Ophthalmology PANRE Review Brock Phillips, PA-C I am not an ophthalmologist, optometrist or certified eye guy of any sort - I am a practicing UC/EM PA-C who frequently evaluates eye/vision complaints, consults Ophtho regularly and has taken an interest in the topic. Eyes are fascinating!
Thanks to Joshua F. Smith, PA-C - who originally created this lecture and graciously allowed me to adapt it Review A&P of the eye and topics covered on PANRE Blueprint – buzzwords & key points are noted in red
Score 100% on the ophthalmology questions!
Augment your clinical practice with a few ophtho pearls, tips and tricks Blepharitis Hyphema Blowout fracture Macular degeneration Cataract Nystagmus Chalazion Optic neuritis Conjunctivitis Orbital cellulitis Corneal abrasion Papilledema Corneal ulcer Pterygium Dacryoadenitis Ectropion Retinal detachment Entropion Retinal vascular occlusion Foreign body Retinopathy Glaucoma Strabismus Hordeolum Work from the outside inward… Gross exam - photophobia, asymmetry, doorknob DXs Visual acuity EOMs and visual fields Periorbital eye, lids, lashes, glands & ducts Conjunctiva, sclera & cornea Iris & limbus Pupillary size & response Anterior chamber Posterior chamber
Always check & document visual acuity! This is considered to be the “vital sign” of the eye. You wouldn’t skip a pulse ox on a PNA pt, would you?! Wall chart (20 ft.) vs. handheld (14”) Can’t see chart? Counting fingers, hand motion, light Monocular vision loss
Heteronymous Hemianopsia (aka “Bitemporal")
Homonymous Hemianopsia
Superior Quadrantanopsia http://openi.nlm.nih.gov/imgs/rescaled512/3223174_pone.0027095.g001.png CN VI Palsy - limited lateral gaze
Inferior Rectus Entrapment – limited downward gaze When no light is present, both pupils are dilated
Presenting light in one eye will result in similar constriction in the opposite pupil
RAPD (Relative Afferent Pupillary Defect) Light in the affected eye causes paradoxical dilatation
Lids and Conjunctiva Blepharitis Ectropion/Entropion Chalazion Hordeolum Dacryocystitis Conjunctivitis Pterygium Chronic inflammation of the eye lids Seborrhea Bacterial infection
Red lids with scales adhered to lashes
TX: Baby shampoo lid scrubbing Topical ABX
Ectropion Edges of the eyelid roll out due to: Trauma Advanced age Facial palsy Infection Entropion Eyelid edges are turned inward due to scarring or muscle spasm TX: Surgery (blepharoplasty) if the above problems are symptomatic Chalazion is a painless cyst in the eyelid due to blocked meibomian gland TX: warm compresses or elective excision
Hordeolum (stye) is a painful nodule or pustule caused by staph infection TX: warm compresses 1st, topical ABX, I&D if not better Inflammation and/or infection of the lacrimal sac 2/2 obstruction of duct
Usually Staph aureus, Strep, Staph epidermidis or Candida
TX: ABX and warm compresses
Surgery if not better after conservative management (DCR) Benign, slow growing tissue of the bulbar conjunctiva Looks like a white vascular triangle, nasal side Encroaches on the cornea Leave alone unless it starts to impact vision, then surgical excision Elevated yellow mass on the conjunctiva, adjacent to the cornea Benign; caused by sun exposure, chronic trauma, chronic dryness Leave alone unless bothersome, then surgical excision Conjunctivitis Allergic Viral Bacterial HSV/Zoster Inflammation of the conjunctiva due to environmental allergies
Nearly always bilateral
Itchy, red, irritated eyes with clear discharge/tearing
Cobblestoning of palpebral surfaces
Associated with other allergic symptoms Rhinorrhea Congestion Sneezing
TX: Topical antihistamine gtts Oral antihistamines Caused by adenovirus Very contagious Unilateral or bilateral Often starts in one eye and transfers to the other Conjunctival injection, clear to mucoid D/C, pre-auricular lymphadenopathy TX: Supportive including warm compresses and artificial tears, +/- ABX ointment Hand/eye hygiene is important Common pathogens include Staph. aureus Strep. pneumoniae Haemophilus sp. Moraxella sp.
Also: Neisseria gonorrhoeae, Chlamydia trachomatis
Red eyes, matted & crusted lids/lashes, unilateral or bilateral copious purulent drainage
Gram stain may help diagnosis
Giemsa stain for chlamydia
TX: topical ABX ointment or gtts targeting organism, hygiene recs. IM/PO ABX for G/C conj.
Herpes Simplex or Varicella Zoster Virus
Most common cause of corneal blindness
Dendritic ulcers on cornea observed on fluorescein staining Zoster may manifest with lesions on tip of nose (”Hutchinson’s sign”)
TX: Topical or oral antivirals
AVOID topical steroids
Inflammation of iris, which is the anterior portion of the uvea Traumatic (delayed in onset) vs. atraumatic(linked to rheum/autoimmune/IBD) S/SX of limbic flush, deeper pain not alleviated by tetracaine, consensual photophobia, “cells and flare” (WBCs in anterior chamber) on slit lamp exam TX’ed w/ steroid & dilating gtts Commonly misdiagnosed as conjunctivitis! Don’t make this mistake!!! Anterior Chamber/Lens Corneal Abrasion Corneal Ulcer Cataract Glaucoma Hyphema
Abrasions only involve superficial epithelium
Due to mechanical trauma SX: pain, FB sensation, photophobia, tearing Look on eye and under lid for residual foreign body - abrasion itself visible with fluorescein
Treatment ABX ointment/gtts (cover pseudomonas in CTL wearers, organic/dirty material) and Tdap Patching/bandage contact lens controversial DO NOT give tetracaine/topical anesthetic for D/C Ulcers involve the epithelium and stroma
Can be caused by: Trauma Infection Contact lenses
SX: Pain, photophobia, tearing Fluorescein staining shows epithelial defect with dense/hazy corneal infiltrate
TX: Refer to Ophtho Avoid steroids (can lead to perforation)
Accumulation of protein within the lens causing opacity and decreased vision Causes: Aging, trauma, diabetes, systemic steroids Signs: lens appears yellow and translucent, difficult to examine retina SX: Gradual vision loss, glare, double vision, spots TX: extraction of lens with placement of intraocular lens
Increased intraocular pressure (IOP ≥ 20) due to inability of aqueous humor to move through trabecular network in iris.
This pressure leads to damage of the optic nerve causing “cupping” and increased cup-to-disc ratio. OPEN CLOSED Closed angle glaucoma is an EMERGENCY
S/SX: painful red eye, fixed/mid-dilated pupil, vision loss, tearing, N/V
TX: Emergent referral to Ophtho IV acetazolamide, topical beta blockers.
DO NOT DILATE EYES
Open angle glaucoma is chronic compared to closed
SX: can cause gradual loss of vision progressing to blindness. Usually asymptomatic at first. First SX is loss of peripheral vision.
TX - topical drops including: Prostaglandins (first line) Beta blockers (timolol) Alpha agonists (brimonidine) Carbonic anhydrase inhibitors