Ophthalmology: The Red Eye & Trauma

Question 1

Papillary vs Follicular Conjunctivitis

Answer 1

Papillary, think “pABillae” = Allergic & Bacterial

Look for red dots of varying size (velvety & vascular)

Follicular = chlamydia, toxic, viral

• Look for avascular/white nodules*
• Picture - papillary left and follicular right*

Question 2

palpebral vs bulbar conjunctivitis

Answer 2

palpebral = eyelids

bulbar = eyeball

Question 3

hallmark of viral conjunctivitis

Answer 3

tearing/watery discharge

other clinical signs: pre-auricular lymphadenopathy, conjunctival folliculitis, antecedent URI, sore throat

Question 4

EKC

Answer 4

Epidemic Keratoconjunctivitis (involves cornea)

Adenovirus (usually 8 or 19)

• 7-14 days: look for bulbar conjunctivitis, water discharge, tender p/a nodes, photophobia*
• 11-14 days: subepithelial corneal infiltrates*

Question 5

When to refer EKC

Answer 5

If infiltrates last > 4wks or if vision is reduced

Note: treatment is supportive (artificial tears, isolation, NO steroids and ABX are NOT necessary)

Question 6

Treatment for Chlamydia Conjunctivitis

Answer 6

Culture then Systemic Abx (Zithromax)

Question 7

Treatment for HSV Keratoconjunctivitis

Answer 7

Viroptic (Trifluridine - antiviral)

Zirgan (Ganciclovir - antiviral)

Cycloplegia (paralyze constrictor muscle)

NO Steroids

Question 8

Topical Steroid Side Effects

Answer 8

Herpes Reactivation

Glaucoma

Cataract

Fungal Infection

Question 9

Treatment for Herpes Zoster Ophthalmicus

Answer 9

Systemic antivirals and Ophtho consult

+/- abx ointment for skin lid lesions

+/- topical cycloplegia, artificial tears

Ophtho will start steroids 24hrs after antivirals

Question 10

Hallmark of Allergic Conjunctivitis

Answer 10

Itching & Bilateral Involvement

Treatment = avoid contactant, topical/oral antihistamines, mast cell stabilizers, topical steroids (per Ophtho)

Question 11

Common Organisms causing Bacterial Conjunctivitis

Answer 11

GPC: staphylococcus

GPR: corynebacterium

GNC: neisseria (hyperpurulent)

GNR: H flu, Klebsiella, E coli, Pseudomonas

Question 12

Treatment of Gonococcal Conjunctivits (hyperacute)

Answer 12

Moxifloxicin drops + Saline rinses + Standard systemic Abx therapy

If cornea involved = IV ceftriaxone x3 days

Question 13

Treatment of Bacterial Keratitis

Answer 13

Focal white opacity in the corneal stroma due to bacterial infection

Sight threatening, emergent treatment (4th gen fluoroquinolone*) and referral

*Vigamox or Zymar q15m for 2h, then q1h for 24h

Question 14

Limbal flush

Answer 14

Hallmark of iritis

Limbus = where the white meets the clear

aka Ciliary or Circumlimbal flush

Question 15

Causes of Anterior Uveitis

Answer 15

Trauma

Idiopathic

Auto-Immune

Systemic Infection

Question 16

True/False

Eyes are surrounded by a layer of pigment

Answer 16

True (aka Uvea)

Uvea consists of the iris, ciliary body, and choroid (all photopigmented structures)

Question 17

Synechiae (sin-knee-key-uh)

Answer 17

Iris-to-lens adhesions

Question 18

True/False

Trauma is a cause of anterior uveitis

Answer 18

True

Question 19

Treatment of Iritis

Answer 19

• Cycloplegia (Atropine, Homatropine, Scopolamine)
• Pred forte q1, oral NSAID
• Consult ophtho
• Monitor IOPs and response

Question 20

How do cycloplegics help treat iritis?

Answer 20

Break synechiae

Relieve pain of ciliary spasm

Reduce inflammation

Question 21

Pre-Septal vs Orbital Cellulitis

Answer 21

Pre-Septal = systemic abx and refer if not improving

Cellulitis & no acute distress

Orbital = medical/surgical emergency (sinus thrombosis, meningitis), get XR/CT/MRI, Admit/AEROVAC, and systemic abx

Cellulitis, Proptosis, Pain, Irritable/Lethargic, +/- LOV and disc edema

Question 22

Why are alkali burns more severe than acid burns?

Answer 22

Alkali burns cause liquefactive necrosis

Note: quite white eye is a sign of significant damage

Question 23

Treatment for chemical burns

Answer 23

Copious irrigation (NS or water)

Topical Abx

Cycloplegics

NO patch or steroids

Question 24

Cycloplegics for chemical burns

Answer 24

Homatropine 5% q12h

Scopalomine 0.25% qd

Question 25

Prophylatic treatment for corneal abrasion

Answer 25

Polytrim QID for 48-72h

Lubricate, Cycloplegic, Oral analgesic, and F/U Next Day (consider infectious keratitis or occult foreign body under lid if worsening)

Question 26

Exam for Corneal Abrasion

Answer 26

1. Topical anesthetic (proparacaine)
2. Fluorescein stain
3. Blue filter

Question 27

Seidel Sign

Answer 27

positive = corneal tear/perforation

Question 28

Treatment for Corneal Foreign Body

Answer 28

1. Topical anesthetic
2. Remove with syringe
3. Alger brush to remove rust ring
4. Topical Abx (Polytrim)
5. Tetanus?
6. F/U Next Day

Question 29

Hyphema

Answer 29

Anterior chamber hemorrhage

Micro (few RBCs) to completely fill chamber (8-ball hyphema)

Question 30

Treatment for hyphema

Answer 30

Bed rest for 3-5 days

Eye shield for 2 weeks

Check IOP and vision daily

Dilate pupil

Topical Steroid for traumatic iritis

Check for sickle trait

Rebleed risk greatest at 72 hours

Question 31

When to refer hyphema

Answer 31

Corneal blood staining

Complete 8 ball

IOP uncontrollable

Question 32

Middle of nowhere ruptured globe treatment

Answer 32

1. Numb eye
2. Dry eye
3. Super glue + Contact
4. Transport

Question 33

Peaked pupils point to the problem

Answer 33

Question 34

Treatment for Ruptured Globe Care

Answer 34

Shield eye (no patch or IOP check)

Consult Ophtho

NPO (for surgery)

Anti-emetics

Systemic Abx

Tetanus?

Bedrest at 45 deg