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