Ophthalmology 2

Question 1

Conjunctivitis: What to do in general

Answer 1

Instill anesthetic eye drops (proparacaine, tetracaine) to determine if this relieves the pain and irritation, therefore suggesting that the problem is limited to the conjunctiva and cornea

Question 2

Bacterial conjunctivitis: What to do

Answer 2

For bacterial cases, instruct the patient in warm/wet compresses, and antibiotic eye solutions:
Erythromycin 0.5% ung q4hrs while awake
If the patient wears contact lenses, Pseudomonas must be considered, so ciprofloxacin 0.3% 1-2gtts q2-4hrs while awake, or gatifloxacin 0.3% 1-2ggts q2hrs while awake, and advise the patient not wear contact lenses for at least one week following treatment

Question 3

Viral conjunctivitis: What to do

Answer 3

For viral cases, instruct the patient in cool/wet compresses
Antihistamines either topical or systemic, or both
If herpes zoster ophthalmicus is suspected, treatment with acyclovir 800mg orally 5 times per day for 1 week is necessary, and prompt ophthalmology and/or optometry follow up is needed

Question 4

Conjunctivitis: What not to do in general

Answer 4

• Don’t forget to wash your hands and clean equipment after examining the patient, bacterial conjunctivitis is very contagious!
• Don’t patch an infected eye, it interferes with drainage
• Don’t routinely culture eye drainage, this is wasteful and doesn’t usually result in treatment changes; reserve this for cases of failed treatment
• Topical antiviral eye solutions have been proven to be of no benefit

Question 5

anesthetic eye drop

Answer 5

proparacaine, tetracaine

Question 6

Corneal abrasions: Characteristics

Answer 6

• Common eye injuries, and can be rather painful
• Usually the patient gives a history of being “poked” in the eye or having something small stuck in his eye, then having severe pain. Frequently this results in blepharospasm, which interferes with proper exam

Question 7

Corneal abrasions: Exams

Answer 7

• • Examine the eye carefully after instilling anesthetic eye drops
    1. Assess visual acuity (should be preserved, but if the abrasion is directly over the pupil, it might interfere with this)
    2. Examine using fluorescein (denuded or dead corneal epithelium will absorb the fluorescein and be immediately visible)
    3. Look for foreign bodies, and remove them delicately if noted
    4. Assess the iris and pupil for iritis (an irregular pupil with consensual photophobia), and if present, speak to your consultant about starting topical steroids or mydriatics

Question 8

Corneal ulcerations: Causes

Answer 8

Ulcerations are caused by infection due to bacteria (more common in contact lens wearers), viruses and fungi

Question 9

Corneal ulcerations: Which case needs to be referred and why

Answer 9

Corneal scarring after ulceration can lead to permanent visual impairment and all cases must be referred

Question 10

Iatrogenic corneal ulcerations: Causes

Answer 10

Due to a patient’s eyes were not attended to while the patient is sedated or under anesthesia

Question 11

Corneal abrasions: What to do

Answer 11

• Most abrasions heal well in a few days, but need some kind of antibiotic preparation to prevent ulcer formation
• NSAID eye drops don’t interfere with healing and can soothe the pain, for example diclofenac 0.1% one drop 4 times a day
• Prescribe oral analgesics as needed
• Arrange for early follow up with either an ophthalmologist or optometrist in the next 24 hours to assure that the abrasion is healing well
• Speak to your consultant directly if you detect an ulcer

Question 12

Corneal abrasions: what not to do

Answer 12

• Don’t be stingy with pain medicine
• Don’t ever let the patient leave with anesthetic eye drops, this will cause harm to the cornea
• Don’t miss anterior chamber trauma, such as hyphema

Question 13

Actinic keratitis: S/Sx, exam findings

Answer 13

S/Sx: Severe, burning bilateral eye pain (about 6-12 hrs post exposure to a high intensity UV light source)
Exam findings: diffuse conjunctival injection and tearing, and fluorescein exam will either be normal, or show diffuse, superficial uptake

Question 14

Actinic keratitis: What to do

Answer 14

• Instill anesthetic eye drops to permit a proper exam, there might be slightly decreased visual acuity due to inflammation (and thereby increased opacity of) of the cornea
• Apply cool compresses, give erythromycin ung, and give liberal oral analgesia
• Consider cycloplgeic drops (cyclopentolate 1%) to help with reflex ciliary spasm
• Resolves in about 24 hours
• F/u with ophthalmology or optometry within 48-72 hours

Question 15

Actinic keratitis: What not to do

Answer 15

• Allow a patient to take with him any anesthetic eye drops

- Patch the eye, this may delay re-epithelialization

Question 16

Anterior uveitis: definition, S/Sx

Answer 16

Definition: inflammation of the middle layer of the eye. This layer includes the iris (colored part of the eye) and the adjacent tissue, known as the ciliary body. If untreated, it can cause permanent damage and loss of vision from the development of glaucoma, cataract or retinal edema
S/Sx: 
    Red, sore and inflamed eye
    Blurred vision
    Sensitivity to light
    Small (or irregular-shaped) pupil

Question 17

Uveitis: exam

Answer 17

1. Look for circumcorneal injection which is called a “limbal flush”

Question 18

Uveitis: What to do

Answer 18

• Measure intraocular pressure with a Tonopen –> pressure is normal or low for uveitis. If high, likely acute glaucoma
• Be clear to the patient that this is a serious condition, and will need ophthalmologic or optometric follow up in the next 24 hours

Question 19

Uveitis: Tx

Answer 19

• Cyclopentolate 1% (paralyzes the pupil and keeps the iris away from the lens, preventing inflammatory adhesions from the iris to the lens)
• Prednisolone 1% (Pred-Forte) 1 drop four times a day
  Prescribe analgesia as needed

Question 20

Uveitis: what not to do

Answer 20

• Don’t allow the patient to be lost to follow up
• Don’t give antibiotics unless you are very sure there is a bacterial infection
• Don’t overlook possible penetrating trauma, which can also cause the pupil to be irregular and poorly reactive

Question 21

Retinal detachment: Causes

Answer 21

• As the result of trauma
• Related to severe myopia, at least -5 diopters, as the deformed shape of the globe predisposes weakness of the retina tissue
• As the result of connective tissue diseases that weaken the integrity of the
• Related to thinning of the retinal tissue due to diabetic retinopathy

Question 22

Retinal detachment: S/Sx

Answer 22

1. Flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision
   Sudden dramatic increase in the number of floaters
2. A ring of floaters or hairs just to the temporal (skull) side of the central vision
3. A dense shadow that starts in the peripheral vision and slowly progresses towards the central vision
4. The impression that a veil or curtain was drawn over the field of vision
5. Straight lines (scale, edge of the wall, road, etc.) that suddenly appear curved (positive Amsler grid test)
6. Central visual loss

Question 23

Retinal detachment: exam finding

Answer 23

Funduscopic exam, use mydriatic if needed

1. Pale yellow irregular line that is one side clear & crisp border of blood vessels and the other side blurry
2. Eye ultrasound gives better image

Question 24

Retinal detachment: Tx

Answer 24

Medical emergency! –> refer to ophthalmologist immediately

Tx: Seal the tear by a surgeon sewing a silicone or inject gas

Question 25

Vitreous hemorrhage: Definition

Answer 25

A rupture of a blood vessel within the choroid can result in hemorrhage spreading underneath the sensory retina, or in the case of a retinal tear, blood can enter the vitreous

Question 26

Vitreous hemorrhage: S/Sx

Answer 26

Flashes or floaters
Blurry vision
Reddish tint to vision or reddish spot in the field of vision

Question 27

Vitreous hemorrhage: Causes

Answer 27

• Traumatic

- Spontaneous: diabetic retinopathy, central retinal vein occlusion, uncontrolled HTN, idiopathic

Question 28

Vitreous hemorrhage: Exam & findings

Answer 28

1. A careful funduscopic exam is needed to make the diagnosis, the patient will need to have mydriatic eye drops
2. Usually the outer structures of the eye appear normal
3. Be sure to assess the IOP using a Tonopen

Question 29

Vitreous hemorrhage: What to do

Answer 29

Refer all cases of confirmed or suspected hemorrhage to an ophthalmologist immediately, as it can progress to retinal detachment

Question 30

Acute angle-closure glaucoma: Definition

Answer 30

refers to an increased pressure inside the globe