HEENT-Eye Flashcards
External Eye Disorders
Blepharitis:
Lower eyelid with posterior lid inflammation and oily white plugs visible at the meibomian gland openings.
S/S- c/o irritation, burning, itching.
Eti-Staph infection, seborrhea, rosacea, or gland dysfunction.
TX-1st Treat with warm compress, baby shampoo.
2nd Tetracycline- topical or oral antibiotic
External Eye Disorders
Hordeolum:
Acute plugging of a meibomian gland
Eti- caused by Staph, may be internal or external.
S/S - tender, red bump seen in the medial lower lid.
TX- 1st WARM COMPRESS;
2ND- I/D if no resolution W/I 48 hrs;
3RD- ERYTHROMYCIN Topical abx q 3 hrs may be helpful.
External Eye Disorders
Entropion:
Ectropion:
Inward turning of the lower eyelid
S/S-eyelashes rubbing against the ocular surface.
ELDERLY (degeneration of lid fascia.)
TX-Botox injection or surgery to correct if corneal irritation occurs.
Outward turning of the lower eyelid with increased exposure of the ocular surface and sensitive mucous membrane of the inner lid. ELDERLY
S/S- normal tear drainage patterns.
TX- Surgery to correct if excessive tearing, exposure keratitis, cosmetic.
Conjunctivitis
Acute Most common eye disease
Acute, subacute, chronic
Serous, allergic, purulent, membranous
S/S-red eye, irritation, ocular discharge
Differential of conjunctivitis includes: Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis (chronic) Mechanical/Chemical conjunctivitis Other causes of red eye Scleritis/episcleritis, keratitis, etc
NEVER topical steroids
Bacterial Conjunctivitis
ETI- Staph aureus-ADULTS, KIDS-Strep. pneumo H. flu, M. cattarhalis in kids (contagious)
Gonorrhea and Chlamydia can cause hyperacute, severe
Sight threatening- 1st ED
GU symptoms
S/S- unilaterally* purulent throughout day ocular dc, erythema at lid margins and corners of eyes, Redness, can be bilateral
TX- Persistent PURULENT, ABX ocular ointment or drops QID x 7 days:1st Erythromycin
Sulfa
Polymixin/trimethoprim
Fluoroquinolones-Cipro in contact lens wearers. throw out. Risk Keratitis, corneal ulcers.
Work 24hr after ABX
Viral Conjunctivitis
ETI- adenovirus, viral syndrome: adenopathy, fever, pharyngitis, URI
S/S- direct contact, highly contagious, conjunctival injection and inflammation, Redness, WATERY ocular dc, morning crusting, irritation of the eyes, bilateral in 24-48 hours. NO pn or photophobia
TX - Artifcial tears, Baby shampoo
Self limiting course of illness, similar to cold
1-2wks
Allergic Conjunctivitis
ETI-IgE mediated response, degradation of mast cells, histamine, inflammatory mediators in the eye
S/S-Diffuse ocular injection, watery discharge, itching, bilateral, sneezing, rhinorrhea, recent exposure, etc
diffuse erythema, cobblestoning of conjunctiva,
PE-Nose, pale, ears, palate may also appear allergic
TX
1st Nasal steroids
artificial tears
or expensive effective ocular drops
- Antihistamine +Decongestant (Naphcon-A),
Mast cell stabilizer + antihistamine Patanol
Corneal Abrasion/Ulceration
foreign body, trauma, improper contact lens use
S/S- c/o severe eye pain, FB
PE-exclusion of open globe and hyphema, visual acuity, fluorescein exam, lid eversion
TX- topical ABX therapy, topical or oral pain medication
Most abrasions heal fully within 24 hours
NO STEROIDS- OMD if complicated
Pinguecula: Conjunctival nodule
yellowish nodule on conjunctiva usually occur nasally, in area of palpebral fissure; common over age 35, often bilateral.
S/S-May cause irritation,
TX- artificial tears, no treatment, no surgery
Episcleritis
*Topical steroids should ONLY be prescribed by an ophthalmologist and then with caution, and should not be used chronically due to increased risk of cataracts, glaucoma, and risk of secondary infection.
inflammation of the episclera
S/S- NO pain, VA intact, Acute onset of redness, irritation, watery, (1/2 bilateral, 30-40y 70% female), Lupus, RA, localized,
PE shows localized erythema, conjuctiva lower eyelide ninjection.
TX- Topicla NSAIDs, lubricants, Oral NSAIds
Intraocular inflammation ( tissue btwn cornea and sclerr, and sclera and choroid, iris, ciliary muscles)
ETI- immunologic
Anterior uveitis: inflammatory cells in aqueous
S/S-Acute pain, erythema, photophobia, visual loss
Granulomatous or nongranulomatous- Keratic precipitates are deposits of leukocytes on the corneal endothelium.
Posterior uveitis: (cells in vitreous)
gradual onset, quiet eye
TX- steroids via OMD, peri/intraocular steroid injections; immunosuppressants, Dilation of pupil to relieve pain in anterior uveitis
Uveitis
Glaucoma
Reduced or blocked drainage of aqueous through trabecular meshwork
Hereditary; secondary to trauma or steroid use, higher prevalence in diabetics. iris root occludes, obstructing drainage of aqueous fluid from the anterior chamber.
S/S-Insidious progressive BL peripheral vision loss, tunnel vision, preserved VA. No sx in early stages; screen routinely over age 40, cupping of optic disks, (IOP) >20 mmHg. conjunctival vessels are dilated, especially near the cornea (ciliary flush) cornea is slightly hazy (edematous).
TX-URGENT, Topical prostaglandin analogs 1st
may combine with topical β-blockers
2-3RD IRIDOTOMY
REFER OMD
URGENT
ETI-Older age group, hyperopes (farsighted), narrow anterior chamber angle
S/S-Rapid severe eye pain, profound visual loss; “halos around lights;” associated n/v, Red eye, steamy cornea, dilated pupil; hard eye to palpation; IOP >20 mmHg
TX- is lowering IOP; permanent visual loss within 2-5 days if untreated
Acetazolamide 500mg IV followed by 250mg PO QID
Definitive treatment with laser iridotomy
Myope=better for near than distance vision (nearsighted)
Acute Angle-Closure Glaucoma
Cataract TX
ETI-congenital, traumatic, or secondary (DM, steroid use, uveitis); smoking increases risk
S/S-Opacity of the lens; BL; blurred vision, PHOTOPHOBIA faded colors, diplopia, Senile cataract most common;
PE- no RED REFlex, Lens opacity seen through pupil with ophthalmoscope causing retinal blurring
TX- if Visual impairment, Surgical removal
spontaneous or due to trauma, Age >50 yrs, myopia, cataract extraction. Fluid vitreous passes through tear behind retina. Superior temporal area most common site
S/S-Curtain spreading across visual field or sudden unilateral visual loss; NO PAIN or erythema
PE-Retina seen hanging in vitreous like gray cloud, may see tears on ophthalmoscope
URGENT TO OMD surgery. FACE DOWN POST OP
Retinal Detachment
Macular Degeneration
URGENT #1 cause of permanent visual loss >50 yo, white race, female, FHx, smoking
S/S-Gradually progressive BL central vision loss; distortion or abnormal size of images, drusen seen by ophthalmoscope
Atrophic (dry): moderate severity, gradual, degeneration of outer retina and retina pigment epithelium; DRUSEN
Exudative (wet): more rapid onset, more severe, choroidal new vessel growth leads to accumulation of serous fluid, hemorrhage, fibrosis; MACULA ENLARGED perifovea
laser therapy, various surgical techniques
vitamin E, antioxidants
Macular Degeneration TX
URGENT to OMD
Central; Branch
S/S-Sudden monocular loss of vision; noticed upon waking, No pain or redness, PE-Widespread retinal hemorrhages seen by ophthalmoscopy
TX-Exclude temporal arteritis in patients >55 yo, CV risks; evaluate carotids, cardiac sources of emboli, screened for DM, HTN, hyperlipidemia, glaucoma, stroke, MI,
Central RVO
Retinal Vessel Occlusions
Background retinopathy: without visual loss, mild retinal hemorrhages, edema, exudates, dilation of veins, microaneurysms, ]
Maculopathy, macular edema, exudates, ischemia of macula
Proliferative retinopathy: retinal new vessels, many around optic nerve
leading cause of new blindness in adults aged 20-65; present in 40% of undiagnosed DM
Diabetic Retinopathy
Damages retina
S/S-Silver-wiring and copper-wiring due to tortuous and narrowed retinal arteries,Flame shaped hemorrhages, edema, *cotton-wool spots, exudates from acute elevations of BP
A-V nicking due to venous compression
Hypertensive Retinopathy
Optic Neuritis
Assoc w/MS and other demyelinating disease; viral infections, lupus/autoimmune disorders, spread of inflammation from meninges, orbits, sinuses
S/S-Subacute UL visual loss with papilledema, flame hemorrhages, central scotoma; pain via eye movements
Optic disc develops pallor
TX- corticosteroids, 40% develop MS within 10 years of first episode of optic neuritis, F 20-30
ETI- DM, HTN, temporal arteritis
opens eye
S/S-May be painful if aneurysm, EOM restricted in all directions except lateral
Eye is abducted- medial rectus lost
Eye is depressed- superior obligue working
Ptosis- lost palpebra, drops
Dialted/nonreactive- lost ciliary muscle (GVEP)
CN III (Oculomotor) Palsy
CN IV (Trochlear) Palsy
S/S-Upward deviation of eye with failure of depression on adduction
Vertical diplopia
Congenital lesions or trauma, neoplasm, DM, HTN, temporal arteritis
Convergent squint with failure of abduction
Horizontal diplopia
ETI-Sign of increased ICP; may be due to trauma, neoplasm, brainstem lesions, medical causes
CN VI (Abducens) Palsy
infection of lacrimal apparatus/sac due to obstruction of the duct system. unilateral, acute or chronic
S/S- Pts c/o pain, swelling, redness in area of sac, may have purulent discharge from lacrimal duct, increased tearing.
Eti- Staph, strep, Candida if chronic.
TX- Acute - systemic abx to cover common causes.
Darcocyctisis
Chronic lesion that develops when a meibomian tear gland of the eyelid becomes obstructed.
S/S-eyelid swelling and erythema and then evolve into a painless, rubbery, nodular lesion. It is seen commonly in patients with eyelid margin blepharitis and in those with rosacea. Scar into a hard.
TX- 1ST incision/curettage
2ND-steroid injection may be effective.
Chalazion
Pterygium
fleshy encroachment of conjunctiva onto nasal side of cornea; usually from exposure, often bilateral.
S/S- may inflamed, use topical NSAIDs or steroid if needed. excision if threatens vision or causes severe irritation; may regrow.
Scleritis
Dangerous inflammation of the sclera
S/S-Acute onset of intense PAIN, photophobia, deep red/purplish hue,
DX- confirmed with slit lamp exam
TX- Urgent Referral OMD, follow closely urgent, Topical NSAIDs, lubricants, Oral NSAIds
Keratitis
URGENT
inflamed cornea, infection
S/S- PAIN, corneal ulcers (HSV zoster) PHOTOPHOBIA, watery, DEC. VA, pericorneal injection, ocular erythema
Bacterial Keritis-
Hazy cornea
Pseudomonas, Pneumococous, Moraxella, Staph
S/S- aggressive, contact wearers, central ulcer w/ hypopyon (pus)
TX- FQ+cephalsporin, or aminoglycoside.
HSV- dendritic cornea ulcer scar
Viral colonizes CNV, reoccurrence, sunlight, fever, immunocomprs
s/s- dendricitic ulcer
TX- NO ULCERS, use flourseinc dye light, acyclovir ointment, debride
Herpes Zoster Opthalmicus
EMERGENT sight-threatening condition, reactivation within the trigeminal ganglion. first division of the trigeminal nerve is most frequently involved, and 50 to 72 percent of patients experience direct ocular involvement.
S/S- headache, malaise, and fever; unilateral pain or hypesthesia in the affected eye, forehead, and top of the head. hyperemic conjunctivitis, episcleritis, and lid droop can occur. develop corneal involvement (keratitis) L/T necrotic ganglionitis; epithelial keratitis- dendriform lesions.
Iritis 40 percent of patients wchronic vasculitis, atrophy, and poorly reactive pupils.
vesicular lesions on the nose-Hutchinson’s sign- nasociliary branch of the trigeminal nerve, which also innervates the globe.
TX- antiviral therapy (acyclovir, valacyclovir, or famciclovir); topical steroid ,surgical procedures including corneal transplant and lid repair are performed less often.
Virtreous Hemorrhage
URGENT referral OMD
ETI- DM retinopathy, retinal tears, trauma, macular degeneration
S/S-Sudden visual loss, abrupt floaters
Eye is not inflamed; visual acuity varies, clear lens but inability to see fundal details clearly
