Exam 3 EENT (cornea/ant chamber/lens)

Keratitis (corneal ulcer)- Etiology/Pathophysiology

Interruption of corneal epithelium and/or abnormal tear film permits entrance of microorganisms, proliferate, and cause ulceration

Commonly due to infectious agents, but noninfectious causes include neurotropic keratitis (loss of sensation), severe dryness, etc

Bacterial keratitis is an EYE EMERGENCY (sight-threatening)

Bacterial keratitis rapidly progresses; corneal destruction in 24-48 hrs

Keratitis (corneal ulcer)- Bacterial responsible for bacterial keratitis are

Streptococcus

Pseudomonas

Enterobacteriaceae (including Klebsiella, Enterobacter, Serratia, and Proteus)

Staphylococcus

Viral: HSZ, HZO

Fungal: common after eye trauma

Keratitis- Risk factors for bacterial keratitis

Contact lens use

Contaminated ocular medications or contact lens solution

Decreased immunologic defenses secondary to malnutrition, alcoholism, and diabetes

Tear film abnormalities

Recent corneal disease (including herpetic keratitis, neurotrophic keratopathy)

Structural alteration or malposition of the eyelids

Use of topical corticosteroids-risk

What is the main risk factor for the development of bacterial keratitis?

Extended contact lens usage

Keratitis Hx

RAPID onset of PAIN, photophobia, and decreased vision

Document:

-contact lens wear (type, wearing time, type of disinfection system)

-Trauma (including corneal surgery)

-use of ocular meds

Decreased immunologic defenses (immunocompromised)

Tear film abnormalities

Recent corneal disease

Structural alteration or malposition of they eyelids

Use of topical steroids

Keratitis- Physical

Ulceration of cornea; infiltrates, surrounding edema

Anterior chamber reaction with or without hypopyon

Eyelid edema

Corneal haze

Conjunctiva hyperemia

Mucopurulent exudate

What is a hypopyon?

Inflammatory cells layered in the anterior chamber

Which of the following symptoms is most suggestive of corneal involvement?

Red eye

Tearing

Decreased vision

Keratitis- Diagnostic assessment

Early diagnosis and prompt treatment to reduce possibility of permanent visual loss

Diagnosis by H&P (fluorescein stain and slit lamp)

Cultures of they eyelids/conjunctiva, topical ocular meds, contact lens cases, and solutions

Referral to ophthalmology for corneal scrapings or biopsy in cases of deep infiltrates, particularly if cultures are negative and eye not improving

Complete corneal destruction from bacterial keratitis can occur in?

1-2 days

Keratitis Tx

Refer suspected cases to ophthalmology immediately

Topical antibiotics - mainstay of treatment

If no organisms are identified on slide or smears not obtained, initiate broad-spectrum antibiotics (Cipro drop)

Depends on size, contact lens use, anterior chamber rxn

Cycloplegic drops, Tylenol

Monitored closely and follow-up in 24hrs to make certain infection responding 

Admission and systemic antibiotics for perforation, refractory or slow to respond to tx, visual loss or specific organisms (N gonorrheae)

In perforation, clear plastic shield

Viral: oral/topical antiviral

Fungal: antifungal eye drop

Keratitis complications

Thinning of the cornea and eventual perforation of cornea may result in endophthalmitis and loss of eye

Keratitis Patient Ed

Pts who are contact lens wearers are instructed not to use lenses with hyperemia, irritation, or FB sensation, and to use sterile contact lens solutions to avoid contamination

Topical antibiotics given routinely after any traumatic injury to the cornea (including surgery) 

Keratitis Prognosis

The visual prognosis depends on:

-Virulence of the organism

-Extent and location of corneal ulcer

-Resulting vascularization and/or collagen deposition

Ultraviolet (Actinic) Keratitis

UV light is the most common cause of radiation injury to eye

Cornea epithelium absorbs UV radiation- cumulative

Prolonged exposure can lead to chronic toxicity, which is associated with pinguecula, pterygium, squamous metaplasia and carcinoma

Inflammation- edema, superficial puctate keratits (SPK, pictured) to total desquamation

Reepithelialization- can occur in 36-72 hrs

Sunburn to cornea

Ultraviolet (Actinic) Keratitis eitology

Unprotected or long exposure to sun, particularly high altitudes

UV radiation reflected off snow, ice, or water

Viewing solar eclipses

Welder’s arcs

Carbon arcs

Sun tanning beds

Photgraphic flood lamps

Lightning

Electric sparks

Halogen desk lamps

Ultraviolet (actinic) keratitis Hx

FB sensation, irritation, pain, photophobia, tearing, blepharospasm, and decreased visual acuity 6-12 hours after exposure

Contact lens use, past ocular trauma or surgery, current meds, and allergies to meds

Document info regarding nature and duration of exposure

Was protective eye wear used?

Always look and document exam/presence of FB

Ultraviolet (actinic) keratitis Physical

Visual acuity

Lids and conjunctiva-lid edema, conjunctival hyperemia, and chemosis. Diffuse corneal haze, severe cases

Fluorescein staining- superficial punctate epithelial surface irregularities, covers entire surface of cornea

Dx: Slit lamp exam with fluorescein

Eye pain from UV radiation occurs in?

6-12 hours

Ultraviolet (actinic) keratitis Tx

Resolves in 24-72 hours if we do nothing

Short-acting cycloplegic drop- relieve pain or reflex ciliary spasm. Administer pain meds- topical ophthalmic NSAID or oral NSAID

Oxycodone (oxytocin) and acetaminophen- breakthrough pain

Topical antibiotic ointment or drops

Topical anesthetic only in office, frequent use retards healing and may lead to corneal ulcer formation 

Follow-up with ophthalmologist not necessary except with extensive corneal damage, persistent pain or vision deficits 48 hrs after injury or preexisting eye conditions

Should not wear contact lenses until symptoms resolve

Ultraviolet (actinic) keratitis Patient Ed

Educate pts about proper eye precautions, such as the use of UV-filtering lenses or limiting exposure to the sun

Complications

-Superinfection- rarely

-Vision loss-rarely

Prognosis

-excellent for full recovery in 24-76 hrs

Reepithelization from UV radiation keratitis generally occurs in?

A few days

An old snowplow operator complains of pain and photophobia in both eyes. Which of the following are TRUE regarding his condition?

Onset of symptoms are delayed 6-12 hours after exposure

What is SPK characterized by?

Small pinpoint defects in the cornea

How should a pt with suspected bacterial keratitis be treated?

Topical antibiotics and follow-up in one week

Corneal abrasions

Very common!

Scraping away of corneal surface from external forces

Cornea and bulbar conjunctiva are affected

Minor or superficial abrasions involve only corneal epithelium

Severe injuries involve deeper, thicker stromal layer

Main causes of corneal abrasion

Trauma (finger nails, tree branches, makeup brushes)

Foreign body (dust, sand, metal, wood)

Contacts (themselves can cause, poor fit)

Iatrogenic (we cause the harm- eye exam, eye surgery)

Corneal abrasions Hx

“something is in my eye”, sudden onset pain, irritation, photophobia, blepharospasm, tearing, redness, and/or visual disturbance

Extended contact wear

Occupational Hx (trades, FB)

Recreation Hx (hunters, beach)

Last tetanus shot (trauma- want to have updated tetanus)

Corneal abrasion Physical

Sudden onset

FB may or may not be seen
Every eyelid for FB

Bulbar conjunctival injection

Visual acuity usually normal, unless abrasion within central visual axis or large

Superinfection- rarely

Vision loss- rarely

Corneal abrasion Dx

Topical anesthetic for severe pain

Severe photophobia causing blepharospasm- (have someone hold eye open so you don’t have to use drops and wait) instillation of cycloplegic 20-30 minutes prior to exam 

Fluorescein instillation and exam with blue light

Slit lamp- anterior chamber for evidence of iritis (cells and flare)

Corneal abrasions Dx cont

Fluorescein can permanently stain soft contact lenses; remove

Corneal ulcer suspected, consider bacterial cultures before instilling antibiotics

Ocular penetration with retained FB suspected, ocular CT scan indicated

Corneal abrasions Tx

Update tetanus

Topical anesthetic and or cycloplegic- comfort and exam (not usually necessary)

Topical anti-inflammatory eye drops- relieve pain, oral if not effective

FB remove with sterile cotton tipped applicator or tuberculin needle

“rust ring” after removal metal - remove rust ring

Once violated, cornea becomes susceptible to infection and prophylactic antibiotic drops used 

Will heal on its own

Corneal abrasions Therapeutics

Large or dirty abrasions, broad-spectrum antibiotic drops

Contact lens- infectious corneal ulcers likely, cover for gram-negative organisms/pseudomonas (don’t wear lenses until healed)

NO EYE PATCHING (increases bacteria risk, doesn’t improve healing)

Avoid neomycin- higher incidence of allergy

Antibiotic drops more comfortable than ointments, but administered every 2-3 hrs (Cipro drops or erythromycin ointment)

Ointments, retain antibacterial effect longer, used less often but blur vision temporarily

Corneal abrasions Consultations

Emergent ophthalmologic consultation warranted for suspected retained intraocular FBs

Urgent consultation is needed for suspected corneal ulcerations (white necrotic areas around abrasion with gray exudates)

Corneal ulcers are round, with upward edges, lumps or divots

Corneal abrasions Patient Ed

Return in 24 hrs for re-evaluation

Minor abrasions heal in 24-48 hrs (no driving)

Larger abrasions examine daily until healed and potential for infection no longer exists

Eye rest- movement interferes with re-epithelialization

Avoid light or wear sunglasses with photophobia

Antibiotics continue until asymptomatic

Protective eyewear at jobs with increased risk,

Corneal abrasions Complications

Recurrent epithelial erosion- days to weeks after healed abrasion

Corneal ulcerations common after contact lens abrasion

Tetanus (rare)

Allergic conjunctivitis, meds (neomycin)

Acute narrow-angle glaucoma precipitated by cycloplegics/mydriatics

Intraocular Foreign Body (IOFB)

Less acute eye damage compared to blunt trauma

Tissue reaction varies with composition. Inert substances such as glass, stone, and plastic better tolerated than metals that oxidize 

Less inert, organic material pose significant tissue reaction. the risk of endophthalmitis increases

Most injuries at work using various tools with metal striking metal- 80%; metallic or magnetic

Incidence higher in males

20-40 years with no protective eye gear

IOFB Hx

What happened-medical-legal and workman’s compensation

Suspect foreign object with projectile (hammering, grinding, etc.)

Feel something enter the eye, no obvious external changes; dismissed

Irritation or conjunctival injection

Decreased visual acuity if visual axis affected 

Determining if IOFB is inert- important to the surgical management

Usually unilateral but need to examine both eyes closely

IOFB Physical

Examine both eyes

Document the vision bilaterally

Location (clock notation)

Slit-lamp exam- anterior segment, fluorescein streaming

Cornea- edema surrounding the perforation site, opacification, irregular shape

Scleral entry- conjunctival injection, darker pigmentation in sclera indicated choroid exposure

IOFB opacification and neovascularization

IOFB Dx

CT scan- test of choice for localization

X-ray plain films if metallic when CT scan not available

MRI avoided if metallic

U/S- adjunct tool in localizing and to determing if metallic

IOFB therapeutics

Get to ophthalmo right away

Minimize pressure on globe

Eye shield

Tetanus updated

24 hr delay in removal increases risk of endophthalmitis

reactive substances, copper and iron, removed urgently because oxidative process induced on retina

Vegetable matter- high risk for endophthalmitis- removed urgently

Inert possible to remove later

Antibiotic coverage for gram pos/neg organisms

Surgical approach for removal depends on if object is anterior or posterior to the iris

IOFB consultations

Radiologist help determine location and type of material

EMERGENCY and referred immediately to ophthalmology

IOFB Pt Ed

Reduce activity and Valsalva (bearing down) maneuvers prior to surgery- Incr. IOP

Daily follow-up exam to watch for complications

The use of polycarbonate safety glasses reduces risk

IOFB complications

Corneal opacity

Cataract

Endophthalmitis

Retinal detachment/vitreous hemorrhage

Optic neuropathy

Siderosis- ocular reaction from iron (cataract)

Hyphema

Trauma to the eye- bleeding in anterior chamber

Stretches limbal vessels and displaces the iris and lens

-may result in tear of iris or ciliary body causing bleeding

Blood exits anterior chamber via trabecular meshwork and Schlemm canal. Blood clots form blocking exit causing hyphema and increased IOP

Males are involved in ¾ of cases

Spontaneous hyphema are secondary to neovascularization (DM, ischemia), ocular neoplasms (retinoblastoma) and vascular anomalies

Hyphema Likelihood/grading system

African Americans & Mediterranean descent screened for sickle cell disease, -early surgery

Grading system:

Grade 1- layered blood occupying less than 1/3 of anterior chamber

Grade 2- blood filling 1/3 to ½ of anterior chamber

Grade 3- layered blood filling ½ to less than total of anterior chamber

Grade 4- Total clotted blood, blackball or 8-ball hyphema

Hyphema

Most hyphemas fill less than 1/3 of anterior chamber

trauma initially may cause a small hyphema

More severe bleeding may follow in 3-5 days

Usual duration of an uncomplicated hyphema in 5-6 days

Mean duration of elevated IOP is 6 days

Hyphema H&P

Eye trauma- eye pain and blurred vision

Nausea and vomiting

Red eye

Layered blood in anterior chamber of eye

Corneal blood staining

Hyphema Dx

Visual acuity test

IOP must be checked

Check for optic atrophy-pale optic disk (funduscopic exam)

Corneal blood staining

Watch for secondary hemorrhage