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8/24/2019 1 Diseases of the Eye, Ear Nose and Throat Patti Parker, PhD, RN, A/GNP, BC, GS-C 2 Introduction Y...
8/24/2019 1 Diseases of the Eye, Ear Nose and Throat Patti Parker, PhD, RN, A/GNP, BC, GS-C 2 Introduction You will see many patients with disorders of the eyes, ears, nose &/or throat [EENT] Most of these—you will manage Buton occasion, some will need to access to a specialist. 1 8/24/2019 3 The Eyes Have It… 4 Eye Disease Anatomy and Physiology— Keratitis revisit and review Dacryocystitis Dry Eyes Uveitis Epiphora Endophthalmitis Eye Pain Scleritis Conjunctivitis Blepharitis 2 8/24/2019 5 Eye Disease Chalazion Chemical Injury Hordeolum Burns Hyphema Iritis Corneal Abrasion Papilledema Foreign Body Cellulitis 6 Eye Disease Impaired Vision Mechanical globe Injury Mechanical Disorders of the Lid Acute Angle Closure Glaucoma Entropion Retinal Detachment Ectropion Central Retinal Vein Occlusion Dermatochalasis Optic neuritis Ptosis Malignancy Involving the Eye and Eyelid Eyelid Retraction Uveal melanoma Blepharospasm Intraocular lymphoma Basal cell carcinoma of the lid Squamous cell carcinoma of the lid 3 8/24/2019 A Review of Anatomy of the Eye THE EYES HAVE IT….. Anatomy and Physiology of the Eye 8 The globe measures about 1 inch in diameter. Housed within the orbit Held in place by connective tissue and muscles Control eye movement Oculomotor nerve [3rd CN] Causes motion of the eyeballs and upper eyelids Optic nerve [2nd CN] Provides the sense of vision 4 8/24/2019 Anatomy and Physiology of the Eye 9 Anatomy and Physiology of the Eye 10 Eye structures Anterior chamber—between Sclera—white of the eye lens and cornea Filled with aqueous humor Cornea Conjunctiva Posterior chamber— between iris and lens Iris Filled with vitreous humor Pupil Lens Retina—converts light impulses to nerve signals 5 8/24/2019 Anatomy and Physiology of the Eye 11 Light rays enter the eyes through the pupil. Focused by the lens Image is cast on the retina The optic nerve transmits the image to the brain. The visual cortex coverts it into a conscious image. Anatomy and Physiology of the Eye 12 Two types of vision Central vision Enables visualization of objects directly in front of you Peripheral vision Enables visualization of lateral objects while a person is looking forward 6 8/24/2019 Anatomy and 13 Physiology of the Eye Lacrimal apparatus Secretes and drains tears from the eye Tears moisten the conjunctivae. 14 General Considerations…. Obtain an accurate history Don’t forget the 7 variables Photophobia Quality and nature Pain Location Foreign body sensation Duration Redness Character Discharge Associated factors Have they tried any OTC Aggravating factors medications? Alleviating factors Recent or past ocular surgeries? Severity Contact lens wearer? 7 8/24/2019 Patient Assessment 15 Symptoms that may indicate a serious ocular condition: Visual loss that does not improve with blinking Double vision Severe eye pain Foreign body sensation Perform a thorough examination and check visual acuity!! Patient Assessment 16 Assess for: Do detailed external eye exam: Pain/tenderness Facial redness Swelling Scaling or dermatosis Abnormal or loss of movement Telangiectasias of cheek, nose, eyelid Sensation changes Asymmetry of lid position—ptosis or retraction Circulatory changes Periorbital edema Deformity Visual changes Lid swelling Normal eyelashes—roughly parallel and Airway compromise of equal length Tear film—thin layer lower lid Excess tearing [Epiphora] 8 8/24/2019 Patient Assessment 17 When assessing ocular function, test: Visual acuity Ability to see large and small letters Peripheral vision Ability to recognize an object entering the visual field Ocular motility Ability to move the eyes in all directions Patient Assessment 18 Immediate referral to ophthalmologist for: Sudden vision loss Painful vision Trauma Immunocompromised 9 8/24/2019 19 Dry Eye Syndrome Keratoconjunctivitis sicca or keratitis sicca Common syndrome—affects 5 million people in the US Commonly affects both eyes—patient feels that there is “sand in their eyes” when blinking Patient presents with burning, lack of tears or in some cases– excess tears as the eyes attempt to compensate 20 Dry Eye Syndrome May be acquired or congenital Acquired disorders may be systemic—Sjögren’s syndrome, lupus, RA May reflect a more local infectious process—such as conjunctivitis Causes of decreased tear production: Meds—anticholinergics, Beta blockers, antihistamines Aging—especially women during and after menopause In some, may be from a diminished blink rate due to working at a computer 10 8/24/2019 21 Dry Eye Syndrome Can present as chronic tearing and eyelid crusting Medial canthus can be painful and swollen with mucopurulent discharge Patient may have excess tears Differential Diagnoses Conjunctivitis, Blepharitis, Contact lens complications, Exophthalmos Ectropion, Bell’s palsy, Med side effects, Sjögren’s syndrome, corneal abrasion Age-related changes, Hormonal changes, Vitamin A deficiency 22 Dry Eye Syndrome Assess for: Inflammation Overflow of tears Discharge Erythema over lacrimal sac Pressure over the lacrimal sac may produce pain Possibly fever and leukocytosis May have nasal mucosal edema, tumors or another abnormality 11 8/24/2019 23 Dry Eye Syndrome Treatment involves 3 levels of intervention—depending on the severity of signs and symptoms Level One Level Two Level Three Education and environment Begin if level one interventions not Autologous serum and dietary modifications effective Special contact lens Eliminate offending meds Ocular lubricants Permanent punctal Artificial tears, lubricants, gels Preservative free tear substitutes occlusion and ointments Anti-inflammatories, immune Systemic anti-inflammatories Wrap around sunglasses modulators [Restasis] and/or Surgical intervention to Humidifiers topical steroids correct lid anomalies Avoid rubbing Topical or systemic Omega 3 fatty Transplantation of salivary Preservative free products— acids gland duct Duratears Naturale, Hypotears, Temporary punctal plugs MURO 128 24 Epiphora Excess tears Many causes—paradoxical response to dry eyes, exposure to an irritant, obstruction of the nasolacrimal duct Common in older adults and in those with allergies Sensitivity to preservatives in eyedrops and contact lens solutions can cause this common problem Excess tearing in only one eye suggests foreign body, corneal irritation/inflammation, infection or contact lens irritation 12 8/24/2019 25 Epiphora Differential Diagnosis Allergens, Dry Eye Syndrome, Viral or bacterial conjunctivitis Blocked lacrimal duct, Ectropion, Trauma, Environmental pollutants Glaucoma, Uveitis, Orbital inflammatory disease, Orbital cellulitis Management involves addressing the underlying cause Treat allergies; cold compresses; topical antihistamines, topical NSAIDs, mast cell stabilizers, systemic antihistamines In the contact lens wearer—if bacterial conjunctivitis suspected, cover Pseudomonas—Ciprofloxin [Ciloxin], Gentamycin, Ofloxacin [Ocuflox] and avoid contact lens until antibiotic concluded 26 Eye Pain Most common cause is trauma, yet may reflect a variety of underlying conditions Eye pain could be referred as part of headache syndrome, sinusitis, TMJ disorders, Herpes Zoster ophthalmicus, postherpetic neuralgia, tumors, stroke, trigeminal neuralgia Or as a result of hordeolum, blepharitis, conjunctivitis, corneal abrasion, foreign body irritation, UV light overexposure, orbital cellulitis, scleritis, episcleritis, uveitis, glaucoma If visual acuity is affected—immediate referral is mandatory 13 8/24/2019 27 Red Eye Nonuniform redness of the conjunctiva from hyperemia—it can be diffuse, localized or in the periphery Most common cause is viral conjunctivitis [pink eye], other causes— bacterial infection, allergies, chemical irritants, eye irritation from lack of sleep, overuse of contact lens, environmental irritants or excess rubbing Differential Diagnoses—conjunctivitis, hordeolum, acute angle closure glaucoma, iritis, corneal abrasion, dry eye syndrome, subconjunctival hemorrhage, orbital cellulitis, scleritis or episcleritis Conjunctivitis 28 Conjunctiva becomes inflamed and red. Often starts in one eye and spreads to the other eye Often caused by bacteria, viruses, allergies, or foreign bodies Most common of all eye disorders 14 8/24/2019 29 Conjunctivitis Bacterial—Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae Hyperacute bacterial conjunctivitis—Neisseria gonorrhoeae, Moraxella catarrhalis Inclusion conjunctivitis—Chlamydia Idiopathic—systemic disease such as thyroid disorders, infectious monoarthritis [Reiter’s syndrome] Viral—adenovirus serotypes 8 and 19, adenovirus 11, coxsackie virus A24, enterovirus 70, HSV, herpes zoster Allergic [atopy]—environmental allergen Autoimmune—Sjögren’s syndrome, Wegener’s granulomatosis Conjunctivitis 30 Check visual acuity first Differential Diagnoses Allergic / Bacterial / Viral conjunctivitis Iritis Dilated pupil exam for proptosis Keratoconjunctivitis optic nerve dysfunction, decrease visual acuity, diplopia or anterior Blepharitis chamber inflammation Pterygium Fluorescein staining to rule out Subconjunctival hemorrhage corneal involvement or keratitis Herpes Zoster ophthalmicus Blue penlight illumination to se Corneal abrasion corneal scratches, cornea Acute closed angle glaucoma dendrites or corneal ulceration Uveitis 15 8/24/2019 31 Allergic Conjunctivitis Presentation Treatment Stringy mucoid discharge Mast cell stabilizers Normal vision Alomide [Iodoxamide] 0.1% Itching and burning complaints Alocril [Nedocromil] 2% Mild, diffuse conjunctival changes Alamast [Pemirolast] 0.1% No pupillary abnormalities Antihistamines No photophobia Emadine [Emedastine] 0.05% Bilateral involvement usual Livostin [Levocabastine] 0.05% Normal IOP Mast Cell Stabilizers and Antihistamines No periauricular lymph nodes Patanol [Olopatadinie] 0.1% Rhinorrhea, sneezing, watery eyes Optivar [Azelastine] 0.05% Most common in fall and spring Zaditor [Ketotifen fumarate] 0.025% Elestat [Epinastine] 0.05% NSAIDs Acular [Ketorolac] 0.5% 32 Viral Conjunctivitis Presentation Treatment Watery discharge Antibiotics not recommended Normal vision unless there is a 2nd bacterial Itching complaints infection Moderate, diffuse conjunctival Ocular lubricants for comfort changes Artificial tears [Refresh, No pupillary abnormalities Celluvisc, Murine] 1-2 gtts 4 to 8 No photophobia times per day Often it is bilateral eye involvement Antiviral agents for HSV or VZV Normal IOP These patient must see an Palpable periauricular lymph nodes ophthalmologist Very contagious Pyrimidine [thymidine] solution Associated with URI [prescribed by eye doctor] Usually self limited Oral Acyclovir, Valcyclovir or Famcyclovir—start within 72 hours to reduce PHN 16 8/24/2019 33 Bacterial Conjunctivitis Presentation Treatment Abrupt onset Treat with broad spectrum topical agents to Purulent, thick crusted lids in the morning cover Streptococcus pneumoniae, H. Normal vision influenzae, Group A Strep, Staphylococcus Sandy, gritty feeing are complaints aureus and pseudomonads Moderately heavy, diffuse conjunctival Sulamyd [Sodium Sulfacetamide] changes E-Mycin [Erythromycin ointment] No pupillary abnormalities AzaSite [Azithromycin gtts] No photophobia Bacitracin Often it is bilateral eye involvement Ciloxan [Ciprofloxacin] Normal IOP Polytrim [[TMP and polymyxin B] No periauricular lymph nodes Tobrex [Tobramycin] Occurs in fall and winter Mycifradin [Neomycin] Ocuflox [Ofloxin] Quixin [Levofloxacin] Besivance [Besifloxacin] Genoptic [Gentamycin] 34 Inclusion Conjunctivitis Seen in sexually active young adults Chlamydia trachomatis is the pathogen; spread by direct contact with eye, nose and throat secretions from affected person or contact with a fomite—towels or washcloths that have had contact with secretions, flies can be a mechanical vector Abrupt onset of ocular discomfort and diffuse conjunctival hyperemia There may be mucopurulent discharge and matting of eyelashes; swollen eyelids and palpebral conjunctiva [the lower lid has small follicles] Preauricular lymphadenopathy Without treatment—it can become chronic and remitting—in 1-2 weeks, superficial corneal inflammation [keratitis] may appear as dots or cloudy streaks on superior part of cornea There may be associated iritis, photophobia, blurred vision, urethritis, cervicitis or vaginal discharge 17 8/24/2019 35 Inclusion Conjunctivitis Diagnosis by history and exam Confirm by looking at conjunctival scraping Giemsa stain—basophilic cytoplasmic inclusion bodies Systemic antibiotics + topical agents are needed Azithromycin 1 gram [one dose] or Doxycycline 100 mg BID or 7 days Ophthalmologist referral is appropriate Treat sexual partners 36 Hyperacute Bacterial Conjunctivitis UsuallyNeisseria gonorrhoeae or M. catarrhalis Infected genitals and then infects eyes Conjunctival scrapings—large number of polymorphonuclear leukocytes and intracellular gram negative diplococci Treatment must be prompt to avoid corneal damage or systemic spread Systemic + topical antibiotics necessary and urgent ophthalmologist consult immediately 18 8/24/2019 37 Hyperacute Bacterial Conjunctivitis Presume co-infection with Chlamydia trachomatis Ceftriaxone 1 gram IM [one dose] + Azithromycin 1 gram orally [one dose] Screen patient for HIV and syphilis Ophthalmologist must rule out corneal perforation 38 Keratitis Inflammatory process of cornea from If bacterial etiology—topical antibiotic adenovirus, HSV, bacteria or fungus should be prescribed Patient has edema of lids, preauricular If viral—urgent ophthalmology referral nodes and chemosis Keratitis caused by HSV frequently happens after conjunctivitis, usually involves one eye UV radiation [from tanning beds, welding, and may be associated with uveitis—blisters photographic equipment] can burn the may be seen on eyelid and fluorescein cornea causing keratitis or stains show dendritic corneal lesions [see keratoconjunctivitis image above] Main risk—contact lens use; others—pre- In this scenario, treatment is short- existing ocular disease and ocular trauma acting cycloplegic drugs, antibiotic solution or ointment and patch can be Pseudomonas aeruginosa, Staphylococcus used on the most severely affected aureus and other coagulase - Staph are eye most common pathogens 19 8/24/2019 39 Dacryocystitis Acute or chronic inflammation/infection of lacrimal sac, usually from a blocked nasolacrimal passage In adults, it is often from chronic sinusitis or facial trauma Consult the eye specialist for dacryocystitis In North America, Staphylococcus aureus [MSSA and MRSA] are the most common pathogens DOC is Augmentin 875 mg BID of Bactrim DS BID for 7-14 days; lacrimal duct drainage may be a needed part of the treatment 40 Uveitis Inflammation of the uvea, iris, ciliary body Visual acuity should be assessed and choroid—it is a leading cause of Fundoscopic exam and measure of blindness in the US—urge eye referral is IOP is needed, along with a slit-lamp needed exam Uveitis is categorized by location—anterior, intermediate or posterior uveitis Infectious causes—CMV, HSV, Cause is often unknown and often linked to Pneumocystis jiroveci and an autoimmune disease, but can be from toxoplasmosis infection, toxin or bruise to the eye Symptoms come on abruptly in one or both eyes Treatment is a cyclomydriatic and Anterior uveitis is most symptomatic—pain, topical corticosteroids; redness, photophobia and decreased vision immunosuppressants may also be part of the regimen—these may be Intermediate uveitis has no pain, but floaters given orally in severe cases and decreased vision 20 8/24/2019 41 Endophthalmitis Traumatic cases often seen in rural areas from Acute, diffuse uveitis exogenous source—contaminated soil and animal matter—so Bacillus must be in the Often this is a complication several days pathogen list after cataract surgery, but may be from ocular trauma or a foreign body Immediate eye referral is needed Can be from an endogenous source Cultures from aqueous and vitreous should be causing the infection done The patient has pain, vision loss, redness In the patient with recent cataract surgery, of conjunctiva and swollen lid [or lids]; requires intravitreal injection of antibiotics and cornea is hazy—a layer of pus may be primary vitrectomy seen With endogenous infection both systemic and Most cases are Gram + coagulase intravitreal antibiotics are required +/- negative pathogens, Staphylococcus vitrectomy aureus and Streptococcus Vancomycin [Gram + pathogens] and Ceftazidime [Gram – pathogens] are DOC 42 Scleritis Focal or diffuse inflammation of the sclera—often linked to Severe pain of both eyes, made worse with autoimmune disease—RA, movement or palpation of the globes; the HLA-B27 spondyloarthropathy, patient will be tearing, have photophobia relapsing polychondritis, SLE, and decreased vision necrotizing systemic vasculitis Urgent eye referral is indicated ½ of these cases are NSAIDs are given to reduce the inflammation + analgesics for pain idiopathic; this process involves Systemic immunosuppressants for the the anterior segment—and is autoimmune disease may be needed if the defined as diffuse, nodular or process does not respond to topical NSAIDs necrotizing 21 8/24/2019 43 Blepharitis Inflammation of the eyelids and their margins Nonulcerative—associated with seborrhea of face and greasy scales of lid margins Associated with Down’s Syndrome, psoriasis, seborrhea, eczema, allergies, poor hygiene, poor nutrition, immune suppression, rosacea, yeast infections Ulcerative—can involve eyelash follicles and meibomian glands of the lid; lashes become thin and break off Secondary infections can occur with either form; styes and/or chalazion can result from long-standing blepharitis 44 Blepharitis Anterior—affects lash hair follicles along the lid’s anterior lamella Can be classified by location Posterior—involves inspissation and inflammation of Meibomian glands along the tarsal plate Evaluate visual acuity; if discharge is present, consider culture and sensitivity; referral is needed for persistent inflammation, thickening of eye lid margin [could be BCC, SCC or sebaceous cell cancer masquerading as blepharitis] 22 8/24/2019 Blepharitis 45 Type of Blepharitis Treatment Regimen Nonulcerative Blepharitis Eyelid scrubs with 1:1 water and baby shampoo with a soft This type may be persistent washcloth Goal is to improve hygiene Warm moist compresses [10-15 minutes every few hours] Eyelid hygiene may be required for life [or symptoms may recur] No eye make-up or contact lens until signs/sx improve [after resolution, use new hypoallergenic make-up and new contact lens] Ulcerative Blepharitis Bacitracin or Erythromycin 0.5% ointment to lids 1-2 times per day Staphylococcus is often the [or at bedtime] after the cleansing and warm compresses [as pathogen cited above]; this regimen will be needed for 7-10 days For resistant infection—quinolone ointment or sulfacetamide/corticosteroid combination [Blephamide sol. Or oint; steroid decreases inflammation and ocular sx] Severe Blepharitis Oral Doxycycline 100 mg BID or Tetracycline 250 mg QID for Associated with rosacea; goal is several weeks cure infection with systemic Continue hygienic measures as above antibiotics Hordeolum/Chalazion 23 8/24/2019 47 Styes Acutely presenting erythematous, tender lump within the eyelid External hordeolum— inflammation / infection of the eyelid margin affecting the hair follicles of the eyelashes Internal hordeolum— inflammation / infection of the meibomian glands 48 Styes Common infection in the glands of the Treatment yes—Staphylococcus aureus is most common pathogen Lid scrubs with dilute Baby Shampoo Sudden onset of localized pain, swelling, Warm compresses several times per day redness and purulent discharge Light massage—but do NOT squeeze Infected gland may be the Meibomian, the area just under the conjunctival side of the If infection suspected—ophthalmic lid—internal hordeolum antibiotic ointment [Erythromycin or External stye—smaller and always points Sulamyd QID or Ciloxan TID to the skin side If resistant—has it been misdiagnosed? Usually self-limited [1-2 weeks] Consider oral course of Cephalexin Differential Diagnoses—BCC or sebaceous cell cancer of the lid, inflammatory lesion, Molluscum contagiosum, HSV 24 8/24/2019 49 Chalazion Granulomatous infection of Differential diagnoses—lid margin Meibomian gland, presenting in the tumor form of a painless swelling on the eyelid—upper lid is more common Visual acuity rarely affected, but may get large enough to cause Usually points to the conjunctival side pressure on cornea and induce Initially, it may be tender and astigmatism erythematous before evolving into a nontender lump Treatment—usually not needed—most Blepharitis can be a risk factor often, it is self-limited; dilute Baby Can develop from an internal stye shampoo scrubs and warm compresses that does not resolve If has not resolved in 4-6 weeks, refer to ophthalmologist for I & D 50 Styes and Chalazions WHAT AM I???? 25 8/24/2019 51 Hyphema Accumulation of blood in the anterior chamber Usually preceded by trauma But could be from a major bleeding disorder or as a SE of blood thinning agents Subconjunctival 52 Hemorrhage Accumulation of blood under the conjunctiva Localized; usually unilateral Bright red area with the palpebral fissure Not painful and does not affect vision May occur spontaneously or from eye rubbing, trauma, Valsalva, coughing, vomiting Topical steroids increase capillary fragility No treatment needed, but if bleeding or bruising elsewhere—then work it up 26 8/24/2019 53 Pterygium Localized fibrovascular tissue; usually in interpalpebral fissure at 3 o’clock or 9 o’clock position Begins as localized conjunctival swelling—called a pinguecula when not extending into cornea Fluorescein stain my help in the diagnosis Minimal discomfort; no discharge or change in vision Risk factors—chronic exposure to UV light, dust or wind, viral infections Lubrication with artificial teats for symptoms Ophthalmology referral—these are surgically removed under local anesthetic 54 Pterygium Interventions to reduce growth and recurrence UV protection Artificial tears Inflamed pterygia do well with a short course of topical steroids [Loteprednol or Fluorometholone] Refer for those that are getting larger and those not responding Again, can be removed under local anesthesia 27 8/24/2019 55 Corneal Abrasion Acute pain, photophobia, tearing May see irregularity of corneal surface, foreign body, corneal opacity or edema Eye should be stained with fluorescein and a cobalt blue filter light used to assess for defects [lesion will be green] If a foreign body is seen—remove it but do not patch Oral and topical NSIADs will reduce pain [Diclofenac 0.1% for 2 days only] Antibiotic ointment may be used to prevent infection [Erythromycin 0.5% or Sulamyd 10% are preferred, except in the contact lens wearer—cover Pseudomonas with a quinolone or an aminoglycoside—limit empiric antibiotics to 72 hours] Avoid wearing contacts until healed; follow up daily until resolved For extensive defects—eye doctor referral 56 Corneal Ulceration Contact lens May lead to blindness Ophthalmologic emergency 28 8/24/2019 Foreign Body 57 Can cause significant pain Sudden onset of sensation of object in the eye Fluorescein staining Commonly caused by machines Embedded bodies should be such as: removed by an ophthalmologist— they may require surgical removal Grinders Topical anesthetic [Ophthaine], then Sanders remove with a sterile needle Nailers Weed whackers Management of Corneal Surface Injuries NO COTTON SWABS Be supportive Erythromycin, Polymyxin B or Bacitracin; No patch— Foreign it encourages infection Oral analgesia; no topical anesthetics—can cause Body corneal melting Cycloplegic drops—might be considered for pain; corneal surface injuries if small are usually healed in 3-5 days Prevention includes protective eye coverings, changing contact lens are suggested by prescriber / manufacturer 58 29 8/24/2019 59 Foreign Body Do not remove an impaled foreign body. Stabilize in place. Cover with a moist, sterile dressing. Place a protective barrier over the object. Cover unaffected eye. Transport promptly. 60 Chemical Injury to the Eye SMOKE, SMOG, DUST RINSE CONJUNCTIVAL SAC COOL COMPRESSED 15-20 TOPICAL IF THE PATIENT HAS IMMEDIATELY AFTER IT IS MINUTES SEVERAL TIMES VASOCONSTRICTORS— GOTTEN ACID OR ALKALI CONTAMINATED PER DAY ALBALON, NAPHCON-A IN THE EYE—COPIOUS OR VASOCON-A IRRIGATION WITH NS, LR OR WATER & IMMEDIATE OPHTHALMOLOGY EVALUATION [THIS IS THE ONE SCENARIO THAT YOU DO NOT CHECK VISION FIRST]—IRRIGATION IS THE TOP PRIORITY—THIS IS AN OCULAR EMERGENCY 30 8/24/2019 Burns of the 61 Eye & Adnexa Can be caused by: Chemicals Heat Light rays Thermal burns Occur when a patient is burned in the face during a fire Burns of the Eye and Adnexa 62 Retinal injuries caused by Generally not painful but may result in permanent damage extremely bright light: May not be painful initially Superficial burns of the Symptoms include conjunctivitis, redness, swelling, excessive eye: tearing Assess for and treat life- threats. Open the eye and irrigate with sterile water or sterile saline May be difficult if eyes solution. are closed Pain may have to be managed before assessment. 31 8/24/2019 Burns of the Eye and Adnexa 63 Assessment and management (cont’d) Assess positions of gaze. Cover an eye burned by ultraviolet light with: Sterile, moist pad until eye doctor can assess Chemical burns require immediate irrigation. Direct as much fluid as possible. Use a device that will control the flow. Do not allow contaminated fluid to enter the eye. Irrigate for at least five minutes. Prevent one eye from draining into the other eye. 64 Burns of the Eye and Adnexa 32 8/24/2019 65 Burns of the Eye and Adnexa Burns of the Eye and Adnexa 66 Assessment and management (cont’d) Use of the Morgan lens (eye irrigation device) Administer a topical anesthetic. Connect the lens to the IV bag, and let it drip. Slide the Morgan lens under the eyelids. Run the fluid at the desired rate. 33 8/24/2019 Burns of the Eye and Adnexa 67 Assessment and management (cont’d) Contact lenses To remove a hard lens, use a small suction cup. To remove soft lens, pinch between thumb and index finger and lift off eye. 68 Iritis Inflammation of the iris Acute causes include: Trauma Irritants Chronic causes include: Autoimmune diseases Arthritis Irritable bowel disease Crohn disease 34 8/24/2019 Iritis 69 Assessment and management On exam, may have direct and consensual Red area surrounding the iris, cloudy photophobia; EOMs are normal vision, or an unusually shaped pupil Visual acuity may be decreased Focus on history. Exam of the conjunctiva reveals 360° Acute iritis may respond to topical perilimbal injection corticosteroids. Scanthe endothelium for keratitic Chronic iritis should be referred to a precipitates [WBCs on the endothelium]—this specialist. is the hallmark of iritis Associated with ocular trauma and systemic diseases—RA, ankylosing Examine the anterior chamber’s aqueous spondylitis, Reiter’s syndrome, sarcoidosis, humor—iritis causes an effect on exam, VZV, syphilis known as a flare, which is similar to that produced by a moving projector beam in a Symptoms—blurred vision, pain, deep ache in the eye, photophobia dark smoky room 70 Iritis Treatment is cycloplegics and corticosteroids Mandates an Keratitic Precipitates ophthalmology referral ASAP If not treated can cause permanent damage and vision compromise Flare—hallmark of Iritis 35 8/24/2019 Papilledema 71 Swelling or inflammation of the optic nerve Patient can present with headache, nausea, temporary vision loss or narrowing vision fields or a “graying” in the field of vision Causes Abscess, tumor, inner ear infection, lung infection, dental infection Other causes High fever, Meningitis, Hypertensive crisis, chronic high BP, Guillain-Barré syndrome This is a medical emergency—patient needs urgent brain imaging and evaluation for malignancy and infection Cellulitis of the Orbit 72 Periorbital cellulitis Orbital cellulitis Presents as a painful, red, swollen Medical emergency eyelid Risk factors: Risk factors: Sinusitis Insect bites Tooth infections Upper respiratory disorders Ear infections Trauma Trauma Sinusitis trauma Trauma Cutaneous infection 36 8/24/2019 73 Cellulitis of the Orbit Preseptal Drainage/abscess—obtain a Eyelid edema and erythema; eye is culture generally spared CBC No chemosis or pupillary changes; usually there is no pain with movement of the If sepsis is suspected—get blood globe cultures Orbital CT of the head Axial proptosis, lid swelling conjunctival chemosis and injection, elevated IOP, pain or restriction wit eye movement May have decreased acuity and infrequently pupillary changes—optic nerve involvement Febrile with leukocytosis 74 Cellulitis of the Orbit Preseptal Cellulitis Orbital Cellulitis Broad spectrum oral antibiotic Vancomycin IV 15-30 mg/kg every 8-12° + Ceftriaxone IV 2gm every 12° + Metronidazole IV Cephalosporin or Augmentin 1 gm every 12° OR Piperacillin-tazobactam IV 4.5 If MRSA is suspected—Clindamycin grams every 8° for 7-14 days and Bactrim DS If suspect MRSA there is a risk for cavernous sinus thrombosis or facial erysipelas—which can lead Follow up in 12-24 hours to blindness or death If patient does not respond— Obtain surgical consultation—make the call for ophthalmologist or the consult—if you cannot get them in—send otolaryngologist for them to the ED hospitalization—call for the consult or send to ED 37 8/24/2019 75 Cellulitis of the Orbit Top image—is Preseptal Cellulitis Bottom image—is Orbital Cellulitis Mechanical Disorders of the Lid 38 8/24/2019 77 Entropion Inward turning of the lid margin Redness Foreign body sensation Eyelashes rub against the eye 78 Ectropion Outward turning of the lid Associated with exposure of tarsal conjunctiva May have incomplete closing of the lid 39 8/24/2019 Dermatochalasis 79 Sagging of the upper [and to a lesser degree] the lower lid Most common in those 65 years and old Sagging is due to lax, redundant skin and fat with poor adhesion to the underlying connective tissue and muscle Major causes are gravity and the loss of elastic tissues over many years Other risk factors—systemic disease, trauma, renal failure Often results in ptosis; the functional loss of the tissue can obstruct the superior visual field by hanging over the lid margin OTC products, such as lid magic; surgery is definitive therapy 80 Ptosis Drooping of the upper lid and is a common involutional eye lid change The droop is from under action of the eyelid protractors relative to the eyelid retractors, which cause the lower lid to be lower than normal—lowering of the upper lid interferes with vision Caused from 3rd nerve palsy, aging of levator muscle, Horner’s syndrome or myasthenia or SE of Botox injections [temporary] Chronic ptosis can be seen by ophthalmologic plastic surgeon—if is happens acutely—immediate referral to rule out 3rd nerve palsy 40 8/24/2019 81 Eyelid Retraction Shrinking or drawing back of the eyelid from its normal resting position It is symptomatic of congenital and acquired diseases including neurogenic, myogenic mechanical and other causes— thyroid disease is the most common Treatment is based on its underlying cause—but usually surgery is required 82 Blepharospasm Focal dystonia from involuntary chronic intermittent or persistent involuntary eyelid closure The closing is from spasmodic contractions of the orbicularis oculi muscles—the spasms may be unilateral or bilateral Most cases are idiopathic; more common in women More than 1/3 have a family history of blepharospasm Type A botulinum toxin injections are the treatment of choice https://www.youtube.com/watch?v=yVTUtvb6xR0 41 8/24/2019 Impaired Vision 84 Impaired Vision Viral infections— Acute angle closure Mechanical injury Retinal detachment herpes zoster glaucoma Other causes— which are much Central retinal vein Optic neuritis more common will occlusion be covered in the sensory module 42 8/24/2019 Mechanical Injury of the Globe 85 Blunt trauma [ball, MVA, assault] or CT of head and orbits should be ordered to penetrating injury [knife or projectile] are detect foreign body or orbital fracture most common and can cause globe Patient should not cough, strain or Valsalva rupture or laceration [anti-emetic may be given to prevent Patient presents with eye pain, redness, vomiting] tearing and decreased vision [or minimal Metal shield should be placed over eye and s/sx] patient should be transferred immediately to Anterior segment should be examined an eye specialist with slit lamp and then fluorescein dye Analgesics and antibiotics [Levofloxacin or and cobalt blue slit lamp to evaluate for Moxifloxacin] should be given lesions/defects If hay, grain or leaves are involved— Globe injury is suggested if irregular pupil, antibiotic that covers Gram – bacteria subconjunctival hemorrhage, or and fungus should be added prolapsed iris through a corneal or scleral wound is seen Acute Angle Closure Glaucoma 86 Only 10% of glaucoma cases—it S/Sx—eye and face pain, red eye, blurred vision, comes on abruptly colored halos around lights, photophobia, nausea, vomiting, headache Iris is pushed [or pulled] up in the The pupil is dilated, fixed and reacts sluggishly, angle blocking drainage of hyperemia of conjunctiva and corneal swelling aqueous humor, which ↑ IOP Treatment is aimed at decreasing IOP—open the Must be recognized & treated angle and meds rapidly blindness will occur from Beta Blocker gtts / Alpha 2 agonist gtts optic nerve damage Carbonic anhydrase inhibitor gtts or orally Risk factors—shallow anterior Mitotic gtts / Systemic hyperosmotic agents chamber, far-sightedness, steep corneal curve, thick lens, short Surgery—laser peripheral iridotomy bilaterally is axial length of globe, older age, curative family history, Asian, Taiwan or Eskimo descent 43 8/24/2019 87 Assessment Acute Angle Closure Glaucoma Discharge None Visual acuity Pain Decreased Severe pain Acute Conjunctival abnormalities Anterior chamber may seem narrow on penlight exam Angle Pupillary abnormalities Mid-dilated; nonreactive or sluggish Closure Photophobia Mild Glaucoma Bilateral involvement Sometimes IOP Increased Preauricular lymph Not enlarged nodes Other symptoms Nausea, vomiting, headache 88 Retinal Detachment Neurosensory layer of retina separates from underlying choroid and retinal epithelium—can occur with a retinal tear or without a retinal tear Detachment with a tear is seen in myopia, cataract surgery or trauma Detachment without a tear is seen in diabetic retinopathy, sickle cell disease, inflammation, malignancy, severe HTN [vitreoretinal traction or transudation of fluid into subretinal space is mechanism here] Uncommon—but can cause rapid loss of vision that can be permanent if not treated promptly 44 8/24/2019 Retinal Detachment and Defect 89 S/Sx—flashing lights, “floaters”, blurred vision, patient may report a dark curtain covers part of the visual field, no pain Requires urgent ophthalmologic evaluation Urgent surgery can restore and treatment vision in 90-95% of patients These patients should be watched closely as 25% will have detachment in the contralateral eye 90 Central Retinal Vein Occlusion Risk factors—embolism from atherosclerotic plaque, endocarditis, fat emboli, atrial myxoma, temporal arteritis [the cause of 10%], older age, DM, SLE, acute leukemia, atherosclerosis, IDA, blunt trauma, hypercholesterolemia, HTN, hypercoagulable states, vasculitis, recent spinal surgery or coronary angioplasty, Wegener granulomatosis S/Sx—painless sudden vision loss or visual field cut; patient may report a recent episode of amaurosis fugax, unilateral vision loss; pupil may react slowly, but will constrict normally when contralateral eye is illuminated Vision loss can occur within 90 to 100 minutes—permanent unless intervention is begun immediately 45 8/24/2019 Digital massage of the closed eyelid should be started immediately for 15 minutes [the hope is to dislodge the clot into a smaller artery], then the patient should be transported into the care of an ophthalmologist On fundoscopic exam—pale opaque Central fundus and a cherry spot on the fovea IOP should be lowered with timolol 0.5% or Retinal Vein Acetazolamide [orally or IV]— unfortunately, treatment often does not Occlusion improve vision, and if treatment is deferred longer than 72°, patient will be blind Those with temporal arteritis should be treated with steroids 91 92 Optic Neuritis Oral or IV steroids are used to Inflammation of optic nerve help restore vision—and this intervention is thought to also Risk factors—meningitis, Lyme disease, delay the onset of syphilis, virus, metastatic tumor, demyelinating disease demyelinating disease [50% with optic neuritis will later on be diagnosed with MS] In adults—vision is at least Most common in those 20-40 years 20/40 in 90 to 95% at one year S/Sx—partial or complete loss of vision At the 15 year mark, 72% of in one eye and eye pain these individuals have 20/20 vision On exam—in late stage disease—optic disk is pale MRI is the diagnostic of choice 46 8/24/2019 93 Viral Causes Main consideration is Varicella zoster—that occurs in the ophthalmic branch of the trigeminal nerve Urgent evaluation and treatment by an ophthalmologist if the patient who develops shingles on the face develops a lesion of the tip of the nose—that means the ophthalmic branch of this nerve IS involved—stat eye referral to prevent vision loss Malignancy Involving the Eye and Eyelid 47 8/24/2019 95 Malignancy Involving the Eye and Eyelid Ocular tumors are rare 50% of uveal melanomas will When they do occur in adults, metastasize [to the liver] melanoma and lymphoma [as In 2019, these primary metastatic disease] are the most malignancies are treated with common—as a downstream event from radium implants—using a breast cancer or primary melanoma national research protocol, developed in large part, by a Uveal melanoma—although rare, peak Dallas ophthalmologist incidence is age 70; affects more males than females; risk factors are the same as for skin melanoma—light skin, light eye color, Caucasian race—symptoms are minimal in uveal melanoma—often found on routine eye exam 96 Intraocular Lymphoma Rare; and it is usually NOT metastatic from a primary lymphoma Unfortunately, with this primary ocular tumor, the patient will most often develop CNS lymphoma Before treatment—complete medical and neurological evaluation to rule out metastatic disease [CNS lymphoma], sarcoid, toxoplasmosis and TB [which can cause a similar presentation] This disease is treated with systemic and intravitreal chemo and XRT 48 8/24/2019 Basal Cell Cancer of the Lid 97 Lid Margin Tumors Risk factors—the same as for these type of Rare; slow-growing skin cancer—fair complexion, light colored Not painful; not associated with eyes, blond or red hair, tendency to burn underlying blepharitis but chronic or freckle with exposure to the sun, history irritation of the eye may induce of sun exposure, use of tanning booths, May prevent lid closure family history of skin cancer, excess use of Squamous [SCC] and basal cell alcohol, immune suppression carcinomas [BCC] can occur More common in men BCC involves lower lid in 55%, medial canthus in 30% and S/Sx—early lesions have no symptoms; upper lid in 0% advanced lesions are associated with nonhealing ulcers, bleeding or pain, a sore Malignant melanomas that does not heal Both require referral to ophthalmologist 98 Basal / Squamous Cell Cancer of the Lid Biopsy should be done to confirm diagnosis; Moh’s surgery is the preferred route of treatment 49 8/24/2019 99 Now, let’s see what we have learned about the Eyes……. 100 The primary risk factor for bacterial keratitis is: Practice Case One A. B. contact lens outdoor trauma C. previous conjunctivitis D. pre-existing ocular disease 50 8/24/2019 101 The primary risk factor for bacterial keratitis is: Practice Case One A. B. contact lens** outdoor trauma C. previous conjunctivitis D. pre-existing ocular disease Which of the following is the most commonly used antibiotic for endogenous endophthalmitis caused by a Gram + pathogen? Practice A. Ceftazidime Case Two B. Vancomycin C. Erythromycin D. Amoxicillin/clavulanic acid 102 51 8/24/2019 Which of the following is the most commonly used antibiotic for endogenous endophthalmitis caused by a Gram + pathogen? Practice A. Ceftazidime Case Two B. Vancomycin** C. Erythromycin D. Amoxicillin/clavulanic acid 103 104 Practice Case Three Optic neuritis is considered to be an early indicator of: A. glaucoma B. meningitis C. multiple sclerosis D. systemic lupus erythematosus 52 8/24/2019 105 Practice Case Three Optic neuritis is considered to be an early indicator of: A. glaucoma B. meningitis C. multiple sclerosis** D. systemic lupus erythematosus 106 Which of the following is the best recommendation for an external Practice hordeolum? Case Four A. glucocorticoids B. incision and drainage C. antibiotic targeting Streptococci D. warm compresses to the affected eye 53 8/24/2019 107 Which of the following is the best recommendation for an external Practice hordeolum? Case Four A. glucocorticoids B. incision and drainage C. antibiotic targeting Streptococci D. warm compresses to the affected eye** 108 Which of the following is recommended as first-line Practice treatment for patients with mild dry- eye syndrome? Case Five A. artificial tears B. punctal occlusion C. ocular lubricants D. topical cyclosporine 54 8/24/2019 109 Which of the following is recommended as first-line Practice treatment for patients with mild dry- eye syndrome? Case Five A. artificial tears** B. punctal occlusion C. ocular lubricants D. topical cyclosporine Questions—on the Eyes? 55 8/24/2019 Disease of the Ears My Ear is Hurting…. 56 8/24/2019 113 Diseases of the Ear Anatomy and Physiology—a quick review Ear Pain Otitis Externa Otitis Media Cerumen Impaction Perforated Tympanic Membrane Foreign Body in the Ear Labyrinthitis / Vestibular Neuritis Cholesteatoma A Review of Anatomy of the Ear WHAT DID YOU SAY??? 57 8/24/2019 The Ear 115 The ear is the primary structure for hearing and balance. Disorders and injuries can leave a person unable to: Communicate React Maintain equilibrium Anatomy and 116 Physiology of the Ear Divided into three anatomic parts 58 8/24/2019 Anatomy and Physiology of the Ear 117 Sound waves enter the ear. Travel to the tympanic membrane. Sound waves set up vibration in the ossicles. Vibrations transmit to the cochlear duct. At organ of Corti, vibrations form impulses. Travel to the brain via the auditory nerve. 118 General Considerations… When a patient presents with a c/o hearing loss—the causes run the gamut: Conductive Disorders of external or middle ear Interfere with mechanical transmission of sound into the inner ear May be a mechanical cause Obstruction of external auditory canal [EAC] Cerumen—a common cause Debris or foreign bodies Otitis externa if edema occludes EAC Tumors—SCC mistaken for OE 59 8/24/2019 Patient Assessment 119 Don’t forget about ototoxic drugs Aminoglycosides Tobramycin and Amikacin—cochleotoxic Gentamicin and Streptomycin—vestibulotoxic Erythromycin Tetracycline Vancomycin Antimalarials—Chloroquine*, Quinine* Antineoplastics—Cisplatin, Bleomycin, 5-fluorouracil, Nitrogen mustard Salicylates—ASA* Loop diuretics* *reversible Patient Assessment 120 Take a complete history Have patient rate his or her pain. Observe ears for: Ask about: Changes in hearing Drainage Tinnitus Excess cerumen Dizziness Inflammation Inspect for: Swelling Wounds Swelling Drainage Mastoid process 60 8/24/2019 121 Ear Pain Differential Diagnoses Otalgia Otitis externa Most common cause is infection, Otitis media but if there are no clinical signs in Otitis media with effusion the ear—must consider dental, sinus, TMJ or mastoid causes Eustachian tube dysfunction Ear pain is more present in summer Barotrauma from swimmer’s ear; sinusitis can be Cerumen impaction the etiology in allergy season Dental disease Primary otalgia is caused by an otic source, referred otalgia is from TMJ dysfunction a non-otic source Perforated TM Sinusitis 122 Otitis Externa Common pathogens: Infection of the external auditory Staphylococcus aureus [most common] canal—also called swimmer’s ear Pseudomonas [most common in necrotizing Causes: disease] Frequent swimming Group A Streptococcus pyogenes Use of fluids in ear for cleaning Bacteroides & Peptostreptococcus—cause of 25% of invasive cases Digging or irritating the canal Aspergillus niger, Malassezia pachydermatitis and Pushing wax and causing trauma Candida albicans are the fungal causes Infection may be bacterial or fungal Exposure to moisture, aggressive Usually self-limiting, but painful; however cleaning of the canal necrotizing OE can be seen in diabetics and Allergies or skin conditions immunosuppressed patients 61 8/24/2019 123 Otitis Externa Patient presents with—severe pain, discharge from ear, foul smell or pressure in ear On exam of external canal, there may be tons of exudate Movement of the tragus and canal is painful There may be yellow, green, white discharge from canal [canal may not be entirely visible]; TM may not be visible TMJ dysfunction Dental Disease Trigeminal or Glossopharyngeal neuralgia Parotitis Chondrodermatitis chronicus helicis [in the elderly] Otitis Externa Otitis Media Excess cerumen / Foreign body Mastoiditis Perichondritis [infection of cartilage from piercing or trauma] 124 62 8/24/2019 Otitis Externa—Treatment 125 Removal of debris carefully! Most cases are treated topically—Ciprodex Otic 4 gtts BID for 7 days OR Floxin Otic 10 gtts daily for 7days—these are the only 2 gtts that can be used if the TM is perforated Other options—Cortane B, Cortisporin-TC 4-5 gtts in affected ear TID or QID for 7 days If there is immense swelling may not be able to remove all drainage or debris and may need to instill gtts with a wick In the diabetic or immune suppressed—oral medications are indicated—1st or 2nd generation Cephalosporin, Augmentin 875 mg BID, Cipro 750 mg BID [if Pseudomonas suspected]—10 day regimen +/- topical therapy Prevention 2% acetic acid or alcohol after swimming 126 Otitis Externa—Treatment If fungus is the pathogen—Fluconazole 200 mg day 1, then 100 mg qd for 3-5 d and topically—VoSol or Otic Domeboro 4 gtts QID for 7-10 days Necrotizing Disease—needs C/S and immediate ENT referral—antimicrobials [usually IV] +/- surgical debridement [this is usually an older patient, or one with DM, AIDS or on chemo] Ceftazidime 2 g IV q 8° OR Tobramycin 1-1.5 mg/kg IV q 8° + ticarcillin 3 g IV q 4° OR Cipro 750 mg BID for 10 day [up to 8 weeks] 63 8/24/2019 127 Otitis Media Otitis media with effusion [OME]—transudation of plasma from middle ear blood vessels, leading to chronic effusion in the absence of the signs and symptoms of acute infection Acute otitis media [AOM]—suppurative OM or purulent OM Recurrent OM—the clearance of middle ear effusion between acute episodes of otic inflammation Chronic OM—inflammation persists > 3 months, typically related to tympanic membrane perforation with either intermittent or persistent otic discharge 128 Otitis Media Ear pain in a common complaint Otitis media is more common in the winter Prevention includes—avoiding tobacco exposure, annual flu vaccine, Prevnar-13 and Pneumovax-23 Risk factors for OME—allergies, sinusitis, rhinitis, pharyngitis—but the most significant risk factor is recent or concurrent URI [influenza A, RSV, adenovirus] Perforated TM, active and passive smoking are risk factors for ALL types of OM, as are crowded or unsanitary conditions and wood-burning stoves 64 8/24/2019 129 Otitis Media Otitis Media with Effusion [OME]—mucous membranes of nasal and oral cavities may be injected or swollen; TM may be dull but usually is not bulging, and eardrum mobility is decreased on pneumatic otoscopy Acute Otitis Media [AOM]—TM may be amber or yellow-orange and may be injected and pinkish gray to fiery-red in color; TM is usually full or bulging in acute cases, with absent or obscured bony landmarks and cone of light reflex 130 Otitis Media with Effusion Dysfunction of Eustachian tube—prevents drainage of fluid from middle ear May be preceding cold, allergies or sinus congestion Smokers at higher risk May develop after AOM and last for weeks or months Mild pain, sensation of popping, cracking, watery ears, ringing, vertigo or dizziness There may be a history of cough, rhinitis, allergies, flying or diving Patient may not be able to pop their ears 65 8/24/2019 131 Otitis Media with Effusion On exam, TM’s may be amber with fluid present, bubbles behind the TM, TM non mobile, fluid level may be present 132 Otitis Media with Effusion—Treatment Generally supportive Can be chronic care Decongestants, intranasal steroids, antihistamines – will enable Eustachian tube to open 66 8/24/2019 133 Acute Otitis Media Suppurative or Purulent OM Marked “deep” ear pain and fever Unilateral hearing loss Otic discharge Recent history of URI Possible dizziness, vertigo, tinnitus, vomiting, nausea Streptococcus pneumoniae the culprit pathogen in 40-50% of adult cases Other pathogens—Haemophilus influenzae [10-30%] and Moraxella catarrhalis—vast majority of these bugs express the beta-lactamase gene and Ac
