eye Flashcards
roof of orbit
frontalsphenoid (lesser)
lateral wall of orbit
zygomaticsphenoid (greater)
floor of orbit
zygomatic maxillarypalatine”zip my pants”
medial wall of orbit
sphenoid (lesser) maxillaryethmoidlacrimal”use medial wall to SMEL”
blepharitis
common, hypersn. rxn to staph toxins, not true infectionsymptoms: itching, burning, tearing, crusting, “greasy”
blepharitis tx
lid hygiene: WC + baby shampoo lid scrubs, OTC lid cleanersif severe: tobradex or maxitrol ointment x1wkoral doxycycline 50 mg bid x 10 days
chalazion
chronic blocking of meibomian glandssymptoms: eyelid lump, swelling, tenderness
hordeolum
acute blocking of meibomian glandssymptoms: eyelid lump, swelling, tenderness
tx of chalazion/hordeolum
WC + Abx/steroid ointmentTHEN oral doxycycline 50 mg bidTHEN steroid injectionsTHEN incision and curettage
molluscum
uncommon, papovaviruschronic follicular conjunctivitispersists until all lesions are removed–> if multiple lesions present and don’t go away–>consider immuncomp–>HIV test
molluscum tx
incision and curettagecryotherapychemical ablatives
preseptal cellulitis
commonsymps: tenderness, red eyelid, mild feversigns: eyelid erythema, edema, warmth tenderness, conjunc. chemosis, eyelid skin tightness, eyelid lymphedema (fluctuant)
preseptal cellulitis etiology
trauma (puncture, insect bite)adjacent infectionS. aureus, Strep, H. flu, HSV, VZV
ddx: preseptal vs. orbital cellulitis: orbital if..
hx of sinus infEOM restrictionAPD, proptosis, pain with eye movementother tests: CT of brain/orbits, CBC w/diff, Gram stain&culture
mild preseptal cellulitis tx
augmentin 500 mg PO tid x10 days(PCN allerg): bactrim DS x10 days
mod-severe preseptal cellulitis tx OR
IV Unasyn or Ceftriaxone(PCN allerg): IV Moxifloxin or Vancomycin x 10-14 days*IV–>PO if improvement
if secondary conjunctivitis present with preseptal cellulitis, tx w/
erythromycin ointment
if abscess present with preseptal cellulitis
I + D and Cx/Gs
make sure to do this with preseptal cellulitis tx
daily follow-up until improve
orbital cellulitis symptoms
uncommonred eye, pain, double/blurred vision, headache, diplopia
orbital cellulitis signs
eyelid edema, erythema, warmth, tenderness, conjunc. chemosis, optic disc edema, purulent discharge, fever, *proptosis, restricted ocular motility w/ pain on attem. mvmnt, +/- APD
orbital cellulitis etiology
extension of sinusitis (ethmoiditis)orbital/dental fracturevascular extension from bacteremia/facial cellulitis
orbital cellulitis organisms
adult: Staph and Strepchildren: Haemophilusdental abscess: mixed aerobes and anaerobesimmunecomps: fungi (mucor, aspergillus)
orbital cellulitis work-up
CBC and blood Cxhead/orbit CTGs and CxLP if ment stat and pn w/ nk flexion (mening)
orbital cellulitis tx
admit for IV Abxadults: vanco + Unasyn or Zosyn(PCN allerg): Vanco + Cipro + metronasal decongestant
if optic neuropathy suspected/severe proptosis suspected with orbital cellulitis…
perform a canthotomy/cantholysis –>relieves eyelid “compartment syndrome”
orbital cellulitis assessment
daily pupil, Va, motility, IOP, WBC–>change to oral Abx if improving (augmentin, bacterim)
if orbital cellulitis not improving with 48-72 hrs of IV..
re-image to look for abcess, surgical drainage
orbital pseudotumor AKA idiopathic orbital inflammatory disease (IOID)
acute onset of pain, red eye, proptosis, diplopia, blurred vision, typ. unilateral in adults, bilat. in kids w/ assoc. fever, malaise
if IOID bilat in adult need to rule out..
systemic disease: Saroid, Wegners, breast Ca metastasis
CT scan of IOID
thickened mm., tendons, and posterior sclera (“ring sign”)–>helps ddx from orbital cellulitis or TED(thyroid orbitopathy): only mm. involved
if uncertain it’s IOID + no response to steroids
biopsy
IOID (orbital pseudotumor) tx
60-100mg prednisone w/ PPI (GI prophylaxix), slow taper**do not want to give orb. cellulitis pts steroids!!
canaliculitis
canaliculi inf.tearing, expressible discharge, erythema, recurrent conjunctivitis, “pouting punctum”
canaliculitis organisms
actinomyces isrealii (MC?)Nocardia, Candida, Fusarium, Asp*take smear and Cx of discharge, Gram and Giemsa stain
Canaliculitis tx
topical ciprofloxacin and oral doxycycline x2 weeksWC + probing and irrigation w/ PCN + iodine 1%canalicular curettageI&Dif fungus: nystatin drops
dacryocystitis organisms
staph & streppseudomonasH. flu
dacryocystitis tx
WC + topical and PO AbxI&D if abscessavoid probing and irrigation during acute phase
dacryocystitis tx after acute inflammation controlled
dacryocystorhinostomy(DCR) crack bone, thread lacrimal system…
dacryoadenitis
rare inf. of lacrimal glandpain, redness, swelling over outer 1/3 of upper lidtyp. seen in kids
dacryoadenitis etiology
inflammatory conditions (most common), bacterial (staph, strep, Neisseria), viral (mumps, mono, Herpes Zoster)
dacryoadenitis tx (aimed at etiology)
if unclear or bac: Abx FIRST: Augmentin or Keflex inflam: Medrol dose pack or systemic steroidsviral: symptomatic relief
if dacryoadenitis tx is not responding: rule out..
lacrimal gland mass
conjunctivitis
red eye, discharge (worse in am) itching, FBS?hx of recent URI
forms of conjunctivitis
viral, allergic, atopic/vernal, bacterial, gonococcal
2 types of conjunctivitis
follicularpapillary
follicular conjunctivitis
follicles- small dome shaped nodules w/out prominent central vesseletiology: virus, bac, chlamydia, toxins-represents aggr. of lymphos and plasma cells in superficial stroma btw tarsus and conjunctiva-may have germinal centers or macrophages
papillary conjunctivitis
papillae- cobblestone arrang. of flattened nodules w/ vascular core-beefy red, in young kidsetiology: allergic/atopic (watery discharge), vernal/limbal (horner trantas dots), gonococcus (sev. purulent discharge), bacterial (scant discharge)-nodules of conj. epi w/ many eosins, lymphos, plasma cells w/ central vascular channel
viral conjunctivitis
adenovirus, typ. after URI+preauricular adenopathyone eye–>both eyeswatery discharge, pseudomembranes, SCH?, symblepharon?
viral conjunctivitis tx
cool compress, art. tears, +/- antihistaminesteroids drops if sub epithelial infiltrates-membrane can be manually peeled
viral conjunctivitis is highly contagious for how long
10 days from onset
bacterial conjunctivitis
follicular/papillaryetiology: staph, strep, moraxella, H. flu-Cx & Gs if purulent, persistent, or recurrent
bacterial conjunctivitis tx
ciloxan or vigamoxpolymyxin B sulfate w/ trimethoprim
gonococcal conjuntivitis
hyperacute, severe purulent discharge + LAD?
gonococcal conjunctivitis tx
IV/IM ceftriaxonetopical FQs q 1 hr if K involved?saline irrigation until discharge resolvescover for chlamydia as well: azythromycin x 1 or doxycycline x 1 wk
allergic conjunctivitis
pediatric red eye, itchy/scratchy, +/- lid involvement, +/- seasonal, typ. both eyes, hx of allergies, absence of URI, no nodes, papillae present-common: young boys w/ eczema–>vernal
allergic conjunctivitis tx
elim. inciting agentcool compress + art. tearsoptivar (mast cell stabilizer) +/- antihistaminetopical steroid if severeif vernal: topical cyclosporine + steroid
subconjunctival hemorrhage
typ. asymptomatic, clears in 1-2 wks, no tx needed causes: valsalva, trauma, HTN, bleeding d/o, idiopathic
if subconjunctival hemorrhage is recurrent
work up: bleeding time, PT, PTT, INR, CBC (leukemia), Protein C and S
pterygium and pingueculum
due to prolonged sun exposure-elastotic degeneration of conjunctivatx: symptomatic: acular + art. tears, resection of affecting /, vision, cosmesis?, recurrent inflammation
keratitis/ulcer
redness, pain, photophobia, dec. vision-focal white opacity (infiltrate) in corneal stroma, dendritic keratitis
keratitis/ulcer etiology
bacterial: most common, assumefungal: organic matter trauma, chr. eye diseaseacanthamoeba: extreme pain, contacts +/- poor hygiene +/- swimmingHSV: unilat, eyelid rash, prev. episodes, nodes, dendritesatyp. mycobacteria: prev. ocular surgery/grafts, indolent course
keratitis/ulcer dx
corneal scraping for smears & cx:-if suspect unusual org. from hx and presentation, > 2mm / in visual axis, if unrespons. to tx
keratitis/ulcer tx
cycloplegicstopical abx according to size, zymar, vigamox, fort. tobramycin/gentamycin + fort. cefazolin/vancooral abx: ciprofloxin, impending perforation
fungal keratitis/ulcer
NAME?
acanthamoeba
severe pain, contacts w/ poor cleaning/swimmingdx: confocal microscopy, cx on nonnutr agar w/ E. colitx: polyhexamethyl biguanide + brolene + neosporin (essen. pool cleaner!)
PS response causes..
ciliary musc to contract–>zonules relax–>inc. AP diameter and diopteric power of lens–>refracts light (accommodation)
total refractory power of lens ? from air-tear interface ?from lens ?
60 D40 D from interface15-20 from lens
cataract
compression and hardening of lens, change in lens proteins cause change in refractive index, scatter, and red. transparency
nuclear sclerotic cataract
“aging”, compr/harden. of lens nuc as new layers of cortical fibers formedimpairs distance more than near vision, second sight (AP growth)
posterior subcapsular cataract
“fish eggs” dec. vision in bright lights (glare), obscured when mitosis/constricted,impairs near more than distant vision
cortical cataract
“spokes on a wheel” worse when eyes dilated/mydriasis, glare and halos around lights
indications for cataract surgery
NAME?
phacoemulsification
(1967, Kelman)small incision made in cornea (no stitches req.)–>US probe inserted into A/C and used to break up cataract–>aspiration of lens–>insertion of pre-measured intraocular lens
iritis
photophobia, redness (perilimbal) dec. visioncauses: trauma, vasculitides (HLA-B27, TB, JRA in kids, sarcoid in AA’s)flare in ant. chamber, keratic precipitates- KP, band keratopathy, synecheia, if no hx trauma, do vasculitis w/u
vasculitis w/u for iritis
CBC, ESR, ANA, PPD, RF, ACE, lysozyme, RPR/FTA-abx, CANCA, HLA-B27
iritis tx
cycloplege (dilate to keep from scarring), pred forte?q1-6oral prednisoneimmunosuppressives
endophthalmitis
dec. vision and painabsent red reflex, vitrifies, hypopyon (eye filled with WBCs), conj. injection
endophthalmitis types
-postoperative (acute: S. epi, S. aureus, strep, pseudomonas; chronic: p. acnes)-traumatic (same ^ + bacillus)-endogenous (endocard, IV feeding, immsupp, brspec abx)–>cx everything (blood, urine, catheters, IV line)
endophthalmitis tx
postop: VA? , tap and inject (cx, smears) intravitreal vanco + amikacin +/- dexa-topical fort. abx + steroidsconsider PO/IV FQstrauma: same ^, tetanus toxoidendogenous: brdspec IV abx (ID consult)aminoglycoside + clindamycin in IV drug users intravitreal vanco + amikacin
aqueous humor production
produced by ciliary bodies in post. chamber–>around pupillary margin into ant. chamber–>drained through trabecular meshwork
glaucoma
grp of diseases: optic neuropathy, assoc. with visual field loss, increased intra ocular pressure is a risk factor, not requirementcup: disc ratio around 0.8 (vs. 0.4) due to atrophylook for patholitis (swelling of optic n., irreg. borders)
types of glaucoma
-open angle: abnorm. that clogs it up–>inc. pressure–>optic neuropathy-angle closure w/ pupillary block: iris buds against ant. lens, AH build up in post chamber–>^^pressure–>vomiting, ha-angle closure w/out pupillary block: something from cornea into iris and pulling it up
indications for glaucoma surgery
progressive glaucomatous optic neuropathy (GON) or visual field changes on MTMTfailed IOP control after laster txintolerance/noncompl to medsgoal of filtering surgery: create pathway for AH to flow from ant chamber thru sclera into subconj and subtenons space
types of glaucoma surgery
trabeculectomy w/ MMC: partial thickness scleral flap allows for controlled filtering of AH form ant cham into subconj space–>conj. bleb formedtub implant: inserted into ant chamber thru sclera, allows for flow of AH from ant chamb into plate at subconjunc space
age related macular degeneration
most common cause of dec. VA in USsymp: metamorphosis (waviness) w/ loss of central vision
dry macular degeneration
most common (80%) drusen: yellow EC deposits btw Bruchs and RPE? RPE atrophy: photorec.loss
dry mac deg tx
AREDS (vitamin C, E, beta carotene? (now omega 3s), zinc, copper)
wet macular degeneration
exudative, break in Bruch’s membrane–>neovasc/bleeding
wet mac deg tx
intravitreal anti-VEGF agents +/- laser
diabetic retinopathy
retinal damage due to chronic hyperglycemia- implies other organs are affectednonprolif: mild or modif severe (4:2:1 rule): 4 quads of diffuse intraret heme and micro aneurysms, 2 quads venous beading, 1 quad IRMAclin. sig macular edema: w/in 500 um fovea, hard exudates w/ adj. edema, edema 1 disc area w/in 1 disc diam. of fovea
proliferative diabetic retinopathy
any NVD w/ VH, 1/4-!/3 disc area NVD1/2 disc area NVE w/ VH
diabetic retinopathy tx
laser, intravitreal anti-VEGF injections
classic visual field loss
bitemporal heminopsia
causes of chiasmal defects
pit tumor, sheehan’s, pit apoplexy, craniopharyngioma, meningioma, glioma
distance chiasm lies above pit gland
1 cm
micro vs macroadenoma
micro presents to endocrinologist, macro presents w/ VF changes?
optic neuritis
inflame of optic n.symps: central visual loss, pain with eye mvmnt, APD w/ dec. color vision (red)
optic neuritis ddx
viral, MS, vasculitis (SLE) granulomatous (syph, sarcoid) idiopathic
optic neuritis w/u
MRI w. flairatyp >1 mo: ANA, anti-DNA, VDRL, RTA-ABS, CXR, ACE, ESR
optic neuritis px
visual recovery (20/40) in 95% untr. ptsMRI: risk of MS:0 lesions 16%, 3+: 50%
optic neuritis tx
do not give oral prednisone! inc. recurrenceIV methylprednisolone rec. vision faster if treated w/in 1st 2 wks but no effect on recurrences
MS
autoimmune attack of myelin causing inflame. demyel. of CNS F>M (2:1)dx: 2 attacks sep by > 1 mo in sep parts of CNS-episodes last wks-mos: diplopia, ataxia, vertigo, parethesias, bladder/bowel dysfunction, extrem. wkness, e- shock-like sens.
eye findings w/ MS
optic neuritis (75%), diplopia, internuclear ophthalmoplegia (INO)
MS lab tests
MRI w. flair, periventr. plaquesspinal fluid: elevated IgG, oligoclonal bands
MS tx:
ABC: Avonex, Betaseron (interferon B), Copaxone
MS disease course
primary progressive (10%) from onsetsecondary prog. (50%): relapsing/remitting w. slow continuous deteriorationbenign (30%): no serious disability
CN III nucleus
in midbrain, level of sup. colliculusmultiple nucleii: -single central located nuc: both levators-paired SR nuc that cross to supply C/L SR-paired nuc that do not cross: supply MR, IR, IO-Edinger-Wesphal nuc supplies PNS input to both eyes
CN III fascicle syndromes
ischemic, infiltrate or inflamm. conditionsaffects fascicles–> I/L CN III paresis + other mdbn structures
CN III: Nothnagel’s
superior cerebellar peduncle, leads to I/L CN III paresis + cerebellar ataxia
CN III fascicle:
travels ventrally traversing red nuc and corticospinal tract
CN III: Benedikt’s
-red nuc, leads to I/L CN III paresis + C/L tremor + C/L dec sens
CN III: Weber’s
pyramidal tract, leads to I/L CN III paresis + C/L hemiparesis
CN III supplies
superior: SR and levatorinferior: IR, MR, IO
PNS from E-W nuc travels w.
inf div of CN III
CN IV
@ mdbrainfascicles: only CN that decussates and exits dorsally
CN IV enters
cavernous sinus, SOF outside annulus of Zinn, inn. SO, longest intracranial course, most common CN injured w/ head trauma
isolated CN IV palsy
congenital: large vert. fusion amp, head tilt in old photosacquired: vertical diplopia, chin down, head tilted away from lesion
CN VI
nuc @ pons medial to CN 7, lesion–> I/L gaze palsy
CN VI fascicles
travel anterolat to PPRF then thru pyramidal tract
Brain stem syndromes:Millard-Gublar
CN 6, 7, + pyramidal tractI/L CN 6, 7 palsies, and C/L paresis
brain stem syndromes:Foville’s
CN 5, 6, 7, +SNS I/L CN 5,6,7, palsieshorizontal conjugate gaze palsy
brain stem syndromes: Raymond’s
CN 6 + pyramidal tractI/L CN 6 palsy + C/L paresis
CN VI nerve exits..
lower pons, climbs over clivus and petrous ridge, vuln. to inc. ICP, common CN palsy affected in pseudo tumor cerebri (30%)travels along base of skull thru Dorello’s canal under Gruber’s ligament–>enters cavernous sinus closest to ICA and SNS (only place to get isolated CN 6 palsy + Horner’s)-enters SOF, innervates LR
CN VI: Gradenigo’s syndrome
mastoiditis of petrous apex following otitis media-CN 6 palsy + I/L dec. hearing + facial pain and paralysis
Pons lesion: INO
lesion in MLF, due to MS or stroke: CN VI stim. I/L LR but C/L CN III cannot stim. MR:adduction deficit (I/L) abducting nystagmus (C/L)
Pons lesion: One and a half syndrome
lesion of MLF and ipsilat CN VI nuc:ipsilat add. deficit, ipsilat conj. gaze paresis, *only movement is contralat abduction
cavernous sinus thrombosis
blood clot of ICA from spread of infection of sinuses-ptosis, chemosis, CN 3, 4, 5, 6 palsies
PNS: pupillary light reflex miosis
optic nerve–>chiasm–>optic tract–>pretectal nuc (synapse), cross to both EW nuclei (synapse), travel via CN III–>ciliary ganglion–>postgang fibers via short ciliary nerves to ciliary body and iris sphincter: constriction
APD/Marcus Gunn Pupil
any damage to ON from retina to pretectal nuc.-swinging flashlight test: pupil dilates
CN 3 palsy”blown pupil”, usually ptosis and dec. EOMsetiology: aneurysm,: posterior communicating artery, tumor, vascular
“blown pupil”, usually ptosis and dec. EOMsetiology: aneurysm,: posterior communicating artery, tumor, vascular
Adie’s tonic pupil
-middle age women (70%)dysfunc. of PNS at ciliary ganglionpost-viral or post orb sympts. mydriasis, more in lightsluggish, segmental pupillary response (vermiform)light-near dissociationdiminished deep tendon reflexessuper sensitive to pilo 0.1%
SNS: pupillary light reflex, mydriasis
1st order neuron: hypothalamus to T1 level of SC2nd order neuron: SC to C2 level of sup. cerv. ganglion (symp)3rd order neuron: cervical gang. through ciliary ganglion to nasociliary and short ciliary nn., follows carotid artery
SNS disorders: PLR, Horner syndrome
PAM:ptosis (Muller’s musc)anhydrosis (always if 1st-order involved)miosis (greater in dark)-iris heterochromia (congen)pain: dissecting carotid aneurysm (3rd order)
Horner syndrome w/u
apraclonidione: if pupil dilates: Hornersthen hydroxyamphetamine: pupil dilates: 1st/2nd orderno dilation: 3rd orderMRI of head (cavernous sinus), neck, lung apices
