Eye Disorders

Visual Field Test

-Used to determine if a lesion is before, at, or behind the optic chiasm

-Normal:

• 100 degree temporal

• 60 nasally, superiorly

• 70 inferiorly

20/200 vision after correction in the better eye

or

Binocular visual field subtending 20 degrees or less.

What are the IRS requirements to be legally blind?

Corneal Abrasion

-Damage to the corneal epithelium.

-Often caused by fingernail, sand, contact lens.

-Slow healing in smokers.

S/S:

• Severe pain, photophobia

• FB sensation, Tearing, Red eye.

Diagnostic:

• Fluorescein dye with any cobalt-blue light.

• Appears as yellow fluorescence of the basement membrane

Treatment:

• Drop of topical ophthalmic anesthetic (only once!)

• Remove Foreign body with moistened cotton-tipped

• Antibiotics for large abrasions/contact lens wearers.

  • Bacitracin-polymyxin ointment

  • Fluoroquinolone topical for contact wearers.

• Patching (not recommended)

• Mydriatic/topical NSAIDs for pain.

Infectious Keratitis

Pathophysiology: Infection of the cornea

• Foggy looking, can find a white spot where infection is located.

Causes: Contact lens (esp. overnight), trauma.

S/S:

• Red eye and pain (more significant than corneal abrasion)

• Excess tears, Eye discharge,

• Difficulty opening the eyelid because of pain or irritation.

• Blurred vision, photophobia, FB sensation.

Diagnostic:

• Slit lamp

• Gram stain culture

Treatment:

• Topical fluoroquinolones (floxacin) are first-line agents if the prevalence of resistant organisms is low.

• Refer emergently to an ophthalmologist.

Herpes

What is a dendritic lesion on the eye indicative of?

Hyphema

Pathophysiology: Blood collection in the anterior chamber.

S/S:

• Eye pain, photophobia

• Sometimes blurred vision is secondary to obstructing blood cells.

• N/V may signal a rise in intraocular pressure (glaucoma) caused by blood cells.

Diagnostic:

• Clinical exam

• Determine underlying causes (blunt trauma most common)(can be spontaneous)

Management:

• Increased risk for vitreous hemorrhage

• Prevention of further hemorrhage is the foremost treatment goal.

• Keep pt at rest in a supine position with head slightly elevated.

• Emergent referral

• Avoid any medications with antiplatelet activity (NSAIDS)

Vitreous Hemorrhage

Pathophys: Any blood in the vitreous cavity is known as vitreous hemorrhage (VH)

S/S:

• Sudden visual loss

• Abrupt onset of floaters that may progressively get worse.

• occasionally can see bleeding within the eye.

initial diagnostic:

• CIues:

  • Inability to see fundus details

  • Presence fo blood in the vitreous in front of the retina.

Initial Management:

• Examination by an ophthalmologist is essential.

Intraocular Foreign body

-Foreign body lodges in any part of the eye.

S/S:

• Hx of “something in my eye”

• Particularly concerning if equipment based propulsion (chainsaw, hammering)

• Visual loss or media opacity.

Diagnostic:

• X-ray

• CT scan

• NO MRI!!!!!!!!!!!!!!!!!!!!!!!!

Management:

• Emergency treatment by ophthalmologist.

• Risk for intraocular infection.

Blow out Fracture

-Fracture of the inferior wall (maxillary sinus) and medial wall (ethmoid sinus through the lamina papyracea)

S/S:

• Diplopia (upward gaze)

  • Entrapment of inferior rectus

• Limitation of upward gaze

• Tenderness or step-offs at the infraorbital rim.

• absent pupillary light reflex → damage to afferent or efferent nervous system.

• Edema and periorbital ecchymosis.

Diagnostic:

• CT scan

Management:

• Refer out.

Globe Rupture

-A break or tear in the eyeball's outer layer (sclera or cornea), leading to intraocular leakage.

-Pathophysiology:

• Penetration/perforation/laceration

• Rupture due to blunt force.

-Epidemiology:

• Children: Sharp objects at home (scissors)

• Adults: Workplace injuries, assaults, MVAs.

• Elderly: Ground-level Falls.

-S/S:

• May be immediate or develop over days/weeks.

• Ecchymosis of eyelids

• Teardrop pupil

• subconjunctival hemorrhage

• hyphema

• everything

-Diagnostics:

• Slit Lamp

• Fluorescein staining → stream of clear aqueous fluid originating from the wound site. (Seidel sign)

• CT scan

• NO pressure on the globe during Evaluation!!!!

• ABCs come first.

• Ophthalmic exam diagnosis

Treatment:

• Patient is NPO

• Urgent ophthalmology consult

• Once the surgery is safe, surgery.

Amblyopia

-Reduced visual acuity in excess of that explicable by organic disease and is caused by prolonged abnormal visual experience in children under the age of 7.

• Strabismus (misalignment of eyes), anisometropia, visual deprivation. Brain favors the stronger eye.

-Epidemiology:

• Common in children

• Risk: FH, premature birth, low birth weight.

-S/S:

• poor depth perception, squinting, tilting of the head or closing one eye.

-Diagnosis:

• Reduced visual acuity → monocular

• Difference between eyes in vision.

-Treatment:

• Non-urgent referral.

• strengthen the vision of the amblyopic eye

• Early intervention is key.

Strabismus

-Any ocular misalignment in which only one eye fixates with the fovea on the object of regard.

• often results from muscular weakness or neurologic issues. Long-standing.

-S/S:

• Misalignment of the eyes.

• Esotropia, Exotropia, Hypertropia, Hypotropia

• Can be constant or intermittent

-Diagnosis:

• Made on a clinical exam.

• Early intervention is important.

-Treatment:

• Refer out.

• Realign the eyes and restore binocular vision

  • binocular glasses, vision therapy, and surgery for eye muscles.

Nystagmus

-A rhythmic, involuntary oscillation of the eyes, typically characterized by repetitive uncontrolled movements.

• The most common cause is from drugs (phenytoin), excessive alcohol, or any sedating med.

• Congenital: Albinism, Leber’s congenital amaurosis, Bilateral cataract.

S/S:

• Repetitive eye movements

• Reduced visual acuity

• abnormal head postures to minimize the effect

• Oscillopsia (illusionary movement of the environment)

Diagnosis:

• Eye Examination

• MRI or CT may be indicated

Treatment:

• Treat underlying cause

• Non-urgent referral

• Corrective lens

• Gabapentin, Baclofen

• Surgical interventions

• Vision rehab.

Conjunctivitis

-Most common cause of red, irritated eye.

-Self-limited typically, will last 10-14 days if not treated.

Epidemiology:

• Viral: Adenovirus

• Bacterial: all the common ones

• Allergic

• Chemical

S/S:

• Symptoms:

  • Discharge

  • FB sensation, photophobia

  • Eyelid matting

• Signs:

  • Red eye, mild or no change in visual acuity

  • Involvement of the bulbar and tarsal conjunctiva.

Diagnosis:

• Hx and smear culture.

Treatment:

• Empiric treatment for 5-7 days:

  • Polymyxin-bacitracin

  • Trimethoprim-polymyxin

  • Ofloxacin (preferred for contact lens)

  • Erythromycin ointment

Scleritis

-Painful, destructive, and potentially blinding. The pain is constant and boring (very intense) and may radiate to the face and periorbital region.

S/S:

• Tearing, photophobia

• Globe tenderness to palpation

• Painful ocular movement

• Red eye

• Signs:

  • The conjunctival vessels are injected.

Initial Diagnostic:

• Check intraocular pressure.

Approach to management:

• An ophthalmology consult is required.

• Treatment varies to underlying disease:

  • NSAID therapy

  • Glucocorticoids

  • Immunosuppressant medications.

Subconjunctival Hemorrhage

-Results from rupture of small vessels bridging the potential space between the episcleral and the conjunctiva.

• Usually spontaneous but can result from blunt trauma, eye rubbing, or vigorous coughing.

S/S:

• A spectacular red eye

• Vision is not affected and the patient often doesn’t realize.

Treatment:

• None needed.

Acute Angle-Closure Glaucoma

-Pupil becomes mid-dilated, and peripheral iris blocks aqueous outflow via the anterior chamber angle and the intraocular pressure rises abruptly.

Epidemology/Risk Factors:

• Asian Highest risk, far sighted, elderly.

S/S:

• Pain, red eye, obscurations, blurred vision, N/V/Headache

• Hard eye on palpation

• Corneal edema, cloudy cornea

• Injections, Pupil moderalty dialated.

Diagnostic:

• Measurement of intraocular pressure during acute attack OR

• Gonioscope (observing the narrow chamber angle with a mirrored contact lens.

Treatment: (untreated → 2-5 days before vison lost)

• Emergent referral.

• Acetazolamide (PO or IV)

  • 500mg IV initially

  • 250mg orally QID

• Topical betablockers

• Prostaglandin analogues

• A2-adenergic agonists

• Pilocarpine to induce miosis.

• Laser Iridectomy

Orbital Cellulitis

-Infection around the orbit (H. Flu, S. Aureus, S. pneumoniae) usually stemming from a sinus or dental infection.

• Without treatment → Optic nerve can be damaged by inflammation and infx can spread to cavernous sinus.

Epidemiology:

• Pediatric: Ethmoid sinus infection (43-100%)

• Adult: Frontal Sinusitis (50%)

S/S:

• Recurrent dental or sinus infections

• Fever, Proptosis

• Restricted ocular movement

• Swelling and redness of the eye.

Diagnosis:

• Blood cultures

• CT of orbits with contrast

Treatment:

• Emergent referral to ophthalmology

• Immediate treatment with IV antibiotics

  • Penicillinase-resistant penicillin (nafcillin) AND

  • Metronidazole or clindamycin

• Trauma → Use cephalosporin for S. Aureus/Group A strep. coverage.

• Surgery for drainage of abscess.

Blepharitis

-Chronic inflammation of the eyelids that are usually colonized by Staph.

S/S:

• Greasy eyelids

• Ulcerated Lids

• Bumps on the under eyelid.

• Crusted with scaling debris that cling to lashes.

Management:

• Eyelid hygiene

• Warm compresses

• Eyelash scrubs with baby shampoo.

Hordeolum

-Caused by Staph infx of the superficial accessory glands of Zei’s or Moll located in the eyelid margins.

• Also called a stye.

• More common in adults than children.

• “shows up overnight”

• Can visualize “head”, typically pointed outward.

S/S:

• Upper or lower lid

• Localized, red, swollen

• Acutely tender lesion

Diagnosis → clinical exam

Treatment:

• Topical antibiotics (Bacitracin/Polymyxin B Opthalmic ointment.)

• Warm compress

• Not improving over 48 Hours → incision indicated.

• Tx any generalized cellulitis of the lid.

Chalazion

-Granulomatous inflammation of a meibomian gland

• This may FOLLOW an internal hordeolum.

• High recurrence rate

• More common in third decade of life.

S/S:

• Painless swelling of the eyelid over weeks or months.

• Slowly enlarging and non-tender

Treatment:

• Warm compress

• Typically completed by ophthalmologist

  • I&D if not improving in 2-3 weeks.

  • Corticosteroid injection.

Amaurosis Fugax

-Transient ischemic attack of the retina → interruption of blood flow to the retina for more than a few seconds, resulting in transient monocular blindness.

• Typically the result of an embolus in an arteriole

• often from atherosclerotic plaque in the carotid artery or aorta.

Risks: (vascular disease)

• Giant cell arthritis

• Carotid Stenosis

• CAD, A-Fib, Valvular disease

• Diabetes, Advanced age

S/S:

• Sudden-onset monocular loss of vision

• Usually lasting a few minutes with complete recovery

• Rapid fading vision like a curtain descending, sometimes only affecting a portion of the visual field.

  • RECOVERY IS KEY!!!!

Diagnostics;

• Urgent neuroimaging to asses for cerebral infraction/identify the source of emboli

• Ophthalmoscopy shows zones of whitening, edematous retina following the distribution of branch retinal arterioles.

Treatment:

• Due to increased risk of stroke, TIA, and MI; treat underlying cause.

• Immediate treatment with oral aspirin (81mg or higher)

Central & Branch Retinal VEIN Occlusion

-Blockage in certain vessels in the retina (you have to guess based on the following 🙂

S/S:

• Sudden monocular loss of vision

• no pain or redness

• Widespread retinal hemorrhages

• Retinal venous dilation and tortuosity

• Retinal cotton-wool spots

• Optic disc swelling

Initial Diagnostic:

• Screen for diabetes, hyperlipidemia, and hypertriglyceridemia for all patients.

• ESR

• Antiphospholipid antibodies.

• Retinal findings distinguish from arterial occlusion.

Management:

• Urgent referral

• Intravitreal injection of VEGF (vascular endothelial growth factor)

Central & Branch Retinal ARTERY Occlusion

-Decreased arterial blood flow to the retina resulting in ischemic damage.

S/S:

• Sudden monocular loss of vision

• no pain or redness

• Widespread or sectoral pale retinal swelling.

Diagnostic:

• Screen for diabetes, hyperlipidemia, and hypertriglyceridemia for all patients.

• ESR and CRP are typically evaluated.

• Urgent brain MRI

• Obtain duplex ultrasonography of carotid arteries, ECG, and echocardiogram

• Ophthalmoscopy: Reveals pale swelling of the retina with cherry-red spot at the fovea.

Treatment:

• Emergent referral to ED for stroke evaluation/urgent ophthalmologist referral.

• Lay patient flat

• Ocular massage

• High concentrations of inhaled oxygen

• Intravenous acetazolamide

• Anterior chamber paracentesis.

Macular Degeneration

-Gradual, Painless, and Bilateral central vision loss

• Exudative:

  • Choroidal layer has new vessel growth under the retina that leads to exudative fluid, hemorrhage, and fibrosis.

• Dry:

  • Accumulation of extracellular deposits called drusen underneath the retinal pigment epithelium.

S/S:

• Bilateral central vision loss

• no pain or redness

• Distortion or abnormal size of images

• Wet (10%) → more rapid onset

• Dry (90%) → Progressive visual lost due to atrophy or outer retina.

Diagnosis:

• Eye Exam with urgent referral to ophthalmologist.

Treatment:

• Must be seen and regularly treated by an eye doctor.

• No dietary change has been directly linked to prevent development.

• Improvement with Vit. C, E, zinc, copper, and carotenoids.

• Wet MD → inhibitors of VEGF (ranibizumab)

Drusen

-The Hallmark of Macular Degeneration.

-Extracellular deposits of lipids, proteins, and cellular debris which are found within the layers of the retina and appear as small, yellow deposits on dilated eye exams.

Diabetic Retinopathy

-Complication to diabetes → retina is damaged.

-Chronic high blood sugar → microvascular changes → weakened vessel walls → → vision impairment or loss.

Epidemiology:

• 33% of all diagnosed diabetic patients.

• More common in type 1

S/S:

• Reduction of vision

Diagnosis:

• Non proliferative DR:

  • Mild, moderate, or severe with microvascular changes limited to the retina

    • Microaneurysm

    • Retinal hemorrhages

    • Venous beading

    • Retinal edema

    • Hard exudates

• Proliferative DR:

  • New blood vessels grow on the surface of the retina, optic nerve, or iris;

    • neovascularization

• Diabetic Macular edema:

  • Central retinal swelling; reduces foveal center visual acuity.

Treatment:

• Acute visual changes → Emergent referral to eye doctor.

• Urgent referral for all other cases.

• Glucose Control

• SCREENING!!!!!!

Retinal Detachment

-Physiologic and anatomic mechanisms of retinal attachment are overcome and the retina separates from the underlying retinal pigment epithelium.

• Can be caused by trauma/injury, previous ocular surgery, nearsightedness, diabetes, sickle cell (via increased traction on the retina.

S/S:

• Monocular decreased visual function

• Shadow or curtain descending over the eye.

• Cloudy or smoky vision

• Floaters

• Momentary flashes of light.

Diagnostic:

• Fundoscopic Exam → billowing or tentlike elevation of the retina.

• Appears gray

• Tears/holes best seen with indirect ophthalmoscopy.

Treatment:

• Urgent referral (within 24 hours)

• Surgery