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Tintinalli Section 19 - Eyes, ENT, and oral surgery > S19C236 - Eye Emergencies > Flashcards

S19C236 - Eye Emergencies Flashcards

1
Q

Components of an eye exam:

A
  • VA (tested at 20 feet -6m)
  • fields
  • EOM
  • pupils
  • lids (and underneath)
  • slit lamp (conjunctiva, sclera, cornea, ant chamber, iris, lens, vitreous)
  • IOP
  • funduscopy
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2
Q

VA

A
  • top number is distance at which pt can read the letter
  • bottom number is distance at which a person with normal vision can read the letter
  • pinhole only allows parallel light in so centers the focus on the retina so gives an estimate of the patients correted VA (if vision does not improve with pinhole this is a sign of something more significant going on_
  • VA is determined by smallest line a pt can read with one half of the letters correct
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3
Q

DDx Abnormal EOM

A
  • trauma, muscle entrapment
  • thyroid orbitopathy
  • myositis
  • cranial nerve palsy from stroke, MG, DM, HTN, tumor, aneurysm, infxn, trauma
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4
Q

Causes of monocular diploplia

A
  • corneal irregularity
  • lens problem
  • malingering
  • *resolution of monocular diplopia with one eye covered may be pathology of an extraocular muscle or its innervation
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5
Q

Teardrop pupil

A

-prolapsed iris

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6
Q

Afferent pupillary defect

A
  • represents optic nerve d/o, retinal pathology or opacification of vitreous with blood
  • aka marcus-gunn pupil
  • no baseline anisocoria
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7
Q

Anisocoria ddx

A
  • posterior communicating artery aneurysm
  • baseline (physiologic)
  • uncal herniation
  • topical cycloplegic
  • uveitis
  • anticholinergic med (ipratropium that is splashed into the eye)
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8
Q

Orbital cellulitis: sx/signs

A
  • limited EOM
  • decreased VA
  • chmosis
  • proptosis
  • abnomral pupillary response
  • involvement of CN 3,4,6 suggest cavernous sinus thrombosis
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9
Q

Stye: defn (external hordeolum)

A
  • acute infxn (staph) of eyelash and associated sebaceous gland (zeis) or sweat gland (moll), located at lash line and has appearance of small pustule
  • internal hordeolum is acute infxn of meibomian glands associated with the eyelashes, pustule occurs on inner surface of tasral plate
  • pain, edema, erythema of eyelid
  • tx: warm compresses QID, erythromycin ointment BID x7-10d
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10
Q

Chalazion

A
  • acute or chronic inflm of eyelid d/t blockage of meibomian/zeis oil glands in tasral plate
  • usually painless lump that develops along lid margin, occassionally mild erythema
  • tx: same as for stye (warm compresses, erythromycin ointment)
  • may require steroid injxn or incision and curettage
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11
Q

Blepharitis

A
  • inflm, crusting, swoleen pruritic eyelids, conjuncitval injxn
  • daily cleansing of edges of eyelids
  • consider abx drops/ointment qhs
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12
Q

Hutchinson’s sign

A
  • HZV involvement of nasociliary nerve with cutaenous lesions on tip of nose
  • high likelihood of ocular involvement
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13
Q

Corneal ulcer tx

A
  • all should be referred to ophtho
  • complications: scar, preforation, synechiae, glaucoma, cataracts
  • topical Abx q1h
  • optho can consider steroids and cycloplegic drops
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14
Q

Iritis findings

A
  • flare and cells in anterior chamber on slit lamp
  • red eye, photophobia, decreased vision
  • painful unilateral eye
  • no purulect d/c
  • periilmbal flush although there may be diffuse conjunctival injection too w/o mucopurulent d/c
  • consensual photophobia
  • miosis
  • if severe: hypopyon
  • fluorescine staining may show abrasion, ulcer, dendritic lesions
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15
Q

Iritis Tx

A

-homatropine or tropicamide OD gtt for pain relief (so iris isn’t moving)
-referral to ophtho
-pred-forte drops q1h
-

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16
Q

Endophthalmitis

A
  • usually occurs with a hx of grinding or surgery
  • Sx: ha/, pain, photophobia, vision loss, ocular d/c
  • erythematic swollen lids, conj/scleral injxn, chemosis, hypopyon, uveitis
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17
Q

Vitreous hemorrhage: cause and findings

A
  • causes: trauma, diabetic retinopathy, posterior vitreous detachement
  • sudden painless vision loss and sudden floaters, unilateral hazy vision
  • RF: diabetes, SCD
18
Q

Conjunctival abrasions

A
  • less innervation than cornea therefore less irritating
  • scratchy FB senstaion ,mild pain, tearing, rarely photophobia
  • normal VA
  • if very small no tx
  • otherwise give erythromycin optho ointment 0.5% QID x2-3d
19
Q

Corneal abrasion

A
  • usually heal w/in 24-48h
  • topical NSAIDs can be used
  • topical Abx (erythro if not needing to cover pseudomonas, cipor/vigamox for contact lens wearers)
  • if abrasion in central visual axis then f/u w/in 24h, if not then f/u 48-72h
20
Q

UV keratitis

A
  • snow blindness, welder’s flash
  • UV light damages corneal epithelial cells
  • sx develop 6-12h after exposure
  • slow onset FB sensation, severe pain, photophobia
  • slit lamp: diffuse puncate corneal edema and abrasions
  • patch both eyes, cycloplegics, topical Abx, oral analgesics
  • healing occurs in 24-36h
21
Q

Hyphema

A
  • all must be seen by ophtho
  • those that occupy 1.3 or less of anterior chamber can be followed as out-pt
  • do not give sickle cell pts CAI drops (diamox), causes sickling of cells and blockage of trabecular meshwork and outflow track
22
Q

blow-out #

A
  • sign: subcu emphysema, diploplia, restricted upward gaze
  • oral Abx (keflex)
  • 1/3 associated with ocular trauma (abrasion, traumatic iritis, hyphema, lens dislocation, retinal tear/detachment)
23
Q

Globe rupture: signs

A
  • decreased VA
  • teardrop pupil
  • RAPD
  • shall anterior chamber or flat
  • hyphema
  • positic seidel test
  • lens dislocation
  • lage subconjunctival hemorrhage
  • hemorrhagic chemosis
  • uveal prolapse
24
Q

Tx Globe rupture

A
  • elevate head of bed

- place protective metal eye shielf

25
Q

Retrobulbar hematoma

A

-if pressure >40 consider lateral canthotomy

26
Q

Chemical ocular injury

A
  • irrigate with NS 1-2L
  • alkali are worse b/c they go deeper
  • check pH if >7.4 continue irrigation until pH remains 7 for >30 mins
  • f/u opththo
  • tx with erythro ointment QID
27
Q

Acute angle closure glaucoma

A
  • sudden onset, painful, h/a, blurred vision, n/v, fixed mid-position pupil, hazy cornea (from edema)
  • usually pressure >50 (>60 in tints)
  • tx: timolol, mannitol if severe, alpha-adrenergic agonist, CAI (acetazolamide) (increase outflow and decrease fluid production),
  • definitive tx: laser iridectomy
28
Q

Optic neuritis

A
  • causes: MS, idiopathic, viral, vaccinations, mono, sarcoidosis
  • decreased vision over hours to days
  • painful, affects color vision, possible visual field defects, RAPD
  • retrobulbar neuritis causes: papilledema, ischemic optic neuropathy, hypertensive retinopathy, orbital tumor
  • MRI for prognostication
29
Q

CRAO

A
  • painless loss of vision
  • first branch of ICA is ophthalmic artery
  • retina infarcts, becomes pale, less transparent and edematous
  • macula becomes a ‘cherry red spot’
  • causes: emobli, GCA, vasculatitis (lupus, polyarteritis nodosa), SCD, trauma, vasospasm (migraine), glaucoma
30
Q

CRVO

A
  • causes retinal venous stasis, edema, hemorrhage
  • RF: DM, HTN, CVA, CVD, hyper coagulable states, vasculitis, glaucoma, thyroid d/o, orbital tumor
  • ranges from blurriness to total vision loss
  • fundoscopy: optic disk edema, diffuse retinal hemorrhages, blood and thunder fundus
  • differentiate from papilledema b/c contralateral fundus will be normal and from optic neuritis b/c in ON the peripheral retina is normal
31
Q

Floaters

A
  • if b/l then intracranial source (migraine)
  • if monocular
  • usual onset is 55yo but can start at 20yo
  • will exist for years until gel liquefies enough for floaters to sink to bottom
32
Q

Retinal Detachment

A
  • vitreous pulls on retina which triggers flashing light sensation
  • fluid gets behind retina and starts peeling it away
  • Sx: floaters, flashing lights, dark veil/curtain, decreased peripheral or central visual acuity
  • emergency referral to ophtho w/in 24h
  • large retinal detachment may look like a billowing parachute on fundoscopy
  • some may occur w/o a tear, just present with mild to severe vision loss and visual field defect which may be positional (exudative)
  • tractional retinal detachments occur in diabetes, SCD, prematurity, toxocariasis, trauma
33
Q

GCA - temporal arteritis

A
  • can cause painless vision loss
  • pts >50y , often with hx of PMR
  • sx: h/a, jaw claudication, myalgias, fatigue, fever, anorexia, temporal artery tenderness
  • if left w/o tx, contralateral eye will also become involved w/in days-weeks
  • Px: RAPD may be present, elevated CRP, ESR (70-110mm/h), temporal artery bxx
34
Q

Bell’s Palsy

A
  • cranial nerve VII pathology
  • palsy of ipsilateral upper and lower face
  • involvement of orbicularis muscle means pt can not close their eyelids completely
  • tx: eye drops, patch the affected eye, refer to ophtho for corneal monitoring, antivirals, corticosteroids
35
Q

DM/HTN cranial nerve palsies

A
  • pupil is spared in acute DM CN III palsy (afferents run in affected central nerve, efferents run in unaffected peripheral nerve)
  • EOM: inhibited ipsilateral medial gaze, upward gaze, downward gaze, ptosis
  • lateral gaze preserved
  • diploplia worsens with adduction
  • cranial nerve VI palsy: lateral gaze diminished on ipsilateral side
36
Q

Posterior Communicating Artery Aneurysm

A
  • acute CN III palsy WITH ipsilateral pupillary dilatation
  • may also have h/a
  • expansion of aneurysm causes compression of outer fibers of CN III where the pupillomotor fibers are located
  • tx: Lower BP, CT, neurosurgery
37
Q

Horner Syndrome: what and ddx

A
  • ipsilateral ptosis, miosis and anhydrosis
  • pathology of sympathetic nerves that control upper eyelid and iris dilators from brainstem to carotid artery (sympathetic plexus surrounds carotid artery)
  • dx: CXR, CT, CTA of head and neck
  • causes: CVA, tumor, interal carotid artery dissection (usually >30yo), herpes zoster, trauma
  • children: neuroblastoma, lymphoma, metastasis
38
Q

Papilledema

A
  • b/l edema of head and optic nerve d/t raised ICP
  • causes: malignant HTN, pseudotumor cerebri, intracranial tumors, hydrocephalus
  • if only one eye with papilledema it could be foster-kennedy syndrome
  • disc margins blurred, cup diminished, nerve head elevated with vascular congestion, flame hemorrhages adjacent to nerve head
  • VA rarely affected (whereas optic neuritis usually does have decreased vision)
39
Q

Idiopathic intracranieal HTN (pseudotumor cerebri)

A
  • increased ICP, papilledema, normal CSF, normal CT/MRI
  • occurs at any age
  • Sx: n/v, h/a, blurred vision, visual field defects, +/- CN VI paresis causing diplopia
  • if CT normal do LP and record opening pressure, consult neurosurgery
  • tx: acetazolamide 500mg PO BID
40
Q

Bulbar U/S

A

-indications: decreased/loss vision, pain, trauma, intraocular FB, head injury

Tintinalli Section 19 - Eyes, ENT, and oral surgery (7 decks)

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