Ophthalmology Review for Year 4 Med Students

1. Maryam Abtahi Paul Yan Ophthalmology Review for Year 4 Med Students

2. Chapter 1 Trauma And red eye

3. Chemical burn In a patient with alkali chemical burn to the eye, what is your first action, Irrigate eye with normal saline Next steps: Check PH of the conjunctival fornix Check vision Check pupils for afferent pupillary defect

4. Chemical burn • Chemical burn : • Acid , coagulate proteins and inhibit further corneal penetration • Alkali, worse prognosis • Never try to neutralize Very severe alkali burn or if not get irrigated early

5. Ruptured globe If a ruptured globe is suspected, the first action to take is to: Shield the eye

6. Ruptured globe • R/o intraocular foreign body with orbital CT scan, specially in metal on metal hammering • NPO • IV antibiotic • Tetanus status

7. Ruptured globe Need to be referred, • Decreased vision • Shallow anterior chamber • Hyphema • Abnormal pupil • Ocular misalignment • Retinal damage

8. Intraocular foreign body The best study to evaluate a patient with intraocular foreign body is CT scan of the orbits

9. orbital floor fracture Management includes surgical repair only in • Fracture of more than 50% of the floor, • Diplopia not improving, • Enophthalmos more than 2 mm

10. Blow out fracture Blow out fracture, white eye • In children , might cause muscle entrapment and ischemia, • Risk of bradycardia . • One of the ophthalmology emergency,

11. Corneal abrasion Corneal abrasion in contact lens wearer Never patch the eye AB Refer to an ophthalmologist The risk of ulceration is significantly higher than in not –contact Lens wearer, specially pseudomona infection

12. Corneal abrasion • Never prescribe topical anesthetics, • No topical steroid • In case of linear abrasions examine under the lid

13. Conjunctivitis Conjunctival injection with discharge, Should be treated with a topical antibiotic if discharge is purulent,( bacterial ) Should be treated with parenteral antibiotic if gonococcal.(fig.) Prominent itching symptoms is in allergic conjunctivitis

14. Papillae • Allergic conjunctivitis • Bacterial conjunctivitis • Follicles • Viral conjunctivitis • Chlamydial conjunctivitis

15. Remember: Gonococcal conjunctivitis should be treated with parenteral antibiotic. Why? Risk of corneal perforation

16. Acute angel closure glaucoma Characteristic of acute angel closure glaucoma High IOP Sever eye pain Decreased vision A fixed and dilated pupil

17. Acute angel closure glaucoma Primary angle closure glaucoma, risk factors Hyperopia Age>70 Female Family history Asian, Inuit people Mature cataract Shallow anterior chamber Pupil dilation

18. Acute angel closure glaucoma What is your next plan: • Refer to ophthalmologist for laser iridotomy What would be the next plan • Laser iridotomy • Aqueous suppression with BACH • Miotics to reverse the pupillary block

19. Cellulitis Distinguishes orbital cellulites from preseptal cellulitis is, Limited ocular motility Decreased vision RAPD

20. Cellulitis • Sinusitis can cause orbital cellulitis • Trauma , skin abrasoin, any skin lesion can cause preseptal.

21. Cellulitis Evaluation and management of orbital cellulitis includes Patient admission Intravenous AB Ophthalmologic consultation Orbital CT scan Blood culture

22. Mucoromycosis • Request stat ophthalmology and ENT consultations to rule out a life–threatening fungal infection (mucoromycosis) • Diabetic patient with ketoacidosi, • Frozen globe, + RAPD

23. Temporal arteritis or Giant cell arteritis • F > 60 y/o • Abrupt monocular loss of vision, pain over temporal artery , jaw claudication, diplopia, PMR, constitutional • scalp tenderness, temporal artery beading • Diagnosis : temporal artery biopsy • Treatment high dose steroid, start immediately , before the biopsy

24. Temporal arteritis Immediately ESR, CRP, A low or normal sedimentation rate does not exclude the diagnoses The most common cranial nerve paralysis that occur involves the third cranial nerve.

25. 13. Possible causes for sudden Visual loss include Temporal arteritis Retinal detachment Non-arteritic optic neuropathy CRAO CRVO

26. What mechanism of action do cycloplegic use to relieve pain? Paralysis of ciliary spasm

27. CRAO Sudden unilateral vision loss and cherry red spot in the macula, Management Digital massage of the globe to dislodge an embolus Topical beta blockers AC paracenthesis by an ophthalmologist Re-breathing CO2

28. CRAO • Cause • Emboli from carotid artery • Emboli heart( arrhythmia, valvular, endocarditis) • Thrombosis • Temporal arteritis

29. Hyphema It is the result of a tear in an iris vessel. It can be associated with other ocular injuries. It should be referred to ophthalmologist. There is risk of re-bleeding in 2-5 days after trauma In management , no aspirin , no valsalva

30. Risk of re-bleed highest on days 2-5 , resulting in • Increased IOP, corneal staining, iris necrosis,

31. Herpes zoster ophthalmicus Herpes zoster involving the ophthalmic division of cranial nerve V is more likely to have ocular involvements if the tip of the nose is involved Hutchinson sign

32. Herpes Zoster Ophthalmicus Management • Oral antiviral • In cases of conjunctival involvement erythromycin • Refer to ophthalmologist • Steroid should be prescribed by ophthalmologist, if needed.

33. Herpes simplex Redness Pain Photophobia Decreased vision With fluorescein and cobalt blue, dendritic ulcer Referral to an ophthalmologist

34. Treatment by ophthalmologist • Antiviral topical or oral • Steroid not at the beginning and with caution, due to risk of geographic ulcer

35. Lid laceration repair should include Assessment of possible canalicular injury Foreign body removal Tetanus prophylaxis

36. Lid laceration repair should include • Assessment of possible canalicular injury • Foreign body removal • Tetanus prophylaxis • All of the above

37. Subconjunctival hemorrhage Asymptomatic Can be associated with HTN, or vasculopathy , or anticoagulant therapy, specially in recurrent one Resolve spontaneously in 2-3 weeks Ne need for stopping NSAID or Systemic anticoagulant for resolution. .

38. Prolonged use of topical ophthalmic anesthetics can cause Corneal damage

39. Topical steroid side effects Worsening of corneal fungal ulcers Worsening of bacterial keratatis Worsening of herpetic dendritic keratitis Cataracts Open-angle glaucoma

40. Chalazion Presents with acute, tender swelling of the lid Management includes warm compresses and lid hygiene for 2 Weeks Chronic case after 2-3 month might requires incision and drainage

41. Chalazion Still a chalazion

42. Conjunctivitis Neonatal Chlamydial conjunctivitis Occurs usually after 21 days of age, between 2-3 weeks Requires two weeks of systemic erythromycin for effective treatment If not treated can cause pneumonitis, arthritis, and other systemic infection

43. Ophthalmianeonatarum • Toxic conjunctivitis occurs in day one secondary to instillation of silver nitrate or erythromycin ointment that used as conjunctivitis prophylaxis , no treatment needed • Gonococcal day 5-7 , is the most serious one • Chlamydial , need systemic treatment • Herpes simplex after 2-3 weeks

44. Pterygium • It is a benign growth of conjunctiva over the cornea • Sun exposure • More common on the nasal side of the conjunctiva • In an early stage into maybe managed with use of artificial tears and topical vasoconstrictors

45. Pterygium In advanced stages needs surgery

46. Episcleritis • Usually complain of mild pain. • Are less likely to have a systemic connective tissue disease, comparing to scleritis. • Have engorged superficial vessels overlying the sclera below the conjunctiva.

47. Scleritis vs. episcleritis • To differentiate, Place a drop of Phenyephrine 2.5% , re-examine after 10-15 min , episceleral vessel should blanch. • Scleritis, causses vision loss , sever pain , wakes patient up at night tiem, causes thining(blue hue) and necrosis of sclera

48. Glaucoma

49. Glaucoma POAG PACG Rare 5% Acute onset Painful red eye Extremely IOP Haze cornea, middilated pupil , N/V, halo around light • Common 95% • Chronic • Painless • Moderate IOP • Normal cornea , pupil • No symptom

50. Glaucoma Risk factor for open-angel glaucoma include • African racial heritage • Age greater than 60 years • Positive family history for glaucoma • Corneal thickness