ENOT/Ophthalmology Flashcards
Sinus pain/pressure (worse with bending down and leaning forward). Facial tap elicits pain.
Acute sinusitis ; MC after URI
MCC of sinusitis & what are the MC organisms
- Viral: Most common, symptoms < 7 days. Bacterial: Symptoms 7+ days and associated with bilateral purulent nasal discharge.
- Organisms: S. pneumoniae, H. influenzae, M.catarrhalis
When would sinusitis be considered to be chronic
-
Chronic = lasts 12 weeks or longer
- Chronic: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard
Indications for abx for sinusitis
antibiotics in rhinosinusitis include the duration of symptoms >10 days without improvement. Treatment is for five to seven days
- Amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) or amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily)
- Penicillin-allergic: Doxycycline 100 mg orally twice daily or 200 mg orally daily
- Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae
- kids Amoxicillin x 10-14 days
Dx of Blepharitis
DX is usually by slit-lamp examination
TX: Warm compresses, daily lid wash with diluted baby shampoo on cotton-tipped swabs; lid massage to express the gland; topical antibiotics used if infection suspected
Causes of Cholesteatoma
- Caused by chronic eustachian tube dysfunction which results in chronic negative pressure and inverts part of the TM causing granulation tissue that over time, erodes the ossicles and leads to conductive hearing loss
TX: Surgical removal
MCC of conjuncitivits
- MC caused by adenovirus; highly contagious, transmission via direct contact/swimming pools
will present with purulent (yellow) discharge from both eyes (“glued shut”), crusting, usually worse in the morning; May be unilateral
Bacterial conjunctivitis
Abx tx for bacterial conjunctivitis
- Gentamicin/tobramycin (Tobrex): aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this agent
- Erythromycin ointment (E-Mycin) Chlamydia for newborns
- Trimethoprim and polymyxin B (Polytrim) This combination is used for ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic.
- Ciprofloxacin (Ciloxan)
Contact wearers abx for bacterial conjunctivitis
Contact lenses use = pseudomonas tx=fluoroquinolone (ciprofloxacin / Ciloxan drops)
- Neisseria conjunctivitis warrants prompt referral and topical + systemic antibiotics
- Chlamydial conjunctivitis systemic tetracycline or erythromycin x 3 weeks, topical ointments as well, assess for STD or child abuse
Allergic conjunctivitis tx
epinastine (Elestat)
- azelastine (Optivar)
- Emedastine difumarate (Emadine)
- Levocabastine (Livostin)
- White spot on the surface of the cornea that stains with fluorescein: round “ulceration” versus “dendritic” pattern like herpes
Corneral ulcer
MCC of corneal ulcer
Contact lens wearers, caused by a deep infection in the cornea by bacteria, viruses or fungi
- Inflammation of the nasolacrimal duct or the nasolacrimal gland (supratemporal)
Dacryoadenitis
Tx of dacrocystitis
Tx: systemic antibiotics: Clindamycin + 3rd gen. cephalosporin
(eversion of the eyelid) occurs when the eyelid turns outward exposing the palpebral conjunctiva, conjunctiva will appear red from air exposure and inflammation
Ectropion
- Peripheral to central gradual visual loss (versus macular degeneration which is a central loss)
Open angle glaucoma
Classic triad of acute narrow angle-closure glaucoma
- Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil, this is an ophthalmic emergency
- Sudden dull or severe eye pain (unilateral), worse in dark rooms
Acute narrow angle-closure glaucoma:
Tx of Acute narrow angle-closure glaucoma
- Acetazolamide IV is the first-line agent - decrease IOP by decreasing aqueous humor production
- Topical beta-blocker (ex. timolol) reduces IOP without affecting visual acuity
- Miotics/cholinergics (ex. Pilocarpine, Carbachol)
- Peripheral iridotomy is the definitive treatment
- A gradual loss of peripheral vision; Painless
Chronic open-angle glaucoma
painful red infection in a gland at the margin of the eyelid
Hordeolum
Painful vs painless eyelid lesion
- Painful warm (hot), swollen red lump on the eyelid = Hordeolum
- Chalazion which is painless
MC organism in Hordeolum
S.aureus
Hordeolum Tx
Warm compress and topical antibiotics
- A hordeolum that does not respond to hot compresses can be incised with a sharp, fine-tipped blade
- Systemic antibiotics (eg, dicloxacillin or erythromycin 250 mg PO QID) are indicated when cellulitis accompanies a hordeolum
Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris) and may cover iris
Hyphema
Dx of Hyphema
DX: orbital CT if indicated + ophthalmology consult
Tx of Hyphema
TX: usually, blood is reabsorbed over days/weeks
- Elevate head at night at 30 degrees, acetaminophen for pain, patch/shield
- May use beta-adrenergic blockers or carbonic anhydrase inhibitors
- Surgery if high pressure/persistent bleeding
- NSAIDs contraindicated (may increase bleeding)
Acute onset, vertigo + hearing loss, tinnitus of several days to a week
MCC of Labyrinthitis
- Usually viral, an absence of neurologic deficits
- Associated with nausea and vomiting
hoarseness following a URI
Laryngitis
In Laryngitis, if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 weeks
Consider squamous cell carcinoma
Laryngitis tx
TX: Relax voice (vocal rest), supportive therapy
- Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
- Bacterial → erythromycin, cefuroxime, or Augmentin for cough or hoarseness
Gradual painless loss of central vision. The macula is responsible for central visual acuity which is why macular degeneration causes gradual central field loss.
Macular degeneration
Difference between dry vs wet macular degeneration
- Dry (85% of cases): atrophic changes with age – a slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY) = yellow retinal deposits
-
Wet: an advanced form of dry age-related macular degeneration
- New blood vessels growing beneath the retina (neovascularization) leak blood and fluid, damaging the retinal cells. These small hemorrhages usually result in rapid and severe vision loss
Tx of wet macular degeneration
- VEGF inhibitors (e.g., bevacizumab)
- Photodynamic therapy
- Zinc and antioxidant vitamins
Tx of dry macular degeneration
Dry age-related macular degeneration
- Zinc and antioxidant vitamin
Meniere dz etiology
Excessive endolymph fluid in cochlea overstimulates hairs causing vertigo and sudden hearing loss with aural fullness - Unknown etiology
Sx of Meinere dz
- Vertigo attacks lasting hours, classic triad of low-frequency hearing loss, tinnitus with aural (ear) fullness and vertigo
Tx of meniere dz
TX: Low salt diet, diuretics (HCTZ + triamterene) to reduce aural pressure
Samters triad
Samter’s triad for nasal polyps
- asthma
- aspirin sensitivity
- nasal polyps
Otitis externa
Bacterial otitis externa “swimmer’s ear”
-
Ear pain (especially with movement of tragus or auricle), pain with eating, purulent cheesy white discharge, palpation of the tragus is painful
- Tuning fork ⇒ bone conduction > air conduction
Bacterial otitis externa
Otitis externa organisms
- Pseudomonas aeruginosa (swimmer’s ear) vs. S. aureus (digital trauma)
Diabetic otitis externa
- Malignant otitis externa is commonly seen in diabetics
Tx of otitis externa
TX: Antibiotic drops ⇒ (aminoglycoside or fluoroquinolone +/- corticosteroids) + avoid moisture
- If perforated or chance of perforation: Ciprofloxacin 0.3% and dexamethasone 0.1% suspension: 4 drops BID × 7 days or ofloxacin: 0.3% solution 10 drops once a day × 7 days
- Diabetic/immunocompromised: malignant otitis externa ⇒ necrotizing infection ⇒ hospitalization with IV abx (caused by aspergillus)
1) bulging of the tympanic membrane or 2) other signs of acute inflammation (eg, marked erythema of the tympanic membrane, fever, ear pain) and middle ear effusion
Otitis media
MC bugs in otitis media
S. pneumoniae 25%, H. influenzae 20%, M. catarrhalis 10%
Dx of otitis media
otoscopic ⇒ bulging, loss of landmarks, redness, TM injection
Otitis media tx
first-line amoxicillin, augmentin = 2nd line (PCN allergy = azithromycin, erythromycin, Bactrim)
- Treat < 2 y for 10 days and > 2 y for 5-7 days
- Recurrent: tympanostomy, tympanocentesis, myringotomy
- Complications: Mastoiditis and bullous myringitis
Optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks
Papilladema
Common causes of papilledema
- Causes include malignant hypertension, brain tumor/abscess, meningitis, cerebral hemorrhage, encephalitis, pseudotumor cerebri
Mumps parotitis MCC
- Mumps is caused by a paramyxovirus.Likely in achild without a complete vaccination series.Transmitted viarespiratory droplets
- Typically, it begins with a few days of fever, headache, myalgia, fatigue, and anorexia, followed by parotitis
- In adult males look for an associated orchitis
Viral parotitis mcc
- Viral infections associated with parotitis include influenza A virus, parainfluenza, adenovirus, coxsackievirus, Epstein-Barr virus (EBV), cytomegalovirus, herpes simplex virus, human immunodeficiency virus (HIV), and lymphocytic choriomeningitis virus
Peritonsillar abscess
- Presents with a hot potato (muffled) voice, severe sore throat, lateral uvula displacement, bulging tonsillar pillar
Tx of peritonsillar abscess
Aspiration, incision and drainage, and/or antibiotics
- IV antibiotics ⇒ amoxicillin, amoxicillin-sulbactam, and clindamycin
- In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
- Tonsillectomy may also be considered in about 10% of patients
Viral pharyngitis mcc
Usually viral - adenovirus most common
- Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot)
- Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
- Fungal in patients using inhaled steroids
Strep pharyngitis centor criteria
- Group A B-hemolytic streptococci (GABHS)
- Centor criteria: 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy
- Not suggestive of strep - coryza, hoarseness, and cough
- If 3 out of 4 Centor criteria are met get a rapid streptococcal test (sensitivity > 90%)
- If negative → throat culture is the gold standard
Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in the inner corner/nasal side of the eye)
Pterygium
Pterygium tx
Tx: Only surgically remove when vision is affected
Retinal detachment
Separation of the retina from the pigmented epithelial layer causing the detached tissue to appear as a flap in the vitreous humor
Tx for retinal detachment
Stay supine (lying face upward) with head turned towards the side of the detached retina
- Consult ophthalmologist
- Pneumatic retinopexy is a procedure for the management of retinal detachment that involves cryoretinopexy followed by injection of an air bubble in the vitreous
Retinal vascular occlusion
⇒ Central retinal artery occlusion (cherry-red spot, ischemic retina)
- Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax)
tx of retinal vascular occlusion
TX: Emergent ophthalmologic consult - Immediate treatment is indicated if occlusion occurred within 24 h of presentation
- Reduction of intraocular pressure with ocular hypotensive drugs (eg, topical timolol 0.5%, acetazolamide 500 mg IV or PO)
- Intermittent digital massage over the closed eyelid or anterior chamber paracentesis
- If patients present within the first few hours of occlusion, some centers catheterize the carotid/ophthalmic artery and selectively inject thrombolytic drugs
- Workup and management of atherosclerotic disease
- Irreversible damage to the retina after 90 min; Poor prognosis
Blood and thunder fundus
⇒ Central retinal vein occlusion; blood and thunder retina (dilated veins, hemorrhages, edema, exudates)
Tx of central vein occlusion
TX: vision resolves with time (partially); workup for thrombosis
- Neovascularization treated with intravitreal injection of VEGF inhibitors
Prolonged hyperglycemia affects eyes
- Prolonged hyperglycemia causes basement membrane thickening, decreased pericytes (hyperproliferation), microaneurysms, and neovascularization
2 types of diabetic retinopathy
- Diabetic retinopathy falls into two main classes: nonproliferative (early) and proliferative (late, advanced)
pain, otorrhea, and hearing loss/reduction
TX: Usually, resolve on own; surgical repair may be necessary with persistent hearing loss
- Keep dry ⇒ water/moisture to the ear should be avoided to prevent secondary infection that impedes closure
- The only class of antibiotics that are non-ototoxic are the Floxin drops and should be used if you are going to be prescribing drops with a perforated TM
- Surgery if persists past 2 months
