Ophthalmology Back to Basics Review

1. OphthalmologyBack to Basics Review • March 29, 2011 • Dr. Andrew Toren

2. MCC Objectives • Eye Redness • Pupil Abnormalities • Amblyopia / Strabismus • Acute / Chronic Visual Loss

3. Pupil Abnormalities • Rationale • Pupillary disorders of changing degree are in general of little clinical importance. If only one pupil is fixed to light, it is suspicious of the effect of mydriatics. However, pupillary disorders with neurological symptoms may be of significance. • -Causal Conditions • Local disorder of iris • Anisocoria (unequal/asymmetric pupils) • Post eye surgery • Impaired pupil constriction (third nerve palsy, tonic pupil, mydriatics) • Impaired pupil dilatation (Horner syndrome) (hypothalamus/brain stem/spinal cord lesions) • Impairment of pupil constriction (without anisocoria) • Unilateral (optic nerve or retinal lesion) • Bilateral (diabetes, syphilis, midbrain lesion, hydrocephalus, factitious) • -Key Objectives • Determine whether there has been previous ocular inflammation, trauma, loss of vision, or eye pain in order to begin ruling out local disorders. • -Objectives • Through efficient, focused, data gathering: • Differentiate clinically between the various mechanisms of pupil abnormalities. • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: • Select patients in need of referral for further investigation. • Conduct an effective plan of management for a patient with pupil abnormalities: • Select patients in need of referral for management. • Applied Scientific Concepts • Outline function of cranial nerves and demonstrate how to examine them. • Describe the mechanism of pupillary constriction

4. Eye Redness • Rationale • Red eye is a very common complaint. Despite the rather lengthy list of causal conditions, three problems make up the vast majority of causes: conjunctivitis (most common), foreign body, and iritis. Other types of injury are relatively less common, but important because excessive manipulation may cause further damage or even loss of vision. • -Causal Conditions • Lids/Lashes/Orbits/Lacrimal system • Blepharitis (infectious, allergic) • Hordeolum (stye)/Chalazion • Foreign body • Cellulitis (pre-septal, orbital) • Naso-lacrimal duct obstruction • Conjunctiva/Sclera • Conjunctivitis (viral, bacterial, chlamydial, allergic, also neonatal) • Subconjunctival hemorrhage • Episcleritis/Scleritis • Pinguecula/Pterygium • Cornea (corneal abrasions, contact lens overwear) • Keratitis, infectious • Foreign body (refer if not better in 24 hours) • Anterior chamber/Iris • Iritis/Iridocyclitis/Uveitis • Glaucoma, acute • Hypopyon • Hyphema • -Key Objectives • Determine whether the condition requires prompt referral. • -Objectives • Through efficient, focused, data gathering: • Differentiate causal conditions that are benign from those that require prompt referral. • Determine if vision is affected (reading with affected eye), is there foreign body sensation (inability to open and keep eye open is objective evidence), photophobia, trauma, discharge persisting throughout the day, headache and malaise, nausea and vomiting. • Determine visual acuity first, then if there is corneal opacity or infiltrate, aversion to light in uninvolved eye, pupil light reaction (not fixed or pin-point), purulent discharge, redness pattern, WBC or RBC in anterior chamber. • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: • Select investigations for diagnosis and required prior to initiation of therapy. • Conduct an effective plan of management for a patient with eye redness: • Outline management for two of the three most common causes of eye redness, conjunctivitis and foreign body. • Select patients in need of referral.

5. Acute Visual Loss • Rationale • Loss of vision is a frightening symptom that demands prompt attention; most patients require an urgent ophthalmologic opinion. • -Causal Conditions • Glaucoma (acute angle closure) • Haemorrhage (diabetic retinopathy, may be traumatic, penetrating, hyphema) • Nervous system/Vascular • Retinal artery/Vein occlusion (TIA/CVA) • Migraine • Occipital infarction/Haemorrhage (TIA/CVA) • Trauma • Blunt (global rupture, corneal abrasion, choroidal rupture, lens dislocation) • Penetrating (globe penetration ( intra-ocular foreign body, corneal/lens perforation, optic nerve injury) • Haemorrhage (may be traumatic, penetrating) • Other (carotid-cavernous sinus fistula, chemical splash) • Retinal/Macular/Optic disc problems • Optic neuritis/Optic nerve injury • Retinal detachment (may be traumatic) • Anterior ischemic optic neuropathy/temporal arteritis • Acute macular lesion • Infectious/Inflammatory • Other (drug toxicity, functional visual loss) • -Key Objectives • Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely). • Examine the eye with external, direct ophthalmoscope, visual fields, and pupils. • -

6. Acute Visual Loss • Objectives • Through efficient, focused, data gathering: • Determine whether the loss is monocular or binocular, and if binocular, is it hemianopic, any exposure to agents or trauma. • Determine character of visual loss, since important associated systemic conditions (diabetes, hypertension, temporal arteritis) or similar past events may suggest cause. • Differentiate causes of visual loss by examination of cornea, pupil, lens, retina, optic disc, and visual fields (listen for murmurs, carotid bruits). • Determine the presence of a foreign body, abnormal extraocular musculature, pupillary reflex. • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: • Since vast majority of cases will be referred urgently, all tests will be arranged by specialist. • Conduct an effective plan of management for a patient with acute loss of vision: • Select patients in need of specialized care.

7. Chronic Visual Loss • CHRONIC VISUAL DISTURBANCE/LOSS • -Rationale • Loss of vision is a frightening symptom that demands prompt attention on the part of the physician. • -Causal Conditions • Pre-retinal conditions • Corneal disorders (dystrophy, scarring, edema) • Lens disorders (age related, traumatic, steroid-induced) • Glaucoma (primary, secondary) • Retinal dysfunction • Diabetic (retinal edema, retinopathy) • Vascular insufficiency • Tumors • Macular degeneration or dystrophy • Post-retinal lesions • Optic chiasm lesions (pituitary adenoma) • Lesions anterior to the optic chiasm (optic nerve/monocular) • Compressive optic neuropathy • Intracranial (masses) • Orbital (thyroid disease) • Toxic/Nutritional (nutritional deficiencies, tobacco-alcohol amblyopia, methanol) • Hereditary optic neuropathies • -Key Objectives • Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely). • Perform direct ophthalmoscope examination of the eye. • -Objectives • Through efficient, focused, data gathering: • Determine whether the visual loss is monocular or binocular. • Differentiate causes of visual loss by examination of cornea, lens, retina, and optic disc. • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: • Perform visual acuity and field-testing. • List indications for fluorescein angiography. • Conduct an effective plan of management for a patient with chronic visual loss: • Select patients in need of specialized care. • -Applied Scientific Concepts • Back to Top • Outline the anatomical pathways involved in vision (pre-retinal structures, retina, optic nerve and its pathway through the chiasm, occipital optic cortex). • Explain potential visual field defects with lesions at various areas in this pathway

8. Key Objectives • Acute / Chronic Visual Loss • Know how to examine the eye & common causes • Eye Redness • Know how to manage and when to refer the patient • Pupil Abnormalities • Know the main causes of pupil abnormalities • Amblyopia / Strabismus • Know what amblyopia is / know the differential and treatment for misaligned eyes

9. Resources • Basic Ophthalmology, American Academy of Ophthalmology , Cynthia A. Bradford; MD • http://www.ophthobook.com/

10. Eye redness • by the end of this lecture students will be able to: • know a differential diagnosis for a red eye • be able to differentiate between serious vision threatening, benign, and non urgent causes of a red eye

13. examination of the eye HOW TO EXAMINE THE EYE FOR DUMMIES • Topical Anesthesia • Light Source • iPhone/Eye Chart • Paper Clips (plastic coated) • visual acuity - don’t forget pinhole! • pupils • conjunctiva: pattern of injection • discharge • evert lids: papillae or follicles? • lymph node

14. slit lamp examination • cornea: fluorscein staining (abrasions, dendrites), opacities • anterior chamber: depth, cells • intraocular pressure

15. history • timing • visual changes • pain, photophobia, tearing • discharge • other risk factors: prior episodes, contact lens use, medical comorbidities

16. the usual suspects • blepharitis • conjunctivitis • viral • allergic • bacterial • subconjunctival hemorrhage • foreign body • pterygium

17. the red eye • Non-Traumatic • Traumatic

18. blepharitis • Inflammation of the lid margin (crusting/redness of lids) • Causes ‘gritty’/foreign body sensation, often concomitant with other ocular surface disease • Associated with recurrent hordeolum (styes) or chalazia • Improvement with warm compresses/lid hygeine, artificial tears, tetracycline

21. the usual suspects • herpes simplex keratitis • herpes zoster • bacterial keratitis • corneal ulcer • iritis / episcleritis / scleritis

22. conjunctivitis • Bacterial - most common in children • Viral - most common in adults • Allergic - bilateral, frequently c/o ‘itch’

23. bacterial conjunctivitis • Signs: • Discharge - purulent vs mucopurulent

25. Question • What type of neonatal conjunctivitis occurs on the first day?

26. Pitfalls: Adult Conjunctivitis • Adult Hyperacute Conjunctivitis • Gonococcus • Signs/symptoms of severe infection • Rapid onset • Chlamydial Conjunctivitis • Sexually active adolescents/adults • Unilateral, Follicular reaction • Chronic (>3 weeks) • Microtrak • Oral Tetracyclin

27. bacterial conjunctivitis • Usually self limited • Treatment necessary? • Limits spread • Shortens course • Patient comfort • Prevents recurrence • Prevents chronic staph conjunctivitis

28. bacterial conjunctivitis therapy • Choice of antibiotic depends on other factors: • Polysporin • no prescription required • Polytrim • Low cost • Well tolerated • Fucithalmic • BID dosing

29. Pitfalls in Treatment • Avoid • Gentamicin • Epithelial toxicity • Steroid containing solutions • Garasone • Tobradex • Blephamide • Increase IOP, Cataract • Geographic Herpes • Worsen Infection • Corneal Spread • Frequent switching of drops

30. Viral Conjunctivitis • History: Infectious Contacts, URTI, Drops/Drugs • Etiology: Adenovirus • Treatment: No specific therapy • Cool compresses, artificial tears, infectious precautions

32. Allergic Conjunctivitis • Symptoms: ITCHING • Signs: mild redness, conjunctival chemosis, watery discharge, papillary hypertrophy • Treatment: cold compress, antihistamines, non-steroidal drops, mast cell stabilizers, topical corticosteroids

34. Subconjunctival Hg • What is the appropriate management of a large subconjunctival hemorrhage • A) Stop any anticoagulation and observe for improvement • B) Observe. If no resolution in 1-2 weeks refer to ophthalmology • C) Observation only • D) If large, refer to ophthalmology

35. Subconjunctival Hemorrhage

38. bacterial keratitis • much less common • pain, reduced vision • management: • Large/Central Ulcer: Culture, Fortified antibiotics, urgent referral • Small Ulcer: topical gtts, refer

39. Pterygium

40. Pterygium

41. Herpes Simplex Keratitis • Unilateral, often have previous history • Pain -variable, photophobia, • Dendrites, Follicular conjunctivitis • Management: • Topical trifluridine 1% (Viroptic) 9X/day ± cycloplegia, refer • NO STEROIDS!

42. Iritis/Episcleritis/Scleritis Necrotizing Scleritis Nodular Scleritis Increasing Ocular Inflammation Diffuse Scleritis Localized Scleritis Episcleritis Increasing Systemic Complications Pingeculitis

43. Episcleritis • Symptoms: Often asymptomatic, Mild irritation and/or photophobia • Signs: Sectoral Redness, superficial injection, localized tenderness • Systemic Associations: RA, SLE, Seronegative spondyloarthropathies • Treatment: Tears, Topical/Oral NSAIDS

46. Scleritis • Symptoms: Pain (Dull, Achy, Deep, Boring), Photophobia, Tearing • Signs: Bluish red injection, deeper structures, nodules, necrosis • Systemic Association in 50%, high 5 yr mortality - needs investigation • Collagen Vascular • Rheumatoid arthritis • Lupus • Wegner’s • Treatment: Topical/Oral Steroid/NSAIDS/Immune suppression

47. Angle Closure Glaucoma (aka Pupillary Block) • Symptoms: dramatic presentation, significant pain, ocular headache, nausea and vomiting, decreased vision, colored haloes • Signs: fixed mid-dilated pupil, steamy cornea, shallow anterior chamber, ELEVATED IOP

48. Angle Closure • Treatment: • Pilocarpine 1% • Pressure lowering medication: • Topical / IV / PO • Definitive Management: Laser Iridotomy

49. Traumatic Red Eye • Red Flags • Loss of vision • Loss of red reflex • Flat anterior chamber • Tear shaped pupil • Uveal prolapse

50. the usual suspects • blepharitis - warm compresses, lid hygeine, artificial tears • conjunctivitis • viral - cool compresses, contact precautions, observe • allergic - avoidance, antihistamine, allergy gtts • bacterial - broad spectrum antibiotic gtts • subconjunctival hemorrhage -observe • foreign body • pterygium