Ophthalmology

Rotation Goals and Objectives

Ophthalmology Learning Checklist


Rotation Logistics

Board Review Questions

An 84-year-old female presents with dryness and irritation in her eyes. Her optometrist recently

diagnosed her with dry eye.

Which one of the medications in this patient’s current regimen is most likely causing her dry eye?

A) Amitriptyline

B) Empagliflozin (Jardiance)

C) Levothyroxine (Synthroid)

D) Liraglutide (Victoza)

E) Metformin (Glucophage)

ANSWER: A

Many systemic drugs have been reported to trigger dry eye, including diuretic agents, -blockers, other

antihypertensive agents such as candesartan, antihistamines, decongestants, medications for Parkinson’s

disease, antidepressant agents such as amitriptyline, anxiolytic agents, antispasmodic agents, anticonvulsant

agents, gastric protection agents, oral contraceptives, and some herbal supplements. Empagliflozin,

levothyroxine, liraglutide, and metformin are not associated with dry eye.


Ref: Clayton JA: Dry eye. N Engl J Med 2018;378(23):2212-2223.

A 70-year-old male sees you for evaluation prior to cataract surgery. He has well controlled hypertension, as well as prediabetes and erectile dysfunction.

Which one of the following would be most appropriate prior to the procedure?

A) No testing

B) A prothrombin time and INR determination

C) A CBC

D) A resting EKG

E) 2D echocardiography

ANSWER: A

Medical testing prior to cataract surgery does not improve outcomes and is not recommended. A

prothrombin time and INR determination, a CBC, a resting EKG, and 2D echocardiography would not be

appropriate prior to this patient’s cataract surgery.


Ref: Pelletier AL, Rojas-Roldan L, Coffin J: Vision loss in older adults. Am Fam Physician 2016;94(3):219-226.

The U.S. Preventive Services Task Force recommends vision screening to detect amblyopia

A) at 2 years of age

B) at 3–5 years of age

C) the summer before the child enters first grade

D) once at 4–5 years of age and once at 8–9 years of age

ANSWER: B

Amblyopia is one of the most common causes of vision abnormalities in children, and early detection and

treatment can help prevent vision loss. The U.S. Preventive Services Task Force recommends vision

screening for all children at least once between 3 and 5 years of age to detect the presence of amblyopia

or its risk factors (B recommendation).


Ref: McConaghy JR, McGuirk R: Amblyopia: Detection and treatment. Am Fam Physician 2019;100(12):745-750.

A 36-year-old female presents to your office with a 24-hour history of redness in her right eye. It is associated with mild pain but no drainage. On examination her visual acuity is 20/20 bilaterally, her pupillary reflex is normal, extraocular movements are intact, and there is no discharge noted. There is a focal area of hyperemia of the episcleral blood vessels noted along the medial aspect of the eye. Fluorescein staining is normal.

This patient’s presentation is most consistent with which one of the following?

A) Bacterial conjunctivitis

B) Viral conjunctivitis

C) Episcleritis

D) Iritis

E) Keratitis

ANSWER: C

An acute red eye is a common presentation in primary care and it is critical to differentiate serious causes

from benign causes. Episcleritis is a self-limited condition that can be idiopathic and presents with mild

discomfort and focal hyperemia. Conjunctivitis is typically associated with a discharge that is clear in viral

cases and mucopurulent in bacterial cases. Iritis is associated with significant pain, a poorly reactive pupil,

diminished vision, and photophobia. This patient does not have changes in visual acuity, photophobia, or

severe pain as seen in keratitis, which would also cause an abnormal fluorescein stain showing corneal

ulceration.


Ref: Cronau H, Kankanala RR, Mauger T: Diagnosis and management of red eye in primary care. Am Fam Physician

2010;81(2):137-144. 2) Pflipsen M, Massaquoi M, Wolf S: Evaluation of the painful eye. Am Fam Physician

2016;93(12):991-998. 3) Goldman L, Schafer AI (eds): Goldman’s Cecil Medicine , ed 25. Elsevier Saunders, 2016, pp

2556-2568.

A 67-year-old male presents to your office for evaluation of chronic redness, flaking, and discomfort of his eyelids. Additionally, his eyes feel irritated, dry, and sandpapery at times. He has had difficulties with these symptoms on and off throughout his life but they have worsened lately. He has not had any vision changes and does not wear contact lenses.

On examination his eyelids appear red and mildly swollen with yellow crusting at the bases of the eyelashes. You note bilateral mild conjunctival injection. Visual acuity is intact, as are pupil reactions and extraocular movements.

Which one of the following treatments is appropriate first-line therapy for this condition?

A) Warm compresses and gentle cleansing with a mild shampoo

B) Sodium sulfacetamide eye drops

C) Topical betamethasone

D) Oral acyclovir (Zovirax)

E) Oral cephalexin (Keflex)

ANSWER: A

This patient has blepharitis, a chronic inflammation of the eyelids. Seborrhea is a common cause in older adults. In younger patients including children, colonization with Staphylococcus may be a contributing factor. Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of tear films, which leads to dry eyes and irritation. Other diagnoses to consider in this patient include conjunctivitis, preseptal cellulitis, and Sjögren’s syndrome. Conjunctivitis typically involves the conjunctiva and an eye discharge but less involvement of the eyelids is present. Cellulitis is an acute rather than chronic condition and involves more pain and swelling. Sjögren’s syndrome causes dry eye but not inflammatory changes of the lid.

The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral antibiotics can be considered for more severe cases.

Ref: Turnbull AM, Mayfield MP: Blepharitis. BMJ 2012;344:e3328.

90. A 30-year-old female sees you for a routine health maintenance visit. She has myopia and says she is considering LASIK eye surgery and wants your advice.

You tell her that LASIK is associated with

A) a moderate reduction in problems with glare

B) a moderate reduction in problems with dry eyes

C) satisfactory improvement of vision in almost all patients

D) prevention of presbyopia

ANSWER: C

LASIK corrective vision surgery has become increasingly common over the last 20 years. A laser is used to cut a flap the size of a contact lens consisting of corneal epithelium and stroma. This flap is repositioned and heals without sutures.

It is important to counsel patients on realistic expectations. Vision following the procedure may not be as clear as with glasses or contact lenses and some individuals still require external correction. Up to 40%of patients experience dry eyes following the surgery (SOR B). These symptoms may be worse in patients with chronic pain syndromes such as fibromyalgia, migraine, and irritable bowel syndrome (SOR C). Glares, halos, and starbursts may affect up to 20% of patients following LASIK. This may be especially bothersome at night (SOR B).

LASIK does not correct age-related presbyopia (SOR C). Reading glasses may be necessary if this develops in certain patients. Overall, however, most patients are satisfied with their results and only 3% are unhappy with their vision following surgery (SOR C).

Ref: Messmer JJ: LASIK: A primer for family physicians. Am Fam Physician 2010;81(1):42-47. 2) Wilkinson JM, Cozine EW, Kahn AR: Refractive eye surgery: Helping patients make informed decisions about LASIK. Am Fam Physician 2017;95(10):637-644.