HEENT Eye Diseases

anterior blepharitis (inflammation of the eye) characteristics

affects outside front of eyelid, where eyelashes are attached

sebaceous glands of zeiss

blepharitis S&S (anterior or posterior)

chronic inflammation of eyelid margins, common recurrent disorder of eye

eye discomfort, redness, tearing, dry eyes, burning, itching, high sensitivity, irritating sandy gritty sensation

anterior blepharitis staphylococcal infection differential S&S

scaling, matted, hard crusts around eye lashes

may have diff opening eye in morning

loss of eyelashes

anterior blepharitis treatment (staphylococcal infection)

warm compress, lid hygiene, antibiotic ointment - erythromycin, bacitracin, sulfacetamide, topical ophthalmic azithromycin 1% solution, steroid use - staph. marginal ulcer

anterior blepharitis (seborrheic infection) differential S&S

greasy flakes/scales along eye lashes and lid margin, seborrheic dermatitis (dandruff)

anterior blepharitis (seborrheic infection) treatment

warm compress, eyelid scrubs, baby shampoo

posterior blepharitis differential S&S

meibomian gland dysfunction, glands plugged with oily secretions

chronic red irritated eyes

lid margins - hyperemic with telangiectasis (widened venules causing threadlike red lines or patterns on skin)

RF: acne rosacea, seborrheic dermatitis

posterior blepharitis Tx

warm compress, lid scrubs, bacitracin or erythromycin eye ointment, oral tetracycline and/or short term topical corticosteroids

Hordeolum (Stye)

acute purulent eyelid inflammation - localized

S. aureus - usual pathogen

external hordeola

due to blockage and infection of ciliary follicle and adjacent sebaceous glands of Moll or Zeis (ciliary glands)

internal hordeola

due to blockage and infection of the meibomian sebaceous glands located in the tarsal plate (under eyelid)

hordeolum S&S

acute onset, painful, red, purulent eyelid inflammation

localized swellings with abscess formation, may lead to cellulitis

hordeolum Tx

usually self-limiting, (5-7 days) warm compresses/soaks

may need incision if no resolution in 48 hr

chalazion

focal, chronic, inflammatory lesion of eyelid due to obstruction of sebaceous gland, often following an internal hordeolum

chalazion S&S

lipogranulomas; NOT infected

slow-growing, painless nodules in middle of eyelid

redness and swelling of adjacent conjunctiva

chalazion Tx

warm compresses/soaks for 10min four times a day**

antibiotic therapy or surgical drainage, steroid injection - if no infection and/or response to treatment

angioedema (swollen blood vessels) S&S

often, but not always bilateral

abrupt onset over minutes to hours; may follow an exposure

scaling usually absent

angioedema Tx

often self-limited; avoid inciting agents

emergency medical attention for upper airway obstruction - IM epinephrine

cellulitis S&S

severe edema, deep violaceous color, and pain

angry red cheek

onset over hours to days

Hx of preceding URTI, local skin trauma, abscess, insect bite, impetigo; sinusitis with 60-80% orbital cellulitis

orbital cellulitis (post-septal)

proptosis, decreased visual acuity, pain with eye movement, limitation of extraocular movements and afferent papillary defect

cellulitis management (pre-septal cellulitis)

broad-spectrum oral antibiotics (e.g. dicloxacillin OR amoxicillin/clavulanate [Augmentin]) and close follow-up

less than 4 years - hospitalize

orbital cellulitis (post-septal) Dx/Tx

WBC, conjunctival cultures, blood cultures, CT scan, referral

ampicillin/sulbactam [Unasyn]

entropion

inward turning of eyelid, usually lower lid, degeneration of lid fascia, may follow extensive scarring of conjunctiva and tarsus

entropion Tx

botulinum toxin injection

ectropion

outward turning of lower lid, common with advanced age,

tearing, dry eyes

ectropion Rx

surgery, If: excessive tearing (epiphora), exposure keratitis or cosmetic problem

pinguecula

yellow elevated nodule on either side of cornea

benign, sun exposure, inflammation occurs

pinguecula Tx

artificial tears beneficial, short course of NSAIDs or weak steroid

pterygium

fleshy triangular area on conjunctiva, nasal side of cornea

unilateral or bilateral; wind, sun, sand, dust

pterygium Tx

artificial tears beneficial, short course of NSAIDs or weak steroid

excision - growth interfering with vision

dacroadenitis

infection of lacrimal gland

dacryocystitis

infection of lacrimal sac due to obstruction of nasolacrimal system

may be related to malformation of the tear duct, injury, eye infection, or trauma

dacryocystitis S&S

usually unilateral

epiphora and discharge, tenderness, redness, swelling

dacryocystitis etiology

acute, S. aureus, B-hemolytic strep.,

chronic, S. epidermidis, anaerobic species, Candida albicans

dacryocystitis Tx/Rx

acute = systemic antibiotics

dacryocystorhinostomy

ocular trauma S&S

foreign bodies “something in my eye”

history consistent with symptoms

FB usually in cornea or conjunctiva

visual acuity is recorded

ocular trauma Tx

local anesthetic, fluorescein, examine eye, sterile wet cotton-tipped applicator, polymyxin-bacitracin ophthalmic ointment

FOLLOW UP IN 24 HRs! referral

ocular trauma - Steel FB

leaves ‘rust ring’, tissue excised under local anesthesia using slit lamp

ocular trauma - FB under upper eyelid

local anesthetic inserted, lid everted, FB removed with applicator

ocular trauma - corneal abrasions (cut/scratch)

H/o trauma to eye

fingernail, paper, contact lens

c/o pain, photophobia, tearing, blepharospasm, FB sensation

ocular trauma - corneal abrasion Dx

visual acuity recorded

fluorescein →examine with light

abrasion seen as a darker green area

ocular trauma - corneal abrasion Rx

polymyxin-bacitracin ophthalmic ointment

follow up in q24 hrs till healing and referral

corneal laceration

significant ocular trauma, metallic object - hand tool

finger nails do not have enough force to lacerate cornea

corneal laceration S&S

c/o intense pain, cut

photophobia, uveitis

visual acuity significantly reduced

bubbles within anterior chamber

corneal lacerations Tx

referral, cover with shield, keep nothing per oral (in case of surgery), X-ray/CT done

hyphema

blood enters anterior chamber of eye between iris and cornea

pt stands up to see blood

corneal ulcer bacterial infection

adnexal infection, lid malposition, dry eye, CL

corneal ulcer viral

HSV, H. zoster oticusco

corneal ulcer protozoan

acanthamoeba in contact lens wearer

corneal ulcer

infection from bacteria, virus, fungal, protozoa

mechanical or trauma

chemical: alkali injuries are worse than acid

blow out fracture

H/o blunt ocular trauma; large, low-velocity object, sports-related

recent trauma: Sx of pain, local tenderness, double vision

blow out fracture (orbital) S&S

edema, ecchymosis of lid tissues, restrictive ocular motility,

orbital crepitus (subcutaneous emphysema)

hypoesthesia of ipsilateral cheek

orbital edema displaces globe

proptotic

orbital blow out fracture Dx/management

CT scan

surgical intervention (wait 10-14 days)

orbital globe rupture

ophthalmic emergency

Hx: trauma, cover eye, NPO

cataract

opacity of lens (clouding), localized or diffused, unilateral or bilateral, does not affect both eyes symmetrically, usually age-related or congenital

cataract etiology

aging, trauma, smoking, alcohol, exposure to x-rays, diabetes

cataracts - Dx

loss of contrast, glare, more light - early Sx

progressive, painless blurring vision; swell → secondary closed-angle glaucoma - later Sx

pupil dilated - examination of red reflex

large cataract may obliterate red reflex

nuclear cataract

central lens nucleus

myopia, change refractive index of lens

posterior subcapsular cataract

cataract beneath posterior lens capsule, reduces visual acuity more when pupil constricts, produce glare, loss of contrast

cataracts prevention and treatment

UV-coated, indirect lighting, polarized lenses - decreased glare

indications for surgery, vision preventing needed or desired activities

retinal detachment

vitreous membrane pulls on and creates a tear in the retina

posterior vitreous detachment

with age, vitreous gel collapses and detaches from retina

retinal detachment S&S

showed of floaters (pepper)

descent of a “web” or “veil” in front of eye or in periphery

permanent vision loss can result

retinal detachment Tx

argon laser or “cryotherapy” - to fix

age-related macular disease (ARMD)

leading cause of irreversible blindness

central part of retina damaged

common in later life

macular degeneration S&S

persistent blurred vision

objects become distorted

small blind spot in central vision

black donut hole in middle

dry macular degeneration

thinning of macula’s layers, vision loss typically gradual

wet macular degeneration

fragile blood vessels develop underneath macula

blood vessels hemorrhage, destroy macular tissue

vision loss can be rapid

macular degeneration Dx

Amsler Grids

when to refer - emergent

visual loss not due to refractive error: pain, marked redness, central retinal artery occlusion, retinal detachment, giant cell arteritis

when to refer - urgent

vision loss associated with: redness, thyroid eye disease, optic neuritis, retinal detachment, retinal vein occlusion, branch retinal artery occlusion, vitreous hemorrhage, diabetic maculopathy, ischemic optic neuropathy, sudden onset macular degeneration

diabetic retinopathy

leading cause of new blindness among adults aged 20-65

diabetic retinopathy payhophysiology

high blood sugar levels dmgs blood vessels, and no good O2 flow

patches in vision blocked because dmged retina

nonproliferative diabetic retinopathy Dx

dilation of veins, microaneurysms, retinal hemorrhage, retina edema, hard exudates white

cotton wool spots - leaks in blood vessel

nonproliferative diabetic retinopathy Tx

control blood glucose (metformin type 2), BP

photocoagulation (prevent further bleeding)

diabetic macular edema VEGF-A

proliferative diabetic retinopathy Dx

neovascularization

extremely fragile, vitreous hemorrhage

prognosis is extremely poor if untreated

proliferative diabetic retinpathy Tx

VGEF-A

photocoagulation, new blood vessels

hypertensive retinopathy

comorbidity chronic hypertension

“copper wiring” - moderate vascular wall changes

“silver wiring” - severe vascular wall hyperplasia

hypertensive retinopathy Dx

funduscopic examination → arteriolar constriction, arteriovenous nicking, flame-shaped hemorrhage, cotton-wool spots (retinal ischemia), papilledema

papilledema

normal pressure glaucoma, increased intracranial pressure

DO NOT DO LP with this

papilledema Dx

eye exam - cupping/pushing out optic nerve

central retinal artery occlusion

blockage of central retinal artery - usually by emobolism

central retinal artery occlusion S&S

sudden, painless, unilateral blindness or visual defect

retina becomes pale because lack of blood

central retinal artery occlusion Dx

history, fundoscopy → pale,opaque fundus with cherry red spot

ESR, diabetes Hx, hyperlipidemia

central retinal artery occlusion Tx

<24 hr: high concentration inhaled O2, IV acetazolamide, anterior chamber paracentesis (decrease intraocular pressure)

central retinal vein occlusion

blockage of central retinal vein by thrombus. usually elderly

central retinal vein occlusion S&S

blue tint, multiple hemorrhages

monocular loss of vision

central retinal vein occlusion onset

painless visual loss can be sudden or gradual

central retinal vein occlusion Dx

fundoscopy

retinal veins appear distended and torturous, hemorrhages, cotton wool spots, optic disk swelling, fundus congested/edematous

amaurosis fugax

‘fleeting blindness’. retinal emboli, choroidal/retinal vascular spasm

amaurosis fugax S&S

‘curtain passing’ vertically across visual field

complete monocular visual loss (few min)

amaurosis fugax Dx

duplex ultrasonography/MRA, echocardiogram

amaurosis fugax Tx

carotid endarterectomy; angioplasty

retinitis pigmentosa

condition affecting rods

inherited disorder - rods gradually degenerate

night vision severely affected. eventually only central vision remains

retinitis pigmentosa Tx

amber-colored glasses with UV absorption coating SLOWS disease progress, but no known Tx otherwise

conjunctivitis

most common nontraumatic eye infx in adults and children, contagious

conjunctivitis S&S

redness all around eye → globally red, “pink eye”

increase tears, discharge (green, white, yellow), itchy eyes, burning, blurred, photophobia

viral conjunctivitis etiology

a history of viral syndrome (adenovirus), STD (Herpes simplex virus), Chlamydia

viral conjunctivitis S&S

clear, watery discharge; scanty exudate; pruritus common

severe photophobia, FB sensation

viral conjunctivitis complication

visual loss