Optho Diseases

Allergic Conjunctivitis

Etio: spring and summer, bilateral, stringy discharge

Risk Factors: PMHx/FMHx of seasonal allergies, asthma, allergic rhinitis, atopic dermatitis

S&S: bilateral, Itching, tearing, redness, clear to white stringy discharge, sometimes photophobia, FB sensation, no fever

Complications: Vernal Keratoconjunctivitis

Tx: Cromolyn sodium 4% solution 1-2 drops/eye 4-6 day, cool compress, wash face/eyes after outside, wear eye protection, no contacts during tx

Vernal Keratoconjunctivitis

Etio: allergic conjunctivitis w/ cobblestone upper tarsal conjunctiva

Risk Factors: Chronic seasonal allergies

S&S: Watery mucoid discharge, FB sensation, itching, burning, no visual symptoms, large "cobblestone" papillae

Tx: Cromolyn sodium 4% solution, referral - ophthalmologist routinely, possible allergist if chronic allergies cannot be controlled, no contacts during tx

Bacterial Conjunctivitis

Etio: S. Aureus, S. Pneumoniae, H. Influenzae, M. Catarrhalis

Considerations: Gonorrhoeae conjunctivitis

S&S: sudden onset, mucopurulent discharge, FB sensation, no blurring of vision, mild discomfort, may be unilateral or bilateral

Tx: Erythromycin ophthalmic 0.5% ointment, warm compress, referral - ophthalmologist if not improved

Gonorrhoeae Conjunctivitis

Etio: Neisseria gonorrhoeae; contagious until cleared x48hrs

S&S: copious mucopurulent discharge, sudden onset, FB sensation, no blurring of vision, morning crust, mild discomfort, positive sexual hx of partner with STD/STI

Testing: STAT gram stain & culture if + report to PH, offer STI workup/preg test

Tx: NKDA: ceftriaxone 500 mg IM OR Ceftriaxone 1gm IM AND Doxy 100 mg BID x7 days OR Azithromycin 1 gm PO AND Bacitracin ophthalmic ointment q 3-4 hr x10 days, Penicillin allergy: Azithromycin 2mg PO AND Cipro 500mg PO, referral - ophthalmologist - urgent

Chlamydia Conjunctivitis

Etio: Chlamydia trachomatis, highly contagious, gradual onset 1-4 weeks, overcrowded public area, partner with STI

S&S: Redness clear to mucopurulent discharge, FB sensation, light sensitivity, no blurring of vision, possible mild discomfort, erythema, commonly pt has re-infections

Complications: epithelial keratitis, corneal neovascularization, palpebral conjunctivitis, corneal scarring, blindness

Testing: swab of discharge (culture) + report to PH, offer STI/preg test

Tx: NDKA: Azithromycin 1gm PA now AND Bacitracin opthalmic ointment, referral - ophthalmologist - urgent, wash eye w/ cloth

Contact Lens Conjunctivitis

Etio: fell asleep w/ contacts in, Pseudomonas aeruginosa (bacterial), halloween contact lens

S&S: FB sensation, no blurring of vision, mild discomfort

Testing: Fluorescein stain to r/o corneal abrasion or corneal ulcer

Tx: 1st line: Ciprofloxacin HCL 0.3% opthalmic solution 1 drop hourly q2hr night, referral - ophthalmology - urgent if corneal defect

Fungal Conjunctivitis

Etio: working near fungus or not cleaning contacts

S&S: Pain, redness, tearing, FB sensation

Testing: fluorescein stain to r/o abrasion or ulcer, fungal wet mount & culture

Tx: 1st line: Natamycin 5% ophthalmic solution 1 drop 4-6x daily x7 days, referral - ophthalmologist, change contacts

Viral (non herpetic) Conjunctivitis

Etio: Adenovirus; very contagious

Risk factors: contacts at school school, pools or public places

S&S: FB sensation, copious clear watery discharge, painful

Tx: no RX- self limiting, wash hands, don't rub eyes, F/U if symptoms turn to white discharge, ER if vision changes

Viral (COVID) Conjunctivitis

Etio: COVID

S&S: Acute conjunctivitis symptoms, redness, ocular irritation, eye soreness, FB sensation, watery discharge, eyelid swelling, congestion, chemosis

Tx: Still being studied, Tx COVID & emergency consult to ophthalmology

Viral (herpetic) Conjunctivitis

Etio: Herpes Simplex 1, very contagious

S&S: Pain, visual blurring, copious clear watery discharge, injection near limbus, FB sensation, photophobia, recurs proceeded w/ fever

Complications: corneal opacities, Herpes Zoster Ophthalmicus, corneal ulcer

Testing: Fluorescein stain with dendrites on cornea, offer STI panel

Tx: steroids are contraindicated, Trifluridine 1% opthalmic solution, systemic tx for HSV, no contacts, referral - Emergent

Herpetic Zoster Ophthalmicus

Etio: contagious, Varicella-zoster virus (VZV), CN V (Trigeminal)

Risk factors: Hx of varicella infection, >50 y/o, stress, immunosuppression

S&S: extremely painful, unilateral, photophobia, blurred vision, tearing/ocular redness; prodromal: fever, malaise, HA, eye pain prior to vesicles; Hutchinson signs: lesions on nose

Complications: vision loss, herpes zoster post, herpetic neuralgia

Testing: Tzanck smear or PCR, direct fluorescent antibody testing

Tx: IV Acyclovir 10mg/kg/dose OR Valacyclovir 1g TID, inpt admit to hospital; prevention: zoster vax, keep vesicles covered, don’t scratch

Keratoconjunctivitis Sicca (KCS) (Dry Eye Disease (DED))

Etio: autoimmune inflammatory disorder, likely hereditary

Risk Factors: PMHx/FMHx Sjogren's syndrome

S&S: chronic bilateral dry eyes and mouth

Testing: Schrirmer test x5 min

Tx: OTC artificial tears, referral- optho and rheumatology, avoid dry outdoor areas w/ polllutants/irritants, no contacts

Keratitis

Etio: viral, bacterial, fungal, or parasites

S&S: inflammation/ulceration of the cornea, FB sensation, red eye w/ PAIN, photophobia, corneal opacity

Tx: emergent consult to ophthalmologist

Pinguecula

Etio: common >35 yo, deposit of protein, fat, or calcium caused by aging

S&S: yellow bump/growth on conjunctiva of eye, rarely grows on cornea

Tx: no treatment; pt reassurance

Pterygium

Risk factors: associated w/ UV exposure; surfers, farmers, lawn care workers, construction workers; sand or dust exposure

S&S: triangular wedge on conjunctiva that crosses to cornea

Tx: no tx until it crosses the VA, referral to optho for routine following, prevention: wear eye protection

Corneal Abrasion

Etio: scratch of the surface of the cornea

Risk factors: contacts, trauma, or FB

Complications: Corneal ulcer

S&S: FB sensation, severe pain, photophobia, pt keeps eye closed

Testing: fluorescein stain w/ positive uptake (linear)

Tx: FB or trauma: Erythromycin ophthalmic 0.5% ointment, avoid bright lights, wear sunglass, no contacts

Corneal Ulcer

Etio: infected open sore or wound (Pseudomonas aeruginosa, M. Catarrhalis, and S. Aureus)

Risk factors: wears contacts overnight, corneal trauma

S&S: acute painful, red eye w/ corneal abnormality: circus-corneal injection, hazy cornea, photophobia, reduced vision, purulent or watery tearing

Testing: fluorescein stain + uptake (pooling)

Tx: 1st line: fluoroquinolones (levofloxacin 0.5% opthalmic solution), emergent optho referral, no contacts, DO NOT patch eye

UV Keratitis (actinic keratitis)

Etio: burns to the cornea, unaware of UV exposure until 6-12 hrs later

Risk factors: sunlamps, welding, skiing, "snow blindness", looking into solar eclipse

S&S: severe pain, severe photophobia

Testing: fluorescein: diffuse punctate staining to both cornea

Tx: emergent consult ophthalmologist, both eyes may have to be patched for 24-48 hrs

Dacryocystitis

Etio: S. Aureus, infection of lacrimal sac

S&S: unilateral pain & swelling, tenderness, redness, purulent discharge

Complications: Orbital cellulitis

Tx: emergent referral to optho; surgery

Nontraumatic Cataracts

Etio: common >60 yo, leading causes of blindness

Risk factors: aging, DM, steroid use, statin use, sunlight, smoking

S&S: gradually progressive blurred vision, no pain/redness, usually bilateral, lens opacification (thickening), glare with lights

Testing: Early: dilated eye exam w/ ophthalmoscope, Late: no red reflex and white pupil

Tx: surgery, annual eye exam, stop smoking, control DM, check HLD regularly

Traumatic Cataracts

Etio: younger ppl, secondary to blunt or penetrating ocular trauma, infrared energy, electric shock, ionizing radiation

S&S: may cause blindness, blurred vision - may present as acute, subacute, or late sequela of ocular trauma

Testing: dilated eye with slit lamp

Tx: emergent referral to optho; surgery, prevent injury

Anterior Blepharitis

Etio: chronic bilateral inflammatory condition of lid margins, infectious: S. Aureus or seborrheic (oil)

S&S: burning, irritation, itching, "red-rimmed" eyes with scales or granulation clinging to lashes, crusting

Complications: recurrent conjunctivitis, hordeolum, chalazion, abnormal lid/lash position

Tx: 1st line: warm compress daily, diluted baby shampoo BID, Erythromycin ophthalmic 0.5% ointment

Age-Related Macular Degeneration (ARMD)

Definition: The leading cause of permanent visual loss in the older population, usually affecting both eyes

S&S: hazy vision, difficulty seeing when going from bright to low light, blank or blurry spot in central vision, drusen on exam, no pain, no redness

Risk Factors: Age >50, smoking, obesity, DM, eye trauma, genetic, HTN, farsightedness, light iris color

Complications: blindness

Tx & Management: May be reduced by oral Tx with: antioxidants Vit. C & E, minerals Zn & Cu, carotenoids: Lutein & Zeaxanthin from vegetables

Pharmacological: Ranibizumab (Lucentis) - blocks growth of abnormal blood vessels in the back of the eye, injected directly into the eye

dry age-related macular degeneration (ARMD)

Etio: slow breakdown of light-sensitive cells (photoreceptors) in the retina, damages center of retina (macula→allows vision of fine details @ central vision), leading cause of permanent vision loss (elderly), bilateral deterioration of central vision (late stage = geographical)

Risks: smoking, obesity, DM, HTN, blue eyes, CV dx, farsighted

Complications: blindness

S&S: many small/large Drusen, yellow deposits under retina, hazy spot in central vision, difficulty adjusting bright → low light

Tx: Vit C & E, zinc, Cu, lutein & zeaxanthin

wet (neovascular) age-related macular degeneration

Etio: abnormal blood vessels grow under the retina, causing scarring, SUDDEN vision loss, damages center of retina (macula→allows vision of fine details @ central vision), leading cause of permanent vision loss (elderly), bilateral deterioration of central vision

Risks: smoking, obesity, DM, HTN, blue eyes, CV dx, farsighted

Complications: blindness

S&S: many small/large Drusen, yellow deposits under retina, hazy spot in central vision, difficulty adjusting bright → low light

Tx: Vit C & E, zinc, Cu, lutein & zeaxanthin

Retinal Detachment

Etio: "curtain" spread across visual fields

Risk Factors: >50 years old, recent cataract surgery, blunt/penetrating trauma

S&S: Rapid loss of vision in one eye, no pain or redness, central vision intact until macula becomes detached

Testing: Ophthalmoscopy - vitreous looks like a grey cloud

Tx: emergent consult to ophthalmology, transport with head position so that gravity will cause retina to fall back

Retinopathy of cytomegalovirus

Etio: CMV that causes death of cells in the retina, CMV occurs when immune system is down

Risk factors: pt with transplants or is immunocompromised

S&S: yellow-white patches

Testing: CD4 < 50 mcL

Referral: emergent consult ophthalmologist and infectious disease

Diabetic retinopathy

Risk Factors: DM patient w/retinal changes w/ or w/o vision loss, any age, leading cause of blindness in the world

S&S: nonproliferative: cotton wool spots, hard exudates (yellowish)

proliferative: neovascularization, vitreous hemorrhage, possible retinal detachment

Complications: Cataracts & Blindness

Tx: must have annual eye exam w/ fundoscopic exam every visit, PCP control DM, HTN, hyperlipidemia, preserve renal function, vision change = emergent

HIV Retinopathy

Etio: positive HIV test

S&S: cotton wool spots

Complications: CMV & blindness

Tx: Urgent consult ophthalmologist & infection control

Hypertension Retinopathy

Risk factors: HTN & severe HTN, pheochromocytoma, preeclampsia

S&S: AV nicking, flame hemorrhage, copper/silver wire, papilledema, cotton wool spots, hard exudates, opaque arterial wall

Complications: Blindness

Tx: severe = emergent cardiology & ophthalmology consults, chronic = control HTN, annual eye exam

Sickle Cell Retinopathy

Risk Factors: Sickle Cell Disease

S&S: fundoscopic sea fan, salmon patches or black sunburst

Tx: Prevent sickle crisis, emergent consult ophthalmologist

Retinoblastoma

Etio: most common eye tumor in children, 90% present before 5 yo, bilateral usually <1 yo, FHx: genetic abnormality

S&S: leukocoria, strabismus, retinal mass, genetic abnormality of RB1 tumor suppressor gene, may see neurological signs

Testing: CT shows intraocular tumor

Tx: refer to children’s tertiary cancer center

Rhabdomyosarcoma

Etio: rare tumor, children

S&S: unilateral proptosis, lid edema, vision loss, nontender mass

Testing: CT usually shows boney involvement, complete work-up for metastases

Tx: urgent consult pediatric ophthalmologist & oncologist

Blowout Orbital Fracture

Etio: traumatic deformity of orbital floor or medial wall, Hx significant blunt trauma

S&S: pain occurs w/ eye movement, diplopia, swelling, enophthalmos, point tenderness, numbness of upper lip/cheek, EOMs restricted

Diagnostic Studies: immediate CT Scan, must r/o ruptured eye (positive Seidel's sign)

Tx: 1st line: Augmentin 600 mg IV or 875 mg BID, OR Azithromycin 500 mg or 1g IV, emergent consult to ophthalmology

Chemical Eye Injury

Risk Factors: working with chemicals, irritants such as household bleach, agricultural pesticides or gas, industrial, mechanics - battery acid, etc.

S&S: photophobia, severe pain, tearing, conjunctival hyperemia, subconjunctival hemorrhage, opacification

Tx & Management: consult and f/u with optho, copious irrigation w/ sterile NS first, wear protective gear

Foreign Body

Risk Factors: work-construction, gardening, mechanics, attics, cleaning crew

Complications: corneal abrasion/ulcer, possible globe rupture

S&S: FB sensation, pain, redness

Testing: fluorescein stain to r/o abrasion

Tx: remove FB w/cotton swab, Erythromycin 0.5% ointment 4-6x times daily until 48 hours after healed

Globe Rupture

Etio: blunt penetrating trauma causing laceration of globe

S&S: Severe pain, decreased VA, tear in cornea

Tx: emergent referral, avoid putting drops into eye, avoid removing any objects; PAIN: IV morphine 0.1 mg/kg, NO NSAIDS, lorazepam 0.05 mg/kg, tetanus prophylaxis

Hyphema

Etio: trauma, blood in anterior chamber

S&S: pain, redness, blood in ant. chamber

Complications: immediate threat to vision, pt's with sickle cell and blood dyscrasias have an increased risk of vision loss, glaucoma

Tx: emergent ophtho consult; NO NSAIDS, Cycloplegic drops x3/day, eye shield, dim lighting, elevate head of the bed, monitor IOP, avoid trauma & heavy lifting

Subconjunctival Hemorrhage

Etio: blood between the sclera and conjunctiva

Risk Factors: childbirth, coughing, vomiting, uncontrolled HTN & DM, blunt trauma, anticoagulation therapy

Tx: resolves by itself in 2-4 weeks

Acute Uveitis (iritis)

Etio: uvea is vascular middle layer of eye, inflamed, hypopyon: leukocytic exudate in ant. chamber

S&S: Anterior: eye pain, marked photophobia, blurred vision, red eye, myosis

Posterior: only with blurred vision and red eye

Tx: tx based on the cause **LOTS of conditions associated with this, emergent referral to optho

Central Retinal Artery Occlusion

Etio: sudden monocular loss of vision

Risk Factors: >50 y/o, DM, HLD, HTN, OC, AFIB, emboli

S&S: cherry-red spot near macula, "Box-car" segmentation

Testing: r/o giant cell arthritis via ESR, DM screen, lipids, cardiac screen

Tx: giant cell= high dose steroids and possible temporal artery bx, cardiac= tx underlying cause

Central Retinal Vein Occlusion

Etio: sudden monocular loss of vision

Risk Factors: DM, HLD, OC, smoking, glaucoma

S&S: no pain, no redness, "blood and thunder" retina, neovascularization

Tx: emergent consult to ophtho → prevent retinal detachment, PCP tx underlying cause

Vitreous Hemorrhage

Etio: sudden loss of vision

Risk Factors: retinal tears, retinal detachment, DM, sickle cell, blood dyscrasias, trauma, ARMD

S&S: floaters

Tx: emergent consult to ophtho

Amaurosis Fugax (ocular TIA)

Etio: Abrupt monocular loss of vision (partial or complete) that lasts only a few minutes, caused by an emboli if vascular

Risk Factors: DM, HTN, hyperlipidemia, giant cell arteritis, migraine

Complications: central retinal artery occlusion, stroke

Testing: complete ocular, cardiac, and neuro exam

Tx: tx underlying cause

Amblyopia

Etio: most common cause of pediatric visual impairment, strabismic (misalignment) and refractive (>2 line difference)

Risk Factors: premature, small size for gestational age, 1st degree relative with amblyopia, neurodevelopmental delay

S&S: reduction in visual acuity, >2-line differences between eyes, usually unilaterally

Tx: pediatric ophtho, tx cause

Chronic (Primary) Open-Angle Glaucoma

Etio: caused by obstruction to drainage of aqueous humor, preventable blindness; almost always follows a lesion of anterior eye segment

Risk Factors: >40 y/o, DM, steroid use

S&S: Elevated IOP, progressive loss of visual fields (usually bilaterally), pathologic cupping of optic disc (>0.5)

Diagnostic studies: IOP > 22

Tx: timolol 0.25%, diet modification, no smoking, decrease caffeine, avoid B blockers

Acute Closed-Angle Glaucoma

Etio: caused by obstruction to drainage of aqueous humor, preventable blindness; almost always follows a lesion of anterior eye segment

Risk Factors: drugs, some medications, cocaine, cocaine, ecstasy, trauma

S&S: sudden onset of severe pain, steamy cornea, fixed mid-dilated pupil, halos, blurred vision, nausea/vomiting, shallow anterior chamber

Testing: IOP > 22

Tx: Timolol 0.5%, emergent consult to ophtho

Scleritis

Etio: inflammatory & autoimmune process involving the sclera

Risk Factors: Rheumatoid arthritis, Wegener's Granulomatosis

S&S: painful, local tenderness, sclera edema, potentially blinding

Tx: NSAIDS (indomethacin 25-75 mg PO TID), consider glucocorticoids (prednisone), emergent consult to ophtho, urgent consult to rheum

Strabismus

Etio: eye deviation from anatomical position - tropia

Risk factors: FMHx, low birth weight, Down's syndrome, cerebral palsy

S&S: diplopia, slit images, HA, n/v; Congenital: poor central vision, retinoblastoma, trauma w. CN palsies; Acquired: intracranial hemorrhage, abscess, encephalitis, measles, fracture, tumor

Testing: MRI and CT (standard of care), CBC w/ diff

Tx: referral ophtho, tx based on cause

Posterior Blepharitis

Etio: chronic bilateral inflammation of meibomian glands, commonly S. Aureus

S&S: hyperemic lids w/ telangiectasias, tears may be frothy or greasy

Complications: recurrent conjunctivitis, hordeolum, chalazion, abnormal lid/lash position

Tx: 1st line: Erythromycin 0.5% ointments applied to lid margins QHS x2 weeks, warm compresses

Ectropion

Etio: muscle weakness, facial paralysis, scars, surgeries, eyelid growths, genetic

S&S: lower lid turns OUTward, older adults, lower eyelid is more commonly affected, excessive tearing, dry eye, saggy eyelid

Complications: Corneal irritation, dryness, abrasions, ulcers

Tx: artificial tears, wear sunglasses, avoid contacts, surgery, ophto referral

Entropion

Etio: infection, irritation, inflamamtion, previous surgeries, congenital origins -trichiasis

Definition: advanced age, FB sensation, inward turning of the lower eyelid, eyelashes directly posterior, causes corneal & conjunctival damage due to lash rub

Complications: corneal abrasions/scarring, corneal thinning, conjunctivitis, no treated → vision loss

Tx: directed at specific etiology, artificial tears, contact-lenses to protect eye, botulinum toxin, refer to optho if no improvement

Hordeolum (Stye)

Internum: Obstruction/Infection of meibomian gland on the tarsal conjunctiva (posterior eyelid); S Aureus most common cause

Externum: Common, results from infection of a har follicle or glands of Zeis at the eyelid margin

S&S: Painful, erythematous, diffuse swelling and severe erythema, develops rapidly, tender to palpation

Risk Factors: blepharitis, eyeliner, seb derm, rosacea, DM, HLD

Tx: promote drainage, 1st line: warm compresses 2nd line: Erythromycin 0.5% ointment, bacitracin ointment, OR sulfacetamide sodium drops 1-2 drops every 1-3 hrs, I&D, excisions of eyelash

Chalazion

Etio: obstruction of meibomian gland

Risk Factors: Blepharitis, rosacea, seborrheic dermatitis, hordeolum

S&S: localized, nontender, non painful, usually upper lid, chronic lipogranulomatous inflammation of lid

Tx: warm compresses to promote drainage, referral to ophtho for steroid injection, excision

Xanthelasma

S&S: yellow lesions on eyelids, pts >50, skin lesions asymptomatic

Risk Factors: hyperlipidemia

Complications: atherosclerotic heart disease

Tx: lipid panel, laser excision, topical trichloroacetic acid, referral to ophtho & PCP

Nystagmus

Etio: rhythmic regular oscillation of the eye (horizontal, vertical, circular); Jerk - slow drift of eyes in one direction, repeatedly corrected with fast movement in reverse direction

Risk Factors: side effect of Rx, ETOH, infarct, demyelination, neoplasms, hydrocephalus

S&S: eye movement, blurred vision

Diagnostic Studies: MRI, r/o mass, check serum B 12 & magnesium, HIV

Referral: consult neurosurgeon, tx depends on cause

Optic Neuritis

Etio: acute inflammatory demyelination of the optic nerve

Risk Factors: MS, hypoparathyroidism

S&S: unilateral central visual loss, pain with eye movement, pain w/ eye movement, decrease in color vision, visual field defects

Tx & Management: admit to hospital, emergent consult ophtho/neurologist/endocrinologist, IV methylprednisone x3 days, then oral tapered dose of steroids

CN III Paralysis

Etio: sudden dysfunction of muscles associated with CN III; subarachnoid hemorrhage, midbrain lesions, intracranial aneurysm, ischemia, trauma

S&S: diplopia, ptosis (droopy eyelid), headache “worst of my life” → subarachnoid hemorrhage

Testing: MRI to r/o lesion, contrast enhanced MRI or CTA to r/o aneurysm, non contrast CT, then LP to r/o meningitis

Tx: admit to hospital, emergent consult to neurosurgeon

CN IV Paralysis

Etio: due to lesion

S&S: diplopia, lack of SO4 movement

Testing: MRI to r/o lesion

Tx: Emergent consult neurosurgeon

CN VI Paralysis

Etio: due to lesion, uni or bilateral

S&S: diplopia, lack of LR6 movement

Testing: MRI r/o lesion

Referral: emergent consult neurosurgeon

Papilledema

Etio: disc swelling, due to severe HTN, increased intracranial pressure, usually bilaterally

S&S: headache, nausea, vomiting, ± vision changes

Complications: vision loss

Testing: fundoscopic exam

Tx: admit to hospital, control causation, control BP

Anterior Periorbital Cellulitis

Etio: infection of the anterior portion of the eyelid, S. aureus or S. pneumo

Risk Factors: recent sinusitis, insect bite, local trauma

S&S: unilateral pain, redness, eyelid swelling

Testing: contrast enhanced CT of orbits and sinus

Tx: Augmentin 875 mg PO BID 5-7 days OR Augmenting 875mg PO AND Bactrim DS PO BID OR Clindamycin 300 mg PO TID, no improvement → IV Abx

Posterior Orbital Cellulitis

Etio: infection of the posterior orbit, S. pneumo, H. influenzae, M. caratthalis, S. aureus

Risk Factors: rhinosinusitis, dacrocystitis, teeth infection, middle ear infection

S&S: unilateral proptosis, swelling, pain with eye movement, redness, edema, diplopia, vision loss

Diagnostic Studies: contrast enhanced CT

Complications: abscess, loss of vision, death if untreated

Tx: IV Vancomycin w/ IV ceftriaxone or IV cipro, then discharged on clindamycin 300 mg PO TID or Bactrim DS PO BID plus Augmentin PO BID 2-3 weeks, admit to hospital, emergent referral to ophthot,

Thyroid Eye Disease

Risk Factors: Graves dz - hyperthyroidism

S&S: bilateral proptosis, exophthalmos, lid lag, stare, +/- enlarged thyroid

Testing: labs FSH,FT4

Tx: Tx thyroid disease, consult endocrinologist

Arygyll Robertson Pupil

Etio: near sight dissociation, Treponema pallidum, neurosyphilis → meningitis

S&S: bilateral small pupils, constrict on accommodation, do not constrict when exposed to bright light

Testing: lumbar puncture

Tx: report neurosyphilis, IV abx for 10-14 days