Ophthalmology Flashcards
describe abnormal findings with this man’s right eye
•scleral injection, FB at 7 o’clock
*you would also want to document (if true): PERRLA, EOMI
In an older patient with sudden onset of eye pain, headache and vomiting, what MUST be on your DDx?
acute glaucoma
stroke
What % of ED visits are related to the eyes?
What are the 4 MC complaints?
•3-10% of ED complaints are related to the eyes
- Ocular pain
- Change in vision
- Change in Appearance
- Trauma
What 3 eye problems are true emergencies and require IMMEDIATE consultation?
Immediate consultation:
- Sudden visual loss
- Globe perforation
- Alkali/Acid burn (alkali is worse than acid burn)
What should you include in taking an initial Hx?
•Chief complaint
•Change in vision
•Change in appearance
•Discomfort (FOB sensation, irritated/scratchy/etc)
•Duration
•Associated symptoms
►Remember to ask about contact use or eye meds
Relevant PMH:
- Surgeries
- Systemic diseases
- Contact lens/vision correction
- Family history
- Ophthamologic medications
List steps in 8 (9) point ER eye exam
- Visual acuity
- Pupils (reactive, symmetric?)
- EOM (LR6SO43)
- Fluoroscein
- Visual fields (specifically test this even if pt reports no deficits→ may be unaware)
- IOP
- Fundoscopic
- Slit Lamp
- (External inspection)
Visual Acuity (single best eye exam)
Uses Snellen chart
•Should be done corrected (with eyeglasses or contacts on or if those aren’t available→ use pinhole card)
•If unable to see chart:
–finger count
–hand motion
–light perception
Pupillary Exam should include:
- Shape
- Size
- Reaction to light
- Accommodation
What is Anisocoria?
unequal pupil size
•Physiologic – 20% of cases
- The Large pupil is abnormal in CN III lesion (Adie’s pupil)
- classically young women
- Small pupil abnormal in Horners syndrome
What is Horner’s syndrome?
•Horners Syndrome – ptosis, miosis, anhidrosis (loss of hemifacial sweating)
– many causes – MS, brain tumors, trauma, carotid artery dissection
What can cause an oculomotor nerve palsy?
- ischemia,
- aneurysm,
- trauma,
- brain tumors
What is a good trick if a patient doesn’t know when you ask them if their current eye presentation is “normal for them”?
ask to see his driver’s license and see how eyes look there
Why is it important to test EOM in all fields, plus convergence?
- Monocular diplopia:
–cornea/lens/malingering
- Binocular diplopia:
–CN source vs EOM source
why is it important to always check visual fields by confrontation?
Visual field defects – glaucoma, stroke, brain tumors, other neuro defects
•Patient may not notice change unless checked
What type of stain is best to evaluate for:
abrasions, dendritic lesions, open globe, ulcers, FB…
Flouroscein
►Have pt pull down lower lid and look medially. Put anesthetic drops in lateral part of globe
What is normal value for intraocular pressure?
What instrument could be used to measure if you were concerned about increased intraocular pressure?
•IOP: 10-20 is normal
A Tonopen
(do this before you dilate the pupils)
What are we looking at on the fundascopic exam?
(many things…!)
- Red reflex
- Cornea/lens/vitreous/retina/macula/optic nerve/blood vessels
- Retina, optic disc, vessels
Describe steps in Slit lamp exam.
- Start exam anterior to posterior
- Lids/lashes/conjunctiva/tear film/cornea/anterior chamber/iris/lens
- Evert the lid!
–esp if have foreign body sensation (flip over a q-tip stick if having trouble)
https://youtu.be/https://youtu.be/g0qqwJIKQlY
Describe components of an external eye exam.
- Systematic
- Orbital rim
- eyelid
- conjunctiva
- mucus membrane that covers the front of the eyeball
- sclera
- the outer wall of the eye, white, fibrous, composed of collagen, and is actually continuous with the clear cornea anteriorly
- At the back of the eye, the sclera forms the optic sheath encircling the optic nerve
- cornea
- iris
*When you examine the “white part” of a patient’s eyes, you’re actually looking through the semi-transparent conjunctiva to the white sclera of the eyeball underneath.
What imaging is quick, done at bedside and is 100% sensitive and 97% specific compared to exam and CT?
•Can Dx scleral and choroidal lacerations, vitreous hemorrhage, retinal detachment, radiolucent and radio-opaque FB, retrobulbar hematomas
When should this imaging NOT be used?
ULTRASOUND
ø Contraindicated in large globe lacerations
What is the MC way to evaluate:
–fractures of the orbit,
-intraocular foriegn body (>1 mm cuts)
►CT
•Indicated when posterior segment can’t be visualized, suspected occult globe rupture or laceration, and metallic foreign bodies
What is the best imaging to evaluate suspected orbital and periorbital tumors, optic nerve disorders?
MRI
May delineate small wooden and organic FB however must be sure no metallic IOFB present
What is the treatment for Blepharitis?
(Inflammation or infection of lid margin)
Tx: Hygiene; topical antibiotics +/- topical steroids
- Staphylococcal infx common (Abx)
- VZV
- Lid lice (pediculosis) (petroleum jelly)
What is an infection of the lacrimal sac called?
What are some S/Sx you may see?
How do you treat?
dacrocystitis
s/s: pain/swelling medial, discharge, tearing, fever, +/-toxic
Tx: express discharge, analgesia, antibiotics, admit if toxic/acute; follow up/consultation/surgery
What are some common causes of dacrocystitis?
etiology: obstruction of lacrimal duct leads to overgrowth of ocular/sinus bacteria (Staph. aureus, HIB); congenital, dacroliths
What is the difference between dacrocystitis and dacroadentitis?
- Dacrocystitis: Infection of lacrimal SAC
- Dacroadenitis: Infection of lacrimal GLAND
add pre-auricular adenopathy to Sx for -adentitis
What are common etiologies of dacroadenitis (adults vs peds)?
adult→ bacteria (Staph/Strep/GC/Chlamydia);
peds→ viral (mumps/CMV/EBV); inflammatory diseases (autoimmune, sarcoid, etc.) tumors (25%)
Essential test for distinguishing between pre and post-septal cellulitis?
extra ocular eye movement
(document whether or not is intact)
CN 3,4,6
Additional Sx with post-septal: proptosis, limitation of eye movement, decreased visual acuity, diplopia
What is one risk factor for orbital cellulitis that is a preventable risk?
lack of vaccination for H. influenza
►orbital cellulitis usually polymicrobial or in unvaccinated
What is the treatment for orbital cellultis?
CT scan, IV ABX, consultation, admission
*if unsure of exam→ err on side of admission
What causes a hordleoum/stye?
Acute infection of oil gland at lid margin
•Staph aureus
What is a chalazion (cyst)?
Noninfectious, often chronic granulomatous inflammation of meibomian gland
•biopsy if chronic or recurrent
•Usually painless, unless acute
•ED tx: warm compresses, +/- topical antibiotic
(pre-orbital)
What isTriachiasis?
misdirected eyelash;
may cause tearing, irritation, corneal abrasion
(pre-orbital)
What is Entropion?
inversion of lid margin; (se bottom lid in photo)
may cause tearing/drying;
tx=lubricants/surgery
(pre-orbital)
What is ectropian?
eversion of lid margin;
may cause tearing/drying (same as entropian)
tx=lubricants/surgery (same as entropian)
Why will a child most likely get topical Abx whether their conjuctivitis in bacterial or VIRAL or ALLERGIC?
can’t go back to school until 24hrs of Abx
(unless CLEARLY allergic)
•Relieved by topical anesthesia (document if pt’s severe eye pain immediately resolved after application→reassuring for non-emergent)
What is the difference between these two scleral pathologies:
- Pterygium
- Pinguecula
A pterygium is a wedge-shaped growth of abnormal vascularised tissue that forms on the surface eye where the clear cornea meets the white sclera. Usually innocuous, but may extend onto cornea and affect vision.
Pinguecuala never grows across the cornea
(Both are thought to be caused by environmental factors, such as a warm climate, dust and UV light)
Presentation of viral conjunctivitis:
•S/S: classic unilateral initially; burning, lid edema, chemosis, thin/watery d/c; hyperemic or follicular palpebral conjunctiva
•etiology: adenovirus
–Concurrent URI
•Tx: cool compresses; meticulous handwashing; +/- topical ABX; Naphazoline (vasonstrictor/reduces sweiing; found in Naphcon and Clear Eyes drops)
Epidemic Keratoconjunctivitis
also caused by adenovirus– same as classical viral conjunctivitis, except:
•More severe viral infx
–Will have pre-auricular LAD
•S/S: viral – flu like sx
–FB sensation, photophobia, subconjuntival hemorrhage, keratitis,
•Tx: supportive, but sx persist 2-3 weeks
Findings with allergic conjunctivitis:
What is Vernal conjunctivitis?
- S/S: recurrent pruritus, injection, burning, clear d/c, chemosis, papillae or follicles in palpebral conj
- No preauricular nodes
•tx: ID/decrease exposure, cool compresses, topical antihistamine (naphazoline) and/or mast cell stabilizer
vernal conjunctivitis= more severe form of allergic conjunctivitis w/ giant papillae/cobblestone appearance
What is this?
What is the treatment?
Chemosis: allergic/ severe eye rubbing (fluid edema)
Tx: Quit touching eye, cold compress, self resolving
Findings when conjunctivitis is bacterial:
- S/S: acute injection and purulent d/c; lash crusting not diagnostic
- etiology: #1. S aureus; strep
- Tx: topical ABX drops/ointment
•Special cases:
–Contact lens wearers: cipro/tobramycin for pseudomonas
–Severe purulent and hyperacute - gonococcus – optho consult, IV Abx
•Rule out corneal ulcer!
How do you rule out an open globe injury?
–Seidel’s test
Paint on flourescein stain → streaming of globe contents (vitreous fluid) means not abrasion and is (+) Seidels
•f/u (+) Seidels with a CT scan
Treatment for corneal abrasion:
- Cycloplegics +/- (stops ciliary spasms)
- Antibiotics
- Pain control
- No need for patching
- Follow up in 1-2 days (should be better by then, still f/u with opthalomology)
Tips for removing a corneal foreign body:
–moist (saline) cotton swab
–18g needle (have someone else hold blue light, you hold eyelids open, needle bevel towards you, go just slightly behind object and then flip it out)
•https://youtu.be/AHL9K6f8veQ
OR
refer to opthalomology
Also give: Td vaccine, Topical ABX +/- cycloplegics
Potential causes of corneal burn:
- chemicals, heat, cold, electrical or radiant energy
- Alkali=liquefaction necrosis (worse)
Acid=coagulation necrosis
•Tx: –chemical: irrigate, ABX, cycloplegic, consult
–thermal: ABX, lubricants, consult for steroids?
What is uveitis?
(Red outer ring is pathognomonic for iritis)
•Uveitis : inflammation of the uveal tract, which includes the iris, ciliary body, and choroid
•Clinical: red eye, photophobia, poor visual acuity
•Idiopathic, genetic, traumatic, or infectious
- Consensual photophobia, miotic/poorly reactive pupil
- Slit lamp exam: WBCs in anterior chamber, flare, sometimes hypopyon
What is the MC infectious cause of corneal blindness in Western Hemisphere?
- Conjunctivitis caused by Herpes simplex virus
- S/S: photophobia, FB sens, pain, chemosis, dendritic lesions
- Recurrence: often (1/3 in 2 years)
- Tx: consult; topical or oral antivirals
What is Hutchison’s sign?
Activation of latent varicella zoster in trigeminal ganglion→ “shingles” of the face
(Hutchinsons sign: if involves nose, typically means ocular involvement →Herpes Zoster Ophthalmicus)
Needs acyclovir (PO/IV)
Going to need good pain control
good prognosis, rare reoccurence
Tx for a Subconjunctival Hemorrhage
self limited (but lasts several weeks)/ reassurance
With which pathologies can you see a tear drop pupil?
open globe
scleral rupture (spills orbital contents)
trauma likely to have occured!
Central Retinal Vein Occlusion presentation:
•Variable presentation
–painless or painful
–Slow or sudden
- Assoc w/ DM, HTN, CVD, CAD, vasculitis
- Stat Optho consult
•Diffuse retinal hemorrhages, cotton wool spots, disc edema/ “blood and thunder”
Central Retinal Artery Occlusion presentation
•Acute Painless Vision Loss
•Embolic, vasospasm, trauma, hypercoag. state
•Stat Optho consult
•Treat:
–ocular massage (~15min)
–Acetazolamide – IV or topical
*likely going to lose sight in that eye, no good Tx
What is the Tx for hyphema?
Tx: sit patient upright, shield, rest
•R/O open globe
•Control IOP
•Emergent Optho consult
• Complications: Rebleed up to 40% post trauma day 3-5
What CC often accompanies retinal detachment?
“floaters”
•also, flashing lights, dark curtain, decreased visual acuity
•Retina peels away from its supporting layer
•Risks: severe myopia, cataract surgery, age
•Medical emergency – stat optho consult
Sx of acute angle glaucoma:
•Severe eye pain
•Ipsilateral headache
•Nausea/vomiting
•Blurry vision
•c/o ‘halos’ around objects
•Cloudy cornea
•Visual defecits
•Classic presentation: “older woman, sitting in the dark, reading or watching a movie” (pupillary dilation)
PE findings with acute angle glaucoma:
- Decreased visual acuity
- Tearing
- Conjunctival injection/ciliary flush
- Pupil is fixed, mid dilated, poorly or nonreactive
- Cornea is cloudy, edematous, “steamy”
- Shallow anterior chamber
- Increased intraocular pressure (40-70 mmHg)/ firm globe
What is the treatment for acute angle glaucoma?
(seconds/minutes are important→ don’t wait to optho to call back before starting beta blockers)
•Beta-blockers (timolol)
→Decrease aqueous humor prod /increase outflow
•Carbonic Anhydrase inhibitors (acetazolamide)
→Decrease aqueous humor production
•Hyperosmotics (mannitol)
→Decrease intraocular volume
•Cholinergics/Miotics (pilocarpine) (when <40mg Hg)
→Allows angle widening and increased outflow
treatment for lens dislocation?
(usually caused by blunt trauma)
SURGERY
What should we do for this patient?
•Refer everything except simple eyelid lacerations of superficial skin
How will you know you are seeing a retrobulbar hematoma?
What should your management be?
- Hx: Blunt trauma
- S/S: exophthalmos, periorbital edema, marked decrease in visual acuity, afferent pupillary defect (Marcus Gun pupil)
•Tx: CT, urgent refer vs. emergent lateral canthotomy
