HEENT Flashcards
Diagnostics for Eye Problems
History: Thorough evaluation of the problem and past medical history. These helps identify any disease that may have visual problems associated with it.
Visual Acuity and ocular exam: Every Visit!
Culture and sensitivity if drainage
Eye Problems: When to Make Referral?
• Visual loss
• Moderate to severe pain
• Chronic eye redness
• Corneal involvement
• Unresponsive to conventional treatment after a month
Blepharitis: Nonulcerative
Form associated with seborrhea
• Occasionally seen in those with Trisomy 21 Down’s syndrome
• Tends to affect people with psoriasis, seborrhea, eczema, allergies, and lice infestations
• Contributing factors: exposure to chemical or environmental irritants, use of eye makeup and contact lenses
Blepharitis: Ulcerative
• Involves the lash follicle and the meibomian glands of the eyelid
• May be pustules at the base of the hair follicles that may crust and bleed
• Lashes become thin and break easily
Hordeolum (stye)
an acutely presenting, erythematous, tender (painful) lump within the eyelid
• External hordeolum: inflammation/infection of the eyelid margin affecting the hair follicles of the eyelashes
• Internal hordeolum: inflammation/infection of the meibomian glands
Chalazion
• A granulomatous infection of a meibomian gland, presenting in the form of painless swelling on the eyelid
• Initially may be tender and erythematous before evolving into a nontender lump
• Blepharitis is frequently associated with chalazia
Treatment for Blepharitis, Hordeolum, Chalazion
• Warm Compresses (teach technique)
• Gentle massage for hordeolum/chalazion
• Consider cephalexin for recurrent hordeolum
• Bacitracin or erythromycin 0.5% ointment blepharitis
• Erythromycin or Ciprofloxin for hordeolum
• Alternative: Sulfacetamide
• Oral doxycycline for sever blepharitis
Dry Eye
• Decreased tear production
• May be acquired or congenital
• Acquired disorders may be systemic
• Sjögren’s syndrome (an autoimmune disease, dry mouth and dry eye are usually first symptoms.)
• May reflect a more local infectious process, as in some forms of conjunctivitis
• May be related to trauma, such as in facial nerve (cranial nerve [CN] VII) palsy
Dry Eye: Causes
• Certain medications: anticholinergic agents, beta-adrenergic blockers, and antihistamines
• Aging, especially women during menopause
• May also have a diminished blink rate due to working at a computer or a microscope
Dry Eye: Subjective and Objective Data
• C/O “a feeling of sand in the eyes”. Eyes feel hot, irritated and gritty
• Objective: May have no physical findings or may have a finding that causes the dry eye
Dry Eye: Treatment
Four levels of treatment depending on severity
• Level 1: education, environmental, and dietary modifications
• Elimination of offending systemic medications
• Use of artificial tear substitutes, lubricants, gels, and ointments
• Possibly eyelid therapy (see link)
• Level 2: treatment (if prior level not effective)
• Ocular lubricants, nonpreserved artificial tear substitutes, and anti-inflammatory agents such as topical cyclosporine A,
topical corticosteroids, or topical/systemic omega-3 fatty acids
• Cyclosporine ophthalmic emulsion (RESTASIS®) for chronic dry eye
Dry Eye: Treatment (con’t)
• Level 3: treatment (when levels 1 and 2 fail)
• Autologous serum, special contact lenses, and permanent punctual occlusion
• Level 4: treatment (when all else fails)
• Systemic anti-inflammatory agents
• Surgical interventions
• To correct abnormalities of the lid
• Grafting of mucous membranes
• Transplantation of a salivary gland duct
Red Eye/Conjunctivitis
Inflammation of the conjunctiva covering the front of the eye. (Itching, watering, and redness of the eye)
Causes:
• Infectious agents: bacterial, viral, or fungal (staph aureaus, strep pneumoniae, Haemophilus influenzae
• Toxicity (from an inciting agent of some sort)
• Allergy
• Foreign body
• See page 275 for different types of conjunctivitis
• Discharge: purulent, thick with crusted lids is bacterial:
• Stringy mucoid is allergic: viral has watery discharge
Red Eye/Conjunctivitis
Inflammation of the conjunctiva covering the front of the eye. (Itching, watering, and redness of the eye)
Causes:
• Infectious agents: bacterial, viral, or fungal (staph aureaus, strep pneumoniae, Haemophilus influenzae
• Toxicity (from an inciting agent of some sort)
• Allergy
• Foreign body
• Discharge: purulent, thick with crusted lids is bacterial:
• Stringy mucoid is allergic: viral has watery discharge
Conjunctivitis: Diagnostic Tests
•USE GLOVES when examining eyes
•Check visual acuity first
•Dilated pupil exam for proptosis, optic nerve dysfunction, decreased visual acuity, diplopia, or anterior chamber inflammation (refer if this is needed)
•Using a blue penlight
• Fluorescein staining to rule out corneal involvement or keratitis
• Blue penlight illumination to see corneal scratches, corneal dendrites, or corneal ulceration
Red Eye/Conjunctivitis: Allergic
Allergic
• Mast Cell Stabilizers (cromolyn sodium ophthalmic solution, Lodaxamide 0.1%) and antihistamines (Azelastine, Olopatadine)
• With allergic Acular can be used which is a topical solution
• Antihistamines
Red Eye/Conjunctivitis: Bacterial/Chlamydial
• Antibiotics (ointments or solutions) Erythromycin, Trimethoprim/polymixin B sulphate
• Chlamydial: add oral antibiotics
• Worsening or no improvement with excessive purulent d/c
Red Eye/Conjunctivitis: Viral
• No antibiotics.
• Use antivirals, systemic or topical (Trifluridine)
• Oral trifluidine, valacyclovir)
Cataracts
An opacity of the natural lens of the eye
• 90 percent of cataracts are age-related
• Other causes of cataracts: congenital, metabolic, and traumatic etiologies
• Excessive exposure to sunlight (ultraviolet B rays) without protective lenses over time
• In the U.S., cataract surgery is the most common surgical procedure performed under Medicare
Cataracts: Subjective/Objective Findings
• Maybe visual changes
• Gradual, painless progressive loss of vision
• May be able to visualize an opacity
• Refer to an ophthalmologist
Glaucoma
• Progressive damage to the optic nerve, resulting in optic nerve atrophy and blindness, most typically associated with elevated intraocular pressure
• Primary or secondary (associated with an ocular condition or a systemic process)
• A congenital form
Glaucoma: Open-angle
• Physical diagnosis of chronic open-angle relies on evaluation of the angle by an ophthalmologist.
• Slow, PAINLESS bilateral peripheral vision loss and poor night vision), seeing halos around lights
• Treatment
• Pharmacologic
• Beta-blockers : timolol, betaxolol,
• Prostaglandin analogs: Bematoprost, latanoprost
• Laser or surgical treatment if not controlled by medication. Laser therapy is often effective only in the first several years
after surgery
Glaucoma: Angle-closure
(Closed-angle, or Narrow-angle glaucoma)
• ACUTE rapid onset with unilateral PAIN and pressure, blurred vision, seeing halos around lights, and photophobia, followed by loss of peripheral vision and then central vision loss. May have headache, n & v.
• Angle-closure glaucoma EMERGENCY
• Medications during the acute attack to lower intraocular pressure
• Acetazolamide (Diamox)
• IV mannitol with a topical miotic such as pilocarpine
• Laser iridotomy or peripheral iridectomy
• Bedrest should be maintained until the attack is broken
Diabetic Retinopathy
• Subjective: visual changes
• Objective: changes on funduscopic exam
• Microaneurysms, intraretinal hemorrhage, macular edema, and lipid deposits
• Nerve fiber layer infarctions (“cotton wool” spots), venous beading and dilation, edema, and, in some cases, extensive retinal hemorrhage
Diabetic Retinopathy (con’t)
• Ophthalmologist must do yearly retinal eye exam on all diabetics
• Visual changes as the disease progresses.
• Through ophthalmoscope microaneurysms, intraretinal hemorrhage, macular edema and lipid deposits
Diabetic Retinopathy: Management
•First goal for patients at risk for microvascular complications, including diabetic retinopathy, is prevention
•The only pharmacologic agent found to slow the progression of diabetic retinopathy is Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor
•Laser surgery for patients with proliferative diabetic retinopathy or clinically significant macular edema
Macular Degeneration
•Leading cause of blindness in patients older than 60
•“Dry”: a slow progressive atrophy and degeneration of the retina
•“Wet”: age-related; new blood vessels develop under the retina in the macula, causing a sudden distortion or loss of central vision
• Refer immediately to an ophthalmologist
• Objective: If vision is less than 20/20, do “pinhole” test
• Vision that corrects with the pinhole test implies an uncorrected refractive error
• Possible unreactive pupil if acute angle-closure glaucoma
• Funduscopic exam is normal in patients with refractive errors
• Yellow round spots (drusen): indicative of early macular degeneration
• Clumps of pigment irregularly interspersed with depigmented areas of atrophy in the macula: later phase of the disorder
Pinhole Test
A quick way to differentiate between the two is by performing the “Pinhole Test”.
• Take a piece of card and perforate it with a pen tip, creating a pinhole about 2mm in diameter.
• Checking one eye at a time, look at an object that appears slightly blurred.
• Then look at the same object through the pinhole. If it appears sharper through the pinhole, you probably have a focusing problem.
• If it does not appear sharper, or looks even more blurred, you should refer this patient to an ophthalmologist immediately
Macular Degeneration: Management
•No proven strategies for preventing AMD
•No treatments for the initial stage of early disease
•In the intermediate stage of the disease, high-dose antioxidant vitamins and zinc supplements possibly help
•Thermal laser photocoagulation for certain forms of wet AMD but of limited value for lesions in the central macula area
