Ophthamology for the Flight Surgeon Flashcards
Name the 4 general rules
- Call
- Cover for infection
- Shield the eye
- Avoid steroids
Name the acronym and items of the Big-8 exam.
Acronym: VVEEPP + 2
Visual acuity (20/xx, finger count, hand motion, light perception) VFs EOMs External exam Pupils (incl swinging flashlight) Pressure (IOP) SLE (slit lamp exam) DFE
Ensure examine with lid retracted to eval for foreign object or laceration
Why do ophthamologists err to give antibiotics?
Concern for losing the cornea
Discuss eye shield relative to eye patch.
Shield goes bone-to-bone
Which chamber of the eye is referred to in acute angle closure glaucoma?
Anterior chamber
What is fluorsceine used to test for?
Corneal abrasion
What do you do when there is a foreign object in the orbit?
Splint in place
What do you do with the orbit if you suspect enucleation in an unconscious patient?
Allow patient to wake up with orbit in place to acknowledge loss of eyesight prior to removing orbit
If there is a severe amount of conjunctival edema, what should you suspect?
What test should you not do?
Suspect open globe
Do not test IOP (don’t push on eye)
What is the clinical meaning of a tear drop pupil in eye trauma?
The iris is plugging the corneal laceration
What is one key exam item to check in orbital trauma? Why?
Visual acuity as it has prognostic value
What antibiotic should be used to treat an open globe? What other medications should also be given?
Antibiotics:
IV fluoroquinolone, typically 400mg QD
Kids: Cefazolin 50 mg/kg/day div TID
Also give anti-emetics
Define TACS. When is it used?
Management of an open globe:
“TACS”:
- Tetanus (currency of prophylaxis)
- Antibiotics, IV (fluoroquinolone)
- CT orbits
- Shield
- Metallic Fox shield
- Bottom of cup
What is the AE priority of an open globe?
Urgent
How is a lid laceration managed?
Don’t debride as the eyelid is very elastic and vascular with all of the parts for repair usually there.
How is a chemical eye injury managed?
Irrigate!!
x 20 min, 2L
Name the three types of traumatic blunt injury to the eye?
Orbit blowout fracture
Hyphema
Traumatic iritis
What key exam findings are seen in orbit blowout fracture?
Trapping of soft tissue causing abn EOMs
Enopthalamos (narrow palebral fissure secondary to eye being drawn back into the socket
What key treatment item do patient’s need to be counseled on with orbit blowout fracture?
What medication can help with this management recommendation?
No activity to increase IOP, such as blowing nose (use Afrin).
When should an orbit blowout fracture be repaired?
7-10 days unless vascular compromise
What is the pain status of an orbit blowout fracture?
Usually painless
How does hyphema present?
Decreased vision
Blood in anterior chamber of eye
What is the management priority of hyphema?
Is not emergent, ophtho follows as outpatient daily
Should you shield the eye? Why?
Yes, to keep pt from breaking up the clot causing increased IOP
How does traumatic iritis present?
Decreased vision
Red eye
Eye pain
Photophobia
At what level is corneal abrasion managed?
How are these patients followed?
PCM, seen daily
How long does it take for a corneal abrasion to heal?
Age dependent:
Neonate– 24 hrs
80 yrs old– 1 week
How is the eye pain managed with cornea abrasion?
Oral pain meds or cycloplegia
Which antibiotic are used to treat corneal abrasion?
Antibiotics, lubrication
- Vigamox or Ciloxan and artificial tears
- Erythromycin ointment
Do you patch a corneal abrasion?
NO
How do you prevent a corneal foreign object?
Eye protection
How do you manage corneal foreign object?
Eye exam Anesthetic drops If peripheral: Remove foreign body (irrigation --> wet cotton tip --> 18G needle on syringe) If central: send to ophtho Treat corneal abrasion
Name the 5 painful red eye disorders.
- Iritis
- Contact lens overwear
- Corneal ulcer
- Herpes keratitis
- Acute angle closure glaucoma
What increased risk do contact lens wearers have for corneal ulcer/keratitis?
4x
What eye finding is seen with iritis?
Limbral flush around iris
Can vision loss occur with iritis? Over what time frame?
Yes, over weeks
With what frequency is iritis seen?
Common
Name 5 causes of iritis?
- Trauma
- Autoimmune (ACE, ANA, ESR)
- Infectious (incl HSV, VZV, RPR, Lyme, TB)
- HLA-B27
How is contact lens overwear managed?
No contact lenses x 1-2 months
Send to ophtho (risk of keratitis)
Moxi or cipro drops QID
What type of organism is most eye infections? What treatment implications does this have?
99% are gram positive
Why erythromycin + Bacitracin is favored treatment (don’t get corneal toxicity)
What is seen on the cornea in a corneal ulcer?
White spot that doesn’t go away with blinking
Represents bacteria
Name the 3 causes of corneal ulcer.
Contact lenses (#1)
Trauma
Inflammation
What antibiotics are used in treating corneal ulcer?
Moxi or cipro drops every 1-2 hours
What is seen on slit lamp with herpes keratitis?
Dendritic corneal epithelial defect (looks like a fern)
What is the treatment for herpes keratitis?
Antivirals - Trifluridine drops 9X/day, or - Acylovir 400mg PO 5X/day Cycloplegia (dilating drops) - Scopolamine 0.25% BID - Atropine 1% BID NO STEROIDS! (this is why to err to not give steroids-- be careful of ABx drops that come with steroids in them)
What age group is acute angle closure glaucoma seen in?
> 45yo
In what type of baseline vision abnormality (myopia, hyperopia, or astigmatism) is acute angle closure glaucoma seen in? Why?
Hyperopia, because the eyeball is short
What does acute angle closure glaucoma look like on exam? Why?
The pupil is mid-dilated (fixed) with the iris pushed up against a hazy cornea secondary to elevated IOP (40-60 mmHg, with normal as 10-20 mmHg)
What is the treatment priority of acute angle closure glaucoma?
Emergent
What disorders are seen in the lacrimal gland system?
Blepharitis Molluscum contagiosum (viral) Dacrocystitis Stye/chalazion Zoster Conjunctivitis
What is blepharitis?
Folliculitis of the eye lashes
What is dacrocystitis?
Stone blocking the lacrimal duct
How is dacrocystitis treated?
Treat for gram positive organisms
Discuss the 3 types of stye/chalazion?
If point outside– external
If point inside– internal
If just in the middle– chlazion
How are styes/chalazions treated?
Warm compress– put warm potato inside warm face cloth
When should a stye/chalazion be referred to ophtho?
If not drained after one month or becomes cellulite
Name the 3 types of conjunctivitis and the appearance of the discharge.
Bacteria– purulent
Viral– clear (pre auricular LAD)
Allergy– stringy, white
When should viral conjunctivitis be referred to ophtho?
Pain, photophobia, decreased vision
Name common causes of subconjunctival hemorrhage.
Sneeze
Rub eye
Is there a difference in severity if the subconjunctival hemorrhage encompasses some or all of the sclera?
No, there is no plane to contain it, so it may spread over the surface of the entire sclera
Where does a pingueculum occur in the eye? What causes it?
Seen at the 3 & 9 positions outside of the iris. Occurs secondary to sun exposure and dry eye (damage from the lid not closing over that area to protect it).
What is the aeromedical risk associated with pingueculum?
Actinic degeneration. Is DQ if crosses the limbus. Therefore, contact optho.
Name common causes of subconjunctival hemorrhage.
Sneeze
Rub eye
Is there a difference in severity if the subconjunctival hemorrhage encompasses some or all of the sclera?
No, there is no plane to contain it, so it may spread over the surface of the entire sclera
Where does a pingueculum occur in the eye? What causes it?
Seen at the 3 & 9 positions outside of the iris. Occurs secondary to sun exposure and dry eye (damage from the lid not closing over that area to protect it).
What is the aeromedical risk associated with pingueculum?
Actinic degeneration. Is DQ if crosses the limbus. Therefore, contact optho.
Differentiate pre- vs post-septal cellulitis?
A white, quiet eyeball is pre-septal (regardless of level of edema). Post-septal is painful, proptotic eye, EOM paralysis; is ophtho emergency.
Name 6 causes of painless vision loss.
Central retinal vein occlusion Central retinal artery occlusion Central serous chorioretinopathy Retinal detachment Optic neuritis Giant cell arteritis
Describe the retinal appearance with central retinal vein occlusion.
“Blood and thunder” funds as blood is backed up/blocked from returning to the cavernous sinus.
What patient population does central retinal occlusion occur in? What work-up should be done.
Usually older patients. Check hypercoag work-up in pts < 50yo.
How does the retina appear in central retinal artery occlusion?
Cherry red (spot).
In what patient population does central retinal artery occlusion occur?
> 55yo, think giant cell arteritis
Name 5 risk factors for central serous chorioretinopathy?
Young male
Type A (increased cortisol levels)
Corticosteroid use (example of guy rubbing around eyes)
High stress lifestyle
What is the treatment for central serous chorioretinopathy? What do you have to be careful of?
Observation (4-5 months). Off-base ophtho will want to seal leak with laser (ACS doesn’t like secondary to risk of vision changes).
How does central serous chorioretinopathy appear on the retina?
Bubble-like
How does central serous chorioretinopathy present?
Painless blurry or distorted central vision
How does a retinal tear present?
Flashes
New floaters
Curtain over vision
What is treatment for retinal detachment?
Reattach early, otherwise eye rest (no reading)
