Exam 2: Eyes [9] Flashcards
Name this condition:
Chronic condition with intermittent exacerbations
Caused by inflammation of eyelids (hair follicles, meibomian glands)
Lid may be colonized by staphylococcus aureus
Associated with seborrheic dermatitis and rosacea
Symptoms: Itching and irritation in the eyelids (upper/lower or both) Burning Gritty sensation Tearing Redness Crusting and matting of the lashes Sometimes a foamy discharge
Blepharitis
Meibomian Gland Disease
Blocked meibomian glands
Person gets dry crusting on the eyelids and then they rub and rub until it’s a bacterial conconjunctivitis
What is the main cause of bacterial conjunctivitis in adults?
Blepharoconjunctivitis
What is the treatment for blepharitis?
Treatment for blepharitis:
Wash with baby shampoo or OTC lid scrub; gently scrub eyelid margins until resolves
Warm compresses to eyelids 2-4x/day during exacerbations to soften debris and relieve itching
Artificial tears helpful
If extremely inflamed:
Refer to ophthalmology
Topical antibiotic solution (erythromycin eye drops) to eyelids 2-3x/day
Carefully monitor intraocular pressure with any use of ocular topical steroid
Name this condition:
Complaints of acute onset of:
Swollen, red, and warm abscess on the upper or lower eyelid involving one hair follicle that gradually enlarges
Can be internal or external
Painful on palpation
May spontaneously rupture and drain purulent exudate
Infection may spread to adjoining tissue (preseptal cellulitis)
Hordeolum (Stye)
An external hordeolum is an abscess of a hair follicle and sebaceous gland in the upper or lower eyelid
Can sometimes see a white pustular head if it’s on the exterior
An internal hordeolum involves inflammation of the meibomian gland
May have a history of blepharitis
What is the treatment for a stye (hordeolum)?
Treatment for hordeolum (stye):
Hot compresses for 5-10 minutes BID to TID until it drains and that’s usually enough to clear it up
If infection spreads (preseptal cellulitis), systemic antibiotics such as dicloxacillin or erythromycin PO QID (may want to refer at this stage)
Refer to ophthalmologist for incision and drainage or no resolution after 2 weeks
Name this condition:
A chronic inflammation of the meibomian gland (specialized sweat gland) of the eyelids
Symptoms:
Gradual onset of a small superficial nodule on the upper eyelid that feels like a bead and is discrete and movable
Painless
Can slowly enlarge over time
If it is large, can press on the cornea and cause blurred vision
Chalazion
Can start as a hordeolum but has lost its painful sensation
What is the treatment for a chalazion?
Treatment for chalazion:
May resolve spontaneously in 2-8 weeks
By an ophthalmologist:
Incision and drainage
Surgical removal
Intrachalazion corticosteroid injections
Name this condition:
More common in the elderly
An inward turning of the lid margin
The lower lashes are often invisible when turned inward
Irritates the conjunctiva and lower cornea
Results in dry eyes and/or excessive tearing
Redness, irritation
Sensitivity to light and wind
Entropian:
An inward turning of the lid margin
The lower lashes are often invisible when turned inward
Exam:
Ask patient to squeeze the lids together and then open them
Check for entropion that is less obvious
Management:
Evert the lashline with a Qtip or tongue blade
Thick ocular ointment such as Refresh PM to moistened eye
Name this condition:
More common in the elderly
The lower lid margin turns outward exposing the palpebral conjunctiva
When the punctum of the lower lid turns outward the eye no longer drains well
Tearing occurs
Ectropian:
The lower lid margin turns outward exposing the palpebral conjunctiva
When the punctum of the lower lid turns outward the eye no longer drains well
Tearing occurs
Involutional ectropion is caused by increased horizontal laxity of the lower eyelid
Cicatricial ectropion is caused by shortening of the anterior lamella, which is comprised of the skin and orbicularis muscle (related to alopecia)
Name this condition:
Inability to close the eyelids completely
Can be associated with exophthalmos (hyperthyroidism)
Lagopthalmos:
Inability to close the eyelids completely
What is the management for lagopthalmos?
Lagopthalmos management:
Thick ocular ointment such as Refresh PM
Refer to oculoplastic surgeon
Name this condition and management:
Most common cause of eyelid dermatitis, especially if bilateral
Symptoms: Itchy, red eyelids
Contact dermatitis:
Most common cause of eyelid dermatitis, especially if bilateral
Management: Find causative agent (preservatives in topical agents, cosmetics, hair products, etc) Stop causative agent Cold compresses Preservative free tears Topical/oral antihistamine
Name 3 types of conjunctivitis
Allergic
Viral
Bacterial
Name this eye condition and the management:
Mild, itchy injection to sclera
Usually happens with a trigger
Allergic conjunctivitis:
Trigger can be a seasonal allergy or something else
Look for papillae on the palpebral conjunctiva
Management:
Topical antihistamines drops BID
Ex: Alaway, Zaditor, Patanol
Name this eye condition and the management:
Pink conjunctivitis
Looks glossy
Can have mucous and crusting
May wake up with a little matting or have the eye crusted shut
Tearing
Burning
Usually starts in one eye and spreads to the other
Viral conjunctivitis “Pink Eye”
Highly contagious Typically associated with recent URI Change pillow cases and towels frequently - wash in hot water Change cosmetics, etc - throw it all out Preservative free artificial tears Cold compresses Self-resolving in 2-3 weeks Because it's viral antibiotics will not help
Refer if vision is affected or pain on blink
Name this eye condition and the management:
Beefy redness
Major discharge that continues throughout the day
Starts itching but then becomes mostly irritated
Bacterial conjunctivitis:
Uncomplicated cases managed with topical antibiotic
Contagious for up to 48 hours once treatment is started
Think about school kids
Complicated cases:
In newborns: ophthalmia neonatorum due to N. Gonorrhea (needs IV fortified antibiotic)
In kids: multiple strains (not all related to the sexual strains), if hyperacute (N. Gonorrhea) treat with oral/IM antibiotic
Chlamydia conjunctivitis: recurrent conjunctivitis not responding to treatment give oral antibiotic
Will need to figure out where the chlamydia came from
Name this eye condition:
Blood that is trapped under the conjunctiva and sclera
Subconjunctival Hemorrhage
Blood is trapped underneath the conjunctiva and sclera secondary to broken arterioles
Can be caused by: Coughing Sneezing Straining Heavy lifting Vomiting Local trauma And can occur spontaneously
What is the management for a subconjunctival hemorrhage?
Subconjunctival hemorrhage:
Very common
Can be very dramatic and cause great concern by the patient/family
Not a medical emergency
Always check BP to rule out HTN especially malignant HTN that needs treated ASAP
Self-resolving within days to weeks until the blood is reabsorbed (similar to a bruise)
Avoid blood thinners if possible (can make it worse and last longer)
Avoid heavy lifting or strenuous activities that could cause it to get worse
Watchful waiting and reassurance to the patient
Follow up until resolution
If recurrent, should do blood work to check for coagulopathy problems
Name this eye condition:
Affects 10-30% of population over the age of 40
Symptoms: Burning Foreign body sensation Itchiness Excessive tearing
Keratoconjunctivitis Sicca (Dry Eye):
Caused by poor tear film quality or inadequate quality
Those living in big cities more at risk due to smog and other particles in the air
What does Schirmer’s Test evaluate?
Schirmer’s Test diagnoses dry eye (keratoconjunctivitis sicca)
Helps to determine how much tear production a patient is having by placing strips on the patient’s eye and having them close it for one minute.
More than 10mm of moisture on the filter paper in 5 minutes is normal.
How is keratoconjunctivitis sicca (dry eye) managed?
Keratoconjunctivitis sicca (dry eye)
Patients should be referred to ophthalmology for diagnosis and treatment
If patient is not making enough tears, artificial tears is given 2-4 times per day along with warm compresses to increase vascularity
If severe, cyclosporine in the form of Restasis is prescribed
** In general, anyone with dry eye syndrome should avoid Visine and any drops that work as a vasoconstrictor because they will cause more dryness over time (rebound effect)
When should we refer patients with painful red eyes?
Refer patients with painful red eyes when the patient has:
Pain Photophobia Change in vision History of recent contact lens wear No improvement despite treatment
Send immediately
Name this eye condition and management:
Infection of soft eyelid tissue anterior to the lid septum (meaning the eyelid itself, not the eyeball)
Often starts as a hordeolum that spreads to the entire lid
Also seen in kids with URI, sinus infection, or an open wound that got rubbed and infected
Preseptal Cellulitis (Periorbital):
Critical to differentiate from orbital cellulitis (medical emergency)
Want to be sure:
No pain on eye movement
Eyes not very red
No change in vision
Optic nerve not swollen
No or only very mild fever
*** If patient would have any of the above present, then send to ED **
Patient should be hospitalized if suspect orbital cellulitis or is < 5 years old
Don’t want preseptal cellulitis developing into orbital cellulitis, which can happen more quickly in kids
Can lead to vision loss
If you are confident it is preseptal cellulitis, you’ll manage with oral antibiotics:
Augmentin or Keflex x 10 days
Warm compresses to increase vascularity to area
What is episcleritis and what are the symptoms and management?
Episcleritis (painful red eye; inflammation in the episclera of the eye):
Mild pain or tenderness*
Sometimes itchy*
Most cases idiopathic*
Can be associated with [IBD, RA, SLE, etc]*
Often sectorial, can be nodular*
Blood work warranted if bilateral (typically happens in one eye) or recurrent
Management:
Self-resolving in 2-3 weeks
Topical steroid drops help with comfort and recovery if it is severe
Clinical Pearl:
Redness BLANCHES with 10% topical phenylephrine and episcleral vessel will be mobile on palpation if it is episcleritis
Scleritis does not blanch and go much deeper into the eye
What is scleritis and what are the symptoms and management?
Scleritis (painful red eye; much deeper infection of the eye than episcleritis):
Painful, dull*
Color: Deep red almost to the point of being bluish*
Injection: Diffuse but sectorial*
DOESN’T BLANCH with TOPICAL PHENYLEPHRINE*
Can cause perforation and significant vision loss
More systemic association than episcleritis*
Management:
Refer to ophthalmology with same day
Patient needs to be dilated to look for iritis and posterior scleritis
They will prescribe oral anti-inflammatory agent (ibuprofen 800 mg or indomethacin) + topical agent to clear up the eye
Herpes Simplex Keratitis: infection of the cornea with HSV
What are the signs and symptoms and management?
Herpes Simplex Keratitis (infection of cornea with HSV):
Dendritic ulcers:
Little hands and bulbs that come off from the main ulcer
Seen with Rose Bengal or Lissamine Green staining (ophthalmology office)
Signs/symptoms of ocular herpes: Acute onset Redness/irritation Aching pain* Lots of tearing* Photophobia* Blurred vision in one eye* Skin vesicles*
Diagnosis:
Fluorescein dye to search for fern-like lines on corneal surface
Management:
Topical antiviral (Trifludine 7 times/day or Ganciclovir 5 times/day)
and/or
Oral antiviral (Zovirax, Valtrex)
Herpes Zoster Ophthalmicus: infection of the cornea with HZV
What are the signs and symptoms and management?
Herpes Zoster Ophthalmicus Eye Infection (shingles):
Ocular lesions appear 2-3 days after initial skin rash
Signs and Symptoms:
Conjunctivitis most common
Ulcers have a tapered end (pseudodentrites)
Can affect stromal tissue, often causing scarring
Can cause necrotizing retinitis
** Affects trigeminal nerve
Tip of nose
One side of forehead/eyelids
Management:
Recognize early and refer to ophthalmology for treatment or ED
How can we differentiate between a herpes simplex and a herpes zoster infection of the eye?
Hutchinson’s Sign:
When vesicles appear on the tip or side of the nose (the dermatome of the trigeminal nerve), this is a positive Hutchinson’s sign and indicates it is a herpes zoster infection.
Herpes zoster often affects the ophthalmic branch of the trigeminal nerve
The ocular lesions form 2-3 days after the initial skin rash
This condition is usually associated with over use or overnight wear of soft contact lenses
Ulcerative Keratitis:
Signs/symptoms:
Severe ocular pain
Injection more severe toward location of ulcer (wherever the ulcer is, that is where it will have the most pain and be the reddest)
Diagnosis:
Needs cornea scraping and culture to find causative agent
Most often Pseudomonas and Strep
Most sight-threatening: Acanthamoeba (fungal)
Management:
Same-day referral
Do not patch the eye! (Can make it worse)
Fortified topical antibiotic every 30 min - 1 hour for 24-hours and then daily follow-ups
Other types of ulcerative keratitis (rare):
Autoimmune (RA, etc)
Peripheral ulcers
Sterile ulcers (inflammation from severe staph blepharitis)
What are the 2 types of acute angle-closure glaucoma and which one is most common?
2 Types of Acute Angle-closure Glaucoma:
** Ophthalmic Emergency **
1. Open Most common Chronic condition Intraocular pressure increases slowly Patient asymptomatic
- Narrow
Sudden increase of pressure of the eye: can be > 50-60 mmHg (normal 12-22 mmHg)
Occurs mostly in dim conditions when the pupil are trying to dilate; the increased pressure causes pain
Can lead to blindness if not treated promptly
Refer immediately same day
Symptoms:
Pain and photophobia
Halos around lights
Headache/N/V
Red eyes/tearing
Blurred or decreased vision (due to swollen cornea)
Mid-dilated pupil that is fixed and non-reactive
Cornea appears cloudy
Fundoscopic exam = cupping of the optic nerve
Management (not done in primary care):
Decrease the entire intraocular pressure immediately using medications
Once pressure is < 30 mmHg, needs laser treatment
Uveitis:
Types:
Anterior, intermediate, posterior, or panuveitis (affects entire eye)
Causes:
Idiopathic, granulomatous, or non-granulomatous
Can be acute, chronic, or recurrent
What are the signs/symptoms and management?
Uveitis:
Signs/Symptoms:
Cells in the anterior chamber are affected causing white deposits on the corneal endothelium
If synechiae (iris adheres to cornea or lens), the cornea becomes swollen and sluggish to reaction with pupil
Pain*
Redness (limbal flush)
Photophobia
Epiphora (overflow of tears on face not from crying)
Decrease in vision
Other systemic symptoms: back pain, joint pain, skin rash, diarrhea, etc
Management for uveitis:
Refer to ophthalmology for treatment (topical steroid and cycloplegic agent)
You need to do:
Systemic work-up if uveitis is recurrent, bilateral, granulomatous, or posterior
TB, sarcoidosis, IBD, syphilis, SLE, Bechet disease, Lyme’s, herpes, toxoplasmosis, etc.
What does refractive error mean?
Refractive error is a fancy way of saying the patient needs glasses.
If a patient states they have decreased vision, what can we do in the office to figure out if a refractive error is present or not (do they need glasses or not)?
The use of a pinhole occluder forces the eye to look through like a tunnel.
If the patient’s vision gets better when looking through the pinhole occluder at something in the distance, the patient simply needs glasses for magnification in order to see.
If the patient’s vision does not get better when looking through the pinhole occuder, they may have decreased vision for another reason and need a workup.
Name this condition:
Sudden onset of a shower of floaters associated with a “curtain” in vision over one eye (gray or black) with sudden flashes of light (photopsia)
Detached Retina:
If the patient has central vision by the time they get to see you, this is EXTREMELY URGENT because their macula is still attached and it may be saved.
If the patient has lost their central vision by the time they get to you, it’s already detached (the entire retina) and it is less urgent but they still need to be seen that day by ophthalmology.
Name this condition:
This type of retinal occlusion is usually due to an embolis
Sudden, painless loss of vision
Cherry red spot when looking at the fundus
Retinal Artery Occlusion:
Usually due to an embolis
Sudden, painless loss of vision
Cherry red spot when looking at the fundus
Window of up to 24 hours to dislodge the embolus before vascular changes and vision loss
Use heroic measures to decrease IOP and dilate blood vessels
If the patient is older than 50 they need an urgent work-up to rule out giant cell arteritis which is a medical EMERGENCY
To start workup could get stat CRP/sed rate (results would be elevated)
