What features help to differentiate Orbital Cellulitis from preseptal cellulitis?
1- Eye pain with movement
2- Proptosis
3- Opthalmoplegia +- diplopia
4- Decrease vision
Most common cause of Orbital cellulitis?
Bacterial Rhinosinusitis
Management of Orbital cellulitis?
Diagnosed clinically and confirmed with CT of orbit and sinuses (with contrast)
IV AB: Vancomycin + ceftriaxone or, ceftoaxime, ampicillin-sulbatamol, piperacillin-tazobactam
If allergic to penicillin, vanco + fluoroquinlone
When switched to oral, should be continued for 2-3 weeks
If CT scan showed abscess >10cm or not responding to AB > require surgical drainage
Complications: Subperisoteal abcess, orbital abcess, vision loss, Cavernous sinus thrombosis, brain abcess
Acute angle-closure Glaucoma versus open angle glaucoma
Types of glaucoma:
- congenital
- Secondry (trauma, injury)
- Closed angle
- Open angle (MOST COMMON)
1- Decrease vision, severe eye pain, headache, Vomiting, red eye
2- Halo around the light
O/E: cloudy/Hazy cornea, mid-dilated poorly reactive pupil (DON’T perform pupil dilation”
Treatment:
- emergent ophthalmology
- decrease aqueous humor production: acetazolamide, timolol, apraclonidine älpha agonist
- reverse angle closure: pilocarpine (topical Miotics), some studies shows that it worsen glaucoma
- decrease inflammation: prednisolone
- reduce IOP: mannitol
- latanoprost: prostaglandin analog that increase outflow of aqueous humor through uveoscleral pathway
Usually: IV acetazolamide followed by laser periphral iridotomy
Open angle glaucoma: rarely present with symptoms, usually found incidentally
Medications causing pupillary dilation can cause an episode of acute angle closure
Risk factors:
Family history
Advanced age
Asian: angle closure
Black and Hispanic: open angle
How to diagnose glucoma?
Tonometry
IOP: >30 mmgHg
Allergic conjunctivitis most common feature and tratment
- Pruritis (most common)
- Redness, Chemosis “conjuntiva edema”, usually bilateral, conjuntival papillar “cobblestone appearance”
- Eye pain is NOT characteristic
Treatment:
- allergen avoidance
- Basic eye care (cool compressor and artifical tear)
Mild symptoms:
- Topical antihistamine and mast cell stabilizer: Olaptadine (2y), azelastine (3y)
- Topical combined vasoconstrictur/antihistamine: nephazoline/pheniramine (6y)
It still uncontrolled:
- Oral antihistamine (citrizine)
- topical NSAIDS (ketorolac)
Severe, or persistent, or refractory:
Refer to specialist for further management
How to differentiate between allergic and viral conjunctivitis?
- Allergic typically occur episodically with shorter duration of symptoms
Hyphema cause, tx, and complication
- Blunt or penetrating trauma
Symptoms and tratment of hyphema
- blurry vision, pain, decrease vision, photophobia, absence red reflex
- Avoid antiplatelets and anticoagulant, and avoid Carbonic anhydrase if sicklet
- elevate bed 45 degree with restriction of movement
- ophthalmology consultation
- Blood in eyes anterior chamber
- treatment: eyesheild, activity limitation, glucocorticoid and cycloplegic eye drops
- Complication: permenant vision loss (most common)
Retinal detachment clinical features
- painless loss of vision
- cobweb vision (FLOATERS)
- flash of light (PHOTOSPIA)
- Visual field defect ( curtain coming down)
PE: hazy gray with white fold
Immediate ophthalmologist consultation to prevent permenant visual loss ( surgery photocoagulation, pneumatic retinopexy )
Pterygium
- History of excessive sunlight exposure, and windy, sandy, dusty enviromenta
- Bulbar conjuntiva growth in the medial side of eye, trinagular in shape
- Observation and reassurance if asymptomatic
- local inflammation or irritation: artifical tear is the first line
- More severe local inflammation and irritation: Topical prednisolone and NSAIDS for two weeks
- If vision affected, or symptoms are refractory: Surgery
- Surgery: Recurrence rate is high and more aggressive course than the primary
Pinguecula: yellow pump or patch but don’t invade the conrea
Corneal abrasion
- Pain. Photophobia (cannot open the eye”, tearing, foreign body sensation
- diagnosis: fluorescein stain (yellow green fluorescence seen in wood lamp detect pseudomonas)
- treatment:
Most of cases are, Self limiting
Superficial abrasion; Pain control with NSAIDs, although AB is common practice to prevent superinfection
Deep abrasion; Topical antibiotic
Contact lens wearing: (add anti pseudomonas “amino glycoside, or fluroquinolone”
Those with evidence of infections keratitis should be referred immediately to ophthalmologist
Anterior versus posterior blephritis?
- Anterior: within eyelash follicles, most commonly staph, or seborrheic dermatitis, roascia
- Posterior: below the eyelash, at the base of eyelid caused by meibomian gland dysfunction (MOST COMMON)
Clinical features: crusting, scaling, red rimming of eyelids
Diagnosis; slit lamp examination
Treatment: irrigation, warm compressions, lid massage, topical antibiotic for flares up
Mechanical cleansing Use a cotton with warm water and baby shampoo to loosen the crust and prevent stinging
Cataract
Risk factors:
Smoking, DM, steriods
Cataract types:
- Nuclear: worsening of distance vision (myopic shift), occur before opacification become evidence
Lens opacity, painless progressive over years blurred vision, can be grossly visible or seen as diminished eye reflex. Typically have halos around light and problems with night vision especially while driving. And yellow tinted vision often reported
Diagnosed with slit lamp
Treatment:
- if vision not affected: watchful waiting
- if vision affected: Surgery
Preoperative evaluation for cataract surgery?
- Similiar to other low risk procedure
- Exclude active cardiac condition + APPROPIATE MANAGEMENT OF HTN TO AVOID INTRAOCULAR HAEMORRHAGE
No need for ECG, CBC,…
Optic Neuritis
- Demylating inflammation of optic nerve
- Sudden loss of monoocular partial or complete vision (often central scotoma)
- afferent papillary defect
- loss of color (red) vision more than visual acuity
- Unthoff phenomenon: transient worsening of vision with increased body temp
Most common cause?
MS
Other causes?
- infection (syphilis, lyme, herpes)
- Autoimmune (Lupus, Neurosarciodosis)
- Methanol poisining
- B12 defiency
- Diabetes
Diagnosis?
Clinically, optic disc will apear swollen. MRI will confirm demyelation
Management?
IV steroids
Recurrent optic neuritis and transverse myelitis?
Neuromyelitis optica (inflammatory disorder)
Central retinal artery occlusion
- Sudden, painless, monocular vision loss
- funoscopy (opthalmoscopy): cherry red spot “means the fovea is prominent with backgroud of pale retina
- immediate opthalmology and neurology consultation
- no clear consensus on best treatment
(AHA says that IV thromolytics may be reasonable if given within 4.5 h for nonarteritic CRAO
Central retinal vein occlusion
Fundoscopy: Blood and thunder appearance
Chlamydia conjunctivitis
- Neonate 5-14 days
- organism: Chlamydia Trachomatis
- symptoms: mucopurelent discharge
- Diagnosis made by: culture
- Complications: Pneumonia (1/3) with typical staccato cough
- Treatment: Oral erythromycin for 2 weeks
- Topical is not effective
Erythromycin or azithromycin use in neonate <2w: associated with pyloric stenosis
Strabismus
Inside: ESOtropia
Outside: EXOtropia
DIfference in pupil size: Anisocoria
(Ophthalmology referral if >4m)***
Can leads to amblyopia of the misaligned eye, and visual acuity loss may become permenant if not corrected by age of 7-8
Treatment:
- address any refractive errors
- patching or use of blurry drops “atropine “in the normal eye.
What childhood cancer can present with strabismus?
- Retinoblastoma
RIsk factors for infantile strabismus?
- Down syndrome
- Cerebral palsy
- Craniofacial dystocia
- low birth weight
- Family history
Macular degenration ( Central scotoma + distortion of straight lines )
- Most common cause of blindess in elderly >50 years old.
- Central vision is lost bilaterally and gradually
- Painless
- Druses spots: Yellow retinal degeneration in DILATED EYE EXAM (with or without hypervascularty and haemorrhage
- PATIENT MAY REOPRT SRAIGHT GRID LINES APPEAR CURVED
DRY: DRUSEN, MORE common, GRADUAL loss of vision, macular THINNING, not total blindness
WET: NEOvasculrization, LESS common, SUDDEN loss of vision, macular BLEEDING, not total blindness but often MORE SEVERE central scotoma
AMSLER GRID TEST
Eating more fish is associated with lower risk of age-related macular degenration. Treatment include smoking cassation, antioxidant vitamins and zinc, intravitreal injection of VEGFI, Photodynamic therapy
Anticoagulant and eye surgeries?
Management of perioperative anticoagulation with warfarin involves balancing the bleeding risk of surgery with the thrombotic risk of stopping anticoagulation.
Low-bleeding-risk surgeries or procedures (eg, cataract surgery) typically require no adjustment or interruption in the warfarin regimen.
High-bleeding-risk surgeries (eg, joint replacement) require a temporary interruption in anticoagulation; the interruption should be accompanied by bridging (eg, low-molecular-weight heparin, unfractionated heparin) in patients at very high thrombotic risk.
Uveitis
- inflammation of the uveal tract ( iris, ciliary body, and choroid )
- Can be infectious (antibiotics)
- Can be non infections (Topical steroids)
- Anterior Uveitis: Unilateral painful, red eye, photophobia. Dx confirmed by identifying leukocytic exudate in the anterior chamber (hypopyon)
Keratitis
- Most common infectious complication of contact lense users
- pain, eyelid swelling, photophobia, and conjunctival injection
- treatment: empiric broad spectrum topical AB with antipseudmonas coverage such as fluroquinolone “gatifloxacin”or aminoglyclosides
New born vision
able to see from birth at a distance of <12 inches due to their 20/400 visual acuity.
They are best able to focus on faces and figures with sharp, contrasting colors. Their vision gradually improves to 20/30 by age 1 year.
Amaurosis fugax
- Painless rapid transient monocular visual loss described as curtain descending over the visual field
- Most common etiology is retinal ischemia caused by atherosclerotic embolism from carotid artery
