Ophthalmology Summary Sept 2014 Eyelid diseases Meibomian cyst (aka chalazion) = chronic inflammation of meibomian gland (firm, nontender nodule) Rx: warm compresses 1-2/52, I+D if doesn t settle, Abs if ruptured Stye: external hordeolum. Acute bacterial infection of glands of Zeis - usually Staph. Red, tender swelling. Rx: warm compresses, topical Abs Hypertensive retinopathy Silver wiring and AV nipping Cotton wool spots, flame haemorrhages and disc swelling more typical of malignant hypertension Pupil Abnormalities Argyll-Robertson (prostitutes pupil) bilateral small pupils, accommodate but don t react (neurosyphilis) Holmes-Adie unilateral dilated pupil, accommodates but doesn t react (viral inflam parasymp ganglion) Horners partial ptosis, miosis, anhidrosis, enophthalmos Brainstem = stroke, tumour Chest = lung cancer Carotid artery = trauma, dissection RAPD - Relative afferent pupillary defect (Marcus-Gunn pupil) = damage to optic nerve or extensive retinal injury (neuro-retinal dysfunction) absent direct response but positive consensual response swinging flashlight Causes: - retina: CRAO, CRVO - optic nerve: neuritis, ischaemia, compression, glaucoma Papilloedema Raised ICP, Malignant HTN, Brain tumour, Normal pressure hydrocephalus Corneal ulcers Bacterial superinfection; pseudomonas in contact lens wearers; other RF = DM, immunocomp White/grey spot on cornea; central lobulated mass with surrounding fluorescein uptake; hypopyon (soupy = Pseudomonas, solid = staph/strep) Ophthalmology review, fortified top Abx Corneal Erosion Abrasion without history of trauma; can be infective; more in low humidity and high altitude; due to weakness of corneal BM; Sx onset on wakening; 50% have adherant flap of cornea Urgent opthalmology reviw, topical NSAIDs, debride flap, N saline drops for 3/12 to prevent recurrence Traumatic Iritis Occurs after days; photophobia, deep eye pain; cells and flare in ant chamber; cycloplegics/steroid drops Ocular FB Hx: type of FB (organic vs inorganic), velocity of impact Exam: VA. size/site/nature FB, depth penetration. Cornea/AC/iris/pupil/lens. Evert lids Mx: topical anaesthesia, removal under slit lamp, rust ring removal, topical Ab +/- cycloplegic for comfort Avoid contact lenses until healed; review 24-36hrs; ophthalmology review if can t remove FB, worsening Sx, recurrent Sx, rust ring overlying pupil; rust ring may require removal over a few days FB penetrating cornea - ophth referral www.shakem.co.nz 1
Penetrating trauma Hx: velocity/type of projectile, eye protection, previous trauma/surgery Sx: decr VA, pain on eye movt, diplopia OE: collapsed globe; decr VA, loss of red reflex; shallow ant chamber; prolapsed tissue; irregular pupil; coloured spot of choroid visible on sclera; chemosis; visible laceration; small subconjunctival haem; decr Iop; cloudy lens; Seidel test, subconjunctival haem Ix: CT; USS (high sens and spec) Mng: shield; antiemetics; avoid topical meds; IV cephalothin and gent; ADT, keep NBM, bed rest, sit 30deg Retrobulbar haematoma Blood accumulates behind globe - proptosis, ischaemia of ON (fixed dilated pupil), visual loss Mng: urgent lateral canthotomy Ruptured globe Ophthalmological emergency Exam: decr movt, slit lamp, blood in anterior chamber, lacerations, red reflex CT scan for orbital wall fracture if indicated Non-urgent referral within 3 days if the above findings are negative. Urgent referral to ophthalmologist if intraocular haemorrhage, ruptured globe or orbital wall fracture Eyelid lac An eyelid laceration is a potential penetrating eye injury until proven otherwise. Imaging if possible FB or # Superficial: 6/0 non-absorbable, ROS 5d. Abs/ADT. Refer if: full thickness, globe as well, palpebral ligament, lacrimal apparatus, tissue loss, lid margins, ptosis, tarsal plate involved, levator palpebrae, within 6-8mm of medial canthus (canalicular system) Hyphaema Blood in anterior chamber Ix: full eye assessment, fundoscopy, facial #s. Decr VA in50% Admit if >25% or over visual axis (=washout), anticoagulants, single eye, decr VA, poor compliance Mx: bed rest, head up 30 deg, shield, limit activity, avoid anticoagulants, analgesia, antiemetics, mydriatic, acetazolamide or timolol if incr IOP; dilate pupils - cycloplegics - cyclopentolate 0.5% 1 drop OD Complications: rebleed (day 3-5), visual los, incr IOP, synechiae, permanent staining cornea, AACG Ocular burns Chemical Burns Alkali more harmful Management of concurrent injuries Eye irrigation - ph optimum 6.5 8.5 acceptable, goal neutral ph 7.4 Evert eyelid clear debris Topical antibiotic drops, cycloplegics and mydriatics. Urgent ophthalmology consult and review if any visual acuity loss or corneal opacification Thermal burns Analgesia, Mydriatic agent, Urgent ophthalmological consult Flash burns Arc eye/snow blindness Intense pain, red eyes usually bilaterally, blepharospasm and tearing Check VA, widespread superficial epithelial defect staining with fluorescein Rx: topical antibiotic QID and cycloplegic; analgesia www.shakem.co.nz 2
Orbital Cellulitis Infection of soft tissues behind orbital septum More common in children: 7-12 years orbital, younger pre-septal Causes Orbital: H influenzae (non-immunised); strep pneumoniae; staph aureus; G-ives; anaerobes Periorbital: Staph aureus Orbital cellulitis secondary to: haematogenous seeding or direct extension from ethmoid sinus Preseptal cellulitis secondary to: contiguous spread from skin Assessment Hx: headache, sinus Sx, fever, pain OE: decr eye mvmt, chemosis, proptosis, decr VA, pupil dilation, RAPD, painful ophthalmoplegia (Periorbital: no proptosis, normal extraocular eye movts) Management Periorbital/preseptal: PO augmentin or cephalexin; if unwell - cefotaxime or ceftriaxone + fluclox Orbital: iv fluclox + cefotaxime / ceftriaxone; urgent ophthalmology review; may need decompressive OT Complications Cavernous sinus thrombosis, Frontal bone osteomyelitis, meningitis, subdural empyema, epidural abscess Red Eye Traumatic - blunt trauma, penetrating trauma, corneal FB Atraumatic - conjunctivitis (allergic, viral, bacterial) - keratitis (bacterial, fungal, HSV, contact lens) - scleritis/episcleritis, iritis - endophthalmitis - cavernous sinus thrombosis - glaucoma Conjunctivitis 1. Allergic: cold compresses, OTC topical vasoconstrictors, histamine-blocking eye drops, oral antihistamines 2. Viral: (usually adenovirus) cold compresses, artificial tears, topical decongestants. 3. Bacterial: Purulent: strep; chlamydia; gonococcal, pseudomonas (contact lens - topical fluoroquinolone) Tx=topical Abs, check for STI (systemic Abs - azithro) Herpes zoster ophthalmicus Sight threatening condition Hutchinson sign = herpes pustules at nose tip and is predictive of ocular involvement. Dendrites on exam. Can cause keratitis, scleritis, uveitis, acute retinal necrosis Usually monocular; vesicular rash in V nerve (cornea involved if tip of nose involved as nasociliary) Rx: analgesia, po acyclovir 800mg 5 times a day 1/52, iv if sight threatened; ophth review within 24hrs Keratitis Whiteness, cells and flare in ant chamber; hypopyon if severe; unilat blurred vision, mild headache Causes: 1. Infection - viral (HSV, zoster, adenovirus) - bacterial (Staph, chlamydia, pseudomonas - contact lens) - amoeba (acanthamoeba - contact lens = serious infection) - fungal (contact lens) 2. Allergic - kerato-conjunctivitis 3. Photo-keratitis - Welders eye/arc eye, snow blindness 4. Exposure - with coma 5. Trauma - corneal ulcer Ix: corneal scraping. Mng: top cipro; top steroids once infection under control www.shakem.co.nz 3
Iritis (anterior uveitis) Causes: ~50% idiopathic. Inflammatory/traumatic/infectious. Trauma; HLA B27/seronegative spondyloarthropathies: RA, IBD, Reiters, Collage vascular disease; TB, sarcoid Hx: sudden, severe, aching pain, red eye, photophobia, decr VA OE: Ciliary Flush = injection maximal around limbus (ie peri-limbic erythema) Photophobia (consensual), mild-mod decr VA, small/normal + irregular pupil, usually unilateral Anterior chamber - WBC (cells) & protein (flare), post synechiae, hypopyon Cornea - keratitis, keratic precipitates, oedema Mng: ophth; top/po steroids if severe and no evidence of corneal infection; dilate pupil Episcleritis Episclera = thin membrane over sclera and beneath conjunctiva Benign, self-limiting inflammatory condition RA, PAN, lupus, IBD, sarcoid, Wegener s, gout, HSV, syphilis Painless; isolated area; unilateral; NSAIDs; usually settles Scleritis Most common immune cause: RA. Most common vasculitis cause: Wegener s Hx: Severe dull eye pain, photophobia, may have decr VA O/E: Sectional redness, blue tinge (deep episcleral plexus vascularly engorged); vessels non-blanching with vasoconstrictor, scleral oedema, nodules Rx: analgesia, NSAIDs, TOP steroids, cycloplegics; refer ophth <24hrs Acute Angle-Closure Glaucoma Compartment syndrome of the eye Incr risk: older, Asian, long sighted, anticholinergics, FHx, DM, pupil dilators (beta agonists, antihistamines) Clinical findings Severe unilateral ocular pain Blurred vision, halos N/V Red eye, cloudy cornea, moderately dilated, non-reactive pupil, conjunctival injection IOP >40 mm Hg Elevated IOP with shallow anterior chamber Treatment Incr outflow aqueous humour Pilocarpine 4% q5min for first hour then qid Block production aqueous humour Acetazolamide 500mg iv/po + Timolol 0.5% 1 drop q2h Reduce volume vitreous humour Mannitol 1mg/kg iv Surgical - laser iridotomy. Supportive: Analgesia, Antiemetic, Avoid anticholinergics Sudden Visual Loss Exam VA, fields, RAPD and pupil reactivity, extraocular movts, red reflex, fundus, slit lamp incl ant chamber IOP (normal 10-20 mmhg) Retinal Artery Occlusion Ocular emergency. Causes: thrombotic (most common - GCA, vasculitis), embolic (carotid/heart) OE: decr VA, RAPD; pale optic disc; cherry red spot (fovea against white infarcted retina),?carotid bruit Management Digital massage; hypercarbia; topical beta-blockers/acetazolamide decr IOP; O2; Steroids if GCA. Hyperbaric www.shakem.co.nz 4
Retinal vein occlusion Infarction not ischaemia Causes: vasculopaths - hyperviscosity, HTN, glaucoma, atherosclerosis, DM Thunderstorm retina, dilated retinal veins, cotton wool spots, disc oedema, RAPD if severe Retinal detachment Associations: myopia, cataracts removal, vitreous diseases, trauma Exam: decr VA, abnormal red reflex, +/- detached retina, field defect Vitreous haemorrhage Trauma; DM (neov); coagulopathy; post vitreous detachment (shaken baby); retinal detachment Red reflex poor or absent, no RAPD Optic neuritis Idiopathic; MS; temporal arteritis; HTN; atherosclerosis; viral (measles, mumps); syphilis, TB: sarcoidosis Assessment: decr vision; unilat; eye pain, esp on adduction (90%); Uhthoff s phenomenon; central scotoma; RAPD; optic disc oedema in 50%; small haemorrhages over disc Ischaemic Optic Neuropathy Most often caused by GCA Usually not complete loss of vision, RAPD common. Symptoms of waking, don t worsen Fundoscopy: Papilloedema with splinter haemorrhages at disc margin Mx: steroids, refer, biopsy Third Nerve Lesions Central (midbrain) Stroke, Tumour, Demyelination Peripheral Compressive = pupil involvement PCOM aneurysm Tumour (nasopharyngeal) Meningitis/CNS abscess Superior orbital fissure syndrome (Tolosa-Hunt) Ischaemic = pupil sparing Arteritis, Diabetes, HTN, Migraine www.shakem.co.nz 5