Ophthalmology

Conjunctivitis

Viral Conjunctivitis

• Diffuse unilateral/bilateral Injection + Watery/Mucoid Discharge + Rhinorrhea + Fever + Sore Throat

• Tarsal Conjunctiva → Follicular appearance (due to lymphocytic aggregates) causing gritty/burning sensation

• Management: Cool, Moist Compresses + adjuvant artificial tears

Allergic Conjunctivitis

• Bilateral injection + Pruritis + Eye lid edema + Watery discharge + hx of atopy

• Management:
• Topical antihistamines OR Mast Cell Stabilizers AND Allergen Avoidance
• Cool compresses are recommended
• If concurrent allergic rhinitis → Oral antihistamine

Neonatal Conjunctivitis

Prophylactic Topical Erythromycin is to prevent against gonorrhea NOT chlamydia

• < 24 hours → Chemical/SE of topical erythromycin; treated with artificial tears

• < 5 days → Gonorrhea; treated with IV/IM Cefotaxime

• 5-14 days → Chlamydia; treated with ORAL erythromycin

• > 14 days → Herpes

External Eye Diseases

Blepharitis

• Inflammation of Eyelids (usually bilateral)

• Common Causes:
• Seborrheic Dermatitis
• Infections (Staph, Herpes)
• Demodex Mites

• Examination shows lipoid plugs at the meibomian glands

• TTT → Warm Compresses, Gentle Scrubs, and Lid Massage

Horoldeum

• External (Stye) → tender erythamtous nodule at the lid margin (inflammation of the eyelash follicle)

• Internal → tender erythematous nodule at the palpebral conjunctiva (inflammation of the meibomian gland)

Lens Disorders

Ectopia Lentis

• Causes
• Blunt Trauma (Most Common)
• Marfan Syndrome (associated with Aortic Root Disease → Do ECHO)
• Homocystinuria (associated with intellectual disability & thrombotic events)

Corneal Disorders

Keratitis

Bacterial Keratitis

 

• Presentation: Acute onset pain, mucopurulent discharge, and corneal opacification/haziness

• CA: Staph aureus & pseudomonas (pseudomonas is buzzy in contact lens users)

• Management → EMERGENCY OPHTHALMOLOGICAL REFERRAL
• Topical abx (Fluoroquinolones are empirical choice)
• Contact lenses are discontinued until ulcer heals

Show Picture of Bacterial Keratitis

 

Photokeratitis

• UV light causes desquamation of corneal epithelium

• Risk Factors: high altitudes & areas of increased UV light reflection (snow, sand, water)

• Features: Bilateral severe eye pain few hours post exposure + tearing, decreased VA, conjunctival erythema

• Dx → Punctate Corneal Staining with fluorescein dye

• Management:
• Supportive (analgesics + oral abx)
• Symptoms resolve after 1-3 days

• Chronic Dry Eye + Dry Oral Membrane
• Eye symptoms: Discomfort, Gritty or FB sensation that ARE WORSE IN WINDY CONDITIONS OR WHEN DOING TASKS WITH DECREASED BLINKING
• Oral symptoms: Cracked Lips

• Pathophysiology: Lymphocytic Infiltration of exocrine glands

• Complications: Decreased VA, Infection, Corneal Ulceration +/- perforation

• Management: Artificial tear, Humidifiers, and eyeglasses with occlusive barrier

Retina

CMV Retinitis

• Management:
• Oral antiviral (valganciclovir)
• IF lesions near the optic nerve or fovea ⇒ add Intravitreal injections to reduce of blindness or retinal detachment due to scarring
• Anti-retroviral therapy should be added 2 weeks after

Show Pic of CMV Retinitis

Candida Endophthalmitis

• Most commonly arises in hospitalized patients with CVC

• Risk Factors: TPN, Immunocompromised patients, abx, recent abdominal surgery

• Management: Systemic antifungals (Fluconazole)
• IF vitreous involved → Vitreous Antifungals injection or vitrectomy

Nonproliferative Diabetic Retinopathy

• Microvascular angiopathy → Microaneurysms → rupture → dot & blot hemorrhages
• Other features → macular edema, hard exudates, cotton wool spots
• Can progress to proliferative DR (neovascularization)

• ttt →
• VEGF inhibitors
• Retinal Laser photocoagulation (in noncompliant patients because fewer procedures are needed for benefit

CRVO

• Unilateral painless loss of vision

• Dx CONFIRMATION BY → Fluorescein Angiography

• Management:
• Conservative with close observation → IF no macular edema or neovascularization
• Intravitreal injection of VEGF → IF significant macular edema

Macular Degeneration

• Earliest Finding is → distortion of straight lines to appear wavy (tested by Grid Test)

• MAIN RISK FACTOR IS ⇒ AGE
• Smoking is important too

• Examination may reveal drusen deposits in the macula

Uveitis

Anterior Uveitis

• Painful Red Eye + Photophobia + Tearing + Decreased VA + Hypopyon

• Associated with:
• Infections (Herpesviruses & Toxoplasmosis)
• Sarcoidosis
• Spondyloarthritis (AS - Reactive Arthritis)
• IBD (doesn’t correlate with disease activity)

• ttt: Dilating eye drops (Cycloplegics) & Topical glucocorticoids

Glaucoma

Open Angle Glaucoma (OAG)

• First Line → Topical PGs

• 2nd Line → Topical BB (Care with asthma patients)

• IF BOTH FAIL OR NOT TOLERATED → Surgery

• ATROPINE IS C.I → DILATION OF PUPILS → INCREASE ANGLE-PRESSURE → acute Angle Closure Glaucoma

Angle Closure Glaucoma (ACG)

• First Line → Topical CA inhibitor (followed by Oral)

Surgery

RAPD following head trauma?

• Dx → Optic Nerve Injury
• Causes:
• Indirect injury (high intensity force to orbit “head injury”)
• Direct (Penetrating eye injury)
• Presentation:
• Acute Vision loss with RAPD
• Dx → CT Scan
• TTT → Conservative OR Surgical Decompression

Ocular Chemical Burns

• EMERGENCY & requires immediate ophthalmological consultation

• Management:
1. Irrigation with water or saline for 30-60 mins until normalization of pH
1. Can take more than 2 hours in alkali injuries
2. Topical anesthesia can be used
3. After Irrigation, the pH should be remeasured by Litmus paper to make sure it is neural

Corneal Abrasion

• Abrasion = “single, small oval area of green uptake”

Retinal Detachment

• Common Complication following intraocular surgery, advanced age, myopia, ocular trauma

• Caused by Posterior Vitreous Detachment

• Features: Flashes of Light, Floaters, Dark spots or webs

• Beings peripherally then progresses centrally

• Examination shows RAPD or Sluggish pupil

• Ophthalmological examination shows Wrinkled appearance

• Surgical Repair is required

Bacterial Endophthalmitis

• Risk Factors: Eye Surgery or Trauma

• Buzzy Features:
• Purulent haziness of AC OR Hypopyon
• Eye Ache

• Dx → Clinically

• Management → IMMEDIATE intravitreal injection of abx AFTER aspiration for culture & gram stain
• IF SEVERE → Vitrectomy

Pediatrics

Strabismus

• Screening should be done at every well-child visit until age 5 years

Visual Acuity testing

• Indications of ophthalmological examination:
• Visual acuity worse than 20/40 at age 4
• Visual acuity worse than 20/30 at age ≥5
• Pupillary asymmetry of ≥1 mm
• Nystagmus
• Ptosis
• Other conditions obstructing the visual field.

Orbital Cellulitis

• Most Common Risk Factor is Sinusitis (Ethmoid & Maxillary)

• Dx → CT

• IV abx +/- drainage if purulent fluid collection is found

Trachoma

• Dx → examination of tarsal conjunctiva (showing white-yellow follicles on inflammed tarsal or scarring)
• Complication → Scarring & Trichiasis (inversion of eyelashes) → painful corneal ulceration, opacification, and blindness

• ttt → Oral Azithromycin to patient & close contacts