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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 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 SA infxn
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 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 (erythromycin ointment 2x/day for 7-10 days); warm compress QID; I&D if persistent
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
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; central vision loss (periphery remains intact) = macular degeneration
macular degeneration, neovascular type: characterized by: confluent, large soft drusen; more rapid loss of vision
macular degeneration, atrophic type: 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
Created by: Adam Barnard Adam Barnard