Ophthalmology 2 Flashcards
Conjunctivitis: What to do in general
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
Bacterial conjunctivitis: What to do
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
Viral conjunctivitis: What to do
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
Conjunctivitis: What not to do in general
- 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
anesthetic eye drop
proparacaine, tetracaine
Corneal abrasions: Characteristics
- 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
Corneal abrasions: Exams
- 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
- Examine the eye carefully after instilling anesthetic eye drops
Corneal ulcerations: Causes
Ulcerations are caused by infection due to bacteria (more common in contact lens wearers), viruses and fungi
Corneal ulcerations: Which case needs to be referred and why
Corneal scarring after ulceration can lead to permanent visual impairment and all cases must be referred
Iatrogenic corneal ulcerations: Causes
Due to a patient’s eyes were not attended to while the patient is sedated or under anesthesia
Corneal abrasions: What to do
- 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
Corneal abrasions: what not to do
- 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
Actinic keratitis: S/Sx, exam findings
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
Actinic keratitis: What to do
- 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
Actinic keratitis: What not to do
- Allow a patient to take with him any anesthetic eye drops
- Patch the eye, this may delay re-epithelialization
Anterior uveitis: definition, S/Sx
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) pupilUveitis: exam
- Look for circumcorneal injection which is called a “limbal flush”
Uveitis: What to do
- 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
Uveitis: Tx
- 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
Uveitis: what not to do
- 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
Retinal detachment: Causes
- 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
Retinal detachment: S/Sx
- Flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision
Sudden dramatic increase in the number of floaters - A ring of floaters or hairs just to the temporal (skull) side of the central vision
- A dense shadow that starts in the peripheral vision and slowly progresses towards the central vision
- The impression that a veil or curtain was drawn over the field of vision
- Straight lines (scale, edge of the wall, road, etc.) that suddenly appear curved (positive Amsler grid test)
- Central visual loss
Retinal detachment: exam finding
Funduscopic exam, use mydriatic if needed
- Pale yellow irregular line that is one side clear & crisp border of blood vessels and the other side blurry
- Eye ultrasound gives better image
Retinal detachment: Tx
Medical emergency! –> refer to ophthalmologist immediately
Tx: Seal the tear by a surgeon sewing a silicone or inject gas
Vitreous hemorrhage: Definition
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
Vitreous hemorrhage: S/Sx
Flashes or floaters
Blurry vision
Reddish tint to vision or reddish spot in the field of vision
Vitreous hemorrhage: Causes
- Traumatic
- Spontaneous: diabetic retinopathy, central retinal vein occlusion, uncontrolled HTN, idiopathic
Vitreous hemorrhage: Exam & findings
- A careful funduscopic exam is needed to make the diagnosis, the patient will need to have mydriatic eye drops
- Usually the outer structures of the eye appear normal
- Be sure to assess the IOP using a Tonopen
Vitreous hemorrhage: What to do
Refer all cases of confirmed or suspected hemorrhage to an ophthalmologist immediately, as it can progress to retinal detachment
Acute angle-closure glaucoma: Definition
refers to an increased pressure inside the globe
