Download B2B Ophthalmology Toren Mar 29 2011

Ophthalmology
Back to Basics
Review
March 29, 2011
Dr. Andrew Toren
MCC Objectives
• Eye Redness
• Pupil Abnormalities
• Amblyopia / Strabismus
• Acute / Chronic Visual Loss
•
•
1.
2.
Pupillary disorders of changing degree are in general of little clinical importance. If only one pupil is fixed to light, it is suspicious of the effect
of mydriatics. However, pupillary disorders with neurological symptoms may be of significance.
-Causal Conditions
Pupil Abnormalities
Local disorder of iris
Anisocoria (unequal/asymmetric pupils)
a.
Post eye surgery
b.
Impaired pupil constriction (third nerve palsy, tonic pupil, mydriatics)
c.
Impaired pupil dilatation (Horner syndrome) (hypothalamus/brain stem/spinal cord lesions)
1.
Impairment of pupil constriction (without anisocoria)
a.
Unilateral (optic nerve or retinal lesion)
b.
Bilateral (diabetes, syphilis, midbrain lesion, hydrocephalus, factitious)
•
-Key Objectives
•
Determine whether there has been previous ocular inflammation, trauma, loss of vision, or eye pain in order to begin ruling out local
disorders.
•
-Objectives
•
Through efficient, focused, data gathering:
◦
Differentiate clinically between the various mechanisms of pupil abnormalities.
•
List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:
◦
Select patients in need of referral for further investigation.
c.
Foreign body
d.
Cellulitis (pre-septal, orbital)
e.
Naso-lacrimal duct obstruction
1.
Conjunctiva/Sclera
a.
Conjunctivitis (viral, bacterial, chlamydial, allergic, also neonatal)
b.
Subconjunctival hemorrhage
c.
Episcleritis/Scleritis
d.
Pinguecula/Pterygium
1.
Cornea (corneal abrasions, contact lens overwear)
a.
Keratitis, infectious
b.
Foreign body (refer if not better in 24 hours)
1.
Anterior chamber/Iris
a.
Iritis/Iridocyclitis/Uveitis
b.
Glaucoma, acute
c.
Hypopyon
d.
Hyphema
•
-Key Objectives
•
Determine whether the condition requires prompt referral.
•
-Objectives
Eye Redness
•
Loss of vision is a frightening symptom that demands prompt attention; most patients require an urgent ophthalmologic opinion.
•
-Causal Conditions
1.
Glaucoma (acute angle closure)
2.
Haemorrhage (diabetic retinopathy, may be traumatic, penetrating, hyphema)
3.
Nervous system/Vascular
a.
Retinal artery/Vein occlusion (TIA/CVA)
b.
Migraine
c.
Occipital infarction/Haemorrhage (TIA/CVA)
1.
Trauma
a.
Blunt (global rupture, corneal abrasion, choroidal rupture, lens dislocation)
b.
Penetrating (globe penetration ( intra-ocular foreign body, corneal/lens perforation, optic nerve injury)
c.
Haemorrhage (may be traumatic, penetrating)
d.
Other (carotid-cavernous sinus fistula, chemical splash)
1.
Retinal/Macular/Optic disc problems
a.
Optic neuritis/Optic nerve injury
b.
Retinal detachment (may be traumatic)
c.
Anterior ischemic optic neuropathy/temporal arteritis
Acute Visual Loss
Acute Visual Loss
•
Objectives
•
Through efficient, focused, data gathering:
◦
Determine whether the loss is monocular or binocular, and if binocular, is it hemianopic, any exposure to agents or trauma.
◦
Determine character of visual loss, since important associated systemic conditions (diabetes, hypertension, temporal arteritis) or
similar past events may suggest cause.
◦
Differentiate causes of visual loss by examination of cornea, pupil, lens, retina, optic disc, and visual fields (listen for murmurs,
carotid bruits).
◦
•
◦
•
◦
Determine the presence of a foreign body, abnormal extraocular musculature, pupillary reflex.
List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and
diagnosis:
Since vast majority of cases will be referred urgently, all tests will be arranged by specialist.
Conduct an effective plan of management for a patient with acute loss of vision:
Select patients in need of specialized care.
c.
Glaucoma (primary, secondary)
1.
Retinal dysfunction
a.
Diabetic (retinal edema, retinopathy)
b.
c.
Chronic Visual Loss
Vascular insufficiency
Tumors
d.
Macular degeneration or dystrophy
1.
Post-retinal lesions
a.
Optic chiasm lesions (pituitary adenoma)
b.
Lesions anterior to the optic chiasm (optic nerve/monocular)
i.
ii.
Compressive optic neuropathy
A.
Intracranial (masses)
B.
Orbital (thyroid disease)
Toxic/Nutritional (nutritional deficiencies, tobacco-alcohol amblyopia, methanol)
iii. Hereditary optic neuropathies
•
•
-Key Objectives
Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the
other eye is covered so that a chronic loss presents acutely).
•
Perform direct ophthalmoscope examination of the eye.
•
-Objectives
•
Through efficient, focused, data gathering:
Key Objectives
•
Acute / Chronic Visual Loss
•
•
Eye Redness
•
•
Know how to manage and when to refer the
patient
Pupil Abnormalities
•
•
Know how to examine the eye & common
causes
Know the main causes of pupil abnormalities
Amblyopia / Strabismus
•
Know what amblyopia is / know the differential
Resources
• Basic Ophthalmology,
American
Academy of Ophthalmology , Cynthia A.
Bradford; MD
• http://www.ophthobook.com/
Eye redness
• by the end of this lecture students will be
able to:
• know a differential diagnosis for a red
eye
• be able to differentiate between serious
vision threatening, benign, and non
urgent causes of a red eye
examination of the
eye
• visual acuity - don’t HOW TO EXAMINE THE
forget pinhole!
•
•
•
•
•
pupils
conjunctiva: pattern
of injection
discharge
evert lids: papillae or
follicles?
lymph node
EYE FOR DUMMIES
• Topical Anesthesia
• Light Source
• iPhone/Eye Chart
• Paper Clips (plastic
coated)
slit lamp examination
• cornea: fluorscein staining (abrasions,
dendrites), opacities
• anterior chamber: depth, cells
• intraocular pressure
history
• timing
• visual changes
• pain, photophobia, tearing
• discharge
• other risk factors: prior episodes,
contact lens use, medical comorbidities
the usual suspects
• blepharitis
• conjunctivitis
• viral
• allergic
• bacterial
• subconjunctival hemorrhage
• foreign body
• pterygium
the red eye
• Non-Traumatic
• Traumatic
blepharitis
•
•
•
•
Inflammation of the lid margin
(crusting/redness of lids)
Causes ‘gritty’/foreign body sensation,
often concomitant with other ocular surface
disease
Associated with recurrent hordeolum
(styes) or chalazia
Improvement with warm compresses/lid
hygeine, artificial tears, tetracycline
the usual suspects
• herpes simplex keratitis
• herpes zoster
• bacterial keratitis
• corneal ulcer
• iritis / episcleritis / scleritis
conjunctivitis
• Bacterial - most common in children
• Viral - most common in adults
• Allergic - bilateral, frequently c/o ‘itch’
bacterial
conjunctivitis
• Signs:
• Discharge - purulent vs mucopurulent
Question
• What type of neonatal conjunctivitis
occurs on the first day?
•
Pitfalls: Adult
Conjunctivitis
Adult Hyperacute Conjunctivitis
•
•
•
•
Gonococcus
Signs/symptoms of severe infection
Rapid onset
Chlamydial Conjunctivitis
•
•
•
•
Sexually active adolescents/adults
Unilateral, Follicular reaction
Chronic (>3 weeks)
Microtrak
•
•
bacterial
conjunctivitis
Usually self limited
Treatment necessary?
•
•
•
•
•
Limits spread
Shortens course
Patient comfort
Prevents recurrence
Prevents chronic staph conjunctivitis
bacterial
conjunctivitis therapy
•
Choice of antibiotic depends on other factors:
•
Polysporin
•
•
Polytrim
•
•
•
no prescription required
Low cost
Well tolerated
Fucithalmic
•
BID dosing
Pitfalls in Treatment
•
Avoid
•
•
•
Gentamicin
•
Epithelial toxicity
Steroid containing solutions
•
•
•
•
•
•
•
Garasone
Tobradex
Blephamide
Increase IOP, Cataract
Geographic Herpes
Worsen Infection
Corneal Spread
Frequent switching of drops
Viral Conjunctivitis
• History:
Infectious Contacts, URTI,
Drops/Drugs
• Etiology: Adenovirus
• Treatment: No specific therapy
• Cool compresses, artificial tears,
infectious precautions
Allergic Conjunctivitis
• Symptoms: ITCHING
• Signs: mild redness, conjunctival
chemosis, watery discharge, papillary
hypertrophy
• Treatment: cold compress,
antihistamines, non-steroidal drops,
mast cell stabilizers, topical
corticosteroids
Subconjunctival Hg
• What is the appropriate management of a
large subconjunctival hemorrhage
• A) Stop any anticoagulation and
observe for improvement
• B) Observe. If no resolution in 1-2
weeks refer to ophthalmology
• C) Observation only
• D) If large, refer to ophthalmology
Subconjunctival
Hemorrhage
bacterial keratitis
• much less common
• pain, reduced vision
• management:
• Large/Central Ulcer: Culture, Fortified
antibiotics, urgent referral
• Small Ulcer: topical gtts, refer
Pterygium
Pterygium
Herpes Simplex
Keratitis
• Unilateral, often have previous history
• Pain -variable, photophobia,
• Dendrites, Follicular conjunctivitis
• Management:
• Topical trifluridine 1% (Viroptic) 9X/day
± cycloplegia, refer
• NO STEROIDS!
Iritis/Episcleritis/Scleri
tis
Necrotizing Scleritis
Nodular Scleritis
Diffuse Scleritis
Localized Scleritis
Episcleritis
Pingeculitis
Episcleritis
• Symptoms: Often asymptomatic,
Mild
irritation and/or photophobia
• Signs: Sectoral Redness, superficial
injection, localized tenderness
• Systemic Associations: RA, SLE,
Seronegative spondyloarthropathies
• Treatment: Tears, Topical/Oral NSAIDS
Scleritis
•
•
•
•
Symptoms: Pain (Dull, Achy, Deep, Boring), Photophobia,
Tearing
Signs: Bluish red injection, deeper structures, nodules,
necrosis
Systemic Association in 50%, high 5 yr mortality - needs
investigation
•
•
•
•
Collagen Vascular
Rheumatoid arthritis
Lupus
Wegner’s
Treatment: Topical/Oral Steroid/NSAIDS/Immune
suppression
Angle Closure
Glaucoma (aka
Pupillary Block)
• Symptoms: dramatic presentation,
significant pain, ocular headache,
nausea and vomiting, decreased vision,
colored haloes
• Signs:
fixed mid-dilated pupil, steamy
cornea, shallow anterior chamber,
ELEVATED IOP
Angle Closure
• Treatment:
• Pilocarpine 1%
• Pressure lowering medication:
• Topical / IV / PO
• Definitive Management: Laser
Iridotomy
Traumatic Red Eye
• Red Flags
• Loss of vision
• Loss of red reflex
• Flat anterior chamber
• Tear shaped pupil
• Uveal prolapse
• blepharitis
- warm compresses,
lid
the usual
suspects
hygeine, artificial tears
• conjunctivitis
• viral - cool compresses, contact
•
•
precautions, observe
allergic - avoidance, antihistamine,
allergy gtts
bacterial - broad spectrum antibiotic
gtts
• subconjunctival hemorrhage -observe
• foreign body
the usual suspects
• herpes simplex keratitis - refer
• herpes zoster - refer
• bacterial keratitis - broad spectrum
antibiotics, refer if no improvement
• corneal ulcer - broad spectrum Abx, refer
• iritis / episcleritis / scleritis - dilate, refer
• angle closure glaucoma - refer urgently
Trauma
•
•
•
Hyphema
•
•
Gross (visible) or micro (visible only on slit
lamp exam)
Rx - Cylcoplegia, rest, refer
Traumatic Mydriasis
Orbital Fracture - CT scan, refer (repair ~1
week), no nose blowing, beware in children
of White Eye-Blow Out Fracture
when to refer
• vision changes
• pain, severe headache, nausea/vomitting
• corneal abnormalities or opacities
• fluorescein staining
• shallow anterior chamber
• increased IOP
• marked purulent discharge
• trauma
• proptosis
Urgent referral - time
sensitive
• acute angle closure glaucoma
• corneal ulcers
• trauma - eg ruptured globe
• endophthalmitis
Urgent referral
<48hrs
• acute anterior uveitis (iritis)
• scleritis
• nasolacrimal infections
Pupil Abnormalities
Anatomy - Pupillary
Response
• Afferent Pathway - CNII
• Efferent Pathway - CNIII
parasympathetic, sympathetic
Parasympathetic
Efferent
Sympathetic Efferent
Irregular Pupil
•
•
•
•
•
•
•
Mechanism: damage to compliance of iris or iris
musculature
Trauma – visible tears in margin or sphincter
Iridodialysis – outer edge of iris is torn away from its
ciliary attachment
Synechiae – can result from intraocular inflammation
causing adherence to lens or cornea
Neovascularization – can distort & impair reactivity
Malformations: coloboma, aniridia
Cataract surgery!
Anisocoria
• Inequality in diameter of the 2 pupils
• Efferent disturbances of pupil size
usually unilateral
• Degree of anisocoria greater in:
• Dim light – weakness in dilator
muscle (or physiologic) of smaller
pupil
• Small Pupil
• Bright light – weakness of sphincter of
bigger pupil
• Large Pupil
Dim Light / Small
Pupil
• Physiologic: <2mm
• Horner’s
• Pharmacologic: cholinergic - stimulation
of parasympathetic efferent pathway
• Eg Pilocarpine
Features
•
•
•
•
Miosis
Ptosis -2-3 mm
•
upside-down ptosis (1-2 mm) of the lower lid
•
Leads to pseudoenophthalmos
Anhydrosis
Other features:
•
•
transient dilation of conjunctival vessels,
increased accomodation
In longstanding cases heterochromia of the
iris may occur (the affected side being less
pigmented)
• Tests:
Horner’s
• Cocaine - Is Horner’s present
or absent?
• Blocks re-uptake of
norepinephrine in the
neuromuscular junction
• NB: apraclonidine (alphaagonist)
• Hydroxyamphetamine Is1st/2nd vs 3rd order
Horner’s?
AAO, Neuro-Ophthalmology
Bright Light / Large
• Damage to parasympathetic
outflow
to
Pupil
iris sphincter muscle
• Oculomotor nerve (CNIII) paresis
• Tonic Pupil
• Intermittent dilation of one pupil
caused by inhibition of
parasympathetic pathway
• Trauma to sphincter
• Pharmacologic stimulation:
cholinergics
Anti-
•
•
•
•
CN III Palsy
Pupil Involvement?
•
Assume to be
aneurysm!
Complete vs
Incomplete?
Young vs
Vasculopathy &
Diabetic?
Needs urgent
neuroimaging - CTA
AAO, Neuro-Ophthalmology
AAO, Neuro-Ophthalmology
Large Pupil: Others
•
•
•
Tonic Pupil
•
•
•
Longstanding
Aberrant regeneration
Light-near disassociation
Pharmacologic
•
•
Red cap drops, Anticholinergics eg scopolamine
Test with Pilocarpine
Traumatic Mydriasis
Amblyopia/Strabismu
s
Extraocular Muscles
AAO, Neuro-Ophthalmology
Important Questions
•
•
Does the diplopia resolve when 1 eye is covered? (i.e.
monocular vs. binocular)
Is it the same in all fields gaze (comitant) or does it
vary with gaze direction (incomitant)?
•
Is it horizontal, vertical, or oblique?
•
Is it constant, intermittent, or variable?
4th Nerve Palsy
•
•
•
•
•
Congenital
•
•
Asymptomatic until 40-60yo (↓ fusional amplitudes)
Chronic head tilt – check old photographs
Ischemic
•
•
Patients older than 50yo with ischemic risk factors
Expect resolution within 3 months
Others: Trauma; MS, tumour, hydrocephalus, aneurysn,
Idiopathic, Graves and Myasthenia
Neuroimaging: little diagnositc value initially
Medical Work-up & Observe
CN III Palsy
AAO, Neuro-Ophthalmology
6th Nerve Palsy
•
•
•
•
Causes esodeviation
Ischemic – most common
•
•
Patients older than 50yo with ischemic risk factors
Expect resolution within 3 months
Other important causes: Tumours, Trauma, raised ICP, demyelinating
disease
Investigations:
•
•
Adults > 50yo
•
•
Medical work-up (BP, fasting BG, lipid profile)
Lack of recovery after 3 months --> MRI
Patients < 50yo
•
•
Rarely ischemic --> must image (MRI/FLAIR)
Consider LP, Tensilon test
AAO, Neuro-Ophthalmology
INO
• Internuclear
Ophthalmoplegia
• Ipsilateral Impaired
ADduction
• Contralateral ABducting
nystagmus
• See most often in
demyelinating disease
• Mneumonic: INO = Insufficient Nasal Output
Diplopia Summary
•
•
•
•
•
•
•
•
•
Remember the 4 questions
Determine onset and course
Check pupils in CN3 palsy
Pupil-involving needs imaging (CTA or MRI)
Other indications for imaging
Non-resolving (presumed ischemic) CN palsy
Younger patients (< 50yo)
Value of a Tensilon test in MG
In older patients, consider GCA (ESR, CRP)
Amblyopia
• Decreased vision in eye from disuse of
eye during development (~before age
8)
• Causes include:
• Refractive error
• Strabismus
• Early detection is key
Strabismus
• Disruption of binocular vision
• Binocular fusion develops <4-6months
• Most common cause is accommodation
from hyperopia
• Rx with glasses
• Rx amblyopia with patching if
necessary
Cover/UnCover
• Tropia :
the eyes are turned all the
time.
• Hyper/Hypo/Exo/Eso
• Phorias:
eye deviations that are only
present some of the time eg .stress,
illness, fatigue, or when binocular
vision is interrupted.
Acute / Chronic
Visual Loss
• Red Eye
• Pupil Abnormalities
• Diplopia
• Amblyopia
•
•
•
•
•
Causes of Acute
Visual Loss
Cornea:
•
•
Surface disorders - eg. exposure kerathopathy, dry eye
Corneal Edema (Acute ACG, other corneal diseases)
Anterior Chamber:
•
Hemorrhage - eg. Neovascularization in Ischemia/Diabetes
Vitreous:
•
Hemorrhage from Ischemia/Diabetes
Retina:
•
Vascular-occlusive disease, macular degeneration, hemorrhage, retinal
detachment
Optic Nerve:
•
Temporal Arteritis / Giant Cell Arteritis vs non-arteritic anterior ischemic optic
neuropathy (NAION); Optic Neuritis; compressive lesions
Chronic Visual Loss
• Glaucoma
• Diabetic Retinopathy
• Age Related Macular Degeneration
• Cataract
Sample Questions
Case 1
• 28y.o. day care worker with 3 days of red
eye
•
•
•
•
•
•
•
•
•
Vision 20/25 OU
Pupils normal
Conjunctiva injected
Discharge clear
Cornea clear
AC deep and quiet
IOP 18
Preauricular node palpable
Hx: no contact lens use, recent URTI
Case 2
• 9 y.o. female complains of red eye for 1
week
• Vision 20/60 OD, 20/20 OSPupils smallConjunctiva: ciliary
• no preauricular node
• Hx: photophobia, recent limp
Case 3
• 68yo. male c/o of burning, foreign body
sensation in both eyes (OS>OD)
• vision: 20/25 OD, 20/30 OS
• conjunctival: injected
• discharge: tearing, discharge in the am
• cornea: debris on cornea, no fluorescein
staining
• AC / IOP / lymph nodes: unremarkable
• Hx: worse with new eye gtts recently
Case 4
•
A 43 female presents with 5 days of pain and redness in
her left eye. She has no discharge and conjunctival
chemosis. She has a history of rheumatoid arthritis.
Which of the following tests would you order next:
1. Conjunctival swabs
2. Corneal swabs
3. CBC, ANA, RF, ACE, and CXR
4. Ophthalmic slit lamp assessment
Case 5
•
A 42 female presents with 3 days of pain and redness in
her left eye. She reports halos in her vision and a dull
pain. Which of the following would be the next
appropriate steps:
1. Visual acuity
2. Slit lamp examination for the presence of anterior
chamber cell
3. Conjunctival swabs
4. Systemic investigations for connective tissues and
rheumatologic diseases
5. Intraocular pressure measurement
6. Dilated fundus examination
Case 6
•
A 44 male presents with 7 days of foreign body irritation
and blurry vision in his left eye following an unknown
foreign body in eye while working in machine shop.
Which of the following would be the next appropriate
steps:
1. Visual acuity
2. Slit lamp examination
3. Eversion of the upper eyelid
4. Conjunctival swab
5. CT orbits
6. Intraocular pressure measurement
7. Dilated fundus examination
Case 7
•
A 44 female with a history of 2 days of severe boring
pain in her right eye. presents with a red eye to the
clinic. She has a history of 5 days of discomfort in both
eyes. Vision is unaffected. On exam her eye looks as
follows. What is the appropriate initial treatment:
1. Oral steroids
2. Topical lubrication
3. Indomethacin 50mg po tid
4. Topical bacitracin and polymyxin B
5. Homatropine 1% 1 gtt tid
6. Topical antihistamines drops
Case 8
•
A 42 male presents with halos, intraocular pain and an
IOP of 65 with corneal edema. The next steps in
management of his condition would include which of the
following:
1. Slit lamp examination and fundoscopy
2. IV Mannitol
3. Topical levobunolol 0.5%
4. Topical pilocarpine 4%
5. Oral acetazolamide 500 bid for 7 days
6. Urgent ophthalmology referral
7. Topical prostaglandins drops
Case 9
•
A 43 male presents with a history of rheumatoid arthritis
presents with a red eye for 5 days self medicated with
topical steroids. Slit lamp examination shows a corneal
dendritic lesion with terminal bulbs and mild anterior
chamber inflammation. Treatment would include the
following:
1. Topical levobunolol 0.5%
2. Immediate ophthalmic referral
3. Topical steroid drops
4. Trifluoridine 1% 1gtt q2h
5. Valtrex 1g po tid
Case 10
•
A 45 male with presents with 7 days of foreign body
irritation and redness in her left eye following foreign
body in eye while working in machine shop. Which of
the following would be the next appropriate steps:
1. Visual acuity
2. Slit lamp examination
3. Eversion of the upper eyelid
4. Conjunctival swab
5. CT orbits
6. Intraocular pressure measurement
7. Dilated fundus examination
Case 11
•
A 4 day old male with presents profuse mucopurulent
discharge in both eyes. What is the management of this
patient?
1. Urgent ophthalmology consultation
2. Topical silver nitrate
3. Conjunctival gram stain
4. Conjunctival culture
5. Blood cultures
6. Cefotaxime 100–150 mg/kg/day IV or IM, 12 hourly
7. Dilated fundus examination
Case 12
•
A 64 year old male with a diffuse red eye, mild
discharge and pain in his right eye. His pupil is newly
dilated and fixed at 6mm and unresponsive to
pilocarpine 2%. What is the management of this patient?
1. Urgent Ophthalmology Consultation
2. Measurement of intraocular pressure
3. CT Angiogram or MRA/MRV of the head
4. ESR, CRP, and CBC
5. Dilated fundus examination
Case 13
•
An 76 year old male presents with complaint of double
vision. History of diabetes and high blood pressure. His
pupil are reactive and IOP is normal. What is the next
step in management of this patient?
1. Urgent CT head scan
2. Measurement of blood glucose, triglycerides, and
cholesterol
3. CT Angiogram or MRA/MRV of the head
4. ESR, CRP, and CBC
5. Patch affected eye
Case 14
•
A 2 month old child is noted to have a significantly large
esotropia. What is the most important next step the
physician should perform?
1. Detailed family history for strabismus or neoplasm
2. Doll’s eye manoeuvre
3. MRI of head +/- abdomen
4. Genetic testing
5. Examine old photo graphs
6. Reassurance