Flashcards in Wills Eye Manual (Most likely on exam) Deck (58)
1) Copious but gentle irrigation with SALINE or Ringer Lactate solution for at least 30 minutes (Tap water can be used and may be more efficacious
2) Wait 5 to 10 minutes; check pH with litmus paper in the fornices. Continue irrigation until pH level is between 7.0 to 7.4.
1) Cycloplegic (Scopolamine 0.25%) ; AVOID PHENYLEPHRINE (VASOCONSTRICTOR)
3) Prednisolone Acetate 1% 4 to 9 times a day
Every few days - monitor for corneal epithelial breakdown
Epithelial defect seen with NaFl, Sharp pain with foreign body sensation ; history will tell you if there was any trauma
Non-CTL : Ointment of Erythromycin, Bacitraicin or Bacitracin/Polymyxin B (q2-4h) or Oph soln. of Polytrim or FLQ QID. If vegetative use Ciprofloxacin or Moxifloxacin q.i.d.
CTL : Think of Psuedomonas ; FLQ QID and possibly fortified with Tobramycin
Cycloplegic (Cyclopentolate 1% to 2% BID to TID)
NON CTL : RTC in 24 hours; if pressure patch, central or large abrasion. If healing happens at the next visit, RTC in 2 to 3 days and then revisit in 3 to 5 days.
CTL : RTC in 1 to 2 days. CTL wear may resume after 1 week after proper course of medication. New CTL should be given at this time.
Corneal and Conjunctival Foreign Bodies
History, trauma and no safety glasses used. Look for FB with Desmarres double eversion technique.
B -Scan can be conducted if intraorbital. AVOID MRI.
Apply topical Anesthetic. Remove FB with golf club spud. Use Ophthalmic Burr to remove deep, central rust ring.
Ointment of Erythromycin, Bacitraicin or Bacitracin/Polymyxin B (q2-4h) or Oph soln. of Polytrim or FLQ QID. If vegetative use Ciprofloxacin or Moxifloxacin q.i.d.
If rust ring remains, 24 hours. Otherwise 2 to 5 days.
If conjunctival FB, then as needed or 1 week for residual FB.
Inspect entire Sclera below the conjunctival laceration for any perforation. Proparacaine the area to observe and then NaFl, look for siedel sign.
Bacitracin or Erythromycin QID
1 week if no concomitant ocular damage
Cycloplegic (Cyclopentolate 2% TID or Scopolamine 0.25% BID)
Prednisolone Acetate 0.125% to 1% QID
5 to 7 days ; if resolved then look into d/c cycloplegic and taper steroid. F/U 1 month for evaluation for angle recession with Gonioscopy and BIO with scleral depression looking for retinal breaks
Hyphema and Microhyphema
-Rule out ruptured globe
-Usually Bedrest; elevate bed to allow blood to settle.
-Atropine 1% or Scopolomine 0.25% BID to TID
-AVOID ASPIRIN or NSAID's
-Mild Analgesics only
-Topical steroids (Prednisolone acetate 1% QID to Q1H)
Evaluate daily - VA's, IOP and Slit lamp
few days to 1 week.
-Disinsertion of the Iris from the Scleral spur
Sunglasses, CTL with an artifical pupil or surgery if pt is symptomatic
-If glaucoma develops, start as POAG therapy (Usually AH suppressants)
Same as POAG
Disinsertion of the CB from the Scleral Spur; this will result in hypotny due to increased uveoscleral outflow
Sunglasses, CTL with artificial pupil
-If glaucoma develops, start POAG therapy (Usually AH suppressants)
Same as POAG
Orbital Blow-Out Fracture
Traumatic event, which involves the orbital floor to be damaged. IR is usually involved, with the maxillary sinus.
-Restricted eye movement
-Hypoesthesia of ipsilateral cheek
-Pain on upgaze
-Recent history of trauma
-Forced duction testing, only after 1 week of restriction
CT of the orbit and midface
1. Broad spectrum oral antibiotics
-Cephalexin 250 to 500mg p.o. QID or
-Erythromycin 250 to 500mg p.o. QID or
-Doxycycline 100mg p.o. BID
for 7 days
2. DO NOT BLOW NOSE
3. Nasal decongestants
-Oxymetazoline nasal spray BID for 3 days
4. Ice pack for 20 minutes q1-2h for 24 to 48 hours
1 to 2 week after trauma
Traumatic Retrobulbar Hemorrhage
-Inability to open the eyelids due to severe swelling
-Recent history of trauma or surgery
-Proptosis with resistance to retropulsion
-Tense eyelids (rock hard)
Decompression of the eyelid
Until stable - check VA's and IOP
Traumatic Optic Neuropathy
Decreased Visual Acuity VF loss, APD defect and EOM restriction
-Same as Retorobulbar Hemorrhage
1 to 2 days; Test APD, color vision and Visual Acuity
-History of trauma
Deteremine what type of trauma and product
DO NOT REMOVE FB
Send to Hospital for surgical removal
-Cornea is not perforated
-Evaluate AC (Shallow AC will display leaking)
-Positive Siedel sign
Cycloplegic (Scopolamine 0.25%)
Antibiotic (Polymyxin B/Bacitracin or FLQ)
Tetanus toxoid for dirty wounds
Re-evaluate daily based on epithelial healing
-Asymptomatic; however sometimes decreased vision
-Confluent area of retinal whitening
-Berlin's edema (posterior pole)
DFE in 2 weeks again
-Asymptomatic; however decreased vision
-Yellow or white crescent shaped subretinal streak.
-Rupture cannot be seen for several days to weeks, due to overlying blood supply.
Intravitreal Anti-VEGF therapy; if CNV occurs
Re-evaluate in 1 to 2 week
-Compression injury to CHEST or HEAD or Lower extremities but not a direct ocular hit
-Multiple Cotton Wool Spots
-Superficial heme's around the Optic Nerve
-Large white retinal superficial region
-Collagen vascular disease
Systemic work up, if chest injury has not occurred.
-Basic metabolic panel, Amylase, Lipase, CBC, BP and rheumatologic evaluation.
-CT of the head, chest or long bones as indicated
None, must treat underlying condition.
Repeat DFE in 2 to 4 weeks. VA's may return to 50% as to before.
Shaken Baby Syndrome/Inflicted childhood Neurotrauma
Syndrome of intracranial heme's, skeletak fractures or multilayered retinal heme's.
-Change in mental status
-New onset of seizures
-Inability to track or follow with eyes
-Child is usually <1 YO and rarely >3 YO
-Symptoms are often inconsistent with history
Multilayered (pre, intra and sub retinal) heme's (80%)
Send to Hospital if Shaken Baby syndrome, to rule out any other damage. Work with Neurosurgery, Pediatric Psychiatry and Social Services
Possible vitrectomy, if vitreal heme is noticed
Monitor and refer to PCP. 30% mortality rate, survivors can suffer from significant cognitive disabilities and severe loss of vision in 20% of children.
Pain, Photophobia, Red eye, FB sensation and mildly decreased vision.
Pinpoint corneal epithelial defects WITH Staining
Superior Staining = CTL disorder (Chemical toxicity, tight lens syndrome, CTL overwear, GPC)
Vertical epithelial defects = FB under the under the upper eyelid
Inferior staining = Blepharitis, Exposure Keratopathy, Topical drug toxicity, Conjunctivitis, Trichiasis/Distachiasis, Entropion or Ectropion
Contact lens wearer = Discontinue CTL, AT's 6x/day ; if large amounts of SPK then add FLQ
Non CTL wearer = Preservative free AT's q2h w/ Bacitracin/Polymixin B or Erythromycin ointment QID
NEVER PATCH, AS IT CAN RESULT IN A CORNEAL ULCER.
2 to 3 days
Recurrent Corneal Erosion
-Occurs in the morning on awakening
-Recurrent attacks of acute ocular pain
Localized roughening of the corneal epithelium
Cyclopentolate 1% and Erythromycin or Bacitracin QID
-Once defect is clear, start AT's QID for 3 to 6 months
5% Muro 128 can be given QID for 3 to 6 months.
Every 1 to 2 days; until epitelium is healed; every 1 to 3 months.
Moderate to severe pain, Red eye, FB sensation, photophobia.
STRANDS of epithelial cells and mucus attached to the anterior surface of the cornea at one end of the strand.
Most common cause = Dry eye syndrome
Treat the underlying condition
Consider debridment of the filaments
Preservative free AT's 6x a day
Acetylcysteine 10% QID (Only available as a compound)
1 to 4 weeks
Irritation, burning, FB sensation and redness of one ro both eyes. Worse in the morning.
Inadequate blinking, leading to dryness in the inferior 1/3 of the cornea
History of Bell's palsy, eyelid surgery or Thyroid disease
Assess Bell's phenomenon
Slit lamp examination
Prevention is critical
Preservative AT's q2-6h
Consider eyelid taping
1 to 2 day in the presence of corneal ulceration
Irritation, redness, decreased vision but maybe asymptomatic.
3 to 9 o'clock position at the limbus
Dellen (thinning of adjacent to cornea) and Stocker's line (Iron deposition)
1. Protect eyes from sun, dust and wind
2. Lubrication with AT's 4 to 8 times a day
3. If Dellen, q2h ointment
1. Asymptomatic - 1 to 2 years
2. Pterygia - 3 to 12 months
3. If treating with Steroids then after a few weeks; re-evaluate IOP and ocular inflammation.
Decreased vision, FB sensation, corneal whitening and maybe asymptomatic
Whitening from 3 to 9 o'clock ; usually calcium plaque at the level of Bowman's
Chronic Uveitis, Interstitial Keratitis, Corneal Edema, Repeated trauma and Phthisis bulbi
AT's 4 to 6/day and AT ointment QHS, Consider bandage contact lens for comfort.
Removal of Calcium deposit using EDTA
1. Surgery removal - every 1 to 2 days with patching
2. Pt to be checked every 3 to 12 months on severity of BK.
Red eye, moderate to severe ocular pain, photophobia, decrease vision, discharge, acute contact lens intolerance
Focal white opacity (Infiltrate) in the corneal stroma.
-Ulcer exists if there is stromal loss with an overlying epithelial defect that stains with NaFl.
Most common - Staphylococcus Pseudomonas> Stretptococcus > Moraxella > Serratia species.
1. FLQ q1h
2. Do not give steriods; unless its a controlled keratitis
3. Cyclopegia to reduce PAS
Pain decreasing is usually the first sign if treatment is positive
Red eye, moderate to severe ocular pain, photophobia, decrease vision, discharge, usually associated with vegetative trauma, contact lens intolerance.
Feathery looking ring
Filamentous fungi : Corneal stromal gray-white opacity , usually Fusarium or Aspergillus
Note: B&L had a product recall in 2006, where ReNu MoistureLoc solution has a fusarium outbreak due to CTL wear.
Non-filamentous fungi : Candida species, usually from a previous diseased eye
Natamycin 5% drop or Amphoteracin B 0.15% q1h for4 to 6 weeks
Contact Lens and Swimming
Severe ocular pain, redness, photophobia over a period of several weeks.
Early: Pseudodendrites on the epithelium and considerable amount of pain.
Late: (3 to 8 weeks); Ring shaped corneal stromal infiltrate
Corneal scraping for Gram, Giemsa and calcofluor white stains
1. PHMB 0.02% drops q1h. Clorhexidine 0.02% can be used as an alternative.
2. Propamidine isethionate 0.1% drops q1h.
3. Discontinue usage of contact lens in both eyes
4. Scopolamine 0.25% tid
5. Oral Steroid for pain or inflammation
1 to 4 days until improvement; then 1 to 3 weeks
Herpes Simplex Virus
Red eye, pain, photophobia, tearing, decreased vision, skin vesicular rash, history of previous episodes, fever blisters; Unilateral
Eyelid/Skin =Clear vesicles on an erythematous base that progesses into crusting
Conjunctivitis = ACUTE UNILATERAL FOLLICULAR CONJUNCTIVITIS WITH AND WITHOUT DENDRITES
Corneal (Epithelium) = Macropunctate, Dendritic Keratitis (terminal end bulbs on the epithelium) - stain well with Rose Bengal or Lissamine Green, decreased corneal sensitivity
Corneal (Stroma) = Disciform Keratitis (non-necrotizing keratitis - disc shaped stromal edema with an intact epithelium, mild iritis with localized granulomatous keratic perciptates is common, increased IOP. No corneal neovascularization.
= Necrotizing Interstitial Keratitis (Uncommon), multiple stromal infiltrates with stromal inflammatory thinning.
Neurotrophic Ulcer = sterile ulcer with smooth epithelial margins
Note the vesicle distribution, if the midline is crossed then we are looking at HSV; if not HZV.
Epithelial defect (NO STEROIDS FOR EPITHELIAL DEFECT)
Based on HEDS (Herpetic Eye Disease Study);
1. Topical ACYCLOVIR ointment 5x/day (SKIN ONLY); however GANCYCLOVIR 0.15% OPH GEL 5xday.
2. Warm or cool soaks to skin lesions TID or PRN
3. If eyelid involved, GANCYCLOVIR 0.15% OPH GEL or TRIFLURIDINE 1% DROPS 5Xday.
Children: Vidarabine 3% ointment 5xday used for 7 to 14 days
IF STROMAL!!!: Topical Steroid ( Prednisolone Acetate 1% QID), GANCYCLOVIR 0.15% OPH GEL 5Xday
2 to 7 days to evaluate response to medication and then every 1 to 2 weeks (based on 5 things you evaluate)
a) Size of epithelial defect/ulcer
b) Thickness of corneal involvement
c) Depth of corneal involvement
d) Anterior Chamber reaction
Herpes Zoster Ophthalmicus/Varicella Zoster Virus
Dermatomal pain, paresthesias, skin rash or discomfort. Possibly preceded by headache, fever, malaise, blurred vision, eye pain and red eye.
Acute vesicular dermatomal skin rash, along the 1st division of CN5 (Trigeminal), Unilateral, Hutchinson's sign (rash on tip of nose) which predicts high chance of ocular involvement, if ocular involvement than usually PSUEDO-DENDRITES seen on the cornea
a) History; is the pt immunocomprimised (Ie. AIDS/HIV)
b) Complete ocular examination, especially DFE and you would be looking for Progressive Outer Retinal Necrosis (PORN)
c)pt's under the age of 40; Medical evaluation of HIV
Pt's 40 to 60 YO = None, unless imunodeficiency is seen
Pt's >60 YO = If steroids' are to be given then workup for systemic steroids
Vast based on immunocomprimised or not. Look at pages 82 to 84 of Wills Eye Manual. Generally Oral Acyclovir 800mg/ 5xday or Famcyclovir 500mg TID
1 to 7 days; depending on severity of ocular complications.
1 to 4 weeks without ocular complications.
Once acute phase has gone, re-check in 3 to 6 months.
Acute symptomatic, occurs in FIRST OR SECOND decade of life.
Acute = Marked corneal stromal blood vessels and edema, KP's sometimes on endothelium
Chronic = Deep corneal haze, scarring, corneal stromal blood vessels containing minimal or no no blood vessels, stromal thinning.
Most common = Congenital Syphilis, Bilateral or both eyes within 1 year of each other
Common = Acquired Syphilis (Unilateral usually sectoral)
TB (Unilateral, usually sectoral)
Cogan syndrome (Bilateral, Vertigo, Tinnitus, hearing loss, negative syphilis serologies, associated with Vasculitis
1. History; Venereal disease during mother's pregnancy? Difficulty hearing or Tinnitus
2. Look for Hutchinson's triad (Saddle nose, teeth and frontal bossing)
3. SLE and DFE
4. VDRL, RPR, FTA-ABS and MHA-TP
b)Topical steroid: Prednisolone Acetate 1% q2h
c)Treat underlying condition
Old inactive with central scarring
Corneal transplant to improve vision
3 to 7 days, then 2 to 4 weeks. Steroids to be reduced over months over time and could take upto 2 years.
Yearly follow up