09 Othal Flashcards
I. A 1-year-old child is suspected of having strabismus. You verify that indeed the corneal reflection from a bright light in your examining room comes from different places from each of his eyes.
II. A 2-year-old child is diagnosed with a congenital cataract obstructing his vision in the right eye.
What is the point of these vignettes? To remind you that the brain “learns” to see what the eyes see during early infancy (up to about age 7). If one eye cannot see (any kind of obstruction) or the brain does not like what they see (double vision), the brain will refuse to process the image and that cortical “blindness” will be permanent (the concept of amblyopia).
Management. The problem has to be surgically corrected as early as possible.
A young mother is visiting your office for routine medical care. She happens to have her 18-month-old baby with her, and you happen to notice that one of the pupils of the baby is white, whereas the other one is black.
What is it? An ophthalmologic and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. This kid needs to see the ophthalmologist not next week, but today or tomorrow. If it turns out to be something more innocent, like a cataract, the kid still needs it corrected to avoid amblyopia.
A 53-year-old woman is in the ER complaining of extremely severe frontal headache and nausea. The pain started about an hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical examination the pupils are mid-dilated and do not react to light; the corneas are cloudy and with a greenish hue, and the eyes feel “hard as a rock.”
What is it? A classic description of acute glaucoma. Not the most common type (most are asymptomatic—but you cannot write a vignette for those), but one that requires immediate treatment.
Management. An ophthalmologist is needed right away—but start treatment with systemic carbonic anhydrase inhibitors, topical beta-blockers, and alpha-2–selective adrenergic agonists. Mannitol and pilocarpine may also be used.
A 32-year-old woman presents in the ER with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye.
What is it? Orbital cellulitis.
Management. Another ophthalmologic emergency that requires immediate consultation, but if asked what to do, CT scan will be indicated to assess the extent of the orbital infection, and surgical drainage will follow.
A frantic mother reaches you on the phone, reporting that her 10-year-old boy accidentally splashed Drano on his face and is screaming in pain, complaining that his right eye hurts terribly.
Management. We know that copious irrigation is the main treatment for chemical burns. The point of this vignette is to remind you that time is a key element. If the lady is instructed to bring the boy to the ER, his eye will be cooked to a crisp by the time he arrives. The correct answer here is to instruct the mother to pry the eye open under the cold water from the tap at home, and irrigate for about half an hour before she brings the kid to the hospital. You will do more irrigation in the ER, remove solid matter, and eventually recheck the pH before the kid goes home. Do not forget to check the eyelid for remaining bits of Drano.
A 59-year-old, myopic gentleman reports “seeing flashes of light” at night when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number 10 or 20, and that he also sees a cloud at the top of his visual field.
What is it? Retinal detachment. One or two floaters would not mean that. More than a dozen is an ominous sign, and that “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye.
Management. Another ophthalmologic emergency. The retina specialist will use laser treatment to “spot weld” the retina and prevent further detachment.
A 77-year-old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurologic symptoms.
What is it? Embolic occlusion of the retinal artery.
Management. Another ophthalmologic emergency although little can be done for the problem, he has to get to the ER instantly. It might help for him to take an aspirin and breathe into a paper bag en route, and have someone press hard on his eye and release it repeatedly.
A 55-year-old man is diagnosed with type 2 diabetes mellitus. On questioning about eye symptoms, he reports that sometimes after a heavy dinner the television becomes blurry, and he has to squint to see it clearly.
What is it? The blurry TV is no big deal: the lens swells and shrinks in response to swings in blood sugar—the important point is that he needs to start getting regular ophthalmologic follow-up for retinal complications. It takes 10 or 20 years for these to develop, but type 2 diabetes may have been present that long before it was diagnosed.
