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HEENT Flashcards

1
Q

Common complaints of blepharitis

A 
Burning
Watering
FB sensation
Crusting and matting of the lashes
Red lids
Sometimes red eyes
Sometimes pain
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2
Q

What are the two categories of anterior blepharitis?

A

Staphylococcal

Seborrheic- chronic scaling of the eye that leads to irritation

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3
Q

DDx of blepharitis

A 
Bacterial or viral conjunctivitis
Contact lens complications
Rosacea
Allergic or contact dermatitis
Preseptal cellulitis
Chalazion
Hordeolum
Dry eye syndrome
Basal cell carcinoma, eyelid
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4
Q

Dx and tx of blepharitis

A

First, apply a warm compress to the eyelid to clean the eye, and do this repeatedly
Abx ointment
-Erythromycin TID x7 days
-Sulfacetamide ointment q4hrs x7 days

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5
Q

Which form of conjunctivitis is more common?

A

Viral > bacterial

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6
Q

What are the four clinical factors associated with viral conjunctivitis

A

Age 6 yrs or older
Presentation in April thru November
No d/c or watery d/c
No glued eye in the morning

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7
Q

Hx of bacterial conjunctivitis

A

Pts complain of eyelids sticking together
Itching, burning or gritty FB sensation
Family members may be infected as well
Acute onset, minimal pain
Staphylococcal and streptococcal species are most common

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8
Q

Presentation of allergic conjunctivitis

A

Very similar in appearance to viral conjunctivitis, but accompanied by nasal congestion, sneezing, eyelid swelling and sensitivity to light. Both eyes are affected. Not contagious

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9
Q

PE of conjunctivitis

A

Erythematous- conjunctiva
May see pus drainage across the eye
Photophobia is minimal
Hx of recent URI is typically associated with a viral cause

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10
Q

Dx of conjunctivitis

A

Do visual acuity and consider fluorescein stain if corneal abrasion or ulceration suspected, or risk of FB
Still need to check for FB
Be sure no risk of chlamydial conjunctivitis
If neonate- immediate referral- if suspect N. gonorrhea or chlamydial infection

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11
Q

Tx for conjunctivitis

A

Viral- supportive care with artificial tears prn, cold compresses
Bacterial
-Polytrim (trimethoprim/sulfa): 1 drop q3h while awake for 5-7 days
-Gentamicin: 2 drops q4h while awake for 5-7 days
-Ciloxan (cipro): 2 drops q4h while awake for 5 days
-Ocuflox (ofloxacin): 2 drops q4-6h for 5 days
Choice depends on cost to pt and allergies. Ciloxan and Ocuflox better for contact lens associated conjunctivitis

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12
Q

Causes of corneal abrasion

A

Dry eye
FB injury
contact lens wear
Traumatic abrasion- fingernails, animal paws, pieces of paper or cardboard, makeup applicators, hand tools, branches or leaves

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13
Q

Pathophys of corneal abrasion

A

Occurs because of a disruption in the corneal epithelium or a scrape to the corneal surface

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14
Q

Procedure of fluorescein stain

A

Use anesthetic drops before stain procedure

Burns for 20-30 seconds

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15
Q

PE findings of corneal abrasion

A

Dx can be confirmed with slit lamp exam and fluorescein installation
Pt complains of eye pain and inability to open eye d/t FB sensation
Often pts are too uncomfortable to work, and pain may interfere with sleep
Photophobia may be present
Excessive tearing

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16
Q

What to do for a PE to look for corneal abrasion

A

Examine eye with lids retracted in order to fully look at the cornea as well as conjunctiva
Assess visual acuity
Apply a topical anesthetic to do a full exam

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17
Q

DDx of corneal abrasion

A

Uveitis
Keratitis
Glaucoma

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18
Q

Prognosis of corneal abrasion

A

Prognosis usually excellent with full recovery of vision and is expected with minor abrasion within 24-48 hrs
Extensive or deep abrasions may require a week to heal
If abrasion is in central line of vision, monitor with ophthalmology
Bacterial keratitis from overnight use of contact lens can become infected with P. aeruginosa, pneumococcus, moraxella and staphylococci
-Treat with moxifloxacin 1 drop TID for one week

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19
Q

Tx of corneal abrasion

A

Traditionally, topical abx are used for prophylaxis even in noninfected corneal abrasions not related to contact lenses, but this practice has been called into question. Gentamicin or Tobramycin have been used as well
Treat pain with topical NSAID drops. Ketolorac- 1 drop q6h prn for pain
Ice packs for 24 hrs prn, then warm compresses

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20
Q

Health maintenance- corneal abrasion

A

Persons who work in high-risk occupations such as auto mechanics, metalworkers, or miners should wear protective eyewear
Contact sports such as hockey, racquetball, pts who farm and ski should also wear protective eyewear
Pts with large abrasions should be reexamined freq by ophthalmologist until healing occurs

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21
Q

Pt complaints with FB

A 
Pain (relieved sig with topical anesthesia)
FB sensation
Photophobia
Tearing
Red eye
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22
Q

What is your first step in trying to remove a FB from an eye?

A

Only try touching with Q-tip if you think you can remove the FB

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23
Q

What’s your second option for FB removal in the eye if the first one doesn’t work?

A

Needle

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24
Q

What is applied to the before and after FB from eye removal?

A 
Antibiotic
Polytrim
Ocuflox
Tobrex
Ciloxan
Bacitracin ointment
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25
What to do with rust rings that remain in the cornea after removal of a metallic FB
May require removal with a rust ring drill | F/u every 2 days until the epithelial defect is well-healed
26
What should be updated after FB removal in the eye
Tetanus booster if not immunized in past 7 years
27
Background information in primary open angle glaucoma
Multifactorial optic neuropathy Chronic and progressive Acquired loss of optic nerve fibers This develops into the presence of open anterior chamber angles, visual field abnormalities, and IOP that is too high Silent onset with no sx or complaints until late
28
What to pay attention to in primary open angle glaucoma
``` Past ocular hx Previous surgery Ocular or head trauma PMH (CAD, DM, HTN) Current meds RFs ```
29
Who is at the highest risk for primary open angle glaucoma?
Advise screening by eye specialist for AAs and elderly
30
What does ocular hx usually include for primary open angle glaucoma?
``` Hx of eye pain or redness Multicolored halos HA Previous eye dz Uveitis Ask about FHx ```
31
Diagnostic testing for primary open angle glaucoma
Lab tests to r/o other causes of optic neuropathy in pts -CBC -ESR -Serology for syphilis Golman tonometry Gonioscopy: microscope used in conjunction with a slit lamp that measures the anatomical angle of the eye's cornea and slit lamp -These tests would be done by an eye specialist
32
PE findings of primary open angle glaucoma
If IOP rises above 21 mm Hg, the % of pts developing vision loss increases rapidly Optic disc cupping and nerve fiber layer losses of up to 40% have been shown to occur before actual visual field loss has been detected
33
Pathophys of primary open angle glaucoma
The aqueous humor passes through the pupil and drains through a special membrane called the trabecular meshwork In open angle glaucoma, the flow of this liquid becomes impaired Too much abnormal pressure damages the optic nerve, which can eventually lead to blindness
34
General approach to primary open angle glaucoma tx
Current medical therapy for primary open-angle glaucoma is limited toward lowering IOP If one med is inadequate in reaching the target pressure, a second med should be chosen that has a different MOA so that the two-drug therapy will have an additive effect
35
Tx for primary open angle glaucoma
Beta-adrenergic blockers: Timoptic, Betoptic-S, Betagan Adrenergic agonists: Alphagon Carbonic anhydrase inhibitors- Truspot, Azopt Antiglaucoma combos- Tomoptic/Alphagon Prostaglandin analogs: Xalatan, Lumigan Miotic agents: Pilocar, Ocusert
36
Acute angle closure glaucoma
A condition in which the iris is apposed to the trabecular meshwork at the angle of the anterior chamber of the eye This blocks the outflow of aqueous from the eye which causes a rapid rise in IOP
37
Hx/PE of acute angle closure glaucoma
Sudden eye pain, blurred vision and N/V Halos around lights <10% of glaucoma in the US are d/t acute angle closure glaucoma
38
PE of acute angle closure glaucoma
Examine with ophthalmoscope, tonometry, and gonioscopy Tonometry may show as high as 40-80 mm Hg Ophthalmoscopy may reveal a swollen optic disc Gray atrophy of the stroma of the iris provides further evidence of a prior attack
39
Tx of acute angle closure glaucoma
Definitive tx is laser iridotomy or surgical iridectomy Intended to prepare the pt for laser iridotomy Cornea should be treated with osmotic agents, pupil constricted, and IOP lowered to prevent acute damage to the optic nerve
40
What meds lower IOP in acute angle-closure glaucoma?
Acetazolamide given as a state dose of 500 mg IV followed by 500 mg PO. A dose of a topical BB (i.e., carteolol, timolol) will also aid in lowering IOP
41
What does laser iridotomy do?
Creates an opening in the iris through which aqueous humor trapped in the posterior chamber can reach the anterior chamber and the trabecular meshwork
42
Pathology of exudative macular degeneration
Pathologic choroidal neovascular membranes (CNMV) develop under the retina. The CNMV can leak fluid and blood and if left untreated, cause a centrally blinding disciform scar
43
What can contribute to the worsening of age-related
Smoking HTN Obesity Dietary fat intake
44
Hx of age-related macular degeneration
Painless, progressive blurring of the central visual acuity, which can be acute or insidious in onset This leads to a central scotoma in which the pt's visual acuity falls below reading level and legal driving level Peripheral visual acuity is usually retained
45
Hard exudates
Lipid deposits which are produced from lipoprotein leakage from blood vessels. When hard exudates are present, one should think of a vasculopathy, seen usually in conditions with chronic vascular leakage
46
Drusen
Waste material and composed of proteins, lipids and many other trace elements such as zinc
47
PE findings of exudative AMD
``` Subretinal fluid Pigment epithelial detachments Subretinal hemorrhages Drusen present Choroid neovascular tissue may be seen as yellow-green subretinal discoloration ```
48
Tx of exudative AMD
Until the start of anti-VEGF agents, ophthalmologists used thermal laser destruction or photodynamic therapy of the choroid neovascular tissue as the primary tx Now, two new drugs: FDA approval of Ranibizumab, but it's still expensive, and bevacizumab, which is still considered off-label Aflibercept is indicated for exudative to bind and prevent activation of vascular endothelial growth factors (VEGF-A)
49
Non-exudative macular degeneration
Characterized by the presence of atrophy that can be associated with severe central visual field loss Peripheral vision is preserved 90% of pts with ARMD have dry ARMD, which is a slower progression Usually affects those >50 yo
50
Tx/followup of non-exudative macular degeneration
10-20% of those with dry ARMD can progress to wet ARMD One trial showed favorable results when treating dry ARMD with large doses of antioxidant multivitamin therapy (vit A, C, E, zinc, and copper)
51
F/u for macular degeneration
``` Support groups and counseling Low-vision aids Handheld or stand magnifiers for reading Talking watches Computers that use large type face ```
52
When does optic neuritis typically first occur?
In young adulthood and is commonly the first manifestation of MS, but ON can occur in isolation Occasionally, ON can result from an infectious process involving the orbits or paranasal sinuses
53
Optic neuritis
A demyelinating inflammation of the optic nerve that often occurs in association with MS and neuromyelitis optica (NMO)
54
PE findings of optic neuritis
Rapidly developing impairment of vision in 1 eye, or less commonly, both eyes Retro-orbital or ocular pain, exacerbated by eye movement Pain may precede vision loss Decreased pupilary light reaction in the affected eye Marcus Gunn pupil Abnl color vision Central scotoma with visual field testing Papillitis (swollen optic disc) in 33% of pts with ON With time- the optic nerve may become pale
55
Lab diagnosis for optic neuritis
Do blood tests to exclude causes of optic neuropathy other than optic neuritis -ESR -Thyroid function testing -ANA -Angiotensin-converting enzyme MRI is highly sensitive for and specific in the assessment of inflammatory changes in the optic nerves
56
DDx for optic neuritis
``` Acute angle closure glaucoma Interstitial keratitis Optic nerve sheath meningioma Anterior ischemic optic neuropathy Compressive neuropathy Sarcoidosis Sudden visual loss Thyroid opathlmopathy Toxic/nutritional optic neuropathy ```
57
Prognosis for optic neuritis
Visual function begins to improve 1 wk to several weeks after onset, even without any tx Permanent residual deficits in color vision and contrast and brightness sensitivity are common
58
Tx for optic neuritis
IV steroids to speed the rate of recovery, BUT do little to affect ultimate visual acuity Treat pain with pain meds Determine with workup whether pt has brain lesions on MRI that indicate high risk for MS. Immunomodulators can improve risk of reoccurrence of optic neuritis for pts with MS
59
Causes of orbital cellulitis
Can be an extension of an infection from the paranasal sinuses, eyelids, dental infections Direct inoculation of the orbit from trauma or surgery Hematogenous spread from bacteremia
60
What are 90% of cases of orbital cellulitis due to?
Ethmoid sinusitis Aerobic bacteria are most frequently responsible in ethmoid sinusitis Anaerobic bacteria from maxillary sinus- bacteroides (from mouth) Eyelid infections can cause orbital cellulitis from S. aureus, S. pneumoniae, S. pyogenes
61
Hx/PE of orbital cellulitis
``` Fever, malaise Hx of recent sinusitis Recent dental work Recent infection/sepsis Swollen conjunctiva Decreased vision Pain on eye movement Lid edema ```
62
Labs/dx of orbital cellulitis
CBC-WBC >15,000 with a shift to the left BCx should be drawn prior to giving abx Culture should be ordered of purulent drainage from the eye or from the orbital abscess High-resolution CT scan with contrast infusion MRI may be helpful in defining orbital abscesses
63
Tx of orbital cellulitis
Pt should be promptly hospitalize for tx until the pt is afebrile and has clearly improved Consider orbital surgery in every case of subperiosteal or intraorbital abscess formation Pt needs to be monitored daily and treated with IV abx started and continued for 1-2 wks then oral abx for 2-3 wks -Nafcillin (staph and strep coverage) -Cefotaxime (H. influenzae, Moraxella) -Vanc, clinda, or TMP-SMX (for MRSA) -Metro (for anaerobes)
64
What is different in papilledema in contrast to other causes of optic disc swelling?
Vision is well preserved with acute papilledema
65
Onset of papilledema
Bilateral and may develop over hours to weeks
66
Cause of papilledema
Rare brain tumor Brain infection: brain abscess, meningitis, encephalitis Severe HTN Pseudotumor cerebri or benign intracranial HTN Optic nerve glioma (unilateral papilledema) Meds (minocycline, lithium, corticosteroid withdrawal) Cerebral edema
67
PE findings of papilledema
Papilledema on retinal exam Peripheral vision affected in some pts Wider blind spot near the nose Afferent pupil defect- pupil is slow to react to light Sixth nerve palsy: double vision and eyes not tracking well together Small hemorrhages on the nerve fiber layer detected with the green light on ophthalmoscope
68
Signs/hx of papilledema
HA Visual changes- vision turns gray briefly or described as if a "veil has fallen over the eyes" with position changes Presents as a bilateral phenomenon and may develop over hrs to wks Pulsatile tinnitus Neck and back pain Nausea with vomiting
69
Labs/rads of papilledema
``` Brain CT or brain MRI CBC Blood sugar ESR RPR ```
70
F/u diagnostic of papilledema
LP should be performed following nl MRI to assess opening pressure of the CSF and to obtain CSF for analysis to r/o neoplastic and infectious etiologies. May provide therapeutic benefit
71
Tx of papilledema
Tailored to the underlying pathologic process Diuretics: Diamox may be useful in selected cases, esp in cases of idiopathic intracranial HTN Corticosteroids may be effective in cases of inflammatory disorders

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