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Clinical Medicine 2 > Lecture 12 (HEENT)- Exam 4 > Flashcards

Lecture 12 (HEENT)- Exam 4 Flashcards

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1
Q

*Lid disorders -
*Lacrimal disorders-
*Orbital disorders-
*Conjunctival disorders-
*Corneal disorders –
*Uveal tract disorders-
*Scleral disorders-

A

*Lid disorders - Blepharitis, Chalazion, Ectropion, Entropion, Hordeolum
*Lacrimal disorders- Dacryocystitis
*Orbital disorders- Orbital cellulitis
*Conjunctival disorders- Conjunctivitis
*Corneal disorders –Cataract, Corneal ulcer, Bacterial/Viral Keratitis, Pterygium, Corneal abrasion
*Uveal tract disorders- Anterior uveitis
*Scleral disorders- Scleritis, episcleritis

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4
Q
  • External eye and adnexa structures?
  • Anterior segment of the eye structures?
  • Posterior segment of the eye structures?
A
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5
Q

Eye Anatomy- External Eye and Adnexa
* What are the eyelids for?
* What is the nasolcarimal system?

A
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6
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7
Q

Conjunctiva
* What is it?
* What are the two parts?

A

Conjunctiva: Clear vascular mucous membrane covering the sclera and inner lids

Two Parts:
* Bulbar- Covers the anterior sclera
* Palpebral- Covers the inner surface of the eye lids

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8
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9
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Eye Anatomy- Anterior Segment
* What is the cornea? What is the fxn?
* What is the sclera?
* What is the lens? What is the fxn?

A

Fluid travels from the posterior chamber of the eye to the anterior chamber
Passes between the lens and the iris to reach the anterior chamber
Uveal Tract important to understanding glaucoma

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10
Q

Eye Anatomy- Anterior Segment
* What are the three parts of the uveal tract? What are their functions?

A

Fluid travels from the posterior chamber of the eye to the anterior chamber
Passes between the lens and the iris to reach the anterior chamber
Uveal Tract important to understanding glaucoma

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11
Q

What is the difference between posterior and anterior chamber?

A

Posterior chamber (right behind iris) and anterior chamber (underneath cornea)

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12
Q

What is the limbus?

A

Limbus= transition zone between the cornea and the sclera

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13
Q

Eye Anatomy- Posterior Segment
* What type of humor?
* What is the choroid?
* What is the retina? What does it do?
* What CN is present?

A
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14
Q

Which part of the retina is central vision and which one is for color?

A
  • Macula- Central vision, center of retina
  • Fovea- Within the macula- best color vision
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15
Q

Left or right eye?

A

Right eye

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16
Q

Where do retinal arteries come out from?

A

Retinal arteries come out from behind cup

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17
Q

What is the history approach to the eye?

A
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18
Q

Approach to Eye- Exam
* What do we look for visual acuity?
* What do you look for pupils?
* What type of mvts?

A
  • Visual Acuity (Snellen or Rosenbaum)- “Vital sign of the eye”- 20/20=normal
  • Pupils- symmetric? reflexes (direct and consensual)
  • Extraocular movements (EOM)
  • Visual field testing (confrontation)
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19
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Approach to Eye- Exam
* What does the external exam look at?
* Identify where what is?
* What exam should you do?

A
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20
Q

What are some diagnostic tools for the eye?

A
  • Fluorescein Exam (Wood’s Lamp)- View of cornea
  • Slit Lamp Exam- (Anterior Chamber)
  • Tonometry (measures IOPs)
  • Ocular US (detects retinal/vitreous detachments)
  • Dilated eye exam (fundoscopic exam performed after dilation with drops, enhanced view of retina)
  • Topical anesthetics (tetracaine, proparacaine for anesthesia of cornea and conjunctiva)
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21
Q

Fluorescein Exam
* how do you do it?
* What does it look for?

A
  • Orange dye impregnated blotting paper used to stain the tear film
  • Blue light utilized to evaluate for corneal abrasions, foreign body

  • Fluoresceinis a specialized dye that stains the cornea and highlights any irregularities of its epithelial surface.
  • A uniform film of dye should cover the normal cornea. If the corneal surface is abnormal, excessive amounts of dye will absorb into or collect within the affected area.
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22
Q

How do you evert the eyelid?

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23
Q

What is a slit lamp exam?

A
  • is a table-mounted binocular microscope with a special adjustable illumination source attached.
  • A linear slit beam of incandescent light is projected onto the globe, illuminating an optical cross section of the eye
    *
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24
Q

What is tonometry? What is the normal range?

A

Tonometry is the method of measuring intraocular pressure using calibrated instruments.
* The normal range is 10–21 mm Hg.

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25
What can you see in an ocular US?
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Blepharitis * Inflammation of what? * Assoicated with what? * What is the etiology?
* Inflammation of eyelid margin (common, often chronic) * Associated eye irritation/inflammation, flaking of eyelashes * **Etiology – irritants, cosmetics, parasites, inflammatory skin conditions (seborrhea, rosacea)**
28
What are the two types of blepharitis?
* Most common – Posterior blepharitis (meibomian glands) * Anterior blepharitis – inflammation of eyelids with dandruff like greasy scaly substance (seborrheic type) or fibrinous scales (staph type)
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What is this?
Those glands are plugged up
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What is this?
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Blepharitis What is the Clinical Presentation
* Red, swollen, itchy eyes * Typically bilateral * May burn, feel “gritty” * Crusting on eyelids/lashes * Flakes/scales * Transient blurring of vision
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Blepharitis- * how do you dx it?
Diagnosis made clinically * Visualize red irritated eyelid margin/crusting of lashes on exam
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Blepharitis- * What is the txt? (1st and 2nd line)
34
Ectropion * What is this? * What is it associated with? * More common in who? * May experience what?
35
Entropion * What is it? * What is it associated with?
* Inward turning of eyelid * Associated with blepharitis and dry eye disease
36
Chalazion * What is it? * how it is on exam? * Caused by what? * How do you dx it?
* Painless localized eyelid swelling * Non-tender rubbery bump on exam * Caused by obstruction of Zeis or meibomian glands * Clinical diagnosis
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Chalazion * What is the txt?
* Warm compresses on eyelid twice daily * Refer if unresolved after 1-2 months for I&D or steroid injection * If recurrent and unilateral, consider malignancy ## Footnote No antibiotics- granulomatous not infections
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Hordeolum (“Stye”) * What is it? * Tender to what? * May be where?
* Localized, acute inflammation of the eyelid (painful) * Tender to palpation, sore, appears quickly * May be external or internal on lid
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Hordeolum (“Stye”) * What is the mc pathogen? * What are the risk factors? * What is it clinical?
* Most common pathogen – staphylococcus (may be sterile) * Risk factors: Rosacea and seborrheic dermatitis * DX – clinical
40
How do you tx hordeolum?
* warm compresses, massage * Often resolves spontaneously * Consider abx (topical erythromycin), I&D if no resolution * No improvement in 2 weeks- Refer to ophtho
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What is this?
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Patient shows up with this, what do you need to ask?
is it painful?
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Dacryocystitis * What is it?
Infection/inflammation of the lacrimal sac
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Dacryocystitis * Usually due to what? * What are the types? * What type of appearance? * What is the presentation? * Pressure on what?
* Usually due to obstruction of tear duct * Acute, chronic, or congenital, strep/staph * Cystic appearance * Presentation- Pain, tenderness, swelling, redness in the tear sac area (usually unilateral) * Pressure on cyst will cause discharge from lacrimal sac ## Footnote Dacryocystitis is inflammation of the lacrimal sac which typically occurs secondarily to obstruction within the nasolacrimal duct and the resultant backup and stagnation of tears within the lacrimal sac.
46
Dacryocystitis * How do you dx? * What do you need to check? * What is the tx?
* Clinical diagnosis * Check acuity, EOMs to r/o more serious causes * Tx: Oral antibiotics (antibiotics with  cephalexin  or amoxicillin–clavulanate) and warm compresses * Curative treatment - surgery
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Dacryostenosis * What is obstructed? * Often what? * Most cases do what? * What are features? * How do you dx? * How do you txt?
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What is this?
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What is the inital txt of dacryostenosis? What if it is not effective?
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Orbital Cellulitis * What is it?
An infection involving the contents of the orbit (fat and ocular muscles).
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Orbital Cellulitis- Presentation * Infection of what? * What are the sx? * More common in who? * Can be assoicated with what?
* Infection posterior to the orbital septum (ocular muscle and fat) * Eye swelling and redness PLUS Ophthalmoplegia, pain with eye movements, and/or proptosis * Kids>adults * Can be associated with acute sinusitis ## Footnote * Proptosis is the bulging of one or both or your eyes from their natural position (exophthalmos) * Ophthalmoplegia is the paralysis or weakness of the eye muscles
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Orbital Cellulitis- Presentation * What is the most common pathogen? * What are the sx? * Pain with that?
* Most common – staph aureus, MRSA, and streptococci * Fever, leukocytosis * pain with eye movement
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What is this?
54
What are the Orbital Cellulitis- Differential Diagnosis?
* Pre-septal cellulitis (just septum, not orbital, no pain with EOM) * Viral (herpetic) or fungal – systemic * Tumors * Severe conjunctivitis * Graves disease * Allergic response * Dacryocystitis
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Orbital Cellulitis: How do you dx? Wht imaging can you do? If you suspect orbital cellulitis, what do you need to do?
* Can be made clinically based on signs and symptoms * Eye immobility, proptosis, impaired vision, and pain with EOM * CT to confirm and assess for complications * If you suspect orbital cellulitis -immediate Ophthalmology evaluation
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Orbital cellulitis: * What features need an CT?
Indications for imaging include the presence of any of the following features: -Proptosis -Limitation of eye movements -Pain with eye movements -Double vision -Decreased vision -Relative afferent pupillary defect -Signs or symptoms of central nervous system (CNS) involvement -Inability to examine the patient fully (usually patients less than one year of age) -Patients who do not begin to show improvement within 24 to 48 hours of initiating appropriate therapy
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Orbital Cellulitis * What are the Complications? * Requires what? * Sluggish response indicates what? * Vision lost and death in who
## Footnote ”do not miss” dx May develop rapidl
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Orbital cellulitis- Complications * What can happen with the Extra-orbital Extension Pathways (3)? * What are the sxs of CNS complication?
## Footnote Optic neuritis -Inflammation of the optic nerve. Pain and temporary vision loss are common symptoms.
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Periorbital Cellulitis * What is it? * EOM? * Common in who? * What type of condition? * Differentiate from what?
* Infection of the soft tissues anterior to the orbital septum * **No pain with EOM, no proptosis** * Common in young children <5 * Mild condition that rarely leads to serious complications * Differentiate from orbital cellulitis, if unsure-> imaging!
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Conjunctivitis * What is the mc etiology? * Usually what? * Does not do what? * ALL conjunctivitis results in what? * Consider what?
* Very common (VIRAL) * Most common etiology of red eye with discharge * Usually benign * **does not typically cause vision change** * ALL conjunctivitis results in red eye, but not all red eye is conjunctivitis * Consider other more serious causes, especially in an ER setting
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What is the conjunctiva?
62
Why can you not lose a contact lens behind your eye?
The conjunctive is continuous so a contact lens can not get lost behind the eye.
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What are the differnet causes of conjunctivitis? What are the organisms?
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Bacterial Conjunctivitis * how does it spread? * What are the sx? * Discharge when? * What are the characterisitcs of the discharge? * What happens in the mornings?
* Spreads easily via direct contact * Redness and discharge in one eye or both (returns immediately after wiping) * Discharge generally persists through day * Discharge is thick, globular may be yellow, green, white * Eye often “stuck shut” in the morning
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How do you dx bacterial conjunctivitis?
Dx: Clinical * Typically will have purulent discharge at the lid/corners * More purulent discharge appears within minutes of wiping the lids.
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Bacterial Conjunctivitis * how do you txt it? (non and contact wearers)
Treatment: Topical Antibiotic Drops * 1st line- erythromycin, polymyxin trimethoprim (Polytrim), sulfacetamide * Contact lens users: ciprofloxacin, ofloxacin
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What is this?
Bacterial conjunctivitis
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Hyperacute Bacterial Conjunctivitis * What organism causes this? * Usually transmitted by what? * What is present? * Is it safe or not?
* N. gonorrhoeae * Usually transmitted from the genitalia, to hands, then eyes. * Concurrent urethritis is typically present * Severe and sight threatening
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Hyperacute Bacterial Conjunctivitis * Discharge? * May have what?
* Profuse purulent discharge, +Rapidly progressing redness, irritation and tenderness to palpation * May have tender periauricular lymphadenopathy
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Hyperacute Bacterial Conjunctivitis * How do you dx and txt it?
* DX – gram stain (looking for gram-negative diplococci) * TX – Immediate ophthalmologic referral, hospitalization with management by Ophthalmology
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What is this?
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What is the leading infection of blindness worldwide?
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Viral Conjunctivitis * What is the MC organism? * May present when? * how does it spread?
* Typically – adenovirus, Highly contagious * May present in conjunction with URI (adenopathy, fever, pharyngitis, etc) * Spread via direct contact or contact with contaminated objects.
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Viral Conjunctivitis * What are key exam findings? * What happens in the morning? * usually starts how then what?
* Key exam findings – injection, watery or mucoid discharge, burning. “gritty” feeling in the eye * Morning crusting of eye/lids. * Usually starts unilaterally, moves to 2nd eye within 48 hours
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how do you tx viral conjunctivitis?
* Self-limited process. Will parallel course of a common cold. * Txt: supportive (cool compresses, artificial tears, handwashing)
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What is this?
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Allergic Conjunctivitis * What is the presentation? * More what than viral? * What is there a hx of? * May include what? * How do you txt it?
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What is this?
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What is the empiric approach for conjuctivitis?
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Corneal Abrasion * Defect in what? * What are the etiologies?
* Defect in the corneal epithelium * Multiple etiologies – infectious, traumatic, structure, foreign body, contact lens use
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Corneal Abrasion What will be the Clinical Presentation
* Very painful * Will be reluctant to open eye (consider tetracaine for exam) * Photophobia * Will think they have something in their eye (foreign body sensation) * Pain typically interferes with daily living and sleep
83
Corneal Abrasion- Diagnosis * how do you dx it? * Need to r/o what? * What is typical? * Delayed treatment of abrasion may result in what?
* Dx made of visualizing corneal defect on fluorescein exam * R/o penetrating trauma, bacterial ulcer, hypopyon, HSV, kertatitis * normal vision, normal pupillary response, + defect with fluorescein exam * ulceration
84
What is this?
85
What is this?
86
Corneal Abrasion- Treatment * What is the txt if small and uncomplicated?
* Treated with topical antibiotic therapy (erythromycin ointment, polymyxin/trimethoprim, etc) * Topical/oral pain meds * Refer if retained foreign body suspected * Don’t patch * Close daily follow up * Most heal within 24 hours
87
Corneal Abrasion- Treatment * What if they use contacts? * Should have quick reduction in what after txt?
* Contact lens use abrasion- Abx needs to cover pseudomonas (cipro, ofloxacin) * Should have quick reduction of pain – if that does not occur – refer to ophthalmology emergently
88
What are the corneal abrasion red flags?
* Large defect (+/- ulceration) * Purulent discharge * Significant drop in vision (more than two rows on Snellen chart) * An infant or child who will not keep eye open * Non-healing in 3-4 days * Persistent pain
89
Keratitis * What is it? * What are the different types?
* Inflammation of the Cornea * Causes include- injury, viral, bacterial, parasitic, fungal
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Bacterial Keratitis/ Corneal Ulcer * Patients will feel what? * Will struggle to do what? * What are the most common organisms? * What is the BIGGEST RISK FACTOR * What are other symtoms?
* Patient will feel as if there is something in eye * Will struggle to keep eye open * Staph aureus, Pseudomonas aeruginosa * Biggest risk factor – **Contact Lens use** * +/- red eye, photophobia, discharge, foreign body sensation
91
Bacterial Keratitis/ Corneal Ulcer- Exam * What are the classic diagnostic findings? * Defect will do what? * Slit lamp exam may show what? * What will severe disease have/
* Classic diagnostic finding – **white spot on the cornea of a red eye (corneal opacity), >.5mm and able to be seen with a penlight** * Defect will illuminate on fluorescein exam * Slit lamp exam may show inflammation/ulceration * Severe disease: **hypopyon** (WBCs in anterior chamber)
92
Bacterial Keratitis/ Corneal Ulcer * How do you treat?
Treatment –Emergent! Same day referral to ophthalmologist, topical antibiotics (hourly for first 48 hours)
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What does this show?
94
What is this?
95
What is this?
96
Viral Keratitis * What virus? * What is a classic finding? * What will the fluorescein stain show? * What are other sxs?
* Herpes Simplex * Classic finding – faint branching grey opacity on penlight exam * Fluorescein stain: dendritic lesion * Red eye, watery eye, photophobia, foreign body sensation
97
How do you tx viral keratitis?
* Typically self-limited. * Symptoms reduced with topical or oral antiviral agents * Refer to ophthalmology within 2-3 days
98
What may also be an etiology of viral keratitis?
Adenovirus may also be etiology – typically associated with conjunctivitis, normal gross exam, but fluorescein stain reveals multiple punctate lesions.
99
What is this?
100
What does this show?
HSV-Virus keratitis
101
Viral Keratitis- Herpes Zoster Ophthalmicus * What is it? * What are risk factors? * What are sx? * What is a sign?
* Herpes zoster involving ophthalmic division of CN5 * Risk factors- Age> 50, immunocompromised, HIV * Zoster rash, periorbital burning/itching (may precede rash) * Herpetic lesion on tip of nose predicts eye involvement **(Hutchinson sign)**
102
Viral Keratitis-Herpes zoster * What does the exam show? * What happens if untreat? * Txt with what? * Refer? * What is the prevention?
103
What is Pterygium?
Abnormal triangular growth of conjunctival tissue
104
Pterygium-Clinical Presentation * Common in who? * May cause what? * What is concerning? * May imact what?
* Common – more common with age, males, outdoor occupations, exposure to UV light * May cause **irritation** * Appearance concerning * May impact vision if it grows large
105
Pterygium * Typically starts how and goes where? * May be what? * Can treat sx with what?
* Typically starts medially on the nasal conjunctiva, extending laterally onto the cornea * May be excised, but excision carries risk of decreased eye mobility and recurrence * **Can treat symptoms with topical lubricants (ie artificial tears)**
106
What is this?
Pterygium
107
What is this?
Pinguecula harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. Appears frequently with aging, first on the nasal and then on the temporal side.
108
Uveitis * What is it?
The process of intraocular inflammation of the uvea (middle portion of eye) due to many possible causes
109
Anterior Uveitis/Iritis * What it is? * What in the anterior chamber? * Sometimes assoicated with what?
* Inflammation of anterior uvea (iris and ciliary body) * Leukocytes in the anterior chamber * Mostly idiopathic, but sometimes associated with systemic conditions (Ex: infectious -CMV, autoimmune- spondylarthritis)
110
Anterior Uveitis/Iritis * What is the presentation? * What does the exam show? * How do you dx?
* Presentation-eye pain, redness, photophobia, vision loss * Exam- ciliary flush, WBC in anterior chamber (**cells and flare**) with slit lamp exam, +/-afferent pupillary defect, +/-constricted pupil * Dx: Clinically with slit lamp and dilated fundoscopic exam, refer to Ophthalmology confirm
111
What is this?
Posterior synchiae * Posterior uveitis will have retinal abnormalities– seen in dilated eye exam
112
Anterior Uveitis/Iritis * What do you need to work up?
* Obtain good history/ROS looking for etiology * Differential changes according to age, sex, race, medication use, history of surgery, or history of trauma (e/f systemic disease) * First case of iritis- no work-up indicated as 50-60% idiopathic. * Refer to ophthalmologist who will perform extensive work-up if recurrent
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Anterior Uveitis/Iritis * how do you tx?
* Urgent referral to ophthalmology * Topical steroids (done in consultation with ophtho) * Cycloplegia- ie. Cyclogyl 1%. (dilation=relief)
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Topical steroids for the eye- Always do what? Why?
115
Scleritis * What is it?
Painful, destructive, and potentially blinding inflammatory disorder of the sclera
116
Scleritis-Definition, Epidemiology & Etiology * What is it? * 50% cases are associated with what? * What type of etiology? (2) * Which groups are affected?
* Inflammation of deeper layers of the eye (sclera) * 50% cases are associated with systemic diseases * Autoimmune etiology (#1 RA, connective tissue disease) * Infectious etiology (Pseudomonas, TB, Syphilis, Herpes Zoster) * 4/100,000, women > men, median age at dx – 56
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Scleritis * What are the Clinical Features (red?, pain?, vision?)
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How do you dx scleritis?
* Diagnosis usually cued by underlying disease process in setting of clinical features * Refer to ophthalmologist * Work up for underlying disease/disorder
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What is the tx for scleritis?
* Initial TX – NSAIDS and/or topical steroids * If not responsive to initial TX – systemic steroids, subconjunctival steroids or immune modulators.
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Scleritis-Prognosis & Follow-up * How many people lose vision? * Follow up per what? * What do you need to educate your patient on?
* Vision loss occurs in 15% * Follow up per ophthalmology * Patient education – importance of follow up by ophthalmology
121
Episcleritis * What is it? * Mostly what? * Resembles what? But what makes it different? * Typically what? * What is the txt?
122

Clinical Medicine 2 (16 decks)

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