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Download B2B Ophthalmology Toren Mar 29 2011
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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