Episode 58 – Ophthalmology

The Free Open Access Medical Education (FOAM) 

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We cover an incredible ophthalmology resource, OphthoBook.com, by Dr. Tim Roots.  This resource has a free book and excellent free video lectures.  Specifically, we detail a hilarious video on eye exam tricks, especially targeting individuals who “can’t see.”

ReasonExam Trick 
"Can't See"Optokinetic DrumEyes track movement in a non-voluntary way and results in pursuit, sacchade. Vision is at least 20/200 if they can do this
"Can't See"Stick out your hand as if to shake theirsOften a habit to reflexively reach out
"Can't See"Have the patient touch their index fingers together in front of them.This is a test of proprioception so if they are unable to do this, they either have a problem with proprioception or are faking.
Visual Field or Possible NeglectHold a pen horizontally in front of the patient's face and ask them to point to midline.If the patient points off of midline, this suggests a visual field deficit
  • Core Content
  • We previously reviewed eye trauma in this podcast. In this episode, we review ophthalmology basics using Tiintinalli’s Emergency Medicine Chapter 241.
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When doing the pupillary exam, it is important to assess for an afferent pupillary defect (APD). Ophthalmologists will want “there is or is NOT an APD” when you consult them for essentially any reason.  Normal pupils constrict when the light is shown in either pupil (direct and consensual constriction). To assess for an APD, perform the “swinging light test.”


Causes: optic nerve pathology (ex: optic neuritis) or occsaionally, retinal pathology (CRAO)


Peer reviewed by Michael Westafer, MD ophthalmologist and glaucoma fellow at Cleveland Clinic.

Generously Donated Rosh Review Questions

A 72-year-old man presents with a painful red eye and visual loss worsening over the last 24 hours. He recently had cataract surgery. Examination of the eye reveals the image above. Which of the following is the most likely?

A. Endophthalmitis

B. Hyphema

C. Uveitis

D. Vitreous hemorrhage


A. Endophthalmitis is an infection involving the anterior, posterior and vitreous chambers of the eye. It results from trauma (blunt globe rupture, penetrating injury, foreign bodies) and alsoiatrogenically after ocular surgery like cataract repair. Patients complain of severe pain in the eye and visual impairment or loss. Examination of the eye reveals decreased visual acuity, injected conjunctiva, chemosis and haziness of the infected chambers. Infections are treated with both systemic and intraocular antibiotics.

A hyphema (B) is blood in the anterior chamber usually caused by trauma. When the patient is in an upright position, blood will layer along the inferior aspect of the anterior chamber. As the hyphema increases in size, it elevates intraocular pressure. In some cases admission is warranted for patients with large hyphemas (>50%), decreased vision, sickle cell disease and elevated intraocular pressure. Treatment is aimed at decreasing pressure with topical (beta-blocker, alpha agonist or carbonic anhydrase inhibitors) and systemic therapy (carbonic anhydrase inhibitor, mannitol). Uveitis (C) occurs after blunt trauma in which the iris and ciliary body are inflamed causing ciliary spasm. Patients complain of significant photophobia with significant eye pain. Examination of the eye reveals perilimbal conjunctival injection (also called ciliary flush) and a small, poorly dilating pupil. Photophobia occurs with light shone on both the affected and unaffected eye. On slit lamp, cells (white and red) and flare (protein) are noted in the anterior chamber. Treatment is with a topical cycloplegic agent to minimize spasm. Vitreous hemorrhage (D) occurs as a result of injuries to the retina, uveal tract and their associated vascular structures. Common associated conditions include diabetic retinopathy, retinal vein occlusion and trauma. Patients complain of decreased visual acuity and floaters. The condition is not typically painful. Diagnosis is made with ocular ultrasound showing blood products in the posterior chamber.

What is a dependent pocket of pus seen in the anterior chamber called?

  • Answer
  • Hypopyon.