Ophtho Flashcards
Components of physical exam for red eye
Visual acuity, pupil shape and reactivity, gross appearance of sclera and conjunctiva, EOM, palpation of preauricular nodes + fluorescein and slit lamp exams
Presence of contact lenses
Common DDx of red eye (list 8)
- Conjunctivitis: infectious (viral including HSV), bacterial, chlamydial
- Allergic or seasonal conjunctivitis
- Chemical conjunctivitis (or other physical agents such as smoke)
- Systemic disease (iritis, scleritis-may have tender red eye with bluish hue) (JIA, KD, IBD, CF, status post-radiation, BMT, SJS)
- Trauma: corneal or conjunctival abrasion, hyphema, traumatic iritis, FB, subconjunctival hemorrhage, traumatic glaucoma, noxious material
- Dry eye syndromes
- Abnormalities of lids and/or lashes: blepharitis, stye or chalazion, periorbital or orbital cellulitis
- Contact lens problems: infectious keratitis (corneal ulcer), allergic conjunctivitis, poor fit, overwear, corneal abrasion
Ophtho findings in Kawasaki disease
bulbar conjunctivitis, limbal sparing, minimal or no discharge
Symptoms and signs of iritis
Red eye, headache, pain, photophobia, conjunctival injection, vision blurring, hypopyon
Name 2 conditions that present with pseudomembranes
Adenovirus (epidemic keratoconjunctivitis) and SJS
Clinical findings of adenovirus conjunctivitis
pseudomembrane, preauricular nodes, tearing, usually bilateral, can see photophobia, sandy foreign-body sensation
Which cranial nerves control the extra-ocular movements
LR-6 (lateral rectus), SO-4 (superior oblique), rest CN3
List 6 life-threatening causes of strabismus
intracranial mass, elevated ICP, myasthenia gravis, orbital tumor, orbital cellulitis, head trauma, meningitis, neoplastic infiltrate of EOM, superior orbital wall fracture, retinoblastoma causing vision loss
Findings in Horner syndrome
mild ptosis, miosis (constricted), ipsilateral anhidrosis
How to determine which pupil is abnormal in anisocoria?
a. Bigger difference in a bright room (pupils normally constrict) – failure to constrict –> large pupil is abnormal
b. Bigger difference in dark room (pupils normally dilate) – failure to dilate –> smaller pupil is abnormal
c. Same difference in dark or light room = physiologic anisocoria
Emergency causes of visual disturbances (list 3)
alkali or acid burns, central retinal artery occlusion, ruptured globe
Toxicologic causes of visual disturbances
methylene glycol, hydrocarbons, quinine, mercury, quinidine, digoxin
What is a “footballer’s migraine”?
total blindness after mild head trauma, with normal physical exam, lasts minutes-hours = cortical blindness
How does central retinal artery occlusion (CRAO) present? And what are some predisposing conditions?
Sudden, painless loss of vision in one eye (with pale white optic nerve) – traumatic or embolic (increased risk in vasculitis, sickle cell, severe HTN)
List 6 causes of acute diplopia
Blowout fractures Poisoning CNS pathology (tumor, bleed, IIH) shunt malfunction arnold-chiari malformation myasthenia gravis head trauma
Clinical findings of a ruptured globe
Tear drop pupil (apex points to the direction of the rupture), 360 subconjunctival hemorrhage, enopthalmos (posterior displacement of eye in the socket) +/- hyphema
What complication of ruptured globe leads to poor visual outcome?
Endophthalmitis: infection of anterior and posterior segments of the eye, leads to poor visual outcome
Management of a ruptured globe?
Stop eye exam, (no eye drops), shield the eye, pain control, antiemetics, elevated head of bed, place eye shield and immediate referral to ophtho; consider broad spectrum antibiotics
Signs and symptoms of a blowout fracture
restriction EOM
enopthalmos (eye sunken in socket)
infraorbital anesthesia (infraorbital nerve)
diplopia
step-off deformity
subcutaneous emphysema
may see proptosis if orbital hemorrhage present (can compress optic nerve)
retrobulbar hemorrhage (pain, proptosis, vision loss from central retinal artery occlusion and may need urgent canthotomy)
Gold standard for imaging in suspected blowout fracture?
CT scan orbit with axial and coronal views and the brain especially if orbital roof fracture suspected
Which eyelid lacerations require ophtho consult?
- full-thickness perforation of lid
- ptosis
- involvement of lid margin
- damage to tear drainage system
- tissue avulsion
- eyeball injury
How to make diagnosis of corneal abrasion?
- Dx by fluorescein + direct visualization with blue light
- Tetracaine 0.5 % : diagnositic ; if pain relieved then there is an ocular surface problem (conjunctiva or cornea)
- Test vision
Which corneal abrasions require ophtho referral?
If pain or FB sensation continues for more than 2-3 days, increasing pain, increasing redness, contact lens wearers, large abrasion over visual axis, hx of ocular herpes
Management of corneal abrasion?
- Do not patch (doesn’t help healing or pain control)
- R/O foreign body
- Lubricating antibiotic ointment (polytrim, erythromycin, bacitracin, vigamox) for 3-5 days; pain control with NSAID/tylenol. NO topical anesthetics
Larger corneal abrasion and those involving visual axis = should see ophtho within 24 hours
Which bacteria is involved in bacterial keratitis in contact lens wearers
Pseudomonas
Complications seen in hyphema (2)
1) rebleeding within first 5 days (especially in sickle cell)
2) increased intraocular pressure –> glaucoma
Management of hyphema
- Urgent ophtho consult
- Shield the eye (not a patch)
- bedrest with HOB to 45 degrees
- cycloplegic +/- corticosteroid eye drops
- avoid NSAIDs
- sometime admitted to hospital for observation
How does traumatic iritis present?
Inflammation in anterior chamber 1-3 days after trauma – eye pain, photophobia, redness (ciliary flush), visual loss, constricted pupil on affected side
Treatment of traumatic iritis?
- Ophtho consult – often associated with other ocular injuries
- Tx: dilating eye drops, topical steroids
Clinical findings of orbital cellulitis?
Decreased or painful EOM, proptosis, decreased vision, papilledema, toxic and highly febrile
Complications of orbital cellulitis
subperiosteal abscess, orbital abscess, CSVT, brain abscess
Which bacteria cause conjunctivitis?
strep pneumo, H. influenzae, S.aureus, Moraxella catarrhalis (chlamydia and gonorrhea in neonates)
How does gonococcal conjunctivitis present in neonates? Management?
sudden, severe, ++pus and exudate, swollen eyelids. Can cause corneal ulceration and perforation -> blindness. Tx: hospital admission, IV ceftriaxone, ophtho consult, saline ocular lavage hourly, topical erythromycin ointment.
Fluorescein pattern seen in HSV keratitis?
Dendrites
Management of conjunctivitis?
Symptomatic relief for all cases: artificial tears, cool compresses
Topical antibiotics for bacterial causes (erythromycin, trimethroprim/polymyxin B) – not required for viral causes
See ophtho if no improvement within 1 week
Cultures of purulent fluid in neonates
Red flags for conjunctivitis?
reduced visual acuity, significant pain/photophobia, corneal opacities, FB sensation, *contact lens wearers
Management of ocular chemical injuries?
o Standard IV set, maximum flow rate, across the eye from medial to lateral. Can use Morgan lens attachment. Irrigate for 2 L or 20 minutes for alkali (1L or 5 minutes for acids). Also evert the upper lid and irrigate in that position.
o Check pH afterwards, aim for 6.5-7.5, equal between both eyes (if only 1 eye was exposed) – repeat pH checks a few times over 30 minutes to ensure it remains stable
o Examine cornea and conjunctiva with fluorescein afterwards
o Consult ophtho
Which ocular chemical injury is worse - alkali or acids?
Alkali
Tx of a stye
eyelash scrubs daily, warm compressed 4X/day, topical abx rarely needed, incision and curettage by ophtho if non-resolving after 4-6 weeks.
Eyelid swelling - DDx
Acute - stye (external hordeolum)
Chronic - chalazion
Complications of dacrocystitis
periorbital or orbital cellulitis, sepsis, meningitis
Steps to finding a “lost contact lens”
look for fine line on the sclera, evert the lids, apply topical anesthetic, patient looks down, sweep over upper fornix gently with moistened cotton-tip applicator. Can use fluorescein drops which would permanently dye the contact lens.
Classic triad of infantile glaucoma?
tearing, photophobia, blepharospasms (eyelid squeezing)
List 5 findings of congenital glaucoma
- Excessive tearing (usually bilateral)
- Rhinorrhea
- Photophobia
- Corneal clouding
- Buphthalmos (asx eye size)
- Increased IOP
- Abnormal red reflex
List 4 complications of congenital glaucoma
Ambylopia Vision loss/blindness Strabismus Large refractive error Myopia Astigmatism Corneal scarring
List 4 serious, major causes of sudden vision loss
Optic Neuritis Central Retinal artery occlusion (CRAO) or central retinal vein occlusion (CRVO) Stroke Complicated Migraine Retinal detachment Ruptured globe Occipital contusion
5 causes of tramatic acute red /painful eye
Corneal abrasion Traumatic Iritis (does not present for 24 to 72 hours after blunt trauma to the eyeball) Hyphema Subconjunctival hemorrhage Foreign body Chemical conjunctivitis
Kid comes in with unilateral red eye, watery discharge and pre-auricular nodes. what is the most likely cause
Herpes keratoconjunctivitis
