Eye MDT Flashcards by Chris Weber

Common chronic bilateral inflammatory condition of lid margins

Blepharitis

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Involves the lid skin, eyelashes, and associated glands

Seborrhea of the scalp, brows, and ears (dermatitis)

Scales or granules can be seen clinging to eyelashes

Anterior blepharitis

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Results from inflammation of Meibomian glands

Strong association with acne rosacea

Meibomian glands and their orifices are inflamed

Posterior blepharitis

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Symptoms and physical exam findings:

Itching, burning, mild pain, foreign body sensation, tearing, erythema of the lids, and crusting around the eyes upon awakening

Frothy/greasy tears

May have conjunctival injection

Blepharitis

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Treatment for blepharitis

Eyelid margins cleaned twice daily with commercial eyelid scrub (Ocusoft) or baby shampoo

Warm compresses for 10-15 minutes, 1-2 times a day

Lid massage
Artificial tears
Omega 3 supplements
Bacitracin ointment

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Long-term, low dose antibiotic therapy for blepharitis

Tetracycline 250mg BID

Doxycycline 100mg BID

Erythromycin 1g/day

Azithromycin 500mg day one, 250mg x4 days

Clarithromycin 250mg BID x 7 days

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Blepharitis follow up

2-4 weeks

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Sebaceous glands connected to the eyelashes, secretions from these glands lubricate the eyelid surface

Gland of Zeis

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Oil glands along the edge of the eyelids where eyelashes are found

Meibomian glands

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Acute infection that usually involves Staphylococcus species

External (Gland of Zeis)

Internal (Meibomian gland)

Hordeolum

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Chronic focal granulomatous inflammation within the eyelid, secondary to the obstruction of a meibomian gland or gland of Zeis (hordeolums)

Chalazion

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Symptoms and physical examination findings:

Localized eyelid tenderness, swelling and erythema
May have foreign body sensation depending on location
Visible, or palpable, well-defined subcutaneous nodule in the eyelid
May also note “pointing” of mucopurulent material
Associated blepharitis or acne rosacea

Hordeolum

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Symptoms and physical exam findings:

Hard and nontender nodule on the eyelid, usually farther back than a hordeolum
Edema on the upper or lower lid
Erythema and edema of the adjacent conjunctiva

Chalazion

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Risk factors of hordeolums and chalazions

1) Touch eyes with unwashed hands
2) Insert contact lenses without thoroughly disinfecting them
3) Leave makeup overnight
4) Used or expired cosmetics
5) Have blepharitis

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Hordeolum or chalazion treatment

Warm compresses 15 minutes four times a day

Massage infected eyelid after warm compress to aid in drainage

Discontinue eye make up

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When would you consider antibiotic ointment for a hordeolum or chalazion?

Concern the patient will develop periorbital cellulitis

- 48 hours of warm compresses does not clear it up

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Most common cause of viral conjunctivitis

Adenovirus

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Nongonococcal bacterial conjunctivitis is caused by:

Staphylococcus aureus
Staphylococcus epidermis
Haemophilus influenzae (associated with otitis media)
Streptococcus pneumoniae
Moraxella catarrhalis

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Ophthalmologic emergency because corneal involvement may rapidly lead to perforation

Gonococcal conjunctivitis

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Sx: Itchy, burning, tearing, gritty or foreign body sensation; History of URI

Signs: Water discharge, red and edematous eyelids, pinpoint subconjunctival hemorrhages, punctate keratopathy (epithelial erosion in severe cases), membrane/pseudo membrane (severe cases)

Viral conjunctivitis

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Sx: Itching, watery discharge, and a history of allergies are typical. Usually bilateral.

Signs: Chemosis (swollen conjunctiva), red and edematous eyelids, conjunctival papillae, periocular hyperpigmentation, no preauricular node

Allergic conjunctivitis

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Sx: Redness, foreign body sensation, discharge, itching is much less prominent. Often complains of having to wipe purulent exudate in morning.

Signs: Purulent discharge of mild to moderate degree.

Preauricular node typically absent

Bacterial Conjunctivitis (nongonococcal)

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Signs: Severe purulent discharge, hyperacute onset (12-24 hrs)

Preauricular adenopathy, eyelid swelling

Gonococcal conjunctivitis

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Treatment for viral conjunctivitis

Mild: Artificial tears

Moderate: Epinastine (Ophthalmic antihistamine)

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Treatment for a patient with viral conjunctivitis that has photophobia

Consult Ophthalmology: Opthalmic Corticosteroids

Treatment for allergic conjunctivitis

Mild: Artificial tears Moderate: Antihistamine (Topical are more effective than oral)

Treatment for: Bacterial conjunctivitis for non-contact lens wearers (non-gonococcal)

Erythromycin Opthalmic ointment -0.5 inch ointment inside lower lid QID for 5-7 days Trimethropim/polymyxin B

Treatment for: Bacterial conjunctivitis for contact lens wearers (non-gonococcal)

Fluroquinolones: -Ciprofloxacin

Added to the antibiotic treatment if associated dacryocystitis (tear duct infection) is present

Amoxicillin/Clavulanate Cephalexin

Treatment for: Gonococcal conjunctivitis

Ceftriaxone 1g IM & Azithromycin 1g PO

Treatment for: Gonococcal conjunctivitis for patients with penicillin/cephalosporin allergy

Gentamicin 240mg IM x1 dose & Azithromycin 2g PO x 1 dose

Causes of a conjunctival hemorrhage

1) Valsava 2) Traumatic 3) HTN and Diabetes 4) Bleeding disorder 5) Antiplatelet/anticoagulant medications 6) Topical steroid therapy 7) Hemorrhage due to orbital mass 8) Idiopathic

Sx: Red eye, foreign body sensation, usually asymptomatic unless there is associated chemosis Signs: Blood underneath the conjunctiva, often in one sector of the eye, entire view of the sclera can be obstructed by blood

Conjunctival hemorrhage

Treatment for: Conjunctival hemorrhage

None required (clears up usually in 2-3 weeks) Artificial tear drops QID for irritation

Degeneration of fibrovascular, deep conjunctival layers resulting in vascular tissue proliferation, which extended onto the cornea Usually related to sunlight exposure, chronic inflammation and oxidative stress

Pterygium

Sx: Irritation, redness, decreased vision; may be asymptomatic Signs: Wing-shaped fold of fibrovascular tissue arising from the interpalpebral conjunctiva and extending onto the cornea. Usually nasal in location.

Pterygia

Pterygium treatment

Protect eyes from sun, dust, wind Artificial tears

Treatment for: Moderate to severe pterygium

Opthalmic corticosteroids NSAID drops

Pterygium surgical removal is indicated when:

Interfering with vision and excessive irritation

Pterygium asymptomatic patients should be checked every:

1 to 2 years

Initially pterygiums should be measured:

Initially, then every 3-12 months

Follow-up: Corneal foreign body noncontact lens wearer

F/U in 24 hours (or sooner if symptoms worsen) -Revisit every 3-5 days until healed

Follow up: Corneal foreign body contact lens wearer

Close follow-up until epithelial defect resolves May resume contact lens wear after the eye feels normal for 1 week

Corneal epithelium regenerates quickly, healing time for abrasions is usually within:

24-48 hours

Symptoms and physical exam: - Severe pain, tearing and photophobia - History of trauma to the eye, commonly a foreign object

Corneal abrasion

Studies: Corneal abrasion

Slit lamp to identify dimensions of abrasion

Treatment: Non-contact lens wearer corneal abrasion

Antibiotic ointment (erythromycin, bacitracin) Antibiotic drops (polymyxin B/Trimethoprim or a fluoroquinolone)

Treatment: Contact lens wearer, corneal abrasion

Fluoroquinolone drops

Infectious keratitis, Serious infection involving multiple layers of the cornea

Corneal ulcer

Biggest risk factor for corneal ulcer

Improper contact lens use

Corneal Ulcer, Bacteria causative organisms

Pseudomonas aeruginosa Streptococcus pneumonia Staphylococcus species Moraxella species

Corneal ulcer, causative viruses

Herpes simplex Varicella zoster

Corneal ulcer, causative fungi agents

Candida Aspergillus Penicillium Cephalosporin

Symptoms and physical exam: - Erythema and edema of lids and conjunctivae; discharge; ocular pain or foreign body sensation; photophobia; blurred vision - Depending on location, may decrease visual acuity - Cornea reveals a round or irregular opacity or infiltrate (classically in the center)

Corneal ulcer

Treatment for: Corneal ulcer

1. Topical antibiotics (Ciprofloxacin, Ofloxacin, Vigomox) 2. Refer to ophthalmologist within 12-24 hours 3. DO NOT patch the eye, risk of pseudomonas infection.

Anterior Cavity: What continually filters out of blood capillaries in the ciliary processes of the ciliary body and enters the posterior chamber. Then flows forward between the iris and lens through the pupil and into the anterior chamber

Aqueous Humor

Where does aqueous humor drain into from the anterior chamber?

Scleral venous sinus (canal of Schlemm) then into the blood

How often is aqueous humor completely replaced?

Every 90 minutes

Accumulation of red blood cells within the anterior chamber, between the cornea and the iris Blood may cover part or all of the iris and pupil

Hyphema

Most common risk factors for hyphema

Trauma or recent ocular surgeries

Etiologies of hyphema

1) Iris neovascularization 2) Herpes simplex or zoster iridocyclitis 3) Blood dyscrasia or clotting disorder (Hemophilia) 4) Anticoagulation 5) Fuchs heterochronic iridocyclitis 6) Intraocular tumor

Symptoms and physical exam findings: ``` -Blood/Clot in the anterior chamber, visible without slit lamp May be black or red -Pain -Photophobia -Blurred, clouded or blocked vision -History of blunt trauma ```

Hyphema

Labs/studies: Hyphema

Complete eye scan Consider CT to scan the orbits and brain

Treatment for: Hyphema

Immediate ophthalmology or optometry consult - Elevate head - Place rigid shield over eye - Avoid aspirin and NSAIDS - Mild analgesics, Tylenol only

Hyphema patient: After initial follow up period, patient may need to be on what medication?

Long-acting cycloplegic agent (atropine 1% BID)

Middle layer of the eyeball

Vascular tunic (Uvea)

Vascular tunic (uvea) is composed of what three parts?

1) Choroid 2) Ciliary body 3) Iris

Inflammation of the anterior segment of the uveal tract. Usually immunologic but possibly infective or neoplastic. Classified as acute or chronic and as Non granulomatous or granulomatous

Iritis/Uveitis

Infectious etiologies: Iritis/Uveitis

Herpes virus Cytomegalovirus Toxoplasmosis Syphilis West Nile Virus

Systemic inflammatory disease that cause iritis/uveitis

Spondylarthritis Sarcoidosis SLE Mutiple sclerosis

Uveitis Sx: Pain, redness, photophobia and visual loss

Acute nongranulomatous anterior uveitis

Uveitis: Blurred vision in a mildly inflamed eye

Granulomatous anterior uveitis

Signs: - Inflammatory cells flare within the aqueous (WBC released from vessels appear as snowflakes) - Blurred vision in a mildly painful mildly inflamed eye - Hypopyon (WBC pool) and fibrin within anterior chamber - Keratic precipitates (KPs) (cells seen on the corneal endothelium)

Uveitis

Labs/Studies: Uveitis

Complete eye exam Labs if required

Treatment for: Uveitis

Only to be initiated by or under direction of Ophthalmologist: - Cycloplegic (for pain and inflammation) - Topical steroid

Infection that affects the eye socket. This can cause the eye or eyelid to swell, keeping the eye from moving properly Typically arise from paranasal sinuses (especially ethmoiditis)

Orbital Cellulitis

Orbital cellulitis: Adult and children organisms

Adult: Staph, strep, Bacteroides species Children: Haemophilus influenzae

Sx: Red eye, pain with eye movement, blurred vision, double vision, eyelid and /or periorbital swelling, nasal congestion/discharge, sinus headache/pressure/congestion, tooth pain, orbital pain, or hypesthesia CT scan shows adjacent sinusitis

Orbital cellulitis

Labs/studies: Orbital cellulitis

- History - Complete eye exam - CT of orbits and sinuses - CBC, blood cultures, gram strain and culture of drainage - Explore and debride of any wounds

Treatment for: Orbital cellulitis

IV Antibiotics Amoxicillin/Clavulanate 875mg PO BID or Ceftriaxone 2g IM Admit to a hospital. Surgery may be required to drain sinuses

Orbital cellulitis: If orbit is tight, an optic neuropathy is present, or IOP is severely elevated, what must immediately be done?

Canthotomy

Follow up for: Orbital cellulitis

Reevaluate at least twice a day in the hospital for 48 hours Clinical improvement may take 24-36 hours

Fracture: Affects the bony outer edges of the orbit A lot of force (MVA's)

Orbital rim fracture

Fracture: Affects the floor or inner wall of the orbit

Blowout fracture

Fracture: | Trauma to the orbital rim pushes the bones back, causing the bones of the eye socket floor to buckle downward

Orbital floor fracture

Sx: Pain, Eyelid edema, Crepitus, Binocular diplopia, numbness of face, acute tearing Signs: Restricted eye movement, Subcutaneous or conjunctival emphysema, decreased sensation, point tenderness, enophthalmos and hypoglobus

Orbital fracture

Labs/studies: Orbital fracture

Complete eye exam CT of the orbit, midface and brain

Treatment: Orbital fracture (meds)

Amoxicillin/Clavulanate, Azithromycin, or Doxycycline Nasal decongestants Ice packs for 20 min every 1-2 hours for the first 24 hours Oral corticosteroids

Surgical repair for orbital fracture: Muscle entrapment with non-resolving bradycardia, heart block, nausea, vomiting, or syncope

Immediate repair within 24-48 hours

Surgical repair for orbital fracture: - Persistent, symptomatic diplopia - Large orbital floor fractures (>50%) - Large combined medial wall and orbital floor fractures - Complex trauma involving the orbital rim, midface, or skull base - Naso ethmoidal complex fractures - Superior or superomedial orbital rim fractures involving the frontal sinuses

Repair in 1 to 2 weeks

Surgical repair for orbital fractures: Old fractures that have resulted in enophthalmos or hypoglobus

Delayed repair, at any later date

Vision returns to normal within 24 hours, usually within 1 hour

Transient visual loss

Sheet of neural tissue containing the rods and cones that lines the posterior two thirds of the inner surface of the glove, extending anteriorly as far as the ciliary body

Retina

What are the three types of retinal detachments?

Rhegmatogenous retinal detachment (most common) Exudative/serous retinal detachment Tractional retinal detachment

Retinal detachment: Development of one or more peripheral retinal tears or holes, allows fluid to move in and separate the overlying retina. Usually spontaneous and occurs in persons over 50 years old. Nearsightedness and cataract extraction are the two most common predisposing causes.

Rhegmatogenous Retinal Detachment

Retinal Detachment: Results from accumulation of subretinal fluid, such as in neovascular age-related macular degeneration or secondary to choroidal tumor

Exudative/serous retinal detachment

Retinal detachment: Occurs when there is preretinal fibrosis, such as in proliferative retinopathy due to diabetic retinopathy or retinal vein occlusion or as a complication of rhegmatogenous retinal detachment

Tractional Retinal Detachment

RD: Sx: Flashes of light, floaters, a curtain or shadow moving over the field of vision, peripheral or central visual loss, or both Signs: The retina is seen hanging in the vitreous like a gray cloud. One or more retinal tears or holes

Rhegmatogenous retinal detachment

RD: Sx: Minimal to severe visual loss or a visual field defect; visual changes may vary with changes in head position Signs: Retina is dome-shaped and the subretinal fluid shifts position with changes in posture

Exudative retinal detachment

RD: Sx: Visual loss or visual field defect; may be asymptomatic Signs: Retina appears concave with a smooth surface. Cellular and vitreous membranes exerting traction on the retina are present

Traction retinal detachment

Labs/Studies: Retinal Detachment

Complete eye exam Ocular ultrasonography Ocular CT Scan

Treatment for: Retinal detachment

Involves fovea: URGENT ocular surgery Otherwise, within 7-10 days of onset

Ultraviolet keratopathy

Flash burns

-Sunlamp without eye protection, exposure to a welding arc, or exposure to the sun when skiing can cause:

Flash burns (ultraviolet)

Sx: Moderate-to-severe ocular pain, foreign body sensation, red eye, tearing, photophobia, blurred vision; often a history of welding or using a sunlamp without adequate protective eyewear. Sx typically worsen 6-12 hours after the exposure. Usually bilateral. Signs: Numerous, punctate lesions or microdots on the corneal surface (after staining)

Flash burns (ultraviolet)

Treatment of: Flash burns (ultraviolet)

``` Pain treatment (mild oral opioids): Oxycodone 5mg Q 4-6 hours -NO topical anesthetics due to corneal toxicity ``` Antibiotic ointment (Erythromycin or Polytrim) 4-8 times a day

Recovery time of flash burns

24-48 hours

Risk factors for chemical burns

Improper use of PPE Job exposure (Mechanics, CS Gas, Cement workers)

Symptoms and physical exam: - Excessive tearing - Conjunctivitis and injection - Moderate to severe eye pain - Blepharospasm - Photophobia - Severe alkali burns will have opacified cornea and scleral blanching

Chemical burns

Initial Management of: Chemical burns

Immediate irrigation with normal saline or water Goal of treatment is to reach neutral pH Normalization takes 30-60 minutes Can test pH of eye with litmus paper

Treatment of: Chemical burns

Topical antibiotics (Erythromycin) Follow-up in 24 hours Consult ophthalmology/optometry if not resolved.

Outer layer, middle layer, inner layer of eye

Outer: Sclera (cornea anteriorly) Middle: Uvea (Choroid posteriorly, ciliary body and iris anteriorly) Inner layer: Retina

Sx: Pain, decreased vision, loss of fluid from eye History of trauma, fall, or sharp object entering globe

Penetrating eye wound

Treatment of: Penetrating wound to the eye

Protect eye with a shield or cup at all times Elevate the head to 45 degrees Systemic antibiotics within 6 hours of injury -Cefazolin or Vancomycin PLUS Fluoroquinolone Antiemetics (prevent Valsalva and possible expulsion of eye contents)

Virus that can affect the eyelids, conjunctiva, and cornea Colonizes the trigeminal ganglion and leads to reoccurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency

Herpes simplex virus

Sx: History of oral or genital herpes infection, photophobia, pain, eye redness, decreased vision Signs: Punctate keratitis. dendritic keratitis, geographic ulcer, corneal sensitivity may be decreased, eyelid may have herpetic vesicular eruptions, palpable preauricular node, conjunctiva can be injected

Herpetic lesion of the eye

Treatment of: Herpetic lesion of the eye

Topical antivirals -Ganciclovir, Trifluridine, Vidarabine Oral antiviral agents -Acyclovir, Valacyclovir, Famciclovir DO NOT prescribe steroids

Follow up of: Herpetic lesion of the eye

Any patients with herpes simples and acute red eye should be referred urgently to an ophthalmologist Reexamined in 2-7 days to evaluate treatment response, then every 1 to 2 weeks

Eye MDT Flashcards

(118 cards)