CN III Palsy
“Down and out”
Blown pupil + ptosis
If pupil blown: likely aneurysm/tumor compressing as parasympathetic fibers run on outside of nerve sheath. If no blown pupil, likely diabetic/vasculopathic/ischemic.
Always get CT/CTA
CN VI Palsy
Cross eyed (stuck in medial gaze) as 6 controls Lateral rectus
Often happens with increased ICP
CT if HA/papilledema to r/o IICP, otherwise no imaging, outaptient f/u
CN IV Palsy
Upward shift on medial gaze and torsional component on lateral gaze.
Can happen with trauma.
CN IV is the only CN that comes off back of brainstem and travels a long way. Controls superior oblique.
No imaging needed if isolated. Outpatient f/u.
Bacterial Conjunctivitis Treatment
Children: Eryrthromycin 5 mg/g opthalmic ointment, 1/2” ribbon lower lid QID X 5-7d
Adults: Trimethoprim-polymyxin B 0.1%-10,000 units/mL (Polytrim) eye drops 1-2 drops QID X 5-7d
Contact Lens Wearers: Vigamox 1-2 drops QID X 7d or Ciloxan 0.3% 1-2 drops QID + ointment (3.5 g) 1/2 inch ribbon at bed-time
Allergic Conjunctivitis Treatment
Age >2: Pataday 1 drop once daily (antihistamine). May use indefinitely. Start 24-48h before anticipated exposure.
Determination of Visual Acuity
1) The visual acuity is determined by the smallest line a patient can read with one half of the letters correct. The number of incorrect letters is listed after the visual acuity as follows: 20/x-y (e.g., 20/40-2)
2) If <20/200, finger counting at 1 m, hand motion at 0.5 m then light perception
Normal VA for children
- 6 mo - 3 y = track object
- 3-5 = 20/40 with 1 line difference between eyes
- >5 = 20/25, no difference between eyes
Opthalmia Neonatorum
- conjunctivitis in neonates
- rapid Gram stain of DC
- chemical
- within first 24h (after prophylaxis with erythromycin at birth)
- bilateral, watery DC, -ve Gram stain
- watchful waiting x 48h
- gonococcal
- usually at 2-7 days
- intense erythema, chemosis, purulent DC
- admit, IV Abx, often pan-culture with LP
- chlamydial
- usually 7-14 days
- purulent DC, redness of palpebral conjunctiva
- often also have pneumonia
- PO + topical erythromycin
- can often DC home with 24h f/u
- other bacterial
- can tx as outpatient except H. flu
- viral
- HSV
- full septic workup + IV Acyclovir
Nasolacrimal Duct Problems, Peds
Dacryostenosis
- most resolve by 12 mo –> refer to optho if not resolved
- yellow DC/tears and fluoro pooling with no conjuctival irritation
- gentle massage downward motion over nasolacrimal duct QID
Dacryocystitis/Dacryoadenitis
- usually post-URI
- purulent DC when pressing on NL duct (cystitis)
- redness + tenderness
- may lead to periorbital cellulitis
- culture
- often need IV cefuroxime or ancef and brief admission but may start with PO Keflex
Dacryocele
- small bluish palpable mass in NL duct –> urgent optho referral for eventual marsupialization
Features of Orbital Cellulitis
- Fever
- pain with EOM
- photophobia
- RAPD
- chemosis
Diplopia Review
Evernote “Eye EM”
