Wills Eye Manual

Transient vision loss

-few seconds: papilledema (bi)

-few minutes: amaurosis fugax (uni)

-vertebrobasilar artery insufficiency (bi)

Monocular double vision

-SRx

-corneal issue

-cataract

-iris defect

Binocular double vision

-palsy

-MG if intermittent

-TED, IOI, CS issue

-CI

-INO

-decompensated phoria

Ophthalmia neonatorum

A purulent inflammation (conjunctivitis) of the cornea in the newborn due to gonorrhea/ chlamydia/ HSV

Blood in schlemm's canal on gonio

-compression of episcleral vells

-sturge-weber

-CCF

-hypotony

Myxedema

hypothyroid

Enlarged corneal nerves

-multiple endocrine neoplasia type IIb

-acanthamoeba

-KCN

-fuchs

Pannus

superficial vascularization of the cornea

-ocular rosacea, phlyctenule, chlamydia, SLK, staph HS, vernal KJS, herpes, burn

Symblepharon

-OCP

-SJS

-burn, trauma, drugs

-long standing inflammation

-EPK

-AKC

Bull's eye macular lesion

-ARMD

-stargardt/ fundus flavimaculatus

-albinism

-cone, rod-cone dystrophy

-chloroquine retinopathy

Choroidal folds

tumor, IOI, TED, post. scleritis, hypotony, RD, hella hyperopia, papilledema

Purtscher retinopathy

results from chest trauma

-hemes and CWS

Disc collaterals

-previous CRVO

-tumor

-chronic papilledema or POAG

Roth spot

-retinal hemorrhages with white centers

-DM, leukemia, anemia

Periphlebitis

sheathing of retinal veins

-syphilis, sarcoid, pars planitis, sickle cell

If involved iris is lighter than normal

Horners, Fuchs, chronic uveitis

Lenticonus

-anterior: convex, Alport syndrome

2. Posterior (concave): idio

Paradoxical pupillary reaction (dilates in light)

congenital stationary night blindness, achromatopsia, ON hypoplasia, Leber's, Best, optic neuritis, RP, albinism, optic atrophy

EOM thickening on imaging

TED or IOI

Medications causing myopia

miotic drops, sulfa drugs, tetracycline

Altitudinal defect

BRAO, BRVO, optic neuritis, NAION

If IOP elevated after chemical burn

oral CAI

Chemical burn follow up

daily then every few days until epi defect is healed

Superglue/ cyanoacrylate

-gentle traction

-fine forceps

-irrigate with saline, warm compresses, ointment

If abrasion in CL wearer

must have anti-pseudomonal coverage (ie. FQL)

-gram negative

Conjunctival laceration follow up

1 week

Traumatic iritis follow up

5-7 days

-tx: cyclo and steroid

-1m after trauma: gonio for angle recession and BIO for RDs

If increased IOP with traumatic hyphema

-nonsickle cell: beta blocker, if needed add alpha agonist or CAI

-sickle cell: beta blocker

Traumatic microhyphema follow up

-3 days then at 1 week

-IOP >25 then daily for 3 days

Cyclodialysis

disinsertion of CB from SS= increased US outflow- hypotony (if hypotony then atropine BID and steroids), glaucoma can also develop

Orbital blowout fracture

-check pupils and color vision to rule out traumatic optic neuropathy

-tx: oral abs, nasal decongestants for 3 days, ice

-follow up: 1-2 weeks

Traumatic optic neuropathy

-APD, decreased color vision, VF defect, decreased VA

-posterior TON: ON looks normal

-anterior TON: disc avulsion (red)

-vitreous H is common

Partial thickness corneal laceration tx

cyclo, ab

Berlin's edema

commotio retinae in the posterior pole

CNVM tx

#1: anti-vegf

others: PDT, photocoagulation (extra-foveal)

Chorioretinitis Sclopetaria

-visual loss, h/o missile injury to orbit

-retinal and choroidal rupture and necrosis, lots of blood

-CT

-DFE every 2-4 weeks until blood clears, looking for RD until atrophic scar replaces H areas

Purtscher's retinopathy

-sudden decreased vision

-h/o chest injury

-CWS, H, usually bilateral

-lesions resolve over a few months

-VA stays semi reduced

Shaken baby syndrome

-abusive head trauma

-retinal H, multilayered

Acute RCE tx

cyclo TID, ab qid, BCL or pressure patch

-never patch a CL wearer

Good for chronic dry eye

cyclosporine

Thygeson's follow up

-weekly during exacerbation, then every 3-6m

-if topical steroids, every 4-12 weeks for IOP check

Inflamed pterygium tx

-mild: artificial tears

-moderate: midl steroid, NSAID or antihistamine/ MCS

Bacterial keratitis

infiltrate with epi defect (think ulcer)

includes: fungal, acanthamoeba, HSV, ulcers, staph HS

If vision threatening ulcer

start with FQL and polymyxin B/ trimethoprim until can get fortified tobra or gentamicin with cefazolin or vancomycin

Pseudodendrites

acanthamoeba or HZO

Crystalline keratopathy

-decreased corneal sensation, vision, photophobia

-crystals subepi or stromal cornea

-etio: Schnyder dystrophy- do lipid profile or infectious CK (grafts and chronically inflamed corneas- strep viridans)

Neurotrophic ulcer

sterile (associated with decreased corneal sensation)

HSV skin lesions tx

bacitracin or erythromycin ointment BID

With antivirals

be careful in those with renal issues

Varicella zoster virus (chicken pox)

-conjunctivitis with vesicles at limbus/ lid

-pseudodendrites

-cool compresses and ab ointment (erythromycin TID)

IK

-congenital or acquired syphilis, HSV/VZV, TB

-stromal BVs and edema

-tx: cyclo, topical steroid

-f/u: 3-7 days then 2-4 weeks

Doxycycline

-has anti-inflammatory effect on sebaceous glands and anti-bacterial action

-MMP inhibition

Staph HS follow up

2-7 days

-if episodes recur despite eyelid hygiene, give doxy

Phylctenulosis follow up

several days, healing occurs at 10-14 day period

-taper steroid, keep ab ointment always

-oral abs for 3-6m

GPC follow up

2-4 weeks

Peripheral corneal thinning ddx

-CT disease

-Terrien's

-Mooren ulcer (hep C)

-Pellucid marginal degeneration

-tx: ab ointment, oral steroids

KCN is associated with

Down syndrome, atopic disease, Turners, Lebers, mitral valve prolapse, RP, Marfans

Corneal hydrops tx

cyclo, ab ointment QID, brimonidine, NaCl ointment BID

Meesman dystrophy

retro shows epi vesicles

Congenital hereditary endothelial dystrophy

bilateral corneal edema, normal IOP, no guttae at birth, AR

Fuchs tx and f/u

NaCl QID and ointment QHS, see every 3-12m to check IOP and edema

Bullous keratopathy

-h/o cx sx

-corneal edema, similar to Fuch's

-NaCl qid and qhs, reduce IOP

-ruptured bullae: ab ointment and cyclo

Corneal graft rejection

-keratic precipitates on endo

-Khodadoust line: endo rejection line

-Krachmer spots: subepi infiltrates

-epi rejection line (elevated)

-stromal neo

-tx: topical steroids q1h or systemic steroids

-f/u: 3-7 days

PAL

-HSV

-chlamydia

-adenovirus

-gonorrhea

Viral conjunctivitis follow up

2-3 weeks, sooner if it worsens or you px steroids

Allergic conjunctivitis follow up

2 weeks

H. influenzae conjunctivitis tx

oral amoxicillin/ clavulanic acid

bacterial conjunctivitis follow up

2-3 days then 1 week until resolved

Chronic conjunctivitis (>4 weeks) differentials

-chlamydia, molluscum, toxic, microsporidial

Chlamydial conjunctivitis tx and f/u

-1g azithromycin OR doxy 100mg BID, erythro 500mg QID for 7 days

-topical erythro or tetracycline ointment BID for 2 weeks

-f/u: 2-3 weeks

Trachoma MacCallan classification

Stage 1: superior tarsal follicles, SPk, pannus, tender PAL, purulent discharge

2: SEIs, limbal follicles, papillae

3: follicles, scarring of sup. tarsal conj

4: no follicles, hella conj. scarring

World Health Organization Classification

1. Trachomatous inflammation: >5 sup. follicles

2. TF: intense: infl. with thickening

3. T scarring

4. T trichiasis: of at least one lash

5. Corneal opacity

Trachoma tx

azithromycin 20mg/kg, doxy 100mg BID or erythromycin 500mg QID for 2 weeks

-tetracycline, erythromycin or sulfacetamide ointment BID for 1m

-f/u 2-3 weeks

Molluscum f/u

2-4 weeks until it resolves (usually in 4-6 weeks)

Microsporidial keratoconjunctivitis

-diffuse, raised punctate keratitis with papillae or follicles that doesn't respond to conservative tx

-tx: antiparasitic and ab

Toxic conjunctivitis meds

glaucoma drops, aminoglycosides, antivirals, preservatives

atropine, miotics, epinephrine

Parinaud Conjunctivitis

-red eye, mucopurulent discharge, FBS

-granulomatous nodules on palpebral and bulbar conj

-ipsi PAL or submandibular lymph nodes

-associated with cat-scratch disease from Bartonella hensalae

UNILATERAL

Parinaud tx

warm compresses for nodes, antipyretics, for cat-scratch it resolves on its own in 6 weeks, azithromycin 500mg QID

f/u 1-2 weeks

SLK tx and f/u

-PFATs, acetylcysteine if filaments, silver nitrate with ab after

-2-4 weeks during exacerbation

OCP stages

1- chronic conjunctivitis

2- cicatrization

3- symblepharon, subepi scarring= lash distortion

4- end stage, ankyloblepharon, severe corneal involvement

OCP follow up

1-2 weeks during exacerbation, 1-6m during remissions

Neosynephrine test

2.5% phenyl into ptotic eye, if ptosis improves after 5 minutes, may be a good candidate for ptosis correction

Epiblepharon

congenital condition, extra lower lid skin folds make eyelashes vertical (moreso in Asians)

Painful

dacryocystitis

Canaliculitis and dacryocystitis and adenitis follow up

1 week

1 day

1 day

Dacryocystocele

mild enlargement of lacrimal sac in an infant caused by NLD (if bi, assess breathing to r/o nasal obstruction)

Preceptal cellulitis tx

-Augmentin: amoxicillin + clavulanic acid

-cephalosporine

-if allergic to penicillin: bactrim or moxifloxacin

If exposure to MRSA is expected

-Bactrim (trimethoprim/ sulfamethoxazole)

-doxy

-clindamycin

-linezolid

If preceptal cellulitis in kids <5 or no improvement in 24-48 hours

hospital for IV vancomycin +

-penicillin, ceftriaxone or cephalosporin

-orbital CT

Orbital disease signs

-common: eyelid swelling, bulging eyes, double vision from EOM restriction

-also: pain, decreased VA and color vision

Categories of orbital disease

1. Inflammatory: TED, IOI, sarcoid, Wegener's

2. Infectious: orbital cellulitis, subperiosteal abscess, mucormycosis

3. Neoplastic

4. Trauma: fracture, retrobulbar H, CCF

5. Malformation

6. Vascular: CCF

Parinaud syndrome

lid retraction and limitation of up gaze with convergence-retraction nystamus and mildly dilated pupils that react poorly to light with intact near response (light- near dissociation)

IOI (idiopathic orbital inflammation)

-hallmark: explosive, painful onset

-red, edema, diplopia, proptosis, unilateral, tendon and body of EOMs are thickened

-kids have a fever

IOI tx

oral steroids with gastric prophylaxis

follow up in 1-2 days

If doesn't improve with IV abs for orbital cellulitis

suspect subperiosteal abscess is needed-get CT

-surgical drainage

Persistent fetal vasculature

-leukocoria

-glial proliferation in vitreous

-small eye, cx

ROP zones

1) posterior pole: 2x disc-fovea distance around the disc, poorest prognosis

2) zone 1 to nasal ora serrata

3) remaining temporal retina

ROP severity

stage 1: flat demarcation line separating vascular from avascular retina

2: ridged line

3: #1 + fibrovascular proliferation or neo

4a: extrafoveal partial RD

4b: foveal partial RD

5: total RD

ROP Plus disease

at least 2 quadrants of engorged veins and tortuous arteries in the posterior pole, poor pupil dilation, vitreous haze (add a + after the stage if present)

ROP tx

laser photocoagulation for type 1, follow type 2 closely