Eye Flashcards
Eye Exam for Eye Complaint
Inspect whole patient Visual acuity- each eye Pupil reactions Lymphadenopathy- pre-auricular nodes Eyelids Conjunctiva (bulbar and palpebral) Cornea (clarity, staining with fluorescein, sensation) Anterior chamber (depth) Pupils shape/ reaction to light / accommodation Funduscopic exam Eye movements
Visual Acuity
OU
OD
OS
Vital sign in occular complaints!!! Test with glasses on OU- Both OD- Right OS- Left eye
Common Causes of Red Eye
Conjunctivitis
Keratitis
Subconjunctival hemorrhage
Dry eye
Conjunctivitis
Name 5 types
Bacterial vs Viral?
Most common eye complaint Can be: Viral, Bacterial, Fungal, Chemical, Allergic Other … Most cases benign & self-limiting
Bacterial or Viral? Viral Tends to be more in the summer Itching common, minimal pain Acute or subacute Recent URI
Bacterial Tends to be more in winter/spring Acute onset, minimal pain Staph/Strep common Discharge thick and purulent
Symptoms of Conjunctivitis
Eyelids sticking Itching/burning Gritty Pus Recent URI No change in visual acuity Others with similar symptoms
Treatment of Conjunctivitis
3 types of medications
Usually supportive
Handwashing
Cold compresses
Antibiotic ointment/drops
Erythromycin ointment
1 cm in eye 4-6 times per day x 7-10 days
Polytrim
1 drop in eye 4-6 times per day x 7 – 10 days
Cipro drops (contact lens wearers)
1-2 drops in eye every 2 hours while awake x 2 days, then every 4 hours x 5 days
Chemical Conjunctivitis
Exposure to a chemical
Contact poison control
Flush eye – may need a Morgan’s Lens
Allergic Conjunctivitis
No pain, very itchy, may be acute/subacute
Clear, watery discharge
Treat with azelastine 0.05% - 1 drop BID
Conjunctivitis Teaching
If no better or worse – REFER to ophthalmology For any conjunctivitis If chemical exposure May need to go to ER or urgent care If contact lens wearer Always avoid wearing x 2 weeks Change case, solution, & contacts Also, change/discard any eye makeup
Bacterial Keratitis
VERY serious!! – Can lead to loss of vision
Complication of contact lens use
Pain, photophobia, decreased vision
Findings: corneal ulceration, upper eyelid edema, conjunctival hyperemia, adherent mucopurulent exudate, surrounding corneal inflammation
REFER, REFER, REFER – may need a corneal biopsy
Treatment – Specialized antibiotic drops and scheduling (every hour)
Subconjunctival Hemorrhage
Causes
Symptoms
Treatment
Bleeding from small vessels within the conjunctival vessels
Causes – trauma, coughing, sneezing, straining, HTN, blood thinners
Symptoms – no pain, normal vision, sudden onset of red eye
Treatment – reassurance, cold compress
Improves on own in 1-2 weeks
Always check blood pressure
If recurrent – consider bleeding disorder
Causes of Dry Eye
Poor quality Meibomian gland disease, Acne rosacea Lid related Vitamin A deficiency Poor quantity Sjogren Syndrome Rheumatoid Arthritis Sarcoidosis VII CN nerve palsy
Corneal Abrasion
Common eye injury
Usually without complications, but if severe can have long term consequences
Any defect in the epithelium of the cornea – injury, dust/debris, foreign body, burn, contact lens, etc.
Symptoms – pain, inability to open eye, foreign body sensation, photophobia, tearing, and conjunctival injection
Use wood’s lamp & fluorescein technique
Treatment – antibiotic ointment/drops, pain control
DO NOT GIVE PATIENT NUMBING AGENTS FOR HOME USE
Cipro drops for contact lens wearers
Patching not recommended or needed
Refer if large, retained foreign body, or deep corneal abrasion
Herpes Zoster Ophthalmicus
What cranial nerve?
Exam
Treatment
Shingles involving the trigeminal nerve (5)
Symptoms: eye pain, fever, malaise, headache, neck stiffness, unilateral eye redness, vision changes, tearing, rash
Exam: vesicular rash, lymphadenopathy, decreased visual acuity, iritis or keratitis
MAY LEAD TO VISION LOSS
Treatment: REFER to optho, Acyclovir 800 mg five times a day for 7-10 days, may need antibiotics if secondary infection, artificial tears, warm compresses, pain control
Acute Angle Closure Glaucoma
Diagnosis: Need 2 of the following:
Ocular pain, N/V, or intermittent blurring with halos
AND at least 3 of the following:
IOP > 21, conjunctival injection, corneal epithelial edema, mid-dilated nonreactive pupil, or shallow chamber in the presence of occlusion
May present with only headache or nausea/vomiting as main complaint
Causes: certain drugs, dim light, rapid correction of hyperglycemia
Exam: MUST include tonometry for evaluation of intraocular pressure (IOP)
REFER IMMEDIATELY to optho
Treatment includes: Acetazolamide IV/PO, topical beta blocker, topical steroid, may require surgery
Iritis/Uveitis
Inflammatory process – genetic, traumatic, immune, or infectious
Pain, redness, photophobia, blurred vision, tearing – can be acute or chronic
Injection all around the limbus (surrounds iris), decreased visual acuity
Bilateral or recurrent uveitis needs workup (not needed if mild case)
CBC, ESR, ANA, RPR, PPD, Lyme, HLA testing for AS, CXR, UA, and/or HIV
Should refer to optho and be seen within 24 hours
Treatment – treat underlying condition if believed to be the cause
Homatropine 5% - 1-2 drops in eye BID-TID
Topical steroids – should be started by optho only
Scleritis
Symptoms
Workup
Treatment
Usually from underlying autoimmune disease (RA, SLE, vasculitis, etc.)
Symptoms: pain, redness, tearing, photophobia, decreased visual acuity, may be unilateral or bilateral, usually chronic
Workup: RF, ANA, ANCA, HLA, IgE, Uric acid, ESR, HBsAg, RPR, Lyme, PPD – dependent on suspected cause
Treatment: NSAIDs, steroids, or immunomodulatory drugs
Primary care – generally oral prednisone or ibuprofen until referred
Refer to optho or rheumatology
Myopia
Nearsighted- unable to see object far away
Hyperopia
Farsightedness- unable to see objects up close
Astigmatism
Objects appear blurry and stretched out
Presbyopia
Age related condition, unable to focus objects clearly
Cataracts
Risk Factors
Symptoms
Treatment
Opacifications of the lens of the eye
Risk factors – older age, females, use of corticosteroids, systemic disease (DM), smoking, UV exposure
Symptoms – decreased visual acuity, decreased color perception, decreased contrast sensitivity, issues with glare
Treatment – change in eyewear prescription, smoking cessation, UV protection, use of good lighting, surgical treatment
Glaucoma
Definition
Risk factors
Symptoms
Treatment
Increased intra-ocular pressure – chronic illness
Risk factors – family history, age over 40, AA race
Symptoms – slow progression of peripheral vision with decreased central visual acuity, difficulty with dim light, decreased contrast sensitivity, difficulty with glare, decreased dark/light adaptation
Early diagnosis/treatment is important to prevent vision loss
Treatment – topical medications including prostaglandins, beta blockers, adrenergics, carbonic anhydrase inhibitors, miotics, oral medication, laser therapy
Usually followed by optho
Tonometry
Must calibrate prior to each use.
Normal reading under 20mm/Hg
Record OU
Open-angle glaucoma causes
May have genetic links; environmental factors may also induce glaucoma; close association with DM
Closed-angle glaucoma
Causes
Common medications- Sulfa-containing meds, Corticosteroids, Cholinergic agents (Pilocarpine), Adrenergic agonists (Albuterol), Antidepressants ACE inhibitors (rare)
Congenital glaucoma
Presentation of disease within first year of life; usually indicative of a genetic anomaly
Juvenile-onset glaucoma
Seen in children ages 5-18; usually caused by genetic factors
Secondary glaucoma
Caused by trauma, inflammation and ischemia to the eye
Glaucoma screening
Every 3-5 years for 40-60 year olds without risk factors
> 60 years old every 1-2 years
No specific screening guidelines per the U.S. Preventative Task Force
Be aware of patients at higher risk for developing glaucoma, will need more frequent screening
Glaucoma risk factors
Open-Angle: European/ African American
Closed-Angle: Asian descent, Inuit descent and patients with shallow anterior chambers
Lower socioeconomic factors at higher risk for vision loss
Male babies/children at higher risk for developing congenital form
Family history of glaucoma
Diabetes
Female
Diabetic Retinopathy
Complication of diabetes, increases with duration of disease
Two types – nonproliferative & proliferative – differentiated by exam findings
Nonproliferative can develop into proliferative
Early treatment/control can prevent retinopathy and vision loss
Symptoms – decreased visual acuity, contrast sensitivity, color perception, & dark/light adaptation, also have issues with glare and distortion
Annual eye exam for ALL patients with diabetes (Type I & II)
Treatment – may need laser surgery
Macular Degeneration
Can be dry or wet
DRY – deposits & areas of depigmentation alternating with hyperpigmentation
WET – Neovascularization
Initially no symptoms then progress to loss of central vision with metamorphopsia (distortion of objects), glare sensitivity, decreased contrast sensitivity, decreased color vision
Risk factors – older age, smoking, HTN, hyperlipidemia, vascular insufficiency, UV light exposure, family history
Should be followed by optho
Treatment – Vitamin C, Vitamin E, beta carotene, zinc, control risk factors, exercise, sunglasses
Retinal Detachment
Causes – trauma, history of previous eye surgery, vascular disease, tumor, degeneration, metabolic disorders, other
Symptoms – flashes of light, visual field defect, floaters, cloudy vision, curtain-like vision
REFER immediately to optho – may need immediate surgery – specifically may need retinal specialist
Can lead to loss of vision or permanent visual defect
Blepharitis
Inflammatory disease of the eyelid
Symptoms – eye irritation, itching, lid redness, flaking, eyelash changes, burning, watering, crusting, red eyes, decreased vision, pain, photophobia, foreign body sensation
Exam – Eyelid redness & crusting of lids/lashes
Related to seborrheic dermatitis & rosacea
Treatment – eyelid hygiene with warm compresses, baby shampoo, antibiotic ointment (ophthalmic), if refractory may need oral ABX (tetracycline)
Usually a chronic condition
Hordeolum
Hordeolum (Stye) Painful lump Base of eyelash Usually bacterial Warm compresses & antibiotic drops/ointment Acute problem Resolves in 1-2 weeks
Chalazion
Chalazion Swollen bump on eyelid Usually non-painful Clogged oil gland Warm compresses May need steroid shots May require surgery Chronic in nature
Orbital cellulitis
Cellulitis of orbital tissue – may lead to infection of eye and vision loss
Symptoms – fever, malaise, history of recent URI/sinusitis, headache, lid edema
Exam – redness, warmth, swelling, pain with eye movement, orbital pain
Workup – CBC, Blood culture, culture if drainage, CT if severe to eval for abscess
Treatment – may require hospitalization (severe), drainage of abscess if present, refer to optho
ABX – clindamycin 300 mg four times daily x 10 days or Bactrim DS BID x 10 days
Traumatic Hyphema
Blood in the anterior chamber of the eye
Usually the result of trauma, but can also be from eye surgery or medical issue
ALWAYS REFER ASAP
Must evaluate for more serious eye injury
Symptoms – eye pain, blurred or loss of vision, photophobia
Exam – Examine sitting and lying back – may change position of blood
Treatment – bed rest, elevate head, protect eye, treat elevated IOP if present, may require surgery
Orbital Fracture
Traumatic injury – assault, MVA, fall, sports injury, etc.
Several different types of fractures – type dictates management
CT to determine type of fracture & to eval globe
Evaluate for – injury to the globe & muscle entrapment, visual disturbances, nerve injuries
Treatment – avoid nose blowing & Valsalva maneuvers, oral ABX, pain control, keep head elevated, may require surgery
Refer – may need ENT, plastics, maxillofacial, or ophthalmology
Orbital hematoma/Globe Rupture
Both are optho emergencies and require immediate referral – both from blunt trauma
Globe rupture is a full-thickness injury to cornea, sclera, or both
Orbital hematoma or compartment syndrome – severe pressure from collection of blood
Treatment – lateral canthotomy
Symptoms – pain, loss of vision, swelling, other symptoms related to mechanism of injury
Globe rupture – do not apply any pressure to eye, leave foreign bodies in place, DO NOT measure IOP, DO NOT instill anything into eye (medication, flush, etc.)
CT to evaluate
Pterygium
Also known as “surfer’s eye”
Growth of fleshy tissue and can cover cornea
Cause – dry eye, exposure to wind, dust, UV light
Symptoms – burning, itching, tearing, visual disturbance
Treatment – sunglasses, eye protection, artificial tears, surgery if severe
