Eyes

Question 1

Blepharitis

Answer 1

Inflammation of BOTH eyelids. Common in pts with Down’s syndrome and eczema

Question 2

Etiologies of blepharitis

Answer 2

Anterior: infectious (Staph aureus, viral) or seborrheic. Anterior involves the skin, eyelashes
Posterior: dysfunction of meibomian gland (associated with rosacea and allergic dermatitis)

Question 3

Manifestations of blepharitis

Answer 3

Eye irritation/itching, eyelid changes: burning, erythema with crusting, scaling, red-rimming of eyelid, and eyelash flaking.

Question 4

Management of blepharitis

Answer 4

Proper hygiene, warm dry compresses, baby shampoo scrubs, artificial tears
S. aureus first line: bacitracin or erythromycin
2nd line: FQ solution

Question 5

Hordeolum

Answer 5

Acute bacterial infection in one or more eyelid glands MCC= staph aureus

Question 6

External and internal hordeolums

Answer 6

External: Zeiss or Moll glands (sweat glands on margin of lids)
Internal: Meibomian glands (sebaceous glands)- only revealed if evert eyelid

Question 7

Presentation of hordeolum

Answer 7

Acute and PAINFUL nodule filled with pus, usually red

Question 8

Tx of hordeolum

Answer 8

External: warm compresses only
Internal: Dicloxicillin (250-500 mg q6h) and warm compresses
If community acquired MRSA: trimethoprim/sulfamehoxazole

Question 9

Education points for hordeolum

Answer 9

Throw away mascara, eye makeup, don’t share with others

Question 10

Chalazion

Answer 10

A subacute, non-tender, usually PAINLESS nodule within the tarsus (eyelid), usually points inside the eye rather than the lid margin
Granulomatous inflammation of Meibomian gland

Question 11

Risk factors of chalazion

Answer 11

Occurs following internal hordeolum, pts with eyelid margin blepharitis, or rosacea

Question 12

Presentation of chalazion

Answer 12

Hard, non-tender swelling on upper or lower eyelid, develops slowly and may be asymptomatic, +/- conjunctivitis, distort vision, may become pruritic/erythematous involving the lid

Question 13

Treatment for chalazion

Answer 13

Small chalazia often resolve without intervention, warm compresses help larger chalazia. Symptomatic or unresolved cases refer to ophthalmology for surgical incision and curettage or direct glucocorticoid injection

Question 14

Dacryoadenitis

Answer 14

Inflammatory enlargement of the lacrimal gland

Question 15

Presentation of dacryoadenitis

Answer 15

Unilateral, severe pain, redness, and pressure in the supratemporal region of the orbit, rapid onset
-Chronic dacryoadenitis: can be bilateral painless enlargement present > 1 mo; more common than acute

Question 16

Causes of dacryoadenitis

Answer 16

Bacterial: S. aureus, S. pneumo, GAS, N. gonorrheae
Viral: Mumps-MCC esp in childhood, EBV, CMV, Coxsachievirus, echoviruses

Question 17

Work up of dacryoadenitis

Answer 17

CT of orbits with contrast
CBC
Culture/smear if purulent d/c present
BCx

Question 18

Tx of dacryoadenitis

Answer 18

Viral: supportive, warm compresses, po NSAIDs
Bacterial: 1st gen cephalosporins- cephalexin 500 mg QID
Referral for ENT, ophthalmology, and ID

Question 19

Pterygium

Answer 19

A fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea. Usually bilateral. Associated with exposure to wind, sun, sand, and dust

Question 20

Tx for pterygium

Answer 20

No tx for inflammation- artificial tears only
May use topical NSAIDs or weak CS (fluorometholone or lotepredonal QID) but MD needs to start this
Surgery indicated for growth that threatens the visual axis, marked induced astigmatism, or severe irritation

Question 21

Education on pterygium

Answer 21

UV sunlight protection, avoid environmental elements, lubricating drops for dry eyes

Question 22

Orbital floor “blowout” fractures

Answer 22

Fractures to the orbital floor (maxillary, zygomatic, palatine) affect the eye as a result of trauma

Question 23

Clinical manifestations of orbital floor blowout fxs

Answer 23

Decreased visual acuity (trapped orbital tissue); enophthalmos ( sunken eye)
Diplopia especially with upward gaze (due to inferior rectus muscle entrapment)
Orbital emphysema (eyelid swelling with blowing the nose from connection to maxillary sinus) May have exophthalmos
Epistaxis, dyesthesias, hyperalgesia, anesthesia to anteriomedial cheek (due to stretch of infraorbital nerve)

Question 24

Diagnosis of blowout fracture

Answer 24

CT scan

Question 25

Management of blowout fracture

Answer 25

Nasal decongestants, avoid blowing nose, prednisone, abx. Surgical repair. Opthalmology referral

Question 26

Macular degeneration

Answer 26

``` Progressive degeneration of the macula CENTRAL vision loss- elderly pts -Atrophic (dry or geographic) Gradual blurring of central vision -Neovascular (wet or exudative) Progresses more rapidly -ARMD is MCC of blindness > 65yoa (90% is neovascular) ```

Question 27

Risk factors of macular degeneration

Answer 27

FHx Smoking Excessive exposure to UV sunlight

Question 28

Presentation of macular degeneration

Answer 28

Loss of visual acuity (poor central vision) in 1 or both eyes, distortion of images, NO PAIN or REDNESS, fundi exam: macular changes, DRUSEN

Question 29

Tx of macular degeneration

Answer 29

Referral to ophthalmology Neovascular: photodynamic therapy, Vascular Endothelial Growth Factor inhibitors Atrophic: no specific tx but magnifying glasses and visual aids help Antioxidants (Vit C and E), zinc, copper, carotenoids

Question 30

Education- macular degeneration

Answer 30

Can affect your driving, visual hallucinations, watch/screen for depression, encourage use of Amsler Grid

Question 31

Diabetic retinopathy

Answer 31

Damage to retinal blood vessels leads to retinal ischemia, edema. Glycosylation (excess sugar attaching to proteins such as the collagen of the blood vessels) causes capillary wall breakdown.

Question 32

Nonproliferative (background) retinopathy

Answer 32

Microaneurysms lead to blot and dot hemorrhages, flame-shaped hemorrhages, cotton wool spots, hard exudates, retinal vein beading, closure of retinal capillaries. Not associated with vision loss.

Question 33

Proliferative retinopathy

Answer 33

Neovascularization: new, abnl blood vessel growth, vitreous hemorrhage

Question 34

Tx of nonproliferative retinopathy

Answer 34

Panlaser tx. Glucose control.

Question 35

Tx of proliferative retinopathy

Answer 35

VEGF inhibitors, laser photocoagulation tx, tight glucose control

Question 36

Maculopathy

Answer 36

Macular edema or exudates, blurred vision, central vision loss. Due to micro aneurysm leakage at macula causing macular edema and damage

Question 37

Hypertensive retinopathy

Answer 37

Management; control HTN 4 grades: Arterial narrowing, copper wiring, silver wiring AV nicking Flame-shaped hemorrhages, cotton wool spots Papilledema

Question 38

Retinal detachment

Answer 38

Retinal tear- retinal inner layer detaches from choroid plexus

Question 39

Predisposing factors to retinal detachment

Answer 39

Myopia (nearsightedness) and cataracts

Question 40

Clinical manifestations of retinal detachment

Answer 40

Photopsia (flashing lights) with detachment Floaters Progressive unilateral vision loss Shadow curtain in peripheral to central visual field and no pain/redness

Question 41

Dx of retinal detachment

Answer 41

Fundoscopy: retina hanging in the vitreous Pos Shafer's sign (clumping of pigment cells in the anterior vitreous) Nl or decreased intraocular pressure

Question 42

Management of retinal detachment

Answer 42

Laser, cryotherapy ocular surgery. No miotics

Question 43

Corneal abrasion

Answer 43

One of the most common eye injuries; disruption of the corneal epithelium or because the corneal surface has been scraped away or denuded

Question 44

Causes of corneal abrasion

Answer 44

``` Dry eyes Contact lenses FB Fingernails Pieces of paper or cardboard Makeup applicators ```

Question 45

Presentation of corneal abrasion

Answer 45

``` Eye pain Inability to open eye bc of FB sensation Pain with EOM Blurred vision Photophobia Tearing Hx of trauma to the eye Toxic chemicals ```

Question 46

Work up for corneal abrasion

Answer 46

Fluorescein dye + blue light (Wood's lamp) to detect FB or damage to cornea, evert eyelid for inspection

Question 47

Tx for corneal abrasion

Answer 47

PPX abx given in contact lens wearers- FQ drops - Moxifloxacin drops - Contact lens wearers- Cipro or Levofloxacin

Question 48

Orbital cellulitis

Answer 48

Acute infection of orbital contents septum, with edema and erythema of the conjunctiva and eyelids

Question 49

Pathology of orbital cellulitis

Answer 49

Extension of infection from paranasal sinuses or other periorbital structures, trauma or hematogenous spread

Question 50

Most common organisms of orbital cellulitis

Answer 50

S. pneumoniae, H. influenza, M. catarrhalis, S. aureus

Question 51

Risk factors of orbital cellulitis

Answer 51

Sinusitis, orbital trauma, retained FB, dental or periorbital infection

Question 52

Work up of orbital cellulitis

Answer 52

``` CT with contrast CBC CRP ESR Blood culture Lactic acid ```

Question 53

Presentation of orbital cellulitis

Answer 53

``` Malaise Fever Diplopia Pain with EOMs MS change Proptosis vision loss Caution with systemic immunosuppression and DM ALERT: ophthamoplegia, MS change, contralateral CN palsy, or bilateral cellulitis leads to CNS involvement ```

Question 54

Tx of orbital cellulitis

Answer 54

ADMIT! Consults! Monitor vision status and CNS change (neuro checks). - Vancomycin + ceftriaxone + metronidazole - Piperacillin/Tazobactam