EYE Flashcards
From your PE what would you expect?
S/s Itching, burning, mild pain, foreign body sensation, tearing, erythema of the lids, and crusting around the eyes upon awakening.
-eyes are “redrimmed” and scales or granulations can be seen clinging to the lashes.
-The lid margin is frequently rolled inward (mild entropion).
-Pink or irritated eyelids, which may have crusting.
May have conjunctival injection.
-Tears may be frothy or abnormally greasy.
Anterior blepharitis
From PE what would you expect?
(a) Hard and nontender nodule on the eyelid
1) usually develops farther back on the eyelid than a hordeolum
(b) Edema on the upper or lower lid
(c) Erythema and edema of the adjacent conjunctiva.
Chalazion
From PE what would you expect?
(a) Localized eyelid tenderness, swelling and erythema
(b) May have foreign body sensation depending on location
(c) Visible, or palpable, well-defined subcutaneous nodule in the eyelid
(d) May also note “pointing” of mucopurulent material
(e) Associated blepharitis or acne rosacea.
Hordeolum
What are some things your patient can do at home to treat hordeolum or chalazion?
- Warm compresses, which are placed on the face for about 15 minutes four times a day.
- Massage and gentle wiping of the infected eyelid after the warm compress can also aid in drainage
When should you give antibiotics for a hordeolum or chalazion?
What antibiotic would you give?
- If there is concern of patient developing periorbial cellulitis
- Bactrim BID for 5-7 days
When should you give antibiotics for a hordeolum or chalazion?
What antibiotic would you give?
- If there is concern of patient developing periorbial cellulitis
- Bactrim BID for 5-7 days
What type of conjunctivitis ?
Symptoms: Itching, burning, tearing, gritty or foreign body sensation; history of recent upper respiratory tract infection or contact with someone with this issue.
Signs: Watery discharge, red and edematous eyelids, pinpoint subconjunctival hemorrhages, punctate keratopathy (epithelial erosion in severe cases), membrane/pseudomembrane (severe cases).
1) Critical signs: Inferior palpebral conjunctival follicles, tender palpable preauricular lymph node.
Viral Conjunctivitis
What type of Conjunctivitis
Symptoms: Itching, watery discharge, and a history of allergies are typical. Usually bilateral.
Signs: Chemosis (swollen conjunctiva), red and edematous eyelids, conjunctival papillae, periocular hyperpigmentation, no preauricular node.
Allergic conjunctivitis
What type of Conjunctivitis?
(a) Symptoms: Redness, foreign body sensation, discharge; itching is much less prominent.
(b) Often complain of having to wipe purulent exudate in morning.
(c) Signs:
1) Critical: Purulent white-yellow discharge of mild-to-moderate degree.
2) Other: Conjunctival papillae, chemosis, preauricular node typically absent (unlike gonococcal).
Bacterial conjunctivitis (nongonococcal)
What type of Conjunctivitis?
1) Critical: Severe purulent discharge, hyperacute onset (classically within 12 to 24 hours).
2) Other: Conjunctival papillae, marked chemosis, preauricular adenopathy, eyelid swelling.
Gonococcal conjunctivitis
Treatment
Viral conjunctivitis
Mild:
Artificial tears or tear ointment
Treatment
Viral conjunctivitis
Moderate:
Epinastine (Elestat) - Ophthalmic antihistamine for symptomatic relief
-0.05% solution 1 drop to affected eye BID
Treatment
Viral conjunctivitis
Severe: If a membrane/pseudomembrane is present,
gently peel with a cotton-tip applicator.
Treatment
Viral conjunctivitis
Severe with significant photophobia
Ophthalmic Corticosteroids
Consult ophthalmology BEFORE giving steroids
Treatment for Allergic conjunctivitis
Mild:
Moderate:
Mild: Artificial tears four to eight times per day
Moderate: Patanol 0.1% BID or Epinastine 0.05% QID
Treatment for Bacterial conjunctivitis (nongonococcal)
Topical antibiotic therapy
Trimethoprim/polymyxin B (Polytrim)
1 drop in affected eye Q 3 hours for 7-10 days.
Treatment for Bacterial conjunctivitis (nongonococcal)
if your patient wears contact lenses
Ciprofloxacin (Ciloxan) or Ofloxacin (Ocuflox) – Fluoroquinolone antibiotic class.
-Dose: 0.3% Solution, use 1-2 drops in affected eye QID for 5-7 days.
Treatment for Bacterial conjunctivitis (nongonococcal)
With associated dacryocystitis
Amoxicillin/Clavulanate (Augmentin)
Dose: 875/125 mg BID or 500/125 mg TID
Or
Cephalexin 500mg PO QID
Treatment for Gonococcal conjunctivitis
Ceftriaxone 1 g IM, PLUS azithromycin 1 g PO both in a single dose.
MEDIVAC
Treatment for Gonococcal conjunctivitis for patients with penicillin/cephalosporin allergy
Gentamicin 240mg IM x 1 dose PLUS Azithromycin 2mg PO x 1 dose.
What would you suspect?
Symptoms: Red eye, foreign body sensation, usually asymptomatic unless there is associated chemosis.
Signs: Blood underneath the conjunctiva, often in one sector of the eye. The entire view of the sclera can be obstructed by blood
conjunctival hemorrhage
Labs/Studies/EKG: for conjunctival hemorrhage?
(1) Complete eye examination
(2) Laboratory bleeding studies (if recurrent)
(3) CT or MRI (if orbital signs are present)
Treatment for conjunctival hemorrhage
(1) None required (usually clears spontaneously within 2 to 3 weeks)
(2) Artificial tear drops QID (for irritation)
What would you suspect?
Symptoms:
Irritation, redness, decreased vision; may be asymptomatic
Signs: Wing-shaped fold of fibrovascular tissue arising from the interpalpebral conjunctiva and extending onto the cornea. Usually nasal in location.
Pterygium
Labs/Studies/EKG for Pterygium
Slit lamp examination to identify the lesion
TX for pterygium
(1) Protect eyes from sun, dust, and wind (UV-blocking sunglasses or goggles).
(2) Lubrication with artificial tears four to eight times per day (for irritation).
TX For an inflamed pterygium: Moderate to severe
Ophthalmic Corticosteroids
NSAID drop
Ketorolac (Acular) 0.5% solution, use 1 drop in affected eye QID
Surgical removal for Ptreygium is indicated ONLY when:
(a) The pterygium threatens the visual axis or induces significant astigmatism.
(b) The patient is experiencing excessive irritation not relieved by the
aforementioned treatment.
(c) The lesion is interfering with contact lens wear.
(d) Consider removal prior to cataract or refractive surgery.
What would you suspect?
Symptoms: Foreign body sensation, tearing, history of trauma.
Signs:
-Conjunctival injection, eyelid edema, mild AC reaction, and SPK. A small infiltrate
may surround a corneal foreign body; it is usually reactive and sterile. Vertically
oriented linear corneal abrasions or SPK may indicate a foreign body under the
upper eyelid.
-Critical: Conjunctival or corneal foreign body with or without a rust ring.
Ocular Foreign Body
What would you ask History of the ocular foreign body
size, weight, velocity, force, shape, and composition of the object
Labs/Studies/EKG for ocular foreign body
- Fluorescein staining for corneal abrasions after open globe ruled out
- Slit lamp examination
- Dilate the eye and examine the posterior segment for a possible intraocular foreign body.
What can you use to remove the foreign body
saline irrigation , foreign body spud, cottontipped
applicator soaked in topical anesthetic, fine forceps
Topical antibiotics for Ocular foreign body
Non-contact lens wearers
Contact lens wearers
Non-contact lens wearers
a) Erythromycin ointment TID – QID applied to lower lid
b) Ointment may be better than drops because functions as lubricant and may reduce disruption of newly generated epithelium.
2) Contact lens wearers
a) Ciprofloxacin ointment
(1. 0.5inch in lower lid Q 1-2 hours for first 2 days then QID for up to 12 days until re-epithelialization has occurred.
True/False
You can remove the foreign body with a needle
FALSE NOOOOOOOOO NEEEEDLEEE
Patient has these issues what would you suspect?
(1) Severe pain, tearing and photophobia.
(2) History of trauma to the eye, commonly involving a foreign object (fingernail, piece of paper, or contact lens).
Corneal Abrasion
Patient has these issues what Labs/studies would you perform?
(1) Severe pain, tearing and photophobia.
(2) History of trauma to the eye, commonly involving a foreign object (fingernail, piece of paper, or contact lens).
Slit lamp to identify dimensions of abrasion.
Patient has these issues
(1) Severe pain, tearing and photophobia.
(2) History of trauma to the eye, commonly involving a foreign object (fingernail, piece of paper, or contact lens).
WHAT antibiotics would you order for a non-contact lens wearer?
Antibiotic ointment (e.g., erythromycin, bacitracin, or bacitracin/polymyxin B q2– 4h) OR Antibiotic drops (e.g., polymyxin B/trimethoprim or a fluoroquinolone)
Patient has these issues
(1) Severe pain, tearing and photophobia.
(2) History of trauma to the eye, commonly involving a foreign object (fingernail, piece of paper, or contact lens).
WHAT antibiotics would you order for a contact lens wearer?
Fluoroquinolone drops
Topical nonsteroidal anti-inflammatory drug (NSAID) drops for Corneal Abrasion
Ketorolac 0.4% to 0.5% q.i.d. for 3 days) for pain control
Pain management for Corneal abrasion
Oral acetaminophen or NSAIDs
True/False
Your Patient can continue to wear their contacts while healing from a corneal abrasion.
False
They should not wear contact lenses
What is the biggest risk factor for corneal ulcer
improper contact lens use
Patient has these issues, what would you suspect
(a) Erythema and edema of lids and conjunctivae; discharge; ocular pain or foreign body sensation; photophobia; or blurred vision.
(b) Visual acuity is decreased if the ulcer is located in the central visual axis
(c) Cornea reveals a round or irregular opacity or infiltrate – classically central in location
(d) Severe cases may have hypopyon (white, hazy base - due to WBC infiltration)
(e) Fluorescein reveals staining epithelial defect
corneal ulcer
Treatment for Corneal Ulcer
True/False
Do not patch the eye because of the risk of Pseudomonas infection, which can cause rapid, aggressive ulceration with corneal melting and perforation.
TRUE
DO NOT PATCH THE DAMN EYE
Patient has these issues, what Antibiotics would you give?
(a) Erythema and edema of lids and conjunctivae; discharge; ocular pain or foreign body sensation; photophobia; or blurred vision.
(b) Visual acuity is decreased if the ulcer is located in the central visual axis
(c) Cornea reveals a round or irregular opacity or infiltrate – classically central in location
(d) Severe cases may have hypopyon (white, hazy base - due to WBC infiltration)
(e) Fluorescein reveals staining epithelial defect
1) Ciprofloxacin (Ciloxan) or Ofloxacin (Ocuflox) Ophthalmic drops
2) Fluroquinolone (Vigamox) Q1h.
For a corneal Ulcer should you patch the EYE?
NO
Why cant you patch the eye for a corneal Ulcer
the risk of Pseudomonas infection
True/False
You can manage a Corneal Ulcer as an IDC
FALSE
MEDIVAC
Refer to an ophthalmologist to be seen within 12 to 24 h.
Your patient has these issues what would you suspect?
(1) Blood or clot or both in the anterior chamber (visible without a slit lamp).
(a) May be black or red
(2) Pain
(3) Sensitivity to light
(4) Blurred, clouded or blocked vision
(5) History of blunt trauma
Hyphema
What labs/studies would you conduct for a Hyphema
(1) Complete eye exam.
(2) Consider a CT scan of the orbits and brain.
Your patient has these issues what is the IMMEDIATE action?
(1) Blood or clot or both in the anterior chamber (visible without a slit lamp).
(a) May be black or red
(2) Pain
(3) Sensitivity to light
(4) Blurred, clouded or blocked vision
(5) History of blunt trauma
Immediate ophthalmology or optometry consult
Hyphemia Treatments
- Bed rest with elevation of the head (to allow blood to settle) or limited activity (No strenuous activity, bending, or heavy lifting).
- Place a rigid shield (metal or clear plastic) over the involved eye at all times.
- Avoid antiplatelet/anticoagulant medications (i.e., aspirin-containing products and NSAIDs) unless otherwise medically necessary.
- Mild analgesics only (e.g., acetaminophen).
Can you give asprin to your Hyphema PT?
NOOOOOOO
HYPHEMA
After initial follow up period, patient may be maintained on what type of agent?
long-acting cycloplegic Agent
True/False
Your Hyphema patient can wear Glasses or an eye shield during the day and eye shield at night.
True
PT has these issues what would you suspect?
Signs:
-Inflammatory cells and flare within the aqueous (WBC released from vessels appear as snowflakes)
-Blurred vision in a mildly painful and mildly inflamed eye
-Hypopyon (WBC pool) and fibrin within the anterior chamber.
-Keratic precipitates (KPs) (cells seen on the corneal endothelium)
Iritis
PT has these issues what Meds would you give?
Signs:
-Inflammatory cells and flare within the aqueous (WBC released from vessels appear as snowflakes)
-Blurred vision in a mildly painful and mildly inflamed eye
-Hypopyon (WBC pool) and fibrin within the anterior chamber.
-Keratic precipitates (KPs) (cells seen on the corneal endothelium)
!!!Only to be initiated by or under the direction of Ophthalmologist!!!
Cycloplegic (for pain and inflammation)
1) Mild to moderate: Cyclopentolate 1% t.i.d.
2) Severe: Atropine 1% b.i.d. to q.i.d.
(b) Topical steroid
1) Prednisolone acetate 1% q1-6h
What labs/studies would you do for a pt with iritis?
- Complete ocular examination
- Labs (if required) are targeted for suspected etiology (e.g. sarcoidosis, syphilis, and TB in at-risk patients)
What are some causes of orbital Cellulitis?
-Direct extension from a paranasal sinus infection especially ethmoiditis,
- Sequela of orbital trauma (e.g., orbital fracture, penetrating trauma, retained intraorbital foreign body).
- Sequela of eyelid, orbital, or paranasal sinus surgery
- Sequela of other ocular surgery (less common).
Patient has these issues what would you suspect?
- Red eye, pain with eye movement, blurred vision, double vision, eyelid and/or periorbital swelling, nasal congestion/discharge, sinus headache/pressure/congestion, tooth pain, infra- and/or supraorbital pain, or hypesthesia.
- Eyelid edema, erythema, warmth, and tenderness. Conjunctival chemosis and injection, proptosis, and restricted extraocular motility with pain on attempted eye movement are usually present.
Orbital Cellulitis
What labs/Studies would you do for Orbital Cellulitis?
(1) History (trauma, surgery, infection)
(2) Complete ophthalmic examination.
(3) CT scan of the orbits and paranasal sinuses.
(4) CBC with differentia, blood cultures, gram stain and culture of any drainage.
(5) Explore and debride any penetrating wound.
ON A SHIP
Patient has these issues what antibiotic would you give?
- Red eye, pain with eye movement, blurred vision, double vision, eyelid and/or periorbital swelling, nasal congestion/discharge, sinus headache/pressure/congestion, tooth pain, infra- and/or supraorbital pain, or hypesthesia.
- Eyelid edema, erythema, warmth, and tenderness. Conjunctival chemosis and injection, proptosis, and restricted extraocular motility with pain on attempted eye movement are usually present.
Ceftriaxone (Rocephin) 2 gram IV
-Amoxicillin/Clavulanate (Augmentin) 875 mg PO BID
Treatment for Orbital Cellulitis
True/False
Surgery may be required to drain the paranasal sinuses or orbital abscess.
True
What type of Fx affects the floor or inner wall of the orbit.
Blowout fracture
Blowout FX: True/FAlse
Crack in the very thin bone that makes up these walls doesn’t pinch muscles and other structures (Getting hit with a baseball or a fist).
False
Can Pinch the muscles or other structures
Pt has theses issues what would you suspect?
(a) Pain on attempted eye movement and local tenderness.
(b) Eyelid edema
(c) Crepitus (particularly after nose blowing)
(d) Binocular diplopia
(e) Numbness of the cheek, upper lip, and/or teeth
(f) Acute tearing is usually due to ocular irritation
Orbital Fx
What studies would you do for an Orbit Fx
(1) Complete ophthalmic examination.
(2) CT of the orbit, midface and brain.
Treatment of Orbital Fx
What prophylactic oral antibiotics to cover sinus pathogens would you use?
(a) Amoxicillin/Clavulanate (500/125 mg TID or 875/125 mg PO BID.)
(b) Azithromycin
Treatment of Orbital Fx
What prophylactic oral antibiotics to cover sinus pathogens would you use if the patient has a penicillin allergy?
Doxycycline 100mg BID
True/False
You should instruct your pt to blow their nose if they have an Orbital Fracture
FALSE
Instruct the patient not to blow their nose
Pt has theses issues what meds would you give?
(a) Pain on attempted eye movement and local tenderness.
(b) Eyelid edema
(c) Crepitus (particularly after nose blowing)
(d) Binocular diplopia
(e) Numbness of the cheek, upper lip, and/or teeth
(f) Acute tearing is usually due to ocular irritation
- Prophylactic oral antibiotics to cover sinus pathogens
- Augmentin
- Azithromycin
- Nasal decongestants (afrin BID for 3 days)
- Apply ice packs to the eyelids for 20 minutes every 1 to 2 hours for the first 24 to 48 hours and attempt a 30-degree incline when at rest.
- Consider oral corticosteroids.
Pt has theses issues; what angle should they attempt to be when at rest?
(a) Pain on attempted eye movement and local tenderness.
(b) Eyelid edema
(c) Crepitus (particularly after nose blowing)
(d) Binocular diplopia
(e) Numbness of the cheek, upper lip, and/or teeth
(f) Acute tearing is usually due to ocular irritation
30-degree incline when at rest.
When is IMMEDIATE surgical repair required for an Orbital FX?
When should toe repair be done?
Muscle entrapment with nonresolving bradycardia, heart block, nausea, vomiting, or syncope.
24 to 48 hours
True/False
You dont need to medivac an ORbital Fx
FALSE
Neurosurgical, otolaryngology or oral maxillofacial surgery consultation needed
What is defined as vision loss that returns to normal within 24 hours, usually within 1 hour
Transient visual loss
Transient visual loss Cause Few seconds (usually bilateral)
Acute change in BP or disc drusen
Transient visual loss Cause
Few minutes:
Unilateral vs bilateral
Amaurosis fugax
transient ischemic attack; unilateral,
vertebrobasilar artery insufficiency; bilateral.
Visual Loss Management
(1) Thorough external inspection of the eye
(2) Test visual acuity and field of vision bilaterally
(3) Neurological examination if you have suspicion of TIA or stroke
(4) Ophalmoscopic examination
(5) Thorough ophthalmoscopic examination
(6) If concern of traumatic rupture globe, use an eye shield
(7) Immediate consult to medical officer and/or optometry or ophthalmology should be done
PT has these issues what would you suspect
Symptoms:
Flashes of light, floaters, a curtain or shadow moving over the field of vision, peripheral or central visual loss, or both
PE:
1) The retina is seen hanging in the vitreous like a gray cloud
2) One or more retinal tears or holes
Rhegmatogenous retinal detachment
Initial Care of the Disease and Follow Up for Retinal Detachment
(1) All cases of retinal detachment must be referred urgently to an ophthalmologist
(2) During transportation, the patient’s head is positioned so that the detached portion
of the retina will fall back with the aid of gravity.
Tx for Retinal Detachment
(1) Involvement of the fovea: Urgent ocular surgery (laser photocoagulation, cryotherapy, pneumatic retinopexy).
(2) Otherwise, within 7 to 10 days of the onset.
Your patient has some or all of these issues what would you suspect?
(a) Symptoms
1) Moderate-to-severe ocular pain, foreign body sensation, red eye, tearing, photophobia, blurred vision; often a history of welding or using a sunlamp without adequate protective eyewear.
2) Symptoms typically worsen 6 to 12 hours after the exposure. Usually bilateral.
(b) Signs
1) Critical: Numerous, punctate lesions or microdots on the corneal surface (after staining and under high magnification using the cobalt-blue light).
2) Other: Conjunctival injection, eyelid edema, corneal edema, miotic pupils that react sluggishly, and mild anterior chamber reaction.
Flash Burns (Ultraviolet Keratopathy)
What Labs/Studies would you do for Flash burn?
(a) History (Welding, Sunlamp)
(b) Slit lamp examination: Use fluorescein stain. Evert the eyelids to search for a foreign body.
Your patient has some or all of these issues what would meds would you treat with?
(a) Symptoms
1) Moderate-to-severe ocular pain, foreign body sensation, red eye, tearing, photophobia, blurred vision; often a history of welding or using a sunlamp without adequate protective eyewear.
2) Symptoms typically worsen 6 to 12 hours after the exposure. Usually bilateral.
(b) Signs
1) Critical: Numerous, punctate lesions or microdots on the corneal surface (after staining and under high magnification using the cobalt-blue light).
2) Other: Conjunctival injection, eyelid edema, corneal edema, miotic pupils that react sluggishly, and mild anterior chamber reaction.
Pain treatment
Oxycodone 5mg Q 4-6 hours PRN severe pain
Antibiotic ointment: 4 to 8 times’ QD
(erythromycin or Trimethoprim/polymyxin B)
Consider a pressure patch for the more affected eye for 24 hours in reliable patients
Initial Care and Follow Up of Flash burns?
(a) All patients recover within 24–48 hours without complications.
(b) If a bandage soft contact lens was placed, the patient is seen in 1 to 2 days.
True/False
FLASH BURNS
Consider mild oral opioids for adequate pain relief as pain can be severe
True
True/False
FLASH BURN
Corneal epithelial healing will be faster if local anesthetic is prescribed
FALSE
Delay of corneal epithelial healing if local anesthetic is prescribed
