ophtho notes

ophtho exam

LLL - lids, lashes, lacrimal system

CS - conjunctiva, sclera

K -cornea (~1mm thick, mostly collagen)

HPI: common chief complaint: eye pain

is it surface, ciliary, or deep orbit?

corneal abrasion, ulcers, lacerations exquisitely painful - goes away with drop of anesthetic (lasts for 20 minutes)

ciliary - iritis, acute angle closure, deep more boring pain, photophobia, light causes ciliary body spasm - narrow angle closure, relieved w/cycloplegics (dilators)

deep orbit -retrobulbar, myositis, optic neuritis multiple sclerosis

?'s - whats symptoms, tearing? time of day? recurrent symptoms? contacts? allergy, seasonal, dry eyes, topical meds? in one eye? suggests recurrent erosion

contact lens history - wearing habits, soft vs rigid vs gas permeable vs hard, cleaning habits?

trauma

sharp vs blunt

establish the force involved - size of object - fist is bigger than orbit, usually bones break globe is preserved. more worried about smaller objects (pencils, golf balls, paint balls etc)

foreign body?

chemical?

infraorbital hypothesia? orbital floor fracture disrupts nerve.

pain and loss of vision may not correlate w/severity of injury

topical anesthetic is epithelial toxic, can cause ulceration over time (no prolonged use)

hypopion - white blood cells in anterior changes

drops:

antibiotics - drop or ointment

corticosteroids - milky white (risk of cataract and increased intraocular pressure)

combo antibiotics and steroids

cycloplegics (red-top)

anti-glaucoma

beta blocker

check airway hypersensitivity

carbonic anhydrase inhbitors

alpha2 blockers - cause depression

prostaglandins

Orals

diamox (acetazolamide) lowers intraocular pressure fast (used in narrow angle and pseudotumor cerebri)- sulfa allergy

oral prednisone

anti-inflammatory - indomethacin

dendrites on the cornea under fluorescein dye- herpes

angular artery will anastomose w/internal circulation (retinal arter)

random clinical notes:

neurofibromatosis1 - can have sphenoid wing dysplasi

scleral show- see sclera above and below the iris secondary to sympathetic tone (muller's muscle, tarsal), seen with exophthalmopathy in grave's

iris becomes pigmented secondary to sympathetic tone (during development and birth). if you have horner's at birth can get anisochromia (different eye colors).

sarcoid - increases size of lacrimal glands bilaterally

iritis - seen in automimmune disease

pseudomonas/gonococcus can eat through the cornea and as fast as 24-48hours

dry macular degeneration progresses to wet

wet - edematous ischemic choroidal neovascularization and retinopathy.

risk factors for macular degeneration

age, white people, fam hx/genetics, smoking, diet (AREDs vitamin help), cardiovascular

AREDs vitamins (vit A,C,E and Zinc shown to decrease relative risk of macular degeneration by 25% (trial AREDs II)

Lutein may help although no RCT's have been conducted

treatment for wet macular degeneration- antiVEGF (intravitreal injection) qmonthly, side effects- may increase risk of CVA

Diabetic retinopathy - 2 signs

macular edema - most common cause of blindness in working age adults

neovascularization - bleed, heal fibrose, cause traction bleeding detachment, tx - laser antiVEGF

neovacular glaucoma - vessels grow near canal of schlemm, membranes form crowding area can cause acute narrow angle closure

radiation therapy can cause a retinopathy results in lipid exudates (hard exudates) that look indistinguishable from diabetic retinopathy

cherry red spot in adult? (without tay sachs!) - central or branch retinal artery occlusion

syphillis - interstitial keratitis (salmon patch)

sudden loss of vision in one eye - check red reflex - if not there can be retinal hemorrhage

External Disease, Review of Common Disorders and Treatment

blepharitis - itchy burning tearing or inflammation of meibomian glands in eyelid (oil layer stabilizes the tear layer from evaporation)

hordeolum or chalazion?

chalazion - lipogranuloma occurs in leibomian gland, can last for months, warm compress helps

hordeolum - occurs anterior in the eyelid in sweat and sebaceous glands (normally staph infxn)

basal cell - crusting in one area only (most commonly on lower lid), if in medial canthus no lashes where tumor is!

viral papilloma - sessile of pedunculated (normally caused by HSV) tx cut it off +cryotherapy

molluscum contagiosum - pox virus, common in kids, round waxy umbilicated, tx excision and cryotherapy

contact dermatitis - can get from eye drops, can involve entire face!

dacrocystitis - infection of lacrimal sac (tear draining) tx - don't drain external if can help it - use systemic antibx and warm compress, if doesn't get better will need laser surgery.

dry eye -

red painful eye impaired- vision or no? (first question) - no vision? need to be seen now. angle closure glaucoma (pain and blindness)

uveitis, trauma

have you had eye surgery recently? painful red eye after surgery - must be seen immediately. rule out endophthalmitis (most dreaded complication) need to be seen and tapped, intravitreal anti-bx

gonococcal keratoconjunctivitis - hyperacute conjunctivitis (<24hours), ask about urethral discharge, can penetrate and bind to healthy corneal epithelium - seen daily by ophthalmologist daily irrigation, anti-bx

conjunctivits- itch?, allergy?

EKC - epidemic keratoconjunctivitis - exposure to symptoms - 5-12 days. systemic symptoms, virus moves to cornea and inflammation subepithelial infiltrates and drop your vision, lesions in cornea can last months or years

hsv dendritic keratitis - active viral replication in epithelial cells, stains w/rose bengal and fluoroscein, can deinnervate the cornea (making painless neurotrophic ulcer), deinnervation decreases healing of cornea. add oral tx, or trifluridine q2 (9 times a day)

sleeping in contact lenses increases risk of bacterial keratitis 20x because of hypoxia under lense tx corneal ulcers w/fortified antibiotics q30minutes! acanthamoeba keratitis - amoeba that gets in during swimming or hot tub w/contacts lenses, ring ulcer