Exam 2: Eyes [9]

Question 1

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

Answer 1

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

Question 2

What is the main cause of bacterial conjunctivitis in adults?

Answer 2

Blepharoconjunctivitis

Question 3

What is the treatment for blepharitis?

Answer 3

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

Question 4

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)

Answer 4

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

Question 5

What is the treatment for a stye (hordeolum)?

Answer 5

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

Question 6

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

Answer 6

Chalazion

Can start as a hordeolum but has lost its painful sensation

Question 7

What is the treatment for a chalazion?

Answer 7

Treatment for chalazion:

May resolve spontaneously in 2-8 weeks

By an ophthalmologist:
Incision and drainage
Surgical removal
Intrachalazion corticosteroid injections

Question 8

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

Answer 8

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

Question 9

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

Answer 9

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)

Question 10

Name this condition:

Inability to close the eyelids completely
Can be associated with exophthalmos (hyperthyroidism)

Answer 10

Lagopthalmos:

Inability to close the eyelids completely

Question 11

What is the management for lagopthalmos?

Answer 11

Lagopthalmos management:

Thick ocular ointment such as Refresh PM
Refer to oculoplastic surgeon

Question 12

Name this condition and management:

Most common cause of eyelid dermatitis, especially if bilateral
Symptoms: Itchy, red eyelids

Answer 12

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

Question 13

Name 3 types of conjunctivitis

Answer 13

Allergic
Viral
Bacterial

Question 14

Name this eye condition and the management:

Mild, itchy injection to sclera
Usually happens with a trigger

Answer 14

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

Question 15

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

Answer 15

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

Question 16

Name this eye condition and the management:

Beefy redness
Major discharge that continues throughout the day
Starts itching but then becomes mostly irritated

Answer 16

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

Question 17

Name this eye condition:

Blood that is trapped under the conjunctiva and sclera

Answer 17

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

Question 18

What is the management for a subconjunctival hemorrhage?

Answer 18

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

Question 19

Name this eye condition:

Affects 10-30% of population over the age of 40

Symptoms:
Burning
Foreign body sensation
Itchiness
Excessive tearing

Answer 19

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

Question 20

What does Schirmer’s Test evaluate?

Answer 20

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.

Question 21

How is keratoconjunctivitis sicca (dry eye) managed?

Answer 21

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)

Question 22

When should we refer patients with painful red eyes?

Answer 22

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

Question 23

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

Answer 23

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

Question 24

What is episcleritis and what are the symptoms and management?

Answer 24

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

Question 25

What is scleritis and what are the symptoms and management?

Answer 25

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

Question 26

Herpes Simplex Keratitis: infection of the cornea with HSV What are the signs and symptoms and management?

Answer 26

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)

Question 27

Herpes Zoster Ophthalmicus: infection of the cornea with HZV What are the signs and symptoms and management?

Answer 27

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

Question 28

How can we differentiate between a herpes simplex and a herpes zoster infection of the eye?

Answer 28

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

Question 29

This condition is usually associated with over use or overnight wear of soft contact lenses

Answer 29

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)

Question 30

What are the 2 types of acute angle-closure glaucoma and which one is most common?

Answer 30

2 Types of Acute Angle-closure Glaucoma: **** Ophthalmic Emergency **** ``` 1. Open Most common Chronic condition Intraocular pressure increases slowly Patient asymptomatic ``` 2. 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

Question 31

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?

Answer 31

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.

Question 32

What does refractive error mean?

Answer 32

Refractive error is a fancy way of saying the patient needs glasses.

Question 33

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)?

Answer 33

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.

Question 34

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)

Answer 34

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.

Question 35

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

Answer 35

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)

Question 36

Name this condition: This type of retinal occlusion is called "blood and thunder" because it's a more dramatic loss of vision It is a partial loss of field of vision

Answer 36

Retinal Vein Occlusion: Central: "blood and thunder" Branch: only partial loss of field of vision Less urgent referral: will only treat if macular edema or neovascularization Needs regular eye exams for the first 6-months to check for neovascularization Check BP, cholesterol If patient is older than 50 they need an urgent work-up to rule out giant cell arteritis which is a medical EMERGENCY - Without prompt treatment, irreversible loss of vision in the other eye can occur in 1-7 days - Check for jaw claudication, scalp tenderness, simultaneous headache, tender temporal artery - Order immediate ESR, CRP, platelets, and temporal artery biopsy if suspicion is high

Question 37

Name this condition: Pain with eye movement Can be the first manifestation of MS (ages 18-45) Loss of vision occurs over days and decreased color perception Nerve can look swollen or normal when looking at the fundus May be accompanied with nystagmus May have aphasia, paresthesia, spasticity, abnormal gait

Answer 37

Optic Neuritis: Pain with eye movement Can be the first manifestation of MS (ages 18-45) Loss of vision occurs over days and decreased color perception Nerve can look swollen or normal when looking at the fundus May be accompanied with nystagmus May have aphasia, paresthesia, spasticity, abnormal gait Need: neuro-ophthalmology consultation/MRI with gadolinium

Question 38

If a patient comes in with complaints of vision loss and you think it could be due to malingering, what observations do you want to make and how do you want to handle?

Answer 38

Malingering: Observe patient: does amount of visual decrease correspond to the way he/she acts? Is the patient able to: Walk to the exam room without bumping into anything? Shake your hand? Tell you the time? Clinical pearl: Pupil reaction has to correspond to visual loss - If unilateral severe visual loss, should see relative afferent pupillary defect (RAPD) - If pupil reacts to light, there is at least light perception Management: Visual field testing at different distances Optokinetic drum; use low-power lenses If history not consistent with exam, go back and look at history for other potential possibilities for the problem

Question 39

If a patient has 1 or 2 new floaters, what could this indicate?

Answer 39

If a patient has 1 or 2 new floaters, what could this indicate? Detached vitreous

Question 40

If patient states they have lots of new floaters, they need an eye exam to rule out what condition?

Answer 40

If patient states they have lots of new floaters, they need an eye exam to rule out what condition? Concurrent retinal tears OR it could be retinal detachment Therefore, any patient who endorses lots of floaters should be sent to ophthalmology urgently

Question 41

Do retinal flashes need an urgent referral to ophthalmology?

Answer 41

No - retinal flashes do not require an urgent referral to ophthalmology that day but should be seen soon Retinal flashes: Last a few seconds One bright flash on the side of the vision Means traction between vitreous and retina; will not necessarily lead to retinal detachment

Question 42

If patient complains of flashes followed by a headache, what could it be?

Answer 42

Migraine

Question 43

If a patient comes in with complaints of double vision, what will you do?

Answer 43

If a patient comes in with complaints of double vision, what will you do? Check for extraocular movements Check for pupil reaction

Question 44

If a patient complains of pain or double vision with extraocular movements, what diagnosis could this be related to?

Answer 44

If a patient complains of pain or double vision with extraocular movements, what diagnosis could this be related to? Thyroid eye disease Multiple sclerosis Need to do a workup

Question 45

If a patient comes in with vision complaint and you check for pupil reaction and it is not dilating correctly, what could this suggest?

Answer 45

If a patient comes in with vision complaint and you check for pupil reaction and it is not dilating correctly, what could this suggest? Third nerve palsy - Medical EMERGENCY

Question 46

If a patient has complaints of intermittent double vision (diplopia), what could this suggest?

Answer 46

If a patient has complaints of intermittent double vision (diplopia), what could this suggest? Multiple sclerosis Myasthenia gravis Thyroid eye disease

Question 47

Is it more concerning if the patient has diplopia in both eyes or just one?

Answer 47

It is more concerning if the diplopia is in both eyes It is less concerning if only in one eye (monocular diplopia) rarely an urgent condition Have the patient cover each eye to test this out

Question 48

How do we treat thyroid eye disease?

Answer 48

Thyroid eye disease: Once we correct thyroid levels in the blood, this typically gets better Most often associated with hyperthyroidism 10% of people with Hashimotos will have visual changes Inferior rectus first muscle involved Associated with exophthalmos, dry eyes, lid retraction

Question 49

How can we try to figure out if vision issues are due to myasthenia gravis?

Answer 49

How can we try to figure out if vision issues are due to myasthenia gravis? Diplopia is worse at the end of the day Get some ptosis (drooping of the eyelids) but never any pupil involvement Ptosis will get worse after sustained up gaze Ptosis will improve with ice

Question 50

Could headaches be related to an eye problem?

Answer 50

Could headaches be related to an eye problem? Usually if associated with binocular vision or uncorrected refractive error: - Toward afternoon - Associated with visual task - Mostly frontal or on the temples - Observe if patient squints to see objects

Question 51

What is RAPD and how is it performed?

Answer 51

RAPD = relative afferent pupil defect "Swinging" light test, comparing the reaction to the light in both eyes Should take the pupil longer to constrict than what we would expect or it may not constrict at all

Question 52

How would you manage a chemical splash to the eye?

Answer 52

Chemical Splashes = Medical Emergency Alkaline burn much worse than acid burn; can cause perforation much quicker Limbal blanching (whiteness around the iris) has the worst prognosis Immediate copious irrigation with sterile water/saline for at least 30 minutes or until EMS arrives at the office Irrigation will often cause corneal abrasion Need to check intraocular pressure The ED will prescribe: Topical lubrication with non-preserved tears and ointment at night Cycloplegic agent to keep pupil dilated Broad spectrum topical antibiotic

Question 53

How would you manage a foreign body in the eye?

Answer 53

Foreign Body in Eye: Check type of foreign body - If vegetative matter: need lab culture to rule out fungal infection (fungal infections = worst prognosis) - If high velocity (BB or rock): CT scan and dilated eye exam - Rule out intraorbital and intraocular foreign body Thoroughly exam the eye with lid eversion looking for embedded foreign body - If no foreign body seen, check for foreign body tracking or abrasion - The more central the foreign body the more careful the approach Check for perforated globe with Seidel test - Look for leaking fluorescein stain; it leaks out of the eye if there is a perforation - Do not remove foreign body if Seidel is positive or if entrapped (stabilize foreign body and refer) If too dangerous to remove foreign body in primary care, patch the eye and get them off to ophthalmology urgently or to the ED

Question 54

What are the signs of corneal abrasion and what can you do for it?

Answer 54

Corneal Abrasion: Significant pain especially with blink Lots of tearing Visualize the scrape with fluorescein dye (cornea is transparent; can't see abrasion with naked eye) Be concerned for uveitis Treatment: Topical antibiotic Bandage or pressure patch if large and painful Do not patch if recent history of contact lens wear (could promote growth of bacteria or fungus) Daily follow-up with ophthalmology Corneal ulcers can heal in 24 hours especially in young patients

Question 55

What will you include in your examination for blunt trauma to the orbit?

Answer 55

Blunt trauma to orbit exam: ** Will need emergency treatment for any blunt trauma to eye - send to ED ** Pupillary reaction to light Confrontation visual field Ocular motility: if not full or pain on movement, suspect entrapment of muscles in orbital wall/floor Palpation of orbital bones: check for step-off, crepitus (if present indicates fracture) Ocular examination for ruptured globe: look for blood in the anterior chamber, irregular shaped pupil, large subconjunctival hemorrhage Order CT scan of orbit if any of above abnormal

Question 56

A preschool child who attends day care has a 2-day history of matted eyelids in the morning and burning and itching eyes. The NP notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI symptoms. Which action is correct? A. Culture the conjunctival discharge B. Observe the child for several days C. Order an oral antibiotic medication D. Prescribe topical antibiotic drops

Answer 56

Answer: Topical antibiotic drops Most cases of bacterial conjunctivitis are self-limiting but using a topical antibiotic will hasten the return to day care. Oral antibiotics not indicated Notes: "Goop" is the hallmark of bacterial conjunctivitis Extremely contagious! After 24 hours on antibiotic drops, wash pillowcases, sheets, towels Different antibiotic drops for anyone wearing contact lenses (mom/dad, etc) Have kid lay on back with eyes closed, place 1-2 drops in corner of eye, have them open eye and should go right in

Question 57

A 13-year-old child has a 2 week history of severe itching of both eyes. The NP notes redness and swelling of the eyelids along with stringy, mucoid discharge. What should be prescribed? A. Saline solution or artificial tears B. Topical mast cell stabilizer C. Topical antihistamine D. Topical vasoconstrictor drops

Answer 57

Answer: These are symptoms of allergic conjunctivitis (not purulent, green goop) Topical antihistamines work for acute symptoms to reduce histamine response Saline or artificial tears useful for milder symptoms Topical mast cell stabilizers useful for chronic symptoms and maintenance Note: Can advise patient to bath/shower before bed including washing hair to prevent allergens to get onto pill while sleeping and face rubbing in it

Question 58

The NP observes tender, swollen, red furuncle on the upper lid margin of a child's eye. What treatment will be recommended? A. Culture the lesion to determine causative agent B. Refer to ophthalmology for incision and drainage C. Topical steroid medication D. Warm, moist compresses 3-4 times per day

Answer 58

Answer: These are symptoms of hordeolum (stye) Often rupture spontaneously and warm, moist compresses may hasten process Refer if hordeolum does not rupture on its own

Question 59

The NP is treating an infant with lacrimal duct obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with topical antibiotics along with message and frequent cleansing of secretions, the infant's symptoms have not improved. Which is the correct action? A. Perform massage more often B. Order oral antibiotics C. Recommend hot compresses D. Refer to ophthalmology

Answer 59

Answer: Infants treated for secondary bacterial conjunctivitis with lacrimal duct obstruction who do not improve after 1-2 weeks of topical antibiotic therapy must be referred to an ophthalmologist for possible lacrimal duct probe The other options are not appropriate

Question 60

A preschool-age child is seen in office after waking up with a temperature of 102.2 F, swelling, and erythema of the upper lid of one eye, and moderate pain when looking from side to side. Which is correct? A. Admit to hospital for IV antibiotics B. Obtain lumbar puncture and blood culture C. Order warm compresses 4 times/day for 5 days D. Prescribe 10-14 days of oral antibiotics

Answer 60

Answer: Child has periorbital cellulitis and must be hospitalized because of having pain with movement of the eye (indicating orbital involvement) ** Painful movement of eyeball is always alarming ** LP is performed on infants under 1 year of age Warm compresses would be for mild cases Oral antibiotics not appropriate

Question 61

A school age child is seen in the clinic after a fragment from a glass bottle flew into the eye. What will the NP do? A. Refer immediately to ophthalmology B. Attempt to visualize the glass fragment C. Irrigate the eye with sterile saline D. Instill a topical anesthetic

Answer 61

Answer: Refer immediately to ophthalmology NEVER attempt to remove an intraocular foreign body or any projective object Visualizing, irrigating, or instilling drops may further damage the eye

Question 62

A school age child is hit in the face with a baseball bat and reports pain in one eye. The NP is able to see a dark red fluid level between the cornea and iris on gross examination but the child resists any exam with a light. What next? A. Administer an oral analgesic medication B. Apply a Fox shield and reevaluate in 24 hours C. Instill anesthetic eye drops into the affected eye D. Refer child immediately to ophthalmology

Answer 62

Answer: This is a traumatic injury with hyphemia to the eye Need ophthalmologist to examine eye to rule out orbital hematoma or retinal detachment Any further attempt to visualize eye could cause more damage A Fox shield is used once more serious injury is excluded (eye patch with holes)

Question 63

The NP performs an eye exam during a well visit and notices a difference of 0.5 mm in size between the patient's pupils. What does this finding indicate? A. A relative afferent pupillary defect B. Indication of a difference in intraocular pressure C. Likely underlying neurological abnormality D. Probable benign, physiologic anisocoria

Answer 63

Answer: A difference in < 1 mm diameter is usually benign A difference in > 1 mm diameter is more likely to represent an underlying neurological abnormality Would want to follow up with ophthalmology for an eye exam

Question 64

A patient presents with diffuse erythema in one eye without pain or history of trauma. The exam revels a deep red, confluent hemorrhage in the conjunctiva of that eye. What is the most likely treatment? A. Lubricating drops or ointment B. Ophthalmic antibiotic drops C. Reassure the patient this will resolve D. Refer to ophthalmology

Answer 64

Answer: Most conjunctival hemorrhages occurring with trauma or Valsalva maneuver will self-resolve and are benign The other options are not indicated

Question 65

A patient reports using artificial tears for comfort of burning and itching in both eyes but reports worsening symptoms. The NP notes redness and discharge along the eyelid margin with clear conjunctivae. The lids are edematous. What is recommended? A. Antibiotic solution drops 4x daily B. Warm compresses, lid scrubs, and antibiotic ointment C. Oral antibiotics given prophylactically for several months D. Reassurance that this is a self-limiting condition

Answer 65

Answer: Patient has symptoms of blepharitis without conjunctivitis Initial treatment involves lid hygiene and antibiotic ointment may be applied after lid scrubs Antibiotic solution is used if conjunctivitis is present Oral antibiotics reserved for severe cases Disorder is genetically chronic

Question 66

Patient with cold symptoms develops conjunctivitis. The provider notes erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes along with a fever. Which treatment do you prescribe? A. Antihistamine vasoconstrictor drops B. Artificial tears and cool compresses C. Topical antibiotic eye drops D. Topical corticosteroid drops

Answer 66

Answer: There is no purulent drainage or goop so this is viral conjunctivitis which accompanies URI and is generally self-limiting, lasting 5-14 days. Symptomatic treatment is recommended (artificial tears and cool compresses) Antihistamine vasoconstrictor drops are for allergic conjunctivitis Topical antibiotics are sometimes used for bacterial conjunctivitis Topical drops are used for severe inflammation ** Do not prescribe steroid eye drops - send to ophthalmology for that **

Question 67

A patient who works in a wood working shop reports sudden onset of severe eye pain while sanding a piece of wood and now has copious tearing, redness, and light sensitivity in the affected eye. On exam the conjunctiva appears injected (redness due to irritation or infection) but no foreign body is visualized. What is the next step? A. Antibiotic eye drops B. Topical fluorescein dye C. Cycloplegic drops D. Irrigation of eye with normal saline

Answer 67

Answer: B; The NP must determine if there is a corneal abrasion and will instill fluorescein dye in order to examine the cornea under a Wood's lamp or black light. Antibiotic drops not indicated Cycloplegic drops used occasionally for pain control but should be used with caution Irrigation of eye is indicated for chemical burns Note: Could use tetracaine eye drops to numb the eye for examination. Instill 1-2 drops; becomes numb in 30 seconds and lasts about 15 minutes. Also used in cataract surgery. Never prescribe this.

Question 68

Which patient(s) should be referred immediately to ophthalmology after eye injury and initial treatment? Select ALL that apply: A. A patient who has been sprayed by lawn chemicals B. A patient who works in a metal fabrication shop C. A patient with a corneal abrasion D. A patient with full-thickness corneal laceration E. A patient with irritation secondary to wood dust

Answer 68

Answer: A (lawn chemicals), B (works in metal fabrication shop), D (full-thickness corneal laceration) Refer immediately to ophthalmology the following: Chemical eye injuries Any possible metallic foreign bodies Full-thickness corneal lacerations Managed in primary care: Corneal abrasions and irritation from wood dust

Question 69

What is the most common bacterial cause of preseptal cellulitis in children? A. Strep pneumoniae B. Moraxella catarrhalis C. Staph aureus D. H. influenzae

Answer 69

What is the most common bacterial cause of preseptal (periorbital) cellulitis in children? Answer: (C) staph

Question 70

What is the most common cause of red eye in the primary care setting? A. Conjunctivitis B. Foreign body C. Subconjunctival hemorrhage D. Glaucoma

Answer 70

What is the most common cause of red eye in the primary care setting? Answer: (A) conjunctivitis

Question 71

A 58-year-old woman with a history of granulomatosis with polyangiitis presents with an acute complaint of red eye associated with eye pain, tearing, and photophobia. Exam is notable for a localized area of redness with a nodular appearance overlying the inferior, medial aspect of the right eye. What is the most likely diagnosis? A. Viral conjunctivitis B. Acute angle-closure glaucoma C. Subconjunctival hemorrhage D. Scleritis

Answer 71

A 58-year-old woman with a history of granulomatosis with polyangiitis presents with an acute complaint of red eye associated with eye pain, tearing, and photophobia. Exam is notable for a localized area of redness with a nodular appearance overlying the inferior, medial aspect of the right eye. What is the most likely diagnosis? Answer: (D) Scleritis - could be a self limiting condition

Question 72

Which of the following antibiotics is recommended as first-line therapy for the treatment of bacterial sinusitis in children without allergies? A. Amoxicillin with clavulanate (Augmentin) B. Azithromycin C. Trimethoprim-sulfamethoxazole D. Levaquin

Answer 72

Which of the following antibiotics is recommended as first-line therapy for the treatment of bacterial sinusitis in children without allergies? Answer: (A) Amoxicillin with clavulanate (Augmentin)

Question 73

What is the most common bacteria found in sinus aspirates in children with acute bacterial sinusitis? A. Strep pneumoniae B. MRSA C. H. influenzae D. M. catarrhalis

Answer 73

What is the most common bacteria found in sinus aspirates in children with acute bacterial sinusitis? Answer: (A) Strep pneumoniae

Question 74

Which of the following antibiotics should be used as first-line therapy in the treatment of an adult with acute bacterial sinusitis and no allergy to medications? A. Doxycycline B. Amoxicillin with clavulanate C. Clarithromycin D. Levofloxacin

Answer 74

Which of the following antibiotics should be used as first-line therapy in the treatment of an adult with acute bacterial sinusitis and no allergy to medications? Answer: (B) Amoxicillin with clavulanate (Augmentin)

Question 75

What is this condition: Acute onset of erythematous swollen eyelid with proptosis (bugling of the eyeball) and eye pain of the affected eye, pain with eye range of motion. Can occur after recent rhinosinusitis or URI.

Answer 75

Orbital cellulitis

Question 76

Which patient population is orbital cellulitis most common in?

Answer 76

Young children

Question 77

What physical sign would you find if the optic disc is swollen with blurred edges due to ICP secondary to bleeding, brain tumor, abscess, or pseudotumor cerbri?

Answer 77

Papilledema

Question 78

What findings are associated with hypertensive retinopathy?

Answer 78

AV nicking | Copper and silver wire arterioles

Question 79

What findings are associated with diabetic retinopathy?

Answer 79

Cotton wool spots Flame hemorrhages Refer to ophthalmology NP needs to get diabetes and HTN under control

Question 80

Name this condition and is it cancerous? A yellow/white deposit on the conjunctiva caused by chronic sun exposure

Answer 80

Pinguecula ("Ping-gwek-ula") This is a non-cancerous growth

Question 81

Name this condition and is it cancerous? A yellow triangular (wedge-shaped) thickening of the conjunctiva that extends across the cornea on the nasal side caused by chronic sun exposure; can be red or inflamed at times and patient may complain of foreign body sensation of the eye. Sometimes called "surfer's eye."

Answer 81

Pterygium ("Tuh-rij-ee-um") This is a non-cancerous growth that can grow and cause blindness until it is removed

Question 82

What is the leading cause of permanent blindness in the elderly (central vision loss) and more common in smokers?

Answer 82

Macular degeneration

Question 83

The first sign in this disorder is central blind spot (scotoma) or curving of straight lines while peripheral and color vision are normal

Answer 83

Macular degeneration

Question 84

What is the treatment for macular degeneration?

Answer 84

Refer | Ocular vitamins

Question 85

This condition presents with opacity in the lens of the eye, decreasing visual acuity

Answer 85

Cataract

Question 86

This condition can be caused by chronic exposure to systemic steroids or it can happen overnight status post trauma to the eye; the patient has a loss of color vision (orange may look pink, etc)

Answer 86

Cataract

Question 87

What is arcus senilis?

Answer 87

Arcus senilis = cataract | Common in elderly

Question 88

What could be the cause of cataracts in young people?

Answer 88

Hypercholesterolemia