end and In general for dry relief at dry Makula degeneration right you find Like the positive of drowson in the eye right and again There's no many treatment options for this you can give like antioxidants like vitamin A C E You can give like zinc you can give better carotene Those are classic things that show up on exams as treatment for weight ARM beyond the other hand There are certain things you can do and I will say classicly on exams First things for exactly right if you look in the eye you'll see like the buzzword on exams You're looking for his neo-vascularization right so you have all these like weird blood vessels That sort of develop in the retina and they leak fluid behind the retina and that's what causes many of the findings and the Presentation in the disease Classically for wet ARMD you go ahead and do like photo-cualgulation You can give vegeph inhibitors like bevacizumab remember vegeph is a growth factor that helps with the formation of new blood vessels So you can give a vegeph inhibitor like bevacizumab or any bizumab those can be used to treat wet AR MD okay, so that's all I think I'm going to say and again the most common cause of vision loss in developed world is actually Machuille degeneration Next slide Okay, so 35 year old male was punched in the eye two hours ago Oops, he is brought to the eb-by of friend with complaints of visual difficulty in his left eye He has a sensation of items Floating in his visual fields along with bright streaks of light What's the diagnosis?

What's the diagnosis so Trauma victim floaters in the eye bright streaks of light. What do you think this is? I hope you think in Retinode attachment, okay?

This is retinode attachment and Actually has a pretty classic presentation on the exams right so I could be a person that recently had cataract surgery or a person that was punched in the I like some victim of trauma or whatever and then the Person could say that oh they have like the sensation of like floaters in the visual field or like bright streaks of light Or they can see that there's like this like shadow that's arising from the periphery of the visual fields and coming more towards the middle Or like a veil coming down over their eyes If you see all those things I really want you to think about a retinode attachment um With regards to risk factors right so like trauma cataract surgery those are like bigger risk factors If you want to keep in mind for exams and really the pathophysiology here is that that trauma basically disengages the neuro-sensory retina from the underlying pigmented epithelium and if the neuro-sensory retina then Becomes a schematic that you could run into a lot of trouble So this is actually an ophthalmologic emergency Call your friendly ophthalmologist ophthalmorezident or intern or whatever and try to get them to fix this as a swiftly as possible actually and there are certain things you could do like on exams classically the thing they go after is like a laser photo-cualgulation That's probably the buzzword you want to go ahead or remember laser photo-cualgulation Uh, there's some other stuff you can do like vitro bubbles blah blah blah but that's lower yield somebody.

We're gonna go there Okay Next slide so a newborn with a white reflex in his right eye. So this is a unilateral white reflex and we're suspecting an intracurricular mass. Well, I hope this gets you thinking about a retinoblastoma, okay? Remember it arises from an RBG mutation and for these kids you want to watch out for Bone tumors in the future, right? Most likely an osteosarcoma Don't forget the classic association with the somber sign, right? So somber sign codmonds triangle on on a radiographic imaging So that's just something I want to keep in mind. This will probably be a pediatric self-exam Question or step-to-sea key question. Okay. Next slide Now different sheeting between amblyopia and Strabismus different sheeting between amblyopia and Strabismus So this thing is uh something many people tend to mix up on exams So let me just spend some time and sort of go over this, right? So Amblyopia means just I mean this is generalization, but this this is fine for example Think of amblyopia as a kind of cortical blindness, okay? These people's eyes are completely normal But the brain just does not recognize vision from that eye, okay? So amblyopia is when the brain has suppressed vision from one eye Now it so happens that there are many things that can cause amblyopia, right? The most common cause of amblyopia.

This is very high up to naturally the most common cause of amblyopia is Strabismus right so strabismus is just some kind of misalignment of the eye So if for example a baby newborn has a problem where like one eye is like Faced in one direction versus the other eye the brain could say okay. You know what this abnormal eye? Let's just go ahead and suppress Vision from that eye. That's why this is actually something you want to fix. Classically. You want to fix it? If it persists for more than three months after a baby is born. You just want to go ahead and just fix it, okay? Because if you wait for the brain to make all its connections If vision is suppressed in that eye then it becomes a permanent problem So it's not something you sort of like full around with So that should not have used that word, but it's not something you mess around with. Let's use that instead. Okay So There are many other things that can cause amblyopia, right? So anything that can basically obstruct light going through the eye right so if a baby has like cataracts If a baby has like glaucoma again all those things can cause a can cause amblyopia, but the most common cause is an eye misalignment Which is a Strabismus Now in general to make the diagnosis of Strabismus there are many tests you can do.

There's like a cover on cover test that you may see on exams But one classic presentation that you give you on an exam is they may say that oh a Fundoscopic exam is done and you try to look at for the popularity right reflex and you notice that The reflection of the light from the cornea is different. It's like at different locations when you look at both eyes That's pretty classic for Strabismus So there's a cover on cover test, but there's that cornea reflex test where you're looking in both eyes And the reflection of the light off of the cornea is in different locations in both eyes It's supposed to be in the same location if you look at both eyes if it's not You're really thinking about Strabismus and in general for Strabismus you want to go ahead and treat with um some kind of like They call it like deprivation therapy if you may Where you penalize the eye that's affected.

I mean, I mean, so the eye that is unaffected see almost me that mistake The pretty common exam mistake for many people you penalize the eye that is unaffected right because you want to force the brain to use the eye that it's trying to suppress Okay, so penalization therapy penalize the unaffected eye Make the brain work the affected eye so that things can be corrected Okay, so I think that's all I'm going to say about Strabismus and Ambiopia and I mean you can Do the penalization like an eye patch or you can actually do it from archeology You can give like a Moscharinic antagonist right remember your Moscharine Your parasympathetic system controls a lot of eye movements right so you can try to paralyze that eye With the Moscharinic antagonist like atroping for example Okay, next question 45-year-old Asian male has the sudden onset of severe pain in his right eye Along with nausea and vomiting He took a nasal decongestant an hour ago for some annoying nasal symptoms So what's the diagnosis right? So look at the keywords here. This is an Asian male right so I'm not just putting Asian here because I'm Racist or anything like that.

No, I'm actually putting this here for a reason right so Asian male Okay, and this Asian male has the sudden onset of severe eye pain if I can you just add in something here Let's assume this patient has a rock hard eye right hopefully you're thinking about acute angle closure glaucoma, okay This nasal decongestant let's assume it's phenoliferin right phenoliferin remember it's an alpha-1 Agonist so because it activates alpha-1 receptors it causes my dry asses so a popularly dilution That popularly dilution can acutely trigger an acute angle closure glaucoma So how do you treat this basically you shoot lasers into the eye you can do like a laser redotomy You can try to reverse that my dry asses by causing myiosis right and you could actually cause them myiosis by Giving like a most chronic agonist like pilot carping for example alternatively you could give like manatelle or as it is on a mind to acutely try to lower and drop in the pressures But usually you want to go ahead and do a laser redotomy this is actually an ophthalmologic emergency So that the patient does not become permanently blind Now the other type of this disorder right this will be the um Opunangu glaucoma right that's that one is more in sedious little more chronic um classically presents with loss of peripheral vision right and the big demographic you're looking for an Exam especially for the opunangu glaucoma is African-Americans for closed angle glaucoma right so the acute closed angle glaucoma you want to think more about agents on exams and the biggest factors for glaucoma right so diabetes is a super super-big risk factor Being African-American is a big risk factor uh, let's see what else if you're taking steroids steroids also very big risk factors for glaucoma Um, although the biggest risk factor right so you for those of you that are taking step 2ck You know they have this uh love for risk f

actors the biggest risk factor for glaucoma is actually an increase in intraocular pressure I know you kind of make sense, but just one of those things you just sort of keep in mind for exams And how is the diagnosis of glaucoma made right so you can meet the diagnosis with Tonometry to try to measure intraocular pressures right uh you may also see like this buzzword on exams go new Scoopy that's also fine but classically on exams the right answer is to perform a Tonometry to measure intraocular pressures and on diagnostic testing right so if you do like a fondus copy exam You'll find an increased uptake cop to disc ratio right so sort of think of it as the as a donut So think of the this ratio as a donut and sort of think of eating the donut from the inside as you're destroying the optic nerve the The circle inside the donut gets bigger and bigger right so the uptake cop to this ratio is getting bigger That's pretty classic for for glaucoma now.

How do you treat glaucoma? The thing is um, there's many drugs that I used to treat glaucoma and Pretty difficult for people to keep it straight so there are certain Ways I try to remember this right then I feel the best way to remember it is just to be organized So what do I mean by that the thing is how does it glaucoma rises because we have like H. S. Humor problems right we have Increasing chocolate pressures So the thing is if you make too much in uh H. S. Humor you could get glaucoma Or if you have some kind of blockade where the H. S. Humor your making is not leaving the eye Then you could also have symptoms of glaucoma and the thing is the structures that make H. S. Humor in the eye are is the Cylaria pithylium and it so happens that the cylaria pithylium is Driven by the sympathetic nervous system.

Okay, so the cylaria pithylium is activated if you may by the sympathetic nervous system classically through bitter receptors bitter receptors so um and we also said that uh So you make this ectus humor from the cylaria pithylium it goes from the anterior chamber of the eye right flows into sorry starts from the posterior chamber of the eye flows into the anterior chamber and then from the anterior chamber it drains through the canals of shle Okay, it drains through those angles the angle between the iris and the cornea drains beyond that through the canals of shlemm think of the canals of shlemm as being blood vessels So they are visoactive so they can respond to visoactive regions and then that uh ectus humor is drained so if you basically understand that if that that's how everything works You can basically just go step by step logically and predict the drugs that you that I used to drink glaucoma So the first drug class where I mentioned that cylaria pithylium mixed ectus humor is driven by bitter receptors so it should make sense that if you give a bitter blocker like uh like needle law or team law right you could potentially treat glaucoma because by blocking those receptors you decrease the synthesis of ectus humor and another thing you could do is you could say okay well norepinephrine is an agonist at bitter receptors so let me just reduce the production of the substrate for bitter receptors like norepinephrine right so if you give a drug that's an offer to agonist remember offer to receptors a GI couple so the inhibitor denulates cyclists they have found a prison aptically so you release less caracolomins like norepinephrine for example so if you give an offer to agonist like aproclonidine obrimonidine those are actually used to treat glaucoma because they decrease the synthesis of norepinephrine so there's less substrate for the activation of bitter recepto

rs on slayer epithylium uh it also so happens that uh bicarb right remember bicarb is osmoticly active it's very good at drain water and increasing the water content of ectus humor and we know that bicarb can be made by carbonic and hydrace right so if you inhibited carbonic and hydrace we drugs like acetyzolomide and adorzolomide you could also potentially decrease the synthesis of ectus humor and relieve the symptoms of glaucoma now so we've dealt with the synthesis right so we say that not less they would drainage right so a drainage problem so we know that the angle that can close in glaucoma is the angle between the iris and the cornea that angle is widened i mean i mean that angle closes when you have my dry asses but it opens when you have meiosis so obviously you want it to open right so you want to give something that causes meiosis and we know that that's under the purview of the parasympathetic nervous system so if you give a drug like pylocarpin which is a most grainy agonist you can actually use that to treat glaucoma and then i also mentioned that the canals of schlem are blood vessels okay so those blood vessels they respond to visodylidors and we know that prostaglandins are very good visodylidors so if you give a prostaglandin and unlock like latano prost or travel prost right those could also be used to treat glaucoma because they dilute the canals of schlem although remember those drugs can cause like hyperpigmentation of the iris or lashes or something like that just one of those weird things you want to keep in mind okay so and you can also give manatal remembrance an osmotic thingy so you can basically acutely reduce uh and chocolate pressures that's used primarily for acute closed angle glaucoma okay so i know it's been time on this slide but that pharmacology is very high yield shows up a lot on an exam so um i will encourage you to sit on mayb

e like rewind that i just listen to it again so that's all i'm going to see with that so let's move on to the next slide okay so we have a 23 year old male presents with a 2 D history of severe right eye pain and blurry vision he has been taken benadro for a sinus problem so let's assume he has sinusitis that began five days ago HEENT exam is notable for pain with right eye movement and 20 over 200 vision that's really bad right so 20 over 200 vision means what a normal person will see a 20 feet you can only see at 200 mean no what a normal person would see at uh uh uh 200 feet you can only see at 20 feet i believe that's what uh that's what's meant by that so um so this uh so this person pain with eye movement uh and they had like sinusitis that started a few days ago right let me add in this information let's assume they have like problems moving the extracurricular muscles so what do you think this is i really hope you're thinking about orbital satellite is okay uh usually for this you actually want to go ahead and do i mean you can diagnose it clinically but many people prefer to get like some kind of ocular image like a CT scan to make the definitive diagnosis because this is actually an ocular this is actually an ocular emergency it's not something you want to mess around with um basically orbital cellulitis you have like inflammation of the eye especially like the fat around the eye or the extracurricular muscles and it's usually caused by like many bugs at the same time right so it's classically polymicrobial although staff orius right and like streps species can also cause a cause this problem but most commonly it's a polymicrobial kind of infection and again you make the diagnosis with an like an ocular CT scan uh remember you want to be able to differentiate this from uh pre-obital or pre-ceptal cellulitis uh although in preceptal cellulitis the big thing yo

u want to remember is that usually these people don't have any pain with eye movement and they do not have like uh involvement of the extracurricular muscles those are two key things that will help you differentiate pre-obital cellulitis from orbital cellulitis and again you come from the diagnosis of orbital cellulitis with an ocular CT scan now how do you treat orbital cellulitis right so i said that and again like all these anti-bary regimens it's really hard to memorize but they're just certain logical ways to think about this right so i just said that these infections are classically caused by like it's usually polymicrobial right but it could be caused by staff orius or streps species right so you already know right of the bad that you want to cover staff orius right um so you really give like a drug cocktail for orbital cellulitis right so you know okay i really want to cover staff orius right so you should make sense that a drug like clinda mycin or bactram right try methylperin cell from the thoxazole could be used to treat orbital cellulitis but they're also streps species that would cause this problem right and streps species are not covered very nicely by clinda right so you usually want to add on something you want to add on some kind of penicillin right you may add like a moxicillin or a moxicillin plus clavolanic acid or like a third generation sephalosporin right like uh except triaxone for example ivesyfftraaxone you could use that for for a bit of cellulitis okay so um let's see is the other thing i want to say here i don't think so so i'm gonna i'm gonna keep going but remember saying this idea is probably like a big risk factor you want to uh so don't keep in mind for exams with albino cellulitis okay now next question of 23 year old female presents with a two day history of severe left eye pain she can barely see anything out of the left eye that'

s not good now here's the kicker the patient mentions that the visual difficulty gets worse after she takes a hot shower so first of what does this patient have?

neurologic symptoms that get worse in warmer temperatures that's something known as utops phenomenon it's pretty classic and multiple sclerosis right so this patient with MS that has visual difficulty obviously has optic neuritis okay this patient has optic neuritis um usually you make the diagnosis clinically if a person has a case of MS present eye pain you're almost pretty certain we have a optic neuritis although if he the diagnosis is like calling to question and they are trying to get it to pick an imaging test on exams go for an uh go for an MRI imaging this can be identified pretty well on an MRI and the classic disease association again multiple sclerosis like if you see multiple sclerosis and eye problems the first thing you should have a basically should have a very good reason to not pick optic neuritis on exams and really the pathophys involves like an inflammation like a dimi-lineeting inflammation if you're may of the optic nerve that's criny under two um so if you have that inflammation it can present as an afferent popularity effect so these people tend to have like visual difficulty they say like oh they're not seen out of this eye they have pain in that eye pain with eye movement blah blah blah and usually it resolves over time like over like two to three month period uh the vision usually comes back at least for the most part um although this is something you definitely want to treat right because uh uh it's pretty painful it's pretty debilitating so usually you start with like a topic or steroid um actually whoops sorry usually start with an IV steroid IV steroid that's why I actually put uh sorry I'm seeing many of these things from memory um but usually start with an IV steroid uh not oral so that's why I actually put this unique treatment business here on exams if they give you two options and IV steroid is one option and oral steroid is anothe

r option go ahead and pick IV steroid known really knows why but in general oral steroids increase the risk of recurrence of optic neuritis so usually when you start treatment you start first with IV steroids and then if you want to like tip her the patient you can then switch to oral steroid but usually very high you to know this actually you start with IV steroids and again the most likely sick well of diseases that it all resolves over time it all resolves over time okay so I think that's what I'm gonna say here so let's jump up to the next slide so 76 year old female comes to her PCP for routine anal exam she complains of a six month history so this is the classic we will give you this question on the exam so you probably want to pay attention here so 76 year old female comes to her PCP for routine anal exam she complains of a six month history of difficulty driving at night and reading root signs difficulty driving at night reading root signs if you see this the first and only thing you should think about on any USMLE exam or NV Me test is cataracts okay you definitely definitely definitely want to think about cataracts and really the pathophys here is that you have something that opacifies the lens okay so you don't see as well so classically these patients they say oh they have trouble reading small print or they cannot read root signs or they cannot drive comfortably at night if you see all those think about cataracts okay and the big metabolic risk factor right is diabetes remember diabetes you have a very high level of glucose alcohol let's see what is that in Zanyolus let's see all those reducties all those reducties sorry I had to put on my step one had their first second but all those reducties converts the glucose to sorbidol and that's sorbidol right usually the lens of the eye does not have a sorbidol dehydrogenase so you cannot convert the sorbidol to

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so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so that's so

Floaters (sensation of floating items), bright streaks of light (photopsia), or a shadow/veil coming from the periphery.

The cornea reflex test showing that the reflection of light off the cornea is in different locations when looking at both eyes.

Strabismus (eye misalignment).

Acute angle closure glaucoma.

It is typically polymicrobial (Staphylococcus aureus + Strep species), requiring coverage like clindamycin plus a penicillin or third-generation cephalosporin.

IV steroids, as oral steroids increase the risk of recurrence.

Diabetes and chronic steroid use.

Wet ARMD; Anti-VEGF agents inhibit neovascularization by targeting growth factors like VEGF.

Orbital cellulitis involves pain with eye movement and involvement of extraocular muscles, which is absent in pre-orbital cellulitis.

Bitter blockers; these decrease the synthesis of aqueous humor by inhibiting sympathetic stimulation of the ciliary epithelium.

Glucose is converted into sorbitol, which accumulates in the lens because the lens lacks sufficient sorbitol dehydrogenase.

Laser photocoagulation (or laser retinopexy).

Diabetes and chronic steroid use.

Wet ARMD; Anti-VEGF agents inhibit neovascularization by targeting growth factors like VEGF.

Orbital cellulitis involves pain with eye movement and involvement of extraocular muscles, which is absent in pre-orbital cellulitis.

Bitter blockers; these decrease the synthesis of aqueous humor by inhibiting sympathetic stimulation of the ciliary epithelium.

Glucose is converted into sorbitol, which accumulates in the lens because the lens lacks sufficient sorbitol dehydrogenase.

Laser photocoagulation (or laser retinopexy).