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Ophthalmology

Terms in this set (39)

What is the best treatment option for penetrating trauma of the eye?
Refer to ophthalmology asap. DO NOT REMOVE FOREIGN BODY.
What does a rust ring on the cornea indicate?
Metallic foreign bodies and best way to remove it is using a rotating burr OR refer to ophthalmology.
What is the first step of an alkali or acidic burn of the eye?
Flush with sterile water or saline for at last 30 minutes. Place an eye shield on the eye and refer to ophthalmology.
What is a blow out fracture and how does it often present?
Blunt trauma that causes the orbital floor composed of maxillary, palatine and zygomatic bones to fracture, which results in trapping of the orbital structures. Patient often present with swelling and misalignment. Movement of globe is often restricted, specifically an inability to look up due to entrapment of infraorbital nerve and musculature. Double vision, subcutaneous emphysema and exopthalmous are all common. Refer to ophthalmology.
Corneal Abrasion
Pain and sensation of foreign body and can be accompanied by photophobia, tearing, injection and blepharospasm. A slit-lamp or flurosecein staining will reveal an epithelial defect, but a clear cornea. Topical anesthetic should only be used for diagnosis. Antibiotic ointment is preferred such as erythromycin or polymyxin/bacitracin. Only patch for large abrasions >5-10 mm and do NOT patch longer than 24 hours.
Retinal Detachment
Definition: The underlying pathogenesis is a separation from the retina from the pigmented epithelial layer, causing the detached tissue to appear as flapping the vitreous humor. Usually begins at the superior temporal retinal area.

Symptoms: blurred/blackened vision that may progress to monocular blindness, often described as "curtain being drawn", "floaters/flashing lights"

Signs: Relative afferent pupillary defect-- swinging flashlight test reveals less constriction when swinging from unaffected to affected pupil; Funduscopic exam reveals retina flapping in vitreous humor

Treatment:Refer to Ophthalmology for possible laser surgery

Prognosis: 80% recover without recurrence, 15% require tx, 5% never reattach
What is considered a Marcus Gunn pupil?
A pupil with a relative afferent pupillary defected (RAPD)
Macular Degeneration
Definition: Macular degeneration is when drusen bodies are found on Bruch's membrane which leads to degenerative changes, loss of nutritional supply, atrophy and neovascularization.

Symptoms: Gradual vision loss

Exam: Decreased VA, Metamorphopsia (wavy or distorted vision) which can be assessed with an Amsler grid; mottling, serous leaks and hemorrhages commonly develop on the retina

Treatment: No effective treatment, maybe vitamiins/antioxidants, if detected early, maybe laser therapy or intravitreal injections of monoclonal antibody drugs which may slow progression
Central Retinal Artery Occlusion
Central retinal artery occlusion is often due to emboli, thrombotic phenomenon or vasculitis.

Symptoms: Sudden, painless and marked unilateral vision loss.

Exam: Funduscopy reveals arteriolar narrowing, separation of arterial flow (box-carring), retinal edema and perioveal atrophy (cherry red spot), Ganglionic death leads to optic atrophy and a pale retina.

Treatment: Refer to ophthalmology.

Key Words: Box-Carring, Cherry Red Spot****
Central Retinal Vein Occlusion
Central retinal vein occlusion usually occurs secondarily to a thrombotic event.

Symptoms: Sudden unilateral, painless blurred vision or completed vision loss.

Signs: Afferent pupillary defect and dilated veins, hemorrhages, edema and exudates of the retina (blood and thunder)

Key Words: Blood and thunder****
What is the leading cause of blindness in the U.S.?
Diabetic retinopathy
What is the leading cause of irreversible central vision loss?
Macular degeneration
What is the difference between non-proliferative and proliferative retinopathy?
Non-proliferative: venous dilation, microaneursyms, retinal edema, hard exudates

Proliferative: neovascularization, vitreous hemorrhage
Treatment of retinopathy?
Based on etiology. Optimized glucose control, regulation of BP, laser photocoagulation, virectomy. Severe disease is permanent.
Cataracts
Definition: Cataract is an opacity of the natural lens of the eye. They may develoop secondarily to natural aging process, trauma, congential causes or medications.

Symptoms: Insidious onset of decreased vision, may also complain of double vision, fixed spots or reduced color perception

Signs: On exam, there is a translucent, yellow discoloration of the lens. Funduscopy reveals a black cataract against a red background.

Treatment: Intracapsular or Extracapsular extractions of the cataract with replacement of the lens.
What are two classes of medications that may lead to cataracts?
Corticosteroids, Stains (lovastatin book has listed)
Glaucoma
Glaucoma is increased intraocular pressure that results in optic nerve damage. Any impediment of the flow of aqueous humor through the trabecular meshwork and canal of Schlemm will increase pressure in anterior chamber. May be acute or chronic. Subtypes include Open-Angle glaucoma and Angle-Closure glaucoma.
Angle-Closure glaucoma
Angle-Closure glaucoma is an ophthalmic emergency due to elevated intraocular pressure causing optic nerve damage.

Symptoms: Painful eye and loss of vision. Nausea, vomiting and diaphoresis are associated.

Exam: Circumlimbal injection, steamy cornea, fixed mid-dilated pupil and decreased VA. Narrowed anterior chamber and elevated intraocular pressure.

Treatment: Refer to Ophthalmologist. Start IV carbonic anyhydrase inhibitor, topical beta-blocker and osmotic diuresis. Ultimate treatment is laser or surgical iridotomy.
Open-Angle glaucoma
Open-Angle glaucoma is a chronic, asymptomatic and potentially blinding disease defined as increased intraocular pressure, defects in the peripheral visual field and increased cup to disc ratios. Often affects people older than 40 and is more common in African Americans and those with family history.

Symptoms: Often asymptomatic

Exam: Increased intraocular pressure, defects in peripheral visual field, increased cup-to-disc ratio on funduscopy.

Treatment: Refer to Ophthalmologist. Topical and/or systemic medications to decrease intraocular pressure.
Orbital Cellulitis
Primariiy occurs in children 7-12 years old.

Symptoms: Ptosis, eyelid edema, exopthalmos, purulent discharge and conjunctivitis

Signs: fever, decrease ROM of eye muscles and sluggish pupillary response

Labs: CBC, blood cultures, culture of drainage

Tests: Sinus radiography & CT may reveal cause and extent

Treatment: Medical emergency requiring IV antibiotics and hospitalization.
What are the most common causative agents of orbital cellulitis?
Streptococcus pneumoniae, staphylcoccus aureus, haemophilus influenzae and gram-negative bacteria.
Periorbital Cellulitis vs. Orbital Cellulitis
Periorbital cellulitis: inflammation and infection of the superficial eyelid, usually from a superficial source.

Orbital cellulitis: infection developing within the orbital soft tissue with associated ocular dysfunction and is usually due to underlying bacterial sinusitis. More serious condition and warrants hospital admission.
Dacryostenosis
Dacryostenosis is when the lacrimal duct does not open and this obstruction usually resolves around 9 months of age. Treatment involves warm compresses or surgery if not resolved.
Dacryocysitis
Dacryocysitis is inflammation of the lacrimal gland causedby obstruction. Pain, swelling, tenderness and purulent discharge are charactersitic. Treatment is warm compresses and antibiotic.
What is a hordeolum and what is it most commonly cause by and what is the difference between external and internal hordeolums? Treatment?
A hordeolum is an acute development of a small, painful nodule or pustule within a gland in the upper or lower eye which is often caused by Staphylococcus aureus.

An internal hordeola is caused by inflammation and infection of the meibomian gland, which are situated deep from the palpebral margin.

An external hordeola (stye) is caused by inflammation and infection of the Moll or Zeis glands, which are immediately adjacent to the palpebral margin.

Treatment involves warm compresses and only topical antibiotics if infection. Refer if not improving.
Chalazion
Relatively painless, indurated lesion deep from the palpebral margin. Often secondary to a chronic inflammation of an internal hordeolum.

Treatment is warm compresses and refer if not improving.
Entropion vs. Ectropion
Entropion is when the lids and lashes are turned in secondary to scar tissue or a spasm of the orbicularis oculi muscles.

Ectropion is when the edge of the eyelid everts secondary to advanced age, trauma, infection or palsy of the facial nerve.

Treatment: surgical repair if excessive tearing, exposure keratitis develops or for cosmetic repair.
Viral Conjunctivitis
Viral conjunctivitis is characterized by the acute onset of unilateral or bilateral erythema of the conjunctiva, copious watery discharge and ipsilateral tender preauricular lymphadenopathy.

Etiology: Adenovirus type 3, 9, 19, usually transmitted by direct contact, but can be transmitted in swimming pools and is common in midsummer to early fall

Treatment: Eye lavage with normal saline BID for 7-14 days, Warm/Coolcompresses
Bacterial Conjuncitivitis
Bacterial conjunctivitis is characterized by the acute onset of copious, purulent discharge from both eyes that may cause a mild decrease in VA and discomfort. Eyes may be crusted shut upon awakening.

Etiology: Common pathogens: Strep pneumoniae, Staph aureus, Hameophilus aeygptius and Moraxella sp
Rare pathogens: Chalmydia and Gonorrhea

Lab:
Gram Stain for Common Pathogens: Polymorphonuclear cells (PMNs) with predominant organisms

Gram Stain for Chlamydia: PMNS + no organism
Gram Stain for Gonorrhea: PMNS + gram negative diplococci

Treatment: Topical antibiotics per specific organism (Erythromycin often used, Polymxin B common as well)
Pinguecula
Pinguecula is an elevated, fleshy, yellowish conjunctival mass found on the sclera adjacent to the cornea

Etiology: chronic actinic exposure, repeated trauma, dry/windy conditions

Treatment: none necessary, unless cosmetic concern
Pterygium
Pterygium: slow growing thickening of the bulbar conjunctiva that is highly vascular triangle mass that grows from the nasal side toward cornea

Treatment: non necessary unless vision interference
Papilledema
Papilledema is defined as an increase in intracranial pressure.

Etiology: Many causes but may include malignant hypertension, hemorrhage strokes, acute subdural hematoma, pseudotumor cerebri

Exam: Disc appears swollen, margins are blurred with an obliteration of the vessels

Treat underlying cause.
Blurred Vision: how to assess location of the lesion
Lesions anterior to the optic chiasm will affect only 1 eye.
Lesions at the optic chiasm will affect both eyes partially.
Lesions posterior to the optic chiasm will yield corresponding defects in both visual fields.
What are differential diagnoses for transient, gradual and sudden visual loss?
Transient vision loss: TIA, embolic (amaurosis fugax), temporal (giant cell) arteritis

Sudden vision loss: CRVO, CRAO, optic neuropathy, papillitis, retrobulbar neuritis, angle-closure glaucoma

Gradual vision loss: macular degeneration, tumors, cataracts, open-angle glaucoma
What is amaurosis fugax?
Transient monocular vision loss likely due to a TIA
Strabismus
Strabismus is a condition in which binocular fixation is not present. Strabismus may occur in one eye or both. A corneal light reflex test will reveal misalignment (manifest or heterotropia strabismus). A cover-uncover test may reveal latent (heterophoria) strabismus which may not be readily apparent otherwise.

Esotropia: inward misalignment
Exotropia: outward misalignment

Strabimus may be corrected with eye exercises (patches) or in severe cases, surgery. If left untreated after age 2, amblyopia will result.
Amblyopia
Amblyopia is reduced visual acuity not correctable by refractive means.

It may be caused by strabismus (commonly), uremia, toxins, lead, or other substances.
Icterus/Jaundice
Yellowing of the sclera secondary to retention of bilirubin
Blue or Cyanotic Sclera
Seen in infants with osteogenesis imperfecta/Ehlers Danlos syndrome
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