1
Q
disorders of eye lids and lacrimal apparatus
A
hordeolum, chalazion, blepharitis, entropion/ectropion, dacryocystitis
2
Q
disorders of the conjunctiva
A
conjunctivitis, pinguecula and pterygium
3
Q
disorders of the cornea and sclera
A
scleritis, episcleritis, keratitis, corneal ulcers/abrasions
4
Q
disorders of the anterior chamber
A
glaucoma, uveitis
5
Q
disorders of the lens
A
cataract, refractive errors
6
Q
disorders of the retina and macula and blood vessels
A
retinal detachment, vitreous hemorrhage, retinopathy (DM/HTN), macular degeneration, vessel occlusions
7
Q
disorders of the optic nerve
A
optic neuritis, papilledema
8
Q
disorders of nerves of the eye
A
CN 3, 4, 6 palsies
9
Q
vital sign of the eye
A
visual acuity
10
Q
legal blindness score
A
20/200
11
Q
slit lamp exam
A
magnification of anterior chamber
12
Q
blepharitis, pt complaints
A
- chronic bilateral inflammation of lid margin
- lower lid: oily white plugs visible at meibomian gland openings
- pt c/o irritation, burning, itching
13
Q
dacrocystitis, cause
A
- infection of lacrimal apparatus/sac due to obstruction of duct system
- edemetous and erythemytous
- usually unilateral, may be acute or chronic
- commonly caused by staph, strep, may be candida if chronic
14
Q
Hordolum, cause, tx
A
- stye
- meibomian gland plugging and therefore abscess at lid margin
- usually caused by staph, may be internal or external
- tx: warm compress, I&D if no resolution w/in 48 hrs, topical abx (erythromycin)
15
Q
chalazion, tx
A
- granulomatous inflammation of meibomian gland
- chronic inflammatory lesion
- result of chronic styes, hardens or scars down to this
- usually painless
- seen usually in patients with blepharitis and rosacea
- tx: I&D, steroid injection may be effective
16
Q
entropion, tx
A
- inward turning of eyelid (usually lower)
- usually in older pts as result of degenerative lid fascia
- tx: botox injection, surgery to correct if corneal irritation occurs
17
Q
ectropion, tx
A
- outward turning of eyelid (usually lower)
- increased exposure of the ocular surface and mucous membrane of inner lid
- disruption of normal tear drainage patterns
- usually occurs in older pts
- tx: surgery
18
Q
conjunctivitis, cause
A
- most common eye disease
- acute, subacute, chronic
- serous, allergic, purulent, membranous
- usually caused by virus or bacteria or noninfectious (allergic or irritant most likely)
19
Q
Acute conjunctivitis, pt complaint
A
-c/o red eye, irritation, ocular discharge
20
Q
Bacterial conjunctivitis, cause
A
- most common cause:
- aduts: S. aureus
- kid: S. aureus, S. pneumo, H.flu, M.cattarhalis
21
Q
bacterial conjunctivitis PE
A
-PE: shows purulent ocular discharge, erythema at lid margins and corners of eyes
22
Q
contact wearers risk
A
-high risk of corneal ulceration, keratitis due to higher risk of pseudomonas infection
23
Q
Bacterial conjunctivitis: Gonorrhea and Chlamydia, tx
A
- can cause hyperacute, severe conjunctivitis infections
- sight threatening, emergency dx
- in newborns, this is scary bc it can cause blindness
- GU symptoms usually also present
- tx: GC tx w/ cephalosporin
- tx: Chlamydia tx w/ doxycycline or azithromycin
24
Q
Viral conjunctivitis, cause
A
- usually caused by adenovirus
- associated with viral syndrome: adenopathy, fever, pharyngitis, URI
25
Viral conjunctivitis PE, tx, prevention
- PE shows mucoid/watery ocular discharge, conjunctival injection and inflammation
- tx: none, self limiting course of illness, similar to cold, NEVER PRESCRIBE STEROIDS FOR THIS
- Prevention: wash hands, avoid contamination
26
Allergic conjunctivitis, sxs
- airborne allergens cause IgE mediated response, degradation of mast cells, infiltration of histamine and other inflammatory mediators in the eye
- diffuse ocular injection, watery discharge, itching, usually bilateral, cobblestoning
- often other allergy sxs will be present: sneezing, rhinorrhea, recent exposure, etc.
27
Allergic conjunctivitis, PE, tx
- PE shows diffuse erythema, cobblestoning of conjunctiva, watery discharge
- nose, ears, palate may also appear allergic
- tx: ocular drops: antihistamine + decongestant (naphcon-A)
- mast cell stabilizer + antibistamine (patanol)
28
Corneal abrasion/ulceration, complaint, PE, tx
- often due to foreign body, trauma, improper contact lens use
- c/o severe eye pain, FB sensation
- PE: exclusion of open globe and hyphema, measure visual acuity, penlight and fluorescein exam, lid eversion for conjunctival FB
- Tx: small uncomplicated corneal abrasions txd w/ topical antibiotic therapy and topical or oral pain medication
- most abrasions heal fully w/in 24 hrs
- if contact wearers, treat with fluoroquinolone
29
Pinguecula
- conjunctival nodule
- usually occur nasally in palpebral fissure
- common over age 35, often bilateral
- may cause irritation, ok to use artificial tears
- no treatment needed
30
pterygium
- conjunctival growth
- usually from exposure
- may become inflamed and grow
- use topical NSAID or steroid if needed
- definitive treatment is excision if it threatens vision
- may regrow
31
episcleritis
- inflammation of the episclera
- acute onset of redness, irritation, watering of the eye (1/2 bilateral; 70% female)
- associated with rheumatoid arthritis
- no pain, no visual acuity changes; PE shows localized erythema
- not dangerous
32
scleritis
- inflammation of the sclera
- acute onset of intense pain, photophobia, deep red/purplish scleral hue
- diagnosis confirmed with slit lamp exam
- dangerous cause of red eye
- DANGEROUS - pain and photophobia are key
33
topical steroids
-should ONLY be prescribed by an ophthalmologist and then with caution, and should not be used chronically due to increased risk of cataracts, glaucoma, and risk of secondary infection
34
Keratitis, pt complaint
- inflammation of the cornea, often associated with corneal ulcers
- bacterial or HSV related
- most commonly due to infection
- c/o pain, photophobia, tearing, decreased vision
35
bacterial keratitis, sxs
- hazy cornea, pain, photophobia, tearing, decreased vision
| - often see central ulcer, hypopyon (pus in the eye)
36
HSV keratitis
- dendritic corneal ulcer and scarring
- colonizes trigeminal ganglion leading to recurrences; precipitated by fever, excessive exposure to sunlight, or immunocompromised
37
Herpes zoster ophthalmicus, sxs tx
- serious sight-threatening condition
- seen with Hutchinson's sign: vesicular lesions on the nose
- has been linked to VZV reactivation within the trigeminal ganglion
- frontal branch in V1 most frequently involved
- begins with headache, malaise, and fever, unilateral pain or hypesthesia in the affected eye, forehead, and top of the head
- hyperemic conjunctivities, episcleritis and lid droop can occur
- 2/3 of HZO pts develop corneal involvement (keratitis) that results from necrotic ganglionitis
- epithelial keratitis may have punctate or dendriform lesions
- iritis in about 40% pts w/ HZO
- tx: acyclovir
38
uveitis, cause, types
- intraocular inflammation
- aka iritis
- various etiologies, usually immunologic
- anterior uveitis: inflammatory cells in aqueous (acute pain, erythema, photophobia, visual loss)
- granulomatous or nongranulomatous classification of anterior uveitis
- posterior uveitis (cells in vitreous) has more gradual onset, quiet eye
39
Glaucoma, sx
-insidious progressive bilateral peripheral vision loss, resulting in tunnel vision, preserved VA
-Reduced or blocked drainage of aqueous through trabecular meshwork
-The conjunctival vessels are dilated, especially near the cornea (ciliary flush) and the cornea is slightly hazy (edematous).
-Hereditary; may be secondary to trauma or steroid use, higher prevalence in diabetics
-no sx in early stages; screen routinely over age 40
Pathologic cupping of optic disks
-elevation of intraocular pressure (IOP)>20 mmHg
40
Acute angle-closure glaucoma, sx
- older age group, hyperopes, narrow anterior chamber angle
- rapid onset severe eye pain, profound visual loss; "halos around light;" associated n/v
- red eye, ,steamy cornea, dilated pupil; hard eye to palpation; IOP>20 mmHg
41
hyperope
farsightedness
42
myope
nearsightednes
43
cataract, sx, tx
- opacity of the lens; usually bilateral; blurred vision, sensitivity to light, faded colors, diplopia
- senile cataract most common; may be congenital, traumatic, or secondary (DM, steroid use, uveitis); smoking increases risk
- lens opacity seen through pupil with opthalmoscope causing retinal blurring, white or black pupil reflection
- visual impairment indication for tx
- tx: surgical removal of cataract and insertion of intraocular lens (phacoemulsification)
44
Retinal detachment, sx, tx
- retinal tear, usually spontaneous or due to trauma, may lead to detachment
- age >50 yrs, myopia, cataract extraction
- fluid vitreous passes through tear behind retina
- superior temporal area most common site
- curtain spreading across visual field or sudden unilateral visual loss; no pain or erythema
- retina seen hanging in vitreous like gray cloud, may see tears on ophthalmoscope
- urgent referral to ophthalmology for surgery
45
vitreous hemorrhage, sx, tx
- multiple causes including DM retinopathy, retinal tears, trauma, macular degeneration
- sudden visual loss, abrupt onset floaters
- eye is not inflamed; visual acuity varies
- ophthalmoscopy shows clear lens but inability to see fundal details clearly
- urgent referral to opthalmology
46
macular degeneration, risk factors, sxs, types
- leading cause of permanent visual loss >50 yo
- other risks are white race, female, FHx, smoking
- gradually progressive bilateral central vision loss; distortion or abnormal size of images
- dry and wet classifications; both are progressive and usually bilateral
47
Atrophic (dry) macular degeneration
-degeneration of outer retina and retina pigment epithelium; moderate severity, gradual
48
exudative (wet) macular degeneration
-choroidal new vessel growth leads to accumulation of serous fluid, hemorrhage, fibrosis; more rapid onset, more severe
49
macular degeneration PE, tx
- retinal drusen seen by ophthalmoscope
- tx includes laser therapy by ophthalmologist, various surgical techniques
- supplements may be helpful (vitamin E, antioxidants)
50
central and branch retinal vein occlusion
- sudden monocular loss of vision; commonly noticed upon waking
- no pain or redness
- widespread or sectoral retinal hemorrhages seen by opthalmoscopy
- all patients should be screened for DM, HTN, hyperlipidemia, glaucoma
- all pts should be referred urgently to ophthalmology
51
central and branch retinal artery occlusions
- sudden profound monocular loss of vision
- no pain or redness
- widespread or sectoral retinal pallid swelling seen by opthalmoscopy
- exclude temporal arteritis in patients >55yo
- consider CV risks in all patients; evaluate carotids, cardiac sources of emboli
- all pts should be referred urgently to ophthalmology
52
Diabetic retinopathy
- background retinopathy: mild retinal hemorrhages, edema, exudates, dilation of veins, microaneurysms, without visual loss
- maculopathy: macular edema, exudates, ischemia of macula
- proliferative retinopathy: retinal new vessels
- leading cause of new blindness in adults aged 20-65yo; present in 40% undiagnosed DM
53
hypertensive retinopathy
- silver-wiring and copper-wiring due to tortuous and narrowed retinal arteries
- AV nicking due to venous compression
- flame shaped hemorrhages, edema, cotton-wool spots, exudates from acute elevations of BP
54
Optic neuritis, sx, tx
- Subacute unilateral visual loss with papilledema, flame hemorrhages, central scotoma; pain exacerbated by eye movements
- Optic disc usually normal in acute stage but subsequently develops pallor
- Strongly associated with MS and other demyelinating disease; also occurs with viral infections, lupus/autoimmune disorders, spread of inflammation from meninges, orbits, sinuses
- Treatment with corticosteroids
55
CN III (oculomotor) palsy
- Ptosis with a divergent and slightly depressed eye
- EOM restricted in all directions except lateral
- If pupil involvement: dilated pupil does not react to light or accommodation
- May be painful if aneurysm
- Medical causes: DM, HTN, temporal arteritis
- any time a pt has isolated CN palsy, they need an MRI of brain to see if its a tumor, etc.
56
CN IV (trochlear) palsy
- Upward deviation of eye with failure of depression on adduction
- Vertical diplopia
- Congenital lesions or trauma, neoplasm, DM, HTN, temporal arteritis
57
CN VI (abducens) palsy
- Convergent squint with failure of abduction
- Horizontal diplopia
- Sign of increased ICP; may be due to trauma, neoplasm, brainstem lesions, medical causes
- Brain MRI for any isolated oculomotor nerve palsy
- Myasthenia and dysthyroid eye disease should be considered in any of these cases
58
Blepharitis cause
-may be caused by staph infection, seborrhea, rosacea, associated gland dysfunction
59
Blepharitis tx
-tx w/ warm compress, baby shampoo, may need topical or oral antibiotic (tetracycline)
60
Dacrocystitis pt c/o:
-pt c/o pain, swelling, redness in area of sac, may have purulent discharge from lacrimal duct, increased tearing
61
dacrocystitis tx
-acute tx = systemic abx; eye ointment is preferred for kids and elderly
62
acute conjunctivitis cause
- possible causes: bacterial, viral, allergic, mechanical/chemical
- other causes of red eye = scleritis/episcleritis, keratitis, etc.
63
bacterial conjunctivitis spread
-spread by direct contact, highly contagious
64
bacterial conjunctivitis PE/pt complaint
-redness, purulent discharge unilaterally; can be bilateral, purulent discharge persists throughout the day, may or may not have decreased visual acuity
65
bacterial conjunctivitis tx
-tx: antibioitc ocular ointment or drops (erythromycin, sulfa, polymixin/trimethoprim, fluoroquinolones in contact wearers
66
viral conjunctivitis spread
-Spread by direct contact, highly contagious
67
viral conjunctivitis sxs
- sxs: redness, watery/mucoid ocular discharge, morning crusting, irritation of the eyes
- Usually becomes bilateral in 24-48 hours
68
episcleritis tx
- self limited, episodic
- topical lubricants, NSAIDs, steroids
- oral NSAIDs
69
keratitis PE
-PE shows ocular erythema, predominantly pericorneal injection, maybe discharge
70
keratitis tx
-prompt referral to ophthalmology is essential
71
bacterial keratitis cause
-aggressive, most common in contact lens wearers especially with overnight wear and with corneal trauma; pathogens most commonly pseudomonas, pneumococcus, morazella, staph
72
bacterial keratitis tx
-tx w/ fluoroquinolone plus cephalosporin or aminoglycoside
73
HSV keratitis tx
- topical steroid will make this worse and can cause permanent visual loss
- acyclovir ointment, debridement if necessary
74
uveitis tx
-Tx: steroids, dilation of pupil to relieve pain in anterior uveitis
75
glaucoma tx
- Topical prostaglandin analogs 1st line therapy; may combine with topical beta blockers
- other types of medications, surgical iridotomy may be used as 2nd or 3rd line therapies; refer to ophthalmology
76
acute angle closure glaucoma tx
- tx: lowering IOP; permanent visual loss w/in 2-5 days if untreated
- tx: acetazolamide 500mg IV followed by 250mg PO QID
- tx: definitive treatment with laser iridotomy
Medicine I
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