30. Ocular Injuries Flashcards
lateral geniculate body, eye misalignment results in lateral geniculate nucleus atrophy, usually unilateral, early detection important because vision develops early in life, with proper visual stimulation in the early months normal acuity develops at 3 years old, can be strabismic with slight misalignment but dense amblyopia, refractive **, presents with failed vision test, strabismus, **, detect by assesing red reflex ***, important to detect because decreased vision in children can also be due to retinoblastoma, can push into the visual axis, cancer cells can seed into the jelly of the eye
amblyopia,
tropia which can manifest or be intermittent, direction of deviation can be eso or inward, exo or outward, hyper or upward, hypo or downward, diplopia is usually absent because the brain suppressed the image **, testing includes general inspection **
strabisumus
fixes and follows an object of interest, head turns for extraocular motion testing, central & steady & and maintained, cover good eye, how does the child react? do they protest, cry, or evade, follow an interesting object for visual acuity and extraocular motion, if not moving the child’s head can demonstrate extraocular motion, photoscreen can determine if they are farsighted/nearsighed/astigmatic
infants
3 year old may perform an E game, picture card, or HOTV chart, cover/uncover test, vision assessment
2-4 year olds
usually snellen test, may perform E game, cover/uncover test, if less than 20/40 refer
child 5 and up
optimize the retinal image, clera the visual pathway with cataract or ptosis surgery, correct the refractive error, glasses vs contacts 35% more likely to be bullied, intensity the neural image to the visual cortex, occulsion therapy full time vs part time, penalization (defocus) with cycloplegic to better eye
amblyopia therapy
occulsion of the unaffected good eye, success of treatment is dependent on age, degree of amblyopia, compliance with patching, better tolerated in younger patients possible up to 18 years old, must be contnued through the patient’s first decade, does not eliminate strabismus, done with patch, occasionally can have allergy to the tape
occlusion therapy
atropine 1% drop every morning in nonamblyopic eye, atropized eye cannot accomodate for near ision, child can still use better seeing eye for distance, child switches fixation at near to amblyopic eye
atropine penalization therapy
glassess alone can correct, ***
strabismus
either strengthen the muscle or weaken the muscle by recession or resection respectively. ***
strabsmus surgery
poor red reflex in one or both eyes, concern about vision by parent or doctor, asymmetric or diminishing visual acuity
immediate referral
less emergent criteria for referral
amblyopia must be detected early, visual acuity testing is cannot be overemphasized, amblyopia may present without strabismus, serious conditions may cause strabismus so refer,
important points
shaken-baby syndrome
non-accidental trauma
premature infants less than ***
retinopathy of prematurity
looks ominous but is harmless, 🏥due to sneezing, coughing, valsalva, goes away
conjunctival hemorrhage
Due to excessiveUV light, elevated lesion, ultraviolet light and sun exposure, gets inflamed, don’t let people touch them
Inflamed pinguecula & pytergium
Inflammation of sclera, episcleritis more superficial, flat or usually benign, can be from environmental allergies, “underneath vessels”, scleritis, if untreated can thin sclera it can perforate leading to infection, key is to treat systemic disease
Episcleritis
Inflammation of the colored part of the eye, anterior uveitis, redness circles the cornea, has photophobia, smaller pupil, cells and flare, hypopyon, and keratitic precipitates 💊cycloplegics, topical/periocular/systemic
Iritis
Refer to ophthalmologist
Endopthalmitis
Topical anesthetic should not be prescribed due to inhibition of growth and healing of the epithelium, loosens cornea which can be rubbed off, if visuals acuity is significantly reduced conjunctivitis is unlikely, check with flourescein for epithelium defects, pupil inequality is danger sign for ocular disease, medications applied in or around eye could be the source of the red eye
Therapeutic warning
Reduced visual acuity in the absence of detectable organic disease, abnormal visual development-suppression, can be bilateral with effective blindness, may cause a lazy eye, eye misalignment results in lateral geniculate nucleus atrophy, commonly unilateral, 💊 before age 5 less likely to be effective if after 10, can be strabismic or refractive, form deprivation can result in cataracts, corneal scarring ptosis, and occlusion amblyopia, presents with failed vision test, one eye can be bigger than the other with congenital glaucoma, can cause a lazy eye, detect by red reflex, visual acuity, and evaluating ocular alignment, decrease vision can be due to retinoblastoma
Amblyopia
Eso, exo, hyper, hypo, diplopia is absent in amblyopia, tested by cardinal positions with cover uncover test
Strabismus
Pupil reflex is not very developed so sluggish, eye movement possibly uncoordinated, red reflex assessment, fundus exam is possible
Newborn exam
Fixes and follows an object of interest, head turn for EOM testing, cover the good eye and see what happens, follow an interesting object
Infant exam
Can start doing e game, cover/uncover test, photo-screener is good but not substitute for visual acuity, if vision is <20/40 refer, hundreds and thousands test
2-4 year olds
Snellen test, may perform e game, cover/uncover, if less than 20/40 refer
5 and up
Optimize retinal image, clear visual pathway, correct the refractive error, glasses vs contacts 35% to be blind, it e sift the neural image to the visual cortex, occlusion therapy full time vs part time, penalization defocus with the cycloplegic eye, occlusion therapy which is better up until 18 yo and doesn’t eliminate strabismus and also causes allergy to tape, atropine penalization therapy 1% drop every morning in the non amblyopia eye
Amblyopia therapy
Glasses straighten them out, occasionally need to give bifocal, surgery by strengthening or weakening the muscle with recession or resection respectively
Strabismus therapy
Poor reflex in one or both eyes, concern about vision by parent or doctor, asymmetric or diminishing visual acuity, constant or acute onset strabismus, less emergency intermittent strabismus on exam, persistent parental concern, associated syndromes or systemic disease
Immediate referral criteria
amblyopia must be detected early, importance of visual acuity testing, amblyopia may present without strabismus, serious conditions may cause strabismus, if poor red reflex or poor vision or large eyes, refer to rule out cataracts, retinal disease, and glaucoma, vision training has no proven value in treatment of amblyopia or strabismus
amblyopia and strabismus important points
shaken baby syndrome
non-accidental trauma
CT
immediate response to trauma
bony orbit, floor which results in vertical diplopia and hypoesthesia, medial wall which results in epistaxis and subcutaneous emphysema, optical canal fracture which results in traumatic optic neuropathy, eyelids which can affect lagopthalmos, lid margins, exposure keratopathy, lacrimal apparatus, conjunctiva and cornea and heals rapidly, anterior chamber can be flat due to loss of aqueous humor, iris & ciliary body which can affect plugs, iritis, hyphema, lens which can affect cataracts, subluxation which can result in partial dislocation, vitreous humor which involves hemorrhage and infections, retina which involves detachment, hemorrhage, edema, and macula
basic anatomy for orbital trauma
place & time of injury, circumstances of occurrence, ocular history, drug allergies, tetanus immunization, if patient unable to respond, ask companion but may need to proceed with the physical exam, hammering on metal intraocular foreign body, grinding may cause corneal foreign body, welding may cause corneal UV burn, racquet sports cause hyphema, and fist fights cause hyphema, BOF, or ruptured globe
orbital trauma
visual acuity, external exam, pupils, motility exam, anterior segment, opthalmopathy, radiologic studies CT is preferred initially because MRI can pull out metal, ultrasound is not first line
orbital trauma exam
