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Ophthalmology

ref: AAFP Monograph 194, July 1995. Cynthia Bradford.

Anatomy and physiology

cranial nerves

• 6th: lateral rectus, look to side
• 4th: superior oblique, look down
• 3rd: all the rest

cornea: superficial layer heals well in 24-48 hours, middle stroma heals slowly over weaks, scars.

visual field defects

• bitemporal hemianopsia: optic chiasm, pituitary tumor
• upper homonymous hemianopsia: lesion in Meyer’s loop, at temporal horn of lateral ventricle

Corneal Abrasion & Foreign Body

• if metallic object, do x-ray to check for retention
• contact lens: tobramycin ointment, no patch, f/u 24h
• cyclogyl (cyclopentate) .5-1.0% 1 gtt -- lasts 6-24 h, onset .5-1 hour or homatropine 2% BID-TID for comfort and NSAID PO
• erythromycin ophthalmic ointment, tobrex if large defect
• patch > 1 cm or for comfort, or children aged 3-7 (won’t leave eye alone)
• recheck daily if patched, else for healing at 2-3 days

danger signs and problems (referral)

• loss or distortion of central vision, or marked difference of acuity between eyes
• sudden loss of peripheral vision
• flashes of light or floaters (ischemia), sudden cobweb or stringy floaters (detachment)
• curtain across eyes (ischemia)
• halos about lights (glaucoma)
• double vision
• intermittent dimming of vision
• strabismus
• cornea > 11 mm in newborn (congenital glaucoma)
• red eye with Red Eye Danger Signs

eyelids

• Eyelid Disorders: Diagnosis and Management - AFP  June 1998
  • anatomy, blepharitis, ocular rosacea, chalazia, hordeolum (stye), hydrocystoma, entropion, ectropion, trichiasis (misdirected eyelash), treating facial palsy (keep lid down)

blepharitis

• dandruff or crust along lashes and erythema of lid margins
• lid hygeine twice daily for a looong time
  • soak for 2-3 minutes
  • dilute baby shampoo for upper and lower lid margins
  • bacitracin or erythro ophthalm ointment at night for one week per month
  • doxycyc 100 BID if severe case
• if multiple ulcer, consider staph coverage. Watch periorbital cellulitis.

Misc notes

• acute angle-closure glaucoma: halos about lights, red painful eye, pain over brow, blurred vision, nausea and vomiting
• amblyopia (apparent) can be due to retinoblastoma
• atraumatic 6th nerve palsy in child has 50% pontine glioma risk
• black spots on red reflex: cataract
• giant cell arteritis: "odd facial/head sensations", severe temporal headaches, jaw claudication, weight loss/weakness/anorexia.
• nasolacrimal duct obstn/dacrocystitis: refer if not relieved by 1 year or severe symptoms. If acute dacrocystitis in child, rx. Augmentin for H flu
• odd pupils
  • Marcus Gunn: better consenusal response to light than direct response. Due to afferent defect from optic nerve disease (MS)
  • Adie’s tonic pupil: dilated pupil poorly responsive to light, constricts with 1/8 % pilocarpine. Benign.
  • Horner’s: ptosis, miosis, anhidrosis. Oculosymp gateway defect (lung tumor)
  • Argyll Robertson: small irregular pupil that reacts to accomod but not to light. Syphillis.
• optic neuritis: gradual (hours to days) visual loss, unilateral, pain on eye movement, globe tenderness, pupillary and visual field defects, abnormal color vision.
• retinitis pigmentosa - lose cones, then rods. Night vision loss > tunnel vision and color blind.
• sporadic inirida in newborn has 30% risk Wilm’s tumor
• strabismus: refer if persist > 6 weeks
• very severe conjunctivitis with copious purulent discharge: think GC, refer (IV abs)
• white reflex in newborn: retinoblastoma

Pediatric: Strabismus and More

• Pediatric Vision Screening 9/1/98 AAFP

Red eye

also see separate attachment

Red Eye Danger Signs

• blurred vision (keratitis, glaucoma, Iritis)
• ciliary flush - perilimbal conjunctival injection (Iritis)
• corneal opacification or epithelial disruption (bacterial keratitis)
• abnormal pupil: nonreactive, small/irregular. (glaucoma, iridocyclitis, Iritis)
• proptosis
• increased intraocular pressure
• colored halos (acute angle-closure glaucoma)
• pain (glaucoma, Iritis, bacterial keratitis)
• Au’s sign: sharp pain in covered (red) eye when uncovered eye is illuminated (Iritis)
• photophobia (iridocyclitis, Iritis)

Iritis and Herpes Zoster Opthalmicus (refer)

• Herpes Zoster Opthalmicus — first branch of Trigeminal nerve (V1). Look for lesions at tip of nose. HZO has conjunctivitis as well, but iritis is the serious complication. Refer for steroid drop therapy.
• other causes of Iritis: ank spond, IBD, syphilis, sarcoid, Reiter’s, psoriasis, Behcets.

Slit Lamp

• on some use joystick turn to raise and lower
• slit width chg tells depth
• green light shows blood
• move chin up and down so canthus lines up with mark (to start)
• light 45 deg temporal, direct medial
• initial exam: slit max ht, min width
• fluorescein: blue filter, beam 3-4 mm
• ant chamber (iritis, hyphema): narrow, 3-4 mm ht. High power, focus between cornea & lens. Focus light on lens to backlight matter in anterior chamber.

Terms

• amblyopia: decreased vision in one or both eyes with no apparent abnormality
• chalazion: obstructed meibomian gland (warm compress 10 minutes QID, may use PO abs) -- if no response x 4 weeks do surgery
• pinguecula/pterygium: benign neoplasms of conjunctiva. Pinguecula is raised yellowish-white near cornea at 3 or 9 oclock. Pterygium is fleshy growth that may spread onto cornea -- hot, dry climates.
• ecropion: outward turning of lower lid
• entropion: inward turning of lid
• episcleritis/scleritis
  • episcleritis: benign, recurrent. localized inflamm, red-purple, below conjunctiva that doesn’t repond to vasoconstrictors.
  • slceritis: deep red inflammation, sometimes nodular. Very painful. More purple. Refer.
• esotropia: eye turns inwards (medial)
• hordeolum: stye
• hyphema: layered blood in ant chamber
• hypopon: layered WBC in ant chamber (severe intraocular inflammation)
• internuclear opthalmoplegia: delayed adduction on lateral gaze, MS.
• keratitis: inflamm of the cornea (Herpes shows dendritic fluorescein stain) Bacterial keratitis (corneal ulcer) is painful red eye, purulent drainage, corneal opacity.
• miosis: constriction, from parasymp via ciliary ganglion
• mydriasis: dilation of pupil
• proptosis (exophthalmos): one eye 3 mm > than other
• uveal tract: iris, ciliary body, choroid
  • uveitis
    • anterior uveitis: iridocyclitis (iris/iritis and ciliary body/pars planitis)
    • post uveitis: choroiditis
  • iritis produces ciliary flush: redness around the limbus

Therapies (eye)

central retinal artery occulsion

a) acute unilateral visual loss, afferent pupilary defect, swollen optic nerve, narrow retinal arteries, “cherry-red” spot on fovea

b) vasodilate by rebreathing into paper bag, topical beta blockers, acetazolamide IV, digital massage

chemical burn

• topical anaesthesia then 10 minutes saline irrigation

emergent rx of angle-closure glaucoma (no ophth. available)

• pilocarpine 2% q10min for 1 hr
• timoptic q30min for 1 hr
• Diamox 500 mg PO or IV
• Glycerin 50% (isosorbide 50% if diabetic) 3ml/kg over ice with lemon juice

mydriatics

• diagnostic: neo-synephrine 2.5%, 3 hrs
• therapeutic: homatropine, 48 hrs
• midriacyl: 2 hours
• cyclogyl 1%: 12-24 h
• scopolamine: 2 w
• atropine: 2-4 w