ISAL 2025

Disclosure

Relevant relationships with commercial entities

None

Potential for conflicts of interest within this presentation

None

Steps take to review and mitigate potential bias

None

Learning Objectives

By the end of this lecture, the learner should be able to:
1.

Describe high-yield ocular anatomy and physiology

2.

Understand the high-yield concepts of refractive error,
pediatric ophthalmology, ocular trauma, glaucoma, and
cataracts

3.

Develop a high-yield differential diagnosis for red eye and
painless vision loss

4.

Ace the ophthalmology section on the exam!

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 1

Which part of the cornea is most responsible for keeping the cornea
clear?

A.

Epithelium

B.

Stroma

C.

Descemet’s membrane

D.

Endothelium

Multiple Choice

Which part of the cornea is most responsible for keeping the cornea clear?

• Epithelium

• Stroma

• Descemet's membrane

• Endothelium

Ocular Anatomy

*

*

*

*

*

*

Question 2

Which one of the following structures, when obstructed, can cause
epiphora?

A.

Orbital septum

B.

Lacrimal gland

C.

Nasolacrimal duct

D.

Trabecular meshwork

Multiple Choice

Which one of the following structures, when obstructed, can cause epiphora?

• Orbital septum

• Lacrimal gland

• Nasolacrimal duct

• Trabecular meshwork

Ocular Anatomy – Adnexal Structures

Question 3

Which part of the retina is most responsible for high resolution vision?

A.

Fovea

B.

Macula

C.

Optic disc

D.

Optic nerve

Multiple Choice

Which part of the retina is most responsible for high resolution vision?

• Fovea

• Macula

• Optic disc

• Optic nerve

Retinal Physiology

*

*

*

Questions about ocular anatomy and physiology?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 4

A 45-year old woman presents to the ER with right then left eye
watery discharge, AM crusting, foreign body sensation and
redness. Does this need antibiotics?

A.

Yes

B.

No

Multiple Choice

A 45-year old woman presents to the ER with right then left eye watery discharge, AM crusting, foreign body sensation and redness. Does this need antibiotics?

• Yes

• No

Question 5

Name that eye redness! How would you describe this eye redness to
the ophthalmologist on call over the phone?

A.

Very red eye

B.

Ciliary flush

C.

Scleral flush

D.

Conjunctival flush

Multiple Choice

Name that eye redness! How would you describe this eye redness to the ophthalmologist on call over the phone?

• Very red eye

• Ciliary flush

• Scleral flush

• Conjunctival flush

Question 6

You suddenly remember your second year of medical school ISAL and say
“Ah yes, esteemed ophthalmologist colleague, this patient has ciliary flush.”
But wait you think to yourself, what was ciliary flush a sign of again?

A.

Eye cancer

B.

Corneal abrasion

C.

Corneal ulcer

D.

Anterior uveitis

Multiple Choice

You suddenly remember your second year of medical school ISAL and say “Ah yes, esteemed ophthalmologist colleague, this patient has ciliary flush.” But wait you think to yourself, what was ciliary flush a sign of again?

• Eye cancer

• Corneal abrasion

• Corneal ulcer

• Anterior uveitis

Question 7

A 27 year old contact-lens-wearing, hot-tub-swimming patient presents
with a 1-day history of right eye redness and pain. Examination is
show in the figure below. What is the diagnosis?

A.

Eye cancer!!!

B.

Corneal abrasion

C.

Corneal ulcer

D.

Anterior uveitis

Multiple Choice

A 27 year old contact-lens-wearing, hot-tub-swimming patient presents with a 1-day history of right eye redness and pain. Examination is show in the figure below. What is the diagnosis?

• Eye cancer!!!

• Corneal abrasion

• Corneal ulcer

• Anterior uveitis

Question 8

You thankfully send this patient with the corneal ulcer to see
ophthalmology. You wonder to yourself, what would ophthalmology do
next with this patient?

A.

Scrape the cornea and send to microbiology

B.

Enucleate the eyeball

C.

Start Visine drops

D.

Draw CBC and blood cultures

Multiple Choice

You thankfully send this patient with the corneal ulcer to see ophthalmology. You wonder to yourself, what would ophthalmology do next with this patient?

• Scrape the cornea and send to microbiology

• Enucleate the eyeball

• Start Visine drops

• Draw CBC and blood cultures

Corneal abrasion vs corneal ulcer

Corneal abrasion
= epithelial defect

Corneal ulcer
= epithelial defect +
white infiltrate

Question 9

A 70-year old Asian woman presents to the emergency department with a
right red painful eye and nausea and vomiting. Her vision is 20/400 in the
right eye, 20/30 in the left eye. Her intraocular pressure is 60 mmHg in the
right eye, and 21 mmHg in the left eye. You also remember to check her
pupils. Which one of the following pupillary findings would you expect?

A.

Normal

B.

RAPD in the left eye

C.

RAPD in the right eye

D.

Fixed, mid-dilated right pupil

Multiple Choice

A 70-year old Asian woman presents to the emergency department with a right red painful eye and nausea and vomiting.  Her vision is 20/400 in the right eye, 20/30 in the left eye.  Her intraocular pressure is 60 mmHg in the right eye, and 21 mmHg in the left eye. You also remember to check her pupils. Which one of the following pupillary findings would you expect?

• Normal

• RAPD in the left eye

• RAPD in the right eye

• Fixed, mid-dilated right pupil

Questions about red eye?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 10

You go see your optometrist and on their glasses prescription
they write +2.00 D. Which best describes the refractive state of
your eye, and where is the image is focused relative to the
retina?

A.

Hyperopic, in front of the retina

B.

Hyperopic, behind the retina

C.

Myopic, in front of the retina

D.

Myopic, behind the retina

Multiple Choice

You go see your optometrist and on their glasses prescription they write +2.00 D. Which best describes the refractive state of your eye, and where is the image is focused relative to the retina?

• Hyperopic, in front of the retina

• Hyperopia, behind the retina

• Myopic, in front of the retina

• Myopic, behind the retina

Question 11

A 50-year old man presents to the family doctor’s office with decreased visual
acuity in both eyes. When asked about his symptoms, he states it is
bilateral, and only at near. Which one of the following would be the most
likely diagnosis?

A.

Myopia

B.

Hyperopia

C.

Cataracts

D.

Presbyopia

Multiple Choice

A 50-year old man presents to the family doctor’s office with decreased visual acuity in both eyes.  When asked about his symptoms, he states it is bilateral, and only at near.  Which one of the following would be the most likely diagnosis?

• Myopia

• Hyperopia

• Cataracts

• Presbyopia

Presbyopia

Presbyopia = decreased
accommodation due to hardening
of the lens from aging (starting
around the age of 40)

Questions about refractive error?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 12

A 7 year old boy is brought in to your clinic by his father because
he noticed that the right eye was turning out occasionally for the
last 2 weeks. On examination, the child looks well and the eye
movements appear full. What is the most likely diagnosis?

A.

Cranial nerve VI palsy

B.

Cranial nerve III palsy

C.

Intermittent exotropia

D.

Intermittent esotropia

Multiple Choice

A 7 year old boy is brought in to your clinic by his father because he noticed that the right eye was turning out occasionally for the last 2 weeks. On examination, the child looks well and the eye movements appear full. What is the most likely diagnosis?

• Cranial nerve VI palsy

• Cranial nerve III palsy

• Intermittent exotropia

• Intermittent esotropia

Strabismus

Question 13

A 3-year old girl is in to see you for her annual examination.
When you examine her, you notice that the right eye has a
decreased red reflex. Which one of the following is the most
appropriate next step?

A. Urgent referral to ophthalmology

B.

Recommend patching of the left eye

C.

Order CT head and orbit

D.

Recommend optometrist visit for refraction

Multiple Choice

A 3-year old girl is in to see you for her annual examination.  When you examine her, you notice that the right eye has a decreased red reflex.  Which one of the following is the most appropriate next step?

• Urgent referral to ophthalmology

• Recommend patching of the left eye

• Order CT head and orbit

• Recommend optometrist visit for refraction

Leukocoria (white reflex)

Leukocoria = URGENT REFERRAL
Think retinoblastoma (life threatening),
cataract (vision threatening)

Questions about pediatric ophthalmology?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 14

A 85-year old woman presents to the ER with sudden loss of vision x 1 day. On
ROS, she states that she has temporal tenderness and jaw claudication. Her ESR
and CRP are elevated. Which one of the following management steps would be the
most appropriate as the next step?

A.

Next-day urgent referral to ophthalmology

B.

Start IV antibiotics

C.

Start IV steroids

D.

Temporal artery biopsy

Multiple Choice

A 85-year old woman presents to the ER with sudden loss of vision x 1 day.  On ROS, she states that she has temporal tenderness and jaw claudication.  Her ESR and CRP are elevated.  Which one of the following management steps would be the most appropriate as the next step?

• Next-day urgent referral to ophthalmology

• Start IV antibiotics

• Start IV steroids

• Temporal artery biopsy

GCA – And that time I didn’t get sued

•Who?

• F>M
• >50 year old ONLY

•What?

• HA, Scalp tenderness, PMR, Jaw claudication, B

symptoms

•Patients who get vision loss:

• 1/3 blind within 1 day
• 1/3 blind within 1 week
• 1/3 blind within 1 month

Question 15

Sign for which spot diagnosis? Go!

A: White moon sign for Central Retinal Vein Occlusion

B: Twilight zone for Central Retinal Artery Occlusion

C: Black dusk spot for Central Retinal Vein Occlusion

D: Cherry red spot for Central Retinal Artery Occlusion

Multiple Choice

Sign for which spot diagnosis? Go!

• White moon sign for Central Retinal Vein Occlusion

• Twilight zone for Central Retinal Artery Occlusion

• Black dusk spot for Central Retinal Vein Occlusion

• Cherry red spot for Central Retinal Artery Occlusion

Central retinal artery occlusion

Central retinal artery occlusion = stroke to eye

Need to get stroke workup

Question 16

A 85-year old woman presents to the ER with sudden loss of vision in the
right eye x 1 day to 20/200. On ROS, she denies temporal tenderness, jaw
claudication or weight loss. Her ESR and CRP are normal. Fundus
examination of the right eye reveals a subretinal hemorrhage; fundus
examination of the left eye reveals multiple yellowish deposits. Based on the
most likely diagnosis, which one of the following would be most appropriate
for the treatment of her right eye?

A.

Prescribe antibiotics

B.

Start IV steroids

C.

Laser retinopexy

D.

Intravitreal anti-VEGF

Multiple Choice

A 85-year old woman presents to the ER with sudden loss of vision in the right eye x 1 day to 20/200. On ROS, she denies temporal tenderness, jaw claudication or weight loss.  Her ESR and CRP are normal.  Fundus examination of the right eye reveals a subretinal hemorrhage; fundus examination of the left eye reveals multiple yellowish deposits.  Based on the most likely diagnosis, which one of the following would be most appropriate for the treatment of her right eye?

• Prescribe antibiotics

• Start IV steroids

• Laser retinopexy

• Intravitreal anti-VEGF

AMD – What do I need to know?

1.

Disease of aging = dysfunctional RPE, garbage builds up,
slow vision loss

2.

Known AMD with acute worsening of central vision = most
likely ”wet” AMD process

3.

Treatment of wet = anti-VEGF

4.

Treatment of dry = AREDS2 vitamins (lifestyle modifications)

Question 17

A 74 year old man presents with new onset of flashes and
floaters. He denies any visual field defects. What is the most
likely diagnosis?

A.

Retinal detachment

B.

Posterior vitreous detachment

C.

Choroidal detachment

D.

Optic nerve detachment

Multiple Choice

A 74 year old man presents with new onset of flashes and floaters. He denies any visual field defects. What is the most likely diagnosis?

• Retinal detachment

• Posterior vitreous detachment

• Choroidal detachment

• Optic nerve detachment

Retinal detachment vs PVD

90% flashes and floaters = POSTERIOR VITREOUS DETACHMENT

10% of PVDs cause a retinal tear that need to be lasered.

This should be seen by ophthalmology within 72 hours.

If no visual field defect, it is NOT a retinal detachment.

Question 18

Your granddad Jim comes to you and tells you that he has “the
diabetus.” His ophthalmologist tells you he has proliferative
diabetic retinopathy without macular edema. What is the
treatment for this condition?

A. Needle to the eye!

B.

Lasers to the eye!

C.

Observe closely the eye!

D.

Cataract surgery the eye!

Multiple Choice

Your granddad Jim comes to you and tells you that he has “the diabetus.” His ophthalmologist tells you he has proliferative diabetic retinopathy without macular edema. What is the treatment for this condition?

• Needle to the eye!

• Lasers to the eye!

• Observe closely the eye!

• Cataract surgery the eye!

Diabetic retinopathy

Diabetic retinopathy management

•If no diabetic retinopathy -> annual follow-up
•If non proliferative diabetic retinopathy -> follow-up in 1-6
months
•If proliferative diabetic retinopathy -> needs laser (PRP)
•If diabetic macular edema -> needs anti-VEGF injection

Question 19

Your grandma comes to you and tells you she has a “SERVO”.
Her ophthalmologist tells you she actually has a CRVO or a
Central Retinal Vein Occlusion, with macular edema. What is the
treatment for this condition?

A. Needles to the eye!

B.

Lasers to the eye!

C.

Observe closely the eye!

D.

Cataract surgery the eye!

Multiple Choice

Your grandma comes to you and tells you she has a “SERVO”. Her ophthalmologist tells you she actually has a CRVO or a Central Retinal Vein Occlusion, with macular edema. What is the treatment for this condition?

• Needles to the eye!

• Lasers to the eye!

• Observe closely the eye!

• Cataract surgery the eye!

Central retinal vein occlusion

If macular edema = anti-VEGF injection

CRAO vs CRVO

Questions about painless vision loss?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 20

A 32 year old man presents with a left eye injury after getting
hammering metal on metal. On examination his visual acuity is
20/20 in the right eye and counting fingers in the left eye.
Examination shows 360 degrees of subconjunctival hemorrhage
and a peaked pupil. What is the next step in management?

A. Check the IOP

B.

Order CT head and orbits

C.

Refer for urgent ophthalmology next day follow-up

D.

Start artificial tears and cool compresses

Multiple Choice

A 32 year old man presents with a left eye injury after getting hammering metal on metal. On examination his visual acuity is 20/20 in the right eye and counting fingers in the left eye. Examination shows 360 degrees of subconjunctival hemorrhage and a peaked pupil. What is the next step in management?

• Check the IOP

• Order CT head and orbits

• Refer for urgent ophthalmology next day follow-up

• Start artificial tears and cool compresses

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture
2. Rust foreign body + high velocity mechanism = tetanus, orbital

x ray

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture
2. Rust foreign body + high velocity mechanism = tetanus, orbital

x ray

3. Globe rupture = Eye shield, IV antibiotics, CT head/orbit *rule

out NSx* NPO, urgent ophthalmology consult for repair

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture
2. Rust foreign body + high velocity mechanism = tetanus, orbital

x ray

3. Globe rupture = Eye shield, IV antibiotics, CT head/orbit *rule

out NSx* NPO, urgent ophthalmology consult for repair

4. Orbital floor fracture = Rule out IR entrapment

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture
2. Rust foreign body + high velocity mechanism = tetanus, orbital

x ray

3. Globe rupture = Eye shield, IV antibiotics, CT head/orbit *rule

out NSx* NPO, urgent ophthalmology consult for repair

4. Orbital floor fracture = Rule out IR entrapment
5. Chemical injury = copious irrigation until pH is normal

Ocular trauma pearls

1. 360 subconjunctival hemorrhage = rule out globe rupture
2. Rust foreign body + high velocity mechanism = tetanus, orbital

x ray

3. Globe rupture = Eye shield, IV antibiotics, CT head/orbit *rule

out NSx* NPO, urgent ophthalmology consult for repair

4. Orbital floor fracture = Rule out IR entrapment
5. Chemical injury = copious irrigation until pH is normal
6. Lid laceration = If it involves the margin, need to call

ophthalmology. If it’s medial, R/O canalicular involvement

Questions about ocular trauma?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 21

Your Aunt May tells you she has glaucoma. What is the best
definition of glaucoma?

A. Never waking up from a real deep sleep

B.

A characteristic optic neuropathy with characteristic visual field
defects

C.

High intraocular pressure disease

D.

A disease that Dr. Glaucomflecken treats on TikTok

Multiple Choice

Your Aunt May tells you she has glaucoma. What is the best definition of glaucoma?

• Never waking up from a real deep sleep

• A characteristic optic neuropathy with characteristic visual field defects

• High intraocular pressure disease

• A disease that Dr. Glaucomflecken treats on TikTok

Glaucoma is like primary hypertension

>90% of hypertension is primary hypertension NOT
hypertensive crisis

>90% of glaucoma is primary open angle glaucoma NOT
acute angle closure glaucoma!

Primary open angle glaucoma top 5 pearls

1.

Main risk factors for POAG are: increasing age, increased c/d ratio, increased
intraocular pressure, family history, ethnic background, and thin central corneal
thickness

2.

Glaucoma is an optic neuropathy that is mainly controlled by lowering IOP; even
though “21 mmHg” is a cut off, other parts of the exam including optic nerve
examination and visual field testing are critical for following and titrating
management

3.

Glaucoma is managed by topical intraocular lowering agents, laser, and surgery

4.

For patients on topical therapy —> consider systemic side effects like
beta-blockers and asthma or bradycardia

5.

Diagnosing glaucoma: History, IOP, optic nerve head cupping, visual field

Questions about glaucoma?

Agenda

1.

Review high-yield ocular anatomy and physiology

2.

Go through important causes for the red eye

3.

Figure out how glasses work

4.

Kiddie eyeball time!

5.

Go through important causes for painless vision loss

6.

Learn how to manage ocular traumas

7.

Figure out what glaucoma is even

8.

Take out some cataracts! (jk)

Question 22

Your uncle Bob is asking you about these “cataracts” in his eye
that his ophthalmologist recently diagnosed. What is the most
likely symptoms he might be having?

A.

Blurry vision in the morning only

B.

Blurry vision at near only

C.

Blurry vision in the distance only

D.

Glare and pinwheels while driving at night

Multiple Choice

Your uncle Bob is asking you about these “cataracts” in his eye that his ophthalmologist recently diagnosed. What is the most likely symptoms he might be having?

• Blurry vision in the morning only

• Blurry vision at near only

• Blurry vision in the distance only

• Glare and pinwheels while driving at night

Cataracts

Causes of cataracts

• Aging

• Trauma

• Medications (eg. long-term steroid use)

• Intraocular inflammation (eg. uveitis)

• Systemic diseases (eg. diabetes)

• Genetic conditions

• Smoking

Question 23

A 65-year old man presents to the emergency department with pain and redness in the right
eye. On history, his past ocular history is significant for a right eye cataract surgery 5 days
ago. On exam, visual acuity is 20/400 in the right eye and 20/30 in the left eye. On slit lamp
exam, a whitish layer of material was seen in the anterior chamber. The tonopen was not
working in the ER. Which one of the following is the most appropriate diagnosis?

A.

Endophthalmitis

B.

Acute angle closure glaucoma

C.

Uveitis

D.

Corneal ulcer

Multiple Choice

A 65-year old man presents to the emergency department with pain and redness in the right eye.  On history, his past ocular history is significant for a right eye cataract surgery 5 days ago.  On exam, visual acuity is 20/400 in the right eye and 20/30 in the left eye.  On slit lamp exam, a whitish layer of material was seen in the anterior chamber. The tonopen was not working in the ER.  Which one of the following is the most appropriate diagnosis?

• Endophthalmitis

• Acute angle closure glaucoma

• Uveitis

• Corneal ulcer

Important complications of cataract surgery

•1-2 days post-op -> increased intraocular pressure!

•2-7 days post-op -> infection!

•1-4 weeks post-op -> inflammation!

Questions about cataracts?

Learning Objectives

By the end of this lecture, the learner should be able to:
1.

Describe high-yield ocular anatomy and physiology

2.

Understand the high-yield concepts of refractive error,
pediatric ophthalmology, ocular trauma, glaucoma, and
cataracts

3.

Develop a high-yield differential diagnosis for red eye and
painless vision loss

4.

Ace the ophthalmology section on the exam!

Questions?

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