Eye disorders Flashcards
Most common cause of orbital fx in kids and adults
- Children, Adolescents
- Sports trauma Projectiles- baseball
- Adults
- Assaults MVC Industrial accidents
What is the most common fracture of the orbital rim
Orbital Zygomatic fx
Orbital Zygomatic fx is often associated w/ fracture of _____________ fracture
orbital floor Zygomaticomaxillary complex (tripod)
Disruption of the medial canthal ligament and lacrimal duct system is what type of fx
Nasoethmoid Fx
type of injury associated w Nasoethmoid Fx
Medial rectus muscle entrapment
type of fracture that results from high impact blow to lateral orbit
Orbital Zygomatic fx
describe an Orbital floor / “blow out” fx
Displacement of the globe
Entrapment of the inferior rectus muscle à Resulting ischemia and loss of muscle function
fx resulting from a small round object hitting eye or direct blow to infraorbital rim
Orbital floor / “blow out” fx
what type of fx
Orbital floor / “blow out” fx
what type of fx has a High association with intracranial injury
Orbital Roof Fx
Injury to infraorbital nerve decreased sensation along the ____, ____ ___, and _____.
cheek upper lip and gingiva
gold standard for imaging orbital fx
- CT Orbit Gold Standard 1-2 mm cuts
- Axial and coronal through orbits
what is hyphema
MOI?
Blood in anterior chamber
Typically caused by blunt trauma or penetrating injury to orbit or globe
- Finger, hockey stick, racquet, ball
- Deployed airbag
- Paintball
- Assault
tx of hyphema
Goal is to prevent secondary hemorrhage and intraocular hypertension, increase absorption of blood
Limit activity
Daily monitoring of IOP
Eye shield
Topical glucocorticoids- prednisone acetate, dexamethasone sodium phosphatate QID- lowers risk of re-bleeds
+/- Cycloplegics and Mydriatics
Regarding hyphema the most common source of blood is tear in the anterior face of the ____ ____.
ciliary body
Pt presents with:
Vision loss
Eye pain with pupillary constriction
Photophobia
dx?
hyphema
what nerve is affected in a corneal abrasion
Trigeminal CN 5
Most frequent cause of visits for ophthalmic emergencies is
FB with corneal abrasion
Tx of corneal abrasion
Topical antibiotics
Erythromycin • Polymyxin • Sulfacetamide
No patching recommended
No ophtho f/u for small abrasions
Contact Wearers: anti-psuedemonals
Ciproflox drops • Oxiflox drops • Gentamicin • Tobramicin
when treating a corneal abrasion in a contact lense wearer what must you conisder adding to tx
Contact Wearers: anti-psuedemonals
Ciproflox drops
Oxiflox drops
Gentamicin
Tobramicin
opth f/u
Indication for ophthalmologist f/u in corneal abrasions
Large abrasions
Contact lens wearer
Young children
Vision changes
Rust ring
Flourescein is an important diagnostic tool that can be used after _____.
after open globe ruled out
common bacterial causes of corneal ulcers
pseudomonas staph strep MRSA Moraxella liquefaciens (DM, alcoholics)
common causes of viral and fungal corneal ulcers
Viral HSV/Zoster
Fungal (Amoebas)
Acanthamoeba- contaminated water
risk factors of corneal ulcers
Contact lens wearer
Previous eye surgery
Eye injury
Hx of herpes- Type 1 and 2
Use of topical or systemic steroids
Immune compromised
tx of corneal ulcer
Aggressively with topical antibiotics
Fluoroquinolone: Ciloxin, Ocuflox
Topical antifungal
Natamycin
Amphoteracin b
Fluconazole
Topical antiviral
Ganciclovir
Acyclovir
NO EYE PATCHES
All suspected corneal ulcers should be referred to ophthalmologist • Within 12-24 hours
open globe injury is considered a ___ prone wound
tetnus
tx for open globe injury
Assess any life-threatening injuries
NPO – may need to go to OR
Do not remove any FB
Avoid any eye manipulation
Nothing in the eye
Patch
Place head at 30 degrees
Treat nausea and pain aggressively
Provide sedation
Begin IV antibiotics
Ophthalmic consult
Needs surgical repair within 24 hours
Sever the inferior arm of lateral canthal tendon results in
Retrobulbar Hemorrhage
why MUST we identify and evacuate septal hematomas
Produces avascular necrosis if not evacuated
Blood collects in space between cartilage and mucoperichondrium and obstructs blood flow
Fracture of the midface that involves the zygoma, lateral orbit and maxilla
Caused by direct blow
Tripod fx
describe the Lefort Injuries classifcation system
I- transverse fx through maxilla above teeth
II- bilateral extend superiorly include nasal bridge, maxilla, lacrimal bones, orbital floor and rim
III- discontinuity between face and skullcranio-facial dissociation
Ethmoid bone fractures often associated with___ _____- head ______ important
CSF leakage
elevation
tx of tripod injury
Needs surgical repair due to instability
describe the classifcation system for tooth fx
Ellis System:
Class I- enamel- not painful
Class II- expose yellow dentin painful
Class III- expose dental pulp seen as red line or dot exquisitely painful
indications for repair of tongue lac
- >2 cm that extend into muscular layers or pass completely through the tongue deep at the lateral border
- large flaps or gaps significant hemorrhage lacerations that may cause dysfunction if healed improperly
tx of tongue lacs
Have suction ready
Closed in LAYERS
Absorbable sutures 3-0 or 4-0 chromic gut or Vicryl
Direct infiltration with 2% lido
IV sedation
Tetanus
Complications
Edema /Hemorrhage
Aspiration
IV decadron
Ice chips, popsicles
try to handle tooth fx
Stored in milk if cannot be immediately reimplanted
Handle tooth by the crown
Don’t wipe or handle the root
Rinse gently with tap water or saline
Replace in socket
Have patient put in between gum and buccal mucosa
Name 3 types of anterior blephritis
Ulcerative – usually associated with Staphylococcus
- Seborrheic – usually associated with seborrhea of other areas
- Parasitic -dermodex follicularum
name si/sx associated w/ anterior blephritis
Red-rimmed” eyes
Scales or granulations on lashes
“Greasy” appearance
tx of anterior blephritis
Routine cleaning of lid margins, eyelashes, with warm H2O/cotton, baby soap
In acute exacerbations – bacitracin or erythromycin eye ointment daily
posterior blephritis is caused by?
Caused by inflammation of the Meibomian gland
blephritis mostly occur in assoc w/ ?
Most occur in association with acne, rosacea or seborrheic dermatitis
tx of posterior bleph?
Regular Meibomian gland expression
- Inflammation of the conjunctiva indicates need for long-term low dose oral antibiotics and possibly short-term topical corticosteroids
- Tetracycline 250mg BID/
- Doxycycline 100mg daily
- Prednisolone 0.125% BID
Short-term treatment with ciprofloxacin 0.3% ophthalmic solution BID can be used for exacerbations
Treatment of dermodex is with tea tree oil
most common causes of viral and bacterial conjuncivitis
viral
Adenovirus is the most common cause
Other causes are HSV, enterovirus, and coxsackie
bacterial
Most common causes is Staphylococci, including MRSA
Other causes- Strep pneumoniae, Haemophilus, Pseudomonas, and Moraxella
Gonococcal conjunctivitis –emergency can lead to corneal perforation
•Diagnosis is confirmed by stain smear and culture
difference in discharge between viral and bacterial and allergic conjuncivitis
viral - watery
bacterial purulent
allergy - string like white discharge (Hallmark sign)
tx of viral conj
Although viral, many providers prescribe erythromycin ophthalmic ointment to prevent bacterial co-infection: 1/2in ribbon TID x 7 days. •
HSV – Ganciclovir 0.15% gel
tx of bacterial conj
Topical antibiotic ointment will usually clear infection in 2-3 days
- Bacitracin ointment
- Erythromycin ointment
Gonococcal – Ceftriaxone IM and topical antibiotics
tx for allergic conj
Cold compresses
- Topical vasoconstrictors: Visene
- Antihistamines: diphenhydramine
- Mast cell stabilizers: olopatadine
Inflammation of the lacrimal drainage system usually due to congenital or acquired obstruction
risk fx?
Dacryocystitis
age, trauma, surgery, systemic disease, certain medications.
acute vs chronic si/sx of Dacryocystitis
Acute signs and symptoms:
- Pain and Swelling
- Tenderness and redness over lacrimal sac area
- Purulent material may be expressed
Chronic signs and symptoms:
- Tearing
- Discharge
- Mucus or pus may be expressed
tx of Dacryocystitis
Systemic antibiotics like Augmentin
Surgery to fix underlying obstruction
• Dacryocystorhinostomy – removes obstruction and formation of a fistula into the nasal cavity
enropin vs ectropin
entropin Inwardly turning eyelid, usually the lower lid
ectropin
Outwardly turned eyelid, sagging lid
Usually the lower lid
tx of entropin
Ointment for lubrication
Eye patching
Surgery may be used to repair muscle laxity
tx of ectropin
Artificial tears
Surgery is indicated if there is excessive tearing, exposure keratitis, or cosmetic problem
name 2 types of Hordeolum (stye)
Internal: blockage of the Meibomian gland (conjunctival side)
External: blockage of the Zeis (sebaceous) or Moll (sweat) glands
si/sx of Hordeolum (stye)
Localized redness
Swelling
tenderness
tx of stye
Antibacterial ointment
Erythromycin ointment: ½ inch ribbon TID x7 days
I&D by ophthalmologist in 1-2 weeks if not improved
May develop into a chalazion
Firm cyst of the upper or lower eyelid
dx and cause?
chalazion
Caused by inflammation or blockage of the Meibomian gland
tx of chalazion
Warm compresses • 2-3 weeks
Incision and drainage
Refer to ophthalmologist
Corticosteroid injection • Triamcinalone (Kenalog)
si/sx of chalazion
Granulomatous
Erythematous
Non-tender
Slow growing
Same risk factors as for hordeolum
risk factors for chalazion and hordeum (stye)
Can affect anyone but increased in patients with diabetes, contact and eye make-up wearers, blepharitis
define Periorbital / Preseptal Cellulitis
Infection anterior to the orbital septum
Cellulitis of eyelid
Most common in children
pathogens responsible for Periorbital / Preseptal Cellulitis vs Orbital cellulitis
Peri
Staph aureus
Strep
H. flu
orbital
Strep pneumoniae
H. Flu
s. Aureus
occasionally fungi or mycobacterium
PE finding differentiating Periorbital / Preseptal Cellulitis vs orbital
peri
No proptosis
No pain or restriction of EOM
orbital
Proptosis
Restriction of EOM
Pain in EOM
Dx confirmed w/
CT or MRI
tx of Periorbital / Preseptal Cellulitis
Oral abx
•Augmentin 10 days
Daily f/u bc it can spread deeper
tx of orbital cellulitis
Ocular emergency – needs rapid dx and tx
Immediate IV abx
•Zosyn or vanco
Admit to hospital
Opth consult
Surgery sometimes needed to drain paranasal sinuses, to decompress pressure on the optic nerve and vessels, or if not improving on antibiotics
what can occur if orbital cellulitis goes untreated
If untreated can lead to optic nerve damage and can spread infection to cavernous sinuses, meninges and brain
expalin the role of retina rods and cones
- Retina transduces patterns of light energy into neuronal signals
- Rods: operate in dim illumination
- Cones: operate in daylight; color perception and high spatial resolution
pt describes as vision being “looking through a frosty or fogged-up window”
cataracts
where is “myopic shift” seen
what is myopic shift
more difficulty with distance vision
cataracts
on fundascopic exam you seeImpaired red reflex* - opacities within the red reflex in an elderly person
dx?
cataracts
describe patho of cataracts
degradation and denaturing of crystallin proteins in the lens
• Compression over time leads to loss of transparency and opacification
what are 2 types of macular degeneration
dry and wet
degenerative dz characterized by loss of central vision
macular degen
leading cause of adult blindness in industrialized countries
macular degen
subretinal drusen deposits are characteristically seen in?
dry AMD
describe the idfference b/w dry and wet macular degen
dry
80-90% of cases - Slow and gradual vision loss
Unknown etiology
wet
Less common, more SEVERE and RAPID vision loss
Growth of abnormal vessels into the subretinal space, usually from the choroidal circulation and less frequently from the retinal circulation
Leakage from these vessels produces elevation of the retina, collections of subretinal fluid and/or blood beneath the retina with distortion (metamorphopsia) and blurring of vision
focal or widespread geographic atrophy of the retinal pigment epithelium and pigment epithelial detachments
dx?
dry AMD
gradual loss of vision in one or both eyes
•first noticed as difficulty reading or driving
scotomas
reliance on brighter light or a magnifying lens for tasks that require fine visual acuity
dry Amd
tx of dry amd
Smoking cessation
Antioxidant vitamins
- Ocuvite or Preservision
- Studies found patients with more extensive dry AMD may benefit
metamorphisia is seen in
wet amd
distortion of straight lines
•Patients may perceive straight edges (such as doors or window blinds) as curved or distorted
tx of wet amd
VEGF Inhibitors
•Bevacizumab, ranibizumab, aflibercept
Antioxidants and vitamins
•Zinc, Vitamin C, Vitamin E, and others
Photodynamic therapy
•Used in patients who fail VEGF inhibitors
An eye disease that results in damage to the optic nerve – not always in the presence of elevated intraocular pressure
glaucoma
after cataracts the leading cause of blindnesss is
glaucoma
describe open angle glaucoma
•optic neuropathy characterized by progressive peripheral visual field loss followed by central field loss in a typical pattern
patho of open angle galucoma
- Increased aqueous production and/or decreased outflow are possible mechanisms
- anatomic or physiologic features of the trabecular meshwork and other outflow structures
myocillin gene (MYOC) is assoc w/
open angle glaucoma
describe angle closure glaucoma
- characterized by narrowing or closure of the anterior chamber angle – presents acutely
- lens is located too far forward anatomically and rests against the iris, resulting in “pupillary block” of aqueous humor
patho of angle closure glaucoma
- Pressure behind the iris causes the peripheral iris to bow forward and cover the anterior chamber angle
- can lead to scarring and functional damage to the trabecular meshwork
si/sx of open angle glaucoma
Usually asymptomatic
May or may not be elevated IOP
progressive peripheral vision loss
Central vision loss is a late presentation
si/sx of angle closure glaucoma
Usually unilateral
Decreased vision
Halos around lights
Headache
Severe eye pain
Nausea and vomiting
often occur in the evening or low light causing mydriasis and folds of the peripheral iris block the narrow angle*
gold standard diagnostic test for angle closure glaucoma
Gonioscopy
“cupping” on fundoscopic exam is ?
- “Cupping”, asymmetry of the cup-to-disc ratio between the eyes
- thinning or notching of the disc rim, progressive change of the size or shape of the cup
open angle glaucoma
tx of open angle glaucoma
If IOP is elevated, treatment to lower IOP may delay or prevent the onset of open-angle glaucoma
Topical Prostaglandins*(Preferred) Latanoprost, bimatoprost, tafluprost
Topical Beta-blockers
• Timolol, Betaxolol
Alpha-adrenergic agonists
• Brimonidine
Laser therapy- trabeculoplasty
Surgery – trabeculectomy
•first-line approach only for patients with severe visual field loss at baseline
tx fo acute angle closure glaucoma
Medical therapy:
one drop each, one minute apart:
- 0.5% timolol maleate;
- 1% apraclonidine; and
- 2% pilocarpine, especially immediately prior to laser peripheral iridotomy
- And 500 mg of oral or IV acetazolamide
- Check pressure in 30 and 60 minutes
tx for chronic angle closure glaucoma
Laser peripheral iridotomy
•tiny hole in the peripheral iris through which aqueous humor can flow
Surgical peripheral iridotomy
•incision into the anterior chamber and surgically excises a small amount of iris tissue to create a passage
standard of care in open angle glaucoma
Visual Field Testing - Automated Perimetry
- Standard of care
- More accurate than confrontational field testing
leading cause of blindness in American adults (aged 20–74 years)*
diabetic retinopathy
primary preventative measure for diabetic retin
Good glycemic control is the primary preventive measure**
explain the 2 types of diabetic retinopathy
Proliferative
presence of neovascularization arising from the disc and/or retinal vessels, preretinal and vitreous hemorrhage, subsequent fibrosis, and traction retinal detachment
Nonproliferative
nerve-fiber layer infarcts (cotton wool spots), intraretinal hemorrhages, and hard exudates and microvascular abnormalities
on fundascopi exam of a pt with diabetic retinopathy you will see?
- flame-shaped and blot hemorrhages
- intraretinal infarcts - “cotton wool” or “soft exudates“
- formation of tortuous loops of the veins
- Change in caliber of the veins
- neovascularization
tx of diabetic retinopathy
Intravitreal Anti-VEGF agents
Focal photocoagulation
- Highly effective
- Often used in poorly compliant patients or patients who have difficulty with follow-up
Combination of the two can be used depending on the patient – treatment individualized
fundascopic exam on HTN retin
- Evidence of retinal hemorrhages, exudates, and/or papilledema
- Arteriovenous nicking, “AV nicking”
- Copper wire arterioles – central light reflex occupies most of the width of the arteriole
tx of htn retinopahty
Rapidly lower the mean arterial pressure by approximately 10 to 15 percent, and no more than 25 % compared with baseline during the 1 st day of therapy
• IV Labetolol • IV Nicardipine • IV Nitroprusside
Gradually reduction of systolic BP to <130 and the diastolic pressure being gradually reduced to <80 over two to three months
Retinopathy may regress with good BP control
what is strabismus snd what are 2 types
Misalignment of the eyes
“Comitant“: describes a deviation that is of the same size in all positions of gaze.
“Incomitant”: deviation that changes depending upon the position of gaze.
common complicatiosn of strabismus
Amblyopia – lazy eye
Diplopia
Secondary contracture of extraocular muscles
Adverse psychosocial consequences
tests in strabismus
Corneal light reflex test - Initial screening test*
Cover test - Manifest strabismus
Cover/uncover test
•Performed if cover test is normal – can detect Latent strabismus
tx of strabismus
Ophthalmology referral – decrease risk of amblyopia
Aimed at treating visual impairment(amblyopia) and misalignment
- Corrective glasses
- Occlusion therapy
- Visual training exercises
•
Surgery
•Reposition or shorten certain extraocular muscles
tx of Pterygium
Artificial tears for symptoms relief
Surgical excision
• Recurrence rate up to 80%, not recommended for small pterygium or cosmetic purposes
Pterygium is caused by
UV radiation may trigger events that produce damage to cellular DNA, RNA, and extracellular matrix composition
what is Pterygium
triangular wedge of fibrovascular conjunctival tissue that typically starts medially on the nasal conjunctiva and extends laterally onto the cornea
visual impairment that results from Pterygium
•Astigmatism – results in blurred vision
define
Acute Transient Visual Loss (Amaurosis fugax)
and
Acute Persistent Visual Loss
acute transient sudden deficit in visual function lasting < 24hours (monocular or binocular
- Temporary vascular occlusion
- Neuronal depression (after seizure or migraine)
acute persistant > 24hours
Characterized by a normal fundus exam initially “The doctor sees nothing, and the patient sees nothing
optic nueritis
highly associated with delyelinating conditions such as MS
optic nuetitis
opth exam of retinal detachment shows
retinal hydration lines;
“billowing sail” or “ripple on a pond”
Retinal detachment often starts with ______and_____ ____ ____ which are warning signs
flashes of light and floaters
warning signs
risk factors for retinal detachment
- Myopia (near sighted)
- Previous ocular surgery (cataract extraction)
- Use of fluoroquinolones •Trauma to the eye
- Family history (i.e. lattice degeneration)
- Marfan Disease
pt shows unilateral vision loss and pain exacerbated by movement
dx?
optic nueritis
tx of MS
•Treatment with interferon Beta-1a can retard the development of more lesions
tx of optic nuetitis
Gradual recovery in vision without treatment typically
Consult neurologist, or neuro-ophthalmologist
Plasmapheresis
Systemic corticosteroids is controversial
- If steroids are prescribed; methylprednisolone followed by tapering dose of oral prednisone
- Steroids accelerate recovery but do not change end point
Physical exam finding during fundoscopic exam
Associated w/ increased IOP = only TRUE cause
papiledema
explain early, fully developed and later papilledeam
1.Early
- Loss of spontaneous venous pulsations
- Optic cup is retained early on.
- Fully Developed
*Optic disc elevated *Cup is obliterated *Disc margins obscured *Blood vessels buried. * Engorged veins. *Flame hemorrhages *Cotton wool spots (result from nerve fiber infarction)
- Late
*Cup remains obliterated. *Hemorrhagic and exudative components resolve. *Nerve appears flat with irregular margins. *Disc pallor.
management of Idiopathic intracranial ht
Many cases self limited
- Careful observation/brief hospitalization
- Weight loss
- Serial lumbar punctures
- Acetazolamide (Diamox) –inhibits carbonic anhydrase
- High dose corticosteroids if rapid vision loss
- Surgery for severe, refractory cases; optic nerve sheath decompression or lumbar peritoneal shunt
dz assoc w pregnant and obese women
Idiopathic Intracranial Hypertension
si/sx of Idiopathic Intracranial Hypertension
Nausea, vomiting, headaches, blurred vision
- Cranial nerve VI paresis/horizontal diplopia (double vision on lateral gaze). •Papilledema
- Spontaneous venous pulsations (retinal vein pulsations) are absent
Visual field defects
explain 2 types of retinal artery occlusion
1.Central retinal artery occlusion (CRAO)
Sudden, profound vision loss in one eye
- Usually painless
- Occasionally preceded by transient monocular blindness (amaurosis fugax), stuttering or fluctuating course
- Rarely ‘flashing lights’ in visual field
- Branch retinal artery occlusion (BRAO)
Monocular vision loss, which may be restricted to just part of the visual field
fundascopic exam shows
Ischemic retinal whitening
• “Cherry red spot” in the macula
retinal a. occlusion
tx of retinal a occlusion
Check ESR and CRP to r/o GCA
Consult opth
There is no definitive therapy to improve vision
PE exam of retinal a occlusion
Visual acuity reduced -severity ranges from loss of part of visual field (BRAO) to nearly complete visual loss (can not tell how many fingers clinician is holding up) -check peripheral fields!
•-afferent pupillary defect (Marcus Gunn pupil) (pupil does not constrict appropriately to light)
findings assoc w GCA
Often very high ESR or CRP
Diagnosis – temporal artery biopsy
• Panarteritis, CD4+ lymphocytes and macrophages
retinal vein occlusion fundascopic findings
features vary from a few scattered retinal hemorrhages and cotton wool spots to a marked hemorrhagic appearance
explain 3 types of retinal vein occlusion
- Branch retinal vein occlusion (BRVO) distal vein is occluded leading to hemorrhage along the distribution of a small vessel
- Central retinal vein occlusion (CRVO) occurs due to thrombus within central retinal vein leading to involvement of the entire retina
- Hemiretinal vein occlusion (HRVO) occurs when blockage is in a vein that drains the superior or inferior hemiretina
sudden vision loss that may present w
Possible unilateral numbness, weakness, slurred speech if related to carotid disease
a form of stroke
retinal a occlusion
si/sx of GCA
- New temporal headache
- Abrupt transient monocular vision disturbance
- Jaw claudication
- Fever, anemia, other constitutional symptoms
risk factors for rental v. occlusion
HTN, diabetes, sickle cell anemia, conditions that slow venous blood flow.
_____ ______ is often described as papilledema but should NOT be
Hypertensive Retinopathy
normal intracranial pressure
(Normal Pressure: 70 - 180 mm H20)
