Wills Eye Manual (Most likely on exam) Flashcards Preview

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Flashcards in Wills Eye Manual (Most likely on exam) Deck (58)
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1

Chemical Burn

EMERGENCY
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.

Treatment
1) Cycloplegic (Scopolamine 0.25%) ; AVOID PHENYLEPHRINE (VASOCONSTRICTOR)
2)Erythromycin q1-q2h
3) Prednisolone Acetate 1% 4 to 9 times a day

Follow up
Every few days - monitor for corneal epithelial breakdown

2

Corneal Abrasion

Epithelial defect seen with NaFl, Sharp pain with foreign body sensation ; history will tell you if there was any trauma

Treatment
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)

Follow up
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.

3

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.

Treatment
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.

Follow up
If rust ring remains, 24 hours. Otherwise 2 to 5 days.

If conjunctival FB, then as needed or 1 week for residual FB.

4

Conjunctival Laceration

Inspect entire Sclera below the conjunctival laceration for any perforation. Proparacaine the area to observe and then NaFl, look for siedel sign.

Treatment
Bacitracin or Erythromycin QID

Follow up
1 week if no concomitant ocular damage

5

Traumatic Iritis

Treatment
Cycloplegic (Cyclopentolate 2% TID or Scopolamine 0.25% BID)
Prednisolone Acetate 0.125% to 1% QID

Follow up
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

6

Hyphema and Microhyphema

-Rule out ruptured globe
-Measure IOP

Treatment
-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)

Follow up
Evaluate daily - VA's, IOP and Slit lamp
few days to 1 week.

7

Iridodialysis

-Disinsertion of the Iris from the Scleral spur
-Asymptomatic
-Unilateral
-Blunt Trauma

Treatment
Sunglasses, CTL with an artifical pupil or surgery if pt is symptomatic
-If glaucoma develops, start as POAG therapy (Usually AH suppressants)

Follow up
Same as POAG

8

Cyclodialysis

Disinsertion of the CB from the Scleral Spur; this will result in hypotny due to increased uveoscleral outflow
-Unilateral
-Trauma

Treatment
Sunglasses, CTL with artificial pupil
-If glaucoma develops, start POAG therapy (Usually AH suppressants)

F/U
Same as POAG

9

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
-Local tenderness
-Eyelid edema
-Binocular diplopia
-Recent history of trauma
-Forced duction testing, only after 1 week of restriction

Management
CT of the orbit and midface

Treatment
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

Follow up
1 to 2 week after trauma

10

Traumatic Retrobulbar Hemorrhage

-Pain
-Decreased vision
-Inability to open the eyelids due to severe swelling
-Recent history of trauma or surgery
-Proptosis with resistance to retropulsion
-Tense eyelids (rock hard)
-Increased IOP

Treatment
Decompression of the eyelid

Monitor
Until stable - check VA's and IOP

11

Traumatic Optic Neuropathy

Decreased Visual Acuity VF loss, APD defect and EOM restriction

Treatment
-Same as Retorobulbar Hemorrhage

Follow up
1 to 2 days; Test APD, color vision and Visual Acuity

12

Intraorbital FB

-Decreased Vision
-Pain
-Double vision
-History of trauma

Deteremine what type of trauma and product

Treatment
DO NOT REMOVE FB
Send to Hospital for surgical removal

Follow up
1 week

13

Corneal laceration

-Cornea is not perforated
-Evaluate AC (Shallow AC will display leaking)
-Positive Siedel sign

Treatment
Cycloplegic (Scopolamine 0.25%)
Antibiotic (Polymyxin B/Bacitracin or FLQ)
Tetanus toxoid for dirty wounds

Follow up
Re-evaluate daily based on epithelial healing

14

Commotio Retinae

-Asymptomatic; however sometimes decreased vision
-Trauma (contrecoup)

Signs
-Confluent area of retinal whitening
-Berlin's edema (posterior pole)

Treatment
None

Follow up
DFE in 2 weeks again

15

Choroidal rupture

-Asymptomatic; however decreased vision
-Trauma

Signs
-Yellow or white crescent shaped subretinal streak.
-Rupture cannot be seen for several days to weeks, due to overlying blood supply.

Treatment
Intravitreal Anti-VEGF therapy; if CNV occurs

Follow up
Re-evaluate in 1 to 2 week

16

Purtscher Retinopathy

-Decreased vision
-Compression injury to CHEST or HEAD or Lower extremities but not a direct ocular hit

Signs
-Multiple Cotton Wool Spots
-Superficial heme's around the Optic Nerve
-Large white retinal superficial region
-Acute Pancreatitis
-Malignant HTN
-Collagen vascular disease

Workup
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

Treatment
None, must treat underlying condition.

Follow up
Repeat DFE in 2 to 4 weeks. VA's may return to 50% as to before.

17

Shaken Baby Syndrome/Inflicted childhood Neurotrauma

Syndrome of intracranial heme's, skeletak fractures or multilayered retinal heme's.

Symptoms
-Change in mental status
-New onset of seizures
-Poor feeding
-Irritability
-Inability to track or follow with eyes
-Child is usually <1 YO and rarely >3 YO
-Symptoms are often inconsistent with history

Signs
Multilayered (pre, intra and sub retinal) heme's (80%)

Work up
Send to Hospital if Shaken Baby syndrome, to rule out any other damage. Work with Neurosurgery, Pediatric Psychiatry and Social Services

Treatment
Support
Possible vitrectomy, if vitreal heme is noticed

Follow up
Monitor and refer to PCP. 30% mortality rate, survivors can suffer from significant cognitive disabilities and severe loss of vision in 20% of children.

18

SPK

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

Treatment
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.

Follow up
2 to 3 days

19

Recurrent Corneal Erosion

-Occurs in the morning on awakening
-Recurrent attacks of acute ocular pain
-Photophobia
-FB sensation
-Tearing

Signs
Localized roughening of the corneal epithelium
NEGATIVE STAINING

Treatment
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.

Follow up
Every 1 to 2 days; until epitelium is healed; every 1 to 3 months.

20

Filamentary Keratopathy

Moderate to severe pain, Red eye, FB sensation, photophobia.

Signs
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

Treatment
Treat the underlying condition
Consider debridment of the filaments
Preservative free AT's 6x a day
Punctal occlusion
Acetylcysteine 10% QID (Only available as a compound)

Follow up
1 to 4 weeks

21

Exposure Keratopathy

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

W/U
History of Bell's palsy, eyelid surgery or Thyroid disease
Assess Bell's phenomenon
Slit lamp examination

Treatment
Prevention is critical
Preservative AT's q2-6h
Lubricating ointment
Consider eyelid taping

Follow up
1 to 2 day in the presence of corneal ulceration

22

Pterygium/Pinguecula

Irritation, redness, decreased vision but maybe asymptomatic.

Signs
3 to 9 o'clock position at the limbus
Dellen (thinning of adjacent to cornea) and Stocker's line (Iron deposition)

Treatment
1. Protect eyes from sun, dust and wind
2. Lubrication with AT's 4 to 8 times a day
3. If Dellen, q2h ointment

Follow up
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.

23

Band Keratopathy

Decreased vision, FB sensation, corneal whitening and maybe asymptomatic

Signs
Whitening from 3 to 9 o'clock ; usually calcium plaque at the level of Bowman's

Etiology
Chronic Uveitis, Interstitial Keratitis, Corneal Edema, Repeated trauma and Phthisis bulbi

Treatment
Mild
AT's 4 to 6/day and AT ointment QHS, Consider bandage contact lens for comfort.

Severe
Removal of Calcium deposit using EDTA

Follow up
1. Surgery removal - every 1 to 2 days with patching
2. Pt to be checked every 3 to 12 months on severity of BK.

24

Bacterial Keratitis

Red eye, moderate to severe ocular pain, photophobia, decrease vision, discharge, acute contact lens intolerance

Signs
Focal white opacity (Infiltrate) in the corneal stroma.
-Ulcer exists if there is stromal loss with an overlying epithelial defect that stains with NaFl.

Etiology
Most common - Staphylococcus Pseudomonas> Stretptococcus > Moraxella > Serratia species.

Treatment
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

25

Fungal Keratitis

Red eye, moderate to severe ocular pain, photophobia, decrease vision, discharge, usually associated with vegetative trauma, contact lens intolerance.

Signs
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

Treatment
Natamycin 5% drop or Amphoteracin B 0.15% q1h for4 to 6 weeks

Follow up
Daily

26

Acanthamoeba Keratitis

Contact Lens and Swimming

Signs
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

Work up
Corneal scraping for Gram, Giemsa and calcofluor white stains

Treatment
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

Follow up
1 to 4 days until improvement; then 1 to 3 weeks

27

Herpes Simplex Virus

Red eye, pain, photophobia, tearing, decreased vision, skin vesicular rash, history of previous episodes, fever blisters; Unilateral

Signs
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

Workup
Note the vesicle distribution, if the midline is crossed then we are looking at HSV; if not HZV.

Treatment
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



Follow up
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
e) IOP

28

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.

Signs
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

Work up
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

Treatment
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

Follow up
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.

29

Intersitial Keratitis

Acute symptomatic, occurs in FIRST OR SECOND decade of life.

Signs
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.

Etiology
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

Work up
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

Treatment
Acute
a)Topical cycloplegia
b)Topical steroid: Prednisolone Acetate 1% q2h
c)Treat underlying condition

Old inactive with central scarring
Corneal transplant to improve vision

Follow up
Acute
3 to 7 days, then 2 to 4 weeks. Steroids to be reduced over months over time and could take upto 2 years.

Old inactive
Yearly follow up

30

Staphylococcal Hypersensitivity

Mild photophobia, mild pain, localized red eye, chronic eyelid crusting, FB sensation or dryness. History of recurrent acute episodes, chalazia or styes.

Signs
Singular or multiple, unilateral or bilateral, peripheral corneal stromal infiltrates and the limbus. NO ANTERIOR CHAMBER REACTIONS

Work up
1) History; Recurrent? Contact Lens wearer
2) SLE with NaFl staining and IOP check

Treatment
Mild - Warm compresses, eyelid hygiene and a FLQ antibiotic QID and Bactiracin Ointment qhs

Moderate to Severe
Same as above but add topical steroid (Loteprednol 0.2% to 0.5% or Prednisolone 0.25% qid)

Follow up
2 to 7 days