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OPTHO REVIEWAmy Begnoche DO
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Anatomy
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Hoarders
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Hordeolum (Sty)Acute painful nodule external lid
Zeis gland
Abcess of eyelid
Usually S. aureus
Tx: warm compress, abx ointment, I&D refractory cases
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Chalazion Chronic stye
Chronic internal granulomatous (sterile) rxn of Meibomian glands
Tx: warm compress, refer to Optho for excision
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Blepharitis
Inflammation of the eyelid
Dandruff of the eyelid
Chronic staph or strep
Tx: gentle scrub with baby shampoo, topical abx
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ConjunctivitisBacterial:-pus drainage-strep or staph-pseudomonal (contact lens, treat with aminoglyc/quinolone)
Tx: topical abx
ghonorrhea: 1st 3 days of life, ocular emergency, pouring pus out of the eye, systemic abx (rocephin, topical erythromycin, cover for chlamydia)
Chlamydia: first 5-14 days of life, systemic and topical abx
Contagious for 2 weeks
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Viral Conjunctivitis
adenovirus
Tx: cool compress, no school
Consider allergic or chemical
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Corneal Abrasion Minor trauma
Painful
Tx: abx ointment, pain meds
***metal on metalsuspect intraocular FB
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Corneal Ulcer Focal white opacity
Pain, redness, photophobia, visual defect
Caused by bacteria, fungal, HSV
Urgent Ophtho referral
No patch (corneal melting from pseudomonas)
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Dacrocystitis
Clogged lacrimal duct
tears don’t drainPurulent discharge
s. aureus
Tx: warm compress, abx (augmentin)
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Foreign Body
Remove with moistened cotton swab, needle
Evert eyelids, stain with flourescein
Rust ring: needs to be removed, burr device, refer ophtho
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Keratitis
Inflammation of the cornea
Punctate: UV exposure (welder, snow blindness)
Supportive care, artificial tears, topical abx
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HerpesSimplex
Keratitis causing foreign body sensation
Dendritic corneal lesion
Tx: urgent ophtho consult, topical/po antiviral, no topical steroids
Zoster
Ophthalmic branch of the trigeminal N. (V1)
Hutchinson sign
Tx: systemic/topical antiviral, emergent ophtho consult, +/- steroids, pain control
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Preseptal v. Orbital Cellulitis
Preseptal/PeriorbitalPain, swollen lid
OrbitalSick, pain with eye movement, proptosis
Tx: CBC, Bld cx, CT obrits, IV abx
Complications: meningitis, sepsis, abscess, cavernous sinus thrombosis (CN 3, 4, 6) vision loss from high IOP
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Glaucoma
Increased intraocular pressure
Problem with flow of aqueous humor through trabecular meshwork and Canal of Schlemm
Leads to damage of optic nerve
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Chronic (Open angle glaucoma)
Gradual peripheral vision loss
age >40, African American, family hx
Tx: topical/systemic meds to decrease aqueous humor production and increase flow
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Acute angle glaucomaPrecipitated by dim light (dilated pupil)
“walking out of a movie theater”
Painful loss of vision, headache, nausea, halos
Eye injected, steamy cornea, elevated IOP 40-70
Tx: emergency ophtho referral, topical/systemic meds to decrease aqueous humor production and increase flow
IV carbonic anhydrase inhibitor, BB gtt, mannitol, pilocarpine gtt
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Iritis Acute painful red eye, blurry vision
Can be traumatic
Ciliary flush – reddening of sclera at the limbus
Cells and flare
No relief with topical anesthetic
Tx: topical cycloplegic
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Hypopyon
Pus in the anterior chamber of the eye
White cells layering out
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Endophthalmitis
Infection of deep eye structures
Pain + vision impairment
Tx: intraocullar and systemic abx
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Optic Neuritis Acute painful (central) vision loss
Pain with eye movement
Inflammation of optic nerve
“Marcus gun pupil” (APD)
Associated with MS
Can be caused by toxins, meds, autoimmune dz
Tx: IV steroids
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Retinal DetachmentTraumatic or atraumatic
Retinal tear allows vitreous fluid to separate retina from choroid
Risk factors: old, degenerative myopia, previous detachment
Painless flashes of light, floaters, curtain over eye
Tx: emergent ophtho consult
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Central Retinal Artery OcclusionOcular emergency
Sudden painless unilateral vision loss
Emboli, thrombotic plaque, vascultitis
Cherry red spot (perifoveal atrophy), box cars (arteriolar narrowing)
Tx: emergency ophtho referral, poor prognosis, atherosclerotic wkup
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Central Retinal Vein Occlusion
Thrombosis
Sudden, painless, unilateral vision loss
“blood and thunder retina”
Tx: thrombosis wkup
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Eye Trauma
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BurnsAlkali: liquefication necrosis (worse)
Acidic: coagulation necrosis
Irrigate the eye until pH is normal (7.4)
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Globe Rupture
Scleral rupture from high IOP
Teardrop pupil, seidel’s sign
NO TONOPEN
Tx: hard shield, analgesia, tetanus, IV abx, ophtho consult
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Hyphema Blood in the anterior chamber
Can lead to increased IOP, eye staining
Trauma, anticoagulation, spontaneous (sickle cell)
Secondary bleeding as clot retracts
Increased risk of glaucoma, adhesions, vision loss
Tx: bedrest, analgesics, no anticoag, ophtho consult
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Orbital Fracture
Orbital walls made of thin bones
Weakest = floor -infraorbital nerve involvement, inhibited upward gaze, numbness of cheek or upper lip, diplopia
Tx: if nml exam, urgent ophtho referral
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Retrobulbar Hematomahematoma causes
increased IOP
pressure on retinal A.
eye ischemia (compartment syndrome)
Vision loss
Tx: lateral canthotomy, meds to lower IOP
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Lid Lacerations
Ophtho repair:
involve lid margin
6-8mm from medial canthus
involving lacrimal duct
involving inner surface of the lid
associated ptosis
<1mm heal spontaneously
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References
Peer VIII
HippoEM
Intensive Review for Emergency Medicine Qualifying Exam
Rivers Emergency Medicine Review