Eyes Flashcards
general things to check for during an eye exam
- physical exam
- visual acuity
- visual field
- color vision
- eye movements
- pupils
- IOP
components of anterior segments
- lids
- conjunctiva
- cornea
- iris
- lens
- anterior chamber
- anterior vitreous
how do you best view the anterior segment
slit lamp
how do you best view the posterior segment
fundoscopy
components of the posterior segment
- retina
- optic disc
what is the best imaging for the eye
CT
what bones of the orbit are most likely to break?
- maxilla
- zygoma
- frontal
medial canthal ligament
- attaches corner of the tarsal plate to the orbital wall
- found inside eyelid
- disruption -> malposition of eyelids
lateral canthal ligament
- attaches to lateral aspect of orbit
- found inside eyelid
- disruption -> malposition of eyelids
who is most likely to get orbital fx?
- children and adolescents d/t sports trauma
- adults d/t assaults or MVA
clinical presentation of orbital fx
- deformity
- pain
- hematoma
- subconjunctival hemorrhage
- pain with eye mvmt
- diplopia
- facial numbness
- N/V
- bradycardia
physical deformities possible d/t orbital fx
- proptosis d/t hematoma
- enopthalmus d/t herniation of globe contents into sinus
- extrusion of intraoccular contents
- subcutaneous emphysema
- widened intracanthal distance
orbit fx types
- orbital zygomatic fx
- nasoethmoid fx
- orbital roof fx
- orbital floor fx
orbital zygomatic fx
- most common fx of orbital rim
- d/t high impact blow to lateral orbit
- usually associated with orbital floor fx
nasoethmoid fx
- medial orbital rim
- disruption of medial canthal ligament and lacrimal duct system
- medial rectus muscle entrapment
orbital roof fx
- more common in kids
- expose larger portion of upper surface
- high association with intracranial injury
orbital floor fx
- aka blowout fx
- d/t small round object hitting eye
- displacement of globe backwards
concerns associated with orbital floor fx
- entrapment of inferior rectus m
- orbital fat
- resulting ischemia and loss of muscle fn
- fx fragment or compression by hematoma
- herniation of tissue into maxillary sinus
hyphema
- blood in anterior chamber
- usually assoc with corneal abrasions
- may be visible on gross inspection
what is the most common source of blood in hyphemas?
- tear in anterior face of ciliary body
- direct blow can also rupture vessels at root of iris
common causes of hyphema
- blunt trauma or penetrating injury
- finger
- hockey stick
- deployed airbag
- paintball
- assault
clinical presentation of hyphema
- vision loss
- eye pain with pupillary constriction
- photophobia
management of hyphema
- slit lamp to exclude open globe injury like laceration
- tetracaine
- pain control, N/V control
- keep head at 30 degrees to promote settling of blood
- patch
- ophthalmic consult
- monitor IOP
- topical steroids
who has a poorer prognosis for hyphema?
- anyone with bleeding disorders or sickle cell
- need to order lab work
- also depends on grading
- grade 4= 100% anterior chamber filling
corneal abrasion
- result of eye trauma, retained foreign body, or improper contact use
- defect in corneal surface epithelium
what innervates the cornea
trigeminal nerve
how many layers does the cornea have
six
what is the most frequent cause for ophthalmic emergencies?
- foreign body with corneal abrasion
clinical presentation of corneal abrasion
- eye pain
- tearing
- redness
- photophobia
- blurred vision
- foreign body sensation
- can sometimes see epithelial defect on gross exam
- normal or decreased visual acuity
- corneal edema
diagnosis of corneal abrasion
- gross exam
- fundoscopy
- slit- lamp exam
- flourescein after globe ruled out
management for corneal abrasions
- topical erythromycin, polymyxin, or sulfacetamide
- no patching
- dont need f/u for small abrasions
management for corneal abrasions in contact wearers
- antipseudomonals
- ciproflox drops
- oxiflox drops
- gentamicin or tobramicin
- ophthalmology f/u
indications for ophthalmologist f/u with corneal abrasions
- large abrasions
- contact lens wearers
- young children
- vision changes
- rust ring
corneal ulcers
- serious
- involves multiple layers of cornea
- major cause of impaired vision and blindness
- extends through stroma
causes of corneal ulcers
- exposure keratitis
- allergies
- severe dry eye
- autoimmune disease
- vit A deficiency
- trauma
- direct microbial invasion
common bacteria that cause corneal ulcers
- pseudomonas
- staph
- strep
- MRSA
- moraxella liquefaciens
common virus that cause corneal ulcers
HSV/ zoster
corneal ulcers risk factors
- contact lens wearer
- previous eye surgery
- eye injury
- hx of herpes
- use of topical or systemic . steroids
- immunocompromised
clinical presentation of corneal uclers
- red eye*
- ocular pain*
- discharge
- swelling of eyelids
- photophobia
- foreign body sensation
- blurred vision
- eyelids and conjunctiva erythematous
- mucopurulent discharge
- round or irregular ucler with white hazy base
corneal ulcer exam
- slit lamp
- r/o herpes zoster
corneal ulcer diagnosis
- made clinically
- scrape ulcer and culture to determine pathogen
- done by ophthalmologist
corneal ulcer treatment
- aggressive topical treatment
- abx- fluoroquinolones
- topical antifungals- fluconazole, amphoteracin
- antivirals- ganciclovir, acyclovir
when should you refer someone to ophthalmologist for corneal ulcers
- within 12-24 hours
complications of corneal ulcers
- corneal scarring
- corneal perforation
- glaucoma
- cataracts
- blindness
what is the worst chemical injury to the eye
- alkali burns
acid burns
- dissociate into H ions in cornea
- damage ocular surface by changing pH
- produce protein coagulation which prevents deeper penetration of acids into eye
common acids that injure eye
- battery acid
- bleach
- glass polish
- vinegar
- hydrochloric acid
alkali burns
- dissociate into hydroxyl ion
- liquifies fatty acid of cell membrane
- can penetrate cell membrane
common alkali that injure eye
- ammonia
- lye
- lime
- airbag rupture
- fireworks
chemical injury managment
- litmus paper
- copious irrigation with saline
- morgan lens use until pH is neutral
- emergent consult and f/u with ophthalmology
corneal foreign body clinical presentation
- pain
- foreign body sensation
- photophobia
- tearing
- red eye
- blurred vision
diagnosis of foreign body
- clinical exam
- evert eyelid
- fluorescein
- slit lamp
exam findings for foreign bodys
- normal or decreased visual acuity
- conjunctival injection
- ciliary injection
- visible foreign body
- rust ring
- epithelial surface defects with fluorescein
- excessive tearing
- corneal edema
foreign body management
- remove foreign body
- topical abx if no open globe injury
- irrigation
- can use q-tip, sterile needle tip
- no contacts
- ophthalmology referral
topical drops for foreign body management
- erythromycin
- cipro
- cycloplegic
open globe injury
- may accompany multiple trauma or serious head injury
- tetanus prone wound
- can be occult on gross exam
clinical presentation of open globe injury
- obvious corneal or scleral laceration
- volume loss
- protruding foreign body
- extruding intraocular contents
- decreased visual acuity
- relative afferent pupillary defect
diagnosis of open globe injury
- CT
management of open globe injury
- NPO- may need sx
- dont remove FB
- patch both eyes
- place head at 30 degrees
- treat nausea and pain aggressively
- provide sedation
- IV abx
- ophthalmic consult
- surgical repair within 24 hours
subconjunctival hemorrhage cause
- fragile conjunctival vessel rupture
- trauma
- increased venous pressure
- spontaneous
treatment for subconjunctival hemorrhage
- reassurance
- will resolve in 2-3 weeks
- multiple episodes warrant further work up
topical cyclopelgics
- paralyze ciliary muscles
- cyclopentolate
- homatropine
conjuctivitis
- red eye d/t inflammation of conjunctiva
- usually self limited
conjunctivitis and contact lens wearers
- high risk of pseudomonal keratitis
- higher risk for extended wear pts
red flags associated with conjunctivitis
- reduction of visual acuity
- ciliary flush
- photophobia
- severe foreign body sensation
- corneal opacity
- fixed pupil
- severe HA with nausea
bacterial conjunctivitis
- more common in kids
- spread- direct contact
- usually unilateral
- yellow/ green/ white d/c
- eye sticks shut, crusting
- sand/gritty feeling
common causes of bacterial conjunctivitis
- s. aureus
- s. pneumoniae
- h. flu
what should you do in any eye complaint
- fluorescein
- fundoscopy
management of bacterial conjunctivitis
- erythromycin ophthalmic ointment
- trimethoprim- polymyxin drops
- fluoroquinolone drops for contact wearers
viral conjunctivitis
- usually have viral prodrome of sore throat, fever, LAD, pharyngitis
- spread by direct contact
- watery d/c with burning
- gritty feeling
- usually affects both eyes
common cause of viral conjunctivitis
- adenovirus
- have rapid test for adenovirus now
management of viral conjunctivitis
- self limited
- gets worse in first 3-5 days
- can use topical antihistamines and compresses
allergic conjunctivitis
- airborne allergens come in contact with eye
- very itchy eyes- possible corneal abrasions
- bilateral
- marked chemosis (swelling)
- allergic shiners
management for allergic conjunctivitis
- remove offending agent
- wear sunglasses
- change filters, clothes
- antihistiamine/ vasoconstrictor combo (naphcon-A)
- steroids (can raise IOP)
traumatic conjunctivitis
- d/t foreign body
- treatment is removal of fb
toxic conjunctivitis
- due to chemical burns
diagnosis of conjunctivitis
- clinical dx
- based on hx and exam
- fluoroscein and fundoscopy exam
preseptal/ periorbital cellulitis
- infection of anterior eyelid
- no orbit involvement
- mild with rare complications
- usually d/t external sources
causes of periorbital cellulitis
- insect/ animal bites
- foreign body
- dacryocystitis
- conjunctivitis
- hordeolum
common bacterial causes of periorbital cellulitis
- s. aureus
- s. pneumoniae
- MRSA
clinical manifestations of periorbital cellulitis
- ocular pain
- eyelid swelling
- erythema
- warmth
diagnosis of periorbital cellulitis
- history and PE
- Ct or MRI
management of periorbital cellulitis
- doxycycline
- clindamycin PO
- keflex PO
- for MRSA can give bactrim plus amoxicillin or ceph
orbital cellulitis
- infection of contents of orbit
- no globe invovement
causes of orbital cellulitis
- rhinosinusitis**
- orbital trauma
- dacryocystitis
- tooth infection
- opthalmic surgery
most common bacterial causes of orbital cellulitis
- s. aureus
- strep
clinical manifestations of orbital cellulitis
- swelling
- erythema
- warmth
- ophthalmoplegia
- proptosis
- pain with eye movement
- diplopia
complications of orbital cellulitis
- orbital abscess
- subperiosteal abscess
- brain abscess
- cavernous sinus thrombophlebitis
dx of orbital cellulitis
- clinical
- confirmed with CT or MRI
management of orbital cellulitis
- vanco plus ceph
- unisyn/ zosyn plus ceph
- should see improvement in 24-48
hours - may require surgery
herpes keratitis
- corneal infection and inflammation
- major cause of blindness
- spread- direct contact
- mostly unilateral involvement
what is the most common type of herpes keratitis
- infectious epithelial keratitis
- endemic in humans
clinical manifestations of herpes keratitis
- pain
- visual burning
- tearing
diagnosis of herpes keratitis
- conjunctival injection
- dendritic lesions on fluorescein
management of herpes keratitis
- topical antivirals for mild cases
- PO plus topical antivirals for more severe cases
what are the meibomian glands?
- found on inside rim of eyelids
- sebaceous glands that secrete oily substance to keep eyes lubricated
- dysfunction -> dry eye
blepharitis
- chronic inflammation of eyelids
- intermittent exacerbations
- anterior less common
- posterior more common
anterior blepharitis
- inflammation at base of eyelids
- more common in young females
- 2 types- staph or seborrheic dermatitis
clinical manifestations of anterior blepharitis
- eyelid edges are pink, irritated, swollen with crust
- malposition of eyelids with chronic
- eyelashes misdirected or thinning
- diffuse conjunctival injection
posterior belpharitis
- associated with other skin conditions like rosacea and seborrheic dermatitis
- gland gets plugged and inflamed -> dry eye
clinical manifestations of posterior blepharitis
- red, swollen eye
- gritty sensation
- burning, excessive tearing
- itchy eyelids
- crusting
- flaking eyelid skin
- photophobia
- blurred vision
diagnosis of blepharitis
- clinical, history and PE
- distinguish anterior from posterior
management of blepharitis
- counseling
- alleviate acute sx
- warm compresses
- lid massage and washes
- artificial tears
- topical abx for anterior, PO abx if severe
hordeolum
- aka stye
- acute, purulent inflammation of eyelid
- can be sterile or show bacteria (staph)
internal hordeolum
- infection of meibomian gland
- conjunctival side
external hordeolum
- infection of eyelash follicle
- lid margin
management of hordeolum
- warm compress
- +/- topical abx
- may harden to chalazion
chalazion
- chronic inflammatory lesion
- d/t blockage and swelling of meibomian gland of eyelid
- usually in pts with eyelid margin blepharitis and rosacea
progression of chalazion
- may start as small, red, tender, swollen
- 2-3 days becomes painless and larger, rubbery, nodular
- inflammation and blockage, not infection
treatment of chalazion
- self limited to few weeks- months
- warm compresses
- eyelid massage
- if non-resolving refer to optho for I&D
ectropion
- lower eyelid rolled out
- sagging eyelid -> dry eye, irritation
- usually d/t aging, can be d/t facial nerve paralysis
clinical manifestations of ectropion
- excessive tearing
- chronic inflammation
- redness
- gritty
- dry eye
- crusting
- multiple infections
- eyelids dont close properly
management of ectropion
- artificial tears as temp fix
- requires surgery
entropion
- eyelid rolls inward
- eyelashes rub against conjunctiva
- causes chronic irritation
- d/t aging, trauma, scarring, surgery
clinical manifestations of entropion
- red eye
- irritated
- gritty
- tearing
- mucous discharge
- photophobia
- corneal abrasions
- absent eyelashes
management of entropion
- artificial tears as temp fix
- surgery
dacryoadenitis
- inflammation of lacrimal glands
- usually d/t bacteria or virus
- most common in kids and neonates
what is the most common viral cause of dacryoadenitis
- mumps
clinical manifestations of dacryoadenitis
- unilateral
- severe pain
- redness
- swelling
- supraorbital pressure
- rapid onset
- conjunctival swelling
- submandibular LAD
- exopthalmos
- ocular motility restrictions
- can have systemic sx
chronic manifestations of dacryoadenitis
- usually bilateral
- painless enlargement
- present more than a month
- more common than acute
dx of dacryoadenitis
- lacrimal gland enlarged
- easily seen with eversion of upper lid
- CT
management of dacryoadenitis
- most common cause= mumps, self limiting
- bacterial- keflex
- inflammatory cause- look for systemic causes like autoimmune diseases
dacryostenosis
- nasolacrimal duct obstruction
- most common cause of persistent tearing in infants
- spontaneous resolutino in 6-12 mo
treatment of dacryostenosis
- massage
- lacrimal duct probing
retinal detachment
- seperation of retina from pigment epithelium and choroid
- traction or tears -> fluid accumulation -> detachment
- can result in permanent blindness
- most uncomplicated spontaneous detachments can be cured
risk factors for retinal detachment
- myopia
- previous ocular surgery
- fluorquinolone use
- trauma
- family hx
- marfan disease
causes of retinal detachment
- tears or holes either traumatic or spontaneous
- traction of retina- usually diabetic retinopathy
- tumors
- exudative process
clinical manifestation of retinal detachment
- increasing number of floaters
- flashes of lights
- shower of black spots
- curtain spreading over visual field
- progression varies
- on exam see “billowing sail” or “ripple on pond” appearance
differentail dx for retinal detachment
- vitreous hemorrhage
- vitreous inflammation
- ocular lymphoma
- intra-ocular FB
- treatment for retinal detachment
- ophthalmologist consult immediately
- drain subretinal fluid
- laser photocoagulation
- cryotherapy
- pneumoretinopexy
- scleral buckle placement
- vitrectomy
- goal= close tears
optic neuritis
- inflammation of optic nerve
- normal fundus exam
- closely associated with MS
causes of optic neuritis
- MS***
- sarcoidosis
- neuromyelitis optica
- herpes zoster
- SLE
clinical manifestations of optic neuritis
- unilateral vision loss*
- pain exacerbated by movement*
- central vision loss
- pain behind eye
- usually improves in 2-3 weeks
differential dx for optic neuritis
- infections of optic n
- retinal detachent
- giant cell arteritis
treatment of optic neuritis
- brain MRI- MS dx
- consult neurologist
- systemic steroid use controversial
- treat MS plaques with interferon beta-1a
papilledema
- PE finding
- loss of definition of optic disc d/t edema
- central vessels get pushed forward and veins dilated
- cause= increased ICP
- may be confused with HTN retinopathy
causes of papilledema
- mass lesions
- cerebral edema
- hydrocephalus
- obstruction of venous outflow
- idiopathic intracranial HTN
clinical manifestations of papilledema
- HA that is worse in AM or when lying down**
- N/V
- diplopia
- transient visual blurring
stages of papilledema
- early
- fully dev
- late chronic
early papilledema
- loss of venous pulsations
- optic cup retained
fully dev papilledema
- disc margins obscured
- cup obliterated
- blood vessels blurred
- flamed hemorrhage
- cotton wool spots
late chronic papilledema
- cup obliterated
- hemorrhage and exudative components resolved
- nerve is flat
- disc pallor
diagnosis of papilledema
- MRI or CT
- LP to check for opening pressure
- visual field test
treatment for papilledema
- reduce and monitor ICP
- diuresis
- hypertonic saline
- steroids
- hyperventilation- ICU
- barbituates
- remove CSF- shunting
- decompressive craniectomy- emergency only
idiopathic intracranial HTN
- bilateral papilledema
- N/V
- HA
- blurred vision/ visual field defects
- CN VI paresis
- most common in obese women of childbearing age
management of idiopathic intracranial HTN
- usually self limited
- weight loss
- serial LPs
- high dose steroids
- surgery for severe cases
retinal a occlusion
- usually d/t embolism
- sudden painless loss of vision
- form of stroke
- vision loss depends on a affected
central retinal a occlusion
- sudden loss of vision in one eye
- transient monocular blindness, stuttering, or fluctuating course
- painless
branch retinal a occlusion
- monocular vision loss
- restricted to just one part of visual field
what is the most common cause of retinal a occlusion
- carotid artery atheroscleorsis
associated sx of retinal a occlusion
- HA if from GSA or carotid dissection
- unilateral numbness, weakness, slurred speech
- marcus gunn pupil
- cherry red spots on macula
- check inflammatory markers on labs
retinal vein occlusion
- d/t chronic diseases that slow venous BF
- results in neovascularization which are fragile and prone to hemorrhage
- either branch, central, or hemiretinal v occlusion
- sudden painless vision loss
conditions associated with retinal v occlusion
- DM
- HTN
- leukemia
- sickle cell disease
- multiple myeloma
esotropia
- eye points in
exotropia
- eye points out
hypertropia
- eye points up
- not common
- usually d/t CN IV palsy from trauma
- pt presents with head turn and head tilt to minimize diplopia
hypotropia
- eye points down
causes of strabismus
- congeital
- refractive error -> esotropia
- convergence error -> exotropia
- certain medical conditions are at higher risk
medical conditions at higher risk of strabismus
- down’s syndrome
- cerebral palsy
- stroke
- head injuries
- prematurity and low birth weight
causes of strabismus in children
- RB
- thyroid eye disease
- oblique palsy
- brown syndrome
- duane syndrome
- down syndrome
- head trauma
- cerebral palsy
treatment for strabismus
- lenses
- prism
- vision therapy
- surgery
- botox
ambliopia
- aka lazy eye
- happens when there is a disruption between retina and brain as a child
- suppression of vision in one eye d/t strabismus -> nerves dont develop
new onset strabismus/diplopia in adults
- aneurysm until proven otherwise (often CN 3 palsy and aneurism in middle cerebral a or posterior communication a)
- gradual onset- tumor
- transient or persisting- temporal arteritis
- variable diplopia
pterygium
- triangular thickening of bulbar conjunctiva growing toward cornea
- usually d/t excessive sun exposure
- aka surfers eye
- 2X more common in males
pathophys of pterygium
- benign fibro-vascular proliferation and basophilic degeneration of corneal collagen
- matrix metalloproteases break down proteins
- destroys bowmans layer -> scarring and vision loss
differential dx for pterygium
- pannus- contact lens overuse
- phlyctenular keratitis- TB or staph sensitivity
treatment for pterygium
- prevention*- sunglasses or hats
- topical lubricants and steroids
- surgery
complications of pterygium
- irritated gritty eyes
- cosmetic appearance
- contact lens intolerance
- astigmatism
- decreased vision
cataracts
- denatured protein in eye, usually d/t UV light
- can be congenital, age related, traumatic, or secondary (DM, steroids)
- creates a lot of glare
nuclear cataracts
- earliest cataracts
- minimal impact on vision
- often assoc with fetal alcohol syndrome or congenital issues
- can dev from rubella or syphillis
cortical cataracts
- added layers to lens throughout life
- starts at edge of lens and grows in like spokes to center
- impacts visual acuity
posterior capsular cataracts
- looks like smudge or dirt on lens
- most visually devistating
treatment for cataracts
- new glasses or prescription
- sunglasses for glare
- surgery (around 20/40 vision mark)
complications of cataracts
- hyper-mature cataract
- decreased vision
- riskier surgery
glaucoma
- increased IOP
- puts pressure on optic N and can result in vision loss (increased cup to disc ratio)
- impacts portions of visual field
what is the most common type of glaucoma
- open angle
types of glaucoma
- primary open angle
- congenital
- secondary
- angle closure glaucoma
- low tension glaucoma
- pigmentary glaucoma
low tension glaucoma
- pressure is not high but is high enough to damage already unhealthy optic n
criteria for legally blind
- 20/200 visual acuity OR
- 10 degrees of visual field
treatment for glaucoma
- topical meds***
- surgery
what are the topical meds commonly used for glaucoma?
- prostaglandins*
- beta blockers*
- alpha adrenergic agonists
- carbonic anyhdrase inhibitors
- miotics
prostaglandins
- glaucoma topical drops
- increase uveoscleral outflow
- ADRs- lash and hair growth, atrophy of orbital fat, worsens ocular inflammation
beta blockers
- glaucoma topical drops
- decrease aqueous humor production
alpha adrenergic agonists
- glaucoma topical drops
- decrease aqueous production and increase outflow
carbonic anhydrase inhibitors
- glaucoma topical drops
- decrease aqueous production
miotics
- glaucoma topical drops
- increase outflow through trabecular meshwork
angle closer glaucoma
- usually unilateral
- occurs in pts with anatomically narrow angles- iris sits closer to cornea
- can occur in pts with cataracts
- very red eyes
- very nauseas
- poor pupillary reaction
meds associated with angle closer glaucoma
- cholinergic meds
- anticholinergic meds
- SSRIs
- antihistamines
- adrenergic agonists
treatment for angle closer glaucoma
- laser peripheral iridotomy
macular degeneration
- accumulation of waste products in the eye (drusen)
- leads to thinning and atrophy of macula
- neovascularization -> vessels susceptible to rupture
- visually devistating
types of macular degeneration
- dry - without new BV
- wet- with new BV that are very leaky (worse prognosis)
risk factors for macular degeneration
- age
- family history
- caucasian
- smoker
- obesity
- CV disease
sx of macular degeneration
- blurry, distorted vision
- blind spots that move wherever the patient looks
management of macular degeneration
- VEGF injections in eye for wet
- lifestyle changes
- vitamins
- photodynamic therapy
- photocoagulation
hypertensive retinopathy
- arteriosclerosis d/t chronically elevated BP
- > 140/90
- dev dot hemorrhages and flame hemorrhages
signs of hypertensive retinopathy
- widening of arteriole light reflex
- arteriovenous crossing signs
- copper or silver wire arteries
- retinal hemorrhages
- cotton wool spots
- exudates (lipids)
- papilledema
diabetic retinopathy
- damage to small blood vessels of eye by sugar in the blood
- blacks, latinos, and native american’s significantly higher risk
stages of diabetic retinopathy
- non-proliferative
- proliferative
- macular edema (can happen in proliferative or nonproliferative)
what does the health of the retina directly reflect?
- kidney health
symptoms of diabetic retinopathy
- blurry vision
- spots or floaters
- dark spot in vision
- difficulty seeing well at night
- occurs as early as A1C of 5.9
- dev fibrovascular structures which can lead to retinal detachment
treatment for diabetic retinopathy
- tight control of sugar and BP
- anti-VEGF injections
- steroid injections/ implants
- laser
- vitrectomy
