Wills Eye Manual (Most likely on exam) Flashcards
Chemical Burn
EMERGENCY
1) Copious but gentle irrigation with SALINE or Ringer Lactate solution for at least 30 minutes (Tap water can be used and may be more efficacious
2) Wait 5 to 10 minutes; check pH with litmus paper in the fornices. Continue irrigation until pH level is between 7.0 to 7.4.
Treatment
1) Cycloplegic (Scopolamine 0.25%) ; AVOID PHENYLEPHRINE (VASOCONSTRICTOR)
2) Erythromycin q1-q2h
3) Prednisolone Acetate 1% 4 to 9 times a day
Follow up
Every few days - monitor for corneal epithelial breakdown
Corneal Abrasion
Epithelial defect seen with NaFl, Sharp pain with foreign body sensation ; history will tell you if there was any trauma
Treatment
Non-CTL : Ointment of Erythromycin, Bacitraicin or Bacitracin/Polymyxin B (q2-4h) or Oph soln. of Polytrim or FLQ QID. If vegetative use Ciprofloxacin or Moxifloxacin q.i.d.
CTL : Think of Psuedomonas ; FLQ QID and possibly fortified with Tobramycin
Cycloplegic (Cyclopentolate 1% to 2% BID to TID)
Follow up
NON CTL : RTC in 24 hours; if pressure patch, central or large abrasion. If healing happens at the next visit, RTC in 2 to 3 days and then revisit in 3 to 5 days.
CTL : RTC in 1 to 2 days. CTL wear may resume after 1 week after proper course of medication. New CTL should be given at this time.
Corneal and Conjunctival Foreign Bodies
History, trauma and no safety glasses used. Look for FB with Desmarres double eversion technique.
B -Scan can be conducted if intraorbital. AVOID MRI.
Treatment
Apply topical Anesthetic. Remove FB with golf club spud. Use Ophthalmic Burr to remove deep, central rust ring.
Ointment of Erythromycin, Bacitraicin or Bacitracin/Polymyxin B (q2-4h) or Oph soln. of Polytrim or FLQ QID. If vegetative use Ciprofloxacin or Moxifloxacin q.i.d.
Follow up
If rust ring remains, 24 hours. Otherwise 2 to 5 days.
If conjunctival FB, then as needed or 1 week for residual FB.
Conjunctival Laceration
Inspect entire Sclera below the conjunctival laceration for any perforation. Proparacaine the area to observe and then NaFl, look for siedel sign.
Treatment
Bacitracin or Erythromycin QID
Follow up
1 week if no concomitant ocular damage
Traumatic Iritis
Treatment
Cycloplegic (Cyclopentolate 2% TID or Scopolamine 0.25% BID)
Prednisolone Acetate 0.125% to 1% QID
Follow up
5 to 7 days ; if resolved then look into d/c cycloplegic and taper steroid. F/U 1 month for evaluation for angle recession with Gonioscopy and BIO with scleral depression looking for retinal breaks
Hyphema and Microhyphema
- Rule out ruptured globe
- Measure IOP
Treatment
- Usually Bedrest; elevate bed to allow blood to settle.
- Atropine 1% or Scopolomine 0.25% BID to TID
- AVOID ASPIRIN or NSAID’s
- Mild Analgesics only
- Topical steroids (Prednisolone acetate 1% QID to Q1H)
Follow up
Evaluate daily - VA’s, IOP and Slit lamp
few days to 1 week.
Iridodialysis
- Disinsertion of the Iris from the Scleral spur
- Asymptomatic
- Unilateral
- Blunt Trauma
Treatment
Sunglasses, CTL with an artifical pupil or surgery if pt is symptomatic
-If glaucoma develops, start as POAG therapy (Usually AH suppressants)
Follow up
Same as POAG
Cyclodialysis
Disinsertion of the CB from the Scleral Spur; this will result in hypotny due to increased uveoscleral outflow
- Unilateral
- Trauma
Treatment
Sunglasses, CTL with artificial pupil
-If glaucoma develops, start POAG therapy (Usually AH suppressants)
F/U
Same as POAG
Orbital Blow-Out Fracture
Traumatic event, which involves the orbital floor to be damaged. IR is usually involved, with the maxillary sinus.
- Restricted eye movement
- Hypoesthesia of ipsilateral cheek
- Pain on upgaze
- Local tenderness
- Eyelid edema
- Binocular diplopia
- Recent history of trauma
- Forced duction testing, only after 1 week of restriction
Management
CT of the orbit and midface
Treatment 1. Broad spectrum oral antibiotics -Cephalexin 250 to 500mg p.o. QID or -Erythromycin 250 to 500mg p.o. QID or -Doxycycline 100mg p.o. BID for 7 days 2. DO NOT BLOW NOSE 3. Nasal decongestants -Oxymetazoline nasal spray BID for 3 days 4. Ice pack for 20 minutes q1-2h for 24 to 48 hours
Follow up
1 to 2 week after trauma
Traumatic Retrobulbar Hemorrhage
- Pain
- Decreased vision
- Inability to open the eyelids due to severe swelling
- Recent history of trauma or surgery
- Proptosis with resistance to retropulsion
- Tense eyelids (rock hard)
- Increased IOP
Treatment
Decompression of the eyelid
Monitor
Until stable - check VA’s and IOP
Traumatic Optic Neuropathy
Decreased Visual Acuity VF loss, APD defect and EOM restriction
Treatment
-Same as Retorobulbar Hemorrhage
Follow up
1 to 2 days; Test APD, color vision and Visual Acuity
Intraorbital FB
- Decreased Vision
- Pain
- Double vision
- History of trauma
Deteremine what type of trauma and product
Treatment
DO NOT REMOVE FB
Send to Hospital for surgical removal
Follow up
1 week
Corneal laceration
- Cornea is not perforated
- Evaluate AC (Shallow AC will display leaking)
- Positive Siedel sign
Treatment
Cycloplegic (Scopolamine 0.25%)
Antibiotic (Polymyxin B/Bacitracin or FLQ)
Tetanus toxoid for dirty wounds
Follow up
Re-evaluate daily based on epithelial healing
Commotio Retinae
- Asymptomatic; however sometimes decreased vision
- Trauma (contrecoup)
Signs
- Confluent area of retinal whitening
- Berlin’s edema (posterior pole)
Treatment
None
Follow up
DFE in 2 weeks again
Choroidal rupture
- Asymptomatic; however decreased vision
- Trauma
Signs
- Yellow or white crescent shaped subretinal streak.
- Rupture cannot be seen for several days to weeks, due to overlying blood supply.
Treatment
Intravitreal Anti-VEGF therapy; if CNV occurs
Follow up
Re-evaluate in 1 to 2 week
Purtscher Retinopathy
- Decreased vision
- Compression injury to CHEST or HEAD or Lower extremities but not a direct ocular hit
Signs
- Multiple Cotton Wool Spots
- Superficial heme’s around the Optic Nerve
- Large white retinal superficial region
- Acute Pancreatitis
- Malignant HTN
- Collagen vascular disease
Workup
Systemic work up, if chest injury has not occurred.
-Basic metabolic panel, Amylase, Lipase, CBC, BP and rheumatologic evaluation.
-CT of the head, chest or long bones as indicated
Treatment
None, must treat underlying condition.
Follow up
Repeat DFE in 2 to 4 weeks. VA’s may return to 50% as to before.
Shaken Baby Syndrome/Inflicted childhood Neurotrauma
Syndrome of intracranial heme’s, skeletak fractures or multilayered retinal heme’s.
Symptoms
- Change in mental status
- New onset of seizures
- Poor feeding
- Irritability
- Inability to track or follow with eyes
- Child is usually <1 YO and rarely >3 YO
- Symptoms are often inconsistent with history
Signs Multilayered (pre, intra and sub retinal) heme's (80%)
Work up
Send to Hospital if Shaken Baby syndrome, to rule out any other damage. Work with Neurosurgery, Pediatric Psychiatry and Social Services
Treatment
Support
Possible vitrectomy, if vitreal heme is noticed
Follow up
Monitor and refer to PCP. 30% mortality rate, survivors can suffer from significant cognitive disabilities and severe loss of vision in 20% of children.
SPK
Pain, Photophobia, Red eye, FB sensation and mildly decreased vision.
Pinpoint corneal epithelial defects WITH Staining
Superior Staining = CTL disorder (Chemical toxicity, tight lens syndrome, CTL overwear, GPC)
Vertical epithelial defects = FB under the under the upper eyelid
Inferior staining = Blepharitis, Exposure Keratopathy, Topical drug toxicity, Conjunctivitis, Trichiasis/Distachiasis, Entropion or Ectropion
Treatment
Contact lens wearer = Discontinue CTL, AT’s 6x/day ; if large amounts of SPK then add FLQ
Non CTL wearer = Preservative free AT’s q2h w/ Bacitracin/Polymixin B or Erythromycin ointment QID
NEVER PATCH, AS IT CAN RESULT IN A CORNEAL ULCER.
Follow up
2 to 3 days
Recurrent Corneal Erosion
- Occurs in the morning on awakening
- Recurrent attacks of acute ocular pain
- Photophobia
- FB sensation
- Tearing
Signs
Localized roughening of the corneal epithelium
NEGATIVE STAINING
Treatment
Cyclopentolate 1% and Erythromycin or Bacitracin QID
-Once defect is clear, start AT’s QID for 3 to 6 months
5% Muro 128 can be given QID for 3 to 6 months.
Follow up
Every 1 to 2 days; until epitelium is healed; every 1 to 3 months.
Filamentary Keratopathy
Moderate to severe pain, Red eye, FB sensation, photophobia.
Signs
STRANDS of epithelial cells and mucus attached to the anterior surface of the cornea at one end of the strand.
Most common cause = Dry eye syndrome
Treatment Treat the underlying condition Consider debridment of the filaments Preservative free AT's 6x a day Punctal occlusion Acetylcysteine 10% QID (Only available as a compound)
Follow up
1 to 4 weeks
Exposure Keratopathy
Irritation, burning, FB sensation and redness of one ro both eyes. Worse in the morning.
Inadequate blinking, leading to dryness in the inferior 1/3 of the cornea
W/U
History of Bell’s palsy, eyelid surgery or Thyroid disease
Assess Bell’s phenomenon
Slit lamp examination
Treatment Prevention is critical Preservative AT's q2-6h Lubricating ointment Consider eyelid taping
Follow up
1 to 2 day in the presence of corneal ulceration
Pterygium/Pinguecula
Irritation, redness, decreased vision but maybe asymptomatic.
Signs
3 to 9 o’clock position at the limbus
Dellen (thinning of adjacent to cornea) and Stocker’s line (Iron deposition)
Treatment
- Protect eyes from sun, dust and wind
- Lubrication with AT’s 4 to 8 times a day
- If Dellen, q2h ointment
Follow up
- Asymptomatic - 1 to 2 years
- Pterygia - 3 to 12 months
- If treating with Steroids then after a few weeks; re-evaluate IOP and ocular inflammation.
Band Keratopathy
Decreased vision, FB sensation, corneal whitening and maybe asymptomatic
Signs
Whitening from 3 to 9 o’clock ; usually calcium plaque at the level of Bowman’s
Etiology
Chronic Uveitis, Interstitial Keratitis, Corneal Edema, Repeated trauma and Phthisis bulbi
Treatment
Mild
AT’s 4 to 6/day and AT ointment QHS, Consider bandage contact lens for comfort.
Severe
Removal of Calcium deposit using EDTA
Follow up
- Surgery removal - every 1 to 2 days with patching
- Pt to be checked every 3 to 12 months on severity of BK.
