Eye Complaints & Evaluation (Exam 3)

Visual Acuity PE

-Do each eye individually (OD, OS)

-Recorded as 20/___

-Best done with glasses

Pupils PE

-Important if suspecting a neurologic problem

-Checking:

-Size of each in bright & dim light

-Response to light

-Response to near

-Marcus Gun Swinging flashlight test: Assess for afferent pupillary defect (presence indicates difference between 2 eyes)

Extraocular Motilities PE

-Important if there is a complain of diplopia

-Perform H motility test to determine if there is a specific EOM that is affected

Eye Alignment PE

-Have pt look at light that is equally projected between 2 eyes

-Look for symmetry at the reflected reflex on cornea

-If reflex is temporal: Esotropic

-If reflex is nasal: Exotropic

Palpating Pre-Auricular Lymph Nodes PE

-Important with complaint of conjunctivitis

-(+) indicates viral conjunctivitis

Intraocular Pressure (IOP) PE

-Helpful if considering pt is in acute angle closure

-Tactile pressure

-Tonopen: Anesthetic; tap center of cornea until IOP is measured; Looking for IOP of -21mmHg or less

Slit Lamp Biomicroscopy

-Allows for increased magnification

-More specific location of lesions/abnormalities

Gross Inspection PE

-Make sure to pull eyelids up/down

-pt look in all directions

Corneal Fluorescein (FI)

-Will pool in areas of corneal defects

Posterior Segment Assessment

-Can be dilated or undilated

-Direct Ophthalmoscopy (DO)

-Optic Nerve Head: Flat, elevated, blurred disc margins, C/D ration

-Retina: Presence of blood, exudates, or other abnormalities

Red Eye Differentiation

Subconjunctival Hemorrhage

-Unilateral, pain-less red eye, usually sectoral

-Blood beneath conjunctiva, may have chemotic appearance

-Etiology: Valsalva; bleeding disorder; antiplatelet meds (Aspirin, Clopidogrel, warfarin, plavix- DO NOT advise to stop using)

-Typically, self-resolves within couple weeks

Dry Eye Syndrome

-Multifactorial disease of tears and ocular surface

-Eye discomfort, visual disturbance & tear film instability

-Etiologies: Evaporative (MC) tear evaporate too quikcly; & Aqueous Deficient is lack of production from lacrimal gland

-Dryness, mild pain, foreign body sensation, redness

-Signs: Injection/hyperemia, lid disease, debris in tear film

-TX: refer to eyecare for chronic management

Episcleritis

-Sectoral redness, unilateral

-Mild irritation, discomfort, prickly sensation in eye

-Does not cause change in vision

-Progressing cases can indicate collagen-vascular disease

-Refer to ECP for TX & management

Bacterial Conjunctivitis

-Unilateral with variable colored discharge

-Signs/SX: Unilateral red eye with white/green discharge

-TX: Topical ABX, refer to ECP

Simple Bacterial Conjunctivitis MC Cause

-S. Aureus

Gonococcal Conjunctivitis MC Cause

-N. Gonorrhea

-Hyperacute onset, severe discharge, pre-auricular lymphadenopathy

-Ask about urethral discharge

Chlamydia/Inclusion Conjunctivitis

-Unilateral, chronic red with marked inferior follicles

-Trachoma Serotypes A-C; Adult inclusion is D-K

-Usually dx of exclusion

-TX: 1g azithromycin PO

-Management: STI panel, refer to ID

Allergic Conjunctivitis

-Bilateral presentation, IgE mediated by allergens

-SX: itching, tearing, redness

-Signs: bilateral red eyes with watery discharge, may have mild chemosis

-Worse in Spring/Summer

-TX Cold compress, mast cell stabilizer/Antihistamines; refer to ECP

Adenovirus Conjunctivitis

-Bilateral, asymmetric, conjunctivitis

-MC viral conjunctivitis presentation

-MC URI transmission

-SX: FBS, tearing, red eyes one eye worse than other

-Signs: Red eyes, watery discharge, NO lymphadenopathy

-Self-limiting condition

-TX: supportive therapy, patient education, refer to ECP

Epidemic Keratoconjunctivitis

-Bilateral, symmetric presentation

-More common in adults

-SX: profuse watery discharge, periorbital pain

-Signs: Bilateral red eyes with serous discharge, pre-auricular adenopathy, pseudomembranes, or subepithelial infiltrates

-TX: Refer to ECP for pseudomembrane peeling, pt education about contagiousness

Anterior Uveitis

-Unilateral or Bilateral

-Non-granulomatous vs granulomatous

-SX: red eye, ocular pain, photophobia

-Signs: Cell and flare in anterior chamber; need slit lamp to see; may have hypopyon

-Can be sign of infectious/autoimmune process

-TX: Topical Steroid q1h, Cycloplegic BID, refer to ECP

Acute Angle Closure

-Unilateral in older pts due to closure of drainage system

-SX: red eye with pain, blurred vision, may have headache/vomiting

-Signs: Pupil rxns is sluggish, hazy cornea, elevated IOP>30 mmHg

-TX: Refer to ECP STAT for Laser Peripheral Iridotomy (LPI)

Corneal Abrasion

-Unilateral

-Hx of injury to eye

-SX: intense ocular pain, redness, photophobia, tearing that follows injury to eye

-Signs: redness, epithelial defect that stains FI

-TX: prophylactic topical abx BID, refer to ECP next day for monitoring

Traumatic Uveitis

-Unilateral

-Usually present after insult/injury to eye

-SX: red, dull/achy eye

-Signs: red eye with anterior chamber rxn- must be observed with slit lamp

-Etiology: Traumatic compromise of blood-aqueous barrier

-R/o orbital drop-off, EOM entrapment

-TX: Long-acting cycloplegics, topical steroids, refer to ECP

Myopia Nearsightedness

-Reduced vision at distance

-Good vision at near

Hyperopia- Farsightedness

-Lower amount are asymptomatic

-Vision worse at near than distance

Astigmatism

-Eye shaped like a football not soccer ball

-Lower amounts are asymptomatic, vision worse at distance & near with higher amounts

Corneal Scars

-Pt has predisposed condition to corneal scarring or previous infection

-Can be bilateral/unilateral based on etiology

-Glasses/Contact lenses will only correct up to point

Cataracts

-Older pts, bilaterally

-Gradual onset

-Extraction may be indicated if affecting ADL's

Vitreous Hemorrhage

-Sudden onset, painless blurred vision in one eye

-Poor control of DM

-Will not be able to evaluate fundus with DO

-TX: URGENT referral to ECP STAT referral to retinal specialist

Retinal Detachment (RD)

-Sudden, painless loss of vision in one or more quadrants

-May report a veil in vision, flashes of light

-Associated with nearsightedness

-Macula-off visually worse than Macula-on

-TX: URGENT referral to ECP STAT referral to retinal specialist

Central Retinal Vein Occlusion (CRVO)

-Sudden, painless blurred vision in one eye

-Associated with HTN

-See "Blood and thunder" on DO

-TX: URGENT referral to ECP STAT referral to retinal specialist

Diabetic Retinopathy

-Gradual change to vision bilaterally

-Hx of DM for many years

-May see blood, exudates, areas of ischemia with DO

-TX: URGENT referral to ECP

Age Related Macular Degeneration (ARMD)

-Gradual change to vision bilaterally

-Wavy vision or central missing spot in vision

-May see drusen in macular region with DO

-TX: URGENT referral to ECP

Glaucoma

-Gradual painless change to vision

-Unilateral or Bilateral

-Hx of being on glaucoma eye drops/surgies

-Will see large cup-to-disc ration on DO

-TX: Urgent referral to ECP

Optic Neuritis

-Sudden, painful change to vision unilaterally

-Younger patient, female>male

-Pain with H-motility testing

-May not see any abnormalities on DO of Optic Nerve

-TX: EMERGENT referral to ECP

Arteritic Ischemic Optic Neuropathy

-Sudden, painful change to vision unilaterally

-Older pt>60 yo

-Jaw claudication, scalp tenderness, malaise

-Swollen optic nerve head

-TX: EMERGENT referral to ECP

Central Retinal Artery Occlusion (CRAO)

-Sudden, painless LOV unilaterally

-Hx of HTN

-Associated with Giant cell arteritis

-Retinal Whitening with cherry red spot (macula)

-TX: EMERGENT referral to ECP/ED

Visual Field Defects

-H/O CVA

-End-stage Glaucoma

-Chronic, longstanding vision loss, typically bilaterally

-Mya have mobility issues

-TX: Urgent referral to ECP

Strabismus

-Ocular misalignment where one eye is fixating

-Other eye is deviating

Strabismus in Children

-Starts as intermittent; may progress to constant

-Parent will report eye turn if questioned

-Child may close an eye (Diplopia)

-Emphasis on Hirschberg Test

-TX: Refer to EPC

Adult Onset Strabismus

-May be neurologic

-Diplopia

-Emphasis on H-motility test to isolate muscles

-TX: Urgent referral to ECP

Exophthlamos

-Eye bulging forward from orbit

-Thyroid eye disease: MC etiology

-Have pt tilt head back

Unilateral Exophthlamos

-Acute onset without thyroid disease

-TX: EMERGENT referral to ECP/ED if:

-Resistance to retropulsion

-Ipsilateral APD

-Restrcited EOM

-Eyelid swelling

-Fever

Bilateral Exophthlamos

-Acute onset with/without hx of thyroid disease

-Urgent if: Restricted EOM

-TX: EMERGENT referral if: APD (in either eye)

Papilledema

-Bilateral Optic Nerve head swelling secondary to increased intracranial pressure

-SX: chronic headaches that worsen with postural changes, pulsatile tinnitus, dimming vision, horizontal diplopia

-Signs: Difficulty with looking to right & left with H-motility test, bilateral swollen/elevated optic disc margins with DO

-Etiologies: Anything that occupies space within the cranium

-TX: EMERGENTLY to ECP/Ed