y

Hordeolum (sty) -------------------------------------------------------------------------------->> o Common staphylococcal abscess characterized by localized red, swollen, acutely tender area on upper or lower lid. o Warm compresses are helpful o Incision may be indicated o AB ointment (Bacitracin or Erythromycin) q3hrs during acute stage

Chalazion------------------------------------------------------------------------------------------->> o Common granulomatous inflammation of a meibomian gland that may follow an internal hordeolum. o Characterized by hard, nontender swelling on the upper or lower lid with redness and swelling of the adjacent conjunctiva. o If large enough, vision will be distorted o Tx with incision and curettage but Corticosteroid injection may also be effective Blepharitis o Common chronic bilateral inflammatory condition of the lid margins o Anterior blepharitis ------------------------------------------------------------------------>>  Involves the eyelid skin, eyelashes, and associated glands.  May be a staph infection or seborrheic

Posterior blepharitis------------------------------------------------------------------------>>  Inflammation of the meibomian gland  Bacterial (staph) or primary glandular dysfunction like with acne rosacea. S/S of Blepharitis  Irritation, burning, itching.  In anterior the eyes are red-rimmed and scales or granulations can be seen clinging to the lashes.  In posterior the lid margins are hyperemic with telangiectasias; the meibomian glands and their orifices are inflamed with dilation of the glands, plugging of the orifices, and abnormal secretions y Lid margin frequently rolled inward (mild entropion) and tears may be frothy or abnormally greasy Treatment of Blepharitis  Anterior Blepharitis y Controlled by cleanliness of the lid margin, eyebrows, and scalp y Scales should be removed from the lids daily with a hot flannel or a damp cotton applicator and baby shampoo. y Antistaphylococcal antibiotic eye ointment (Bacitracin or Erythromycin)  Posterior Blepharitis

Long-term low-dose systemic antibiotic therapy, usually with tetracycline (250 mg BID), doxycycline (100 mg daily), erythromycin (250 mg TID) , and possibly short-term topical steroids (prednisolone 0.125% BID) Topical therapy with antibiotics such as ciprofloxacin 0.3% ophthalmic solution BID may help but should be restricted to short courses.

Entropion ----------------------------------------------------------------------------------------->> o Inward turning of usually the lower lid o Occurs occasionally in older people as a result of degeneration of the lid fascia, or may follow extensive scarring of the conjunctiva and tarsus o Tx with surgery if lashes rub on the cornea  Botulinum toxin injections may also be used for temporary correction Ectropion ---------------------------------------------------------------------------------------->>> o Outward turning of the lower lid o Common with advanced age o Surgery is indicated if there is excessive tearing, exposure keratitis, or a cosmetic problem. Dacryocystitis (Dacryoadentitis) ------------------------------------------------------------->> o Infection of the lacrimal sac due to obstruction of the nasolacrimal system o Acute or chronic o Most often in infants and in persons over 40 yrs o Usually unilateral o MC infections Staph aureus, B-hemolytic strep in acute cases. Staph epidermidis, anaerobic strept, or Candida albicans in chronic dacryocystitis o S/S  Acute characterized by pain, swelling, tenderness, and redness in the tear sac area y Purulent material may be expressed y Tx: systemic antibiotic therapy .Surgical relief of the underlying obstruction is usually done electively but may be performed urgently in acute cases  Chronic tearing and discharge are the principal signs, and mucus or pus may also be expressed. y Tx: may be kept latent with antibiotics, but relief of the obstruction is the only cure. o Adults standard procedure for obstruction is dacryocystorhinostomy, which involves surgical exploration of the lacrimal sac and formation of a fistula into the nasal cavity. o Laser-assisted endoscopic dacryocystorhinostomy and balloon dilation or probing of the nasolacrimal system are alternatives.  Can be congenital. Conjunctivitis  The most common eye disease  Acute or chronic  MC are due to bacterial or viral infections o Bacterial Conjunctivitis --------------------------------------------------------------->>

MC staphylococci, streptococci (S. pneumo usually), Haemophilus species, Pseudomonas, and Moraxella.  S/S: y Copious purulent discharge y NO blurring of vision, and only mild discomfort  Tx: y Self-limiting usually, lasting about 10-14 days if untreated. y Topical sulfonamide (e.g., sulfacetamide, 10% ophthalmic solution or ointment TID) will usually clear the infection in 2-3 days. y Povidone-iodine may also be effective  Gonococcal Conjunctivitis y Acquired usually thru contact with infected genital secretions, typically causes copious purulent discharge y OPTHALMOLOOGIC EMERGENCY because corneal involvement may rapidly lead to perforation y Dx: confirmed by stained smear and culture of discharge. y Tx: 1-g dose of IM Ceftriaxone (Rocephin) o Topical AB such as erythromycin and bacitracin may be added  Chlamydial Keratoconjunctivitis y Trachoma (Chlamydia trachomatis serotypes A-C) o Major cause of blindness worldwide o Scar tissue can form of the tarsal conjunctiva leading to entropion and trichiasis in adulthood with secondary central corneal scarring. o Dx: immunologic tests or Polymerase Chain Reaction (PCR) confirms dx but treatment should be started on the basis of clinical findings o Tx: Single dose therapy with oral azithromycin 20 mg/kg is effective  Alternative oral tetracycline or erythromycin 250 mg QID or doxycycline 100 mg BID x 3-4 wks  Surgical treatment includes correction of eyelid deformities and corneal transplantation. y Inclusion conjunctivitis (C. trachomatis serotypes D-K) o Common cause of genital tract disease in adults o S/S the disease starts with acute redness, discharge, and irritation. The eye findings consist of follicular conjunctivitis with mild keratitis. A nontender preauricular lymph node can often be palpated. o Dx: confirmed by immunologic tests or PCR on conjunctival samples o Tx: oral tetracycline or erythromycin 500 mg QID or Doxycycline 100 mg BID x 1-2 wks  Single dose therapy with azithromycin 1 g may be effective o Before treatment, all cases should be assessed for genital tract infection so that management can be adjusted accordingly and other venereal disease sought. Viral Conjunctivitis -------------------------------------------------------------->>>  Adenovirus type 3 is the MC  3

Can have associated with pharyngitis, fever, malaise, and preauricular adenopathy. S/S y Palpebral conjunctiva is red y Copious watery discharge y Scanty exudates  Children are more common than adults and contaminated swimming pools are sometimes the source of infection  Lasts 10 days  May have some visual loss due to corneal subepithelial infiltrates is effected by adenovirus types 8, 19, 29, and 37 (Epidemic keratoconjunctivitis) y This is more severe and would last at least 2 wks Dry Eyes (Keratoconjunctivitis Sicca) ----------------------------------->>  Common in elderly women  May be caused by hypofunction of the lacrimal glands, hereditary disorder, systemic disease (Sjogren s syndrome), or systemic and topical drugs  Hormone replacement therapy may increase risk of dry eyes  S/S: y Dryness, redness, scratchy feeling of the eyes y Severe cases persistent discomfort with photophobia, difficulty in moving the eyelids, and often excessive mucus secretion  Treatment y Depends on cause y Artificial tears y Lacrimal punctual occlusion by canalicular plugs y Surgery Allergic Eye Disease (Allergic Conjunctivitis, Vernal keratoconjunctivitis, atopic keratoconjunctivitis)  Allergic conjunctivitis -------------------------------------------------------->>> y benign disease, occurring usually in late childhood and early adulthood. It may be seasonal, developing usually during the spring or summer, or perennial. Clinical signs are limited to conjunctival hyperemia and edema (chemosis), the latter at times being marked and sudden in onset  

Vernal keratoconjunctivitis ---------------------------------------------->>>> y tends to occur in late childhood and early adulthood. Usually seasonal, with a predilection for the spring. Large cobblestone papillae are noted on the upper tarsal conjunctiva. There may be lymphoid follicles at the limbus. Atopic keratoconjunctivitis ------------------------------------------>> 4

more chronic disorder of adulthood. Both the upper and lower tarsal conjunctivas exhibit a fine papillary conjunctivitis with fibrosis, resulting in forniceal shortening and entropion with trichiasis. Staph blepharitis is a complicating factor. Corneal involvement including refractory ulceration is frequent during exacerbations of both vernal and atopic keratoconjunctivitis. The later may be complicated by herpes simplex keratitis

S/S:

y Conjunctival hyperemia and edema (chemosis) y Itching, tearing, redness, stringy discharge, and occasionally photophobia and visual loss  Treatment y Topical histamine H1-receptor antagonist such as levocabastine hydrochloride 0.05% or emedastine difumarate 0.05% or ketoralac tromethamin, a NSAID agent QID. y Ketotifen 0.025% has histamine H1-receptor antagonist, mast cell stabilizer, and eosinophils inhibitor activity BID-QID y Topical mast cell stabilizers Cromolyn sodium 4% QID y Topical corticosteroids are essential to the control of acute exacerbations o Corticosteroid-induced side effects include cataracts, glaucoma, and exacerbation of herpes simplex keratitis y Topical cyclosporine effective y Systemic corticosteroid therapy and even plasmapheresis may be required in severe cases y In allergic conjunctivitis, specific allergens may be identifiable and thus avoidable y In vernal keratoconjunctivitis, a cooler climate often provides significant benefit Pterygium----------------------------------------------------------------------------------------->>>> o Is a fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea and is usually associated with constant exposure to wind, sun, sand, and dust o Often bilateral o Become inflamed and may grow o Treatment  No treatment is usually required for inflammation of pterygium, but artificial tears are often beneficial, and short course of topical NSAIDs or weak corticosteroids (prednisolone 0.125% TID) may be necessary  Indications for excision of pterygium are growth threatening vision by approaching the visual axis, marked induced astigmatism, or severe ocular irritation. o Recurrence is common and often more aggressive than the primary lesion. Corneal ulcer -------------------------------------------------------------------------->>>>> o Most commonly due to infection by bacteria, viruses, fungi, or amebas o S/S:  Pain, photophobia, tearing, and reduced vision  Eye is red, with predominantly circum-corneal injection and there may be purulent or watery discharge o Bacterial Keratitis ---------------------------------------------------------------------->>>>  Pursues an aggressive course 5

Precipitating factors include contact lens wear and corneal trauma (including refractive surgery) MC pathogens Pseudomonas aeruginosa, Pneumococcus, Moraxella, and Staph. S/S y Cornea is hazy, with a central ulcer and adjacent stromal abscess y Hypopyon (puss in eye) is often present  TX: y Ulcer is scraped to recover material for Gram stain and culture prior to starting treatment with high-concentration topical antibiotics applied hourly day and night for at least the first 48 hrs y Fluoroquinolones Ciprofloxacin 0.3%, ofloxacin 0.3% and norfloxacin 0.3% are first-line agents y Levofloxacin 0.5% is more effective against pneumococci than Cipro y 4th generation fluoroquinolones (moxifloxacin and gatifloxacin) are also effective against mycobacteria, may become the preferred agent y Gram + cocci can also be treated with cephalosporin such as Cefazolin 100 mg/mL y Gram bacilli can be treated with aminoglycoside such as tobramycin 15 mg/mL o If no organisms are seen, use Cefazolin + Tobramycin together Herpes Simplex Keratitis ---------------------------------------------------------------->>>  Important cause of ocular morbidity in adults  S/S: y Dendritic (branching) ulcer is the most characteristic manifestation. y More extensive ( geographic ) ulcers also occur, particularly if topical corticosteroids have been used. y Ulcers are seen easily with fluorescein and examination with a blue light y Increasingly severe corneal opacities with each recurrence  TX y Simple debridement and patching y More rapid healing can be achieved with topical antivirals such as trifluridine drops or acyclovir ointment y Long-term oral acyclovir reduces the rate of recurrent epithelial disease, for which topical corticosteroids must not be used Fungal Keratitis -------------------------------------------------------------------->>>  Treat with Natamycin or Amphotericin  Systemic imidazoles may be helpful  Corneal grafting is often required   

Acanthamoeba Keratitis --------------------------->>  Treat with polyhexamethyl biguanide, chlorhexidine, propamidine isethionate, or neomycin.  Epithelial debridement  Corneal grafting may be required 6

Acute Angle-Closure Glaucoma ---------------------------------------------->>>>> o Essential of Diagnosis  Older age group and Asians  Rapid onset of severe pain and profound visual loss with halos around lights  Red eye, steamy cornea, dilated pupil  Hard eye to palpation o Cause  Occurs only with closure of a preexisting narrow anterior chamber angle found in older age groups (owing to enlargement of the lense), hyperopes, Inuits, and Asians  May be precipitated by papillary dilation and thus can occur from sitting in a darkened theater, at times of stress, or rarely from drugs such as Anticholinergics, or sympathomimetic agents (eg, nebulized bronchodilators, atropine, antidepressants, nasal decongestants, or tocolytics)  Secondary acute angle-closure glaucoma may be observed with anterior uveitis, dislocation of the lens, or topiramate therapy. o S/S  Extreme pain and blurred vision  Halos around lights  Nausea and abdominal pain may occur  Red eye, cornea steamy, and pupils moderately dilated and nonreactive to light  IOP usually over 50 mm Hg, producing a hard eye on palpation o Treatment  Initially control IOP. y A single 500 mg IV dose of acetazolamide, followed by 250 mg po QID is usually sufficient y Osmotic diuretics such as glycerol and IV urea or mannitol - all three dosed 1-2 g/kg may be necessary if there is no response to acetazolamide y Laser therapy to the peripheral iris (iridoplasty) or anterior chamber paracentesis is also effective  Once the IOP has started to fall, topical 4% pilocarpine 1 drop q15 minutes for 1 hr and then QID is used to reverse the underlying angle closure  * the definitive treatment is laser peripheral iridotomy or surgical peripheral iridectomy, which should be performed prophylactically on the fellow eye.  If it is not possible to control IOP medically, glaucoma drainage surgery as for uncontrolled openangel glaucoma may be required o Secondary  In secondary acute angle closure glaucoma, systemic acetazolamide is also used, with or without osmotic agents o Prognosis  Untreated may result in severe and permanent visual loss within 2 -5 days after onset of symptoms Chronic Glaucoma ------------------------------------------------------------------------>>>> o Essentials of Diagnosis 7

 

No symptoms in early stages Insidious progressive bilateral loss of peripheral vision, resulting in tunnel vision but preserved visual acuities

 Pathologic cupping of the optic disks------------------------------------->>>>>  Usually associated with persistent elevations of IOP  May lead to complete blindness General considerations  Chronic glaucoma is characterized by gradually progressive excavation ( cupping ) and pallor of the optic disk with loss of vision progressing from slight constriction of the peripheral fields to complete blindness  Treat increase IOP  Flow of aqueous into the anterior chamber angle is obstructed in chronic angle-closure glaucoma  Primary open-angle glaucoma is bilateral  Increased prevalence in first-degree relatives of affected individuals and in diabetics  More frequent in blacks  Secondary open angle glaucoma may result from uveitis, ocular trauma, or corticosteroid therapy Diagnosis  Requires consistent and reproducible abnormalities in at least 2 of 3 parameters optic disk, visual filed, and IOP  Optic disk cupping is identified as an absolute increase or an asymmetry between the two eyes of the ration of the diameter of the optic cup to the diameter of the whole optic disk (cup-disk ratio) Prevention  All persons over age 40 yrs should have IOP measurement and optic disk examination every 2-5 yrs  In persons with diabetes and in individuals with family history of glaucoma, annual examination is indicated Tx:  Prostaglandin analogs (Latanoprost 0.005%, bimatoprost 0.03%, and travaprost 0.004% QD at night; or unoprostone isopropyl 0.15% BID) are commonly used as first line therapy. y All may produce conjunctival hyperemia (increased blood flow), permanent darkening of the iris and eyebrow color, and eyelash growth. y Latanoprost has been associated with reactivation of uveitis and macular edema  Topical Beta blockers such as timolol 0.25% or 0.5% , carteolol 1%, levobunolol 0.5%, and metipranolol 0.3% solutions BID or timolol 0.5% gel QD may be used alone or in combination with a prostaglandin analog y Contraindicated in pts with reactive airway disease or heart failure. (Betaxolol 0.25% or 0.5% - a selective beta blocker) is theoretically safer in reactive airway disease but less effective at reducing IOP 8

Brimonidine 0.2%, a selective alpha 2 agonist, and dorzolamide 2% or brinzolamide 1% topical carbonic anhydrase inhibitor also can be used in addition to a prostaglandin analog or a Beta blocker (twice daily) or as initial therapy when prostaglandin analogs and Beta blockers are contraindicated (Brimodnidine BID, dorzolamide and brinzalomaide TID)  Laser trabeculoplasty is used as an adjunct to topical therapy to defer surgery and is also advocated as primary treatment  Surgery is generally undertaken when IOP is inadequately controlled by medical and laser therapy but it may also be used as primary treatment (Trabeculectomy) o Prognosis  Untreated chronic glaucoma that begins at age 40-45 yrs will probably cause complete blindness by age 60-65. Cataract --------------------------------------------------------------------->>> o Essential of Diagnosis  Gradually progressive blurred vision  No pain or redness  Lens opacities (may be grossly visible) o General Considerations  Usually bilateral  May be congenital, traumatic, or secondary to systemic disease (diabetes, myotonic dystrophy, atopic dermatitis), systemic or inhaled corticosteroid treatment, or uveitis.  Senile cataract is the MC type  Most persons over age 60 have some degree of lens opacity  Cigarette smoking increases the risk of cataract formation o S/S:  Lens opacities o Treatment:  in adults, functional visual impairment is the prime criterion for surgery  Laser treatment may be required subsequently if the posterior capsule opacifies  Ultrasonic fragmentation (phacoemulsificatoin) of the lens nucleus allows cataract surgery to be performed thru a small incision without the need for sutures, thus reducing the postoperative complication rate and accelerating visual rehabilitation  It is routine to insert an intraocular lens at the time of surgery o Prognosis  Cataract surgery in adults improves visual acuity in 95% of the cases and can have a profound impact on quality of life. 

Retinal Detachment ------------------------------------------------------------------------->>> o Essentials of Diagnosis  Curtain spreading across field of vision or sudden onset of visual loss in one eye  No pain or redness  Detachment seen by ophthalmoscopy 9

General Considerations  Primary event in retinal detachment is the development of a retinal tear  Once there is a tear in the retina, fluid vitreous is able to pass thru the tear and lodge behind the sensory retina  The area involved rapidly increases, causing corresponding visual loss usually spreading upward across the field of vision  Central vision remains intact until the macula becomes detached. o Treatment  Must be referred urgently to an ophthalmologist  During transportation, the pts head is positioned so that the detached portion of the retina will fall back with the aid of gravity.  Treatment is directed as closing the tears  A permanent adhesion between the neurosensory retina, the retinal pigment epithelium and the choroid is produced in the region of the tears by applying cryotherapy to the sclera or laser photocoagulation to the retina.  Subretinal fluid drainage via an incision in the sclera  Injection of an expansile gas into the virtreous cavity followed by positioning of the patients head to facilitate reattachment of the retina  Once the retina is repositioned, the tear is sealed by laser photocoagulation or cryotherapy. Age-Related Macular Degeneration -------------------------------------------->>> o Essentials of Diagnosis  Older age group  Gradually progressive simultaneous or sudden sequential deterioration of central vision in both eyes  Distortion or abnormal size of images  No pain or redness  Macular abnormalities seen by ophthalmoscopy o General considerations  Leading cause of permanent visual loss in the older population  Increased in whites, females, family history, and cigarette smoking  2 types y Atrophic ( dry ) y Exudative ( wet ) o Both progressive and bilateral usually o S/S:  Retinal drusen  Hard Drusen appear opthalmoscopically as discrete yellow deposits o 10

  

Soft Drusen are larger, paler, and less distinct Large, confluent soft Drusen are particularly associated with exudative age related macular degeneration Atrophic degeneration (DRY) --------------------------------------------->>> y Gradually progressive bilateral visual loss of moderate severity due to atrophy and degeneration of the outer retina and retinal pigment epithelium. Exudative degeneration (WET) ------------------------------------>>> y Choroidal new vessels grow between the retinal pigment epithelium and Bruch s membrane, leading to accumulation of serous fluid, hemorrhage, and fibrosis. y The onset of visual loss is more rapid and more severe in exudative. y Bilateral y Exudative disease accounts for about 90% of all cases of legal blindness due to age-related macular degeneration

TX: 

Conventional laser retinal photocoagulationfor well-defined classic choroidal neovascular membranes away from or adjacent to the fovea  Photodynamic laser therapy (PDT) y Involves IV injection of verteporfin activated by subsequent retinal laser irradiation to produce selective vascular damage is indicated for well-defined lesions lying under the fovea  Antiangiogenic angents y Inhibitors of vascular endothelial growth factors (VEGF) o Reverse the neovascularizatoin and thus could be beneficial in both well and poorly defined ( occult ) lesions o When to refer  Older patients developing sudden visual loss due to macular disease particularly paracentral distortion or scotoma with preservation of central acuity should be referred urgently Central & Branch Retinal Vein Occlusions ---------------------------------------------------------->> o Essentials of Diagnosis  Sudden monocular loss of vision  No pain or redness  Widespread or sectoral retinal hemorrhages seen by ophthalmoscopy o S/S  Visual impairment commonly first noticed upon waking  Exam shows retinal hemorrhages, retinal venous dilation and tortuosity, retinal cotton-wool spots, and optic disk swelling  Sudden loss of vision o Complications  If associated with retinal ischemia, manifesting as poor visual acuity (20/200 or worse); with florid retinal abnormalities; and with extensive

11

area of capillary closure on fluorescein angiography, there is a high risk of development of neovascular glaucoma, typically within first 3 months o Treatment  Screen for diabetes, systemic HTN, Hyperlipidemia, and glaucoma  In younger patients, antiphospholipid antibodies, inherited thrombophilia, and hyperhomocysteinemia should be considered  Intravitreal injections of bevacizumab an inhibitor of VEGF  Laser photocoagulation  Vitrectomy with direct injection of tissue plasminogen activator into the retinal venous system or incision of the sclera at the edge of the optic disk  Arteriovenous sheathotomy o Prognosis  In central retinal vein occlusion, severity of visual loss initially is a good guide to visual outcome. Visual acuity of 20/60 or better indicated a good prognosis  Visual prognosis is poor for eyes with neovascular glaucoma o Refer  All patients should be referred urgently! Central & Branch Retinal Artery Occlusion o Central retinal artery occlusion ----------------------------------------------->>>

o o

Branch Retinal artery occlusion------------------------------------------------>>> Essentials of Diagnosis  Sudden monocular loss of vision  No pain or redness  Widespread or sectoral retinal pallid swelling seen by ophthalmoscopy S/S:  Visual acuity is reduced to counting fingers or worse, and visual field is restricted to an island of vision in the temporal field  Swelling of retina with cherry-red spot at the fovea.  The retinal arteries are attenuated and box-car segmentation of blood in the veins may be seen  When swelling subsides over 4-6 wks, leaving normal retinal appearance but a pale optic disk and attenuated arterioles Tx:  IF the patient is seen within a few hours after onset, emergency treatment including laying the patient flat, ocular massage, high concentrations of inhaled oxygen, IV acetazolamide, and anterior chamber paracentesis  Exclude giant cell arteritis y Clinical features jaw claudication, markedly elevated serum inflammatory markers, usually erythrocyte sedimentation rate and C-reactive protein, o Prednisone po immediately

12

 

Carotid and cardiac sources of emboli must be identified so that appropriate treatment is given to reduce the risk of stroke Migraine, oral contraceptives, systemic vasculitis, congenital or acquired thrombophilia, and hyperhomocysteinemia should be considered in young patients, internal carotid artery dissection when there is neck pain, or a recent history of neck trauma, and diabetes, Hyperlipidemia, and systemic hypertension in all patients

Refer  Refer emergently to an ophthalmologist Diabetic Retinopathy -------------------------------------------------->> o Essentials of Diagnosis  Present in about 40% of diagnosed diabetics  Present in up to 20% of type 2 diabetics at diagnosis  Mild retinal abnormalities without visual loss in back-ground retinopathy  Macular edema, exudates, or ischemia in maculopathy  Retinal new vessels in proliferative retinopathy o General considerations  Leading cause of new blindness among adults aged 20-65 yrs  Progressive o Clinical Findings  Nonproliferative retinopathy manifests as dilation of veins, microaneurysms, retinal hemorrhages, retinal edema, and hard exudates  Background retinopathy the abnormalities are mild and do not cause any impairment of visual acuity  Maculopathy manifests as edema, exudates, or ischemia involving the macula. y Assessment requires stereoscopic examination of the retina and sometimes retinal imaging with optical coherence tomography (OCT) or fluorescein angiography (or both). y Visual acuity is a poor guide to presence of treatable maculopathy y Maculopathy the MC cause of legal blindness in maturity onset diabetes  Proliferative retinopathy characterized by neovascularizatoin arising from either the optic disk or the major vascular arcades. y Vitreous hemorrhage is a common sequel y Without treatment, prognosis is much worse than that with nonproliferative retinopathy. o Screening  Adult patients with diabetes should undergo yearly screening y Fundal photography thru dilated pupils o Tx:  Optimizing blood glucose, blood pressure, renal function, and serum lipids  Laser photocoagulation, intravitreal injection of corticosteroid or a VEGF inhibitor, or vitrectomy for macular edema and exudates (NOT FOR ISCHEMIA THOUGH)  Proliferative retinopathy y Panretinal laser photocoagulation o 13

Regression of neovascularization can also be achieved by intravitreal injection of a VEGF inhibitor  Vitrectomy is necessary for removal of persistent vitreous hemorrhage, to improve vision and allow panretinal laser photocoagulation for the underlying retinal neovascularization  Proliferative diabetic retinopathy is not a contraindication to treatment with thrombolytic agents, aspirin, or warfarin unless there have been recent vitreous or pre-retinal hemorrhage Hypertensive Retinopathy ----------------------------------------------->>>> o The most florid disease occurs in young patients with abrupt elevations of BP such as may occur in pheochromocytoma, malignant HTN, or pre-eclampsiaeclampsia o Flame-shaped hemorrhages occur in the nerve fiber layer of the retina o Cotton-wool spots, retinal hemorrhages, retinal edema, and retinal exudates o Retinal pigment epithelial infarcts  May be focal, linear, or wedge-shaped Orbital cellulitis ----------------------------------------------------------------------->> o Manifested by an abrupt onset of fever, proptosis, restriction of extraocular movements, and swelling with redness of the lids o Infection of the paranasal sinuses is the usual underlying cause o Tx  Immediate tx with IV antibiotics is necessary to prevent optic nerve damage and spread of infection to the cavernous sinuses, meninges, and brain  In immunocompromised patients, zygomycosis must be considered Conjunctival & Corneal Foreign Bodies ------------------------>> o FB is usually present on the cornea or under the upper lid even though it may not be visible o Visual acuity should be tested before treatment is instituted as a basis for comparison in the event of complications o Tx:  Corneal FB y Local anesthetic propracaine 0.5% instilled y Examine eye with hand flashlight y Fluorescein may help see corneal FB s y Remove with a sterile wet cotton-tipped applicator y Polymyxin-bacitracin ophthalmic ointment should be instilled y Don t patch the eye y 14

y y

Re examine 24 hrs later for secondary infection of the crater If cannot remove FB in this manner, the patient should be referred to an ophthalmologist If a rust ring, excise it under local anesthesia using a slit lamp  Upper Lid FB ----------------------------------------------------->>> y In case of FB under the upper lid, a local anesthetic is instilled and the lid is everted by grasping the lashes gently and exerting pressure on the mid portion of the outer surface of the upper lid with an applicator. y If the FB is present, it can easily be removed by passing a wet sterile cotton-tipped applicator across the conjunctival surface. Intraocular foreign body ---------------------------------------------------------->> o Requires emergency treatment by ophthalmologist Corneal Abrasion o A patient with a corneal abrasion complains of severe pain and photophobia o Often a history of trauma to the eye o Assess visual acuity o Examine cornea and conjunctiva with light and loube to rule out a FB o Sterile Fluorescein allows to view abrasion  The area of abrasion will stain a deeper green than the surrounding cornea o Tx  Plymyxin-bacitracin ophthalmic ointment, mydriatic (cyclopentolate 1%), and analgesics either topical or oral NSAIDs.  Padding the eye is not helpful  Reassess pt within 48 hrs to be certain the cornea has healed Orbital Fracture (Blowout Fracture)------------------------------------------------------------>> o Refer to class notes!!!! y y y

Hyphemia --------------------------------------------------------------------------------->>>> o a term used to describe bleeding in the anterior chamber (the space between the cornea and the iris) of the eye. It occurs when blood vessels in the iris bleed and leak into the clear aqueous fluid. Hyphemas are usually characterized by pooling of blood in the anterior chamber that may be visible to the naked eye. The red blood cells of very small hyphemas are visible only with magnification. Even the slightest amount of blood in the anterior chamber will cause decreased vision when mixed in the clear aqueous fluid. o Bleeding in the anterior chamber is most often caused by blunt trauma to the eye. It may also be associated with surgical procedures. Other causes include abnormal vessel growth in the eye and certain ocular tumors. 15

S/S
y y y

Decreased vision (Depending on the amount of blood in the eye, vision may be reduced to only hand movements and light perception only) Pool of blood in the anterior chamber Elevated intraocular pressure (in some cases)

Diagnosis
y

It is very important for the doctor to determine the cause of the hyphema. If the hyphema is related to an ocular injury, any detail regarding the nature of the trauma is helpful. The doctor will assess visual acuity, measure intraocular pressure, and examine the eye with a slit lamp microscope and ophthalmoscope.

Treatment
y

The treatment is dependent on the cause and severity of the hyphema. Frequently, the blood is reabsorbed over a period of days to weeks. During this time, the doctor will carefully monitor the intraocular pressure for signs of the blood preventing normal flow of the aqueous through the eye's angle structures. If the eye pressure becomes elevated, eye drops may be prescribed to control it. The pupils are also evaluated to rule out damage to the iris. In some cases, a procedure is performed to irrigate the blood from the anterior chamber to prevent secondary complications such as glaucoma and blood stains on the cornea. Patients with significant hyphemas must rest and avoid strenuous activity to allow the blood to reabsorb.

Strabismus (crossed eyes; esotropia; exotropia; squint; walleye,) --------------------->> o Definition  Disorder that causes one eye to be misaligned with the other when focusing o Causes 16

 

  o S/S

Lack of coordination between the eyes. As a result, the eyes look in different directions and do not focus at the same time on a single point Children - May be associated with retinopathy of prematurity, retinoblastoma, traumatic brain injury, hemangioma near the eye during infancy, Apert syndrome, Noonan syndrome, Prader-Willi syndrome, Trisomy 18, Congenital Rubella, Cerebral Palsy) Adults some disorders associated with strabismus in adults include diabetes, eye disease/injury, stroke, traumatic brain injury, paralytic shellfish poisoning (PSP), Guillain-Barre syndrome, Botulism Family history of strabismus is a risk factor, farsightedness may be a contributing factor. In addition, any other disease causing vision loss may produce strabismus as a complication

Eyes that appear crossed Eyes that do not align in the same direction Uncoordinated eye movements (eyes that do not move together) Double vision Vision in only one eye, with loss of depth perception (depth perception is our ability to see 3D, and recognize the order of objects in the space around us) Exams and Tests  PE  Standard ophthalmic exam  Visual acuity  Retinal exam  Neurological examination Treatment     
Initially, strategies to strengthen the weakened muscles and thereby realign the eyes are attempted. Glasses may be prescribed. Eye muscle exercises may be prescribed.  If amblyopia (lazy eye) is present, patching of the preferred eye may be done to force the child to use the amblyopic eye. Surgery may be required to realign the eye muscles if strengthening techniques are unsuccessful. Prognosis  With an early diagnosis, the defect can usually be correct  With delayed treatment, vision loss in one eye may be permanent Complications  Loss of vision in one eye due to amblyopia (lazy eye)  Embarrassment over facial appearance with eye patch 

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