Week 3 'Eyes' Flashcards
Acute Allergic Conjunctivis
SSxs:
PE:
Lab:
Allergic conjunctivitis:
a. acute allergic - also called vernal (seasonal) conjunctivitis
recurs in spring and lasts through summer (with hay fever)
Signs & Sxs: sudden, mild to moderate to bilateral severe swelling of conjunctiva & lids
not painful, but pruritus is extremely common
clear, watery discharge is typical
PE:Palpebral conjunctiva appears pale; conjunctival injection is moderate
preauricular adenopathy is absent; chemosis (thickened, boggy conjunctiva) is common.
discharge amount is usually sparse; discharge quality is clear, thin, stringy
Lab: Wright stain of discharge shows eosinophils
Chronic Allergic Conjuctivitis
SSxs:
Chronic allergic – non-seasonal, on/off throughout year
little evidence of inflammation but itching, burning and photophobia may be present
eyelid eversion may show velvety projections on palpebral conjunctiva
Giant Papillary Conjunctivitis
Etiology:
SSxs:
PE:
giant papillary conjunctivitis – allergy to soft contact lenses; may be slow to develop
etiology: autoimmune response to pt’s own proteins or to the “trauma” of the lens wear
Signs & Sxs: excessive pruritus, mucous production, increasing intolerance to contact use.
PE: inflamed conjunctiva – red, itchy, and irritated
may have a thick discharge, worse in morning
eyelid eversion: see giant papillae usu on upper palpebral conjuctitva (cobblestone granulations)
Viral Conjunctivitis
What is it most commonly caused by?
SSxs:
PE:
Viral conjunctivitis: !adenovirus!, common, lasts 1 – 2 wks
Signs & Sxs: pruritus, minimal pain; clear, thin, watery discharge is typical.
occasionally severe photophobia and foreign-body sensation occurs, usually caused by adenovirus when associated with keratitis (inflammation of cornea) (epidemic keratoconjunctivitis [EKC])
common concomitants: sore throat, nasal discharge (rhinitis)
PE:pre-auricular adenopathy is common in EKC and herpes; chemosis is variable.
discharge: amount—moderate or sparse; quality—thin, seropurulent
conjunctival injection is moderate to marked
Herpes simplex virus (viral conjunctivitis)
SSxs:
-early:
-late:
Herpes Simplex virus conjuctivitis HSV (less common than adenovirus)
affects one eye, most often occurs on the cornea which results in herpes keratitis
recurrences usu take form of dendritic keratitis, with a characteristic raised lesion of the cornea “veins of a leaf”; nodules at terminal end of each “branch”
Signs & Sxs:
early: foreign body sensation lacrimation
photophobiaconjunctival injection
late: anesthesia of cornea & dendritic keratitis lesion diagnostic
ulceration and permanent scarring of cornea may result (loss of vision)
Triggers fever, stress, sunlight, trauma
associated with oral herpes, genital herpes
immune compromised pts (HIV, DM)
zoster (shingles) on the tip of the nose moving to cornea, resulting in uveitis and glaucoma
Bacterial Conjunctivitis:
Etiology: What are the most common pathogens? (2)
SSxs:
PE:
Bacterial conjunctivitis:
Etio: Staph and Strep are most common pathogens
Signs & Sxs:
acute onset, minimal pain, occasional pruritus
PE: preauricular adenopathy; chemosis is common.
Discharge: copious; thick and purulent
conjunctival injection is moderate to marked
acute infx - gram stain or culture to identify
chronic may produce little or no d/c except for crusting of eyelashes in AM, no itching
Neisseria gonorrhea (bacterial conjunctivitis)
Adult ssxs:
Neonate ssxs:
Neisseria gonorrhea
i) adult - rare, 12-48 hr incubation period
severe, purulent discharge, usu unilateral, lids swollen
complications: corneal ulceration, abscess, blindness
ii) neonate- purulent discharge, 2-5 days after birth, may be severe lid edema
Chlamydia trachomatis
i) adults
ii) neonates
Chlamydia trachomatis
i) adult inclusion conjunctivitis
“swimming pool conjunctivitis”- infected genital secretions
other exposures from sharing eye make-up, etc
tends to be chronic with exacerbation and remission
pre-auricular adenopathy is occasional
discharge: scant; seropurulent
conjunctival injection is moderate
ii) neonatal inclusion conjunctivitis (inclusion blennorrhea—exposure from cervix)
5-14 day incubation, sx may be mild to severe
chemosis, mucopurulent d/c, often bilateral, no corneal damage occurs
Trachoma (granular conjunctivitis) Caused by \_\_\_\_\_\_\_\_\_\_\_. Endemic in what countries? Most common in what ages? SSxs: PE:
Trachoma (Granular conjunctivitis) chronic infection of cornea and conj. caused by chlamydia
Endemic in Africa, Asia, Middle East, Latin America, Pacific Islands, and aboriginal
communities in Australia
active disease most common in preschool children
Signs & Sxs: Often asymptomatic incubation of 7 days, most contagious in early stages usu. bilateral mucopurulent keratoconjunctivitis photophobia, lacrimation, pain PE: conjunctival surface of the upper eyelid shows a follicular/ inflammatory response (yellow- gray granules eyelid edema, may be corneal ulceration cornea may have limbal follicles, superior neovascularization (pannus), and punctate keratitis.
Pinguecula
SSxs:
Pinguecula: (pin gwek u la)
harmless slightly raised bumps, fatty deposits (yellow-white material) under conjunctiva (nasal side)
no tendency to grow onto the cornea, may become inflamed and red
Pterygium
SSxs:
Pterygium: (ter ij e um)
conjunctival thickening from chronic inflammation from wind, dust
often distinct triangular lesion which may grow over cornea & affect vision
Corneal Trauma
Etiology:
SSxs:
PE:
Corneal trauma
Etiology: foreign body and/or abrasion
Signs & Sxs: pain, photophobia, blepharospasm (spasm of lid, treated with botulism toxin to paralyze lid), may be blurred vision
PE: evert lid to inspect for foreign body, Check cornea for foreign material or hemorrhage
fluorescein stain picked up by blue lens
Check PERRLA
Ophthalmoscopic exam for retinal or vitreous hemorrhages or retinal detachment.
Corneal Ulcer
Etiology:
SSxs:
Corneal ulcer:
Etiology: HSV most common cause contact lenses (particularly soft lenses)
traumatic corneal injury chronic topical steroid use
varicella-zoster virus (VZV)—shingles in ophthalmic branch of trigeminal N
{Hutchinson’s sign: The nasocilliary branch of CN V enervates tip of nose and cornea
leads to loss of corneal sensation, may lead to blindness}
Bacterial infections - staphylococcal spp, P aeruginosa, Streptococcus pneumoniae, and Moraxella spp
Signs & Sxs:
erythema of eyelid and conjunctivamucopurulent discharge
foreign body sensationblurred vision
photophobiapain
Band Keratopathy
Band keratopathy:
hard, white calcified plaques (bands) at 2, 5, 7, 10 o’clock of limbus
may be hypercalcemia, secondary to kidney disease
Arcus Senilis (corneal arcus)
What is it?
Age:
May be related to _____________.
Arcus senilis (corneal arcus):
whitish deposits around limbus; usu in elderly
may be related to hyperlipoproteinemia
UV keratitis
Etiology:
SSxs:
PE:
UV keratitis:
Etiology: exposure to UV lights, welding arcs, “snow blindness”
Radiation damage to the corneal epithelium is cumulative
Signs & Sxs: onset of foreign-body sensation, irritation, pain, photophobia, tearing,
blepharospasm
PE: decreased visual acuity 6-12 hours after the exposure diffuse staining with fluorescein dye (loss of epithelium) lid edema, conjunctival hyperemia variable
List some of the main questions to ask for the eye during Hx:
ask about vision changes, eye pain, discharges, etc
Eye exam should include
EYE EXAM—see CPD lab notes Inspection of structures Visual acuity—central, peripheral, color PERRLA: Extra ocular movements: Fundoscopic exam
If someone reports vision loss, what questions should you ask?
DDX:
Vision Loss
Ask rate of onset, pain or no, central or peripheral, uni- or bilateral?
DDX: Vision Loss
Errors of refraction; Define
i. Hyperopia:
ii. Myopia:
iii. Astigmatism:
iv. Presbyopia:
Errors of Refraction
i. Hyperopia (far-sightedness) - most common; distant objects are clear, and close-up objects blurry.
ii. Myopia (near-sightedness) - faraway objects will appear blurry
iii. Astigmatism - the cornea or the lens has a slightly different surface curvature. Often present at birth and may occur in combination with nearsightedness or farsightedness.
iv. Presbyopia - a slow loss of ability to see close objects or small print. With age, the lens becomes less pliable and eventually cannot accommodate in response to the action of the ciliary muscles
What questions should you ask if someone presents with conjunctival discharge?
Conjunctival discharge: color, quality, quantity, irritating?
bacterial or viral conjunctivitis, allergic reaction
List some common causes of eyestrain:
Eyestrain
COMMON: prolonged reading or close work, computer screens
sensation of tired eyes, increasing difficulty focusing or seeing, eye dryness, headache
Photophobia
Causes:
Photophobia - abnormal visual intolerance of light.
Causes:
eye infectioneye injuryconjunctivitisallergies
acute glaucomacataractsmigraine headache
Eye inflammation (uveitis, iritis, keratitis)
Corneal disorder (foreign body, abrasion, ulcer)
Scotoma:
aka:
Scintillating scotoma:
Scotoma “blind spots”
area of partial or complete blindness, usually within the central 30-degree area. From damage to nerve fiber layer in retina.
“scintillating scotoma” - an irregular outline around a luminous patch in the visual field following mental or physical work, eyestrain or migraine prodrome (visual aura)
Floaters
aka:
Etiology:
May be associated with:
Floaters (perception of them called “myodesopia”)
Deposits within the eye’s vitreous humor Appear as “spots” or “threads” which slowly “float”
Visible because of the shadows they cast or refraction of light
Etiology:
Developmental, acquired (degenerative changes in vitreous humor or retina)
May be associated with
autoimmune uveitisdiabetic retinopathy
posterior vitreous detachment (PVD) with aging
What types of HA’s can come with eye symptoms
Headaches with eye symptoms
types: cluster, sinusitis, migraines
Field Defects Hemianopsia: 1)homonymous hemianopsia: 2) Crossed hemianopsia: 3)Quadrant hemianopsia:
Field defects:
Hemianopsia: blindness or decreased vision in half of visual field of one or both eyes (All are concerning!)
1) Homonymous hemianopsia:
same side of both eyes, can be transient, lose pupillary reflexes, usu optic tract problem
2) Crossed hemianopsia:
opposite sides, often pituitary problem
3) Quadrant hemianopsia:
level of brain, pupil reflex present as optic tract not affected
Dry eyes
Etiology:
Dry eyes: Etiology Aging (esp postmenopausal) Medications: antihistamines, nasal decongestants Post-eye surgery Mal-positioned eyelids Dry climate Vitamin A deficiency Chemical burn to eye Keratoconjunctivitis sicca*
Keratoconjunctivitis sicca
*Keratoconjunctivitis sicca
bilateral dryness of eyes from lack of tears, more common in adult females
eye redness, swelling, itching, burning and perhaps reduced vision
Can be in conjunction with autoimmune dz. (RA, SLE or Sjogren’s)
Eye contusion
aka:
Eye Contusion: from blunt trauma “black eye”
Red eye
Hemorrhage of conjunctival vessels:
Hemorrhage of conjunctival vessels –
sclera gets very red; due to minor trauma- straining, sneeze or cough
not painful; no vision change, but alarming to pt.
Red eye Injection: a. Conjunctival b. Ciliary (which is more common?)
Injection (Congestion of vessels)
a. Conjunctival (common) - peripheral, brick-red, tortuous superficial vessels; fade toward the iris; move with conjunctiva; blanch and refill with pressure (eg conjunctivitis)
b. Ciliary (less common) – (also known as ciliary flush or circumcorneal injection) violet or rose colored; fine, deep vessels that radiate out from limbus fade toward periphery; don't blanch or move with conjunctiva. (eg iritis or acute glaucoma)
Acute Uveitis Most common age range: Most commonly classified as i) ii) iii) Etiology: a)ankylosing spondylitis: b)Reactive arthritis: c)infx: d)Sarcoidosis: e)auto-immune:
SSxs:
PE:
Acute Uveitis (inflammation of uveal tract) (iris, ciliary body, choroids)
most common in adults (age 20-50 yr)
anatomically classified as:
i) anterior (iritis), ciliary body (cyclitis), or both (iridocyclitis)
ii) intermediate (peripheral uveitis)
iii) posterior; rare, serious condition (choroiditis, chorioretinitis)
Etio: often is associated with an underlying systemic disease, or may be idiopathic
i) ankylosing spondylitis - more common in men
pain, redness, photophobia in 1 or both eyes
HLA-B27 +, SI involvement, rib cage involved
ii) Reactive arthritis- (triad of arthritis, urethritis, conjunctivitis)
mainly males, HLA-B27 +, SI joint involved, previous STI or GI infection
iii) infection- HSV, cytomegalovirus, VZV, toxoplasmosis, TB, histoplasmosis, syphilis
iv) sarcoidosis—retina becomes inflamed, can lead to blindness
v) auto-immune- collagen vasc. dz., juvenile rheumatoid arthritis (RA), Sjorgren’s
Signs and Sxs:
Anterior uveitis
acute - unilateral, painful ciliary flush, blurred vision, photophobia, and tearing
Intermediate uveitis: painless; floaters and blurred vision Posterior uveitis: blurred vision, floaters, eye pain, photophobia
PE: 360° peri-limbal injection, which increases in intensity as it approaches the limbus.
visual acuity may be decreased in the affected eye.
What is the main pathology of the lens?
cataracts
LENS Cataract Etiology: 1) developmental 2)degenerative
SSxs:
PE:
LENS
Cataract:
opacity of the lens with painless, progressive, gradual visual loss. May see with a light or ophthalmoscope (positive diopters).
Etiology:
1) developmental – “juvenile cataract” congenital or early life from poor diet, toxic inflammation or hereditary metabolic causes (important to check on child exams)
2) degenerative - senile degeneration, x-ray, UV light, trauma, diabetes; use of cortisone
Signs & Sxs and PE:
decreased visual acuity is the most common complaint
increased glare (bright sunlight or at night the glare of headlights)
progression of cataracts leads to mild-to-moderate myopia
No red reflex
Glaucoma
2 types
Increased intraocular pressure
- Acute Closed Angle glaucoma (EMERGENCY); red eye
- Chronic Open Angle Gluacoma; no red eye
Acute Closed Angle Glaucoma
i) Acute Closed Angle Glaucoma (WILL have red eye) EMERGENCY
Etio: mechanical blockage of outflow channels in angle
precipitating factors include drugs (ie, sympathomimetics, anticholinergics, antidepressants),
and rapid correction of hyperglycemia.
Signs & Sxs: patients are elderly, hyperopic, and have no history of glaucoma
most commonly, present with peri-orbital pain and visual deficits; pain with eye movement, pain
is “boring”, concomitant ipsilateral headache.
blurry vision, describes seeing “halos around objects.”
PE: blurred vision, can detect hand movements but can’t identify numbers or letters.
corneal and scleral injection, ciliary flush. Edematous, cloudy cornea obscures fundoscopic exam.
increased IOP (normal limit, 10-20 mm Hg) and ischemia:
Dilated non-reactive pupil
Medial crescent shadow seen
Ophthalmoscopic exam: increased cup/disc ratio
DDx: conjunctivitis, acute iritis
Tx: REFER immediately, eyesight may be lost permanently from increased pressure on optic nerve.
Chronic Open Angle Glaucoma
Chronic Open Angle Glaucoma- (NO red eye)
90% of all glaucoma; caused by a malfunction of the eye’s drainage system, often from organic
changes associated with aging.
Etio: decreased rate of aqueous outflow. Bilateral, genetic predisposition (autosomal recessive?)
Signs & Sxs: gradual loss of peripheral vision. When uncontrolled, late loss of central vision and ultimate blindness
Prevention: ocular tonometry every 3-5 years or with family hx yearly (10-21 mm Hg = normal) (abn. = 25-50 mm Hg., N pressure has diurnal variations of 3-4 mm Hg or more, so one normal does not R/O)
Hyphema
Hyphema:
hemorrhage into ant. chamber from trauma, see fluid line
danger of recurrent bleeding which may cause glaucoma and visual loss
Orbit
a. Preseptal (periorbital) cellulitis:
etiology:
SSxs:
ORBIT
A. Preseptal (periorbital) Cellulitis: inflammation/infection of eyelid and surrounding skin anterior to the orbital septum (common in kids)
Etiology: trauma, infection spread from nasal sinus or tooth, insect bite on face, seeding from bacteremia (S pneumoniae, S aureus, H flu), eyelid injury, conjunctivitis, chalazion
Signs & Sxs: tenderness, swelling warmth, redness of eyelid. Visual acuity not affected
Typically mild condition, rarely leads to complications
Thus, Less of an emergency, but sometimes difficult to distinguish from orbital cellulitis.
Orbit Orbital cellulitis Etiology: SSxs: PE: DDX: Tx:
Orbital Cellulitis: Emergency!
infection of the orbital tissues (fat and muscles) posterior to the orbital septum. More common in kids
Etiology: extension of infection from ethmoid sinus (~ 90% cases), local trauma, infx on face or teeth
Same pathogens as above
Progresses rapidly, can cause retinal artery or vein thrombosis, increased intraocular pressure - retinal damage, brain abscess, meningitis, cavernous sinus thrombosis
Signs & Sxs: swelling and redness of eyelid and surrounding tissues, proptosis (down & lateral)
extreme orbital pain (unilateral), and pain with eye movement, dec eye motility
depending on cause: nasal d/c, sinus bleeding, tooth abscess
presence of fever, malaise, headache raise suspicion of meningitis (rash is late sign)
PE: conjuctival hyperemia and chemosis
decreased visual acuity
DDX other causes of eyelid swelling - allergy, insect bite, trauma, tumor
Tx: refer to ophthalmologist or EENT for hospitalization. CT, IV antibiotics, possibly drainage
Orbit
Exopthalomos
aka:
Etiology:
Exopthalomos: bulging of eyes, also known as “proptosis”
Etiology: orbital inflammation, edema, injuries, hyperthyroid, leukemia, meningioma
Acute Conjunctivits aka: Etiology: Predisposing factors: Vision: PE:
Acute Conjunctivitis (pink eye): very common
Etiology: allergic (common), viral, bacterial
Predisposing factors: irritation from wind, dust, smoke, air pollution, common cold,
corneal irritation from intense light/reflection
Vision: unchanged unless exudate clouds the eye
PE: usually bilateral superficial dilated vessels (conjunctival injection)
(unilateral disease suggests toxic, chemical, mechanical, or lacrimal origin).
normal intraocular pressure, PERRLA, normal vision
Retina/Macula
A. Retinal detachment
etiology:
SSxs:
RETINA/MACULA
A. Retinal detachment–emergency
Etiology:
causes: trauma, diabetes, inflammatory disorder; posterior vitreous detachment (most common),
may be idiopathic
usually occurs aged 40-70 years.
Signs & Sxs: painless, dark or irregular floaters, flashes of light (photopsia), blurred vision which worsens progressively, curtain or veil in the field of vision, no redness; tears or retinal pieces hanging in vitreous humor
Retina/Macula
B. Posterior vitreous detachment
SSxs:
Posterior vitreous detachment
With age, the vitrious gel can collapse and pull forward (may tear the retinal in the process)
SSX: painless, floaters, flashes of light
Retina/Macula
Macular degeneration
SSxs:
Opthalmoscopic exam:
Macular degeneration:
leading cause of visual loss in the elderly (more common in whites than blacks)
hemorrhagic disturbance in the macular region of the involved eye
slow or sudden, painless loss of central visual acuity (wavy lines on Amsler grid)
Ophthalmoscopic exam: drusen bodies
Diabetic Retinopathy
Early Signs:
Late Signs:
Refer if….
Diabetic retinopathy:
major cause of blindness in diabetics
Early signs: venous dilation and small, red well demarcated lesions (microaneurisms), then macular edema develops which affects vision. Best seen with fluorescein angiography.
Late signs: soft exudates (cotton-wool spots) (microinfarcts) caused by anoxia, or hard white-yellow (waxy) exudates caused by chronic edema from damaged capillaries
Tortuous retinal neovascularization
REFER if develop blurred vision (over 2 days) not assoc. with elevated glucose, sudden loss of vision in one or both eyes, black spots, cobwebs or flashing lights in the field of vision.
Hypertensive Retinopathy
i) copper wire
ii) silver wire
iii) AV nicking
iv) hemorrhages
v) soft exudates
vi) hard exudates
vii) papilledema
Hypertensive retinopathy:
Vascular changes with extent and persistence of hypertension
i) copper wire- brightening and widening of central strip on artery, moderate arteriosclerosis
(yellow from lipids )
ii) silver wire- central light reflex is entire width of arteriole from thickened walls
iii) AV nicking- arteriole crossing a venule, thickened arteriole walls compress and obscure the vein
iv) hemorrhages (often flame hemorrhages)
v) soft exudates-“cotton wool” (retinal edema)- fuzzy, gray-white, irregular border (infarcts
vi) hard exudates (macular star)
well defined yellow-white deposits, may have serrated edges d/t deposits of serum, lipid
and protein
vii) Papilledema: optic disc swollen, margin blurred
Retinitis Pigmentosa
Retinitis Pigmentosa:
inherited, slowly progressive, bilateral, retinal degeneration à loss of photoreceptors and blindness
night blindness and peripheral vision loss may become symptomatic in early childhood
central island of vision gradually constricts over time
Eyelids A. Blepharitis causes: SSxs: PE:
EYELIDS:
A. Blepharitis: (inflammation of lid margins causing irritation, itching, occasionally red eye)
Causes: rosacea, seborrheic dermatitis, allergic or contact dermatitis, dry eye syndromes, chalazion, trichiasis, conjunctivitis, Sjogren’s syndrome, exposure to chemicals or irrantants
Signs & Sxs:
eye irritation (burning, gritty sensation, watering) itching and erythema of the lids
tearing, photophobia, blurred vision
crusting and matting of the lashes and medial canthus, esp in morning
Typically a chronic course with intermittent exacerbations and eruptions
PE:often findings of associated conditions
loss of lashes (madarosis), whitening of the lashes (poliosis), scarring and misdirection of lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid margin ulcers, and lid irregularity (tylosis).
corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal ulcers.
Eyelids
B. Hordeolum
SSxs:
Hordeolum “stye”
Acute localized infection or inflammation of the eyelid margin involving sebaceous gland Staphylococcus aureus in 90-95% of cases, Common in kids
SSX: begins with pain, redness, tenderness of lid margin followed by small, round, tender induration
lacrimation, photophobia, foreign body sensation
pustule on lid margin, ruptures and heals spontaneously.
Chalazion or meibomian cyst
ssxs:
Chalazion or meibomian cyst:
chronic enlargement of meibomian gland from infection & occlusion of its duct, often following inflammation of the gland
at onset, looks like a stye but painless; chronic stage may appear like BCC or SCC
after few days, infection resolves leaving a painless, slowly growing, firm mass in the lid
evert lid to see hyperemia and localized cyst
