Ocular Disorders: Anterior Flashcards
Indications for Topical Ophthalmic Steroids
- Inflammatory condiSons of the anterior segment of the globe
- Ex// allergic conjuncSviSs, uveiSs, episcleriSs, scleriSs, phlyctenulosis,
superficial punctate keraSSs, intersSSal keraSSs, vernal conjuncSviSs, & post-
op inflammaSon
Contraindications for Topical Ophthalmic Steroids
- HypersensiSvity reacSons
- Microbial (bacterial/viral/fungal) keraSSs
- Ocular hypertension
- Glaucoma
T/F Topical Ophthalmic Steroids Should be managed by Ophthalmology
T
Topical Ophthalmic Steroids
Serious Adverse Effects
- Cataracts (prolonged use)
- Corneal perforation
- Exacerbation of viral infections (herpes simplex)
- Glaucoma
- Immunosuppression
Corneal Abrasion
Clinical Presentation
- Unilateral symptoms
- Foreign body sensation
- Eye pain
- Inability to open eye
- Photophobia
- Excessive tearing
Corneal Abrasion
Diagnosis
- No obvious laceration on initial exam
- Assess visual acuity
- Instill topical anesthetic
- Fluorescein & Wood’s lamp
- Slit lamp examination if no obvious abrasion
- If penetrating injury suspected , CT or MRI
- If ulcer suspected, obtain cultures prior to antibiotics
Corneal Abrasion
Management - prophylaxis
- Prophylaxis
- Topical antibiotics until patient is
asymptomatic - Ciprofloxacin, tobramycin,
trimethoprim/polymyxin B
Corneal Abrasion management
- Small abrasions can be managed outpatient
- Ice compresses for 24-48 hrs to reduce edema
- Warm compresses
- Eye rest
- Close follow-up until healed
Abrasions from contact lenses Tx
- Prophylactic topical antibiotics
- Pseudomonas aeruginosa
Abrasions from vegetable matter Tx
Fungal
* Natamycin – topical ophthalmic antifungal
Corneal Ulcer
- Ophthalmologic emergency
- ~20,000 cases per year in US
- Viral occur on a previously intact corneal epithelium
- Bacterial generally follow a traumatic break in the
corneal epithelium
Corneal Ulcer Tx
Topical ophthalmic corticosteroid = funga
Corneal Ulcer presentation
- Redness
- Severe pain
- Foreign body sensation
- Tearing
- Discharge
- Blurred vision
- Photophobia
- Swelling of the eyelids
- A white spot on the cornea
What pattern will a corneal abrasion take if it is HSV?
Dendritic pattern if HSV
Corneal Foreign Body
Presentation
- Red eye
- Pain
- Foreign body sensaSon
- Photophobia
- Tearing
Corneal Foreign Body diagnosis
Dilated examination by ophthalmology
* InfecSous corneal infiltrates/ulcers generally
require scrapings for smears & cultures
* Exclude intraocular foreign body
* Orbital CT
* B-scan ultrasound
* Ultrasound biomicroscopy (UBM)
* If metallic object suspected, consider
x-ray as initial study
Do NOT patch a corneal foreign body if:
- A chance of a perforation of the globe exists
- A corneal infiltrate is present
- A chance of a retained intraocular foreign
body is possible
Keratitis
Infection/Inflammation of the cornea
Keratitis
Epidemiology/Etiology
- Emergent Condition
- 25,000 cases in US/year
- Complication of contact lens use
& refractive corneal surgery - Bacterial
- Streptococcus, Pseudomonas,
Enterobacteriaceae, Staphylococcus
Infection/Inflammation of the cornea
Corneal leukoma
Keratitis Pathogenesis
- Corneal ulceration, stromal abscess
formation, surrounding corneal edema,
anterior segment inflammation - Corneal destruction complete in 24-48 hrs!
hypopyon
Leukocytic exudate
- can happen with keratitis when Outpouring of inflammatory cells into the
anterior chamber
Keratitis Clinical Presentation
- Reduced vision
- Sudden eye pain, severe
- Increased light sensitivity
- Tearing
- Excessive discharge from the eye
Keratitis
Diagnosis
- Cultures
- Scrapings
- Corneal biopsy
Keratitis management
- Antimicrobials
- Cycloplegic drops
- IV antibiotics
- Surgery
- Vitreoretinal specialist
Keratitis
Complications
- Corneal leukoma: Scar tissue formation with the presence of corneal vascularization necessitating corneal
- Irregular astigmatism: Uneven healing of the stroma → irregular astigmatism
- Corneal perforation: Most feared complication may result in endophthalmitis & eye loss, Corneal destruction complete in 24-48 hours
Most feared complication of keratitis
Corneal perforation
Ultraviolet (UV) Keratitis
Ultraviolet radiation injury to the eye
Ultraviolet (UV) Keratitis
Epidemiology/Etiology
- Most common cause of radiation injury to the eye
- Cornea absorbs most UV radiation
- Similar to a sunburn on dermal epithelium
Ultraviolet (UV) Keratitis Clinical Presentation (6 - 12 hours later)
- Foreign-body sensation
- Irritation
- Pain
- ↓ visual acuity
- Photophobia
- Tearing
- Blepharospasm
Exam findings in Ultraviolet (UV) Keratitis
- Varying lid edema & conjunctival hyperemia
- Diffuse corneal haze in severe cases
Ultraviolet (UV) Keratitis
Diagnosis
Fluorescein
* Superficial punctate epithelial surface irregularities
* Small pinpoint defects
Ultraviolet (UV) Keratitis
Treatment
Short-acting cycloplegic (paralysis of ciliary muscle)
drops
* Cyclopentolate 1% (Cyclogyl®)
* Mydriasis (dilation of the pupil)
* ↓ the pain of reflex ciliary spasm
Ultraviolet (UV) Keratitis Treatment
- Topical Anesthetics?
- Yes, 24 hours only → relief is immediate
- Don’t allow the patient to take the bottle
- Frequent topical anesthetic use slows epithelial
healing & → corneal ulcer formation
Chemical Keratitis epidemiology
- True ocular emergency
- 10-20% ocular traumas
- Men > women
- Industrial accidents, usually alkali chemicals
- building materials & cleaning agents
4 important pieces of information in chemical keratitis
- Toxicity of chemical (Type? acid v. alkali)
- Duration of contact
* When
* How long until rinsed? Time rinsing? - Depth of penetration (Pressurized?)
- Area of involvemen
Chemical Keratitis
Exam
- Check pH first*
* If not in physiologic range
* Irrigate to bring the pH to an appropriate range (7 - 7.2) - After irrigation: Assess the extent & depth of injury
- Fluorescein
- Intraocular pressure
What should you not do with chemical keratitis?
Do not neutralize acid with an alkali or vice versa
* Heat → damage
* Morgan lens with normal saline or lactated Ringer’s solution to a pH of 7
Elemental metals to be aware of in chemical Keratitis
Na+・K+・Mg2+・P–・Li+・Cs+・TiCl4
Iritis
Anterior Uveitis - Inflammation of iris & ciliary body
Iritis
Clinical Presentation
- Unilateral eye symptoms
- Eye pain
- Photophobia
- Redness
- Watering
Iritis Exam
- Pain/photophobia early signs
- Ocular findings
- Red & watering eyes
- MioSc pupil
- Pupil may have irregular shape
- Pupil may be sluggish to react
- ↓ accommodation due to pain
- S/S consistent w/ ankylosing spondylitis
Synechiae in iritis
- Iris adheres to cornea or lens
- Pupil has an irregular shape due to
posterior synechiae which have
bound the iris posteriorly to the
lens
What is this
Synechiae
Features that warrant further investigation in Iritis
- Bilateral inflammation
- Recurrent, moderate/severe inflammation
with granulomatous features - Systemic symptoms or signs suggesting
underlying medical condition
Iritis
Diagnosis
- Visual acuity with “pinhole test”
- Tonometry (↓ IOP)**
- Gonioscopy
- Sacroiliac & spine x-ray
- HLA-B27 typing
Iritis Tx
- Initiate cycloplegic agents
- Pain, synechiae prevention
- Ophthalmology
Iritis complications
- Macular edema
- Vision loss (permanent or temporary)
- Retinal detachment
Preseptal Cellulitis
Infection of the dermis anterior to the orbital septum
Most common organisms in Preseptal Cellulitis
S. Aureus, S. Epidermidis, Streptococcus
What to consider if Preseptal Cellulitis Pain disproportionate to clinical findings?
periorbital necrotizing fasciitis
Preseptal Cellulitis exam findings
- Typically, unilateral
- Involves the lid
- Erythema
- Swelling
- Induration
- Tenderness
- Warmth
- Fever & leukocytosis
- Often absent 2° trauma
ophthalmic signs in preseptal cellulitis, should make you think ___
orbital cellulitis
** Painful and/or limited eye movement
* Afferent Pupillary defect
* Increases resistance to globe retropulsion
What is this
Preseptal Cellulitis
Preseptal Cellulitis Tx
- No data establishing a standard
treatment - Treat empirically for S. Aureus &
Streptococci - Penicillins or Cephalosporins
- If you are thinking MRSA
- Clindamycin
- TMP-SMX
What is this
Orbital Cellulitis
Risk Factors or orbital cellulitis
- Recent facial trauma, surgery, dental work
- Hematogenous spread
*Note: Incidence of periorbital cellulitis has ↓ with H. influenzae vaccination
Orbital Cellulitis
Clinical Presentation
- Fever, malaise, & Hx of recent sinusitis or URI
- Conjunctival chemosis
- Decreased vision
- Pain on eye movement
- Headache
- Lid edema
- Rhinorrhea
Orbital Cellulitis
Diagnosis
- CBC c/ diff
- Blood cultures prior to antibiotics
- Eye discharge culture
Imaging - High-resolution contrast CT scan of the orbit with axial & coronal views
- R/O peridural & parenchymal brain abscess
- MRI
- Lumbar puncture if cerebral or meningeal signs develop
Orbital Cellulitis
Management
- Inpatient care until afebrile x 48 hours & clearly improved
- Broad-spectrum IV antibiotics should be started immediately
- Ophthalmology, ENT, infectious disease consults
- Continually monitor vision
- Repeat CT if symptoms worsen
Orbital cellulitis Tx
- IV antibiotic therapy for 1-2 weeks
- Oral antibiotics for an additional 2-3 weeks
- Amoxicillin clavulanate, ampicillin, cefpodoxime, cefuroxime, cefprozil
- Fungal infection requires IV antifungal therapy along with surgical debridement
Orbital Compartment Syndrome Tx
- Canthotomy
- lengthen palpebral fissure
- Cantholysis
- canthotomy + incision of inferior
branch of lateral
canthal tendon
Hyphema
Post-injury accumula=on of blood in the anterior chamber
What is this
Hyphema
Hyphema
Epidemiology/Etiology
- Incidence = 17-20 per 100,000
- Blunt trauma to the eye
- balls, rocks, projectile toys, air gun pellets,
BB gun pellets, car airbag, hockey puck..
Hyphema management
- Ophthalmology
- Consider open globe injury
- Surgical intervention is rarely indicated for hyphemas that occupy < ½ of the ant. chamber
- Resolves spontaneously
Hyphema complications
synechiae, corneal bloodstaining, opSc atrophy, secondary glaucoma
What is this
Orbital Blowout Fracture
Orbital Blowout Fracture Leads to entrapment of the ____ muscle
inferior rectus
½ orbital fractures involve _____
inferior wall/floor of the orbit
What is this
Corneal ulcer
What is this
Chemical Keratitis
