Ophthalmic Disorders

Strabismus: General

Ocular misalignment

Only one eye fixates on an object

Present in ~4% of children

"Ocular instability of infancy"

Strabismus: Risk Factors

family history, prematurity, refractory error, neuro disorders

esotropia

inward turning of the eye

exotropia

outward turning of the eye

hypertropia

upward deviation of one eye

hypotropia

downward deviation of one eye

-phoria

strabismus that is present only when binocular fusion is

disrupted (i.e. when one is covered)

-tropia

strabismus that is present when there is no

disruption of binocular fusion

strabismus: most common causes

CN palsy, trauma, orbital disease, hyperthyroidism

strabismus: diagnostic tests

Corneal light reflex (aka Hirschberg test)

Cover test (detects tropia)

Cover/uncover test (detects phoria)

strabismus: complications

Amblyopia (in up to half of younger children with strabismus)

Diplopia (in acquired strabismus in patients > 8 years old

strabismus: when to refer?

Constant strabismus at any age

Intermittent manifest strabismus after 4-6 months of age

Persistent esodeviations after 4 months of age

Abnormal corneal light reflex test or cover test

Deviation that changes depending on position of gaze

Diplopia or asthenopia

Parental concern about ocular alignment

strabismus: tx

Nonsurgical: glasses, contacts, occlusion therapy,

visual training exercises

Surgical: recession, resection and transposition of

extraocular muscles

amblyopia: general

Functional reduction in visual acuity caused by abnormal visual development early in life

50% of cases related to strabismus

Predominantly unilateral

Refer to ophthalmology/optometry if suspected

amblyopia: risk factors

prematurity, small for gestational age, first-degree

relative with amblyopia, neurodevelopmental delay

what is the MCC of pediatric visual impairment (1-4% of children)

amblyopia

leukoria

White pupillary reflex

leukocoria: common causes

Retinoblastoma

Cataract

Coats disease

Retinal detachment

RETINOBLASTOMA: general

Most common primary intraocular malignancy of childhood

Typically presents as leukocoria in a child < 5 years

RETINOBLASTOMA: signs and symptoms

Leukocoria

Strabismus

Red, inflamed eye

Decreased vision

RETINOBLASTOMA: tx

Deadly if untreated, but treatment is very successful! (>95% 5-year survival rate)

Treatment involves multidisciplinary approach and may include chemotherapy, surgery, cryotherapy, laser photoablation

RETINITIS PIGMENTOSA: general

degeneration and dysfunction of retina, rods then cones

May occur alone or as part of a syndrome

May be inherited or occur sporadically

what does retinitis pigmentosa cause

progressive loss of night and peripheral vision

retinitis pigmentosa: ophthalmic findings

Attenuation of retinal blood vessels

Waxy pallor of optic disc

Intraretinal pigmentation in a bone-spicule pattern

retinitis pigmentosa: tx

No great treatment currently; experimental therapies underway

conjunctivis: general

Inflammation of the mucous membrane that lines the surface of the eyeball and inner eyelids

Viral, bacterial, or allergic

conjunctivis: transmission

direct contact of contaminated fingers orobjects to other eye or other persons

conjunctivis: symptoms

Foreign body sensation

Scratching / burning

Itching

Photophobia

Sensation of fullness around eyes

viral conjunctivitis: mcc

adenovirus

viral conjunctivitis: general

May or may not be part of viral prodrome followed by adenopathy,

fever, pharyngitis, URI

Usually sequential bilateral disease

Spreads easily

viral conjunctivitis: presentation

Conjunctival injection with watery or mucoserous discharge

± preauricular lymphadenopathy

+/- follicular appearance of tarsal conjunctiva

viral conjunctivitis: tx

No specific treatment

Lasts up to 2 weeks; may get worse before it gets better

Artificial tears and cold compresses may help discomfort

bacterial conjunctivitis: mcc

staph aureus, Strep pneumo, Haemophilus species, Pseudomonas (contact lens wearers), Moraxella

bacterial conjunctivitis: general/clinical presentation

Purulent eye discharge

Eyelid matting

unilateral

bacterial conjunctivitis: tx

Usually self-limited

Lasts 10-14 days if untreated

Topical antibiotics may hasten remission- Erythromycin ointment, Polytrim drops

Contact wearers- Ciprofloxacin, Ofloxacin drops

GONOCOCCAL CONJUNCTIVITIS: general

Usually acquired through genital secretions

Ophthalmologic emergency!

Corneal involvement may lead to perforation

Caused by N. gonorrhoeae

GONOCOCCAL CONJUNCTIVITIS: clinical presentation

Copious purulent discharge

GONOCOCCAL CONJUNCTIVITIS: diagnosis

Confirm with stained smear and culture of discharge

GONOCOCCAL CONJUNCTIVITIS: tx

Single dose ceftriaxone IM

Also treat for chlamydia- doxycycline

Consider other STIs

CHLAMYDIAL CONJUNCTIVITIS: Trachoma general

chronic keratoconjunctivitis caused by recurrent infection with C. trachomatis

Recurrent episodes causes entropion and trichiasis leading to corneal scarring/opacity

NOT sexually transmitted

Trachoma transmission

secretions, contaminated objects, flies, NOT sexually transmitted

Trachoma treatment

SAFE: surgery, antibiotics, facial cleanliness, environmental improvement

CHLAMYDIAL CONJUNCTIVITIS: Adult inclusion conjunctivitis

Chronic conjunctivitis caused C. trachomatis

associated with genital chlamydia

Usually unilateral follicular conjunctivitis lasting weeks-months that has not responded topical antibiotics

Adult Inclusion Conjunctivitis transmission

spread by autoinoculation from genital infection

Adult Inclusion Conjunctivitis dx

Conjunctival NAAT

Adult inclusion Conjunctivitis tx

Single dose of azithromycin PO or 7 days of doxycycline

ALLERGIC CONJUNCTIVITIS: general

Usually associated with atopy (Eczema, asthma, allergic rhinitis)

May be seasonal (hay fever); usually in spring/summer

Bilateral

ALLERGIC CONJUNCTIVITIS: clinical presentation

Itching

Conjunctival hyperemia and edema (chemosis)

Watery discharge

Cobblestoning of upper tarsal conjunctiva

Bilateral

ALLERGIC CONJUNCTIVITIS: tx

Avoid known allergens, rubbing, contact lenses

Cool compresses, Artificial tears

First line- topical olopatadine or ketotifen

Oral H1 antihistamines

DACRYOCYSTITIS: general

Infection of lacrimal sac secondary to obstruction of nasolacrimal duct

sometimes seen in infants that have a membrane that blocks the duct

DACRYOCYSTITIS: pathogens

strep or staph

DACRYOCYSTITIS: clinical presentation

Tearing/discharge

Inflammation, pain, swelling, tenderness beneath medial canthal tendon in area of lacrimal sac

May be able to express purulent drainage through lacrimal puncta by applying pressure to sac

DACRYOCYSTITIS: dx

usually clinical, imaging if concerned for orbital involvement

DACRYOCYSTITIS: tx

systemic antibiotics, cannot use drops

ophthalmology referral for abscess drainage

KERATOCONJUNCTIVITIS SICCA: general

AKA dry eye disease (DED)

decreased tear production and/or increased evaporation —> unstable tear film

KERATOCONJUNCTIVITIS SICCA: symptoms

bilateral burning/gritty sensation, may find relief immediately after blinking, reflex tearing may occur

KERATOCONJUNCTIVITIS SICCA: risk factors

Advanced age

Sjogren syndrome

Contact lens wear

Certain medications

Dry environments

KERATOCONJUNCTIVITIS SICCA: tx

Artificial tears ± lubricating ointment at night

Warm compresses

Discontinue offending medications if possible

HSV KERATITIS: clinical presentation

Due to reactivation of HSV in trigeminal ganglion

unilateral, decreased corneal sensation, vesicles may occur

Dendritic (branching) corneal ulcer w fluorescein staining

HSV KERATITIS: dx

Slit lamp examination

Fluorescein stain showing branching dendritic lesion

HSV KERATITIS: tx

Topical: Trifluridine drops, ganciclovir gel

Oral: Acyclovir, valacyclovir

*Avoid topical corticosteriods (leave to ophtho)

BACTERIAL KERATITIS: mc pathogens

staph/strep; Pseudomonas aeruginosa with contact wearers

BACTERIAL KERATITIS: risk factors

Contact lens wear (especially overnight)

Corneal trauma

BACTERIAL KERATITIS: clinical presentations

painful red eye, photophobia, ± decreased vision

Central corneal ulcer

+/- hypopyon

BACTERIAL KERATITIS: dx

visual acuity + slit lamp exam + fluorescein staining

BACTERIAL KERATITIS: tx

Urgent ophtho referral, emergency!

Topical fluoroquinolones

HERPES ZOSTER OPHTHALMICUS: general

Herpes zoster frequently involves ophthalmic division of trigeminal nerve

Potentially sight-threatening

HERPES ZOSTER OPHTHALMICUS: clinical presentation

Hutchinson’s sign- vesicles on the tip, side, or root of the nose indicates increased risk of ocular involvement

Painful, unilateral vesicular rash of forehead/upper eyelid that typically does not cross midline

HERPES ZOSTER OPHTHALMICUS: tx

Urgent ophtho referral

Acyclovir, valacyclovir, famciclovir within 72 hrs of onset

PERIORBITAL CELLULITIS: general

AKA preseptal cellulitis

Infection of soft tissues anterior to orbital septum

May follow sinusitis, local skin infection, trauma, insect bite

PERIORBITAL CELLULITIS: clinical presentation

Unilateral eyelid swelling and erythema

Does NOT affect visual acuity or extraocular movements, NO proptosis

PERIORBITAL CELLULITIS: tx

Mild- Amoxicillin/clavulanate, reassess within 24-48 hrs

Consider admission in children < 1 year old, severely ill, or unsure if orbit is involved

ORBITAL CELLULITIS: general

Emergency!

Infection posterior to orbital septum (fat and extraocular muscles)

Typically caused by sinusitis

ORBITAL CELLULITIS: clinical presentation

Eyelid erythema ± Fever

Proptosis

Painful or restricted extraocular movements

Decreased visual acuity

ORBITAL CELLULITIS: dx

CT orbits and sinuses with IV contrast

ORBITAL CELLULITIS: tx

Hospitalization and Urgent broad-spectrum IV abx

Urgent optho consult

may require surgical drainage

ORBITAL CELLULITIS: complications

Cavernous sinus thrombosis

Intracranial extension

Vision loss

Orbital abscess

BLEPHARITIS: general

Chronic bilateral inflammatory condition of lid margins

Common cause of recurrent conjunctivitis

BLEPHARITIS: anterior

scales/crust at the eyelashes

associated with staph and seborrheic dermatitis

BLEPHARITIS: posterior

results from inflammation of meibomian glands (oil)

BLEPHARITIS: clinical presentation

gritty sensation, burning, itching

eyelid crusting especially on awakening

can contribute to dry eye

BLEPHARITIS: tx

First line: warm compresses, eyelid cleansing with baby shampoo,

Persistent anterior: erythromycin ointment

Refer for severe

CHALAZION: general

Sterile obstruction/inflammation of a meibomian gland

Associated with blepharitis/meibomian gland dysfunction

CHALAZION: clinical presentation

Hard, painless nodule on upper or lower lid away from lash line

May blur vision

CHALAZION: treatment

Warm compresses + gentle lid massage

Refer if persistent, optho can do steroid injection or I&C

Recurrent in same location needs to be biopsied for malignancy

HORDEOLUM: general

AKA stye

Acute infection/abscess of either meibomian gland (internal) or gland of Zeis (external)

HORDEOLUM: mc

Staph aureus

HORDEOLUM: clinical presentation

Localized red, swollen, tender eyelid nodule

HORDEOLUM: tx

Warm compresses ± gentle massage

Refer if large/persistent

CATARACTS: general

Opacities of crystalline lens

Usually bilateral

Leading cause of blindness worldwide

CATARACTS: risk factors

MCC: age

DM, smoking, steroid use, trauma, UV exposure

CATARACTS: clinical presentation

Progressive, painless blurring of vision

Flare in bright lights or night driving, faded colors, diminished red reflex

CATARACTS: tx

Mild- optimize with glasses

Surgery (improves visual acuity in 95% of cases)

Glaucoma risk factors

Older age, family hx, Black/African, Hispanic/Latino

Primary open angle glaucoma

Chronic optic neuropathy associated with elevated IOP due to reduced drainage of aqueous fluid through trabecular meshwork

Primary open angle glaucoma- clinical presentation

gradual peripheral vision loss, painless

Primary open angle glaucoma- dx

cupping of optic disc on fundoscopy

assess IOP with tonometry + gonioscopy

Primary open angle glaucoma- tx

First line- prostaglandin analog (latanoprost)

Acute angle closure glaucoma

Sudden obstruction of flow of aqueous fluid into anterior chamber

Emergency!! permanent vision loss if untreated

quick pupil dilation can trigger it

Acute angle closure glaucoma- clinical presentation

severe unilateral eye pain

blurred vision, headache, N/V

poorly reactive pupil