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HEENT Flashcards

1
Q

Common complaints of blepharitis

A 
Burning
Watering
FB sensation
Crusting and matting of the lashes
Red lids
Sometimes red eyes
Sometimes pain
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2
Q

What are the two categories of anterior blepharitis?

A

Staphylococcal

Seborrheic- chronic scaling of the eye that leads to irritation

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3
Q

DDx of blepharitis

A 
Bacterial or viral conjunctivitis
Contact lens complications
Rosacea
Allergic or contact dermatitis
Preseptal cellulitis
Chalazion
Hordeolum
Dry eye syndrome
Basal cell carcinoma, eyelid
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4
Q

Dx and tx of blepharitis

A

First, apply a warm compress to the eyelid to clean the eye, and do this repeatedly
Abx ointment
-Erythromycin TID x7 days
-Sulfacetamide ointment q4hrs x7 days

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5
Q

Which form of conjunctivitis is more common?

A

Viral > bacterial

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6
Q

What are the four clinical factors associated with viral conjunctivitis

A

Age 6 yrs or older
Presentation in April thru November
No d/c or watery d/c
No glued eye in the morning

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7
Q

Hx of bacterial conjunctivitis

A

Pts complain of eyelids sticking together
Itching, burning or gritty FB sensation
Family members may be infected as well
Acute onset, minimal pain
Staphylococcal and streptococcal species are most common

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8
Q

Presentation of allergic conjunctivitis

A

Very similar in appearance to viral conjunctivitis, but accompanied by nasal congestion, sneezing, eyelid swelling and sensitivity to light. Both eyes are affected. Not contagious

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9
Q

PE of conjunctivitis

A

Erythematous- conjunctiva
May see pus drainage across the eye
Photophobia is minimal
Hx of recent URI is typically associated with a viral cause

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10
Q

Dx of conjunctivitis

A

Do visual acuity and consider fluorescein stain if corneal abrasion or ulceration suspected, or risk of FB
Still need to check for FB
Be sure no risk of chlamydial conjunctivitis
If neonate- immediate referral- if suspect N. gonorrhea or chlamydial infection

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11
Q

Tx for conjunctivitis

A

Viral- supportive care with artificial tears prn, cold compresses
Bacterial
-Polytrim (trimethoprim/sulfa): 1 drop q3h while awake for 5-7 days
-Gentamicin: 2 drops q4h while awake for 5-7 days
-Ciloxan (cipro): 2 drops q4h while awake for 5 days
-Ocuflox (ofloxacin): 2 drops q4-6h for 5 days
Choice depends on cost to pt and allergies. Ciloxan and Ocuflox better for contact lens associated conjunctivitis

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12
Q

Causes of corneal abrasion

A

Dry eye
FB injury
contact lens wear
Traumatic abrasion- fingernails, animal paws, pieces of paper or cardboard, makeup applicators, hand tools, branches or leaves

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13
Q

Pathophys of corneal abrasion

A

Occurs because of a disruption in the corneal epithelium or a scrape to the corneal surface

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14
Q

Procedure of fluorescein stain

A

Use anesthetic drops before stain procedure

Burns for 20-30 seconds

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15
Q

PE findings of corneal abrasion

A

Dx can be confirmed with slit lamp exam and fluorescein installation
Pt complains of eye pain and inability to open eye d/t FB sensation
Often pts are too uncomfortable to work, and pain may interfere with sleep
Photophobia may be present
Excessive tearing

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16
Q

What to do for a PE to look for corneal abrasion

A

Examine eye with lids retracted in order to fully look at the cornea as well as conjunctiva
Assess visual acuity
Apply a topical anesthetic to do a full exam

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17
Q

DDx of corneal abrasion

A

Uveitis
Keratitis
Glaucoma

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18
Q

Prognosis of corneal abrasion

A

Prognosis usually excellent with full recovery of vision and is expected with minor abrasion within 24-48 hrs
Extensive or deep abrasions may require a week to heal
If abrasion is in central line of vision, monitor with ophthalmology
Bacterial keratitis from overnight use of contact lens can become infected with P. aeruginosa, pneumococcus, moraxella and staphylococci
-Treat with moxifloxacin 1 drop TID for one week

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19
Q

Tx of corneal abrasion

A

Traditionally, topical abx are used for prophylaxis even in noninfected corneal abrasions not related to contact lenses, but this practice has been called into question. Gentamicin or Tobramycin have been used as well
Treat pain with topical NSAID drops. Ketolorac- 1 drop q6h prn for pain
Ice packs for 24 hrs prn, then warm compresses

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20
Q

Health maintenance- corneal abrasion

A

Persons who work in high-risk occupations such as auto mechanics, metalworkers, or miners should wear protective eyewear
Contact sports such as hockey, racquetball, pts who farm and ski should also wear protective eyewear
Pts with large abrasions should be reexamined freq by ophthalmologist until healing occurs

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21
Q

Pt complaints with FB

A 
Pain (relieved sig with topical anesthesia)
FB sensation
Photophobia
Tearing
Red eye
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22
Q

What is your first step in trying to remove a FB from an eye?

A

Only try touching with Q-tip if you think you can remove the FB

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23
Q

What’s your second option for FB removal in the eye if the first one doesn’t work?

A

Needle

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24
Q

What is applied to the before and after FB from eye removal?

A 
Antibiotic
Polytrim
Ocuflox
Tobrex
Ciloxan
Bacitracin ointment
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25
Q

What to do with rust rings that remain in the cornea after removal of a metallic FB

A

May require removal with a rust ring drill

F/u every 2 days until the epithelial defect is well-healed

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26
Q

What should be updated after FB removal in the eye

A

Tetanus booster if not immunized in past 7 years

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27
Q

Background information in primary open angle glaucoma

A

Multifactorial optic neuropathy
Chronic and progressive
Acquired loss of optic nerve fibers
This develops into the presence of open anterior chamber angles, visual field abnormalities, and IOP that is too high
Silent onset with no sx or complaints until late

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28
Q

What to pay attention to in primary open angle glaucoma

A 
Past ocular hx
Previous surgery
Ocular or head trauma
PMH (CAD, DM, HTN)
Current meds
RFs
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29
Q

Who is at the highest risk for primary open angle glaucoma?

A

Advise screening by eye specialist for AAs and elderly

30
Q

What does ocular hx usually include for primary open angle glaucoma?

A 
Hx of eye pain or redness
Multicolored halos
HA
Previous eye dz
Uveitis
Ask about FHx
31
Q

Diagnostic testing for primary open angle glaucoma

A

Lab tests to r/o other causes of optic neuropathy in pts
-CBC
-ESR
-Serology for syphilis
Golman tonometry
Gonioscopy: microscope used in conjunction with a slit lamp that measures the anatomical angle of the eye’s cornea and slit lamp
-These tests would be done by an eye specialist

32
Q

PE findings of primary open angle glaucoma

A

If IOP rises above 21 mm Hg, the % of pts developing vision loss increases rapidly
Optic disc cupping and nerve fiber layer losses of up to 40% have been shown to occur before actual visual field loss has been detected

33
Q

Pathophys of primary open angle glaucoma

A

The aqueous humor passes through the pupil and drains through a special membrane called the trabecular meshwork
In open angle glaucoma, the flow of this liquid becomes impaired
Too much abnormal pressure damages the optic nerve, which can eventually lead to blindness

34
Q

General approach to primary open angle glaucoma tx

A

Current medical therapy for primary open-angle glaucoma is limited toward lowering IOP
If one med is inadequate in reaching the target pressure, a second med should be chosen that has a different MOA so that the two-drug therapy will have an additive effect

35
Q

Tx for primary open angle glaucoma

A

Beta-adrenergic blockers: Timoptic, Betoptic-S, Betagan
Adrenergic agonists: Alphagon
Carbonic anhydrase inhibitors- Truspot, Azopt
Antiglaucoma combos- Tomoptic/Alphagon
Prostaglandin analogs: Xalatan, Lumigan
Miotic agents: Pilocar, Ocusert

36
Q

Acute angle closure glaucoma

A

A condition in which the iris is apposed to the trabecular meshwork at the angle of the anterior chamber of the eye
This blocks the outflow of aqueous from the eye which causes a rapid rise in IOP

37
Q

Hx/PE of acute angle closure glaucoma

A

Sudden eye pain, blurred vision and N/V
Halos around lights
<10% of glaucoma in the US are d/t acute angle closure glaucoma

38
Q

PE of acute angle closure glaucoma

A

Examine with ophthalmoscope, tonometry, and gonioscopy
Tonometry may show as high as 40-80 mm Hg
Ophthalmoscopy may reveal a swollen optic disc
Gray atrophy of the stroma of the iris provides further evidence of a prior attack

39
Q

Tx of acute angle closure glaucoma

A

Definitive tx is laser iridotomy or surgical iridectomy
Intended to prepare the pt for laser iridotomy
Cornea should be treated with osmotic agents, pupil constricted, and IOP lowered to prevent acute damage to the optic nerve

40
Q

What meds lower IOP in acute angle-closure glaucoma?

A

Acetazolamide given as a state dose of 500 mg IV followed by 500 mg PO. A dose of a topical BB (i.e., carteolol, timolol) will also aid in lowering IOP

41
Q

What does laser iridotomy do?

A

Creates an opening in the iris through which aqueous humor trapped in the posterior chamber can reach the anterior chamber and the trabecular meshwork

42
Q

Pathology of exudative macular degeneration

A

Pathologic choroidal neovascular membranes (CNMV) develop under the retina. The CNMV can leak fluid and blood and if left untreated, cause a centrally blinding disciform scar

43
Q

What can contribute to the worsening of age-related

A

Smoking
HTN
Obesity
Dietary fat intake

44
Q

Hx of age-related macular degeneration

A

Painless, progressive blurring of the central visual acuity, which can be acute or insidious in onset
This leads to a central scotoma in which the pt’s visual acuity falls below reading level and legal driving level
Peripheral visual acuity is usually retained

45
Q

Hard exudates

A

Lipid deposits which are produced from lipoprotein leakage from blood vessels. When hard exudates are present, one should think of a vasculopathy, seen usually in conditions with chronic vascular leakage

46
Q

Drusen

A

Waste material and composed of proteins, lipids and many other trace elements such as zinc

47
Q

PE findings of exudative AMD

A 
Subretinal fluid
Pigment epithelial detachments
Subretinal hemorrhages
Drusen present
Choroid neovascular tissue may be seen as yellow-green subretinal discoloration
48
Q

Tx of exudative AMD

A

Until the start of anti-VEGF agents, ophthalmologists used thermal laser destruction or photodynamic therapy of the choroid neovascular tissue as the primary tx
Now, two new drugs: FDA approval of Ranibizumab, but it’s still expensive, and bevacizumab, which is still considered off-label
Aflibercept is indicated for exudative to bind and prevent activation of vascular endothelial growth factors (VEGF-A)

49
Q

Non-exudative macular degeneration

A

Characterized by the presence of atrophy that can be associated with severe central visual field loss
Peripheral vision is preserved
90% of pts with ARMD have dry ARMD, which is a slower progression
Usually affects those >50 yo

50
Q

Tx/followup of non-exudative macular degeneration

A

10-20% of those with dry ARMD can progress to wet ARMD
One trial showed favorable results when treating dry ARMD with large doses of antioxidant multivitamin therapy (vit A, C, E, zinc, and copper)

51
Q

F/u for macular degeneration

A 
Support groups and counseling
Low-vision aids
Handheld or stand magnifiers for reading
Talking watches
Computers that use large type face
52
Q

When does optic neuritis typically first occur?

A

In young adulthood and is commonly the first manifestation of MS, but ON can occur in isolation
Occasionally, ON can result from an infectious process involving the orbits or paranasal sinuses

53
Q

Optic neuritis

A

A demyelinating inflammation of the optic nerve that often occurs in association with MS and neuromyelitis optica (NMO)

54
Q

PE findings of optic neuritis

A

Rapidly developing impairment of vision in 1 eye, or less commonly, both eyes
Retro-orbital or ocular pain, exacerbated by eye movement
Pain may precede vision loss
Decreased pupilary light reaction in the affected eye
Marcus Gunn pupil
Abnl color vision
Central scotoma with visual field testing
Papillitis (swollen optic disc) in 33% of pts with ON
With time- the optic nerve may become pale

55
Q

Lab diagnosis for optic neuritis

A

Do blood tests to exclude causes of optic neuropathy other than optic neuritis
-ESR
-Thyroid function testing
-ANA
-Angiotensin-converting enzyme
MRI is highly sensitive for and specific in the assessment of inflammatory changes in the optic nerves

56
Q

DDx for optic neuritis

A 
Acute angle closure glaucoma
Interstitial keratitis
Optic nerve sheath meningioma
Anterior ischemic optic neuropathy
Compressive neuropathy
Sarcoidosis
Sudden visual loss
Thyroid opathlmopathy
Toxic/nutritional optic neuropathy
57
Q

Prognosis for optic neuritis

A

Visual function begins to improve 1 wk to several weeks after onset, even without any tx
Permanent residual deficits in color vision and contrast and brightness sensitivity are common

58
Q

Tx for optic neuritis

A

IV steroids to speed the rate of recovery, BUT do little to affect ultimate visual acuity
Treat pain with pain meds
Determine with workup whether pt has brain lesions on MRI that indicate high risk for MS. Immunomodulators can improve risk of reoccurrence of optic neuritis for pts with MS

59
Q

Causes of orbital cellulitis

A

Can be an extension of an infection from the paranasal sinuses, eyelids, dental infections
Direct inoculation of the orbit from trauma or surgery
Hematogenous spread from bacteremia

60
Q

What are 90% of cases of orbital cellulitis due to?

A

Ethmoid sinusitis
Aerobic bacteria are most frequently responsible in ethmoid sinusitis
Anaerobic bacteria from maxillary sinus- bacteroides (from mouth)
Eyelid infections can cause orbital cellulitis from S. aureus, S. pneumoniae, S. pyogenes

61
Q

Hx/PE of orbital cellulitis

A 
Fever, malaise
Hx of recent sinusitis
Recent dental work
Recent infection/sepsis
Swollen conjunctiva
Decreased vision
Pain on eye movement
Lid edema
62
Q

Labs/dx of orbital cellulitis

A

CBC-WBC >15,000 with a shift to the left
BCx should be drawn prior to giving abx
Culture should be ordered of purulent drainage from the eye or from the orbital abscess
High-resolution CT scan with contrast infusion
MRI may be helpful in defining orbital abscesses

63
Q

Tx of orbital cellulitis

A

Pt should be promptly hospitalize for tx until the pt is afebrile and has clearly improved
Consider orbital surgery in every case of subperiosteal or intraorbital abscess formation
Pt needs to be monitored daily and treated with IV abx started and continued for 1-2 wks then oral abx for 2-3 wks
-Nafcillin (staph and strep coverage)
-Cefotaxime (H. influenzae, Moraxella)
-Vanc, clinda, or TMP-SMX (for MRSA)
-Metro (for anaerobes)

64
Q

What is different in papilledema in contrast to other causes of optic disc swelling?

A

Vision is well preserved with acute papilledema

65
Q

Onset of papilledema

A

Bilateral and may develop over hours to weeks

66
Q

Cause of papilledema

A

Rare brain tumor
Brain infection: brain abscess, meningitis, encephalitis
Severe HTN
Pseudotumor cerebri or benign intracranial HTN
Optic nerve glioma (unilateral papilledema)
Meds (minocycline, lithium, corticosteroid withdrawal)
Cerebral edema

67
Q

PE findings of papilledema

A

Papilledema on retinal exam
Peripheral vision affected in some pts
Wider blind spot near the nose
Afferent pupil defect- pupil is slow to react to light
Sixth nerve palsy: double vision and eyes not tracking well together
Small hemorrhages on the nerve fiber layer detected with the green light on ophthalmoscope

68
Q

Signs/hx of papilledema

A

HA
Visual changes- vision turns gray briefly or described as if a “veil has fallen over the eyes” with position changes
Presents as a bilateral phenomenon and may develop over hrs to wks
Pulsatile tinnitus
Neck and back pain
Nausea with vomiting

69
Q

Labs/rads of papilledema

A 
Brain CT or brain MRI
CBC
Blood sugar
ESR
RPR
70
Q

F/u diagnostic of papilledema

A

LP should be performed following nl MRI to assess opening pressure of the CSF and to obtain CSF for analysis to r/o neoplastic and infectious etiologies. May provide therapeutic benefit

71
Q

Tx of papilledema

A

Tailored to the underlying pathologic process
Diuretics: Diamox may be useful in selected cases, esp in cases of idiopathic intracranial HTN
Corticosteroids may be effective in cases of inflammatory disorders

DSE (14 decks)

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