Eye MDT Flashcards
Common chronic bilateral inflammatory condition of lid margins
Blepharitis
Involves the lid skin, eyelashes, and associated glands
Seborrhea of the scalp, brows, and ears (dermatitis)
Scales or granules can be seen clinging to eyelashes
Anterior blepharitis
Results from inflammation of Meibomian glands
Strong association with acne rosacea
Meibomian glands and their orifices are inflamed
Posterior blepharitis
Symptoms and physical exam findings:
Itching, burning, mild pain, foreign body sensation, tearing, erythema of the lids, and crusting around the eyes upon awakening
Frothy/greasy tears
May have conjunctival injection
Blepharitis
Treatment for blepharitis
Eyelid margins cleaned twice daily with commercial eyelid scrub (Ocusoft) or baby shampoo
Warm compresses for 10-15 minutes, 1-2 times a day
- Lid massage
- Artificial tears
- Omega 3 supplements
- Bacitracin ointment
Long-term, low dose antibiotic therapy for blepharitis
Tetracycline 250mg BID
Doxycycline 100mg BID
Erythromycin 1g/day
Azithromycin 500mg day one, 250mg x4 days
Clarithromycin 250mg BID x 7 days
Blepharitis follow up
2-4 weeks
Sebaceous glands connected to the eyelashes, secretions from these glands lubricate the eyelid surface
Gland of Zeis
Oil glands along the edge of the eyelids where eyelashes are found
Meibomian glands
Acute infection that usually involves Staphylococcus species
External (Gland of Zeis)
Internal (Meibomian gland)
Hordeolum
Chronic focal granulomatous inflammation within the eyelid, secondary to the obstruction of a meibomian gland or gland of Zeis (hordeolums)
Chalazion
Symptoms and physical examination findings:
- Localized eyelid tenderness, swelling and erythema
- May have foreign body sensation depending on location
- Visible, or palpable, well-defined subcutaneous nodule in the eyelid
- May also note “pointing” of mucopurulent material
- Associated blepharitis or acne rosacea
Hordeolum
Symptoms and physical exam findings:
- Hard and nontender nodule on the eyelid, usually farther back than a hordeolum
- Edema on the upper or lower lid
- Erythema and edema of the adjacent conjunctiva
Chalazion
Risk factors of hordeolums and chalazions
1) Touch eyes with unwashed hands
2) Insert contact lenses without thoroughly disinfecting them
3) Leave makeup overnight
4) Used or expired cosmetics
5) Have blepharitis
Hordeolum or chalazion treatment
Warm compresses 15 minutes four times a day
Massage infected eyelid after warm compress to aid in drainage
Discontinue eye make up
When would you consider antibiotic ointment for a hordeolum or chalazion?
- Concern the patient will develop periorbital cellulitis
- 48 hours of warm compresses does not clear it up
Most common cause of viral conjunctivitis
Adenovirus
Nongonococcal bacterial conjunctivitis is caused by:
- Staphylococcus aureus
- Staphylococcus epidermis
- Haemophilus influenzae (associated with otitis media)
- Streptococcus pneumoniae
- Moraxella catarrhalis
Ophthalmologic emergency because corneal involvement may rapidly lead to perforation
Gonococcal conjunctivitis
Sx: Itchy, burning, tearing, gritty or foreign body sensation; History of URI
Signs: Water discharge, red and edematous eyelids, pinpoint subconjunctival hemorrhages, punctate keratopathy (epithelial erosion in severe cases), membrane/pseudo membrane (severe cases)
Viral conjunctivitis
Sx: 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
Sx: Redness, foreign body sensation, discharge, itching is much less prominent. Often complains of having to wipe purulent exudate in morning.
Signs: Purulent discharge of mild to moderate degree.
Preauricular node typically absent
Bacterial Conjunctivitis (nongonococcal)
Signs: Severe purulent discharge, hyperacute onset (12-24 hrs)
Preauricular adenopathy, eyelid swelling
Gonococcal conjunctivitis
Treatment for viral conjunctivitis
Mild: Artificial tears
Moderate: Epinastine (Ophthalmic antihistamine)
Treatment for a patient with viral conjunctivitis that has photophobia
Consult Ophthalmology:
Opthalmic Corticosteroids
Treatment for allergic conjunctivitis
Mild: Artificial tears
Moderate: Antihistamine (Topical are more effective than oral)
Treatment for:
Bacterial conjunctivitis for non-contact lens wearers (non-gonococcal)
Erythromycin Opthalmic ointment
-0.5 inch ointment inside lower lid QID for 5-7 days
Trimethropim/polymyxin B
Treatment for:
Bacterial conjunctivitis for contact lens wearers (non-gonococcal)
Fluroquinolones:
-Ciprofloxacin
Added to the antibiotic treatment if associated dacryocystitis (tear duct infection) is present
Amoxicillin/Clavulanate
Cephalexin
Treatment for:
Gonococcal conjunctivitis
Ceftriaxone 1g IM & Azithromycin 1g PO
Treatment for:
Gonococcal conjunctivitis for patients with penicillin/cephalosporin allergy
Gentamicin 240mg IM x1 dose & Azithromycin 2g PO x 1 dose
Causes of a conjunctival hemorrhage
1) Valsava
2) Traumatic
3) HTN and Diabetes
4) Bleeding disorder
5) Antiplatelet/anticoagulant medications
6) Topical steroid therapy
7) Hemorrhage due to orbital mass
8) Idiopathic
Sx: Red eye, foreign body sensation, usually asymptomatic unless there is associated chemosis
Signs: Blood underneath the conjunctiva, often in one sector of the eye, entire view of the sclera can be obstructed by blood
Conjunctival hemorrhage
Treatment for:
Conjunctival hemorrhage
None required (clears up usually in 2-3 weeks)
Artificial tear drops QID for irritation
Degeneration of fibrovascular, deep conjunctival layers resulting in vascular tissue proliferation, which extended onto the cornea
Usually related to sunlight exposure, chronic inflammation and oxidative stress
Pterygium
Sx: 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.
Pterygia
Pterygium treatment
Protect eyes from sun, dust, wind
Artificial tears
Treatment for:
Moderate to severe pterygium
Opthalmic corticosteroids
NSAID drops
Pterygium surgical removal is indicated when:
Interfering with vision and excessive irritation
Pterygium asymptomatic patients should be checked every:
1 to 2 years
Initially pterygiums should be measured:
Initially, then every 3-12 months
Follow-up:
Corneal foreign body noncontact lens wearer
F/U in 24 hours (or sooner if symptoms worsen)
-Revisit every 3-5 days until healed
Follow up:
Corneal foreign body contact lens wearer
Close follow-up until epithelial defect resolves
May resume contact lens wear after the eye feels normal for 1 week
Corneal epithelium regenerates quickly, healing time for abrasions is usually within:
24-48 hours
Symptoms and physical exam:
- Severe pain, tearing and photophobia
- History of trauma to the eye, commonly a foreign object
Corneal abrasion
Studies:
Corneal abrasion
Slit lamp to identify dimensions of abrasion
Treatment:
Non-contact lens wearer corneal abrasion
Antibiotic ointment (erythromycin, bacitracin)
Antibiotic drops (polymyxin B/Trimethoprim or a fluoroquinolone)
Treatment:
Contact lens wearer, corneal abrasion
Fluoroquinolone drops
Infectious keratitis, Serious infection involving multiple layers of the cornea
Corneal ulcer
Biggest risk factor for corneal ulcer
Improper contact lens use
Corneal Ulcer, Bacteria causative organisms
Pseudomonas aeruginosa
Streptococcus pneumonia
Staphylococcus species
Moraxella species
Corneal ulcer, causative viruses
Herpes simplex
Varicella zoster
Corneal ulcer, causative fungi agents
Candida
Aspergillus
Penicillium
Cephalosporin
Symptoms and physical exam:
- Erythema and edema of lids and conjunctivae; discharge; ocular pain or foreign body sensation; photophobia; blurred vision
- Depending on location, may decrease visual acuity
- Cornea reveals a round or irregular opacity or infiltrate (classically in the center)
Corneal ulcer
Treatment for:
Corneal ulcer
- Topical antibiotics (Ciprofloxacin, Ofloxacin, Vigomox)
- Refer to ophthalmologist within 12-24 hours
- DO NOT patch the eye, risk of pseudomonas infection.
Anterior Cavity:
What continually filters out of blood capillaries in the ciliary processes of the ciliary body and enters the posterior chamber.
Then flows forward between the iris and lens through the pupil and into the anterior chamber
Aqueous Humor
Where does aqueous humor drain into from the anterior chamber?
Scleral venous sinus (canal of Schlemm) then into the blood
How often is aqueous humor completely replaced?
Every 90 minutes
Accumulation of red blood cells within the anterior chamber, between the cornea and the iris
Blood may cover part or all of the iris and pupil
Hyphema
Most common risk factors for hyphema
Trauma or recent ocular surgeries
Etiologies of hyphema
1) Iris neovascularization
2) Herpes simplex or zoster iridocyclitis
3) Blood dyscrasia or clotting disorder (Hemophilia)
4) Anticoagulation
5) Fuchs heterochronic iridocyclitis
6) Intraocular tumor
Symptoms and physical exam findings:
-Blood/Clot in the anterior chamber, visible without slit lamp May be black or red -Pain -Photophobia -Blurred, clouded or blocked vision -History of blunt trauma
Hyphema
Labs/studies:
Hyphema
Complete eye scan
Consider CT to scan the orbits and brain
Treatment for:
Hyphema
Immediate ophthalmology or optometry consult
- Elevate head
- Place rigid shield over eye
- Avoid aspirin and NSAIDS
- Mild analgesics, Tylenol only
Hyphema patient:
After initial follow up period, patient may need to be on what medication?
Long-acting cycloplegic agent (atropine 1% BID)
Middle layer of the eyeball
Vascular tunic (Uvea)
Vascular tunic (uvea) is composed of what three parts?
1) Choroid
2) Ciliary body
3) Iris
Inflammation of the anterior segment of the uveal tract. Usually immunologic but possibly infective or neoplastic.
Classified as acute or chronic and as Non granulomatous or granulomatous
Iritis/Uveitis
Infectious etiologies:
Iritis/Uveitis
Herpes virus
Cytomegalovirus
Toxoplasmosis
Syphilis
West Nile Virus
Systemic inflammatory disease that cause iritis/uveitis
Spondylarthritis
Sarcoidosis
SLE
Mutiple sclerosis
Uveitis
Sx: Pain, redness, photophobia and visual loss
Acute nongranulomatous anterior uveitis
Uveitis:
Blurred vision in a mildly inflamed eye
Granulomatous anterior uveitis
Signs:
- Inflammatory cells flare within the aqueous (WBC released from vessels appear as snowflakes)
- Blurred vision in a mildly painful mildly inflamed eye
- Hypopyon (WBC pool) and fibrin within anterior chamber
- Keratic precipitates (KPs) (cells seen on the corneal endothelium)
Uveitis
Labs/Studies:
Uveitis
Complete eye exam
Labs if required
Treatment for:
Uveitis
Only to be initiated by or under direction of Ophthalmologist:
- Cycloplegic (for pain and inflammation)
- Topical steroid
Infection that affects the eye socket. This can cause the eye or eyelid to swell, keeping the eye from moving properly
Typically arise from paranasal sinuses (especially ethmoiditis)
Orbital Cellulitis
Orbital cellulitis:
Adult and children organisms
Adult: Staph, strep, Bacteroides species
Children: Haemophilus influenzae
Sx: Red eye, pain with eye movement, blurred vision, double vision, eyelid and /or periorbital swelling, nasal congestion/discharge, sinus headache/pressure/congestion, tooth pain, orbital pain, or hypesthesia
CT scan shows adjacent sinusitis
Orbital cellulitis
Labs/studies:
Orbital cellulitis
- History
- Complete eye exam
- CT of orbits and sinuses
- CBC, blood cultures, gram strain and culture of drainage
- Explore and debride of any wounds
Treatment for:
Orbital cellulitis
IV Antibiotics
Amoxicillin/Clavulanate 875mg PO BID
or
Ceftriaxone 2g IM
Admit to a hospital.
Surgery may be required to drain sinuses
Orbital cellulitis:
If orbit is tight, an optic neuropathy is present, or IOP is severely elevated, what must immediately be done?
Canthotomy
Follow up for:
Orbital cellulitis
Reevaluate at least twice a day in the hospital for 48 hours
Clinical improvement may take 24-36 hours
Fracture:
Affects the bony outer edges of the orbit
A lot of force (MVA’s)
Orbital rim fracture
Fracture:
Affects the floor or inner wall of the orbit
Blowout fracture
Fracture:
Trauma to the orbital rim pushes the bones back, causing the bones of the eye socket floor to buckle downward
Orbital floor fracture
Sx: Pain, Eyelid edema, Crepitus, Binocular diplopia, numbness of face, acute tearing
Signs: Restricted eye movement, Subcutaneous or conjunctival emphysema, decreased sensation, point tenderness, enophthalmos and hypoglobus
Orbital fracture
Labs/studies:
Orbital fracture
Complete eye exam
CT of the orbit, midface and brain
Treatment:
Orbital fracture (meds)
Amoxicillin/Clavulanate, Azithromycin, or Doxycycline
Nasal decongestants
Ice packs for 20 min every 1-2 hours for the first 24 hours
Oral corticosteroids
Surgical repair for orbital fracture:
Muscle entrapment with non-resolving bradycardia, heart block, nausea, vomiting, or syncope
Immediate repair within 24-48 hours
Surgical repair for orbital fracture:
- Persistent, symptomatic diplopia
- Large orbital floor fractures (>50%)
- Large combined medial wall and orbital floor fractures
- Complex trauma involving the orbital rim, midface, or skull base
- Naso ethmoidal complex fractures
- Superior or superomedial orbital rim fractures involving the frontal sinuses
Repair in 1 to 2 weeks
Surgical repair for orbital fractures:
Old fractures that have resulted in enophthalmos or hypoglobus
Delayed repair, at any later date
Vision returns to normal within 24 hours, usually within 1 hour
Transient visual loss
Sheet of neural tissue containing the rods and cones that lines the posterior two thirds of the inner surface of the glove, extending anteriorly as far as the ciliary body
Retina
What are the three types of retinal detachments?
Rhegmatogenous retinal detachment (most common)
Exudative/serous retinal detachment
Tractional retinal detachment
Retinal detachment:
Development of one or more peripheral retinal tears or holes, allows fluid to move in and separate the overlying retina. Usually spontaneous and occurs in persons over 50 years old.
Nearsightedness and cataract extraction are the two most common predisposing causes.
Rhegmatogenous Retinal Detachment
Retinal Detachment:
Results from accumulation of subretinal fluid, such as in neovascular age-related macular degeneration or secondary to choroidal tumor
Exudative/serous retinal detachment
Retinal detachment:
Occurs when there is preretinal fibrosis, such as in proliferative retinopathy due to diabetic retinopathy or retinal vein occlusion or as a complication of rhegmatogenous retinal detachment
Tractional Retinal Detachment
RD:
Sx: Flashes of light, floaters, a curtain or shadow moving over the field of vision, peripheral or central visual loss, or both
Signs: The retina is seen hanging in the vitreous like a gray cloud. One or more retinal tears or holes
Rhegmatogenous retinal detachment
RD:
Sx: Minimal to severe visual loss or a visual field defect; visual changes may vary with changes in head position
Signs: Retina is dome-shaped and the subretinal fluid shifts position with changes in posture
Exudative retinal detachment
RD:
Sx: Visual loss or visual field defect; may be asymptomatic
Signs: Retina appears concave with a smooth surface. Cellular and vitreous membranes exerting traction on the retina are present
Traction retinal detachment
Labs/Studies:
Retinal Detachment
Complete eye exam
Ocular ultrasonography
Ocular CT Scan
Treatment for:
Retinal detachment
Involves fovea: URGENT ocular surgery
Otherwise, within 7-10 days of onset
Ultraviolet keratopathy
Flash burns
-Sunlamp without eye protection, exposure to a welding arc, or exposure to the sun when skiing can cause:
Flash burns (ultraviolet)
Sx: 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.
Sx typically worsen 6-12 hours after the exposure. Usually bilateral.
Signs: Numerous, punctate lesions or microdots on the corneal surface (after staining)
Flash burns (ultraviolet)
Treatment of:
Flash burns (ultraviolet)
Pain treatment (mild oral opioids): Oxycodone 5mg Q 4-6 hours -NO topical anesthetics due to corneal toxicity
Antibiotic ointment (Erythromycin or Polytrim) 4-8 times a day
Recovery time of flash burns
24-48 hours
Risk factors for chemical burns
Improper use of PPE
Job exposure (Mechanics, CS Gas, Cement workers)
Symptoms and physical exam:
- Excessive tearing
- Conjunctivitis and injection
- Moderate to severe eye pain
- Blepharospasm
- Photophobia
- Severe alkali burns will have opacified cornea and scleral blanching
Chemical burns
Initial Management of:
Chemical burns
Immediate irrigation with normal saline or water
Goal of treatment is to reach neutral pH
Normalization takes 30-60 minutes
Can test pH of eye with litmus paper
Treatment of:
Chemical burns
Topical antibiotics (Erythromycin)
Follow-up in 24 hours
Consult ophthalmology/optometry if not resolved.
Outer layer, middle layer, inner layer of eye
Outer: Sclera (cornea anteriorly)
Middle: Uvea (Choroid posteriorly, ciliary body and iris anteriorly)
Inner layer: Retina
Sx: Pain, decreased vision, loss of fluid from eye
History of trauma, fall, or sharp object entering globe
Penetrating eye wound
Treatment of:
Penetrating wound to the eye
Protect eye with a shield or cup at all times
Elevate the head to 45 degrees
Systemic antibiotics within 6 hours of injury
-Cefazolin or Vancomycin PLUS Fluoroquinolone
Antiemetics (prevent Valsalva and possible expulsion of eye contents)
Virus that can affect the eyelids, conjunctiva, and cornea
Colonizes the trigeminal ganglion and leads to reoccurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency
Herpes simplex virus
Sx: History of oral or genital herpes infection, photophobia, pain, eye redness, decreased vision
Signs: Punctate keratitis. dendritic keratitis, geographic ulcer, corneal sensitivity may be decreased, eyelid may have herpetic vesicular eruptions, palpable preauricular node, conjunctiva can be injected
Herpetic lesion of the eye
Treatment of:
Herpetic lesion of the eye
Topical antivirals
-Ganciclovir, Trifluridine, Vidarabine
Oral antiviral agents
-Acyclovir, Valacyclovir, Famciclovir
DO NOT prescribe steroids
Follow up of:
Herpetic lesion of the eye
Any patients with herpes simples and acute red eye should be referred urgently to an ophthalmologist
Reexamined in 2-7 days to evaluate treatment response, then every 1 to 2 weeks
