Eye I and II Flashcards

1
Q

Red eye etiologies

A

Red eye etiologies

  • inflammation
    • blepharitis
    • chalazion / hordeolum
    • cellulitis
    • conjunctivitis
    • dacroadenitis / dacrocystitis
    • corneal ulcer (keratitis)
    • scleritis
    • uveitis
  • traumatic
    • subjunctival hemorrhage
    • corneal abrasion
    • fb
    • hyphema
  • other
    • glaucoma
    • tumor
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2
Q

Blepharitis

  • What is it
  • Anterior vs posterior blepharitis
  • Clinical presentation
  • Physical exam
  • Complications
  • Treatment
A

Blepharitis

  • Blepharitis is a chronic condition - inflammation of the eyelids, typically with intermittent exacerbations
  • Anterior blepharitis may have either infectious (S. aureus) or seborrheic (e.g. dandruff)
  • Posterior blepharitis is from meibomian gland dysfunction
  • Treatment is the same for both types

Clinical presentation

  • red eyes
  • gritty or fb sensation
  • burning sensation
  • excessive tearing
  • crustiness in lashes
  • light sensitivity
  • blurry VA

Physical exam

  • diffuse conjunctival injection
  • eyelid margins inflammed and red
  • crusting and matting of eyelashes
  • plugged glands with magnification
  • collarettes (debris along lashes)

Complications

  • if meibomian gland clogs, then chalazion can form
    • painless
    • rubbery
    • nodule
  • if chalazion gets infected, turns into hordeolum
    • painful
    • infected
    • purulent

Treatment

  • warm compress
  • lid massage
  • lid hygiene
  • topical abx (erythromycin ointment)
  • oral abx for severe cases
  • prevention: omega 3 supplements
  • chalazion / hordeolum tx
    • frequent warm compresses
    • topical steroids or abx
    • possible oral abx
    • may require sx
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3
Q

Cellulitis: periorbital and orbital

  • Difference betweent the two?
  • Etiologies
  • Clinical presentation
  • Physical exam
  • Diagnosis
  • Treatment
A

Cellulitis: periorbital and orbital

  • Periorbital cellulitis
    • Infection of the soft tissues around the eye that does not extend into the orbit
    • Can be complication of blepharitis
    • More common
    • Can tx easily with abx
  • Orbital cellulitis
    • Infection of the fat and muscle tissue surrounding the globe
    • Will usually start in the sinuses
    • Infection travels deeper, more complicated to tx
    • Infection can spread to the brain via the cavernous sinus
  • Neither involves infection into the globe
  • Both are more common in kids
  • Tx is very different for both

Etiologies

  • Periorbital cellulitis
    • External sources
      • Blepharitis
      • Insect bites
      • FB
    • Sinusitis
  • Orbital cellulitis
    • Most often caused by an extension of infection from the paranasal sinuses (ethmoid sinuses)

Clinical presentation

  • Periorbital cellulitis
    • eye pain
    • eyelid swelling and erythema
    • no VA change
    • no fever
    • no pain with eye movement
  • Orbital cellulitis
    • eye pain
    • eyelid swelling and erythema
    • VA changes
    • fever
    • pain with eye movements

Physical exam

  • Periorbital cellulitis
    • no proptosis
    • no ophthalmoplegia
  • Orbital cellulitis
    • proptosis
    • ophthalmoplegia
    • conjunctivitis
    • discharge

Diagnosis

  • If in doubt, tx as if it were orbital cellulitis
  • Workup includes:
    • CBC
    • blood cultures
    • culture of any discharge
    • CT of orbits and sinuses

Treatment

  • Periorbital cellulitis
    • Outpatient
    • Empiric abx therapy
      • Staph aureus
      • Staph pneumoniae
      • MRSA
    • If MRSA not suspected, use Amoxicillin-Clavulanic acid
    • If MRSA is suspected, use oral Bactrim (trimethoprim sulfamethoxazole) or oral Clindamycin PLUS Amoxicillin, Amoxicillin-Clavulanic acid, Cefinir, or Cefpodoxime
  • Orbital cellulitis
    • Hospitalization and opthalmology consult
    • Start immediate tx with IV abx to prevent optic nerve damage and spread of infection to cavernous sinus, and thus to meninges or brain
    • Abx should be broad spectrum until cultures returned
    • Sx drainage if abscess formation
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4
Q

Conjunctivitis

  • Viral, bacterial, and allergic
  • MC etiologic agent
  • Clinical presentation
  • Treatment
  • Unilateral or bilateral
A

Conjunctivitis

  • Inflammation of the white of the eye (conjunctiva)
  • Most common eye disease
  • Viral is most common
  • Can also be caused by bacterial infection, allergies, or chemicals
  • Transmits via direct contact

Viral conjunctivitis

  • MC etiologic agent: adenovirus
  • Clinical presentation
    • Pharyngitis
    • Fever
    • Malaise
    • Watery discharge
    • Preauricular adenopathy
  • Tx: cold compress

Bacterial conjunctivitis

  • MC etiologic agents
    • S. aureus
    • S. pneumoniae
    • H. influenzae
    • Pseudomonas (CL wearers)
  • Clinical presentation
    • Copious amounts of discharge is common
    • Eyes matted shut in the morning
  • Treatment
    • Abx drops or ointment
      • Erythromycin ointment
      • Fluroquinolone drops
        • Moxifloxacin
        • Ciprofloxacin

Allergic conjunctivits

  • Bilateral
  • Can be seasonal
  • Clinical presentation
    • Itchiness
    • Conjunctival injection and swelling (chemosis)
  • Treatment
    • Cold compress
    • Topical or oral antihistamines
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5
Q

Daryocystitis

  • What is it
  • Secondary to what
  • More common in what population
  • Treatment
A

Daryocystitis

  • Infection of the lacrimal sac
  • Usually secondary to a nasolacrimal duct obstruction
  • More common in children
  • Tx with agressive abx
    • Clindamycin
    • IV vancomycin
  • May require sx (NLD probing)
  • Infection can spread to the brain
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6
Q

Entropion

  • What is it
  • Causes
  • Treatment
A

Entropion

  • Inward turning of the eyelids (especially lower lid)
  • May occur with age as result of degeneration of lid tissues or due to childhood facial structure
  • Damage may occur with rubbing of lashes on the surface of the eye
  • Treatment: lubrication
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7
Q

Extropion

  • What is it
  • Causes
  • Treatment
A

Extropion

  • Outward turning of the eyelids (especially lower lid)
  • May occur with age as result of degeneration of lid tissues

Treatment

  • Lubrication
  • Surgery if excessive tearing or exposure keratitis
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8
Q

Pingueculum

  • What is it
  • Common in what population
  • Treatment
A

Pingueculum

  • Yellow, elevated nodule most commonly located on the nasal side of the conjunctiva
  • Common in people over age 35
  • Rarely grow and do not require tx
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9
Q

Pterygium

  • What is it
  • Risk factors
  • Treatment
A

Pterygium

  • Bad cousin of the pingueculum
  • Fleshy, triangluar growth of the conjunctiva that typically spreads and may threaten cornea and visual axis
  • Associated with wind, sun, and dust exposure

Treatment

  • AT
  • Anti inflammatories
  • Excision
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10
Q

Chemical conjunctivitis

  • Clinical presentation
  • Physical exam
  • Treatment
A

Chemical conjunctivitis

  • Caustic chemical exposure

Clinical presentation

  • Acute pain and burning
  • Blurry and impaired VA

Physical exam

  • VA decreased
  • Corneal abrasion
  • Red, pink, or white

Treatment

  • Irrigate!!!
  • Topical lubricants
  • Abx
  • Refer to ophthalmology
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11
Q

Subjunctival hemorrhage

  • What is it
  • Causes
  • Clinical presentation
  • Physical exam
  • Treatment
A

Subjunctival hemorrhage

  • Blood under the conjunctiva due to vessel rupture
  • Can result from trauma or trivial events (cough, sneeze, valsalva)

Clinical presentation

  • Acute
  • Asymptomatic

Physical exam

  • VA unaffected
  • Diffuse, flat red patch that stops at the limbus

Treatment

  • None, will resolve in 2-4 weeks
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12
Q

Hyphema

  • What is it
  • Clinical presentation
  • Physical exam
  • Treatment
A

Hyphema

  • Results from injury to anterior chamber that disrupts the vasculature suporting the iris or ciliary body

Clinical presentation

  • Acute onset of pain
  • Photophobia
  • Tearing
  • Nausa, vomiting may indicate rise in IOP

Physical Exam

  • Vision decrease
  • Layered heme in the anterior chamber

Treatment

  • Ophthalmology referral
  • Bed rest, supine with head elevated
  • Goals of treatment
    • Control IOP
    • Ease discomfort
    • Prevent complications
  • Oral diuretic - acetazolamide
  • Topical diuretic - dorzolamide
  • Topical cycloplegic - atropine (dilate)
  • Possible topical steroid
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13
Q

Conjunctival and corneal FB

  • Clinical presentation
  • Physical exam
  • Examination
  • Treatment
A

Conjunctival and corneal FB

  • FB on the cornea or under the upper lid presents with a patient complaint of “something in my eye” or a FB sensation

Clinical presentation

  • Hx of something entering eye
  • Pain
  • Unable to open eye
  • May have attempted irrigation

Physical exam

  • VA usually unaffected
  • Tearing (eye is trying flush out)
  • Conjunctival injection
  • Presence of FB
  • Staining with fluorescein if there is an abrasion

Examination

  • Use topical anesthetic to help with exam (tetracaine drops)
  • Check VA pre and post tx
  • Evert eyelid to look for FB
  • Check with fluoresceine for abrasion/FB
  • Examine pupils (if suspected intraocular FB, refer)

Treatment

  • FB removal with irrigation or cotton swab
  • Lubricant or abx eye drops
  • Refer to ophthalmology if unable to remove or concern for large abrasion
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14
Q

Perforated globe

  • Causes
  • What to look for on exam
  • Treatment
  • Avoid what during exam
A

Perforated globe

  • Results from penetrating trauma, must have high suspicion based on hx (hammering or shaving metal)
  • Look for signs of loss of anterior chamber depth, misshapen pupil, or vitreous leakage (jelly)
  • Emergency referral for sx repair
  • Avoid manipulaton until seen by specialist
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15
Q

Corneal abrasion

  • What is it
  • Clinical presentation
  • Physical exam
  • Treatment
A

Corneal abrasion

  • Defects in the corneal epithelial tissue
  • Often from trauma to eye (fingernail, paper, CL)

Clinical presentation

  • Acute onset pain
  • FB sensation
  • Tearing
  • Light sensitivity
  • Inability to open eyelids

Physical exam

  • VA maybe affected
  • Visible epithelial defect
  • Abrasions best seen with fluorescein dye and black light

Treatment

  • Topical abx drops
    • Moxifloxacin
    • Azthromycin
  • Topical lubricants
  • Cornea heals quickly, f/u in 1-2 days
  • Never send patients home with anesthetics!
    • Inhibit healing
    • Lack of sensation
    • Anesthetic keratitis may occur and require corneal transplant
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16
Q

Corneal ulcer (keratitis)

  • What is it
  • Risk factors
  • Clinical presentation
  • Physical exam
  • Treatment
A

Corneal ulcer (keratitis)

  • Commonly due to infection (bacterial, viral, fungal, or amebic)
  • May start with corneal abrasion and infection worsens
  • Associated with CL abuse

Clinical presentation

  • Eye pain
  • Photophobia
  • Tearing
  • Decreased VA

Physical exam

  • Conjunctival injection, especially by limbus
  • Cloudy, hazy opacity overlying cornea
  • Possible hypopyon (purulent discharge)
  • Dendritic pattern on fluorescein staining (HSV)

Treatment

  • Ophthamology referral
  • If bacterial, use moxifloxacin
  • If HSV, use topical acyclovir 9x q day
17
Q

Scleritis

  • What is it
  • Risk factors
  • Types
  • Clinical presentation
  • Physical exam
  • Diagnostics
  • Treatment
A

Scleritis

  • Potentially blinding inflammatory condition affecting the sclera
  • Often associated with systemic immunologic disease (e.g. RA, Wegener’s)
  • Types
    • Anterior: more visible, less severe
    • Posterior: less visible, more severe
    • Necrotizing variant

Clinical presentation

  • Severe, constant pain
  • Radiating pain to face or periorbital area
  • Worse at night or early in the morning
  • VA may be affected
  • May be severe enough to limit activity and prevent sleep

Physical exam

  • EDEMA
  • Eye redness (deeper than conjunctivitis)
  • Tender globe
  • Pain with EOMs
  • Diagnosis
    • Anterior scleritis
      • Eye pain
      • Violaceous redness
      • Localized tenderness
      • Dilation of episcleral vascular plexus seen on slit lamp exam
    • Posterior scleritis (requires more extensive exam)
      • Slit lamp exam
      • Deep ophthalmoscopy
      • Possible US, CT, or MRI

Diagnostics

  • CBC, CMP, UA microscopy
  • ESR and CRP
  • RF and ANA (for RA)
  • ANCA (Wegener’s granulomatosis with polyangitis)
  • CXR to r/o systemic disease
  • If CXR positive, do chest CT

Treatment

  • Coordinated by ophthalmology and rheumatology
  • Depends on severity of disease
  • Systemic therapy
    • NSAIDS
    • Glucocorticoids (may need IV)
    • Possisble immunosuppressive drug
  • If severe, treatment continues for 6-12 months
18
Q

​Uveitis / iritis

  • What makes up the uvea
  • What can escape into the aqueous humor
  • Causes
  • Clinical presentation
  • Physical exam
  • Diagnosis
  • Treatment
A

Uveitis / iritis

  • Inflammation of the uvea, which consists of the iris, ciliary body, and choroid
  • Inflammation of the uvea tract allows proteins and WBCs to escape into the aqueous humor
  • MC cause is immunologic, but can also be caused by trauma

Clinical presentation

  • Eye pain
  • Redness
  • Photophobia
  • Headache
  • Tearing

Physical exam

  • Decreased VA
  • Ciliary flush / circumlimbal injection (redness around edges of iris)
  • Constricted pupils
  • Cells and flare on SLE
  • IOP is low or normal

Diagnosis

  • Find infectious cause
    • HSV
    • Herpes zoster
  • Find systemic inflammatory cause
    • Ankylosing spondylitis
    • Arthritis
    • IBS

Treatment

  • Prompt ophthalmology referral
  • Topical steroids (prednisolone)
  • Topical cycloplegics (cyclopentolate)
19
Q

Blow out fracture

  • What is it
  • Classic mechanism
  • Clinical presentation
  • Diagnosis
  • Treatment
A

Blow out fracture

  • Direct compressive force to the globe
  • Classic mechanism is a baseball to the eye

Clinical presentation

  • Pain
  • Dilopia
  • Restricted EOMs (secondary to entrapment of the inferior rectus muscle)
  • Decreased sensation along inferior orbital rim
  • Palpable step off of orbital rim
  • Enopthalmos (posterior displacement of the globe)

Diagnosis

  • CT is test of choice
  • Can use XR too

Treatment

  • Emergency referral
  • Empiric abx ASAP (amoxicillin-clavulanate)
20
Q

Glaucoma

  • What is it
  • Types
  • Clinical presentation
  • Physical exam
  • Treatment
  • Diagnosis
A

Glaucoma

  • Group of ocular diseases characterized by changes in the optic disk (resulting from increased IOP) and progressive loss of visual fields

Types

  • AACG - emergency, rare in real life
  • COAG - more common

Acute angle closure glaucoma

  • Narrow anterior chamber
  • Secondary to pupil dilation
  • Outflow is obstructed (pupillary block) and pressure builds due to fluid build up
  • Clinical presentation
    • Extreme eye pain
    • HA
    • Photophobia
    • Blurred VA
    • Haloes
    • Nausea, vomiting (include glaucoma for ddx acute abdomen)
  • Physical exam
    • Patient looks sick
    • Decreased VA
    • Red eye
    • Steamy cornea
    • Fixed mid dilated pupil
    • Crescent shadow
    • Increased IOP
      • Firm globe
      • IOP over 50 mmHg
  • Treatment
    • Control IOP
      • IV acetazolamide (Diamox), followed by po
      • Topical timolol
      • Can add miotic drop (constrict)
    • Check IOP hourly until ophthalmology consult
    • LPI

Chronic glaucoma

  • Gradual progressive damage
  • Cupping
  • Increased IOP results from reduced drainage through trabecular meshwork (chronic open angle) or obstruction of flow into anterior chamber (chronic closed angle)
  • Everyone over 40 years should have dilated fundus exam every 2-5 years (unless FHx or DM, then yearly)
  • Clinical presentation
    • Typically asymptomatic in beginning
    • Usually bilateral disease
  • Diagnosis
    • Optic disk
    • VF
    • IOP
  • Treatment
    • Gtts
    • Laser trabeculoplasty
    • Sx trabeculectomy