Ophthalm Study Guide

8/6/2019 Ophthalm Study Guide

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y Hordeolum (sty) -------------------------------------------------------------------------------->>

o Common staphylococcal abscess characterized by localizedred, swollen,

acutely tender area onupperorlowerlid.

o Warmcompresses are helpful

o Incisionmay beindicated

o ABointment (Bacitracinor Erythromycin) q3hrs during acute stage

y Chalazion------------------------------------------------------------------------------------------->>

o Commongranulomatous inflammationof a meibomiangland that may

follow aninternal hordeolum.

o Characterized by hard,nontender swellingon theupperorlowerlid with

redness and swellingof the adjacent conjunctiva.

o Iflargeenough,vision will bedistorted

o Tx with incision andcurettage but Corticosteroidinjectionmay also beeffective

y Blepharitiso Commonchronic bilateralinflammatory conditionof thelidmargins

o Anterior blepharitis ------------------------------------------------------------------------>>

Involves theeyelid skin,eyelashes, and associatedglands.

May be a staph infectionor seborrheic

o Posterior blepharitis------------------------------------------------------------------------>>

Inflammationof themeibomiangland

Bacterial (staph) or primary glandulardysfunctionlike with acne

rosacea.

o S/SofBlepharitis

Irritation, burning,itching.

In anterior theeyes are red-rimmed and scales orgranulations can be seenclinging to the

lashes.

In posterior thelidmargins are hyperemic with telangiectasias; themeibomianglands and their

orifices areinflamed with dilationof theglands, pluggingof theorifices, and abnormal secretions

y Lidmargin frequently rolledinward (mildentropion) and tears may be frothy or abnormally

greasy

o Treatment ofBlepharitis

AnteriorBlepharitis

y Controlled by cleanliness of thelidmargin,eyebrows, and scalp

y Scales should beremoved from thelids daily with a hot flannelor a damp cotton applicator

and baby shampoo.

y Antistaphylococcal antibioticeyeointment (Bacitracinor Erythromycin)

PosteriorBlepharitis


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MC staphylococci, streptococci (S. pneumousually),Haemophilus species,Pseudomonas, and

Moraxella.

S/S:

y Copious purulent discharge

y NO blurringofvision, andonly milddiscomfort

Tx:

y Self-limitingusually,lasting about 10-14 days ifuntreated.

y Topical sulfonamide (e.g., sulfacetamide, 10%ophthalmic solutionorointment TID) willusually clear theinfectionin2-3 days.

y Povidone-iodinemay also beeffective

GonococcalConjunctivitis

y Acquiredusually thrucontact with infectedgenital secretions, typically causes copious

purulent discharge

y OPTHALMOLOOGIC EMERGENCY becausecornealinvolvement may rapidly lead to

perforation

y Dx:confirmed by stained smear andcultureofdischarge.

y Tx: 1-gdoseofIMCeftriaxone (Rocephin)

o TopicalAB such as erythromycin and bacitracinmay be added

Chlamydial Keratoconjunctivitis

y Trachoma (Chlamydia trachomatis serotypes A-C)

o Majorcauseof blindness worldwide

o Scar tissuecan formof the tarsalconjunctiva leading toentropion and trichiasis in

adulthood with secondary centralcorneal scarring.

o Dx:immunologic tests orPolymeraseChain Reaction (PCR) confirms dx but

treatment should be startedon the basis ofclinical findings

o Tx:Singledose therapy with oral azithromycin20mg/kgis effective

Alternative oral tetracyclineorerythromycin250mg QIDordoxycycline

100mgBIDx 3-4 wks

Surgical treatment includes correctionofeyeliddeformities andcorneal

transplantation.

y Inclusionconjunctivitis (C. trachomatis serotypes D-K)

o Commoncauseofgenital tract diseasein adults

o S/S thedisease starts with acuteredness,discharge, andirritation. Theeye

findings consist of follicularconjunctivitis with mild keratitis. Anontender

preauricularlymph nodecanoften be palpated.

o Dx:confirmed by immunologic tests orPCR onconjunctival samples

o Tx:oral tetracyclineorerythromycin500mg QIDorDoxycycline 100mgBIDx 1-2

wks

Singledose therapy with azithromycin 1 gmay beeffective

o Before treatment, allcases should be assessed forgenital tract infection so that

management can be adjusted accordingly andothervenerealdisease sought.

o ViralConjunctivitis -------------------------------------------------------------->>>

Adenovirus type 3 is theMC


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Can have associated with pharyngitis, fever,malaise, and preauricular adenopathy.

S/S

y Palpebralconjunctiva is red

y Copious watery discharge

y Scanty exudates

Children aremorecommon than adults andcontaminated swimming pools are sometimes the

sourceofinfection

Lasts 10days May have somevisualloss due tocorneal subepithelialinfiltrates is effected by adenovirus types 8,

19,29, and 37 (Epidemic keratoconjunctivitis)

y This is more severe and wouldlast at least 2 wks

o Dry Eyes (Keratoconjunctivitis Sicca) ----------------------------------->>

Commoninelderly women

May becaused by hypofunctionof thelacrimalglands,

hereditary disorder, systemicdisease (Sjogrens syndrome),

or systemic and topicaldrugs

Hormonereplacement therapy may increaserisk ofdry

eyes

S/S:

y Dryness,redness, scratchy feelingof theeyes

y Severecases persistent discomfort with photophobia,difficulty inmoving theeyelids, and

oftenexcessivemucus secretion

Treatment

y Depends oncause

y Artificial tears

y Lacrimal punctualocclusion by canalicular plugs

y Surgery

o Allergic EyeDisease (AllergicConjunctivitis,Vernal keratoconjunctivitis, atopic keratoconjunctivitis)

Allergicconjunctivitis -------------------------------------------------------->>>

y benigndisease,occurringusually inlatechildhood and

early adulthood. It may be seasonal,developingusually

during the springor summer,or perennial. Clinical signs are

limited toconjunctival hyperemia andedema (chemosis),

thelatter at times beingmarked and suddeninonset

Vernal keratoconjunctivitis ---------------------------------------------->>>>

y tends tooccurinlatechildhood andearly adulthood.

Usually seasonal, with a predilection for the spring. Large

cobblestone papillae arenotedon theupper tarsal

conjunctiva. Theremay belymphoid follicles at the

limbus.

Atopic keratoconjunctivitis ------------------------------------------>>


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y morechronicdisorderof adulthood. Both theupper andlower tarsalconjunctivas exhibit

a fine papillary conjunctivitis with fibrosis,resultingin forniceal shortening andentropion

with trichiasis. Staph blepharitis is a complicating factor. Cornealinvolvement including

refractory ulcerationis frequent duringexacerbations of both vernal and atopic

keratoconjunctivitis. Thelatermay becomplicated by herpes simplex keratitis

S/S:

y Conjunctival hyperemia andedema (chemosis)

y Itching, tearing,redness, stringy discharge, andoccasionally photophobia andvisualloss Treatment

y Topical histamineH1-receptor antagonist such as levocabastine hydrochloride0.05%or

emedastinedifumarate0.05%or ketoralac tromethamin, a NSAID agent QID.

y Ketotifen0.025% has histamineH1-receptor antagonist,mast cell stabilizer, andeosinophils

inhibitor activity BID-QID

y Topicalmast cell stabilizers Cromolyn sodium 4% QID

y Topicalcorticosteroids areessential to thecontrolof acuteexacerbations

o Corticosteroid-induced sideeffects includecataracts,glaucoma, andexacerbationof

herpes simplex keratitis

y Topicalcyclosporineeffective

y Systemiccorticosteroid therapy andeven plasmapheresis may berequiredin severecases

y In allergicconjunctivitis, specific allergens may beidentifiable and thus avoidable

y Invernal keratoconjunctivitis, a coolerclimateoften

provides significant benefit

y Pterygium----------------------------------------------------------------------------------------->>>>

o Is a fleshy, triangularencroachment of theconjunctiva onto thenasal side

of thecornea andis usually associated with constant exposure to wind,

sun, sand, anddust

o Often bilateral

o Becomeinflamed andmay grow

o Treatment

No treatment is usually required forinflammationof pterygium, but artificial tears areoften

beneficial, and short courseof topicalNSAIDs or weak corticosteroids (prednisolone0.125%TID)

may benecessary

Indications forexcisionof pterygium aregrowth threateningvision by approaching thevisual axis,

markedinduced astigmatism,or severeocularirritation.

o Recurrenceis common andoftenmore aggressive than the primary lesion.

y Cornealulcer -------------------------------------------------------------------------->>>>>

o

Most commonly due toinfection by bacteria,viruses, fungi,oramebas

o S/S:

Pain, photophobia, tearing, andreducedvision

Eyeis red, with predominantly circum-cornealinjection and

theremay be purulent or watery discharge

o Bacterial Keratitis ---------------------------------------------------------------------->>>>

Pursues an aggressivecourse


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Precipitating factors includecontact lens wear andcorneal trauma (includingrefractive surgery)

MC pathogens Pseudomonas aeruginosa,Pneumococcus,Moraxella, andStaph.

S/S

y Cornea is hazy, with a centralulcer and adjacent stromal abscess

y Hypopyon (puss ineye) is often present

TX:

y Ulceris scraped torecovermaterial forGram stain andculture prior to starting treatment

with high-concentration topical antibiotics applied hourly day andnight for at least the first48 hrs

y Fluoroquinolones Ciprofloxacin0.3%,ofloxacin0.3% andnorfloxacin0.3% are first-line

agents

y Levofloxacin0.5%is moreeffective against pneumococci thanCipro

y 4thgeneration fluoroquinolones (moxifloxacin andgatifloxacin) are alsoeffective against

mycobacteria,may become the preferred agent

y Gram + coccican also be treated with cephalosporin such as Cefazolin 100mg/mL

y Gram bacillican be treated with aminoglycoside such as tobramycin 15mg/mL

o Ifnoorganisms are seen,useCefazolin + Tobramycin together

o Herpes Simplex Keratitis ---------------------------------------------------------------->>>

Important causeofocularmorbidity in adults

S/S:

y Dendritic (branching) ulceris themost characteristic

manifestation.

y Moreextensive (geographic) ulcers alsooccur, particularly

if topicalcorticosteroids have beenused.

y Ulcers are seeneasily with fluorescein andexamination with a bluelight

y Increasingly severecornealopacities with each recurrence

TX

y Simpledebridement and patching

y Morerapid healingcan be achieved with topical antivirals such as trifluridinedrops or

acyclovirointment

y Long-termoral acyclovirreduces therateofrecurrent epithelialdisease, for which topical

corticosteroids must not beused

o Fungal Keratitis -------------------------------------------------------------------->>>

Treat with NatamycinorAmphotericin

Systemicimidazoles may be helpful

Cornealgraftingis oftenrequired

o Acanthamoeba Keratitis --------------------------->>

Treat with polyhexamethyl biguanide,

chlorhexidine, propamidineisethionate,

orneomycin.

Epithelialdebridement

Cornealgraftingmay berequired


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y AcuteAngle-ClosureGlaucoma ---------------------------------------------->>>>>

o EssentialofDiagnosis

Older agegroup andAsians

Rapidonset of severe pain and profoundvisualloss with

halos aroundlights

Redeye, steamy cornea,dilated pupil Hardeye to palpation

o Cause

Occurs only with closureof a preexistingnarrow anteriorchamber angle foundinolder agegroups

(owing toenlargement of thelense), hyperopes,Inuits, andAsians

May be precipitated by papillary dilation and thus canoccur from sittingin a darkened theater, at

times of stress,orrarely fromdrugs such as Anticholinergics,or sympathomimetic agents (eg,

nebulized bronchodilators, atropine, antidepressants,nasaldecongestants,or tocolytics)

Secondary acute angle-closureglaucoma may beobserved with anterioruveitis,dislocationof the

lens,or topiramate therapy.

o S/S Extreme pain and blurredvision

Halos aroundlights

Nausea and abdominal painmay occur

Redeye,cornea steamy, and pupils moderately dilated andnonreactive tolight

IOPusually over50mmHg, producing a hardeyeon palpation

o Treatment

InitiallycontrolIOP.

y A single500 mgIVdoseof acetazolamide, followed by 250mg po QID is usually sufficient

y Osmoticdiuretics such as glycerol andIVurea ormannitol - all threedosed 1-2g/kg may

benecessary if thereis noresponse to acetazolamide

y Laser therapy to the peripheraliris (iridoplasty) or anteriorchamber paracentesis is also

effective

Once theIOP has started to fall, topical 4% pilocarpine 1 drop q15minutes for 1 hr and then QIDis

used toreverse theunderlying angleclosure

* thedefinitive treatment is laser peripheraliridotomy or surgical peripheraliridectomy, which

should be performed prophylactically on the fellow eye.

Ifit is not possible tocontrolIOPmedically,glaucoma drainage surgery as foruncontrolledopen-

angelglaucoma may berequired

o Secondary

In secondary acute angleclosureglaucoma, systemic acetazolamideis alsoused, with or without

osmotic agents

o Prognosis

Untreatedmay result in severe and permanent visualloss

within2 -5days afteronset of symptoms

y ChronicGlaucoma ------------------------------------------------------------------------>>>>

o Essentials ofDiagnosis


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No symptoms inearly stages

Insidious progressive bilateralloss of peripheralvision,resultingin tunnelvision but preservedvisua

acuities

Pathologiccuppingof theopticdisks------------------------------------->>>>>

Usually associated with persistent elevations ofIOP

May lead tocomplete blindness

o Generalconsiderations

Chronicglaucoma is characterized by gradually progressiveexcavation (cupping) and pallorof the

opticdisk with loss ofvision progressing from slight constrictionof the peripheral fields tocomplete

blindness

Treat increase

IOP

Flow of aqueous into the anteriorchamber angleis obstructedinchronic angle-closureglaucoma

Primary open-angleglaucoma is bilateral

Increased prevalencein first-degreerelatives of affectedindividuals andindiabetics

More frequent in blacks

Secondary open angleglaucoma may result fromuveitis,ocular trauma,orcorticosteroid therapy

o Diagnosis

Requires consistent andreproducible abnormalities in at least 2of 3 parameters opticdisk,visual

filed, andIOP

Opticdisk cuppingis identified as an absoluteincreaseor an asymmetry between the twoeyes of

therationof thediameterof theopticcup to thediameterof the wholeopticdisk (cup-disk ratio)o Prevention

All persons over age 40 yrs should haveIOPmeasurement andopticdisk examinationevery 2-5 yrs

In persons with diabetes andinindividuals with family history ofglaucoma, annualexaminationis

indicated

o Tx:

Prostaglandin analogs (Latanoprost 0.005%, bimatoprost 0.03%, and travaprost 0.004% QD at night;

orunoprostoneisopropyl0.15%BID) arecommonly used as first line therapy.

y Allmay produceconjunctival hyperemia (increased blood flow), permanent darkeningof the

iris andeyebrow color, andeyelash growth.

y Latanoprost has been associated with reactivationofuveitis andmacularedema TopicalBeta blockers such as timolol0.25%or0.5%,carteolol 1%,levobunolol0.5%, and

metipranolol0.3% solutions BIDor timolol0.5%gel QDmay beused aloneorincombination with a

prostaglandin analog

y Contraindicatedin pts with reactive airway diseaseor heart failure. (Betaxolol0.25%or0.5%

- a selective beta blocker) is theoretically saferinreactive airway disease but less effective at

reducingIOP


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Brimonidine0.2%, a selective alpha 2 agonist, anddorzolamide2%or brinzolamide 1% topical

carbonic anhydraseinhibitor alsocan beusedin addition to a prostaglandin analogor a Beta blocker

(twicedaily) or as initial therapy when prostaglandin analogs andBeta blockers arecontraindicated

(BrimodnidineBID,dorzolamide and brinzalomaideTID)

Laser trabeculoplasty is used as an adjunct to topical therapy todefer surgery andis also advocated

as primary treatment

Surgery is generally undertaken whenIOPis inadequately controlled by medical andlaser therapy

but it may also beused as primary treatment (Trabeculectomy)o Prognosis

Untreatedchronicglaucoma that begins at age 40-45 yrs will probably causecomplete blindness by

age60-65.

y Cataract --------------------------------------------------------------------->>>

o EssentialofDiagnosis

Gradually progressive blurredvision

No painorredness

Lens opacities (may begrossly visible)

o GeneralConsiderations

Usually bilateral May becongenital, traumatic,or secondary to systemicdisease (diabetes,myotonicdystrophy,

atopicdermatitis), systemicorinhaledcorticosteroid treatment,oruveitis.

Senilecataract is theMC type

Most persons over age60 have somedegreeoflens opacity

Cigarette smokingincreases therisk ofcataract formation

o S/S:

Lens opacities

o Treatment:

in adults, functionalvisualimpairment is the primecriterion for surgery

Laser treatment may berequired subsequently if the posteriorcapsuleopacifies

Ultrasonic fragmentation (phacoemulsificatoin) of thelens nucleus allows cataract surgery to be

performed thru a smallincision without theneed for sutures, thus reducing the postoperative

complicationrate and acceleratingvisualrehabilitation

It is routine toinsert anintraocularlens at the timeof surgery

o Prognosis

Cataract surgery in adults improves visual acuity in 95%of thecases andcan have a profoundimpact

on quality oflife.

y RetinalDetachment ------------------------------------------------------------------------->>>


Curtain spreading across fieldofvisionor suddenonset ofvisual

loss inoneeye

No painorredness

Detachment seen by ophthalmoscopy


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o GeneralConsiderations

Primary event inretinaldetachment is thedevelopment

of a retinal tear

Once thereis a tearin theretina, fluidvitreous is able to

pass thru the tear andlodge behind the sensory retina

The area involvedrapidly increases,causing

correspondingvisualloss usually spreadingupward

across the fieldofvision Centralvisionremains intact until themacula becomes

detached.

o Treatment

Must bereferredurgently to anophthalmologist

During transportation, the pts headis positioned so that

thedetached portionof theretina will fall back with the

aidofgravity.

Treatment is directed as closing the tears

A permanent adhesion between theneurosensory retina, theretinal pigment epithelium and the

choroidis producedin theregionof the tears by applyingcryotherapy to the sclera orlaserphotocoagulation to theretina.

Subretinal fluiddrainagevia anincisionin the sclera

Injectionof anexpansilegas into thevirtreous cavity followed by positioningof the patients head to

facilitatereattachment of theretina

Once theretina is repositioned, the tearis sealed by laser

photocoagulationorcryotherapy.

y Age-RelatedMacularDegeneration -------------------------------------------->>>


Older agegroup

Gradually progressive simultaneous or sudden sequential

deteriorationofcentralvisionin both eyes

Distortionor abnormal sizeofimages

No painorredness

Macular abnormalities seen by ophthalmoscopy

o Generalconsiderations

Leadingcauseof permanent visualloss in theolder

population

Increasedin whites, females, family history, andcigarette

smoking

2 types

y Atrophic (dry)

y Exudative (wet)

o Both progressive and bilateralusually

o S/S:

Retinaldrusen

HardDrusen appearopthalmoscopically as discrete yellow deposits


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Soft Drusen arelarger, paler, andless distinct

Large,confluent soft Drusen are particularly associated with exudative agerelatedmacular

degeneration

Atrophicdegeneration (DRY) --------------------------------------------->>>

y Gradually progressive bilateralvisualloss ofmoderate severity due to atrophy and

degenerationof theouterretina andretinal pigment epithelium.

Exudativedegeneration (WET) ------------------------------------>>>

y Choroidalnew vessels grow between theretinalpigment epithelium andBruchs membrane,leading

to accumulationof serous fluid, hemorrhage, and

fibrosis.

y Theonset ofvisualloss is morerapid andmore

severeinexudative.

y Bilateral

y Exudativedisease accounts for about 90%of allcases

oflegal blindness due to age-relatedmaculardegeneration

o TX:

Conventionallaserretinal photocoagulationfor well-defined classicchoroidalneovascular

membranes away fromor adjacent to the fovea

Photodynamiclaser therapy (PDT)

y Involves IVinjectionofverteporfin activated by subsequent retinallaserirradiation to

produce selectivevasculardamageis indicated for well-definedlesions lyingunder the fovea

Antiangiogenic angents

y Inhibitors ofvascularendothelialgrowth factors (VEGF)

o Reverse theneovascularizatoin and thus could be beneficialin both well and poorly

defined (occult) lesions

o When torefer

Older patients developing suddenvisualloss due tomaculardisease particularly paracentral

distortionor scotoma with preservationofcentral acuity should bereferredurgently

y Central & Branch RetinalVeinOcclusions ---------------------------------------------------------->>


Suddenmonocularloss ofvision

No painorredness

Widespreador sectoralretinal hemorrhages seen by

ophthalmoscopy

o S/S

Visualimpairment commonly first noticedupon waking

Exam shows retinal hemorrhages,retinalvenous dilation and tortuosity,retinalcotton-wool spots,

andopticdisk swelling

Suddenloss ofvision

o Complications

If associated with retinalischemia,manifesting as poorvisual acuity

(20/200or worse); with floridretinal abnormalities; and with extensive


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area ofcapillary closureon fluorescein angiography, thereis a high risk ofdevelopment of

neovascularglaucoma, typically within first 3 months

o Treatment

Screen fordiabetes, systemicHTN,Hyperlipidemia, andglaucoma

In younger patients, antiphospholipid antibodies,inherited thrombophilia, and

hyperhomocysteinemia should beconsidered

Intravitrealinjections of bevacizumab aninhibitorofVEGF

Laser photocoagulation Vitrectomy with direct injectionof tissue plasminogen activatorinto theretinalvenous systemor

incisionof the sclera at theedgeof theopticdisk

Arteriovenous sheathotomy

o Prognosis

Incentralretinalveinocclusion, severity ofvisualloss initially is

a goodguide tovisualoutcome. Visual acuity of20/60or

betterindicated a good prognosis

Visual prognosis is poor foreyes with neovascularglaucoma

o Refer

All patients should bereferredurgently!y Central & Branch RetinalArtery Occlusion

o Centralretinal artery occlusion ----------------------------------------------->>>

o Branch Retinal artery occlusion------------------------------------------------>>>


Suddenmonocularloss ofvision

No painorredness

Widespreador sectoralretinal pallid swelling seen by

ophthalmoscopy

o S/S:

Visual acuity is reduced tocounting fingers or worse, andvisual

fieldis restricted to anislandofvisionin the temporal field

Swellingofretina with cherry-red spot at the fovea.

Theretinal arteries are attenuated and box-car segmentationof bloodin theveins may be seen

When swelling subsides over 4-6wks,leavingnormalretinal appearance but a paleopticdisk and

attenuated arterioles

o Tx:

IF the patient is seen within a few hours afteronset,emergency treatment includinglaying the

patient flat,ocularmassage, high concentrations ofinhaledoxygen,IV acetazolamide, and anterior

chamber paracentesis

Excludegiant cell arteritis

y Clinical features jaw claudication,markedly elevated seruminflammatory markers,usually

erythrocyte sedimentationrate andC-reactive protein,

o Prednisone poimmediately


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Carotid andcardiac sources ofembolimust beidentified so that appropriate treatment is given to

reduce therisk of stroke

Migraine,oralcontraceptives, systemicvasculitis,congenitalor acquired thrombophilia, and

hyperhomocysteinemia should beconsideredin young patients,internalcarotid artery dissection

when thereis neck pain,or a recent history ofneck trauma, anddiabetes,Hyperlipidemia, and

systemic hypertensionin all patients

o Refer

Referemergently to anophthalmologist

y Diabetic Retinopathy -------------------------------------------------->>


Present in about 40%ofdiagnoseddiabetics

Present inup to20%of type2diabetics at

diagnosis

Mildretinal abnormalities without visualloss

in back-groundretinopathy

Macularedema,exudates,orischemia in

maculopathy

Retinalnew vessels in proliferativeretinopathyo Generalconsiderations

Leadingcauseofnew blindness among adults aged20-65 yrs

Progressive

o ClinicalFindings

Nonproliferativeretinopathy manifests as dilationofveins,microaneurysms,retinal hemorrhages,

retinaledema, and hardexudates

Backgroundretinopathy the abnormalities aremild anddonot cause any impairment ofvisual

acuity

Maculopathy manifests as edema,exudates,orischemia involving themacula.

y Assessment requires stereoscopicexaminationof theretina and sometimes retinalimaging

with opticalcoherence tomography (OCT) or fluorescein angiography (or both).

y Visual acuity is a poorguide to presenceof treatablemaculopathy

y Maculopathy theMCcauseoflegal blindness inmaturity onset diabetes

Proliferativeretinopathy characterized by neovascularizatoin arising fromeither theopticdisk or

themajorvascular arcades.

y Vitreous hemorrhageis a common sequel

y Without treatment, prognosis is much worse than that with nonproliferativeretinopathy.

o Screening

Adult patients with diabetes shouldundergo yearly screening

y Fundal photography thrudilated pupils

o Tx:

Optimizing bloodglucose, blood pressure,renal function, and serumlipids

Laser photocoagulation,intravitrealinjectionofcorticosteroidor a VEGFinhibitor,orvitrectomy for

macularedema andexudates (NOTFOR ISCHEMIATHOUGH)

Proliferativeretinopathy

y Panretinallaser photocoagulation


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y Regressionofneovascularizationcan also be achieved by intravitrealinjectionof a VEGF

inhibitor

Vitrectomy is necessary forremovalof persistent vitreous hemorrhage, toimprovevision and allow

panretinallaser photocoagulation for theunderlyingretinalneovascularization

Proliferativediabeticretinopathy is not a

contraindication to treatment with thrombolytic

agents, aspirin,or warfarinunless there have been

recent vitreous or pre-retinal hemorrhagey Hypertensive Retinopathy ----------------------------------------------->>>>

o Themost floriddiseaseoccurs in young patients with

abrupt elevations ofBP such as may occurin

pheochromocytoma,malignant HTN,or pre-eclampsia-

eclampsia

o Flame-shaped hemorrhages occurin thenerve fiberlayer

of theretina

o Cotton-wool spots,retinal hemorrhages,retinaledema,

andretinalexudates

o Retinal pigment epithelialinfarcts May be focal,linear,or wedge-shaped

y Orbitalcellulitis ----------------------------------------------------------------------->>

o Manifested by an abrupt onset of fever, proptosis,restrictionof

extraocularmovements, and swelling with redness of thelids

o Infectionof the paranasal sinuses is theusualunderlyingcause

o Tx

Immediate tx with IV antibiotics is necessary to prevent

opticnervedamage and spreadofinfection to the

cavernous sinuses,meninges, and brain

Inimmunocompromised patients,zygomycosis must beconsidered

y Conjunctival & CornealForeignBodies ------------------------>>

o FBis usually present on thecornea orunder theupper

lideven though it may not bevisible

o Visual acuity should be tested before treatment is

instituted as a basis forcomparisonin theevent of

complications

o Tx:

CornealFB

y Local anesthetic propracaine0.5%

instilled

y Examineeye with hand flashlight

y Fluoresceinmay help seecornealFBs

y Remove with a sterile wet cotton-tipped applicator

y Polymyxin-bacitracinophthalmicointment should be

instilled

y Dont patch theeye


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y Reexamine24 hrs later for secondary infectionof thecrater

y Ifcannot removeFBin this manner, the patient should bereferred to anophthalmologist

y If a rust ring,exciseit underlocal anesthesia using

a slit lamp

UpperLidFB ----------------------------------------------------->>>

y IncaseofFBunder theupperlid, a local anesthetic

is instilled and thelidis everted by grasping the

lashes gently andexerting pressureon themidportionof theouter surfaceof theupperlid with

an applicator.

y If theFBis present,it caneasily beremoved by passing a wet sterilecotton-tipped

applicator across theconjunctival surface.

y Intraocular foreign body ---------------------------------------------------------->>

o Requires emergency treatment by ophthalmologist

y CornealAbrasion

o A patient with a corneal abrasioncomplains of severe pain and

photophobia

o Often a history of trauma to theeye

o Assess visual acuity

o Examinecornea andconjunctiva with light andloube toruleout

a FB

o SterileFluorescein allows toview abrasion

The area of abrasion will stain a deepergreen than the surrounding

cornea

o Tx

Plymyxin-bacitracinophthalmicointment,mydriatic (cyclopentolate

1%), and analgesics either topicalororalNSAIDs.

Padding theeyeis not helpful

Reassess pt within 48 hrs to becertain thecornea has healed

y OrbitalFracture (Blowout Fracture)------------------------------------------------------------>>

o Refer toclass notes!!!!

y Hyphemia --------------------------------------------------------------------------------->>>>

o a termused todescribe bleedingin the anteriorchamber (the space

between thecornea and theiris) of theeye. It occurs when blood

vessels in theiris bleed andleak into theclear aqueous fluid.

Hyphemas areusually characterized by poolingof bloodin the anterior

chamber that may bevisible to thenakedeye. Thered bloodcells of

very small hyphemas arevisibleonly with magnification. Even the slightest amount of bloodin the anterior

chamber willcausedecreasedvision whenmixedin theclear aqueous fluid.

o Bleedingin the anteriorchamberis most oftencaused by blunt trauma to theeye. It may also be associated

with surgical procedures. Othercauses include abnormalvesselgrowth in theeye andcertainocular

tumors.


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o S/S

y Decreasedvision (Dependingon the amount of bloodin theeye,visionmay bereduced toonly hand

movements andlight perceptiononly)

y Poolof bloodin the anteriorchamber

y Elevatedintraocular pressure (in somecases)

o Diagnosis

y It is very important for thedoctor todetermine thecauseof the hyphema. If the hyphema is related

to anocularinjury, any detailregarding thenatureof the trauma is helpful. Thedoctor will assess

visual acuity,measureintraocular pressure, andexamine theeye with a slit lamp microscope and

ophthalmoscope.

o Treatment

y The treatment is dependent on thecause and severity of the hyphema. Frequently, the bloodis

reabsorbedover a periodofdays to weeks. During this time, thedoctor willcarefully monitor the

intraocular pressure for signs of the blood preventingnormal flow of the aqueous through theeye's

angle structures.I

f theeye pressure becomes elevated,eyedrops may be prescribed tocontrolit. The pupils are alsoevaluated toruleout damage to theiris.

y In somecases, a procedureis performed toirrigate the blood from the anteriorchamber to prevent

secondary complications such as glaucoma and blood stains on thecornea.

Patients with significant hyphemas must rest and avoid strenuous activity to allow the blood to

reabsorb.

y Strabismus (crossedeyes; esotropia; exotropia; squint; walleye,) --------------------->>o Definition

Disorder that causes oneeye to bemisaligned with theother when

focusing

o Causes


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Lack ofcoordination between theeyes. As a result, theeyes look indifferent directions anddonot

focus at the same timeon a single point

Children - May be associated with retinopathy of prematurity,retinoblastoma, traumatic brain

injury, hemangioma near theeyeduringinfancy,Apert syndrome,Noonan syndrome,Prader-Willi

syndrome,Trisomy 18,Congenital Rubella,CerebralPalsy)

Adults somedisorders associated with strabismus in adults include diabetes,eyedisease/injury,

stroke, traumatic braininjury, paralytic shellfish poisoning (PSP),Guillain-Barre syndrome,Botulism

Family history of strabismus is a risk factor, farsightedness may be a contributing factor. In addition,

any other diseasecausingvisionloss may produce strabismus as a complicationo S/S

Eyes that appearcrossed

Eyes that donot alignin the samedirection

Uncoordinatedeyemovements (eyes that donot move together)

Doublevision

Visioninonly oneeye, with loss ofdepth perception (depth perceptionis our ability to see 3D, and

recognize theorderofobjects in the space aroundus)

o Exams andTests

PE

Standardophthalmicexam

Visual acuity

Retinalexam

Neurologicalexaminationo Treatment

Initially, strategies to strengthen the weakened muscles and thereby realign the eyes are attempted.Glasses may be prescribed. Eye muscle exercises may be prescribed.

If amblyopia (lazy eye) is present, patching of the preferred eye may be done to force the child to usethe amblyopic eye. Surgery may be required to realign the eye muscles if strengthening techniquesare unsuccessful.

o Prognosis With an early diagnosis, the defect can usually be correct With delayed treatment, vision loss in one eye may be permanent

o Complications

Loss of vision in one eye due to amblyopia (lazy eye) Embarrassment over facial appearance with eye patch

Documents

Ophthalm Study Guide