CSA Proficiency

25-year-old male presents with acute eye pain, tearing, and photophobia after grinding metal without eye protection. Fluorescein shows a corneal epithelial defect with a small metallic FB and rust ring.

• Diagnosis: Foreign body

• 2 Differentials: Corneal abrasion, Infectious keratitis

• In office tests: CT scan of the orbit, NaFl staining for foreign body tracks

• Treatment and management:

  • Instill an anesthetic and remove the foreign body

  • Topical antibiotic: Polytrim QID

• Patient ed:

• Follow-up schedule: F/U in 1-2 days

18-year-old male punched in the eye presents with diplopia and pain on upgaze.

• Diagnosis: Orbital Trauma/Floor fracture

• 2 Differentials: Orbital cellulitis

• In office tests: EOMs, CT orbit, NaFl staining: (+) Seidel sign, slit lamp: rust ring if metallic, lens subluxation, Vossius ring, iridodialysis, hyphema

• Treatment and management:

• Patient ed:

• Follow up schedule:

32-year-old female with a painless, firm nodule on upper eyelid for 3 weeks

• Diagnosis: Chalazion

• 2 Differentials: Sebaceous Carcinoma, Hordeolum

• In office tests: Lid eversion, press on meibomian glands

• Treatment and management:

  • Lid Cleaning BID

  • Warm compress 15 min BID

  • Antibiotic ointment: Erythromycin ointment QID x 1 week

  • Steroid injections, kenalog

• Patient ed: Due to blockage of oil gland near the eyelashes. Good prognosis if compliant but can be recurrent otherwise

• Follow up schedule: F/U in 3-4 weeks if not resolved

Acute, tender red bump at lash line

• Diagnosis: Hordeolum

• 2 Differentials: Chalazion, Preseptal Cellultiis

• In office tests: Lid eversion, temperature

• Treatment and management: Antibiotic ointment: Erythromycin ointment QID x 1 week

• Patient ed:

• Follow up schedule:

College student with red eye, watery discharge, and preauricular lymphadenopathy after roommate had similar symptoms.

• Diagnosis: Viral Conjunctivitis / Epidemic keratoconjunctivitis (EKC)

• 2 Differentials: allergic conjunctivits, bacterial conjunvtivitis

• In office tests: Palpate pre-auricular nodes, look for inferior follicles

• Treatment and management:

  • Highly contagious → maintain good hygiene

  • Artificial tears and cool compress

  • Pred Forte 1% QID x 1 week

• Patient ed: Inflammation of the mucous membranes lining the lids and lashes

• Follow up schedule:

  • F/U in 2 weeks

  • F/U in 1 week if steroid is rx’ed

Teen with bilateral itching, watery discharge, and history of seasonal allergies.

• Diagnosis: Allergic conjunctivitis

• 2 Differentials: viral conjunctivitis, dry eye

• In office tests: lids - papillae, (-) preauricular nodes

• Treatment and management:

  • Artificial tears and cool compresses

  • Topical combination antihistamine/MC stabilizer: Pataday 0.2% QAM x 2-3 weeks before allergy season starts

• Patient ed:

• Follow up schedule:

10-year-old boy with severe itching, photophobia, and giant papillae on upper lid; worse in spring.

• Diagnosis: Vernal keratoconjunctivitis (VKC) - superior cobblestone papillae

• 2 Differentials: Atopic - microscopic papillae inferiorly

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Child with red eye and thick purulent discharge causing lids to stick shut in the morning

• Diagnosis: Bacterial conjunctivitis

• 2 Differentials: Viral, Gonococcal

• In office tests:

• Treatment and management:

• Patient ed:

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Sexually active adult with hyperacute onset, copious purulent discharge, and chemosis; rapid progression.

• Diagnosis: Gonococcal Conjunctivitis

• 2 Differentials: Chlamydial, severe bacterial

• In office tests:

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• Patient ed:

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65-year-old notices bright red patch on eye after coughing episode; no pain or vision loss.

• Diagnosis: Subconjunctival Hemorrhage

• 2 Differentials: Trauma, Bleeding disorder

• In office tests:

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Middle-aged outdoor worker with yellowish conjunctival bump nasally; mild irritation.

• Diagnosis: Pinguecula

• 2 Differentials: Pterygium,

• In office tests:

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• Patient ed:

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Chronic UV exposure patient with triangular fibrovascular growth encroaching onto cornea causing astigmatism.

• Diagnosis: Pterygium

• 2 Differentials: Pinguecula, Neoplasia

• In office tests:

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• Patient ed:

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Postmenopausal woman with burning, fluctuating vision, worse with screen use.

• Diagnosis: Dry Eye syndrome

• 2 Differentials: Blepharitis, Allergic Conjunctivitis

• In office tests:

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• Patient ed:

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Patient with Bell’s palsy unable to fully close eye; presents with dryness and inferior corneal staining.

• Diagnosis: Exposure keratopathy

• 2 Differentials: Dry eye, neurotrophic keratitis

• In office tests:

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• Patient ed:

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Young adult with recurrent unilateral red eye and dendritic ulcer on fluorescein staining

• Diagnosis: Herpes Simplex Virus (HSV)

• 2 Differentials: Zoster, Abrasion

• In office tests:

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• Patient ed:

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Elderly patient with vesicular rash in V1 distribution and eye pain; positive Hutchinson sign suggests ocular involvement

• Diagnosis: Herpes Zoster Ophthalmicus (HZO)

• 2 Differentials: HSV, Cellulitis

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40-year-old on chronic steroids complains of glare and difficulty reading; worse in bright light.

• Diagnosis: Posterior subcapsular cataract (PSC)

• 2 Differentials: NSC, dre eye

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70-year-old with gradual vision decline and “second sight” (improved near vision).

• Diagnosis: Nuclear sclerotic cataract (NSC)

• 2 Differentials: PSC, AMD

• In office tests:

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Patient reports glare and halos at night; spokes seen in lens periphery.

• Diagnosis: Anterior Cortical Cataract

• 2 Differentials: PSC, Dry eye

• In office tests:

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Young adult with photophobia, ciliary flush, and consensual pain; small irregular pupil

• Diagnosis: Uveitis

• 2 Differentials: Keratitis, Angle Closure

• In office tests:

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60-year-old with progressive peripheral vision loss; elevated IOP and cupping of optic nerve.

• Diagnosis: Glaucoma

• 2 Differentials: Ocular hypertension, Optic neuropathy

• In office tests: pachymetry

• Treatment and management:

• Patient ed:

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Obese young woman with headaches, transient visual obscurations, and papilledema.

• Diagnosis: Idiopathic Intracranial Hypertension (IIH)

• 2 Differentials: Brain tumor, venous sinus thrombosis

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75-year-old with sudden vision loss, scalp tenderness, and jaw claudication—medical emergency

• Diagnosis: Arteritic AION / Giant Cell Arteritis (GCA)

• 2 Differentials: NAION, CRAO

• In office tests: ESR/CRP, Temporal artery biopsy

• Treatment and management:

• Patient ed:

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Patient with recurrent visual aura (scintillating scotoma) followed by headache.

• Diagnosis: Migraine

• 2 Differentials: vTIA, retinal detachment

• In office tests:

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65-year-old with sudden floaters and flashes; Weiss ring seen.

• Diagnosis: Posterior Vitreous Detachment

• 2 Differentials: Retinal tear, retinal detachment

• In office tests:

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Patient reports “curtain coming down” over vision with flashes and floaters.

• Diagnosis: Retinal Detachment

• 2 Differentials: PVD, Vitreous hemorrhage

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Sudden painless vision loss; cherry-red spot on fundus.

• Diagnosis: Central Retinal Artery Occlusion

• 2 Differentials: AION, BRAO

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Sectoral vision loss corresponding to occluded branch artery.

• Diagnosis: Branch Retinal Artery Occlusion (BRAO)

• 2 Differentials:

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“Blood and thunder” retina with diffuse hemorrhages and dilated veins.

• Diagnosis: Central Retinal Vein Occlusion (CRVO)

• 2 Differentials: Diabetic retinopathy, Ocular ischemic syndrome

• In office tests: OCT, FA

• Treatment and management:

• Patient ed:

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Sectoral hemorrhages along affected vein distribution.

• Diagnosis: Branch Retinal Vein Occlusion (BRVO)

• 2 Differentials: Diabetic retinopathy, CRVO

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Patient with uncontrolled HTN; AV nicking, flame hemorrhages, cotton wool spots.

• Diagnosis: Hypertensive Retinopathy

• 2 Differentials: Diabetic retinopathy, CRVO

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• Patient ed:

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Long-standing diabetic with microaneurysms, dot-blot hemorrhages, and possible neovascularization.

• Diagnosis: Diabetic Retinopathy

• 2 Differentials: CRVO, Hypertensive

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Post-cataract surgery patient with decreased central vision and OCT showing cystic spaces

• Diagnosis: Cystoid Macular Edema (CME)

• 2 Differentials: AMD, ERM

• In office tests:

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Young stressed male with central blur and metamorphopsia; serous retinal detachment.

• Diagnosis: Central Serous Chorioretinopathy (CSCR)

• 2 Differentials: AMD, CME

• In office tests: OCT, FA

• Treatment and management:

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Elderly patient with central vision loss; drusen (dry) or CNVM (wet)

• Diagnosis: Age Related Macular Degeneration

• 2 Differentials: Macular hole, ERM

• In office tests:

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Elderly female with central vision loss and distortion; full-thickness hole on OCT.

• Diagnosis: Macular Hole

• 2 Differentials: ERM, AMD

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Patient with gradual distortion (metamorphopsia); “cellophane maculopathy” appearance.

• Diagnosis: Epiretinal Membrane (ERM)

• 2 Differentials: Macular hole, AMD

• In office tests: OCT, Amsler

• Treatment and management:

• Patient ed:

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