CM- Chronic Vision Loss and Trauma Flashcards
What vision conditions are vision threatening?
- corneal infections
- acute glaucoma
- scleritis
- hyphema
- iritis
- orbital cellulitis
[cash it out– you visions going]
What is the very first thing you should do when seeing a patient with a red eye?
What is the purpose?
ALWAYS check vision first!
- provides a baseline visual acuity should the patient’s vision change
- it can distinguish less serious conditions from more serious
What is the DDx for a patient presenting with itching eyes?
Allergies
What is the DDx for a patient presenting with scratchiness and burning eyes?
lid, conjunctival, corneal disorders like:
- foreign body
- dry eye
- trichiasis
What is the DDx if the patient presents with localized lid tenderness?
- Hordeolum [stye- staph infection of sebaceous gland]
2. chalazion- blocked, inflamed meibomian gland
What is the DDx if the patient presents with deep intense eye pain?
Which are non-vision threatening?
Which are vision threatening?
- corneal abrasion - most are not threatening
- scleritis -threatening
- iritis- threatening
- acute glaucoma- threatening
What is the DDx if a patient presents with photophobia?
Which are non-vision threatening?
Which are vision threatening?
- corneal abrasion - most are not threatening
- acute glaucoma- threatening
- iritis- threatening
What is the DDx if a patient is having halo vision?
Corneal edema due to:
- acute glaucoma
- contact lens overwear
What are hordeolum and chalazion?
How do they both present?
What is the treatment?
Hordeolum is acute gland malfunction that results in localized lid pain with swelling
Chalazion is chronic granulomatous inflammation that presents as localized lid pain with swelling
Treatment is to promote drainage so:
- warm compress 3x daily for horeolum
- incision/curettage from the conjunctiva for chalazion
What is blepharitis?
What are the 3 types?
What is the presentation?
Treatment?
It is chronic inflammation of the eyelid margin by:
- staph
- seborrheic
- combo
Presents with a feeling of foreign body, burning
Treatment:
- good hygiene
- antibiotic opthalmic ointment
A patient presents with a diffuse, erythematous edema of the eyelids.
Visual acuity, motility, and pupillary response are normal.
There is no proptosis.
What is the problem and how is it treated?
preorbital/preseptal cellulitis.
treatment: oral antibiotics, compresses
A patient presents with red, swollen lids.
It is painful for them to move their eyes.
They have proptosis.
Vision is decreased and they have optic disk edema.
What is the problem?
What is treatment?
What are the 3 most common causative organisms?
What are complications?
Orbital cellulitis
Treatment: hospitalization, IV antibiotics
[requires culture and CT of orbits to look for abscess]
- staph
- strep
- H. flu
Complications: it can lead to meningitis or cavernous sinus thrombosis
A patient presents with one red eye, persistent tearing and occasional discharge that fails to respond to antibiotics on the same side.
You note the patient to have a swollen, inflamed lacrimal sac.
What is the diagnosis and how do you treat?
Dacryocystitis- treat with relieving the nasolacrimal duct obstruction
Describe normal conjunctiva.
How does this change when it is inflamed?
smooth, moist lining of:
- palpebral conjunctiva [eyelids]
- bulbar conjunctiva [anterior eyeball]
When it is inflamed, both bulbar and palpebral conjunctival blood vessels become dilated and readily apparent.
When should a patient with inflamed conjunctiva consult an opthamologist?
- infection is suspected and vision is impaired
2. patient fails to respond to therapy in 3-4 days
What are the 4 major causes of primary conjunctivitis?
How can they be differentiated?
- bacteria - purulent discharge
- virus- watery, serous discharge w/ tender perauricular lymph nodes
- allergies- watery and stringy white mucus
- tear deficiency
A 12 year old child presents with red and painful eyes with a thick purulent discharge. He says that in the morning, he has to wash his eyes with water to get them to open.
What is the Dx?
What are the 3 potential causes?
What is treatment?
Do you need to refer to an opthamologist?
Bacterial conjunctivitis
- children»_space; adults
- purulent discharge
Causes:
- staph
- strep
- haemophilus
Treat with topical opthalmic solution 4x daily [erythromycin]; warm compresses
Refer to an opthamologist if there is no clinical improvement in 4 days
If a patient presents with copious purulent discharge, what organism is added to the DDx?
What should be done stat?
N. gonorrhea is a possible cause
- stat gram stain and culture
- refer to opthamologist b/c corneal involvement may develop
What type of discharge is produced by viral conjunctivitis?
What viral is the cause?
What PE sign differentiates viral from bacterial conjunctivitis?
What is treatment for viral conjunctivitis?
Watery discharge
- adenovirus
- palpable/tender preauricular lymph nodes
- it is self-limited [10-14 days] and has no treatment
When should viral conjunctivitis be referred to the opthamologist?
- persists beyond 2 wks
- pain
- photophobia
- decreased vision
A patient presents with conjunctivitis marked by water discharge. He has an upper respiratory infection with sore throat, fever, and generalized malaise.
On palpation, his preauricular lymph nodes are tender.
What is the likely problem?
What is treatment?
viral conjunctivitis- no treatment.
it is self-limited
A patient presents with itchy eyes. there is watery, stringy white mucus.
What is the likelydiagnosis?
What are causes?
Allergic conjunctivitis
- hay fever, asthma, eczema
- drugs, chemical cosmetics
What classifies a conjunctivitis as “neonatal”?
What are the 3 major types?
Neonatal conjunctivitis is 4wks or younger
- chemical - from silver nitrate
- bacterial - staph, strep, n. gonorrhea, chlamydia
- viruses- herpes
A baby is born to a mother suspected of having Chlamydia. Silver nitrate was used. The baby had lid swelling with no discharge for 48 hours. What is the cause of the conjunctivitis?
Neonatal chemical conjunctivitis
[silver nitrate is ineffective against chlamydia, so now erythromycin ointment is used]
A baby presents with conjunctivitis on the first day of life. You do a conjunctival scraping for gram stain and smears.
The organism identified is G+.
What are the 3 most common organisms?
What is treatment?
- staph aureus
- strep pneumonia
- group A and B strep
Treat with erythromycin 4x a day for 4 days
A baby presents with conjunctivitis on the first day of life. You do a conjunctival scraping for gram stain and culture.
The organism is G-.
What are 3 potential organisms that cause conjunctivitis?
What is treatment?
Which would require referal to opthamologist?
- H. flu
- e. coli
- p. aeruginosa
1 & 2 are treated with tobramycin every 4 hours for 5 to 10 days.
Pseudomonas can damage the cornea and thus is referred to the opthalmologist
An infant presents with swollen lids, purulent exudate, beefy-red conjunctiva and conjunctival edema. What is the likely cause?
What are negative sequelae?
When should you refer to an opthalmologist?
Gonococcal conjunctivitis
Sequelae: corneal ulceration, perforation if treatment is delayed
URGENT referral to an ophthalmologist
What is the leading cause of neonatal conjunctivitis?
How does it present?
What tests need to be done?
What is treatment?
Chlamydia is the leading cause of neonatal conjunctivitis and is acquired during vaginal delivery.
The infection can show up anytime in neonatal period [4weeks].
Mild, unilateral or bilateral, mucopurulent discharge with mild lid edema, pneumonitis, otitis media
IT IS IMPOSSIBLE TO CLINICALLY DIFFERENTIATE FROM BACTERIAL
Cultures and smears are required to make diagnosis
treatment: erythromycin 4x daily for 4 weeks
A baby presents with mild mucopurulent conjunctivitis, moderate lid edema. She has otitis media and pneumonitis.
What organism are you suspicious of?
Chlamydia
A patient was really sick last week with a terrible cough. Now she has noticed a bright red eye. It is not painful. She has normal vision.
What is the likely problem?
What are typical causes of this condition?
What do you tell the patient about treatment?
Subconjunctival hemorrhage - frequently caused by trauma
- trauma can be anything from a punch in the eye to increased venous pressure due to profound coughing or vomiting.
There is no treatment. Reassure that it is not serious and should clear in 2-3 weeks
A patient presents complaining of a burning in his eye. “it feels like I have some sand in there”. You do an examination and note mild redness and lack of luster.
What condition does he have?
keratoconjunctivitis sicca - deficiency in tear production resulting in dry eye
What are common causes of dry eye/tear deficiency states?
What is treatment?
- aging process
- rheumatoid arthritis
- Stevens-Johnson syndrome
4 meds
Treat with artificial tears, and lubricating ointment at bedtime
When should tear deficiency states be referred to an opthalmologist?
They should be referred when they are severe because of an increased risk for corneal ulcerations
What is exposure keratitis?
What are 3 common causes?
What is treatment?
It is a syndrome symptomatically similar to dry eye arising from incomplete eyelid closure during blinking or sleep.
- Bell’s palsy
- scarred or malpositioned eyes
- thyroid exopthalmos [Graves]
Treat with lubricating solution and ointments.
*do NOT patch the eye because increased risk for corneal abrasion
Tape eyelids shut at night
What is the similarities and difference between episcleritis and scleritis?
When should they be referred to opthalmologists?
Similarities:
- inflammatory conditions that present with redness and tenderness
- localized
- idiopathic or associated with RA, autoimmune
Differences:
- episcleritis is benign and self-limited while scleritis can lead to vision-threatening complications
- episleritis has minimal pain, scleritis has moderate to severe pain
- epi is more superficial [bright red] while scleritis is purple [depth of inflammation]
- epi is treated with NSAIDs, scleritis with steroids
They should ALWAYS be referred to ophthalmologist because differentiation and management is crucial
What are the 3 major components of the anterior segment?
- cornea
- anterior chamber
- iris
[behind which lies the lens and ciliary body]
A patient presents with red eye, tearing, pain and photophobia. Initially he said “he felt like something was in there, but now it doesn’t. It just hurts.”
What are you suspicious that this might be?
How do you diagnose?
What is treatment?
Corneal abrasion-
Diagnosis: introduce fluorescein dye onto the cornea and observe where the fluorescent dye accumulates
Treatment: designed to foster fast healing and prevent secondary infection
- cycloplegic drops to relieve pain from ciliary body reflex spasms
- antibiotics with pressure patch
When a patient gets a chemical burn, what is the first thing they should do?
Which burns are worse, acid or alkali?
What are complications and sequelae of a chemical burn?
Immediately they need to do 15-20 minutes of irrigation with water [more may occur at the hospital]
Acids produce the extent of damage on contact, while alkali burns continue to damage long after the initial contact.
Sequelae = corneal melting, perforation, and severe chronic glaucoma
When should chemical burns be referred to an ophthalmologist?
Alkali burns require IMMEDIATE referral
Acid burns/other chemicals are treated like a corneal abrasion and referral can wait until the next day
A patient presents with a red painful eye with purulent discharge.
Examination with a penlight reveals discrete corneal opacity and decreased vision.
What is the problem?
When should the patient be referred to the ophthalmologist?
Bacterial keratinitis- emergency referral for diagnosis and treatment is required
What are the 3 most serious ocular side effects of ophthalmic steroid use?
- patient may harbor undetected HSV of the cornea. Steroids facilitate penetration of herpes to deeper layers of the cornea–> permanent scarring and perforation
- local steroids can elevate ocular pressure –> steroid induced glaucoma
- fungal ulcers of the cornea can be potentiated from steroid misuse
What is hyphema? What is the cause?
When should the patient be referred to ophthalmology?
Hyphema is hemorrhage into the anterior chamber.
It is usually caused by blunt force trauma to the eye that can damage the iris, and other intraocular structures.
It is an ocular emergency so refer immediately to ophthalmology
A patient recently got hit in the eye with a baseball. Now it is red, painful, and he is having trouble seeing.
What is the most likely issue?
Hyphema - blunt force trauma injuring the iris and intraocular structures
A patient presents with circumcorneal redness, pain, photophobia and decreased vision.
What is the likely cause?
What is most likely accompanying this condition?
Uveitis/iritis - frequently accompanies other inflammatory conditions like:
- infections
- arthritis
- sarcoidosis
- urethritis
- bowel disorders
- blunt force trauma
Describe acute angle glaumcoma.
Intraocular pressure is increased because the outflow of aqueous humor from the anterior chamber is suddenly blocked.
It typically occurs after dilation of the pupil in dim lighting or by dilating eye drops.
A patient presents with severe ocular pain, frontal headache, blurred vision and the appearance of halo around lights.
He says these “attacks” come on when he is in dim lighting.
The eye is red and the pupil is mid-dilated and oval. The cornea is cloudy.
What is the diagnosis?
Acute angle-closure glaucoma
What are the 5 locations where aqueous flow can be reduced, resulting in glaucoma?
- ciliary body processes [when swollen with congestion, fibrin debris]
- pupillary block by anterior position of the lens
- pretrabecular by neovascular or cell membranes
- trabecular by abnormal accumulation of ECM material
- post-trabecular due to increased episcleral venous pressure
Acute episode of angle-closure glaucoma is an ocular emergency. What is treatment?
- pilocarpine- constricts pupil
- acetazolamide
- glycerine or isosorbide served over ice and drunk slowly by the patient
What is open angle glaucoma?
What are 4 risk factors for the development?
It is chronic optic neuropathy characterized by:
- progressive vision field loss
- optic disk cupping.
- elevated intraocular pressure [sometimes]
Risks:
- advanced age
- high intraocular pressure
- family history
- AA or Hispanic
What is cataracts?
What are the visual symptoms?
Cataracts is an opacity in the crystalline lens of the eye.
- blurry vision
- glare
- change in refractive error
What are the 3 main causes of congenital cataracts?
- autosomal dominant
- rubella
- galactosemia
What are the 3 main risks for adult cataracts?
- advanced age
- ocular trauma
- in response to metabolic disorder: diabetes
What is treatment for cataracts early on? Late?
Early- glasses
Late- surgical removal with lens implant
What are the 5 risk factors for age-related macular degeneration [the most common cause of central vision loss in the elderly]?
- advanced age
- smoking
- fair skin
- cardiovascular disease
- family history of age-related macular degeneration
What are the 2 main types of age-related macular degeneration?
Which is more rapid?
What are the characteristics of each?
- Atrophic [dry] - gradual central vision loss, drusen, geographic atrophy of the macula
- Exudative [wet] - sudden vision loss, subretinal neovascularization, accumulation of blood and fluid within and underneath the retina
How is age-related macular degeneration managed?
- cessation of smoking
- control of cardio disease
- anti-VEGF for exudative
- high fruit/veggie diet
- antioxidants
What is the epidemiology of ocular trauma?
What sex, age, etc?
What are the 5 most common causes of trauma?
What is the #1 cause?
Ocular trauma is 40% of monocular blindness in the US.
80% are males with the average age 30. It is more frequent with low SES.
- occupational [most common]
- domestic
- motor vehicle
- sports-related
- Blunt objects [leading cause of ocular trauma]
What is the eyewall?
sclera and cornea
What is the difference between a closed-globe and open-globe injury?
Closed-globe means the eye wall does not have a full thickness wound
Open-globe means the eyewall DOES have a full-thickness wound
What is the difference between an eyewall rupture and laceration?
Rupture- full thickness wound of the eyewall from a blunt object
Laceration - full thickness wound of the eyewall from a sharp object
What is the difference between a perforating and penetrating injury to the eye?
Perforating - two full thickness lacerations of the eyewall caused by sharp objects or missile
Penetrating - single full thickness laceration of the eyewall by a sharp object
What is meant by:
- intraocular foreign body
- contusion
- lamellar laceration
- retained foreign object causing entrance laceration
- closed-globe injury resulting from impact of a blunt object
- closed-globe injury caused by a sharp object
