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Eye
EENT
| Question | Answer |
|---|---|
| Cause of blindness, more common in patients >70 y.o. = | Macular degeneration |
| Marcus-Gunn pupils (afferent pupillary defect): due to: | Optic nerve lesion (optic neuritis); or tertiary syphilis |
| Bilateral pinpoint pupils may be 2/2: | Pontine hemorrhage |
| Bilateral DILATED pupils may be 2/2: | Anticholinergics, TCA, anti-parkinsonian drugs, profound hypoxemia |
| Bilateral/bitemporal hemianopia | Optic chiasm lesion |
| Loss of central vision | Ipsilateral optic nerve lesion? |
| Superior contralateral quadrantopia | Temporal optic radiation |
| Eye trauma, diplopia. Exophthalmos, fixed upward gaze, hyphema | Orbital blow-out fracture; Immediate ophthalmology referral |
| Hard, nontender swelling/nodule on upper or lower eyelid. Large lesion may cause astigmatism or distorted vision (2/2 pushing on cornea) = | Chalazion; usually 2/2 blocked meibomian gland |
| Painful swelling of upper or lower eyelid. Visual acuity normal = | Hordeolum; usually 2/2 Staph aureus infection |
| Painless, elevated fleshy yellow nodule on sclera adj to cornea | Pinguecula; 2/2 actinic exposure, trauma, dry windy conditions |
| Transient monocular vision loss | Amaurosis fugax (2/2 TIA, embolus) |
| Vision loss over hours to days, painful EOM | Optic Neuritis (assoc. w/ MS) |
| Recurrent episodes of vision change, diplopia that resolve | MS |
| Red eye, watery discharge, sticky lids, preauricular LAD | Viral conjunctivitis; usu 2/2 adenovirus 3, 8, or 19 |
| Red eye, lid edema, copious purulent discharge = | Gonococcal conjunctivitis. Likely concurrent urethritis.Vision not blurred in bac conjunctivitis |
| Red eye, hyperemia, chemosis, nodular conjunctivia | Allergic conjunctivitis |
| Acute painful red eye, halos around lights, hazy cloudy steamy cornea; circumlimbal injection; pupil less reactive & mid-dilated. Onset after being in dark room | Acute angle-closure glaucoma |
| Diplopia, dysarthria, dysphagia | Vertibrobasilar insufficiency |
| Penetrating eye trauma: do not | remove object |
| Rust ring on cornea = | metallic foreign body |
| Chem burns to eye | irrigate with water >30 min; eye shield, ED |
| Blow out fx of eye | cannot look up (infraorbital n. entrapment), cross eyed, exophthalmos, subQ emphysema |
| Corneal abrasion on slit lamp or dye: | epithelial defect but clear cornea (use proparacaine as ocular anesthetic) |
| Corneal abrasion tx | Abx (Erythromycin or Polytrim drops), APAP, cycloplegic agent (cyclopentolate, homatropine), consider patch 24 hrs. If contact wearer: must cover pseudomonas (tobramycin ointment or cipro/ofloxacin drops) |
| Drugs causing macular degeneration | chloroquine, phenothiazine |
| Metamorphopsia= | wavy vision (mac degen), test w/Amsler grid |
| Halo seen around lights; black spots in red reflex; no color vision; pupil whitens = sx of: | cataracts |
| Chronic, Asx until late, increased IOP, peripheral visual field defects, increased cup:disc ratio on fundoscopy = | Open angle glaucoma |
| Ptosis, lid edema, exophthalmos, pus, conjunctivitis; fever, dec eye mx ROM, sluggish pupils: | orbital cellulitis |
| Scurf (seborrhea), collarettes (SA) (red rim); epithelial keratitis = | blepharitis |
| Internal hordeolum location | meibomian gland abscess; deep to palpebral margin |
| External hordeolum location | glands of Moll or Zeis; adjacent to palpebral margin; smaller |
| Slow growing thickening of bulbar conjunctiva | pteryigium; grows from nasal side toward cornea |
| Papilledema causes | malig HTN, hemo stroke, subdural hematoma, pseudotumor cerebri |
| Optic disk swollen, blurred margins, vessels obliterated: | papilledema |
| Lesion anterior to optic chiasm affects: | only one eye |
| Homonymous hemianopia (defect in both R or both L halves of visual fields of both eyes): | lesion of optic tract or lateral geniculate nucleus (R lesion = L side vision loss) |
| Reduced visual acuity not correctable by refractive means= | amblyopia |
| Cyanotic sclera may = | osteogenesis imperfecta |
| Hordeolum tx | May resolve spontaneously. Topical Abx (bacitracin or erythro ointment BID x7-10 days). Warm compress QID. I&D if persistent. Systemic Abx if preseptal cellulitis |
| Chalazion tx | Visual acuity testing. Warm compress QID; refer to Eye Dr if persistent; corticosteroid injection vs I&D if persistent |
| After a VII CN palsy: excess lacrimation, drooping eyelid = | ectropion (lid turned outward). Tx: artificial tears vs lid tightening surgery |
| Blepharitis causative bugs | SA / seborrhea (anterior), S epi, Coag neg Staph. Also meibomian gland dysfn (posterior) |
| Blepharitis mgmt | Anterior: hygiene (lid scrubs, remove scales), bacitracin ointment. Posterior: meibomian gland (MG) expression, Derm, oral Abx (doxy) for MG dysfn |
| Bacterial conjunctivitis: bugs | Chlamydia, gonococci, SA, S pneumo, Hemophilus, Pseudomonas, Moraxella |
| Bac conjunctivitis mgmt | Viral (strict hygiene, toss contacts & case); Bac: topical erythromycin oint or sulta gtt 5-7d. |
| Gono conjunctivitis mgmt | Eye Dr referral ASAP. Hosp for IV & topical Abx: emergency (poss corneal involvement) |
| Dacryocystitis workup | CBC, ANA (to r/o lupus), ANCA Ab (r/o Wegner); consider CT or MRI if uncertain etiology |
| Dacryocystitis Tx | Peds: Aug + topical abx gtt, warm compress. Adults same Abx, dacryocystorhinotomy may be nec |
| Orbital cellulitis: etiology & patho | paranasal sinusitis (most common); eye surg comp, dental infxn, orbit trauma. May cause brain abscess or meningitis |
| Orbital cellulitis: bugs | SA, S pyogenes, S pneumo, H flu |
| Genetic (M>F), HPV, tumor suppressor p53, HLA Ag; triangular conjuctival thickening growing inward to cornea = | pterygium |
| Gray circumscribed opacity that necrosis & forms an excavation of the cornea = | corneal ulcer (refer to Eye ASAP) |
| Fluorescein stain: bright green area (seen under black light) = | corneal abrasion |
| Fluorescein stain: dark, with a surrounding area of bright green (seen under black light) = | corneal foreign body |
| Etio includes MS, viral, SLE, MEtOH, vascular; unilateral pain with any eye movement = | optic neuritis (refer to Eye Dr ASAP) |
| flame-shaped peripapillary hemorrhages may be seen = | optic neuritis |
| 2 types of diabetic retinopathy | proliferative; nonproliferative |
| Leading cause of blindness in US = | DM retinopathy (MCC). Most common in patients <70 yo |
| Diabetic retinopathy: capillary microaneurysms, tortuous/dilated veins, flame hemorrhages, cotton wool patches = | non-proliferative |
| Diabetic retinopathy 2/2 ischemia: neovascularization, vitreous hemorrhage | proliferative |
| Etio/pathology of HTN retinopathy | 2/2 atherosclerosis (2/2 htn); acute BP elevation -> loss of autoregulation in retinal vessels -> vasoconstriction & ischemia |
| HTN retinopathy: funduscopy | retinal hemorrhage & edema, cotton wool exudates, Cu/Ag wiring, AV nicking |
| Curtain or veil top-to-bottom over eyes, new onset floaters = | Retinal detachment |
| Retinal detachment usually begins at: | superior temporal retinal area; afferent pupillary defect |
| 3 types of retinal detachment | rhegmatogenous residual detachment/RRD (most common); exudative/serous (ERD); tractional detachment (TRD) |
| RRD detachment etiology | penetrating or blunt trauma (or spontaneous) |
| ERD detachment etiology | accumulation of subretinal fluid (2/2 inflammation or tumor) |
| TRD detachment etiology | adhesions (2/2 SCDz, trauma, proliferative DM retinopathy) |
| Retinal detachment sx/sx | Photopsia (flashes of light), shower of floaters, wavy distortion of objects. IOP >5-5mmHg. |
| Sudden painless unilateral vision loss. History of TIA, palpitations, arrhythmia, carotid disease, embolic source | CRAO (pale retina, cherry red macula) |
| CRAO causes | emboli, thrombi, vasculitides |
| Arteriolar narrowing, box-car appearance of arterial flow, cherry red spot (perifoveal atrophy), retinal edema (1st 4-6 wks), possible pale retina & optic n., local cotton-wool = | CRAO |
| Sudden painless unilateral vision blurring or loss, often upon waking. History of HTN | CRVO (blood & thunder, retinal hemorrhages); usually 2/2 thrombotic event |
| Neovascular glaucoma can develop in the first 3 months in: | CRVO |
| CRVO mgmt: | W/U to R/O & prevent CVA; panretinal laser photocoag if glaucoma; vitrectomy; tPA? |
| CRAO mgmt: | W/U to R/O & prevent CVA; high-flow O2; IV acetazolamide; IOP reduction, ?anterior chamber paracentesis |
| Painless opacities of the lens (usually bilateral) = | cataracts |
| Dz of optic n. 2/2 abnormal drainage of aqueous humor from trabecular meshwork -> high IOP -> decreased peripheral fields / blindness = | glaucoma |
| Fundoscopy: excavated or enlarged optic disk with pallor. IOP >50 = | Acute angle-closure glaucoma |
| Glaucoma RFs | AA, Asian, Inuit; vascular dz (HTN, migraine, DM, CVD); older pts, myopia, FH |
| Open angle glaucoma Mgmt | Adrenergic blocking eye gtt (timolol, levobunolol, betaxolol), epi eye gtt, beta-agonist gtt, CAI. Laser surg. Cyclophotocoagulation. |
| Acute angle-closure glaucoma mgmt | Decrease IOP via laser; then pilocarpine (after Eye Dr). Drops (timolol, dorzolamide, brimonidine), systemic acetazolamide, isosorbide, IV mannitol. Laser peripheral iridotomy. |
| Hirschberg light reflex test is used to dx: | strabismus (esotropia or exotropia) |
| If abnormal nystagmus on exam, order: | electroretinogram to r/o retinal pathology |
| Unilateral progressive vision loss; painless central vision loss (periphery remains intact) = | macular degeneration |
| macular degeneration, neovascular (wet/exudative) type: characterized by: | confluent, large soft drusen; more rapid loss of vision |
| macular degeneration, atrophic type (dry): characterized by: | bilateral gradual & progressive vision loss |
| macular degeneration mgmt | Stop smoking; exercise; dark green veg & omega 3 FAs; avoid sunlight |
| macular degeneration Dx testing | biomicroscopic funduscopic exam; fluorescein angiography to confirm wet age-related MD |
| Increased intracranial pressure causing swelling of the optic disk = | papilledema |
| papilledema etiologies | meningitis, encephalitis, pseudotumor cerebri, cerebral trauma / ICH, tumor, abscess |
| papilledema funduscopic exam | tortuous retinal veins, optic disk retinal hemorrhages, swollen & hyperemic optic disk |
| orbital blowout fx: upward gaze diplopia signifies entrapment of which muscle? | inferior rectus |
| Medical conditions with higher risk for hyphema (due to elevated IOP) | SCD or anemia |
| treatment of hyphema | Shield eye (no patch), bedrest (with b/r privileges), elevate head of bed to 30 degrees, topical atropine, no aspirin/NSAIDs, consider topical steroids, monitor intraocular pressure |
| infectious keratitis tx | Broad spectrum antibiotic drops |
| endophthalmitis tx | Injection of intravitreal antibiotics (empiric vancomycin and ceftazidime) or surgery ASAP |
| orbital cellulitis mgmt | Emergent CT of the orbits and sinuses, ophthalmologic consultation and admission for cefuroxime IV |
| Mgmt of ruptured globe | Call ophthalmologist immediately. Metallic eye shield, first gen cephalosporin, antiemetic (prevent Valsalva), tetanus update, CT to look for foreign body. |
| How long after the first 2L of irrigation fluid should you wait to check the pH in an eye that has suffered a chemical burn? | 5-10 minutes |
| Use to decrease pressure if the IOP is >50 mmHg | Acetazolamide IV |
| Use to decrease IOP if it does not do so with first line agents after 1 hour | Give 1-2g/kg mannitol IV |
| Once IOP is below 40 mmHg in acute angle closure glaucoma, what can be given as long as the patient has an intact lens in place | Pilocarpine drops |
| Tx if there is a strong suspicion of giant cell arteritis | Admit pt for methylprednisolone 250 mg IV every 6 hours |
| chalazion = | inflammatory condition 2/2 foreign body reaction to sebum from meibomian glands |
| Corneal abrasion | severe pain/photophobia; fluorescein: abrasion stains deeper green; tx polymyxin-bacitracin ointment, analgesics |
| glaucoma tx | pressure to <16; prostaglandins (latanoprost); topical BB or CAI; laser trabeculoplasty |
| int/ext hordeolum | internal: meibomian glands; ext: zeis |
| hordeolum tx | topical Abx (bacitracin or erythro)if w/ blepharoconjunctivitis; systemic if preseptal cellulitis (keflex/aug) |
| chalazion = | inflammatory condition 2/2 for body rxn to sebum from meibomian glands |
| Corneal abrasion | severe pain/photophobia; fluorescein: abrasion stains deeper green; tx polymyxin-bacitracin ointment, analgesics |
| hordeolum = | infxs process in eyelid; usu staph aureus |
| glaucoma tx | pressure to <16; prostaglandins (latanoprost); topical BB or CAI; laser trabeculoplasty |
| Homonymous hemianopia with central sparing = | lesion at occipital lobe |
Created by:
Abarnard
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