Overview of the Eye, Red Eye PDF

OVERVIEW OF THE EYE, RED EYE Ryane Lester PA-C. MPAS January 27, 2025 Clinical Medicine II OBJECTIVES  DEFINITIONS Visual Acuity (VA) – clarity of vision OD – right eye OS – left eye OU – both eyes  V...

OVERVIEW OF THE EYE, RED EYE Ryane Lester PA-C. MPAS January 27, 2025 Clinical Medicine II OBJECTIVES  DEFINITIONS Visual Acuity (VA) – clarity of vision OD – right eye OS – left eye OU – both eyes  VISUAL ACUITY Patient stands or sits at a distance of 6 meters (~20 ft.) from the Snellen or E chart The smallest line read is expressed as a fraction, e.g. 20/40. the upper number refers to the distance (in meters) the chart is from the patient & the lower number is the distance (in meters) at which a “normal” eye can read that line of the chart The use of a pinhole can help overcome most refractive errors The VA for each eye is recorded stating whether it is with or without correction. (Ex: Right VA/OD = 20/40 with correction, Left VA/OS = 20/40 without correction)  REFRACTIVE ERRORS § Refractive error = cause of reduced clarity/reduced visual acuity § Tx with glasses, contacts, surgery § Refraction is the bending of light rays § For vision – light reflection from an object is refracted by the cornea and lens, focused on the retina § Contact lenses – very common § Biggest risk is corneal infection (5x more risk with soft extended wear) § Pt education – avoid overnight wear, extending past replacement date, wearing expired contacts, inform of lens hygiene § Surgery: § Laser = “laser eye surgery” § Reshapes the middle layer, stroma of the cornea  COMMON REFRACTIVE ERRORS Emmetropia – perfect focus Myopia (nearsightedness) → nearby objects look clear, far- away objects look blurry (can’t see far) Hyperopia (farsightedness) → distant objects look clear, nearby objects look blurry (can’t see close) Astigmatism (abnormal curvature of the cornea)- both far- away and nearby objects look blurry or distorted Presbyopia – changes in the lens’ curvature, ↓ lens’ elasticity, & ↓ ciliary muscle’s strength due to age → the inability to see things up close https://shorturl.at/zDRT4  Vision: do a formal visual acuity, use a Near Card. If not available, try a magazine or your ID badge Eye Pressure: finger/tractile pressure over the eyelid or handheld devices such as Tonopen or iCare OCULAR Tonometers VITAL Pupils: Size, Symetry, Shape, Reactivity to light SIGNS Motility: are the eyes moving together? Visual Fields: confrontation fields (one eye at a time) SLIT LAMP AND OPHTHALMOSCOPE Slit lamp is more for the anterior of the eye, much greater magnification and much more detail Ophthalmoscope/funduscope is more for the back of the eye, optic nerve, blood vessels etc. So what do you use in rotations/office?  INTRAOCULAR PRESSURE Think of testing IOP with any eye PAIN (use your judgement on that) Recall – aqueous humor is constantly being made The same amount that is made, has to equal the amount being drained Pressure stays stable if this occurs If fluid builds up, pressure rises à damage to optic nerve  INTRAOCULAR PRESSURE What would cause elevated IOP: Various ways to test DON’T TEST IF SIGNIFICANT TRAUMA Protects and maintains the refractive surfaces, helps keep shape constant Normal 10 to 21 mm Hg EYE DIAGNOSES  CONJUNCTIVITIS Inflammation of the mucous membrane that lines the surface of the eyeballs and inner eyelids Viral, bacterial, chemical Bacterial (gonococcal) When inflamed due to infection or irritant, the BV in the conjunctiva dilate à redness/hyperemia Acute or chronic, non infections or infectious Most common under 7, 0-4 mostly, then 22-28 Etiology: viral is most common Viral: adenovirus most common, rarely do you confirm Bacterial: staphylococci, (MRSA), Strep. Pneumoniae, Haemophilus, Pseudomonas, Moraxella More common in kids Allergic: all in relation to atopy (atopic dermatitis, allergic rhinitis, allergic asthma) Seasonal – ASK!  CONJUNCTIVITIS S/s: Allergic: Viral (2 weeks): watery discharge and follicular Itching and burning conjunctivitis Watery, tearing Red eye, engorgement of the blood vessels History of atopy/allergies, edematous eyelids Bilateral Pain, maybe photophobia, maybe itching Might be associated with other URI symptoms - LAD Bacterial (10-14 days) : purulent discharge, matting of the eyelid Purulent – it is formed from being removed from the eye Mucopurulent, thicker and adheres to the eyelashes Blurry vision, pain, photophobia FB sensation  CONJUNCTIVITIS PE: Visual acuity, FB assessment Observe either bacterial or viral symptoms Allergic: conjunctival hyperemia and edema (chemosis) Tx: Ointment vs. drops Viral – discourage abx drops Bacterial: azithromycin, bacitracin, ciprofloxacin, erythromycin, etc Allergic: Artificial tears, cold compress Various topicals Antihistamines: Olopatadine hydrochloride, Ketotifen, Ketotifen fumarate  CONJUNCTIVITIS Things to think about: If s/s of HSV à make sure to stain the eye to r/o herpetic lesion If there is true vision loss and/or pain à think deeper DDx: Glaucoma, iritis, keratitis, episcleritis, scleritis, corneal abrasion/ulcer, FB, blepharitis, etc  CHEMICAL CONJUNCTIVITIS Chemical burns – OUCH!!! IRRIGATION, IRRIGATION, IRRIGATION!!! PE: Remove any foreign material ASAP Ensure no globe trauma, eval for retained objects Alkali exposures are more serious, take more irrigation Ocular pH with litmus paper – as soon as at emergency care/urgent care etc Irrigation, irrigation, irrigation – at the scene Tx: Analgesic S/s: they will tell you Irrigation, irrigation, irrigation Severe pain, blepharospasm, redness, photophobia Poison control Topical abx: erythromycin ointment, polymyxin/trimethoprim drops Significant injury à optho LID DISORDERS  HORDEOLUM Acute infection to the upper or lower eyelid Internal: meibomian gland abscess Can lead to cellulitis External: stye, abscess of the gland of Zeis Smaller, on the lid margin Etiology: Staph aureus S/s: Red, swollen, acute tender Tx: warm compress I and D if not resolution Abx ointment to lid +/-  CHALAZION Granulomatous inflammation of the meibomian gland Can follow an internal hordeolum S/s: Hard, NON tender swelling on the eyelid Redness and swelling Tx: Warm compresses I and D in 2-3 weeks  BLEPHARITIS Inflammatory condition of the lid margin Bilateral Anterior: lid skin, eyelashes, and glands Etiology: Staphylococcus (ulcerative), or seborrheic (seborrhea of scalp, brows, etc) Posterior: inflammation of the meibomian glands Etiology: staphylococcus or gland dysfunction Risk factors: Chronic inflammatory skin conditions, dermatitis, eczema, etc  BLEPHARITIS S/s: PE: Irritation, burning, itching, red Irritated eyelids or lid margins Gritty sensation Crusting, or scaling flakes Crusting, matting, flaking of lids or lashes Conjunctival injection Anterior: red rimmed eyes, scales, collarette on lashes Tx: Posterior: hyperemia lid margins, telangiectasias, Anterior: hygiene (warm compresses), eyelid scrubs inflammation of the gland Abx eye ointment: bacitracin or erythromycin Posterior: Meibomian gland expression and warm compresses Abx: oral macrolide, doxycycline, topical corticosteroid, topical abx  DDX Distinguish the differences with the following: Conjunctivitis Hordeolum Chalazion  ENTROPION AND ECTROPION Entropion: inward turning of the lid margin Usually lower lid, common Surgery if scarring the cornea Botulism injections Ectropion: outward turning of the lower lid Common in advanced age Surgery if excessive tearing or for cosmetic purposes LACRIMAL DISORDERS  DACROCYSTITIS Infection of the lacrimal sac More common in infants and > 40 y.o Usually unilateral Etiology: obstruction of the nasolacrimal system à stagnant tears Infection: due to Staph epidermidis, strep, ore gram neg bacilli if chronic Chronic: secondary to systemic disease S/s: Acute: Pain, swelling, redness in the tear sac Swelling at the inferomedial canaliculi Purulent discharge or expression Chronic: Tearing and discharge  DACROCYSTITIS Tx: Acute: Congenital often resolves with conservative measures Topical antibiotics for acute flares Oral antibiotics Surgery to remove obstruction Chronic: Abx, ultimately surgery Dacryocystorhinostomy  DACROADENITIS Inflammation of the lacrimal gland Children and young adults Acute or chronic Acute = infection, most often from the conjunctiva; also skin/trauma Viral > bacterial Inflammatory (usually causes for chronic) Viral: Epstein Barr, adenovirus, herpes, mumps Bacterial: Staph aureus and (MRSA), strep pneumo, gram neg rots  DACROADENITIS S/s: Tx: Acute: erythema, tenderness, enlargement of gland Viral: no tx, self resolving Lateral portion of the eyelid might droop Bacterial: Discharge – no suppurative if viral abx Lymphadenopathy If atypical symptoms or unresolving à workup Fever Older adult, bilateral, systemic symptoms Inflammatory: painless swelling  DACROSTENOSIS Narrowing/obstruction of the nasolacrimal duct Usually benign Congenital (6% of all newborns) or acquired Can cause some complications Causes watery eyes Dx: mostly clinical S/s: Fluorescein dye test Mucoid discharge and persistent tearing Other diagnostics, imaging First few days/weeks of life Tx: PE: Lacrimal duct massage Concern is to ensure there isn’t anything more concerning Lacrimal duct probing going on Stent placement Increase in tears, eyelash debris, etc Balloon, Surgery  KERATOCONJUNCTIVITIS SICCA Inflammatory condition of the conjunctiva (conjunctivitis) and cornea (keratitis) Associated with viral, bacterial, autoimmune, and allergic etiologies infectious and non infectious Dry eye syndrome = very common Etiology: autoimmune systemic Abnormality in the tear film and inflammatory changes to conj. and cornea Loss of the aqueous componenent of tears  KERATOCONJUCTIVITIS SICCA S/s: Chronic Discomfort/irritation, pruritis, blurring, photophobia Burning, stinging, FB sensation, watery discharge Bilateral PE: Do a thorough eye exam Conjunctival injections, discharge Eyelid erythema and telangiectasias, reduced tears  KERATOCONJUCTIVITIS SICCA TX: If keratoconjunctivitis sicca is suspected – consider testing for Sjogren Artificial tears or ointments Warm compresses or lid scrubs Fish/flaxseed oil supplement Serum drops with anti-inflammatory factors CORNEAL DISORDERS  CILIARY FLUSH This will often come up as a PE sign with numerous eye conditions Dilated blood vessels around the cornea of the eye Iritis, corneal ulcers, uveitis, glaucoma Different from diffuse conjunctival injection that affect the whole outer layer of the eye in conjunctivitis  PINGUECULA AND PTERYGIUM PINGUECULA PTERYGIUM Yellowish, raised conjunctival nodule Fleshy, triangular, encroachment of the conjunctiva onto the cornea Near palpebral fissure Due to prolonged exposure to wind, Over 35 y.o, dust, sand, wind Bilateral, nasal side Bilateral, nasal side Rarely grow May grow Tx: artificial tears Tx: artificial tears  CORNEAL ABRASION Scratch to the cornea Cornea: Avascular, highly innervated (CN ?), refracts light Transparent, covers the iris and the pupil, allows light to enter Very common ED presentation Almost half of eye related complaints are due to corneal abrasions Disruption or loss of cells in the top layer of the cornea (epithelium) Changes the interface between the cells and matrix Non penetrating trauma Traumatic, FB related, finger induced, contact lens related, or spontaneous  CORNEAL ABRASION S/s: PE: FB sensation Decreased visual acuity, photophobia, tearing, redness Difficulty opening eye, photophobia Injection of the conjunctiva Eye pain, redness, excessive tearing Eyelid eversion for FB Blurred vision Topical anesthetics Fluorescein staining to see the defect: Fluorescein stain Often linear but can be geographic Contacts can be multiple punctate lesions à coalesce  CORNEAL ABRASION Red flag symptoms: Tx: Significant trauma or significant pain Non contact wearer Erythromycin ointment Abnormal pupils or pupil reaction Sulfacetamide 10%, polymyxin/trimethoprim, Hyphema CONTACT WEARER COVER FOR Significant decrease in visual acuity PSEUDOMONAS Dendrite on stain Ciprofloxacin drops Previous patching – NO LONGER RECOMMENDED Tetanus not needed for superficial injuries  CORNEAL ULCER Involves the stroma, vision threatening Etiology: Bacterial: Staph. Aureus, Pseudomonas, coag neg staph Viral: HSV Fungi or amoebas Non infectious = forms of keratitis Dry eye Trauma Risk factors: CONTACT LENS WEARERS Other chronic eye conditions and systemic conditions Prompt referral and tx to avoid corneal scarring  CORNEAL ULCER Ask about contact lens and habits, surgery, trauma, Examine eye and conjunctiva, evert eyelid (look for exposures, PMH corneal ulcer here) There is usually a rapid onset of pain and some Bacterial: vision loss Ulcers appear as clearly defined infiltrates (slit lamp S/s: = flare and cells from iritis) Pain, redness, FB sensation, photophobia, tearing and Round or irregular ulcer with a white, hazy base, discharge, swelling blurred vision, gritty feeling maybe raised edges PE: Viral: Visual acuity Ulcers appear as dendritic lesions with fluorescein uptake (slit lamp = flare and cells from iritis) Pressures Cell and Flare Pupil response  CORNEAL ULCER TX: Ophthalmologic consultation Bacterial: Topical antibiotics – fluoroquinolone (ciprofloxacin or ofloxacin) Viral: Acyclovir ointment, ganciclovir gel Maybe debridement Oral antivirals  ABRASION VS. ULCER Symptoms of each? Layer of the cornea Morbidity of the injury How does the physical exam look How do we treat corneal abrasion Contacts? How do we treat corneal ulcer Bacterial? Viral?  INFECTIOUS KERATITIS Keratitis is the inflammation of the cornea and is characterized by (infection and non infectious) – think of this as not an open wound yet – but can become an ulcer Corneal edema Infiltration of inflammatory cells Ciliary congestion Bacterial: Staph (MRSA), strep, pseudomonas Viral – HSV S/s, PE, and tx, same and corneal ulcer ORBITAL DISORDERS  PERIORBITAL CELLULITIS Also called preseptal cellulitis S/s: Periorbital and orbital are a spectrum of infection Can be a results of URI infections (sinusitis, hordeolum, chalazion), bites or trauma Periorbital is an infection of the eye lids and periocular tissues ANTERIOR to the orbital septum URI symptoms, fever Usually in children Tearing, erythema, edema, warmth tenderness to lids and soft tissues around the eye Etiology: No complaints of lack of EOM or vision changes Staph aureus PE: Staph epidermidis NORMAL VISUAL ACUITY, PUPILLARY REACTIONS, AND Streptococcus EOMS Anaerobes TX: Abx: amoxicillin/clavulanate, or cephalosporin, close follow up If severe à admit  ORBITAL CELLULITIS Infection of the orbital soft tissues POSTERIOR to the orbital septum Spread from the paranasal sinuses – ethmoid Trauma, FB, spread from periorbital, surgery Etiology: often polymicrobial S. pneumoniae, Staph, H influenzae S/s: Onset of URI symptoms (rhinitis, facial pressure, fever) PE: Fever, proptosis, swelling, redness of the lids Pain with EOMs, chemosis, abnormal pupillary response, decreased visual acuity RESTRICTION OF EOMs  ORBITAL CELLULITIS IMMEDIATE IV ABX – prevent vision loss and spread CNS Emergent referral Admit CT scan TX: Broad coverage: Vancomycin + cephalosporin/pip tazo/imipenem/meropenem Add metronidazole or clindamycin for aerobic Nafcillin Add metronidazole or clindamycin for aerobic, if trauma, add cephalosporin (covers staph and strep) Lateral canthotomy if IO elevated or optic neuropathy is present INFLAMMATORY DISORDERS  SCLERITIS Severe ocular inflammatory condition of the sclera = painful and potentially blinding Diffuse, nodular, or necrotizing = anterior (90%) Diffuse or nodular = posterior, more rare Unilateral or bilateral Etiology: Idiopathic or triggered by infection or trauma or due to underlying autoimmune disorder 50% of patients with have an underlying autoimmune disorder  SCLERITIS S/s: Anterior: Pain and tenderness – worse at night Pain with EOM’s Blue hue of the deeper vessels Photophobia, tearing, maybe decreased vision  SCLERITIS PE: Nodular: Anterior: Multiple nodules, scleral edema, Diffuse: most common of the anterior congestion of vessels Extensive scleral edema, congestion More localized of vessels Necrotizing: Localized or extensive Intense congestion, severe pain, inflammation can spread Blue hue  SCLERITIS Tx: Topical corticosteroid drops Oral NSAIDS Oral corticosteroids Subconjunctival corticosteroid injections QUESTIONS?