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EMERG > Red Eye > Flashcards

Red Eye Flashcards

1
Q

How does HSV keratitis present? (5)

A 
Pain
Photophobia
\+/- change in VA
Corneal lesion -- dendritic or ulcer, or punctate
\+/- herpetic lesions on lips
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2
Q

What is herpes ophthalmicus? How does it present (3)?

A

1) Reactivation of HSV in CN V1
2) - rash on forehead/upper lid
- involvement of nasociliary branch predicts ocular involvement
- pseudodendritis on cornea

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3
Q

How does the treatment of herpes ophthalmicus and HSV keratitis differ (5, 5)?

A

HSVK

  • topical acyclovir 1% 9 x /d x 14 –> consider PO if topical not available or if process severe
  • NO steroids (worsen infxn)
  • emergent ophtho f/u
  • NSAIDs for pain
  • consider prophylactic topical abx if symptoms of iritis

HO

  • PO antivirals (higher dose, acyclovir 800 5x/d or valacyclovir 1000 mg TID x 7-10d)
  • topical antibiotics
  • emergent ophtho f/u
  • consider topical steroids (discuss with ophtho)
  • lubrication to maintain healthy ocular surface
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4
Q

What is are the management considerations for chemical ocular burns? (7) What acid in particular requires an additional consideration?

A
  • Freeze eye (pre-irrigation)
  • Morgan lens IRRIGATION!!! (2L acids, 4L alkali minimum)
  • Re-check pH 10 min post-irrigation ( target > 7)
  • ABX (ointments preferred)
  • IOP check
  • Analgesia
  • may consider steroids (consult with ophtho)

– for hydrofluoric acid, consider calcium gluconate (1% solution for irrigation)

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5
Q

List complications of ocular chemical burns (7)?

A 
Increased IOP
Perforation
Scarring
Corneal Neovascularization
Glaucoma
Cataracts
Symblepharon (Adhesion of bulbar + palpebral conjunctiva)
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6
Q

What is the difference between bulbar + palpebral conjunctiva?

A 
Bulbar = conjunctiva overlying the sclera 
Palpebral = conjunctiva lining the eyelids
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7
Q

What intraocular FBs are well tolerated? Which are poorly tolerated? (7 , 2)

A 
WT
- stone
- glass
- plastic
- iron
- lead
- steel
- aluminum
PT
- organic
copper
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8
Q

What is your management of INTRAocular FB? (5)

A 
Consult ophtho -- examine in OR
Protective shield
Tetanus
NPO
Analgesia/antiemetics
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9
Q

Most common bugs for bacterial conjunctivitis? (6)

A 
Strep pneumo
S. aureus
H. influenza
Pseudomonas aureginosa
Chlamydia
Gonorrhea
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10
Q

Most common bugs for viral conjunctivitis? (5)

A 
Adenovirus
Enterovirus
Coxackie virus
HSV
Rubella
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11
Q

What is epidemic keratoconjunctivitis? How is it managed?

A

Keratoconjuncitivitis (with punctate keratitis) caused by adenoviruses with tendency to occur in epidemics. Require 14d off work. Manage with supportive care + topical steroids for moderate-severe disease.

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12
Q

What is more likely in viral conjunctivitis vs. bacterial? (3)

A
  • cobblestoning/follicles (lower lid esp.)
  • pre-auricular nodes
  • viral prodrome
  • -> IF PRESENT. not good NPV
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13
Q

What are characteristics of allergic conjunctivitis? (5)

A 
Pruritis
Watery discharge
Bilateral conjunctival injection
Hx atopy
Mild eyelid swelling
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14
Q

What is management of allergic conjunctivitis? (4)

A
  • Ketotifen 1 drop BID 0.025% (antihistamine; alternatives azelastine, emedastine)
  • Patanol 1 drop BID (anthistamine, anticholinergic, 0.1% )
  • Nasal spray (e.g. avamys)
  • Claritin PO PRN / daily / other OTC anti-allergy meds
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15
Q

What is otitis conjuncitivitis and prevelance? What is most common pathogen?
Treatment?

A

25% patients with conjunctivitis have concurrent otitis media even w/o ear pain.
Mostly h. influenzae – tx with PO anitbiotics (no topical abx)

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16
Q

Causes of conjunctivitis in neonatal period and what is this called? (4) What is the management? (3)

A 
I.e. Ophthalmia neonatorum
Chemical irritant
Chlamydia
Gonorrhea
HSV

Culture eye (PCR)
FULL septic w/u (incl LP)
Irrigate eye

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17
Q

What are causes of conjunctivitis in toddlers/school-aged kids? Prevalence of bacterial vs. viral?

A

Bacteria 2x > viral

  • H. influenza
  • S. pneumonia
  • Gonorrhea
  • Chlamydia
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18
Q

How does chlamydia vs. gonorrhea ophthalmia neonatorum differ in presentation? (2)

A

Chlamydia (+other bugs/viruses) typically at 5 - 14d, and more mild conjuncitivitis
Gonorrhea – more severe, can disseminate, day 2 -7

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19
Q

How would you treat chlamydia conjunctivitis in a child? (1) Gonorrhea conjuncitivits? (2)

A

PO Medications (not topical) – oral doxycycline, azithromycin.

If gono:

  • CTX IV/IM x1 (50mg/kg to max 125 mg)
  • can’t use ctx if getting IV calcium, give cefotaxime (100mg/kg IV)instead
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20
Q

What percent of bacterial conjuncitivitis present with bilateral eyes? AOM?
What about viral?

A 
Bact:
- 50 - 75%
- 30-40% AOM
Viral:
- 35%
- 10% AOM
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21
Q

What are the symptoms/findings of scleritis? (7) How does this differ from episleritis? (3)

A 
Severe pain
Radiates to ipsilateral fae
Photophobia
\+/- change VA
Blueish-purplish hue
50% bilateral
50% systemic etiology

Vs episcleritis:

  • Blue/purple hue vs. red-hue
  • Typically involves more of the globe and deeper vessels of the globe (scleral vessels darker, more radial pattern)
  • Apply phenylephrine (2.5%) – episcleral vessels will blanch + pupil will dilate, scleral vessels will not
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22
Q

What are the typical etiologies of scleritis? (7)

A 
Rheumatoid arthritis
Vasculitis (e.g. Wegners)
Malignancy
Gout
TB
Viral: HSV/EBV
Surgery
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23
Q

What is the treatment of scleritis? (5)

A 
PO NSAIDs
\+/- (often) topical steroids
\+/- cycloplegics
Emergent ophtho f/u
\+/- immunosuppresion (systemic CCS + immunosuppresion if topical fails)
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24
Q

What are the complications of scleritis? (5)

A 
Decreased VA
Uveitis
Ulcerative keratitis
Glaucoma
Cataracts
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25
Q

What are the clinical fx of episcleritis? (4)

A

Rapid Onset
Minimal pain
Normal VA
Localized (nondiffuse) redness

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26
Q

What are the etiologies of episcleritis? (3)

A

Inflammatory processes – benign, idiopathic, dilation of episcleral vessels

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27
Q

What are the two types of uveitis? (2)

A

Anterior uveitis / iritis = iris and ciliary body involvement

Panuveitis = ant + intermediate and posterior chambers

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28
Q

What is the typical presentation of uveitis? (8)

A 
Painful EOM
Pain
Photophobia
Erythema
\+/- change VA
ciliary flush
sluggish / miotic pupil
Cells / flare
\+/- hypopyon
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29
Q

Etiologies of uveitis? (4 general; give at least 4 specific)

A

– most often is autoimmune inflammation of uvea

Post-traumatic
Infectious (HSV, CMV, TB, HIV, spirochetal infxn etc)
Autoimmune (esp. seronegative arthritides, ankylosing spondylitis, psoriatic arthropathy, IBD arthritis, reactive arthritis)
CTD

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30
Q

Treatment considerations of uveitis? (4)

A

F/U ophtho w/n 24h
Topical steroids
+/- mydriatics (prevent synchiae)
Measure IOP (r/o AACG)

31
Q

Complications of uveitis? (4)

A

Glaucoma
Cataracts
Retinal detachment
Synechiae (adhesion of iris to cornea or lens)

32
Q

What are the referral indications for lid lacerations? (7)

A 
Orbital septal injury
Canalicular laceration
Levator tendon laceration
Canthal tendon laceration
IO FB
Lid margin
Extensive tissue loss/anatomy distortion
Full thickness laceration
33
Q

What is the difference between a stye and chalazion? (3)

A

Stye = hordeolum

  • infection of eyelid glands
  • internal meibomian gland or extender gland of zeis/or apocrine gland of moll
  • red + tender

Chalazion

  • sterile, chronic inflammation from blocked meibomian gland
  • may develop from internal hordeolum
  • hard + nontender
34
Q

What is management of styes/chalazia?

A

Conservative tx: warm compresses (10-15min, 3-5x/d)
ophtho ref for I+D if not responsive
If infected oil glands may need abx (blepharitis, cellulitis)

35
Q

What is dacryocystitis? What are the common organisms? (6)

A

Infection of lacrimal sac 2o to obstruction of nasolacrimal duct @ sac jxn

Steph pneumo
S. aureus
H. flu
Serratia marcescens
Pseudomonas
emerging MRSA
36
Q

What is management of dacryocystitis? (6)

A
  • Massage / warm compress
  • Systemic antibiotics
  • CUlture (pressure to NL duct to express fluid)
  • If infants, medical emergency – can lead to post-septal orbital cellulitis – admit
  • Occasionally req. ophtho for drainage of sac (once infxn controlled)
  • Otherwise d/c w/ ophtho f/u 24-48h
37
Q

What is blepharitis? What is the management? (4)

A

Inflammation of the eyelid at the base of the eyelashes due to obstruction of meibomian glands.

Conservative: warm massage with washcloth 10-15min 3-5x/d
Clean lids with cotton swab (mild baby shampoo) BID
If concern for infection, topical abx (azithro, erythro, levo)
If uncomplicated d/c fu w/n week to ophtho (1-3d if infection concern)

38
Q

What is the grading for hyphema? (5)

A 
0 = microscopic
I = <1/3
II = 1/3 - 1/2
III = > 1-2 
IV = full 8 ball
39
Q

What is traumatic hyphema (blunt) associated with?

A

Cyclodialysis (Tear in which ciliary muscle avulsed from scleral spur)

40
Q

What are indications for admission for hyphema? (4)

A
  • Hyphema > 50% (can lead to severely high IOP, perm corneal damage)
  • SCD
  • uncontrolled IOP (diamox, , timolol etc, clonidine…)
  • anticoagulated patients
41
Q

What is general management for traumatic hyphema? (5)

A
  • If < 50% + uncomplicated, dispo home with elevated HOB (45%) and gentle ambulation at home
  • analgesia (NSAIDs)
  • topical/oral agents to lower IOP (avoid carbonic anhydrase inhibitors in SCD due to increased sickling)
  • consider antifibrinolytics (systemic/topic aminocaproic acid)
  • -> in general ALL tx in conjunction with ophtho
  • f/u next day with ophtho to r/a IOP and evaluate for paracentesis criteria
42
Q

When does hyphema rebleed occur and in what proportion?

A

5 - 30%, at days 2 - 5 typically

43
Q

What are complications of hyphema?

A 
Corneal Staining
Elevated IOP/glaucoma
Rebleed
Synechiae (iris adhere to cornea)
Optic neuropathy
44
Q

How do you manage elevated IOP in SCD patients?

A

(Unsure - ? methazolamide)

45
Q

When do you consider antibiotics in patients w/ corneal abrasion? (4)

A

Immunocomp
Contact lens wearers
Significantly contaminated wound e.g. organic material
Deep

46
Q

What treatment options are there for corneal abrasion for abx? (3) Other treatments?

A 
Erythromycin ointment (TID - QID depending on person) 
Vigamox = moxifloxacin (TID)
-- need pseudomonas coverage for contact lens wearers --> moxi or cipro
47
Q

What are complications of corneal abrasions? (4)

A

Bacterial keratitis
Corneal Ulcer
Traumatic irritis
Recurrent erosion syndrome

48
Q

How do corneal lacerations differ from corneal abrasions? (1)

A

Deeper than a corneal abrasion – if full thickness laceration causes globe rupture. Linear-ish, should be able to see some depth

49
Q

Management of corneal laceration? (4)

A

Ophtho consult
ABx
Topical cycloplegics (paralyse ciliary muscle)
Patch eye (per AAO)

50
Q

Complications of corneal laceration?

A

Endopthalmitis

51
Q

What are common cause of corneal lacerations? (5)

A 
Cutting metal
Carving stone
Breaking Glass
Trimming grass
Cutting wood
52
Q

What are etiologies of corneal ulcers? (2)

A

Post contact lens use

Bacterial infection post-corneal trauma

53
Q

Management of corneal ulcer? (5)

A 
No contacts!
PO analgesia
ABx (moxiflox q15 min x 1h, then q1h d+n until see ophtho; consider adding tobra if large or if on visual axis)
?Cycloplegics
Urgent ophtho f/u
54
Q

Complications of corneal ulcer? (2)

A

Perforation

Hypopion

55
Q

Etiologies of photokeratitis? (5)

A 
Sunlamps
High Altitude
Snow/Water reflection
Welder's Arc
Eclipse viewing
56
Q

Tx of photokeratitis? (4)

A

Topical abx, cycloplegics, analgesia, f/u ophtho w/n 24h

57
Q

Typical presentation of photokeratitis? (4)

A

Latent 6-10h (like sunburn)
Pain + photophobia
Decreased VA
Punctate lesions (uptake)

58
Q

What is pinguecula and pterygium? What is the difference?

A

Pinguecula is yellow spot or bump (Deposit) of tissue over conjunctiva; pterygium (Surfer’s eye) is when these tissue covers part of the cornea.

59
Q

What is blepharitis?

Tx?

A

Inflammation of eyelids from meibomian gland blockae

60
Q

What are treatment considerations for high IOP in SCD/hyphema?

A

Cannot use diamox - predisposes to sickling.

61
Q

What is the management of orbital floor #? (4)

A 
Nasal decongestant
Ice packs
ABX prophylaxis (?only if infected sinus)
Avoid valsalva, nose blow
No driving
62
Q

What are XR signs of orbital wall/floor #? (6)

A 
Sinus opacification
Air-fluid level
Floor disruption (#)
Tear drop sign
Orbital empysema
Soft tissue swelling
63
Q

Advantage of CT over XR for orbital floor #? (6)

A 
Size of defect
Muscle entrapment
GLobe rupture
IO hemorrhage
Optic nerve injury
Retrobulbar hematoma
Intracranial injury
64
Q

Signs of orbital wall #? (7)

A 
Ecchymoses
Tissue swell
Hypoesthesia of trigeminal n.
Double vision
Blurry vision
Enopthalmos
Ptosis
65
Q

What is the oculocardiac reflex?

A

Decrease in HR by 10%+ (+/- N, pre/syncope) following pressure to globe or traction of EOM.

66
Q

Signs suggestive of open globe? (5)

A 
Loss of ant chamber depth
Prolapsed iris
Irregular or teardrop pupil
Blood in ant chamber
360o conjunctival hemorrhage
67
Q

What is sympathetic ophthalmia?

A

Inflammation of injured eye weeks to months later – autoimmune reaction to exposed uveal tissue in injured eye.

68
Q

Etiologies of endophthalmitis? (4)

A

Penetrating trauma
FB
Sx
Hematogenous seeding

69
Q

Tx of endophthalmitis? (3)

A

EM ophtho consult
IV +/- intravitreal abx
Admit

70
Q

Symptoms of orbital cellulitis? (6)

A 
Swelling
Proptosis
Change in VA
Diplopia
Pain with EOM
Optic disc edema
Increased IOP
Fever
71
Q

Common etiologies of orbital cellulitis? (2)

A

Staph

Strep

72
Q

Dx of orbital cellulitis (2)?

A

CT

Ophtho exam

73
Q

What is iridodialysis?

A

Tear of iris root causing movement of pupil from ciliary body, can look like two pupils.

74
Q

What is your tx for orbital cellulitis?

A

Ophtho
CTX + Vanco IV
Admit

EMERG (14 decks)

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