CAM I: Ophthalmology 2

CAM I: Ophthalmology 2

• Course taught by Professor Boucher
• Course offered at South College

Learning Objectives

• Recognize and explain basic types and treatment of eye trauma
• Describe the etiology, signs, symptoms, and physical examination findings for diabetic retinopathy and hypertensive retinopathy
• Recognize and describe common ocular abnormalities (nystagmus and retinal detachment)
• Describe the visual pathway
• Recognize and describe common abnormalities of the optic nerve and orbital cavity
• Describe the signs, symptoms, diagnosis, and treatment of glaucoma
• Compare and contrast diseases causing blindness
• Describe the pathophysiology, diagnosis, signs, symptoms, and treatment of cataracts
• Describe the pathophysiology, diagnosis, signs, symptoms, and treatment of macular degeneration

Eye Trauma

• Ruptured globe ("open globe") is trauma to the eye, usually from a sharp object or projectile
• Full thickness break of the eye wall (sclera and cornea)
• Requires emergency ophthalmic consultation
• Leave the eye alone
• Apply an eye shield
• Do not put anything in the eye
• Avoid any pressure on the globe or eye exam procedures
• Avoid topical meds
• CT scan of orbits
• IV antibiotics (typically Vancomycin + Ceftazidime)

Orbital Fractures

• Common in young males, usually caused by assaults, MVCs, or being struck by an object to the face/eye
• Involves any of the bones surrounding the eye
• Superior orbital rim, roof of orbit - Frontal bone; frontal sinus; supraorbital nerve
• Lateral wall of orbit - Sphenoid bone; lateral canthal ligament
• Infraorbital rim & floor of orbit - Zygoma; inferior oblique & inferior rectus muscles; maxillary sinus; infraorbital nerve
• Medial wall of orbit - Maxillary & ethmoid bones; medial canthal ligament; lacrimal duct system.

Blowout Fracture

• History of small, round, high-speed object impact to eye/orbit (e.g., baseball)
• Often involves the inferior wall or floor of the orbit
• Symptoms include bruising, soft tissue swelling, and pain
• Diagnosed with CT imaging
• Requires ophthalmology referral and hospitalization
• Significant consequence: entrapment of inferior rectus muscle and/or orbital fat
• Potential ischemia of muscle & subsequent loss of muscle function from edema and hemorrhage

Chemical Ocular Injury

• Urgent evaluation and treatment needed for eye contact with any acids or alkalis to prevent vision loss
• Severity depends upon agent, exposure duration & penetration depth
• Alkaline substances (e.g., drain cleaners, bleach) can cause more severe damage than acids (can eat through the eye quickly)
• Referral to ophthalmology before leaving the office is critical
• Treat with continuous irrigation with water or saline until neutral pH

Retinopathy

• Complication of conditions like hypertension (HTN) or diabetes mellitus (DM)
• Damages blood vessels in the light-sensitive tissue at the back of the eye (retina)
• Involves abnormal growth of blood vessels within the retina
• Can cause preventable blindness, particularly in the 20-74 age range
• Patients with risk factors should have regular eye exams

Diabetic Retinopathy

• Microvascular complication of DM.
• Damage to retinal blood vessels leads to retinal ischemia and edema
• Presentation: Asymptomatic until late stages
• Nonproliferative (early): Microaneurysms, dot & blot hemorrhages, hard exudates, cotton wool spots.
• Proliferative (late): New abnormal vessels grow onto the retina.
• Requires urgent treatment. Early detection and management are crucial to prevent vision loss.

Hypertensive Retinopathy

• Retinopathy related to chronic elevated blood pressure.
• Leads to ischemia
• Presentation: Asymptomatic until late stages causing vision impairment.
• Findings include copper/silver wiring of arterioles, exudates, flame-shaped hemorrhages, subretinal edema, optic disc swelling, and AV nicking.
• Early detection and management is essential to prevent vision loss.

Visual Pathway

• Light travels through cornea, aqueous humor, lens, and vitreous humor to the retina.
• Light is refracted by the cornea and lens (and perhaps glasses or contacts)
• Focused onto the retina
• Transformed into an electrochemical signal
• Transmitted via the optic nerve to occipital lobes

Optic Neuritis

• Acute inflammation and demyelination of the optic nerve
• Causes acute monocular vision loss and pain with eye movement
• Often associated with multiple sclerosis (MS).
• Symptoms: Monocular vision loss (one eye only), blurred vision & pain in affected eye
• Diagnosis: Fundoscopy (blurred optic disc), Relative afferent pupillary defect (RAPD), swinging flashlight test, MRI.
• Treatment: intravenous methylprednisolone, referral to neurology

Papilledema

• Swelling of the optic disc due to increased intracranial pressure
• Classically bilateral
• Symptoms often include headache, dizziness, nausea/vomiting, and minimally impaired vision.
• Diagnosis: Fundoscopy reveals a diffuse optic disc swelling.
• Management focuses on treating the underlying cause to decrease intracranial pressure as quickly as possible (e.g., head injury, tumor)
• Need immediate referral to neurology for diagnosis and treatment

Blindness

• Common causes include: uncorrected refractive errors (myopia, hyperopia, astigmatism, presbyopia), cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy
• Leading causes worldwide include cataracts (39%), uncorrected refractive errors (18%), and age-related macular degeneration (17%).

Chronic Vision Loss

• Common causes in the elderly: glaucoma, cataracts, and age-related macular degeneration
• Regular screening is essential to catch these conditions early to preserve vision

Glaucoma

• Chronic open-angle glaucoma - characterized by gradual vision loss
• Acute angle-closure glaucoma - medical emergency with a rapid increase in intraocular pressure. This leads to severe pain and decreased vision.
• Features include raised intraocular pressure (IOP), haziness of the cornea, and dilated pupils
• Early detection and treatment are necessary for significant damage

Cataracts

• Opacity of the lens causing blurring or distorted vision
• Most common cause of blindness worldwide.
• Risk factors include aging, UV exposure, smoking, etc
• Diagnosis typically includes a complete ophthalmic exam, including the dilated fundus exam.
• Treatment usually involves surgical removal.

Age-Related Macular Degeneration (AMD)

• Most common cause of vision loss
• Gradual vision loss mostly affecting central vision.
• Usually more chronic (Dry AMD) though can be more acute and sudden (Wet AMD)
• Risk factors include age (>65 years old), smoking.
• Diagnosis includes thorough fundoscopic exam, Amsler Grid test, and OCT testing
• Management includes treatment with anti-VEGF drugs for Wet AMD and vitamins/nutrients to slow progression.
• Drusen - a defining feature of this condition.

Giant Cell Arteritis

• Inflammation of the arteries near the temples, most often in older adults
• Risk factors include age (>60-70 years old) and correlation with polymyalgia rheumatica
• Symptoms include headaches, scalp tenderness, jaw pain (claudication), unexplained fever, and significant vision problems
• Left untreated can lead to blindness
• Diagnostics: elevated ESR, CRP levels
• Treatment: IV steroids (methylprednisolone), and hospital admission for temporal artery biopsy.

Retinal Detachment

• Medical emergency where the thin layer of tissue lining the back of the eye (retina) detaches.
• Hallmark signs include flashes of light, floaters, sudden vision loss, or a curtain-like shadow in the visual field
• Risk factors include increasing age, myopia, family history, and prior eye surgeries.
• Diagnosis by fundoscopy
• Treatment is usually ophthalmologic emergency with pneumatic retinopexy (air injection), or cryoretinopexy to reattach retina.

Retinoblastoma

• Rare malignant eye cancer
• Commonly found in children
• Physical examination: absence of the red reflex.

Visual Field Defects

• General term for loss of sight or impairment in vision.
• Various causes for this condition, including glaucoma, cataracts, age-related macular degeneration, retinal detachment, and others.