Week 2: Opthalmology

Question 1

What is the clinical presentation & management plan for retinal detachment?

Answer 1

Photopsia, visual field defect, floaters

Emergent ophthalmology consult

Question 2

What is the clinical presentation & management plan for optic neuritis?

Answer 2

Preceding viral infection, pain with eye movement, dyschromotopsia, vision loss with exercise/heat, objects appear curved
Pupil light reflex decreased, decreased visual acuity, abnormal color vision, central scotoma, swollen optic disc

Emergent ophthalmology consult

Question 3

What is the clinical presentation & management plan for amaurosis fugax?

Answer 3

Transient monocular loss of vision d/t ischemia of the retina/choroid/optic nerve
Monocular Gray curtain from periphery, transient (2-30 minutes)

Send to ER for stroke workup

Question 4

How can you distinguish between viral and bacterial conjunctivitis?

Answer 4

Viral may have water discharge, bacterial will have thick purulent dc, sticky eyes

Question 5

What is the clinical presentation & management plan of allergic conjunctivitis?

Answer 5

Non-painful red eye
Bilateral, pruritis, clear/white stringy discharge; allergic shiners and boggy conjunctiva

resolve allergens present, oral antihistamine (loratadine, fexofenadine); ocular mast cell stabilizers; artificial tears, cool compresses, removal of contact lenses

Question 6

What is the clinical presentation & management plan of atopic/vernal conjunctivitis?

Answer 6

Non-painful red eye
Severe itching, burning and tearing
Ocular mast cell stabilizers

Question 7

What is the clinical presentation & management plan of chemical conjunctivitis?

Answer 7

Non-painful red eye
redness and irritation
Flush eyes

Question 8

What is the management plan of viral conjunctivitis?

Answer 8

artificial tears and cool compresses

this is highly contagious

Question 9

What is the management plan of bacterial conjunctivitis?

What timeframe should patients start to see improvement once starting on treatment?

Answer 9

empiric use of topical abx if no improvement in sx (gentamicin, cipro, azithromycin, erythromycin, sulfacetamide, trimethoprim/polymyxin B)

For peds:
Younger children - start empiric treatment
Older children: can utilize conservative options first

Should see improvement in sx within 3 days on tx

Question 10

What would you treat bacterial conjunctivitis with if it is also present w/ otitis media?

Answer 10

Augmentin

Question 11

What is the clinical presentation & management plan of uveitis?

Answer 11

Painful red eye
Acute pain, photophobia, pupil constriction, blurred vision, epiphora; ciliary flush
Management: same day referral to ophthalmology

Question 12

What is the clinical presentation & management plan of keratitis?

Answer 12

Painful red eye
Defect of the corneal epithelium – severe pain, redness, photophobia, discharge; green stain w/ fluorescein stain

Prompt referral to ophthalmology

Question 13

What is the clinical presentation & management plan of herpes zoster opthalmicus?

Answer 13

Painful red eye
malaise and Hutchinson’s sign; vesicular lesions along trigeminal nerve dermatome, foreign body sensation, tearing, blurred vision, photophobia

Oral antivirals, corticosteroids; urgent referral to ophthalmology

Question 14

What is the clinical presentation & management plan of scleritis?

Answer 14

Painful red eye
Severe eye pain, eye tenderness, blurred vision, inflamed sclera, tearing, photophobia

Urgent referral to ophthalmology

Question 15

What condition do these symptoms describe and how would you manage it?

Pain, redness, blurred vision, HA, N/V
Difference in pupillary diameter on the affected side

Answer 15

Acute Angle Closure Glaucoma - ER referral

Question 16

What condition do these symptoms describe and how would you manage it?

Yellow scales/swelling at the eyelid margin
burning, foreign body sensation, tearing, itching, discharge

Answer 16

Blepharitis

Lid hygiene, warm compresses
Doxycyline if severe

Question 17

What is the most common causative agent of blepharitis and hordeolums?

Answer 17

staph aureus

Question 18

What condition do these symptoms describe and how would you manage it?

Painful nodule on eyelid margin

Answer 18

Hordeolum

Lid hygiene, warm compresses

Question 19

What can a hordeolum progress to?

Answer 19

Chalazion

Question 20

What is the most common causative agent of periorbital and orbital cellulitis?

Answer 20

strep, staph

Question 21

What is the presentation of periorbital (preseptal) vs. orbital cellulitis?

Answer 21

Preseptal: eyelid edema, warmth and erythema extends beyond eyebrow; no actual “eye” symptoms
Orbital: conjunctival chemosis and injection, pain or restriction with eye movement, centered in the middle of the eye

Question 22

How do you manage periorbital vs. orbital cellulitis?

Answer 22

periorbital can be managed outpatient for those 2+ w/ dicloxacillin or cephalexin, clindamycin if suspected MRSA

Orbital cellulitis and periorbital less than 2yo needs hospitalization

Question 23

What is the presentation of nasolacrimal duct obstruction vs. dacryocystitis?

Answer 23

Nasolacrimal duct obstruction: ○ Chronic tearing, mucoid ocular dc, eyelash crusting, eyelid inflammation
Dacryocystitis: focal swelling, fluctuance, erythema or tenderness of the medial canthus

Question 24

How do you manage nasolacrimal duct obstruction vs. dacryocystitis?

Answer 24

Nasolacrimal: crigler massage (downward pressure on the lacrimal sac, warm compresses; topical abx if infection suspected

Dacryo: need referral to ENT - may need IV abx (Keflex, augmentin, erythromycin)

Question 25

What are the general categories of patho of dry eye syndrome?

Answer 25

autoimmune (aqueous) or evaporative

Question 26

What is the presentation of dry eye syndrome?

Answer 26

Dryness, foreign body sensation, burning or stinging pain, itching or ocular fatigue

Question 27

What test can be done for dry eye syndrome?

Answer 27

Schirmer test - test for aqueous production

- abnormal = <5mm w/o anesthesia, 10mm w/ anesthesia

Question 28

How can you manage dry eye syndrome?

Answer 28

avoid exacerbating enviro or tasks
artificial tears
refer to ophthalmology if moderate to severe sx or persistent/poorly controlled

Question 29

What is subconjunctival hemorrhage?

Is this something that should be worrisome?

Answer 29

bleeding between conjunctiva and sclera

No - should resolve on its own w/in 2 weeks

Question 30

What is the presentation and management of episcleritis?

Answer 30

non-painful localized scleral injection

artificial tears PRN