EYE Flashcards
HPI evaluation of the eyes
Location, severity, circumstances surrounding onset
Quality or character of complaint, aggravating/alleviating/associated factors
Duration, frequency, timing, impact on ADLs
Current or prior use of eye medications
Recent or current systemic illnesses
PMH evall of eyes
Ocular history DM, HTN Current medication Drug allergies? Use of corrective lenses?
family history eval of eyes
Glaucoma, cataracts, macular degeneration, etc.
RA, DM, HTN, CAD, renal disease, autoimmune disorders
social history eval of eyes
Employment setting
Leisure activities
Contact lens hygiene practices
person tested identifies letters at 20 feet that a person with average vision sees at 80 feet
20/80
test for visual acuity
- pedi version with shapes available
Snellen Chart
eye chart for near vision - held 12-14 in from eye (reading vision)
Jagger Chart
eye tool to measure color discrimination - full test consists of 38 different plates
Ishihara
PERRLA
Pupils equal, round, and reactive to light and accommodation
what is Anisocoria
(unequal pupils)
Physiologic or simple anisocoria occurs in 20% of the population`
Difference is usually less than 0.5 mm but can be up to 1 mm
what to check when examining the eye
PERRLA, Extraocular muscle function (Cover–uncover test)
Visual field evaluation
External evaluation (Eyelid, eyebrow, orbital rim)
Intraocular pressure
Ophthalmoscopic evaluation
when to do vision screening tests in kids?
Preschool/prekindergarten physical
Not before age three
Do check for red reflex, deviated gaze, strabismus, structural abnormalities
how often should older adults get vision checked
Routine in older adults (recommendations range from every 1–10 years)
American Academy of Ophthalmology recommends comprehensive eye exam every 1–2 years starting at age 65
DM = yearly dilated eye exam
how often does a diabetic need a vision exam?
every year
2 major eye defense mechanisms
- tears
2. conjunctival immune system
Contain immunoglobulin A and lysozymes that provide an important washing action
tears
what makes up the conjunctival immune system
Lymphocytes, plasma cells, neutrophils
Inoculation of the eye with virulent organisms or trauma disrupts the normal defense mechanisms, leading to redness
Differential Diagnosis: Red Eye (no pain or vision loss)
Conjunctivitis
Subconjunctival hemorrhage
Episcleritis
Differential Diagnosis: Red Eye, normal vision)
Episcleritis Keratitis Cluster headache Corneal abrasion Corneal ulcer
Differential Diagnosis:
Red Eye
(Pain, vision impaired)
Iritis Glaucoma Orbital cellulitis Scleritis Corneal abrasion Corneal ulcer Keratitis
corneal disorders with intraocular irritation ( corneal ulceration)
mixed conjunctival injection
conjunctival disorders (redness) near the cornea: rosacea, corneal lesions near the limbus, foreign body, herpetic keratitis
Pericorneal Conjunctival Injection
disorders of deeper tissues and intraocular structures: (red ring around the pupil) episcleritis, scleritis, disciform keratitis, iritis, cyclitis
ciliary conjunctival injection
conjunctival disorders: conjunctivitis (general diffuse redness)
conjunctival injection
Most common cause of red/pink eye
Inflammation of the bulbar or palpebral conjunctiva
Can either be surface of eye or surface of inner eyelids
Occurs in all age groups
Conjunctivitis
type of conjunctivitis? seasonal or contact as with contact lens solution- S/S: bilateral, itchy, tearing watery discharge, HX of allergies
Allergic
type of conjunctivitis? often adenovirus, highly contagious, can be spread at public swimming pools; can be HSV or HZV
Viral
type of conjunctivitis? from chlamydial infection, can occur in neonate or in persons at risk for STI
Inclusion conjunctivitis:
type of conjunctivitis? from exposure to noxious agents (chlorinated water, hair sprays, etc.)
toxic
type of conjunctivitis?
unilateral, resolves in 1-2 weeks, ABX drops -can return to school after 24 hours of utilizing drops, NO ANTIHISTAMINES unless allergic component
Bacterial
the most helpful factor in making conjunctivitis diagnosis
history - Symptoms depend on cause and severity
how to examine conjunctivitis
Make sure to examine the pupils, eyelids
Use magnification to check for foreign body
Assess for other skin lesions near eye
Assess preauricular and submandibular lymph nodes
Most common sign is conjunctival hyperemia (redness)
Diffuse dilatation of vessels with redness that tends to be maximal at the periphery
•
Can also involve the tarsal conjunctiva that lines the inside of eyelids
Conjunctival injection
do you need to take cultures on pt with conjunctivitis
Cultures generally not necessary (unless neonate or person at high risk for STI)
what to do if complaint of sensation of foreign body in eye
Corneal fluorescein exam
Generalized hyperemia, mild to severe itching, clear/watery or stringy/mucoid discharge; possible chemosis (conjunctiva swelling: can appear boggy)
Conjunctiva can have “cobblestone” appearance
Allergic Conjunctivitis
how to treat Allergic Conjunctivitis: OTC
OTC topical decongestant/antihistamine
Naphcon-A
Vasocon-A
how to treat Allergic Conjunctivitis: Selective antihistamines
Levocabastine hydrochloride 0.05% (Livostin)
Emedastine 0.05% (Emadine)
how to treat Allergic Conjunctivitis:
Mast Cell stabilizers
Olopatadine 0.1% (Patanol)
Azelastine 0.05% (Optivar)
what can also help tx allergic conjunctivitis
Also helpful: topical steroid therapy (can increase IOP), NSAIDs, systemic antihistamine, some nasal sprays (Veramyst)
Cool compresses
why neonates get erythromycin immediately after birth
Viral Conjunctivitis- chlamydia (neonates or people at risk for STI)
Acute onset, unilateral or bilateral
Watery discharge
Preauricular or submandibular lymphadenopathy
Photophobia or sensation of foreign body may be present
If HSV or HZV suspected—fluorescein stain to check for corneal lesions
Hutchinson’s sign: herpetic lesion on tip of nose
Viral Conjunctivitis
How to tx Viral Conjunctivitis
Usually self limiting, can take weeks to resolve
May use cool compresses
Anti-infective, steroids, and topical vasoconstrictors should not be used
If herpetic etiology: refer to ophthalmologist for antiviral therapy
Acute onset often begins in one eye and then spreads to other
Not associated with systemic illness
Hyperemia, chemosis, photophobia with blepharospasm, and tearing may be present
“Matted shut” with thick mucopurulent drainage upon waking
Bacterial Conjunctivitis
Preauricular lymphadenopathy is only associated with ________from Neisseria species or gonococcal organisms; if this is present, assess risk for STI
Bacterial Conjunctivitis
How to treat Bacterial Conjunctivitis
Often self-limiting
Topical abx may hasten resolution
Lots of options of abx eye drops
Sulfacetamide 10% (Bleph-10) or tobramycin (Tobrex) effective for uncomplicated cases
Ask about sulfa allergies with Bleph-10; these tend to sting more
.. for severe cases=
Topical fluoroquinolones—ofloxacin 0.3% (Ocuflox) or moxifloxacin 0.5% (Vigamox) are used in more severe cases
If chlamydia or gonorrhea, topical and systemic abx therapy—refer to ophthalmologist
pt education for bacterial conjunctivitis
Hand washing!
Limit public contact and do not share linens during acute drainage
Discard all open eye makeup
Replace contact lenses, cases, and opened solutions
Day care rules
Why treat allergic conjunctivitis
Severe allergic conjunctivitis can lead to corneal ulceration
why treat bacterial conjunctivitis
Untreated bacterial conjunctivitis can also involve cornea
Can also lead to scarring and other complications
when to refer pts with conjunctivitis
Unresponsive bacterial conjunctivitis
Neonates
Significant ocular pain, decreased visual acuity, significant drainage, recurrence, or suspected herpetic virus
eye redness that can be associated with fever, pharyngitis—especially in children
Viral Conjunctivitis
benign inflammation of the covering of the sclera
BILATERAL with mild stinging
The peripheral injection is present, NO eye discharge
No visual acuity impairment
Tearing and photophobia may be present
Usually improves without treatment
Episcleritis
Inflammation of sclera can result in destructive disease
UNILATERAL
Associated with rheumatoid arthritis, systemic immunological disease, autoimmune disorders
Pain and ciliary injection (redness all the way to edge of pupil)
Tearing
Visual acuity can be affected
Scleritis
S= single eye
Inflammation of the inside of the eye Can be a serious ocular condition 3rd leading cause of blindness worldwide Related to several autoimmune disorders Treatable
Uveitis
Iris, ciliary body, choroid: collectively known as _____
uveal tract
Also known as iritis, inflammation of the anterior part of the eye
redness circles the pupil of the eye
Inflammation of the iris and ciliary body
Can be idiopathic or develop in response to coexistent conjunctivitis, keratitis, eye trauma
Can also occur with chronic inflammatory or infectious processes
Anterior uveitis/ iritis
Pain; photophobia, conjunctival hyperemia, pupil constriction, may have epiphora (watery eyes) but no mucopurulent drainage
Usually unilateral, Visual acuity is usually decreased
Central redness of the eye with ciliary flush!!!
- refer to opthomologist
Uveitis/Iritis
How to examine and treat uveitis/ iritis?
Exam
Needs slit lamp exam to confirm
Pain in affected eye when light shown in unaffected eye (both pupils move and the movement causes pain)
Treatment
Refer!
Steroid eye drops as well as drops to dilate pupils
Involves the posterior aspect of the uvea, which contains the choroid, a layer of blood vessels, and connective tissue
Also known as choroiditis
Can develop with systemic infection or auto-immune disease__
Posterior uveitis
Similar symptoms to iritis but pain is at the back of eye
Usually mild, treated with sun protection; possible use of steroid eye drops or pupil dilation drops; should be prescribed by an ophthalmologist
Posterior uveitis
Painful, red eye with decreased vision =
refer immediately
Uveitis/Iritis
Partial or complete defect in epithelial layer of cells after some traumatic event or exposure to UV light
Corneal Abrasion
Partial or complete defect
• Not associated with trauma
corneal erosion
Deeper involves underlying stromal
layer; may or may not be infected
corneal ulcer
Foreign boy sensation with intense PAIN, photophobia, conjunctival hyperemia, may have decreased visual acuity,
Corneal foreign body, abrasion
Presentation: intense eye pain, feeling of
foreign object in eye, redness, tearing,
photophobia
corneal surface defect
pus in anterior chamber of eye…. emergency referral
hypopyon
what is included in physical exam for corneal surface defect?
observe for presence of
foreign body, use of fluorescein staining;
complete eye exam
How to manage minor corneal abrasions?
Refer if severe and r/o bacterial infection if wearing contacts
If no sx of infection: 0.5% erythromycin ointment or polymyxin/trimethoprim, ciprofloxacin, or ofloxacin 4x/day for 3-5 days
Oral analgesics or ophthalmologic NSAIDs for discomfort
How to treat foreign body in the eye?
Topical anesthetic
• Moist cotton tipped applicator to remove object
• If superficially embedded, may use a 25 gauge needle
• Need magnification and someone skilled in procedure
• Prescribe topical antibiotic prophylactically
• Do not patch!
When to refer a corneal surface defect?
All cornea ulcers
All corneal erosions
Penetrating foreign bodies
Foreign body with rust ring
Foreign body not readily removed with irrigation
Corneal abrasion not improved in 24 hours
Corneal abrasion not resolved in 72 hours
Hordeolum
Stye
Infection of one of the oil glands that surrounds an eyelash follicle
• Usually caused by Staphylococcus aureus
• May point to the conjunctival side of the lid or may involve the lid margin
Hordeolum (stye)
Local or diffuse swelling of eyelid
• Tenderness/pain
• Erythema spreading away from localized site
of infection
• Occasional sensation of “grit” or foreign object in eye
Hordeolum
how to do physical exam for a hordeolum?
Assess visual acuity
• Inspect eyelids for inflammation, swelling, and discharge
• Palpate eyelids for induration and masses
• Evert the eyelid and examine inner surface for
pointing
• Internal hordeolum: points to skin or conjunctival
• External hordeolum: points to lid margin
• Examine the sclera and conjunctiva for abnormalities
• Palpate for preauricular adenopathy
plan to treat hordeolum?
Warm compresses, 10–15 minutes QID: most hordeola will resolve on their own or just with warm compresses
• Cleanse eyelids daily with neutral soap
• Antibiotic (Polytrim) eye drops or erythromycin eye ointment BID for seven days if symptoms persist; OTC stye ointment can provide comfort (sterile eye ointment of mineral oil and white petrolatum)
Refer if not responsive, may need incision and drainage or oral abx (doxycycline)
pt education hordeolum
Patient education: good lid hygiene, abstain from eye makeup
until clear, and replace eye makeup; do not squeeze or try to
“pop”
BLOCKED oil gland- Chronic inflammation of eyelid resulting in lymphogranuloma of meibomian gland, which lie posterior margins of eyelid, round, PAINLESS mass remains
• Usually away from the lid border
Chalazion
Inflammation of eyelid margins • Can be acute or chronic • Chronic is more common • Can be anterior or posterior
Blepharitis
abnormal function of
Meibomian gland
Posterior Blepharitis
inflammation of anterior lid margin
surrounding the eyelashes, can
extend to posterior lid margin, conjunctiva, and cornea
Anterior Blepharitis
Caused by staph infection (S. Aureus) • Also caused by seborrheic dermatitis, rosacea, or allergies • 80% of patients are women • Eye makeup
Blepharitis
Signs and symptoms
• Scaling of eyelid margins
• Itching, crusting, and erythema
• May have sensation of foreign body, burning, eye discomfort
• Severe and chronic cases may produce purulent discharge and
over time permanent changes in the eyelid structure can occur
• Usually has history of recurrent chalazion or hordeolum
Blepharitis
History when asking about Blepharitis
make sure to ask about eye rubbing, flaking, crusting, previous/present skin conditions, particularly of face and
scalp; ask about chronic exposure to irritants (smoke, cosmetics, chemicals)
how to tx blepharitis?
If identified, treat source of irritation (avoiding
allergen, treating other skin conditions)
• If eyes are dry, can use Cellufresh or Bion Tears
Lid hyegine for pt with Blepharitis
Instruct patient in lid hygiene
• Apply warm wet compresses for two minutes, 2–4 times day to increase circulation, mobilize
Meibomian secretions and help cleanse crusting debris
• gently scrub eyelids once daily with fingertips or cotton tip applicator using a baby shampoo diluted 1:1 with clean water to remove crust and scale
• Blepharitis associated with seborrhea is often improved with use of dandruff shampoo on scalp and eyebrows
• For flares, topical antibiotic ointment may be helpful, especially if anterior
• Refer if severe or nonresponsive
most common type of Nasolacrimal Duct Obstruction, caused by inflammation or fibrosis without precipitating cause
Primary
Complete or partial obstruction of the tear duct or nasolacrimal duct
Nasolacrimal Duct Obstruction (NLDO)
multiple other factors that cause NLDO (infection, inflammation, neoplasm, trauma)
Secondary
Causes disruption of normal tear drainage
•
Symptoms can be mild or severe
•
Chronic tearing, ocular discharge, eyelash crusting
Nasolacrimal Duct Obstruction (NLDO)
Risk Factors for NLDO
TX?
Chronic allergies, sinusitis, prior facial trauma, or radiation, Systemic inflammatory diseases
Treatment
Mild—warm compresses and topical antibiotics
If severe swelling or purulent drainage = warm compresses, broad spectrum abx eye drops and oral penicillinase-resistant abx
Occurs when eye does not produce tears properly or the tears are not of the correct consistency; can lead to inflammation of the surface of eye
Dry Eye Syndrome
Signs and symptoms: dry stinging eyes, sandy/gritty feeling in eyes, episodes of tearing followed by periods of dryness, stringy discharge, redness and pain of eye, eye fatigue/heavy eyelids
•
Can be vague in presentation
•
Aggravated by dry air, prolonged computer work/reading, contact lens use
•
Can be acute or chronic
Dry Eye Syndrome
How to Tx dry eye syndrome?
Treat the cause first; artificial tears, eye lubricants also helpful; warm compresses, lid massage; avoid aggravating activities
•
Cyclosporine (Restasis)—the only FDA approved treatment for chronic dry eye
a common,noncancerous growth of the conjunctiva
small, yellowish nodule on the conjunctiva near the cornea; it can appear on either side of the cornea, but tends to appear more on the nasal side
Confined to the bulbar conjunctiva
Does not encroach on the cornea
Usually detectable to naked eye
Pinguecula
how to treat Pinguecula?
Usually no treatment is necessary; rarely removed for discomfort or cosmetic reasons
Slow growing
Can be a precursor to pterygium
Fibrovascular mass/growth of thickened bulbar conjunctiva that extends into the cornea (nasal side)
Painless, may itch, occasional ℅ blurred vision
Starts as pinguecula (doesn’t cross to iris) (yellow appearing area on cornea)
Pterygium
Risk factors = exposure to sunny, dusty, sandy, or windblown areas; farmers, fishermen, and people living near the equator are often affected; pterygium is rare in children
No treatment necessary can use mild vasoconstrictors or short term steroids- loteprednol, fluorometholone
Surgical removal if impedes vision
Risk factors and tx for Pterygium
more severe case of NLDO - may cause painful swelling at medial canthus
dacryocystitis
How to tx Corneal foreign body/ abrasion/ ulcer
topical antibiotic (for prophylaxis) and systemic pain relievers. no patching
microscopic or visible blood layering in the anterior eye chamber usually after blunt trauma
- urgent ophthalmologist referral
Hyphema
pain, photophobia, conjunctival hyperemia, corneal cloudiness with stromal involvement -> progress to corneal ulceration and blindness (Viruses, bacteria, trauma, allergic rxn)
- refer to an ophthalmologist (medical emergency)
Keratitis
no subjective symptoms, bright red spot of blood visible, the remainder of conjunctiva white
Subconjunctival hemorrhage
most common cause of double vision and brain ignoring information from one eye, screen all kids
Cover and uncover test (start 3-5 years old)/ red reflex (all kids)
Patching- patch good eye to strengthen the weaker eye
Atropine-
Strabismus- “lazy eye”
Chalazion tx? Mgmt?
BLOCKED oil gland
Mgmt: hot compress, massage the gland* refer for surgical incision or topical corticosteroids injection if unresolved (can affect vision d/t pressure)
Eye problem… THINK systemic symptoms- more symptoms like recent or current URI more likely its viral, Clears in 7-14 days, check lymph system usually enlarged (preauricular nodes)
OPTHO!!
S/S: tearing/ WATERY DRAINAGE, pharyngitis with enlarged preauricular nodes (key finding)
Mgmt: Hygiene- transmission, HSV-REFER,
Viral (bilateral) Conjunctivitis
What should you do if the ABX don’t clear bacterial conjunctivitis infection?
Get a culture
Eye management in newborns
Non-gon: Erythromycin 0.5%, trimethoprim, polymyxin B fluoroquinolone
Herpes: REFER
Chlamydial: systemic erythromycin 50mg/kg.day /4 does for 14 days)
eyelids invert causing abrasions to corneal surface
Pain, irritation and photophobia
Surgery may be indicated
Entropion
eyelid margins evert
Cause: congenital, infection, scarring after trauma
Tx-lubrication or surgery
Ectropion
wide palpebral fissure with appearance of sagging half of the lower eyelid (temporal side). Often confused with Ectropion. Caused by: Down syndrome, associated with other ocular anomalies.
Euryblepharon
What not to give for eye foreign body?
Do not give a prescription for topical anesthetics b/c thin and melt cornea and no steroid shots due to delayed healing.
Pale or necrosed appearance of surrounding skin and eyelids
Opacity of corneal tissue, swollen corneas
Visual impairment
Initial exquisite pain or delayed complaints of pain (UV burns, pain is 6hrs post exposure)
Photophobia; tearing within 12 hrs
Fluorescein stain revealing pinpoint uptake
Eye Burns … caused by thermal, chemical (emergency!), or UV light
Myopia
Hyperopia
Nearsightedness
Hyperopia = farsightedness (distant objects seen clearly, close up blurry)
uneven curvature of the cornea or lens. Vision blurry close-up and far away
Astigmatism
