Adult & Child Eye Disorders 2021 PDF

Eye Disorders DR. KIM BALLONE, DNP, APRN-CNP  Eye Disorders  Sign and Symptoms that suggest problems of the eyes  Halos around lights in surrounding darkness: can indicate cataracts and glaucoma  Loss of peripheral vision: glaucoma and retinal det...

Eye Disorders DR. KIM BALLONE, DNP, APRN-CNP  Eye Disorders  Sign and Symptoms that suggest problems of the eyes  Halos around lights in surrounding darkness: can indicate cataracts and glaucoma  Loss of peripheral vision: glaucoma and retinal detachment  Pain: May warrant investigation of glaucoma, foreign body and corneal abrasion  Sudden change in vision: Consider retinal detachment, foreign body, corneal abrasion, optic neuritis, temporal arteritis, migraine headaches, TIA or stroke, tumor, etc.  Eye Disorders  Common eye disorders:  Cataracts  Conjunctivitis  Corneal Abrasion  Retinal Detachment  Central and Branch Retinal Artery Obstruction  Hordeolum (Stye)  Chalazion  Glaucoma  Cataracts  Clouding of the natural lens of the eye  Leading cause of reversible blindness worldwide  Early findings: painless, progressive loss of visual acuity, blurred vision, glare from headlights, difficulty reading, difficulty seeing at night, sensitivity to light, and the perception of halos around lights, double vision.  Second sight: refers to the temporary improvement in vision experienced by some individuals with cataracts, often described as a “clearing” or “brightening” of vision.  Interventions: Early lens changes, micro incision surgery, foldable lenses, phacoemulsification  Priority differentials: Macular degeneration and diabetic retinopathy  Conjunctivitis “Pink Eye”  A common, acute, painful inflammation with or without infection of the conjunctiva, but involving the cornea or deeper structures of the eye  Most cases are acute, but can be chronic  Many are infectious  Touches face- can transfer to other eye  Can be bilateral or unilateral  Etiology/predisposing factors of Conjunctivitis  Spread by direct inoculation via fingers or droplets  Bacterial Conjunctivitis  Staphylococcus aureus  Pseudomonas  Haemophilus influenzae  Moraxella  Gonorrhea and chlamydia  Viral Conjunctivitis  Commonly adenovirus  Herpes virus (may be vision threatening)  Other Predisposing factors of Conjunctivitis  Allergens (pollen, dust, contact lenses, dyes, eye drops, make up). Supportive treatment first (artificial tears, cool compress), if symptoms persist then an antihistamine vasoconstrictor (naphazoline-pheniramine). Watch for rebound vasodilation, if using longer than 3-7 days (cause medication induced conjunctivitis). Zerviate provides rapid relief of itching.  Viral: artificial tears and cool compresses. Lasts 5-14 days. Contagious if tearing for at least 1 week  Trauma (chemical and UV flash burns)  Dry Eye (Keratoconjunctivitis sicca)  Parasitic infection (pediculosis pubis)  Medication adverse effects (e.g. antihistamines and anticholinergics)  Environmental insults (wind, heat, sun, and smoke) Subjective & Objective findings of Conjunctivitis  Subjective  Redness or excessive tearing (sense of a foreign body in the eye)  Swelling or itching  History of allergy, infection, trauma  Discharge, edema of external eye or lid  Objective  Evert the upper lid by rolling it externally  Examine for foreign body or papillary changes  Drainage may be purulent or serous, obtain culture before drops or irrigation is instilled  Management of Conjunctivitis  Nonpharmacological  Cool Eye compresses for itching, irritation  Warm Eye compresses for crusting  Pharmacological  Bacterial (if immunocompromised, diabetic, glaucoma surgery, healthcare workers)  Topical antibiotic ophthalmic solutions or ointments  Gentamicin 3 mg/ml solution 1-2 drops q4hrs. for 5 days  Neomycin 1-2 drops q6hrs. Or ointment ½ inch ribbon q3-4hrs. for 7-10 days  * 15% risk for adverse reaction to neomycin products  Polymyxin apply ointment q3-4hrs for 7-10 days  Ofloxacin 0.3% solution 1-2 drops into affected eye q6hrs depending on severity  Gonococcal: Ceftriaxone 1 gm IM once  Chlamydial: Azithromycin 1 gm PO once  Corneal Abrasion  Disruption of the epithelium of the cornea (the clear, anterior covering of the eye  Usually associated with chemical, burn, or mechanical trauma  Result of outdoor activity, occupational hazards and lack of proper eye protection  Welding, painting, construction  Very common eye disorder  Always ask if patient wears contact lenses!! Prolonged use can result in injury and corneal epithelial breaks  Subjective & Objective findings of Corneal Abrasion  Subjective  Sudden, Intense pain associated with sensory nerve supply of the eye  Sense of a foreign body in the eye  Report of redness or discharge of the conjunctiva  History of decreased visual acuity or vision  Complaint of tearing or photophobia  Decrease in visual acuity  Objective  Evert the lid and inspect for foreign body and signs of trauma  Fluorescein staining of the cornea  Appears as increased uptake of dye when the area is illuminated by a Wood lamp or UV light  Management of Corneal Abrasion  Refer to Ophthalmologist  Immediate referral for hypopyon (inflammatory debris in the inferior anterior chamber), peaked, nonreactive or irregular pupil (penetrating injury), extruded ocular contents, metallic foreign bodies, nonhealing epithelial defects, chemical injuries, infectious keratitis, full thickness corneal laceration, or elevated IOP > 30 on tonometry  A fluorescein exam is used to confirm the diagnosis of a corneal abrasion  Apply antibiotic ointment or solution  Gentamicin ophthalmic ointment 0.3%  Sulfacetamide solution 10%  Cycloplegic or mydriatic drops (do not use with angle closure conditions, glaucoma)  Apply a soft eye patch (removed by the clinician in 24 hours)  Update tetanus immunization if indicated  Reevaluate in 24 hrs. at which time healing should be complete  Retinal Detachment  Separation of the neural retina from the choroid after trauma, hemorrhage, increased intraocular pressure or transudation of fluid leaving the retina without oxygen and nourishment  Annually, 10 out of every 100,000 persons suffer a retinal detachment without a rhegmatogenous tear (tear with fluid between the retinal layers)  1-3% of patients undergoing cataract surgery suffer a retinal detachment  The following are associated with retinal detachment:  Diabetes Mellitus  Sickle cell anemia  Myopia and cataract extraction Subjective and Objective findings of Retinal Detachment  Sudden onset of painless visual changes, floaters, light flashes, and blurred vision  A “curtain” may obscure part or all of the visual field  Large detachments may produce a Marcus Gunn pupil (afferent pupil that reacts more consensually than directly)  Elevations of the retina related to tears  Exudative, bullous elevation without tears Management of Retinal Detachment  Immediate referral to ophthalmologist for evaluation and treatment:  Diathermy- technique to stimulate circulation through heat, electric current  Cryotherapy/cryopexy  Photocoagulation  Pneumatic retinopexy  Vitrectomy  If the detachment is a result of traumatic insult, patch the eye with a metal shield (Fox eye shield). Central and Branch Retinal Artery Obstruction  An abrupt blockage of the central retinal artery or its branches, causing a sudden loss of visual fields  Permanent partial or complete visual loss may ensue without immediate intervention  Causes: thrombosis, embolism, arteritis of the central artery  Associated with:  Migraine  History of vasculitis  Atrial fibrillation  Diabetes  Hypertension  Inflammatory condition  Coagulopathies Subjective and Objective findings of Retinal Artery Obstruction  Sudden, painless gross visual loss (monocular), or visual field loss  Ipsilateral, intermittent monocular blindness (Amaurosis fugax) is associated with ipsilateral carotid disorder and is sign of impending stroke  Intraocular hemorrhage can occur in patients on antiplatelet and anticoagulant therapy. Ask if this has happened before….  Visual loss may be central or peripheral  Partial dilatation of the pupil, which is sluggishly reactive to direct light may have a normal consensual response  Fundoscopic exam  May reveal a pale, opaque fundus and characteristic “cherry-red spot” at the forvea or bifurcation of the arteries where emboli is most likely to become lodged  Retina may be edematous  Arterial vessels may appear pale and bloodless Labs & Diagnostic Findings of Retinal Artery Obstruction  Elevated Erythrocyte Sedimentation rate (ESR) associated with giant cell arteritis  Consider testing to evaluate for coagulopathies  CBC for anemia, polycythemia, and platelet disorders  Fasting blood sugar, Hgb A1c, cholesterol, triglycerides and lipid panel for atherosclerotic disease  Blood cultures for bacterial endocarditis and septic emboli  Fluorescein angiography  Visual acuity, visual field exam  Management of Retinal Artery Obstruction  Immediate consultation with an ophthalmologist  Intermittent digital massage of the anterior chamber by gentle pressure over the eyelid may be sight saving. If an embolus can be dislodged, retinal ischemia can be relieved  Consider rebreathing CO2 per air-tight mask or bag to decrease alkalosis  Consider IV anticoagulant (i.e. heparin 10,000 units)  Treatment of underlying comorbidities such as carotid and cardiac disease causing emboli, hypertension, migraine, oral contraceptive use, or thrombophilia.  Other common eye disorders  Hordeolum (Stye)  An external hordeolum is an abscess of a hair follicle and sebaceous gland in the upper or lower eyelid. An internal hordeolum involves inflammation of the meibomian gland.  Treatment: Hot compresses 5-10 minutes 2 times to 3 times until it drains  If infections spreads: dicloxacillin or erythromycin po 4x/day  Refer to ophthalmologist for I&D  Chalazion  A chronic inflammation of the meibomian gland (specialized sweat gland) of the eyelid. Usually resolves in 2-8 weeks.  Small, painless, movable superficial nodule on upper eyelids feels like a bead  Treatment is I&D, surgical removal, intrachalazion corticosteroid injection  Glaucoma (affects optic nerve), Sudden Thief of Sight Open-Angle Glaucoma Closed- Angle Glaucoma  Gradual onset of increased IOP >22 (normal 10-20)  Sudden blockage of aqueous humor causes a marked increase of due to blockage of the drainage of aqueous humor IOP resulting in ischemia and permanent damage to the optic nerve (CNII) inside the eye. If untreated permanent damage  occurs. IOP is measured with a tonometer. Most commonly seen in elderly, esp. Caucasians, African Americans, and diabetics.  Treatment  Decreased vision, halos, headache, severe eye pain, n/v, mid-  Betimol 0.5% (timolol) beta blocker eye drops dilated, oval-shaped pupils, cloudy cornea  Suggests rapid increase in IOP: conjunctival redness, corneal  Latanoprost(Xalatan) prostaglandin eye drop edema, shallow anterior chamber, mid-dilated pupil (4-6 mm) that  reacts poorly to light Refer to an ophthalmologist, and regular eye checks  Refer to ophthalmologist, emergent exam of both eyes, visual if family history acuity, pupil eval, IOP measurement, slit lamp exam, visual fields,  Pachymetry is used to measure corneal thickness, undilated fundus exam which is indicated in open-angle glaucoma to further  Pupillary dilation can exacerbate angle closure glaucoma and evaluate the risk of development and progression should be deferred when diagnosis is suspected.  Gold standard to diagnose: Gonioscopy  Topical beta blocker and acetazolamide 500 mg IV or PO  Other danger signs  Diabetic Retinopathy  Microaneurysms (small bulges in retinal blood vessels that often leak fluid) caused by neovascularization (new fragile arteries in the retina that rupture and bleed). Appears cotton wool spots (fluffy yellow-white patches on the retina)  Hypertensive retinopathy  Copper and silver wire arterioles (caused by arteriosclerosis). Look for Arteriovenous nicking (when arteriosclerotic arteriole crosses retinal vein, it indents the vein). Appear as retinal hemorrhages.  Papilledema  Optic disc swollen with blurred edges due to increased intracranial pressure secondary to bleeding, brain tumor, abscess, pseudotumor cerebri Optic Neuritis (Seen in Multiple Sclerosis) A young adult with new or intermittent loss of vision of one eye (Optic Neuritis) alone or accompanied by nystagmus or other abnormal eye movements. Refer to neurologist.. Age Related Macular Degeneration  Breakdown of part of the retina (macula), death of light sensitive receptors in the central retina, causing distortion, blurred vision, but no change in peripheral vision.  Increased age, smoking, and family history are risk factors  Other danger signs  Herpes Keratitis  Acute onset of severe eye pain, photophobia, tearing, and blurred vision in one eye  Diagnosed by using fluorescein dye  An infection due to herpes simplex virus. There are 2 types of herpes virus that can infect the eye  If the infection is caused by shingles of the trigeminal nerve (CN V ophthalmic branch it is called herpes zoster ophthalmicus.  Herpes zoster opthalmicus has acute eruption of crusty rashes that follow the ophthalmic branch (CNV) of the trigeminal nerve (one side of the forehead, eyelids and tip of the nose)  Refer to ED What is the best test for diagnosing Glaucoma? A. Fluorescein staining B. Tonometry C. Snellen vision exam D. The refractive index The correct answer is: B. Tonometry Rationale: A tonometer is used to measure the intraocular pressure (IOP) of the eye to screen for glaucoma. Normal range IOP 10-20 mmHg.  Which of the following eye findings is seen in patients with diabetic retinopathy? A. Arteriovenous nicking B. Copper wire arterioles C. Flame hemorrhages D. Neovascularization  The correct answer is: D. Neovascularization Rationale: Microaneurysms (small bulges in retinal blood vessels that often leak fluid) caused by neovascularization (new fragile arteries in the retina that rupture and bleed. Appears cotton wool spots (fluffy yellow-white patches on the retina. Diabetic retinopathy is the most common cause of blindness in adults. AV Nicking, copper wire arterioles and flames hemorrhages are associated with hypertensive retinopathy. A patient presents with severe eye pain. The patient is reluctant to open the eye due to photophobia. They report working on their house earlier in the day and feeling something fall in their eye. The NP performs a visual acuity and fundus exam. Which of the following diagnostic studies is indicated next? A. Ultrasonography B. Fluorescein exam C. CT D. MRI  The correct answer is:  B. Fluorescein exam  This patient is presenting with signs of corneal abrasion A patient presents with a headache, severe eye pain, visual disturbances, and halos around lights. Physical assessment reveals conjunctival redness and cloudiness of the cornea. Emergent opthomologic exam is necessary. Which of the following diagnostic tests is indicated? A. Dilated fundus exam B. Pachymetry C. Fluorescein exam D. Measurement of intraocular pressure  The correct answer is:  D. Measurement of intraocular pressure  This patient is presenting with signs of primary angle closure glaucoma A 40 year old male presents with a 2 day history of foreign body sensation and excessive tearing of the right eye. What type of exam is recommended initially? A. Cardiac B. Visual C. Neurologic D. Cerebellar  The correct answer is:  B. Visual Optic Neuritis is usually associated with what condition? A. Mumps B. Diphtheria C. Measles D. Multiple Sclerosis  The correct answer is:  D. Multiple Sclerosis  A patient comes to clinic with diffuse erythema in one eye without pain or history of trauma. The examination reveals a deep red, confluent hemorrhage in the conjunctiva of that eye. What is the most likely treatment for this condition?  a. Order lubricating drops or ointments.  b. Prescribe ophthalmic antibiotic drops.  c. Reassure the patient that this will resolve.  d. Refer to an ophthalmologist  The correct answer is:  c. Reassure the patient that this will resolve.  Most subconjunctival hemorrhage, occurring with trauma or Valsalva maneuvers, will self resolve and are benign. Lubricating drops are used for chemosis. Antibiotic eye drops are not indicated. Referral is not indicated.  During an eye examination, the provider notes a red-light reflex in one eye but not the other. What is the significance of this finding?  a. Normal physiologic variant  b. Ocular disease requiring referral  c. Potential infection in the ―red‖ eye  d. Potential vision loss in one eye  The correct answer is:  b. Ocular disease requiring referral  The red reflex should be elicited in normal eyes. Any asymmetry or opacity suggests ocular disease, potentially retinoblastoma, and should be evaluated immediately.  A primary care provider may suspect cataract formation in a patient with which finding?  a. Asymmetric red reflex  b. Corneal opacification  c. Excessive tearing  d. Injection of conjunctiva  The correct answer is:  ANS: A An asymmetric red reflex may be a finding in a patient with cataracts. Corneal opacification, excessive tearing, and corneal injection are not symptoms of cataracts  Which are risk factors for development of cataracts? (Select all that apply.)  a. Advancing age  b. Cholesterol  c. Conjunctivitis  d. Smoking  e. Ultraviolet light  The correct answer is:  ANS: A, D, E  Most older adults will develop cataracts. Smoking and UV light exposure hasten the development of cataracts. Cholesterol and conjunctivitis are not risk factors.  A child has a localized nodule on one eyelid which is warm, tender, and erythematous. On examination, the provider notes clear conjunctivae and no discharge. What is the recommended treatment?  a. Referral to an ophthalmologist  b. Surgical incision and drainage  c. Systemic antibiotics  d. Warm compresses and massage of the lesion  The correct answer is:  ANS: D This child has a hordeolum, which is generally self-limited and usually spontaneously improves with conservative treatment. Warm compresses and massage of the lesion are recommended. Referral is not necessary unless a secondary infection occurs. Surgical intervention is not indicated. Systemic antibiotics are used to treat secondary cellulitis.  A patient who has symptoms of a cold develops conjunctivitis. The provider notes erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes, along with a fever. Which treatment is indicated?  a. Antihistamine-vasoconstrictor drops  b. Artificial tears and cool compresses  c. Topical antibiotic eye drops  d. Topical corticosteroid drops  The correct answer is:  ANS: B Viral conjunctivitis accompanies upper respiratory tract infections and is generally self-limited, lasting 5 to 14 days. Symptomatic treatment is recommended. Antihistamine-vasoconstrictor drops are used for allergic conjunctivitis. Topical antibiotic drops are sometimes used for bacterial conjunctivitis. Topical corticosteroid drops are used for severe inflammation.  A patient who works in a furniture manufacturing shop reports a sudden onset of severe eye pain while sanding a piece of wood and now has copious tearing, redness, and light sensitivity in the affected eye. On examination, the conjunctiva appears injected, but no foreign body is visualized. What is the practitioner’s next step?  a. Administration of antibiotic eye drops  b. Application of topical fluorescein dye  c. Instillation of cycloplegic eye drops  d. Irrigation of the eye with normal saline  The correct answer is:  ANS: B The practitioner must determine if there is a corneal abrasion and will instill fluorescein dye in order to examine the cornea under a Wood’s lamp. Antibiotic eye drops are not indicated as initial treatment. Cycloplegic drops are used occasionally for pain control but should be used with caution. Irrigation of the eye is indicated for chemical burns  Which patients should be referred immediately to an ophthalmologist after eye injury and initial treatment? (Select all that apply.)  a. A patient who was sprayed by lawn chemicals  b. A patient who works in a metal fabrication shop  c. A patient with a corneal abrasion  d. A patient with a full-thickness corneal laceration  e. A patient with irritation secondary to wood dust  The correct answer is:  ANS: A, B, D Patients with chemical eye injuries, any with possible metallic foreign bodies, and those with full-thickness corneal lacerations must have immediate referral. Corneal abrasions and irritation from wood dust may be managed by pcps