eyes Flashcards
ophthalmic exam
-Should be a part of every well-child assessment
-Poor vision, misalignment of eyes, failed vision screening, eyelid malposition, abnormal pupil reactivity/shape, asymmetric/abnormal red reflex > ophthalmology referral
-Birth – 3 years
-History, vision assessment, inspection of eyelids/eyes, pupil examination, ocular motility, red reflex check; instrument-based screening may be attempted
-Children > 3 years
-Same as above plus visual acuity testing with eye charts and/or instrument-based screening
visual acuity (VA)
-Sleeping newborn: Presence of lid squeezing to bright light
-6 weeks of age: Eye-to-eye contact with slow, following movements
-3 months of age: Fixing/following movements with objects at distance (2-3 feet)
-6 months of age: Interest in movement across the room
-> 3 years: Eye charts
-Both eyes, then monocularly
-Passing = correctly answering majority of optotypes present on “critical line”
-Versus “threshold testing”
-Instrument-based screening: (dont need to know)
-Photo screeners - Screens for amblyogenic factors (strabismus, media opacities, eyelid ptosis, and refractive errors)
-Autorefractors- Above screening plus identification of refractive errors
red reflex test
-Ophthalmoscope at arm’s length from child with child looking straight at light
-Reflex should be light-orange/yellow in color
external exam
Penlight/blue light, eyelid eversion, fluorescein staining
pupils
Evaluated for reaction to light, regularity of shape, equality of size, presence of afferent pupillary defect
alignment/motility
-Evaluated in 6 cardinal positions of gaze
-Alignment:
-Observation (educated guess) < corneal light reflex < cover testing
-Corneal light reflex: Shine penlight and check where light reflects off each cornea
-know which defect causes medial and lateral displacement
-Cover test: Child focuses on target, each eye alternatively covered
-Shift in an eye’s alignment as it assumes fixation on target is possible indication of misalignment
amblyopia
-Unilateral or bilateral reduction in VA resulting from abnormal or inadequate stimulation of the visual system during the critical early period of visual development (prior to 8 years of age)
-Unilateral: MC causes are strabismus (misalignment of eyes) and anisometropia (difference in refractive error between two eyes)
-Bilateral: MC from high refractive errors (high hyperopia, myopia, or astigmatism)
-May have decreased contrast sensitivity, stereoacuity (3D vision), and fixation stability
-Screening with VA in each eye: Difference of two lines or more on an acuity chart between two eyes
-Pre-verbal screening: Strabismus, media opacities, unequal red reflexes, and/or family history
amblyopia tx
-Continued until amblyopia resolves (at least until 8-9 years of age)
-Eradication of refractive errors (glasses), cataracts/opacities
-If ineffective x 3-4 months:
-Increase stimulation of the amblyopic eye by part-time occlusion (patching) of sound eye
-Or fogging sound eye with cycloplegic drops, lenses, and filters
-patch the good eye to make the other eye work harder
strabismus: esotropia (cross eye)
-Deviation of eyes toward the nose (may involve 1 or both eyes)
-May be primary infantile (prior to 1 year), acquired (2-5 years), associated with syndrome, sign of CNS disease (> 5 years)
-Corneal light reflex – not centered in one or both eyes
-Restricted eye movements in certain positions of gaze
-Face turned towards affected eye to maintain binocularity (away from paretic muscle)
-Cover testing – Refixation movements laterally
-Complications: Amblyopia and poor stereoacuity/depth perception
-Treatment:
-Primary esotropia: Surgical correction between 6 months and 2 years
-Acquired/accommodative esotropia: Glasses with or without bifocals
-Neurologic causes: Specialist evaluation
strabismus: exotropia (wall eyed)
-Deviation of eyes toward the ears
-Begins intermittently and occurs after 2 years of age
-All children with constant, congenital exotropia require CNS imaging
-Corneal light reflex – displaced nasally in deviated eye
-Cover testing – Refixation movements nasally
Complications: Amblyopia < poor stereoacuity/depth perception
-Treatment:
-Observation, glasses, surgery
blepharitis
-Inflammation of the eyelid margin
-Higher levels of S. aureus and S. epidermidis cultured in those with blepharokeratoconjunctivitis
-Clinical diagnosis: Lid margins with thickening, telangiectasia, stye, crusting, collarettes
-Treatment:
Lid scrubs with baby shampoo daily
chalazion
-Obstruction of the eyelid meibomian glands with resultant inflammation, fibrosis, and lipogranuloma formation
-Eyelid nodule of variable size, nontender, painless lesion
-Treatment:
-Warm compresses with microwavable heat packs/eye masks, lid massage to express glands
-If slow to resolve/recurrent, may require I&C
hordeolum (stye)
-Usually caused by staphylococcal infection from stasis of eyelid glands (no production of antiseptic secretions)
-External hordeolum (MC): Blockage of sebaceous (Zeis) and sweat (Moll) glands
-Painful, red, swollen bump that develops into a pustule
-Treatment:
-Spontaneous drainage without treatment
-Warm compresses, lid massage/scrubs
-Erythromycin ointment for lubrication
-PO antibiotics if pre-septal cellulitis suspected
-I&D performed by specialist
nasolacrimal duct obstruction
-Congenital NLDO occurs from mechanical obstruction located distally
-More commonly seen in individuals with craniofacial abnormalities or Down syndrome
-Unilateral, bilateral, and asymmetric in severity
-Tearing or mucoid discharge, especially in the morning (no sx throughout the day)!!!!!!
-Conjunctiva non-injected!!!!
-these 2 differentiate from pink eye
-Treatment:
-Duct massage (eyes down into nose)
-Topical antibiotics only for concurrent conjunctivitis or dacryocystitis
-Surgical tx (> 12 months): Probing of duct has 75-80% success rate
congenital dacryotocele
-Obstructions proximal and distal to nasolacrimal sac
-Presents within first 10 days of life
-Often unilateral, bluish mass lesion
-> 50% associated with intranasal cysts
-Nasal endoscopic examination should be performed in all cases
-Up to 85% develop infection (dacryocysitis), which may progress to orbital cellulitis/sepsis
-Treatment:
-Referral to ophthalmologist due to high risk of infection and possible need for surgical intervention
-Nasolacrimal probing and endoscopic marsupialization of the intranasal cyst are often required
acute dacryocystitis
-MCC by S. aureus, S. pneumoniae, and Haemophilus species
-Congenital NLDO is the MC risk factor in children
-Presents with inflammation, swelling, tenderness, and pain over the lacrimal sac
-Purulent discharge with sac pressure
-Complications include cellulitis/sepsis - want to get it before it reaches the brain
-Treatment:
-Systemic antibiotics
bacterial conjunctivitis
-MCC: Haemophilus species, S. pneumoniae, M. catarrhalis, and S. aureus
-Injected conjunctiva with significant discharge (purulent), typically unilateral > bilateral
-very contagious
-Treatment:
-Topical antibiotics: Polymyxin/trimethoprim sulfate or fluoroquinolones
-Systemic therapy for conjunctivitis associated with C. trachomatis, N. gonorrhoeae and N. meningitidis
not on test: meds
->12mo - start flouroquinolones -> covers pseudomonas especially for contact wearer
-<2mo - erythromycin
viral conjunctivitis
-MCC is adenovirus
-Injected conjunctiva with watery discharge, typically unilateral > bilateral
-Enlarged preauricular lymphadenopathy can be present
-red w/ no purulent discharge
-Treatment:
-Supportive
-Contagious 10-21 days from day of onset or as long as the eyes are red/tearing persists
-Herpes conjunctivitis: Topical versus PO antivirals
-when can you go back to school -> until you stop seeing discharge and at least 24hrs on the antibiotic
allergic conjunctivitis
-Itchy, watery eyes with injected conjunctiva, usually bilateral!
-Allergic shiners may be present -> nasal congestion causes venous congestion
-may be a hx of asthma or other allergies
-chemosis if severe- bubbling, swelling of conjunctiva
-Treatment:
-Topical solutions that combine antihistamine and mast cell stabilizer
-Systemic anti-histamines
-Limitation of exposure to allergen
-if not old enough for drops -> cool packs
keratitis/ulcer
-MC risk of infectious keratitis and corneal ulcer is contact lens! use (extended wear, overnight use, using tap water for cleaning)
-Ocular trauma is risk factor in < 3-year-olds
-do not miss this -> threatens vision
-Common pathogens: Pseudomonas aeruginosa, staphylococci, Acanthamoeba
-Acute pain, photophobia, conjunctival injection, and decreased VA
-Ulcer: White spot on cornea with overlying epithelial defect that stains with fluorescein (dendritic lesion with HSV)
-Treatment: Urgent specialist referral, ER
congenital cataracts
-May be unilateral or bilateral, isolated defects or accompanied by other ocular disorders/systemic disease
-amblyopia (lazy eye) risk if untreated
-Systemic: Down and Lowe syndromes and metabolic disorders, like galactosemia, Wilson disease, diabetes, and hypocalcemia
-Genetic: Autosomal dominant pattern of inheritance MC
-Treatment:
-Early identification to prevent amblyopia in children < 9 years of age
-Visually significant unilateral cataracts removed in infants < 6 weeks of age; bilateral cataracts < 8 weeks of age
-Contact lenses, glasses, bifocals, and artificial intraocular lenses for refractive errors after extraction
congenital glaucoma
-Primary signs are buphthalmos (enlargement of eye) and corneal clouding
-increase IOP -> eye compensates by enlarging
-Buphthalmos from elevated eye pressure > enlargement of globe due to low scleral rigidity of an infant eye
-Classic triad: Tearing, photophobia, and blepharospasm
-Treatment:
-Surgery often indicated for eye pressure control
retinoblastoma
-Tumor that arises from the retina due to mutation of both copies of the RB1 tumor suppressor gene
-From retina, can grow into vitreous, invade choroid and sclera into orbit, spread via optic nerve to CNS, metastasize hematogenously to brain
-MC presenting sign is leukocoria
-Strabismus, red eye, glaucoma, or pseudohypopyon (pus-like material in anterior chamber)
-Complications: Can be fatal, decreased vision depends on location of tumor, loss of vision/loss of eye
-Treatment:
-Staging examination under anesthesia and MRI
-CTX combined with focal treatment (laser, cryotherapy), radiotherapy, or surgery
pre-septal cellulitis
-Arises from a local exogenous source (abrasion/insect bite), from other infections (hordeolum, dacryocystitis), or result after hematogenous spread
-May progress to orbital cellulitis
-Red, swollen eyelids; pain; mild fever
-Vision, eye movements, and eye itself are normal!
-Treatment: PO antibiotics- amox clav (not on slide)
orbital cellulitis
-Serious complications: Subperiosteal abscess, meningitis, septicemia, and optic neuropathy
-MC arises from paranasal sinus infection
-Proptosis!, eye movement restriction, decreased vision
-Eye red and chemotic
-decrease visual acuity
-CT w/ contrast to establish extent of infection and evaluate for subperiosteal abscess
-Complications: Permanent vision loss (compressive optic neuropathy), corneal exposure/drying/scarring (proptosis), cavernous sinus thrombosis, intracranial extension, blindness, death
-Treatment:
-Initially, broad-spectrum antibiotics
-Surgical drainage of abscesses/sinuses
corneal abrasion
-Sudden, severe eye pain
-Decreased vision, tearing, conjunctival injection, poor cooperation with ocular exam
-Diagnosis: Fluorescein dye > illumination with Wood lamp
-Evert upper/lower eyelids to evaluate for FBs
-Treatment:
-Ophthalmic ointment, follow-up until healing complete
-preventative antibiotics
-refer to specialist 2-3 days later to make sure healing
-if the pt cant tolerate drops for staining -> empiric tx and f/u with specialist who can sedate and view the eye
foreign bodies
-Cause discomfort, tearing, and a red eye
-Pain with blinking suggests FB trapped under eyelid/corneal surface
-every time you blink can be scratching the cornea
-Treatment:
-Eyelid eversion!
-Removal with irrigation or cotton applicator
-Referral to specialist for failed attempt/corneal FB
-Topical antibiotics typically prescribed for several days following FB removal
-corneal FB / rust ring (photo) -> specialist
blunt ocular trauma
-Blunt trauma can lead to orbital fractures, retrobulbar hemorrhage can lead to orbital compartment syndrome > permanent vision loss
-Orbital blowout fracture: Diplopia, pain with eye movements, restriction of EOM
-CT scan! useful in dx extent of injuries
-Orbital compartment syndrome: Severe eyelid edema and proptosis (can progress to this)
-Neuroimaging will show retrobulbar hemorrhage and proptosis
-Treatment:
-OBF: Nonurgent repair to prevent enophthalmos, advise not to blow nose (orbital emphysema/proptosis)
-OCS: Emergent lateral eyelid canthotomy and cantholysis to decompress orbit
hyphema
-Blunt trauma to globe > bleeding into anterior chamber
Clinical Manifestations:
-Note height and color of hyphema
-Total hyphema (eight ball hyphema) > pupillary block and secondary angle closure
-Treatment: Eye shield, head elevation, go right to specialist
ocular burns
-May be thermal, chemical, or radiant
-Chemical: Cleaning supplies, spilled drain cleaner, and bleach; airbag deployment
-Radiant: UV light
-Pain, tearing, injection
-Eyelashes singed (thermal)
-Important to check pH after any suspected burn injury
-Complications:
-Alkalis tend to penetrate deeper than acids into ocular tissue and often cause severe injury (scarring and vision loss)
-Treatment:
-Copious irrigation and removal of precipitates
-pH normalized to 7
-Topical antibiotics, cycloplegic agent (reduces ciliary spasm > pain), topical steroids (by specialist)
abusive/non-accidental head trauma
-Shaking mechanism of injury, shaking with impact, or impact alone
-Retinal hemorrhages occur due to the vitreoretinal traction from accelerating-decelerating forces from shaking alone/combined with impact
-Irritability, changes in mental status, unexplained seizures
-Retinal hemorrhages in 75% of patients
-First 24-72 hours of incident (resolve rapidly)
-Lid ecchymosis, subconjunctival hemorrhage, hyphema, and optic nerve edema
-Complications: Amblyopia, strabismus, significant refractive error
-Treatment:
-Observation by specialist
-Surgical treatment for large hemorrhages
