HEENT: Conditions of the Eyes

What are the external structures of the eye?

- bony orbit

- extra-ocular muscles (EOM)

- eyelids

- lacrimal apparatus

- conjunctiva

What is the function of the bony orbit of the eye?

add a bony structure of support to the eye with the roof, medial wall, lateral wall, and floor

what is the importance of the extra-ocular muscles of the eye?

4 rectus muscles and 2 oblique muscles that allow the eye to move left, right, up, down, and rotary

- Superior, inferior, medial, and lateral rectus

-Superior and inferior obliques

what innervates the extra-ocular muscles?

cranial nerve III, IV, and VI

what does the eyelids contain?

the meibomian glands, eyelashes, and conjunctivae, lacrimal apparatus

Conjuctiave

thin, clear mucus membrane made up for 2 distinct parts

• Bulbar

• Palpebral

3 layers of the eye

Outermost = cornea anteriorly and Sclera posteriorly

Middle = ciliary body and iris anteriorly and choroid posteriorly

Inner = retina

what is the cornea?

the anterior region of the internal eye that is clear, avascular structure with sensory innervation

-Contributes to refractive power of the eye

what is the slcera?

the white of the eye

yellow - jaundice

blue - iron deficiency (brittle bone syndrome)

what is the Uvea?

Uveal tract Middle layer. contains the ciliary body - pupil and lens and choroid and iris

Ciliary body

Contains

Pupil - central portion of the iris, allows light to travel through the retina

Lens - pigmented, rich in vascular. supplies O2 to the outer layer of the retina

what is the retina?

the inner layer of the internal eye that is the sensory network of the eye

Photoreceptors and neurons transform light impulses into electrical impulses which are then transferred to the optic nerve-optic tract-optic radiation-visual cortex

TURNS ELECTRICAL STIMULATION TO IMAGES

BINOCULAR VISION

What are the two types of abnormal vision?

- visual hallucinations

- diplopia

what are visual hallucinations?

seeing things that are not there

what are floater visual hallucinations?

appearance of things in the periphery

what are fortification spectra visual hallucinations?

seeing shimmery things

what are scintillating scotoma visual hallucinations?

loss of vision in a specific region. Usually like a c shaped

what is photopsias visual hallucinations?

lights with geometric-like structure and can be halos, starbursts, or glares

what is diplopia?

double vision

what are the three distributions of diplopia?

vertical, horizontal, or oblique

what is the important feature to test for diplopia?

if it is monocular or binocular

what does decreased vision mean?

a refractive error where a component of the eye's optical system fails to focus the optical image in the correct location of the retina

A normal eye creates a clear image by bended (refracting light) in order to focus the image in the right location of the retina

what is myopia?

nearsightedness where one cannot see distant objects

what is hyperopia?

farsightedness where one cannot see close objects

what is an astigmatism?

occurs when an individual sees a glare surrounding lights

what is tunnel vision?

occurs when a person loses peripheral vision

what are the most causes of vision loss in patients over 40yoa in the US?

- age-related macular degeneration

- cataracts

- glaucoma

- diabetic retinopathy

what is the level of disability of mild vision loss (partially sighted)?

no special aids needed, may require reading glasses

what is the level of disability of moderate vision loss?

special aids needed for tasks

what is the level of disability of severe vision loss (legally blind)?

can read only with special aids at reduced speed and endurance

20/200 to 20/400

what is the level of disability for profound vision loss?

reading and mobility are impaired, relies on other senses for some tasks

what is the level of disability for near total blindness?

relies on other senses, can NOT benefit from maginification

what is the level of disability for total blindness?

no vision, relies completely on other senses

what constitutes legal blindness?

vision that cannot be corrected better than 20/200

what are the common eye complaints?

- the red eye

- eye pain

- edema

- changes in vision

- decrease or loss of vision

- trauma-related eye disorders

What must be done quickly for an eye condition?

Must determine if it is an emergent eye condition in order to have the best possibility of vision preservation

what is the "red eye"

ocular erythema that is a sign of ocular inflammation. The most common cause is conjunctivitis and it is essential to recognize when emergent referral is needed

Mostly affecting the cornea

what are eye emergencies?

any eye condition that threatens the vision and requires urgent intervention and or urgent referral to ophthalmology

Examples:

Orbital/Eye trauma

Retinal detachment

Central retinal artery occlusion

Acute angle-closure glaucoma

Optic neuritis

Orbital cellulitis

Scleritis/anterior uveitis/keratitis

what is essential risk assessments evaluate in H&P for eye problems?

cataracts and genetic eye conditions

what are the four main components of a vision physical exam?

- visual acuity: measures the sharpness of your distance or near vision using an eye chart.

- external exam: looking at structures

- EOM and Pupils : checks extraocular motility (how well the muscles move your eyes in different directions) and pupil size, shape, and reaction to light.

- Fundoscopic exam : uses a specialized magnifying tool (ophthalmoscope) to look deep inside the eye at the retina, optic nerve, and blood vessels.

What are common diagnostic tests for eye exams?

- Standard peripheral fields assessment = automated perimetry

- measurement of intraocular pressure

- lab tests

- fluorescein staining: most common for corneal trauma

- slit lamp - a specialized, high-intensity microscope used by eye doctors to examine the front and internal structures of the eye in fine detail.

- retinal mapping (picture of back of eye)

- CT/MRI/X-ray/Ultrasound

what is an opthalmologist?

someone who attended medical school and then specialized in the eye. Attended residency and fellowship

what is an optometrist?

provider of primary vision care and attended a post-grad optometry school “eye doctor”

what is an optician?

someone who helps fit contacts and glasses typically 2 years of schooling

what are antimicrobials used for in eye treatment?

treatment and prevention of ocular infections

what are anti-inflammatory agents used for in eye treatment?

allergic eye disorders, post-op inflammation, dry eye disease, steriod responses

what are glaucoma and ocular HTN meds used to treat for the eye?

reduction of intra-ocular pressure

what are other treatment modalities for the eye?

contacts and glasses

what are ocular procedures and surgeries that are common treatment for the eye?

- punctal plugs : inserted into the tear ducts to treat dry eye disease

- lasik : Laser vision correction surgery.

- lasek : A variation of laser vision correction

- PRK

- cataract surgery : removal of the eye's natural lens when it becomes cloudy, and replacing it with an artificial on

- corneal transplant

- many specific surgeries

what is hordeolum?

localized abscess of the eyelid. also called a “stye”

what are the risk factors of hordeolum?

underlying skin condition or contaminated eye make up

Blockage of the meibomian glands

how does hordeolum clinically present?

acute onset of pain and edema with a localized pustule or abscess

how is hordeolum diagnosed?

clinically

how is hordeolum treated?

warm compresses

what is a chalazion?

formation of a granulomatous nodule secondary to meiboian gland obstruction

how does a chalazion clinically present?

painless, localized eyelid swelling

how is a chalazion diagnosed?

clinically

what is the treatment of a chalazion?

normally self-limiting, but consider malignancy of persistent or recurrent

what is dacryoadenitis?

inflammation/infection of the lacrimal gland

how does dacryoadenitis clinically present?

acute onset of a tender, edematous mass in the upper outer eyelid with overlying erythema

how is dacryoadenitis diagnosed?

clinically, but can get a CBC to aid in determining viral or bacterial origin and a CT scan ro r/o other conditions

how is dacryoadenitis treated?

if viral, supportive. If bacterial, oral antibiotics

what is keratoconjunctivitis sicca?

less than adequate tears in the eye, AKA "dry eye disease"

what is the etiology of keratoconjunctivitis sicca?

any condition that decreases tear production or increases tear evaporative loss

how does keratoconjunctivitis sicca clinically present?

complaints of dryness, irritation, gritty/burning/FB sensation, light sensitivity, or blurred vision with potential for conjunctival irritation/injection, reduced blink rate, breakdown of ocular surface, and visual acuity deficit

how is keratoconjunctivitis sicca diagnosed?

Schirmer Test - thin paper under eye to see how wet it becomes

how is keratoconjunctivitis sicca treated?

- rewetting drops

- immunomodulators to increase tear production

- puntal plug procedure

What is periorbital cellulitis?

skin and soft tissue infection around the eye that anterior to the orbital septum and caused by bacterial invasion via skin breech

S. aures, s. pneumonia, strep, anaerobes

how does periorbital cellulitis clinically present?

- edema, erythema, pain and tenderness

- NORMAL VISION

- NO PAIN WITH EOM MOVEMENT

how is periorbital cellulitis diagnosed?

CBC with differential or a CT scan to r/o orbital cellulitis

how is periorbital cellulitis treated?

oral antibiotics

what is orbital cellulitis?

an ocular emergency that is a skin and soft tissue infection posterior to orbital septum and caused bu advanced periorbital cellulitis or ocular trauma

how does orbital cellulitis clinically present?

- edema. erythema, pain and tenderness

- Proptosis - eye bulging out

- PAIN AND LIMITATION IN EOM MOVEMENT

- DIPLOPA, BLURRY VISION

how is orbital cellulitis diagnosed?

CBC and CT

what is the treatment for orbital cellulitis?

- consult opthalmalogy

- IV antibiotics

what is conjunctivitis?

inflammation of the conjunctiva and can be infectious, allergic, or non-infectious/non-allergic

***Most common cause of red eye

what causes bacterial conjunctivitis?

Staphylococcus aureus, streptococcus pneumonia, H flu, and M cat

what causes hyperacute bacterial conjunctivitis?

neisseria species

May cause corneal perforation

how does bacterial conjunctivitis present clinically?

- unilateral, but may spread to be bilateral

- c/o disharge and matting, eye irritation

- purulent discharge

how is bacterial conjunctivitis diagnosed?

clinically

how is bacterial conjunctivitis treated?

warm compresses or topical antibiotics

what is viral conjunctivitis?

pink eye, most commonly caused by adenovirus

how does viral conjunctivitis clinically present?

- bilateral

- clear/mucoid discharge, eye crusties

- mild-moderate amount of discharge

- conjunctival injection

how is viral conjunctivitis diagnosed?

clinically

how is viral conjunctivitis treated?

supportive only

what is allergic conjunctivitis?

can present as episodic/acute, seasonal or perennial

how does allergic conjunctivitis present clinically?

- timing on history is key

- patient complains of ocular pruritis, gritty feeling, water discharge

- bilateral conjunctival infection

- manifestations of other atopic disease

how his allergic conjunctivitis diagnosed?

clinically or patch testes

How is allergic conjunctivitis treated?

topical anti-inflammatory drops

what is looked at when assessing the pupils?

- size

- shape

- position

- reactivity

- symmetry

what is anisocoria

pupillary asymmetry

what does it mean when pupils are fixed and dilated?

there is no reactivity to lite and there is potential brainstem damage

what is mydriasis?

pupil dilation

what are common causes of mydriasis?

- mydriatic eye drops

- CO poisoning

- Medication side effects

- acute opiiod withdrawal

what is miosis?

pupil constriction

what are common causes of miosis?

- miotic eye drops

- opiod use

- intracranial tumor/hemorrhage

- other meds/drug toxicities

What is anisocorisa?

pupil asymmetry

what can cause aniscoria?

congenital or acquired by trauma, iris sphincter atrophy, intraocular tumor

What is a corneal abrasion?

defect isolated to the corneal surface epithelium

what are the types of corneal abrasions?

- traumatic (FB or contact lens use)

- Spontaneous