EENT Precision & Pearls #1 (Eye) Flashcards
Bacterial conjunctivitis is MCC by what bacteria? What are the symptoms?
Staph Aureus
-Purulent discharge
-unilateral
-lid crusting (eye stuck shut in morning)
-no vision changes, no itching
Treatment for Bacterial conjunctivitis (both non-contact lens wearer, and contact lens wearer)
-Non contact lens: Topical ABX (Erythromycin ointment, Trim-Poly B, Moxifloxacin, Ofloxacin)
-Contact lens use: Topical Ciprofloxacin or Ofloxacin
What bacteria are you concerned about covering if the patient wears contact lens’?
Pseudomonas Aeruginosa
Viral conjunctivitis, MCC by _______, is MC in children. What is something that spreads this condition and what are the symptoms
Adenovirus
Swimming pools –> outbreaks
-Starts unilaterally –> bilaterally
-FBS/grittiness
-Copious watery tearing
-Preauricular LAD
-Punctate staining
Treatment for viral conjunctivitis
Supportive (cool compresses, artificial tears, antihistamines)
On the other hand, symptoms of allergic conjunctivitis include
-Conjunctival erythema with normal vision
-Other allergic symptoms (congestion, sneezing)
-Often bilateral
-Cobblestone mucosa
-chemosis (conjunctival edema)
-watery discharge
Treatment for allergic conjunctivitis
-Symptomatic
–Topical antihistamines (Olopatadine, Pheniramine-Naphzoline)
Neonatal conjunctivitis (ophthalmia-neonatorum), is conjunctivitis contracted during delivery. What are the causes in the following time frames:
-Day 1:
-Day 2-5:
-Day 5-7:
Day 1: Chemical conjunctivitis caused by silver nitrate
Day 2-5: Gonococcal MCC
Day 5-7: Chlamydia MCC
Management for Gonococcal conjunctivitis
is there anything you can do to prevent this?
IM or IV Ceftriaxone
Prophylaxis: Topical Emycin ointment
Management for Chlamydia conjunctivitis in a neonate
is there anything you can do to prevent this?
Oral Erythromycin
No prophylaxis effective to prevent this condition
What should you give an adult with chlamydial conjunctivitis?
Azithromycin 1000mg single dose, Doxycycline, Tetracycline, or Erythromycin
Cataract is ________ and some of the causes/risks for developing these include….
What are some symptoms of this?
Lens opacification (thickening)
Aging (MC), Congenital, Smoking, Corticosteroid use, DM, Trauma
Halos around lights, difficulty driving at night, painless/slow progressive blurry vision, absent red reflex, opaque lens
If the patient has a corneal abrasion, what is seen on slit lamp examination?
With fluoroscein stain, ice rink/linear abrasions.
Evert the eyelid to look for foreign bodies
Management for an ocular foreign body/ocular abrasion (contact lens vs non contact lens)
-Eye wash and irrigation, topical anesthetic
-Non contact lens: Emycin ointment, Tri-Poly B
-Contact lens: Topical Cipro or Ofloxacin
-DO NOT PATCH if Pseudomonas expected (contact lens use)
When should you remove a rust ring with an ocular foreign body?
in 24 hours with a burr
Management for a sub conjunctival hemorrhage
-Check VA, EOM’s, slit lamp, IOP
-If history of trauma, rule out ruptured globe and retrobulbar hemorrhage
-Give artificial tears, most resolve spontaneously and on their own
Keratitis is corneal inflammation or a corneal ulcer. If bacterial in nature, what is the MCC in a non-contact lens wearer? How about if they do wear contacts?
What are the risks for this condition?
Staph A, Strep
Pseudomonas
Improper contact lens usage (MC), Immunosuppression, dry ocular surface
Symptoms of keratitis include…
What diagnostic is done and what do you see with bacterial keratitis?
What do you see with herpes keratitis?
Pain, redness, vision changes, photophobia, FBS, ciliary injection, hazy cornea
Slit lamp: increased uptake of fluoroscein stain
Herpes: dendritic branching with fluoroscein stain
Treatment for bacterial keratitis?
Treatment for herpes keratitis?
-Fluoroquinolone topical (Moxifloxacin)
-Herpes: Topical Antivirals (Trifluridine) or PO Acyclovir
What is photokeratitis, what is it from, and what is seen on fluoroscein stain on slit lamp?
Excessive UV exposure (snow/sun, welding, sun lamps)
Presents 6-12 hours after exposure
Diffuse defects on staining
Describe a pterygium
What are some risks associated with this condition?
Elevated, fleshy, triangular shaped growth that starts medially (nasally) and grows outward
UV exposure in tropical climates, sand, wind, dust exposure
On the other hand, describe a pinguecula and explain some risks associated with it
Slowly growing thickening of the conjunctiva. Yellow, slightly elevated nodule on nasal side of sclera that doesn’t grow onto the cornea
Eye irritation (dry, windy, sunny)
Dacryocystitis is an infection of the lacrimal sac due to __________.
The MCC is _____, but other causes are Staph Aureus and GABHS.
Obstruction of the nasolacrimal duct
Staph Epidermidis
Symptoms of dacryocystitis
-Tearing, tenderness, warmth, swelling to medial/canthal side of lower lid area
-May have purulent discharge
Treatment for dacryocystitis
-acute: warm compresses + ABX (Clinda, Vanco + Ceftriaxone)
-Chronic: Dacryocystorhinostomy
Blepharitis is inflammation of the eyelid margin. Some risk factors associated with this condition are….
There are two types. Posterior and Anterior. Explain the different etiologies between them.
Symptoms of this condition
Risks: Seborrheic dermatitis, Down’s Syndrome, Rosacea
Posterior: MC type. MGD
Anterior: Infectious. Staph A.
Scaling, crusting of the lids or lid margins. Flaking on lashes. Red rimming of eyelid.
Treatment for blepharitis
Eyelid hygiene, artificial tears
If severe: Topical Azithromycin or Erythromycin
Describe a chalazion. What is it from? What are the symptoms? What is the treatment?
Painless nodule of internal meibomian gland due to obstruction of meibomian gland
Painless, slowly growing nodule. Eyelid swelling, erythema, recurrent
Warm compresses, eyelid massage
On the other hand, describe a hordeolum (stye) and what is it MCC by?
Localized abscess of eyelid margin. Painful, erythematous, warm nodule on the eyelid
MCC by Staph Aureus
Treatment for a stye
-warm compresses, I&D if no spontaneous drainage by 48 hours
-May add topical Erythromycin if needed
Explain the pathophysiology of an entropion and an ectropion
Entropion: eyelid inverted due to spasms of orbicularis oculi muscle
Ectropion: eyelid everted due to relaxation of orbicularis oculi muscle
Treatment for ectropion/entropion
Artificial tears is conservative
Blepharoplasty is definitive
What is papilledema, what are causes, and what are symptoms?
Swelling of optic disc due to increased ICP
Brain tumors, intracranial hypertension, etc.
H/a, n/v, AMS, vision loss, diplopia, blurriness
What diagnostics should you get for papilledema?
Fundus exam: swollen optic disc with blurred margins, retinal hemorrhages
MRI/CT followed by LP to rule out mass
What medication can be given to lower intracranial pressure and what does it do?
Acetazolamide (decreases production of CSF)
Optic Neuritis (CNII Inflammation) is acute inflammatory demyelination of the optic nerve. What are some causes of this condition?
Who does it most commonly occur in?
MS, Ethambutol, infections (HSV, Syphillis)
Young females. Remember association with MS and Ethambutol (TB medication)
Symptoms of optic neuritis
Diagnostics that should be done and what confirms it.
Treatment for optic neuritis
-Sudden, PAINFUL loss of vision
-Desaturation (loss of color vision)
-Central scotoma
-Unilateral symptoms
-pain worse with eye movement
-Marcus-Gunn Pupil: pupil DILATES with light
Fundus exam: Optic disc swelling. Usually a clinical diagnosis. MRI Confirms diagnosis
IV Methylprednisolone then oral corticosteroids
Orbital (Septal) Cellulitis is an infection of the orbit POSTERIOR to the orbital septum. it is MC in children (7-12 years old). What are the bacteria that cause it?
What is the MC etiology?
Symptoms of this condition
-Polymicrobial: Staph, Strep, Hflu
-Secondary to sinus infection (ethmoid sinus)
-Pain with eye movement, ophthalmoplegia (EOM weakness), diplopia, proptosis, eyelid erythema/edema
What diagnostic should be done for orbital cellulitis?
What is the treatment?
High resolution CT scan of orbits
Admission + IV ABX (Vanco + Ceftriaxone/Cefotaxime)
On the other hand, preseptal (periorbital) cellulitis is an infection ANTERIOR to orbital septum. What are the symptoms of this condition?
-Unilateral ocular pain, eyelid edema
-NO PROPTOSIS, OPTHALMOPLEGIA, or PAIN WITH EOM
Treatment for preseptal cellulitis
-Outpatient if older than 1 year old
–Oral Clindamycin or Bactrim + Amoxicillin
If the patient has bitemporal hemianopsia, where would you expect the optic lesion to be?
Lesion of the optic chiasm
Risk Factors for a retinal detachment.
What is the MC Type of RD and what does that mean?
Symptoms of an RD
Myopia (nearsightedness), Age, Trauma, Previous Cataract surgery
Rhegmatogenous (full thickness tear of retina)
Photopsia (flashes), floaters, progessive unilateral peripheral vision loss, curtain or veil coming down, no ocular pain
What is seen on fundoscopy of a patient with a retinal detachment?
What is the treatment and what should you do with the patient?
Fundoscopy: tissue flapping in vitreous. Shafer sign: clumping of brown pigment cells in anterior vitreous that looks like tobacco dust
Ophthalmic emergency – Referral! Keep patient supine with head turned to the side of the detachment.
Macular degeneration is the MCC of permanent legal blindness and vision loss in older adults. What are the symptoms of this condition?
Bilateral, progressive central vision loss (detailed and colored vision)
Metamorphsia (curvy lines)
Micropsia (objects are smaller than they actually are)
On Fundoscopy, what is seen with both types of macular degeneration?
Dry (atrophic): drusen bodies, small round yellow/white spots
Wet (Exudative): new, abnormal vessels that cause hemorrhage and scarring
Treatment for both types of macular degeneration
-Dry: Zinc and antioxidant vitamins (C & E)
-Wet: Intravitreal VEGF inhibitors (Bevacizumab) which decreases new vessel formation
-Laser photocoagulation can be done as well
Risk Factors for macular degeneration
Females, smoking, >50 years old, Caucasians
What is the MCC of new, permanent vision loss in ages 20-74
Diabetic retinopathy
What are the two types diabetic retinopathy? Explain them.
Nonproliferative: micro aneurysms, cotton wool spots, hard exudates, blot and dot hemorrhages, flame shaped hemorrhages
Proliferative: neovascularization (new vessels) that lead to vitreous hemorrhage
Treatment for both types of diabetic retinopathy
Nonproliferative: glucose control, laser
Proliferative: VEGF inhibitors, laser
How often should those with diabetes get an eye exam?
Annually (once per year)
Hypertensive retinopathy is due to chronic, uncontrolled hypertension. There are three severities of this condition. What are the symptoms of each?
Mild: copper wiring (moderate narrowing), silver wiring (severe narrowing) AV nicking
Moderate: hemorrhages, cotton wool spots, hard exudates, MCA’s
Severe: All of the above with papilledema (blurring of optic disc)
What is a hyphema? What are some etiologies of this condition?
Collection of RBC’s in the anterior chamber
Trauma, post-op, coagulopathy (sickle cell)
What is one thing to remember in a patient with a hyphema (What is one association you should keep in mind)
Sickle Cell can have a hyphema as a complication of trauma
What should you keep in mind when treating a hyphema?
Bed rest with head elevation > 45’
Analgesics, eye shield
Explain symptoms of amaurosis fugax and what is it commonly associated with?
Transient, monocular vision loss that lasts minutes, with complete recovery
Commonly associated with stenosis of internal carotid artery (retinal emboli)
An orbital floor (blowout fracture) occurs due to blunt trauma (baseball to the eye, etc.) What is the MC type of fracture? What is a complication of this?
Inferior (MC)
Orbital fat and inferior rectus muscle may prolapse into maxillary sinus
Symptoms of an orbital floor fracture
-Diplopia with upward gaze (inferior rectus muscle entrapment)
-Decreased VA
-Orbital emphysema (eyelid swelling after blowing nose)
-Anesthesia to anteromedial cheek due to stretching of infraorbital nerve
What diagnostic should you get for a suspected orbital floor fracture and what is the treatment?
CT scan: Teardrop sign
Nasal decongestants, avoid blowing the nose
-ABX (Ampicillin-Sulbactam or Clindamycin)
-Surgical repair
Symptoms of a globe rupture
Pain suddenly after injury or trauma
Teardrop or irregular pupil
Severe conjunctival hemorrhage (360’ bulbar)
Positive Seidel’s Test: parting of fluoroscein dye by clear stream of aqueous humour
Management for a globe rupture
-Leave impaled objects undisturbed
-Rigid eye shield
-Emergent oph consult
-Tetanus prophylaxis
A central retinal artery occlusion (CRAO) is MC due to _______.
Symptoms of this are:
Emboli from carotid artery
-Acute, sudden painless monocular vision loss
-Ipsilateral carotid bruit
What is seen on a fundoscopy exam for a CRAO?
What is the treatment for CRAO?
Pale retina with cherry red macula. Boxcar appearance of vessels
ocular massage, oxygen, lower IOP, Poor prognosis
On the other hand, a CRVO, has symptoms similar to that of a CRAO? What are they?
What is seen on a fundoscopy exam?
What is the treatment for a CRVO?
Sudden, painless monocular vision loss
Fundus exam: extensive retinal hemorrhages (blood and thunder appearance). May have a Marcus-Gunn Pupil, optic disc swelling
Good prognosis. Anti-VEGF injections, surgery, laser
What is the pathophysiology of chronic open angle glaucoma?
What are the symptoms?
Decreased aqueous humor drainage through the TM damages the optic nerve
Slow, progressive, painless bilateral peripheral vision loss
-Tunnel vision
-Cupping of optic discs
-Increased CD ratio
-Notching of disc rim
Treatment for chronic open angle glaucoma
-Prostaglandin analogs (Latanoprost) first line
-Beta Blockers (Timolol), Acetazolamide
-Laser therapy (Trabeculoplasty), Surgery
The leading cause of preventable blindness in the US is _____.
Risks for this include…
Acute angle closure glaucoma
Hyperopia (far sighted), females, age > 60
Precipitating factors for acute narrow angle closure glaucoma?
What will likely be the scenario in which this is presented on the exam?
Mydriasis (dilation), Dim lights, anticholinergics
Walking outside into a dimly lit movie theater
Symptoms of acute narrow angle closure glaucoma
-Sudden onset of severe, unilateral eye pain
-Halos around lights
-Loss of peripheral vision
-Cloudy cornea
-Mid-dilated fixed pupil
-Eye hard on palpation
Diagnostics for acute narrow angle closure glaucoma
What is the treatment?
-Tonometry: IOP > 21mmHg
-Fundoscopy: optic disc blurring or cupping
-Treatment: combination of topical agents (Timolol, Pilocarpine) with systemic agents (PO or IV Acetazolamide or IV Mannitol)
-Definitive treatment: Iridotomy
Diagnostics for acute narrow angle closure glaucoma
What is the treatment?
-Tonometry: IOP > 21mmHg
-Fundoscopy: optic disc blurring or cupping
-Treatment: combination of topical agents (Timolol, Pilocarpine) with systemic agents (PO or IV Acetazolamide or IV Mannitol)
-Definitive treatment: Iridotomy
What is amblyopia? What are three common etiologies (SOS)? When should you refer a child with amblyopia?
Unilateral abnormal visual development during childhood (lazy eye)
-Etiologies: Spectacles (refractive error), Obstruction (cataract, retinal disease), Strabismus
Refer if > 2 lines difference between the eyes in VA, abnormal red reflex, or ptosis in one eye
What is the treatment for amblyopia?
Patch the good eye to strengthen the weak one!
What may be a on a history of a patient with color blindness?
What test can be done to assess?
Usually inherited - ask about family history
-Difficulty distinguishing between shades of red and green
-Chemical exposure may be a cause
Ishihara test for red-green deficiencies
Strabismus is a misalignment of one or both eyes. What is esotropia and what is exotropia?
What diagnostics/tests can be done for this condition?
What is the treatment?
-Esotropia: convergent = deviated inward (nasally)
-Exotropia: divergent = deviated outward (temporally)
Hirschberg Corneal light reflex testing: asymmetric deflection of light reflex
-Cover uncover test!
Patch normal eye to strengthen weak eye!
An ocular chemical burn is an ophthalmic emergency. Is an alkali burn or an acid burn worse? What should you do for this condition?
Alkali burns are worse = liquefactive necrosis and denaturing of proteins
Irrigation started ASAP with LR or Normal Saline for 30 minutes and at least 2 L of fluid. Until pH of 7.0-7.4 is achieved.
Then, give ABX: Moxifloxacin, Trim-Poly, Emycin Ointment
Scleritis is MC in young women and has an association with what? Name some symptoms of this condition as well.
Associated with autoimmune or connective tissue diseases (RA, SLE)
Deep/boring eye pain. Pain with eye movement. Deep violaceous patches beneath bulbar conjunctiva.
Scleritis should be referral to an ophthalmologist ASAP. What is the treatment they will likely be started on?
Topical corticosteroid drops
There are two types of uveitis (iritis). Name them, explain them, and describe the symptoms associated with them.
Anterior: inflammation of iris.
-Unilateral severe eye pain, photophobia, redness, blurriness, decreased vision
Posterior: inflammation of choroid.
-Blurriness, may not be painful
Symptoms of both: mitosis, ciliary injection, photophobia
Uveitis may be associated with what conditions?
Systemic inflammatory and autoimmune
–HLA-B27, Sarcoidosis, IBD
–CMV, TB, Syphillis
What is seen on fundus exam in a slit lamp of a patient with uveitis?
What is the treatment for both types of uveitis?
Inflammatory cells and flare
-WBC and proteins
Anterior: topical glucocorticoids
Posterior: systemic glucocorticoids
What is the MC interocular malignancy of childhood?
What gene mutation is this due to ?
Retinoblastoma
Mutation in RB1 gene on chromosome 13
Symptoms of a retinoblastoma
-Leukocoria (abnormal white reflex)
-Nystagmus, strabismus (+/-)
What diagnostic is done for a retinoblastoma?
Treatment?
Ocular US = intraocular mass
Radiation, chemo, enucleation
What is another name for epidemic keratoconjunctivitis? What are the main causes?
Viral conjunctivitis
Adenovirus (types 8, 19, 37, and 54)
What is retinitis? What are two types and what symptoms can be associated with these conditions?
Disease that damages that retina
Retinitis Pigmentosa (genetic), CMV retinitis (herpes virus)
Floaters, blurry vision, loss of central vision at first and then peripheral vision, can affect color vision too
What is one health maintenance thing to remember for retinitis pigmentosa?
Protect the eyes from UV by wearing sunglasses, etc.
What is conjunctival chemosis and what is it commonly from?
Swelling of the tissue that lines the conjunctiva
Usually from irritation, allergies, watery eyes, itchiness, etc.
What is an Argyll-Robertson Pupil?
What is it MCC by?
Pupil that constricts on accommodation but does not react to bright light
Neurosyphillis
Describe the 6 EOM muscles, where they are located, and what motions they each perform.
MR: Adduction (middle)
LR: Abduction (outer)
SR: Elevation, Adduction, Intorsion
IR: Depression, Adduction, Extorsion
IO: Elevation, Abduction, Extorsion
SO: Depression, Abduction, Intorsion
Xanthelasma
-Define
-Causes
-Treatment
Soft yellow plaque filled with cholesterol on medial canthus of eye
Associated with hyperlipidemia, DM, and thyroid dysfunction
Treatment: Lower lipids, excision, cauterization if needed
Ocular melanoma risk factors and exam findings
-RF: Sun exposure, tanning, outdoor activities. occurs in choroid or iris of the eye
Exam: blurry vision, color change of iris, pain, pressure like sensation
Surgical resection and chemotherapy are treatment
