43 terms

Eyes

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Lids & Lacrimal apparatus:
Hordeolum
-Staphylococcal infection
-External: infection of gland of Zeis or Moll
-Internal: infection of Meibomian gland
-localized, red, swollen, tender area on upper or inner eyelid
-treat with warm compresses
Lids & Lacrimal apparatus:
Chalazion
-chronic, granulomatous inflammation of meibomian gland
-hard, non-tender swelling on upper/lower lid
-warm compresses, remove for cosmetic reasons or if interrupting vision
Lids & Lacrimal apparatus:
Blepharitis
-Anterior: staphylococcus (ulcers) or seborrheic (no ulcers); "red-rimmed" eyelids, scales, loss of eyelashes
-Posterior: staphylococcus or meibomian gland; telangiectasias, greasy tears
-chronic, bilateral inflammation of lid margins
-Anterior TX: hot wash cloth, AB eye ointment (bacitracin or erythromycin)
-Posterior TX: massage M. gland, oral AB (-cyclines) and prednisone
Lids & Lacrimal apparatus:
Entropion
-elderly due to degeneration of eyelid fascia
-inward turning of eyelid causing irritation, pain or watery eyes
-lashes and skin touching eye (corneal damage?)
-surgery, botox, artificial tears
Lids & Lacrimal apparatus:
Ectropion
-outward turning of lower lid exposing conjunctiva (dry, painful eye)
-surgery, artificial tears & moisten cornea
Lids & Lacrimal apparatus:
Dacryocystitis
-infection of lacrimal sac (acute- staph aureus, chronic- staph epidermidis) &/or complication of dacryostenosis
-congenital or acquired obstruction of nasolacrimal system
-usually unilateral, pain, swelling, tenderness and redness of tear duct with possible purulent material
-dacryocystorhinostomy, systemic antibiotics for acute and topical ABs (-mycin, moxifloxicin) for chronic & cleanse the lids
Lids & Lacrimal apparatus:
Conjunctivitis (viral)
-adenovirus; highly contagious
-bilateral; watery, serous discharge (scant); very red eye
-no effective therapy
Lids & Lacrimal apparatus:
Conjunctivitis (bacterial)
-S. aureus, Strep., Pseudomonas
-unilateral; copious, purulent or mucopurulent discharge throughout the day
-warm compresses & topical sulfonamide or topical ABs (levo-, gati-, moxifloxacin)
Lids & Lacrimal apparatus:
Conjunctivitis (gonococcal)
-copious hyperpurulent discharge
-EMERGENCY: IM ceftriaxone with added topical ABs (erythromycin, bacitracin)
-IV penicillin G, ceftriaxone or gentamicin for newborn
Lids & Lacrimal apparatus:
Conjunctivitis (chlamydial-- Trachoma)
-unilateral infection with often involvement of preauricular node
-most common infectious cause of blindness
-PO azithromycin in adults and oral erythromycin in infants
Lids & Lacrimal apparatus:
Conjunctivitis (chlamydial-- inclusion)
-starts with acute redness, discharge and irritation to follicular conjunctivitis with mild keratitis, non-tender preauricular lymph node
-PO azithromycin
Lids & Lacrimal apparatus:
Conjunctivitis (keratoconjunctivitis sicca)
"dry eyes"
-hypofunction of lacrimal glands causing loss of aqueous component of tears, or excessive evaporation of tears, or abnormalities of lipid component of tear film
-dryness, redness or foreign body sensation, burning, gritty sensation, lack of corneal/conjunctival luster
-lubrication, artificial tear treatment, punctual plugs
Lids & Lacrimal apparatus:
Conjunctivitis (chemical and allergic)
-history of atopy
-usually bilateral, watering with stringy mucous and intense itching
-topical antihistamine, possible topical corticosteroids
Lids & Lacrimal apparatus:
Pterygium & Pinguecula
-exposure to sun, wind and dust
-thickening of conjunctival tissue (solar elastosis changes)
-bilateral redness & irritation
-Pinguecula: yellow, elevated nodule in conjunctiva
-Pterygium: soft, fleshy, clear triangle of fibrovascular conjunctival tissue location on nasal side of eye
-surgery if vision threatening, artificial tears for redness & irritation, topical NSAIDs for anti-inflammatory
Cornea/Sclera:
Corneal ulcer
-infection, exposure keratitis, dry eyes, allergies
-trauma or necrosis to corneal tissue
-pain, photophobia, tearing, reduced vision w/ central dilation and peripheral constriction of vessels
-white or opaque spot when visualized with pen light
-fluorescein stain
-refer due to possible corneal scarring & infection
Cornea/Sclera:
Infectious keratitis
-bacteria: hazy cornea w/ ulcer & adjacent stromal abscesses, purulent discharge, pain
-viral: red eye w/ watery discharge
-herpes zoster ophthalmicus: malaise, fever, headache, and periorbital burning and itching, preceeding rash eruption
-fungal: multiple stromal abscesses and intraocular infection
-parasitic: severe pain w/ infiltrates in stroma
-culture to determine causative agent
-corneal grafting, ALWAYS refer keratitis-- possible vision loss
Cornea/Sclera:
Chemical keratitis
-assess severity of burns w/ slit lamp exam
-Irrigate IMMEDIATELY!!!
-DO NOT prescribe topical anesthesia (proparacaine, tetracaine)
-dilate pupil w/ 1% cyclopentolate to relieve discomfort and prophylactic topical ABs should be started
Cornea/Sclera:
Ultraviolet
-exposure of sources of UV rays
-no immediate findings, then 6-12 hrs agonizing pain and severe photophobia
-fluorescein stain
-all recover w/i 24-48 hours w/o complications
-binocular patching and 1-2 drops of 1% cyclopentolate (dilates eye), eye protection in light
Lens:
Cataracts
-opacities of crystalline lens (congenital, trauma, secondary, systemic corticoid treatment)
-gradual progressive blurred vision, no pain or redness, lens opaque
-retina becomes difficult to visualize and lens becomes white
-cataract surgery
Intraocular:
Acute Angle-Closure Glaucoma
-old age, family history, steroid use, race
-closure of pre-existing narrow anterior chamber angle, enlarging crystalline lens, pupillary dilation, iris ballooned forward, increased intraocular pressure
-rapid onset of severe pain and profound vision loss with "halos around lights", red eye, cloudy cornea, hard eye, nausea, ab. pain, rim thinning and notching
-IV dose of Acetazolamide (diruetic, decrease IOP), then topical 4% pilocarpine (miotic); laser surgery (peripheral iridoplasty)
Intraocular:
Chronic Glaucoma
-African descent, genetics, DM
-cupping of optic disks, intraocular pressure elevated due to reduced drainage of aqueous fluid through trabecular meshwork
-progressive bilateral loss of peripheral vision (tunnel vision), increased cup-disk ratio, increases intraocular P, rim thinning and notching
-prostaglandin analogs (-prost), topical beta-adrenergic blocking agents
(-olol), alpha-2 agonist (-onidine), topical carbonic anhydrase inhibitors (-zolamide), laser trabeculoplasty, surgery
Intraocular:
Uveitis
-usually immunologic
-intraocular inflammation ant. or post.
-circumcorneal redness, pain, photophobia, decreased vision, constricted pupil
-large "mutton-fat" keratic precipitates
-hypopyon (layered collection of white cells)
-Ant. TX: topical corticosteroids (dilate pupil to relieve discomfort)
-Post. TX: systemic corticosteroids
Intraocular:
Vitreous hemorrhage
-many etiologies
-sudden vision loss, abrupt onset of floaters, occasional "bleeding w/i the eye", no inflammation
-inability to see fundus, but clear lens
-refer urgently
Intraocular:
Age related macular degeneration
-age, smokers, CFH gene
-Atrophic (dry): gradual progressive bilateral visual loss, atrophy and degeneration of the outer retina, hyperpigmentation, drusens
-Neovascular: sudden vision loss, choroidal new vessels grow between the RPE and Bruch membrane resulting in serous fluid, hemorrhage, fibrosis
-acute or chronic degeneration of CENTRAL VISION, no pain or redness, macular abnormalities
-anti-VEGF (anchor, marina-- reduce neovascularization), laser retinal photocoagulation (reduces drusens), and Lampalizumab (anti-complement)
Intraocular:
Transient monocular vision loss
-caused by ocular ischemia, GCA, occluded carotid artery
"curtain passing vertically across visual field"
-lasts few minutes w/ complete recovery
-antiplatelet/coagulation, carotid a. endarterectomy, calcium channel blocker, oral aspirin & CONTROL vascular risk factors
Intraocular:
Ischemic optic neuropathy
-Ant: due to inadequate perfusion of posterior ciliary arteries that supply anterior portion of optic n., optic disc swelling
-Post: involves retrobulbar optic nerve NOT causing optic disc swelling
-sudden painless visual loss with signs of optic nerve dysfunction
-emergent, high dose systemic corticosteroids-- refer!
Intraocular:
Optic neuritis (inflammatory optic neuropathy)
-associated with demyelinating disease, MS, sarcoidosis, viral, autoimmune, SLE
-subacute unilateral visual loss over a few days, pain w/ eye movements or behind eye, field loss is central, color vision loss, optic disc may become pallor
-in demyelinating TX is IV/oral methyl-prednisolone, otherwise prolonged corticosteroid therapy
Intraocular:
Optic disc swelling
-result of intraocular disease, nerve lesions, severe HTN, raised intracranial pressure
-Papilledema = bilateral, enlargement of blind spot w/o loss of acuity
-image and monitor
Retina:
Retinal detachment
-usually due to one or more peripheral retinal tears
-rapid loss of vision in one eye, no pain or redness, detachment seen by ophthalmoscopy (rhegmatogenous, traction, and serous)
-close retinal tears, laser therapy, expansile gas, treat underlying cause
Retina:
Central & Branch retinal VEIN occlusion
-HTN, heart disease, increase BMI, history of glaucoma
-sudden monocular loss of vision, no pain or redness
-Central: widespread retinal hemorrhages, retinal venous dilation and toruosity, retinal cotton-wool spools, optic disc swelling --> high risk of neovascular glaucoma
-Branch: superficial hemorrhages, retinal edema and confined cotton-wool --> neovascularization or chronic macular edema
-photocoagulation laser, anti-VEGF (ranibizumab, aflibercept, bevacizumab, pegaptanib)
Retina:
Central & Branch retinal ARTERY occlusion
-GCA, DM, hyperlipidemia, HTN, emboli (branch), artherosclerotic (central)
-Central: sudden profound monocular vision loss, reduced visual acuity, pallid swelling with cherry-red spot at fovea, thinned retinal arteries, "box-car" segmentation; EMERGENT
-Branch: sudden loss of vision of visual field, retinal swelling and adjacent cotton-wool spots: URGENT
-assess BP, identify carotid/cardiac emboli w/ ultrasonography, ECG
-ocular massage, inhaled oxygen, IV acetazolamide, high dose corticosteroids (prednisolone), anticoaguation (reduce stroke risk)
Retina:
Diabetic retinopathy
-nonproliferative: microaneurysms, retinal hemorrhage, venous bleeding, hard exudates, retinal edema, diabetic macular edema, macular ischemia, cotton-wool spots, vision loss or decrease in
-proliferative: neovascularization, decreased red reflex, retinal detachment, vitreous hemorrhage, floaters, sudden onset of very decreased vision
-fluorescein to diagnose macular edema (most common cause of vision loss from DM)
-laser photocoagulation (for proliferative macular edema), anti-VEGF (regresses neovascularization), virectomy (remove vitreous hemorrhage), intraocular steroid injections (Fluocinolone)
Retina:
Hypertensive retinochoroidopathy
-increase in BP results in loss of autoregulation of retinal circulation~ leading to breakdown of endothelial integrity
-cotton-wool spots, retinal hemorrhages, retinal edema, retinal exudates, vasoconstriction and ischemia in choroid, serous retinal detachments, infarcts (similar to DM)
-ACUTE: elsching spots
-SEVERE: flame-shaped hemorrhages
Ocular trauma:
Foreign bodies
"something in my eye"
-visual acuity first, then local anesthetic exam, fluorescein
-remove or excise w/ sterile wet cotton-tipped applicator, then bacitracin-polymyxin ointment, no patch
Ocular trauma:
Corneal Abrasion
-severe pain, photophobia
-bacitracin-polymyxin ointment, mydriatic (cyclopentolate) drops, non-steroidals, anti-inflammatories
Ocular trauma:
Contusions
-ecchymosis, subconjunctival hemorrhage, edema, rupture of cornea, hyphema, iridodialysis, pupillary sphinctor paralysis, cataract, lens dislocation, vitreous hemorrhage, retinal hemorrhage, retinal detachment, choroid rupture, orbital floor fracture, optic n. injury
-perform an orbital CT scan
-rest with frequent ophthalmologic assessment
Ocular trauma:
Lacerations
-determine location/severity & refer cornea/sclera lacerations to ophthalmologist
-suture lid lacerations, prevent infection w/ topical sulfonamide or AB, bandage cornea/sclera damage
Ocular trauma:
Hyphema:
-follows trauma
-decreased vision, pain and blood in anterior chamber
-refer! chance of secondary hemorrhage
Miscellaneous:
Ocular Motor Palsy (oculomotor)
-IO, SR, MR, IR, levator
-aneurysm of posterior communication a
-ptosis w/ divergent and slightly depressed eye, extraocular muscles restricted (except laterally), eye rotates inward, aniscoria
Miscellaneous:
Ocular Motor Palsy (trochlear)
-SO
-trauma, congenital
-upward deviation of eye, failure of depression on adduction
Miscellaneous:
Ocular Motor Palsy (abducens)
-LR
-raised intraocular pressure, trauma, neoplasms, brainstem lesions
-convergent squint w/ failure of abduction of affected eye producing horizontal diplopia
Miscellaneous:
Thyroid eye disease (Graves ophthalmology)
-deposition of mucopolysaccharides and infiltration w/ chronic inflammatory cells of orbital tissues
-proptosis, lid retraction, lid lag, extraocular muscle dysfunction
-radioiodine therapy
-if optic n. compression, IV or oral prednisolone, radiotherapy, surgery
Miscellaneous:
Orbital Cellulitis
-infection of paranasal sinuses, trauma, URI, otitis, sinusitis
-fever, proptosis, restriction of extraocular movements, swelling with redness of lids, decreased vision, RAPD, optic disc edema
-cool compress, systemic ABs (-cillin, -mycin, cephalosporin)
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