Week 2 Ophthalmology and ENT Flashcards
non painful red eye conditions
conjunctivitis (allergic, viral, bacterial, chemical)
dry eye syndrome
subconjunctival hemorrhage
If acute otitis media is associated with conjunctivitis, that’s commonly due to _____ bacteria. So treat with ____
haemophilius influenza
Amoxicillin clavulanate
Viral conjunctivitis key findings
Adenovirus
- redness, itchy, swollen conjunctiva
- tearing, clear watery discharge
- fever, headache, anorexia, malaise
- blepharitis
- pharyngitis with enlarged preauricular nodes
- concurrent URI
Adenoviral conjunctivitis management
- Cool compresses
- Lubricating drops
- Good handwashing
- avoid touching the eyes,
- don’t share any towels
- wash pillowcases
- resolves in 1-2 weeks
- NO prophylaxis antibiotics
- Antihistamine ophthalmic for sx relief
If non responsive conjunctivitis in sexually active adults, suspect
chlamydial conjunctivitis
- concurrent genital infection
Bacteria conjunctivitis key findings
- Yellow - green purulent discharge
- Encrusted and matted eyelid on awakening
- injected conjunctiva
- photophobia
- petechiae on bulbar conjunctiva
- normal vision
bacterial conjunctivitis: what organisms?
haemophilus influenzae, strep pneumoniae, and staph aureus.
H flu more common in children (dec-april)
Bacterial conjunctivitis: adult management vs children
adult: conservatively if not immunocompromised = observe or empiric antibiotic x 1 week
- if Chlam/gon = refer CDC
children: empiric (trimethoprim + polymyxin B sulfate ophthalmic soln, erythromycin 0.5% ointment to cover H influ),
Older children/teens = watch and wait! resolves in 1 week no matter what
Allergic conjunctivitis results from ____ and is associated with ___
igE mediated hypersensitivity
a/s with atopic disorders, asthma, atopic dermatitis, seasonal, perennial plant
allergic conjunctivitis sx’s and on exam
- bilateral severe eye itching, teary
- rhinitis
- clear, white stringy mucoid discharge
- teary boggy conjunctiva
- allergic shriners/dark circles
allergic conjunctivitis management
Identify/avoid the allergen
Cold compresses and artificial tears
Oral antihistamines if systemic allergy sx’s
- NO antibiotics/steroids
- eye drops:
- Ketotifen (antihistamine)
- Patanol or Olopatadine (prescription); Used > 3 yrs old
how does chemical conjunctivitis occur
Benign: fumes, smoke, chlorine or toxic
- if causes severe pain, vision disturbances = refer!
vernal conjunctivitis
type of allergic conjunctivitis
common in childhood and spring
bilateral
more severe
atopic conjunctivitis
common in >50 yrs old
bilateral itchy, burning, tearing
tx w mass stabilizer eye drop or refer
refer!
dry eye syndrome sx’s
- foreign body sensation
- scratchy gritty feeling stinging, tearing
what test to do for dry eye vs lacrimal problem? Explain.
schirmer test
assesses aqueous production. using filter paper and placing it in the inferior culdesac, measure tear production after 5 mins. < 5 mm = tear deficiency
dry eye management and treatment
Avoid causative medications
anticholinergics or diuretics
Avoid air conditioners or fans
1st line: preservative-free lubricants (OTC) if not work refer and cyclosporin rx
Subconjunctival hemorrhage
- benign
- from increased intrathoracic pressure (coughing sneezing, straining)
- no pain
- common in HTN or blood thinner pts
- resolves in 2 weeks
what are ocular adnexal disorders? Name them.
disorders of structures that surround the eye
Blepharitis
Hordeolum (stye)
Chalazion
Nasolacrimal duct obstruction
Preseptal and orbital cellulitis
flakey, yellow scaly debris over eyelid margins on awakening
inflammation of eyelid or follicles
Blepharitis
blepharitis management (3)
- 1st line: warm compresses x 10 mins several times a day
- dilute baby shampoo with warm water and just cleanse the eyelid every day
- Topical antibiotic is only needed if due to a staph infection.
usu resolves with conservative treatment.
If it’s persistent or severe, doxycycline often not needed.
Define hordeolum (stye) and symptoms
Acute infection and inflammation of eyelid gland d/t to a blocked meibomian gland
Staph aureus
- contact lens use
- painful furuncle/nodules
- NO injection, NO discharge, NO redness
- foreign body sensation
resolves 1-2 weeks (ruptures from compresses or I&D)
Define chalazion and management
Chronic, inflammation of eyelid from lipogranuloma of meibomian
non-painful, non-infectious nodule; results from hordeolum
Warm compresses, gentle massage, weeks to resolve, I&D if persistent
Hordeolum vs Chalazion
chalazion results from a hordeolum
Chalazion: located AWAY from the eyelid margin, more firm, and it’s non-tender, deeper in eyelid
Hordeolum: closer to the eyelid margin
Nasolacrimal duct obstruction (dacryostenosis) symptoms and management
- tearing, mucoid discharge
- blepharitis
- painful, tenderness/swelling over duct
- elevated WBC from exudate
manage:
- Daily massage of the lacrimal duct. If it doesn’t resolve by 12 months = refer for probing procedure.
Complications from dacryostenosis (2)
Dacryocystitis (inflammation of duct = infection)
I&D or systemic antibiotics
Peri/orbital cellulitis
preseptal cellulitis aka periorbital cellulitis sx’s and treatment
- NOREFER!
- staph aureus
- superficial infection
- NO painful eye movement, eye is spared, no fever
- infection that’s ANTERIOR to orbital septum
- tx < 1 yrs: hospitalization, IV antibiotics
- >2 yrs: mild (no vision changes, eye moves, no ptosis):
- oral amoxicillin, cefdinir, cefpodoxime 1-2 weeks
- warm soaks 2-4 hrs x 15 mins
- f/u 24 hrs
- oral amoxicillin, cefdinir, cefpodoxime 1-2 weeks
what is orbital cellulitis and how does it affect the eye?
- IMMEDIATE CT SCAN! Can go blind
- severe infxn of soft tissue POSTERIOR to orbital septum
- affects eye: PAIN with eye movement or restricted eye movement, chemosis, ptosis (late), dec visual acuity
Painful red eye conditions
- URGENT REFERRAL!
- Severe eye pain
- Loss of visual acuity
- Loss pupillary reactivity
- Hypopyon
- Neutrophils and fibrin in anterior chamber
- Hyphema
- Blood in aqueous anterior chamber
pain, photophobia, conjunctiva hyperemia, hypopyon, cloudy appearance, pupil constriction, blurred vision, epiphora
ciliary flush, pupil constriction
uveitis
inflammation of middle layer (choroid, ciliary body, iris)
inflammation of cornea affecting visual acuity
- can progress to corneal ulceration and blindness
- Severe pain, foreign body
- Photophobia
- Erythema
- Spasms of eyelid
keratitis
keratitis major risk factor and diagnostic
trauma: contact lens
seen using a slit lamp, stained green with a fluorescent strip
Herpes zoster ophthalmicus’s classic symptom is called ___
hutchinson sign
lesion at tip/right side of nose (but absent does not r/o it)
vesicular eruption along trigeminal nerve causing conjunctivitis
severe eye pain, tenderness, blurred vision, tearing, photophobia
pain radiates into the brow bone or jaw
occurs in autoimmune disorder disorders (uveitis, IBD, lupus)
scleritis
inflammation of sclera
episcleritis
superficial inflammation
not painful, resolves w/o tx
severe pain, photophobia, decreased vision, disrupted tear film over corneal epithelium
uses fluorescein stain (woods lamp)
from trauma to eye like fingers, lens, airbags, job
corneal abrasion
corneal abrasion management
- topical antibiotic ointment.
- ibuprofen
- Eye patch does NOT improve healing but if must wear, max 24-48 hrs
- Educate it’ll heal within 1-3 days. If not improving after 3 days, refer
- if have these, refer:
- purulent discharge, worsening eye pain, photophobia = refer !
Severe pain; nausea, vomiting; halos around lights; photophobia; conjunctival hyperemia; pupil mid-dilated and
fixed; firm globe; shallow anterior chamber
acute angle closure glaucoma
abrupt increase in intraocular pressure
REFER!!!!
sudden onset of visual field defects, floaters, photopsia/flashing lights
retinal detachment
refer! need surgery and NPO
1 eye, dyschromatopsia (abnormal color vision), pain with eye movement, vision loss worse with exercise and heat, central scotoma (blind spot in center)
preceding viral infection
objects appear curved
optic neuritis
optic neuritis management
REFER!
IV then oral steriods
brain MRI (demyelinating lesions for MS)
transient monocular loss of vision
grey curtain peripheral vision
30 seconds
amaurosis fugax
form plaque buildup in carotid artery
refer! get cardio workup, assess carotid
otitis media risk factors
- allergies
- upper respiratory infection
- cleft palate
- adenoid hypertrophy
- tobacco exposure.
otitis media sx’s
- ear pain
- pulling at ear
- fever (otitis externa has NO fever)
- TM erythema and pain
- worse when child lying down
- otorrhea
mild vs severe otitis media
mild: < 102.2F, sx’s < 48 hrs
severe: >102.fF, sx’s > 48 hrs
otitis media management
Pain control (Tylenol)
Only treat amoxicillin(-clavulanate) or cephalosporin if healthy children (no Down S, cleft palate, tubes):
- severe sx’s > 6 months, then f/u 48-72 hrs of onset of sx’s
- no severe sx’s, < 24 months, bilateral
- if sx’s persist after 48-72 hrs of sx onset
DON’T treat if:
- < 24 months, no severe sx’s, unilateral
- > 24 months, not severe sx’s
Complications of otitis media
- mastoiditis (fever, pain behind ear, swelling posterior ear over mastoid process)
- perforation of TM
- otorrhea
- effusion (fluid; hearing test if > 3 months; refer if > 6 months or hearing lost but watch and wait 48 hrs if mild)
- cholesteatoma (cyst in ear; pearly white lesion = refer!)
acute otitis externa risk factors and sx’s
inflammation of external canal aka swimmers ears
- foreign bodies (q tips, ear buds)
- sx’s (pain when palpate tragus/auricle, otorrhea, fullness/clogged, hearing loss, intense itching)
- TM normal
- infection with edema, discharge, erythema
- furuncles or small abscesses at hair follicles
- infection of epidermis
otitis external differentials and treatment
- acute otitis media
- TMJ because sometimes the pain can refer into the jaw.
- fungal infection (uncommon)
- tx (topical antibiotic drops)
Otitis externa education
- educate cerumen = protective mechanism
- NO Q-tips
- Keep their ears dry.
- NO swimming or submerging their head until the infection has cleared.
- Use hair dryer when they come out of the pool or shower = ears dry
- If 1st episode, use earplug or cap when swimming
-
improve in 5 to 7 days.
- come back if they’re not improving or if their symptoms are worse
Persistent AOM vs Recurrent AOM
Persistent AOM: does not resolve when finished antibiotic therapy or recurs within days of treatment
Recurrent AOM: 3 separates bouts of AOM w/in 6 month period or 4 within 12 month period
- often positive hx of otitis media and other ENT dz
AOM with perforation treatment
if mild, wait and watch. Tylenol/motrin, hydration
if no improvements within 48 hours, amoxicillin
Peripheral vertigo conditions
- benign paroxysmal vertical
- vestibular neuritis
- bacterial labryinthinis
- viral
- meniere’s disease
- neuroma
central vertigo conditions
- Brain stem PIA
- Infarcts
- Neurological tumors
- Multiple Scerlosis
- Basilar migraines or vestibular migraines
- Cardiac - bradycardia, tachy, anemia, medications, toxins, hypotension
episodic dizziness/vertigo, triggered, nausea, nystagmus
confirm with what test and what treatment
dix hall pike to confirm benign paroxysmal positional vertigo and treat with epley maneuver, meclizine, antiemetic
refer to vestibular rehab if epley doesn’t work
vestibular neuritis
viral or post inflammatory disorder affecting vestibular portion of 8th CN or from otitis media
persistent continuous vertigo/dizziness, occurs spontaneously, horizontal nystagmus, nausea/vomiting, instability gait, tinnitus
what is it? & treatment?
vestibular neuritis
1st line: anticholinergics and antihistamines(Meclizine), antiemetics, vestibular rehab
episodic, spontaneous vertigo, unilateral hearing loss, unilateral tinnitus, ear fullness, nausea, vomiting
meniere’s disease
meniere’s disease management
excessive fluid putting pressure and swelling distorts sound and balance
- referral to ENT
- limit sodium, alcohol, caffeine
- H1 receptor agonist (beta histamine, diuretics)
herpes zoster oticus (Ramsay Hunt) symptoms
herpes zoster activation affecting geniculate ganglion
severe ear pain and vertigo, ipsilateral facial paralysis
vesicles in auditory canal and auricle
Bell’s palsy vs Ramsay hunt
both have ipsilateral facial paralysis and vessel in auditory canal/aurical as typical features
BUT Ramsay hunt has severe ear pain and vertigo
labyrinthe concussion
from traumatic peripheral vestibular injury after concussion
vertigo, n/v, imbalance, hearing loss/issues
vestibular neuritis vs labyrinthine concussion
labyrinthine has hearing loss
vestibular neuritis has tinnitus but hearing intact
vestibular neuritis vs labyrinthine concussion
labyrinthine has hearing loss
vertigo, migraine, h/a, photophobia, nausea photophobia
vestibular migraine
What does the HINTS exam do?
diagnose vestibular neuritis vs stroke in pt with hrs/days of ongoing vertigo and nystagmus
- nystagmus
- vertigo skew test
- head impulse (want rapid movement in both eyes = vestibular neuritis)
yellow raised growth on conjunctiva
-usu on side near nose; deposit of fat, protein, calcium
pinguecula
from UV (sun), wind, dust
wear sunglasses, glasses/goggles
growth of fleshy tissue (blood vessels) that may start as pinguecula
pterygium
from UV (sun), wind, dust
wear sunglasses, glasses/goggles
corneal arcus
blue or gray crescent shape (arc) made of lipid (fatty) deposits that curves around the outer edges of the cornea of the eye.
from high blood pressure, high cholesterol, and atherosclerosis
