Ch 19. HEENT Flashcards
Which bones border the orbit (4) and which is the most likely to break? (4+1)
- Superior – frontal sinus
- Medially – ethmoid sinus
- Inferior – maxillary sinus
4. Laterally – zygomatic bone *
The ethmoid bone (lamina papyracea) is paper thin and most likely to break in blunt eye trauma*
A history of sudden painless vision loss is ________ until proven otherwise (1)
- Central retinal artery occlusion (stroke – think AFib, carotid stenosis)
Which cranial nerves control EOM? (3)
- Superior oblique (CN IV) – moves the eye down and in
- Lateral rectus (CN VI)
- Everything else is CN III
What does a Marcus-Gunn pupil mean? (1)
- A RAPD (swinging light test) tells you that light isn’t getting to the optic nerve, or the optic nerve isn’t working.
* Think optic neuritis, central retinal artery occlusion, retinal hemorrhage or detachment *
Define hypopyon, hyphema, flare, seidel test (positive) (4)
- Hypopyon – a layer of WBC in the anterior chamber
- Hyphema – a layer of blood in the anterior chamber
3. Flare – cells visible in the anterior chamber (usually clear) – anterior uveitis! - Seidel test – aqueous humour waterfalls down a full thickness corneal wound
What is normal IOP and what is associated with AACG? (2)
- Normal IOP 10-20mm Hg
2. AACG IOP >30, often >50
Chalazion vs hordeolum (2)
- Chalazion – acute/chronic blockage of a Meibomian oil gland. Painless lump. Refer to optho.
2. Hordeolum (stye) – Staph infection of an eyelash follicle. Rx warm compress, erythro ointment.
Red eye DDx (10)
- Conjunctivitis (viral, allergic, bacterial)
2. Corneal abrasion – scratch to the cornea
3. Corneal ulcer – bacterial infection of the cornea - Corneal foreign body – foreign body to cornea
- Keratitis – mild pain (unless UV keratitis)
- Scleritis – severe pain
- Subconjunctival hemorrhage – painless, normal VA
- Iritis/uveitis – pain, photophobia, decreased VA, watery discharge, pupil constricted, flare,
- AACG – severe pain, HA, N/V, decreased VA, cloudy cornea
- Endopthalmitis – infection of the globe. Ocular pain, photophobia, fever, decreased VA, purulent discharge, flare.
11. Preseptal cellulitis – mild pain, fever, normal VA - Orbital cellulitis – severe eye pain, pain with eye movement, fever, decreased VA (LATE)
13. Chemical burn – chemical exposure. - Hordeolum/Chalazion – mild pain. Normal VA.
Differences between periorbital cellulitis and orbital cellulitis (2) How do you know when an orbital cellulitis evolves to cavernous sinus thrombosis? (1)
- Periorbital cellulitis – often peds. Staph, strep. Eye not involved (full + Painless EOM). Rx clavulin
2. Orbital cellulitis – bacterial infection of the orbit. Pain with EOM. Decreased VA. Proptosis. Often results from spread of paranasal sinusitis through the ethmoid sinus (thin). Polymicrobial – staph, strep, anaerobes. Admit for IV antibiotics. CT orbit. Consult optho. Ceftriaxone flagyl.
3. Suspect cavernous sinus thrombosis with cranial nerve involvement (3-4-6)
Aggressive facial infection in diabetics (1)
- Mucormycosis
Can’t miss eye infections of the neonate (3)
- Gonococcal conjunctivitis
- Chlamydial conjunctivitis
- HSV keratitis
Treatment of bacterial conjunctivitis, with and without contacts (2)
- No contacts – erythromycin ointment
2. Contacts - erythromycin ointment or moxifloxacin ointment
Dx and treatment of HSV keratoconjunctivitis, Herpes zoster opthalmicus (4)
- HSV keratoconjunctivitis – red eye, + dendrites with fluorescein. Rx Valacyclovir PO and topical. Consult optho and FU 24 hours.
- Herpes zoster opthalmicus – shingles of V1. + Hutchinson sign (lesion on tip of nose). Rx valacyclovir. Consult optho.
Clinical findings in iritis/uveitis (4). DDx of iritis/uveitis (5)
- Iritis/uveitis is inflammation of the anterior eye. Sign/Sxs: painful, photophobia, perilimbal flush, +flare and cells, +consensual photophobia.
DDx iritis/uveitis:
1. Systemic disease: JRA, Ank Spond, Ulcerative colitis, Reactive arthritis, Sarcoidosis, Behcet’s - Infectious: TB, lyme, HSV, VZV, toxoplasmosis, syphilis
- Malignancy: leukemia, lymphoma, melanoma
- Trauma: blunt trauma, corneal foreign body, UV/chemical exposure
Q. What is the Dx?
1. Sudden painless vision loss immediate and over hours (2)
2. Sudden painless vision loss with black spots, haziness, and cobwebs
3. Trauma with decreased VA and shallow anterior chamber
4. Trauma with resulting restriction to upward or lateral gaze
5. Trauma with hyphema
6. Trauma with eye pain and elevated IOP
7. Sudden onset of eye pain, HA, V, with a fixed midposition pupil, cloudy cornea, conjunctivitis
8. Sudden painless vision loss with a blood and thunder fundus
9. Sudden onset flashers and floaters (DDx 2)
10. Transient vision loss with headache, jaw claudication, myalgia, fever
- Sudden painless vision loss = central retinal artery occlusion - immediate, or optic neuritis (hours-day). Consult neurology/optho immediately. Treatment is unclear ?maybe tPA.
- Sudden painless vision loss with black spots, haziness, and cobwebs = vitreous detachment/hemorrhage
3. Trauma with decreased VA and shallow anterior chamber = ruptured globe (also look for abn pupil shape, RAPD, hyphema, + Seidel test. Dx. CT. Rx tetanus and ceftriaxone, consult optho. - Trauma with resulting restriction to upward or lateral gaze = blowout fracture with entrapment. Rx Keflex consult optho/plastics for repair.
- Trauma with hyphema = traumatic hyphema is ruptured uvea. CT orbits. Consult optho.
- Trauma with eye pain and elevated IOP (and proptosis) = post-septal hemorrhage or retro-bulbar hematoma. IOP >40mm Hg = emergency lateral canthotomy. Consult optho.
- Sudden onset of eye pain, HA, V, with a fixed midposition pupil, cloudy cornea, conjunctivitis = AACG. Measure IOP (elevated IOP >30, especially >50 is a medical emergency)
- Sudden painless vision loss with a blood and thunder fundus = central retinal vein occlusion. Consult neuro/optho.
9. Sudden onset flashers and floaters (DDx 2)=retinal detachment or vitreous detachment. Beside US and refer to optho. - Transient vision loss with headache, jaw claudication, myalgia, fever = temporal arteritis. Start steroids. The biopsy will be positive for a week after steroids.
Treatment of AACG (4)
- IV mannitol 1g/kg IV
2. Topical beta blocker (blocks aqueous humor production) - Topical alpha-2 agonist (blocks aqueous humor production)
- Carbonic anhydrase inhibitor, acetazolamide 500mg IV (blocks aqueous humor production)
- Topical pilocarpine 1% one drop q15min – facilitates outflow of aqueous humor
Indications for eyelid laceration referral to ophthalmology (5)
- Involve lid margin
- Within 8mm of the medial canthus
- Involve the lacrimal duct
4. Ptosis
5. Involves tarsal plate * Have a high suspicion for underlying corneal laceration and globe rupture
Chemical ocular injury management (4)
- Irrigate eye with 1-2L NS continuously (topical anaesthetic PRN)
2. Test the eye pH: if pH >7.4 continue irrigation until pH is less than 7.4 - Document VA and measure IOP
- Consult opthomolagy
- Rx tetanus IM and erythromycin ointment * Alkali (base) injuries are worse than acid, especially lye and ammonia
Define amaurosis fugax (1)
- Amaurosis fugax: transient monocular blindness from transient retinal ischemia
What is the difference between binocular floaters and monocular floaters (1)
- Binocular = brain (ex ophthalmic migraine), monocular = eye.
Treatment of Bell’s Palsy (3)
- Prednisone 50mg daily for 6 days, then a 10 day taper
- Val-acyclovir 1000mg PO TID 10 days
- Eye drops, and tape eye shut during sleep
What is Genu VII Bell’s Palsy (1)
- Genu VII Bell’s Palsy: a stroke masquerading as a CN VII Bell’s Palsy, but the patient cannot ABDUCT the eye.
* Do EOM testing in all Bell’s Palsy patients.
Dx: pupil down and out (1)
- Pupil down and out = CN III palsy (with pupil dilatation) is a posterior communicating artery aneurysm until proven otherwise. Urgent CT/CTa and neurosurgery.