Red Eye Flashcards
How does HSV keratitis present? (5)
Pain Photophobia \+/- change in VA Corneal lesion -- dendritic or ulcer, or punctate \+/- herpetic lesions on lips
What is herpes ophthalmicus? How does it present (3)?
1) Reactivation of HSV in CN V1
2) - rash on forehead/upper lid
- involvement of nasociliary branch predicts ocular involvement
- pseudodendritis on cornea
How does the treatment of herpes ophthalmicus and HSV keratitis differ (5, 5)?
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
What is are the management considerations for chemical ocular burns? (7) What acid in particular requires an additional consideration?
- 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)
List complications of ocular chemical burns (7)?
Increased IOP Perforation Scarring Corneal Neovascularization Glaucoma Cataracts Symblepharon (Adhesion of bulbar + palpebral conjunctiva)
What is the difference between bulbar + palpebral conjunctiva?
Bulbar = conjunctiva overlying the sclera Palpebral = conjunctiva lining the eyelids
What intraocular FBs are well tolerated? Which are poorly tolerated? (7 , 2)
WT - stone - glass - plastic - iron - lead - steel - aluminum PT - organic copper
What is your management of INTRAocular FB? (5)
Consult ophtho -- examine in OR Protective shield Tetanus NPO Analgesia/antiemetics
Most common bugs for bacterial conjunctivitis? (6)
Strep pneumo S. aureus H. influenza Pseudomonas aureginosa Chlamydia Gonorrhea
Most common bugs for viral conjunctivitis? (5)
Adenovirus Enterovirus Coxackie virus HSV Rubella
What is epidemic keratoconjunctivitis? How is it managed?
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.
What is more likely in viral conjunctivitis vs. bacterial? (3)
- cobblestoning/follicles (lower lid esp.)
- pre-auricular nodes
- viral prodrome
- -> IF PRESENT. not good NPV
What are characteristics of allergic conjunctivitis? (5)
Pruritis Watery discharge Bilateral conjunctival injection Hx atopy Mild eyelid swelling
What is management of allergic conjunctivitis? (4)
- 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
What is otitis conjuncitivitis and prevelance? What is most common pathogen?
Treatment?
25% patients with conjunctivitis have concurrent otitis media even w/o ear pain.
Mostly h. influenzae – tx with PO anitbiotics (no topical abx)
Causes of conjunctivitis in neonatal period and what is this called? (4) What is the management? (3)
I.e. Ophthalmia neonatorum Chemical irritant Chlamydia Gonorrhea HSV
Culture eye (PCR)
FULL septic w/u (incl LP)
Irrigate eye
What are causes of conjunctivitis in toddlers/school-aged kids? Prevalence of bacterial vs. viral?
Bacteria 2x > viral
- H. influenza
- S. pneumonia
- Gonorrhea
- Chlamydia
How does chlamydia vs. gonorrhea ophthalmia neonatorum differ in presentation? (2)
Chlamydia (+other bugs/viruses) typically at 5 - 14d, and more mild conjuncitivitis
Gonorrhea – more severe, can disseminate, day 2 -7
How would you treat chlamydia conjunctivitis in a child? (1) Gonorrhea conjuncitivits? (2)
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
What percent of bacterial conjuncitivitis present with bilateral eyes? AOM?
What about viral?
Bact: - 50 - 75% - 30-40% AOM Viral: - 35% - 10% AOM
What are the symptoms/findings of scleritis? (7) How does this differ from episleritis? (3)
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
What are the typical etiologies of scleritis? (7)
Rheumatoid arthritis Vasculitis (e.g. Wegners) Malignancy Gout TB Viral: HSV/EBV Surgery
What is the treatment of scleritis? (5)
PO NSAIDs \+/- (often) topical steroids \+/- cycloplegics Emergent ophtho f/u \+/- immunosuppresion (systemic CCS + immunosuppresion if topical fails)
What are the complications of scleritis? (5)
Decreased VA Uveitis Ulcerative keratitis Glaucoma Cataracts
What are the clinical fx of episcleritis? (4)
Rapid Onset
Minimal pain
Normal VA
Localized (nondiffuse) redness
What are the etiologies of episcleritis? (3)
Inflammatory processes – benign, idiopathic, dilation of episcleral vessels
What are the two types of uveitis? (2)
Anterior uveitis / iritis = iris and ciliary body involvement
Panuveitis = ant + intermediate and posterior chambers
What is the typical presentation of uveitis? (8)
Painful EOM Pain Photophobia Erythema \+/- change VA ciliary flush sluggish / miotic pupil Cells / flare \+/- hypopyon
Etiologies of uveitis? (4 general; give at least 4 specific)
– 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
Treatment considerations of uveitis? (4)
F/U ophtho w/n 24h
Topical steroids
+/- mydriatics (prevent synchiae)
Measure IOP (r/o AACG)
Complications of uveitis? (4)
Glaucoma
Cataracts
Retinal detachment
Synechiae (adhesion of iris to cornea or lens)
What are the referral indications for lid lacerations? (7)
Orbital septal injury Canalicular laceration Levator tendon laceration Canthal tendon laceration IO FB Lid margin Extensive tissue loss/anatomy distortion Full thickness laceration
What is the difference between a stye and chalazion? (3)
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
What is management of styes/chalazia?
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)
What is dacryocystitis? What are the common organisms? (6)
Infection of lacrimal sac 2o to obstruction of nasolacrimal duct @ sac jxn
Steph pneumo S. aureus H. flu Serratia marcescens Pseudomonas emerging MRSA
What is management of dacryocystitis? (6)
- 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
What is blepharitis? What is the management? (4)
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)
What is the grading for hyphema? (5)
0 = microscopic I = <1/3 II = 1/3 - 1/2 III = > 1-2 IV = full 8 ball
What is traumatic hyphema (blunt) associated with?
Cyclodialysis (Tear in which ciliary muscle avulsed from scleral spur)
What are indications for admission for hyphema? (4)
- Hyphema > 50% (can lead to severely high IOP, perm corneal damage)
- SCD
- uncontrolled IOP (diamox, , timolol etc, clonidine…)
- anticoagulated patients
What is general management for traumatic hyphema? (5)
- 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
When does hyphema rebleed occur and in what proportion?
5 - 30%, at days 2 - 5 typically
What are complications of hyphema?
Corneal Staining Elevated IOP/glaucoma Rebleed Synechiae (iris adhere to cornea) Optic neuropathy
How do you manage elevated IOP in SCD patients?
(Unsure - ? methazolamide)
When do you consider antibiotics in patients w/ corneal abrasion? (4)
Immunocomp
Contact lens wearers
Significantly contaminated wound e.g. organic material
Deep
What treatment options are there for corneal abrasion for abx? (3) Other treatments?
Erythromycin ointment (TID - QID depending on person) Vigamox = moxifloxacin (TID) -- need pseudomonas coverage for contact lens wearers --> moxi or cipro
What are complications of corneal abrasions? (4)
Bacterial keratitis
Corneal Ulcer
Traumatic irritis
Recurrent erosion syndrome
How do corneal lacerations differ from corneal abrasions? (1)
Deeper than a corneal abrasion – if full thickness laceration causes globe rupture. Linear-ish, should be able to see some depth
Management of corneal laceration? (4)
Ophtho consult
ABx
Topical cycloplegics (paralyse ciliary muscle)
Patch eye (per AAO)
Complications of corneal laceration?
Endopthalmitis
What are common cause of corneal lacerations? (5)
Cutting metal Carving stone Breaking Glass Trimming grass Cutting wood
What are etiologies of corneal ulcers? (2)
Post contact lens use
Bacterial infection post-corneal trauma
Management of corneal ulcer? (5)
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
Complications of corneal ulcer? (2)
Perforation
Hypopion
Etiologies of photokeratitis? (5)
Sunlamps High Altitude Snow/Water reflection Welder's Arc Eclipse viewing
Tx of photokeratitis? (4)
Topical abx, cycloplegics, analgesia, f/u ophtho w/n 24h
Typical presentation of photokeratitis? (4)
Latent 6-10h (like sunburn)
Pain + photophobia
Decreased VA
Punctate lesions (uptake)
What is pinguecula and pterygium? What is the difference?
Pinguecula is yellow spot or bump (Deposit) of tissue over conjunctiva; pterygium (Surfer’s eye) is when these tissue covers part of the cornea.
What is blepharitis?
Tx?
Inflammation of eyelids from meibomian gland blockae
What are treatment considerations for high IOP in SCD/hyphema?
Cannot use diamox - predisposes to sickling.
What is the management of orbital floor #? (4)
Nasal decongestant Ice packs ABX prophylaxis (?only if infected sinus) Avoid valsalva, nose blow No driving
What are XR signs of orbital wall/floor #? (6)
Sinus opacification Air-fluid level Floor disruption (#) Tear drop sign Orbital empysema Soft tissue swelling
Advantage of CT over XR for orbital floor #? (6)
Size of defect Muscle entrapment GLobe rupture IO hemorrhage Optic nerve injury Retrobulbar hematoma Intracranial injury
Signs of orbital wall #? (7)
Ecchymoses Tissue swell Hypoesthesia of trigeminal n. Double vision Blurry vision Enopthalmos Ptosis
What is the oculocardiac reflex?
Decrease in HR by 10%+ (+/- N, pre/syncope) following pressure to globe or traction of EOM.
Signs suggestive of open globe? (5)
Loss of ant chamber depth Prolapsed iris Irregular or teardrop pupil Blood in ant chamber 360o conjunctival hemorrhage
What is sympathetic ophthalmia?
Inflammation of injured eye weeks to months later – autoimmune reaction to exposed uveal tissue in injured eye.
Etiologies of endophthalmitis? (4)
Penetrating trauma
FB
Sx
Hematogenous seeding
Tx of endophthalmitis? (3)
EM ophtho consult
IV +/- intravitreal abx
Admit
Symptoms of orbital cellulitis? (6)
Swelling Proptosis Change in VA Diplopia Pain with EOM Optic disc edema Increased IOP Fever
Common etiologies of orbital cellulitis? (2)
Staph
Strep
Dx of orbital cellulitis (2)?
CT
Ophtho exam
What is iridodialysis?
Tear of iris root causing movement of pupil from ciliary body, can look like two pupils.
What is your tx for orbital cellulitis?
Ophtho
CTX + Vanco IV
Admit
