Lecture 2: EENT (enochs) Flashcards
What are the 3 CNs that control eye movement and their corresponding muscles?
- CN3 (Oculomotor): Superior, Medial, Inferior, Inferior oblique
- CN4 (Trochlear): Superior oblique
- CN6: (Abducens): Lateral
Superior oblique: Down and out
Inferior oblique: Up and out
label this and tell me what each one does!
What can chronic use of ophthalmic drops do?
- Chemical conjunctivitis
- Inflammatory changes to cornea
What oral medications increase the risk for glaucoma?
- Dilating eye drops
- TCAs
- MAOIs
- Antihistamines
- Antiparkinsonian drugs
- Antipsychotics
- Antispasmolytics
What kind of eye injury requires intervention prior to PE?
Chemical injury
What is the ideal way to assess VA?
With corrective lenses.
when is the finger counting or hand motion perception test used? if this fails, what other tests come next?
- VA worse than 20/200 -> finger counting @ 3ft away or hand perception at 1-2ft.
- if unable to detect hand motion -> determine if light perception is present
- if unable to detect light perception -> check hx of nystagmus
What test assess for afferent pupillary defect?
Swinging light test
( switch light back and forth between eyes every 2 seconds. if normal, pupils will constrict each time the light hits them. if one side is affected, the pupils will both remain dilated while the light is on the affected pupil)
What is normal IOP? When should you NOT check IOP via tonopen?
- 10-20 mmHg
- CI if globe rupture from trauma
- remember IOP is checked last in the exam due to discomfort. (only exception is fundoscopic exam IF you require dilation!)
How do you differentiate preseptal cellulitis from orbital cellulitis?
Presence of inflammatory proptosis of the eye = orbital.
what is periorbital cellulitis
infection anterior to the orbital septum
can arise from sinusitis, skin trauma, insect bite or hordeolum.
generally benign -> tx w outpatient therapy
What recent infections may suggest possible orbital cellulitis? How is this different from periorbital cellulitis
- Ethmoid sinusitis
- Maxillary sinusitis
- infection extends behind the orbital septum
- life and vision threatening. requires IV inpatient therapy.
what are s/s of periorbital and orbital cellulitis
- fever (uncommon in periorbital)
- excessive tearing
- erythema
- edema
- warmth
- tender to palpation of lids and periorbital soft tissue.
What are the red flags for orbital involvement of an infection?
- Pain with EOM
- Chemosis
- Proptosis
- Increased IOP
- VA changes
If we suspect orbital cellulitis in a young child who is difficult to examine, what is the ideal imaging?
Orbital CT w/ con
Management for periorbital cellulitis OP for older child and up
- Augmentin or keflex (clinda for PCN allergy)
- Hot compresses
- f/u in 24-48h with oph
Management of periorbital cellulitis for young children/severe presentation
- Admit
- (IV rocephin) OR (unasyn + vanco)
- PCN allergy: FQ + metro/clinda
- Oph consult
Management of orbital cellulitis
- Immediate ophthalmology consult
- IV abx: (Rocephin) or (unasyn + vanco) or (FQ + metro/clinda)
- Topical nasal decongestant
- Lateral canthotomy for increased IOP or optic neuropathy
Describe a hordeolum.
- Stye
- Acute infection of follicle or meibomian gland
- Redness
- Tender
Describe a chalazion.
- Swelling d/t obstructed meibomian gland
- Hard, non-tender
What are the S/S of both a hordeolum and chalazion?
- Pain (more common in hordeolum)
- Erythema
- Swelling
How do you treat a hordeolum or chalazion?
- Warm, moist compresses QID
- Erythromycin ointment
- Do not manipulate lesion
what is the presentation of bacterial conjunctivitis
- painless mucopurulent discharge w matting of the eyelids
- conjunctiva injected w occasional chemosis (swelling of eye membranes)
- cornea is clear without fluorescent uptake
What diagnostics are indicated in bacterial conjunctivitis?
- Fluorescein exam to r/o herpes, ulcers, abrasions
- C&S if severe purulence
Management for bacterial conjunctivitis
- Topical abx of TMP-polymyxin B
- FQ or tobramycin for contact lens d/t pseudomonas
- Admit for infants < 30d or hyperacute onsets.
What PE finding would suggest viral rather than bacterial conjunctivitis?
Watery discharge
will also see:
conjunctival injection
chemosis
preauricular lymphadenopathy
Management of viral conjunctivitis
- Cool compresses
- Topical antihistamine/decongestant
- Artificial tears
Much less dangerous
What PE findings suggest allergic conjunctivitis primarily over other etiologies?
- Intense itching
- Papillae on inferior conjunctiva
- Watery discharge
- Cobblestoning
What diagnostic is appropriate for allergic conjunctivitis?
Fluorescein to r/o herpetic lesions
Management of allergic conjunctivitis
- Cool ompresses
- Antihistamine/decongestants
- Artificial tears
- Refer if severe or resistant
Pretty much same as viral
How does anterior uveitis/iritis present?
- Unilateral/bilateral pain
- Photophobia with consensual photophobia HALLMARK
- Conjunctival injection/ciliary flush
- Miosis with poor reactivity
- Diminished VAs
What diagnostics are appropriate for anterior uveitis?
- Slit-lamp: keratic precipitates (Inflammatory cells), aqueous flares (protein)
- Hypopyon check
- Fluorescein stain
- IOP measurement (usually normal)
Management of anterior uveitis
- Cycloplegics (dilate pupil to keep iris from lens)
- Topical prednisolone
- Refer to oph
Cyclogyl or cyclopentolate or homatropine (DOC) for cycloplegic
When are topical steroids not indicated for anterior uveitis?
- Corneal abrasion
- Infectious
- Elevated IOP
What is a corneal ulcer and what causes it
- infection of the corneal stroma
- bacterial/viral/fungal
- can be associated w trauma (specifically contact lens wearers)
S/S of a corneal ulcer
- Pain
- Redness
- Tearing
- Photophobia
- Blurry vision
Diagnostics for corneal ulcer and expected findings
- Fluorescein: staining defect with white hazy infiltrate, iritis, and/or hypopyon
- Culture ulcer
Management of corneal ulcer
- Ophthalmic FQ (ofloxacin or cipro or tobramycin)
- Topical cycloplegic
- AVOID eye patching
- Consult oph for immunocompromised
- AVOID TOPICAL STEROIDS
what is HSV keratoconjunctivitis?
an infection of the cornea and conjunctiva by HSV
S/S of HSV keratoconjunctivitis
- Unilateral photophobia
- Pain, redness
- VA loss
- Preauricular LAN
- Vesicular eruption arund eye
Diagnostics for HSV keratoconjunctivitis and expected finding
Fluorescein stain with dendritic lesion uptake or geographic ulcer
Management of HSV keratoconjunctivitis
- Eyelid involvement: oral antiviral
- Conjunctival involvement: topical trifluridine (virpotic) with erythromycin ointment
- Corneal involvement: urgent oph consult
- AVOID topical steroids
If < 30d old, admit
What is HZV ophthalmicus?
HZV infection of V1 of trigeminal
Ramsay Hunt syndrome
S/S of HZV ophthalmicus
- Painful vesicular rash on erythematous vase involving upper eyelid and tip of nose hutchinson sign
- Fever, malaise, HA
- Red eye, blurred vision, eye pain/photophobia
- Keratitis, uveitis
- Elevated IOP
Hunt at the zoo, so you know its zoster and not simplex
Diagnostics for HZV ophthalmicus and expected findings
Fluorescein stain showing pseudodendrites.
Small, no central ulceration, no terminal bulbs, lack of central stain.
Management of HZV ophthalmicus
- Consult
- If severe: admit for IV acyclovir
- Skin involvement: Cool compresses, oral antivirals for short-term rash, topical abx (bacitracin/erythromycin)
- Ocular involvement: erythromycin ointment, cycloplegics, opioids, cool compresses
- If anterior uveitis present: topical steroids via oph
- If occurring in patient < 40y, work up for immunocompromised state
S/S of subconjunctival hemorrhage
- Bright red blood under bulbar conjunctiva
- Hx of trauma by sneeze, cough, valsalva, HTN
Management of subconjunctival hemorrhage
Reassurance
2-3 weeks to self-resolve
S/S of UV keratitis
- Slow onset of FB sensation and mild photophobia
- Blepharospasm, tearing, conjunctival injection
Foreign body
Risk factors for UV keratitis
- Welding
- Tanning
- Prolonged sun exposure
Dx of UV keratitis
- Slit lamp showing diffuse, punctate corneal edema
- Fluorescein showing punctate corneal abrasions
Management of UV keratitis
- +/- eye patching
- Cycloplegic, oral analgesics, topical abx
S/S of corneal abrasion
- Tearing, photophobia, pain
- Blepharospasm
- Often need topical anesthetic
Dx of corneal abrasion
- Look for any ocular FBs
- Fluorescein
Management of corneal abrasion
- Ketorolac drops
- Erythromycin ointment
- FQ/tobramycin for contact lens
- DO NOT RX topical anesthetics
What may occur if a FB persists in an eye > 24 hrs?
WBC ring forms in anterior corneal chamber
Presence of what suggest globe perforation due to corneal FB?
Hyphema or microhyphema
Do seidel test if suspected. (cobalt blue light)
Hyphemas present with pain, subconjunctival is often painless
When would a CT orbit be added for suspected corneal FB?
If we think its intraocular or globe rupture