HEENT - Red Eye - Exam 2 Flashcards
What is the conjunctiva?
Clear, mucous membrane of the eye
What is the episclera?
Fibrous layer above sclera and below conjunctiva
What is the sclera?
Fibrous connective tissue that proves structural rigidity to the eye
What is choroid?
The layer containing blood vessels between the retina and sclera
What is the uvea?
The part of the eye that includes the choroid, ciliary body, and iris
What is the ciliary body?
The muscular structure behind the iris, adjusts the lens, and produces aqueous humor
What is the corneal limbus?
Border between the cornea and sclera
What does the aqueous humor do?
Maintains intraocular pressure and nourishes the cornea and lens
What does the vitreous humor do?
Maintains the shape of the eye.
Contacts resting and keeps it in place.
What is the trabecular network?
Tissue in the anterior chamber of the eye that allows for aqueous outflow
What is epiphora?
Excessive tearing of the eye
What is chemosis?
Swelling of the conjunctiva
What is hypopyon?
Leukocytic exudate in anterior chamber of the eye
What is ciliary flush?
Dilated conjunctival and episcleral vessels adjacent and circumferential to the corneal limbus
What is hyperemia?
Dilated conjunctival vessels
What is keratitis?
Inflammatory condition of the cornea
What is proptosis?
Protrusion of the eye
If the patients vision is worse than 20/400 and they cannot read the snellen chart, what tests can you do?
- Count fingers at a given distance
- Hand motion
- Light perception
- No light perception
What does tonometry test?
Intraocular pressure (IOP)
What is normal intraocular pressure (IOP)?
8-21
What is the presentation of Blepharitis?
- Eyelid inflammation due to Meibomian gland dysfunction
- Iching, burning, scratching
- No vision decrease
- Erythema, scales, and debris
- Worse in morning
What is the treatment for blepharitis?
- Bacitracin ophthalmic ointment
- Erythromycin or azithromycin ophthalmic ointment (Oral antibiotics if these are not effective)
- Warm compresses
- Baby shampoo lid scrubs
What condition does Blepharitis contribute to?
Dry eye syndrome
Other than blepharitis, what are other causes of dry eye syndrome?
Autoimmune disease, hormone changes, ectropion, contact lenses, medications, refractive eye surgery
What is dry eye syndrome?
Deficient aqueous tear production
What is the presentation of dry eye syndrome?
- Chronic itching, burning, and scratching.
- Tired eyes, worse in PM
- Vision fluctuation
- Punctate epithelial erosions on slit lamp exam
- Positive shirmer test
What is the shirmer exam?
determines whether the eye produces enough tears to keep it moist.
What is the treatment of dry eye syndrome?
- Artificial tears
- Ophthalmology referral
- Topical cyclosporine increase production of tears
- Topical glucocorticoids
- Punctal plugs
What is the cause of Hordeolum?
Infected Eyelash root
What is the presentation of Hordeolum?
Painful, swelling, and may affect entire eyelid
What is the treatment for Hordeolum?
Warm compresses, antibiotics if needed, steroid injection, and possible surgical drainage
What is the cause of Chalazion?
Clogged oil glands
What is the presentation of Chalazion?
Typically painless swelling of eyelid, unless it is very large. Does not make the entire eye lid swell
What is the treatment for Chalazion?
Warm compresses, antibiotics if needed, steroid injection, and possible surgical drainage
What is the presentation of Dacryoadentitis?
- Swelling of the outer upper lid with pain and erythema.
- Epiphora
- Preauricular lymphadenopathy
What is Dacryoadentitis?
Inflammation of the lacrimal gland
What causes Acute Dacryoadenitis?
Viral or bacterial source - Mumps EBV, staphylococcal, gonococcal
What causes chronic Dacryoadentitis?
Noninfectious inflammatory disorders and orbital tumors
What is ectropion?
What causes it?
Edge of the eyelid is everted.
Caused by advanced age, trauma, infection, and palsy of facial nerve
What is entropion?
What causes it?
Eyelid and lashes are inverted inwards towards the eye.
Caused by scar tissue or spasm of orbicularis oculi.
What is the treatment for entropion and ectropion?
Surgical repair if there is excessive tearing, exposure keratitis, cosmetic distress, or the lashes are growing toward or into the eye
What is a pinguelcula?
Clear, thin tissue that covers part of the sclera
- Unknown cause, but possibly from long term sun exposure and aging
- Usually does not cause vision loss
What is a pterygium?
Thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea.
- May interfere with vision as it encroaches on the pupil.
- Usually on the nasal side.
What is the treatment for a pinguecula or a pterygium?
Lubricating drops, sunglasses use, possible surgery for cosmetic change or vision changes
What is preseptal and periorbital cellulitis most often caused by?
What are other possible causes?
- Extension of a sinus infection; ethmoid sinus is most common
- Can also be and extension from a dental infection, URI, or middle ear infection
What bacteria most often cause cellulitis?
S. Pneumonia, S. Aureus, S pyrogenes, and H Influenza
What is the presentation of Preseptal cellulitis?
Eyelid pain, eye pain, erythema, swelling, and fever.
- No proptosis or impairment of vision
- No pain with ocular movement
- Chemosis is rare
How is preseptal cellulitis diagnosed?
CT with contrast or MRI
What is the outpatient treatment for preseptal cellulitis?
- Clindamycin OR trimpethoprim/sulfamethoxazole (Bactrim)
- PLUS Augmentin OR Cefpodoxime
- Referral to Opthamologist
What is the inpatient treatment for preseptal cellulitis?
- Vancomycin PLUS ceftriaxone PLUS Metronidazole
- Ophthalmologist consult
What is the presentation of Orbital cellulitis?
- Eyelid swelling, erythema
- Fever
- Impaired and painful ocular movement
- Proptosis is common, may be subtle.
- Possible chemosis and leukocytosis
How do you diagnose orbital cellulitis?
CT with contrast or MRI
What is the treatment for orbital cellulitis?
- Vancomycin PLUS ceftriaxone PLUS metronidazole
- Ophthamology consult
- Hospital admission
- Surgery if abscess or to decompress orbit
What is conjunctivitis?
What is the etiology?
Inflammation of the conjunctiva.
Viral, bacterial, or allergic
What is the presentation of viral conjunctivitis?
- Acute, often following URI with respiratory symptoms (Most often adenovirus or enterovirus)
- Typically bilateral with severe injection
- Watery discharge
- Preauricular lymphadenopathy
- Photophobia and foreign body sensation (severe cases)
What is the management of viral conjunctivitis?
- Warm compresses
- Supportive
- Self limiting
- Ophthalmology referral with possible antivirals
What is the most common cause of Bacterial Conjunctivitis in adults?
Staph aureus
What is the most common cause of bacterial conjunctivitis in children?
S. Pneumoniae, H influenza, and M catarrhalis
What is the presentation of Bacterial conjunctivitis?
- Acute onset of symptoms
- Moderate injection
- Thick, mucopurulent discharge
What is the treatment for bacterial conjunctivitis?
- Erythromycin ophthalmic ointment
- Trimethoprim-polymyxin B ophthalmic solution
- Ciprofloxacin ophthalmic solution
- Azithryomycin ophthalmic solution
Treat for 5-7 days and no contact use until infection has resolved
What are the rare forms of bacterial conjunctivitis?
C. trachomatis and N. gonorrhea
- Transmitted via direct contact in adults
- Transmitted to neonate via vaginal delivery in children
What is the presentation of bacterial conjunctivitis caused by C. trachomatis?
- Bilateral and may be associated with keratitis
- Nontender preauricular adenopathy common
- Chronic conjunctivitis may develop
How do you diagnosed bacterial conjunctivitis caused by C trachomatis?
Culture and PCR
How do you treat bacterial conjunctivitis caused by C. Trachomatis?
- Erythrymycin
- Azithromycin
How do you treat bacterial conjunctivitis caused by N. Gonorrhea?
- Hospitalization
- Ceftriazone (Rocephin)
- Ophthamology consult
What is presentation of bacterial conjunctivitis cased by N. Gonorrhea?
- Profuse, purulent discharge, striking in quantity
- Chemosis
- Moderate to severe injection
- Irritation and tenderness, lid swelling
- Preauricular adenopathy
- Severe and sight threatening
- Hyperacute onset within 12 hours of inoculation
How do you diagnose bacterial conjunctivitis caused by G. Gonorrhea?
Giemsa stain, gram stain, culture on selective media
What is the presentation of allergic conjunctivitis?
- Chronic/Bilateral
- Itching (hallmark sign)
- Mild injection
- Chemosis
- Stringy discharge
- History of atopy/seasonal allergies
What is the treatment for allergic conjuntivitis?
- Lubricating eye drops
- Cool compresses
- OTC antihistamine
- Ophthalmic anti-histamine drops
What is a subconjuntival hemorrhage?
Blood in the conjunctiva, harmless.
- Typically spontaneous with no known injury but can result from trauma
- Asymptomatic
What are the signs of a subconjuntival hemorrhage?
- Vision unaffected
- Diffuse red patch (not vascular engorgement)
What is the treatment for subconjunctival hemorrhage?
Reassurance
What is scleritis?
Inflammatory and autoimmune disorder of the sclera particularly vasculitis
- Can occur as an isolated incident OR 50% of the time it is associated with underlying systemic disease
- Potentially blinding!
What are the 3 subtypes of Anterior scleritis?
- Diffuse (most common)
- Nodular (highest recurrence rate)
- Necrotizing (rare)
Is anterior or posterior scleritis more common?
Anterior
What are the subtypes of posterior scleritis?
Diffuse, nodular, and necrotizing
-Same subtypes of anterior scleritis, but often delayed diagnosis due to location
What is the presentation of anterior scleritis?
- Severe constant eye pain that is worse in the morning
- Pain radiates to face and periorbital region
- Pain with EOMs and activity
- Headache and Epiphora
- Diffuse hyperemia
- Possible photophobia
What is the presentation of posterior scleritis?
- No hyperemia unless associated with anterior scleritis
- Milder symptoms than that anterior scleritis
- Slit light exam can show optic disc edema
How is anterior scleritis diagnosed?
- Violaceous redness of the eye
- Pain with pressure on the eyelid
- Scleral edema on slit lamp exam
How is posterior scleritis diagnosed?
- If isolated, orbit will appear normal
- Slit lamp exam shows inflammation, choroidal thickening
What is the treatment for both posterior and anterior scleritis?
- Referral to ophthalmologist and rheumatology ASAP
- Oral NSAIDS
- Oral glucocorticoids
- Immunosuppresive medications if severe
What is episcleritis?
Abrupt onset of inflammation of episclera in one or both eyes
What are the two types of episcleritis?
Nodular and diffuse
What is presentation of episcleritis?
- Bright red episcleral discoloration
- Irritation
- Epiphora
- Vision NOT affected
- Typically no pain
- Normal sclera on slit lamp exam
How is episcleritis diagnosed?
Clinical, normal appearing underlying sclera
What is the treatment for episcleritis?
- Referral to ophthalmologist
- Topical lubricants
- Topical and/or oral NSAIDs
- Topical glucocorticoids
- Assess for systemic disease
What is the presentation of Corneal Abrasion?
- Acute onset of pain, foreign body sensation
- Epiphora
- Possible affected vision
- Epithelial defect
What is the treatment for a corneal abrasion?
- Fluorescein stain
- Topical lubricants
- Topical antibiotics
- Oral pain meds
- No patching!
- Do not give topical anesthetic eye drop prescription!
Why should you not prescribe anesthetic drops to a patient?
It can cause corneal toxicity
What is the presentation of a chemical injury to the eye?
- Acute pain, burning
- Blurred vision
- Vision decreased
- Possible corneal abrasion
What is the management of a chemical injury to the eye?
- Irrigate immediately
- Morgan lens for prolonged irrigation
- Topical lubricants/antibiotics
- Ophthalmology referral
What is the presentation of a corneal foreign body?
- Acute onset of foreign body sensation usually with an associated event.
- Vision is usually unaffected
- Visible foreign body
What is the treatment for a corneal foreign body?
- Determine mechanism of injury (beware of intraocular foreign body)
- Remove with irrigation, cotton tipped applicator, specialized removal tool
- Lubricant/antibiotic drops
- Possible referral to ophthalmology
What is keratitis/corneal ulcer?
Infection or inflammation of the cornea
What is the presentation of a corneal ulcer?
- Acute onset of pain
- Mucous discharge
- Contact lens abuse
- Vision usually decreased
- White infiltrate
- Possible hypopyon
How is a corneal ulcer treated?
- Intensive topical antibiotics
- Ophthalmology referral
If you see a dendritic pattern in the eye, what should you be concerned about?
HSV
How do you treat keratitis caused by HSV?
- Topical antivirals.
- Do not use steroids!
- Referral to ophthalmology
What is Hyphema?
Blood in the anterior chamber, typically from trauma to iris and/or pupil
What is the presentation of hyphema?
- Acute onset of pain
- Photophobia
- Nausea and vomiting
- Possible vision decrease
- Layered heme
If a patient has microhyphema, what are the chances that patients vision could return with 20/50 or better?
90%
What are the changes of vision returning to 20/50 or better with a grade 4 hyphema?
50%
What is the treatment for Hyphema?
- Correct any underlying coagulopathy
- Treat pain, nausea, and vomiting (want to control IOP)
- Eye shield and bed rest
- Elevate head of bed
- Referral to ophthalmology because this can result in permanent vision loss
What are the pros and cons of using an eye patch?
Pros: minimize cornea and eyelid rubbing, prevent corneal exposure, and good for post surgery
Cons: Can worsen infection
What does an eye shield do?
Prevents external pressure on the eye, good for post-trauma and post op
What is uveitis?
- Inflammation of the uveal tissue.
- Can occur as an isolated process or as a result of immune-mediated response, drug response, or infection
What is anterior uveitis also known as?
Iritis
What is anterior uveitis?
Inflammation of the iris and ciliary body.
-Leukocytes in the anterior chamber of the eye
What is posterior uveitis?
- Inflammation posterior to the lens (choroid body)
- Leukocytes in the vitreous humor
What is panuveitis?
Inflammation of the anterior and posterior uvea
What type of uveitis is most common?
Anterior uveitis
What is the presentation of anterior uveitis?
- Pain
- Ciliary flush
- Photophobia
- Hypopyon
- Blurred vision
- Increased tearing
- Increased IOP
What is the presentation of posterior uveitis?
Painless, floaters, and blurred vision
How is uveitis diagnosed?
Clinically and slit lamp exam
What is the treatment for uveitis?
- Ophthamology referral
- Topical glucocorticoids and NSAIDs
- Consider oral if bilateral and no response to topical
- Cycloplegic (dilating gtts) drops if increased IOP
- Typically resolves in 6-8 weeks
What are the complications of uveitis?
- Cataracts
- Irregular pupil due to scar tissue
- Swelling and increased eye pressure
