Ophthalmology PANRE Review Brock Phillips, PA-C
I am not an ophthalmologist, optometrist or certified eye guy of any sort - I am a practicing UC/EM PA-C who frequently evaluates eye/vision complaints, consults Ophtho regularly and has taken an interest in the topic. Eyes are fascinating! Thanks to Joshua F. Smith, PA-C - who originally created this lecture and graciously allowed me to adapt it
Review A&P of the eye and topics covered on PANRE Blueprint buzzwords & key points are noted in red Score 100% on the ophthalmology questions! Augment your clinical practice with a few ophtho pearls, tips and tricks
Blepharitis Blowout fracture Cataract Chalazion Conjunctivitis Corneal abrasion Corneal ulcer Dacryoadenitis Ectropion Entropion Foreign body Glaucoma Hordeolum Hyphema Macular degeneration Nystagmus Optic neuritis Orbital cellulitis Papilledema Pterygium Retinal detachment Retinal vascular occlusion Retinopathy Strabismus
Work from the outside inward Gross exam - photophobia, asymmetry, doorknob DXs Visual acuity EOMs and visual fields Periorbital eye, lids, lashes, glands & ducts Conjunctiva, sclera & cornea Iris & limbus Pupillary size & response Anterior chamber Posterior chamber
Always check & document visual acuity! This is considered to be the vital sign of the eye. You wouldn t skip a pulse ox on a PNA pt, would you?! Wall chart (20 ft.) vs. handheld (14 ) Can t see chart? Counting fingers, hand motion, light
Monocular vision loss Heteronymous Hemianopsia (aka Bitemporal") Homonymous Hemianopsia Superior Quadrantanopsia
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CN VI Palsy - limited lateral gaze Inferior Rectus Entrapment limited downward gaze
When no light is present, both pupils are dilated Presenting light in one eye will result in similar constriction in the opposite pupil RAPD (Relative Afferent Pupillary Defect) Light in the affected eye causes paradoxical dilatation
Lids and Conjunctiva Blepharitis Ectropion/Entropion Chalazion Hordeolum Dacryocystitis Conjunctivitis Pterygium
Chronic inflammation of the eye lids Seborrhea Bacterial infection Red lids with scales adhered to lashes TX: Baby shampoo lid scrubbing Topical ABX
Ectropion Edges of the eyelid roll out due to: Trauma Advanced age Facial palsy Infection Entropion Eyelid edges are turned inward due to scarring or muscle spasm TX: Surgery (blepharoplasty) if the above problems are symptomatic
Chalazion is a painless cyst in the eyelid due to blocked meibomian gland TX: warm compresses or elective excision Hordeolum (stye) is a painful nodule or pustule caused by staph infection TX: warm compresses 1st, topical ABX, I&D if not better
Inflammation and/or infection of the lacrimal sac 2/2 obstruction of duct Usually Staph aureus, Strep, Staph epidermidis or Candida TX: ABX and warm compresses Surgery if not better after conservative management (DCR)
Benign, slow growing tissue of the bulbar conjunctiva Looks like a white vascular triangle, nasal side Encroaches on the cornea Leave alone unless it starts to impact vision, then surgical excision
Elevated yellow mass on the conjunctiva, adjacent to the cornea Benign; caused by sun exposure, chronic trauma, chronic dryness Leave alone unless bothersome, then surgical excision
Conjunctivitis Allergic Viral Bacterial HSV/Zoster
Inflammation of the conjunctiva due to environmental allergies Nearly always bilateral Itchy, red, irritated eyes with clear discharge/tearing Cobblestoning of palpebral surfaces Associated with other allergic symptoms TX: Rhinorrhea Congestion Sneezing Topical antihistamine gtts Oral antihistamines
Caused by adenovirus Very contagious Unilateral or bilateral Often starts in one eye and transfers to the other Conjunctival injection, clear to mucoid D/C, pre-auricular lymphadenopathy TX: Supportive including warm compresses and artificial tears, +/- ABX ointment Hand/eye hygiene is important
Common pathogens include Staph. aureus Strep. pneumoniae Haemophilus sp. Moraxella sp. Also: Neisseria gonorrhoeae, Chlamydia trachomatis Red eyes, matted & crusted lids/lashes, unilateral or bilateral copious purulent drainage Gram stain may help diagnosis Giemsa stain for chlamydia TX: topical ABX ointment or gtts targeting organism, hygiene recs. IM/PO ABX for G/C conj.
Herpes Simplex or Varicella Zoster Virus Most common cause of corneal blindness Dendritic ulcers on cornea observed on fluorescein staining Zoster may manifest with lesions on tip of nose ( Hutchinson s sign ) TX: Topical or oral antivirals AVOID topical steroids
Inflammation of iris, which is the anterior portion of the uvea Traumatic (delayed in onset) vs. atraumatic(linked to rheum/autoimmune/ibd) S/SX of limbic flush, deeper pain not alleviated by tetracaine, consensual photophobia, cells and flare (WBCs in anterior chamber) on slit lamp exam TX ed w/ steroid & dilating gtts Commonly misdiagnosed as conjunctivitis! Don t make this mistake!!!
Anterior Chamber/Lens Corneal Abrasion Corneal Ulcer Cataract Glaucoma Hyphema
Abrasions only involve superficial epithelium Due to mechanical trauma SX: pain, FB sensation, photophobia, tearing Look on eye and under lid for residual foreign body - abrasion itself visible with fluorescein Treatment ABX ointment/gtts (cover pseudomonas in CTL wearers, organic/dirty material) and Tdap Patching/bandage contact lens controversial DO NOT give tetracaine/topical anesthetic for D/C
Ulcers involve the epithelium and stroma Can be caused by: Trauma Infection Contact lenses SX: Pain, photophobia, tearing Fluorescein staining shows epithelial defect with dense/hazy corneal infiltrate TX: Refer to Ophtho Avoid steroids (can lead to perforation)
Accumulation of protein within the lens causing opacity and decreased vision Causes: Aging, trauma, diabetes, systemic steroids Signs: lens appears yellow and translucent, difficult to examine retina SX: Gradual vision loss, glare, double vision, spots TX: extraction of lens with placement of intraocular lens
Increased intraocular pressure (IOP 20) due to inability of aqueous humor to move through trabecular network in iris. This pressure leads to damage of the optic nerve causing cupping and increased cup-to-disc ratio.
OPEN CLOSED
Closed angle glaucoma is an EMERGENCY S/SX: painful red eye, fixed/mid-dilated pupil, vision loss, tearing, N/V TX: Emergent referral to Ophtho IV acetazolamide, topical beta blockers. DO NOT DILATE EYES
Open angle glaucoma is chronic compared to closed SX: can cause gradual loss of vision progressing to blindness. Usually asymptomatic at first. First SX is loss of peripheral vision. TX - topical drops including: Prostaglandins (first line) Beta blockers (timolol) Alpha agonists (brimonidine) Carbonic anhydrase inhibitors