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 questions!

 Augment your clinical practice with a few ophtho pearls, tips and tricks   Blowout fracture   Corneal abrasion     Retinal vascular occlusion  Foreign body   Hordeolum  Work from the outside inward…  Gross exam - , asymmetry, doorknob DXs  Visual acuity  EOMs and visual fields  Periorbital eye, lids, lashes, glands & ducts  , & & 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 (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 are dilated

 Presenting light in one eye will result in similar constriction in the opposite

 RAPD  (Relative Afferent Pupillary Defect)  Light in the affected eye causes paradoxical dilatation

Lids and Conjunctiva Blepharitis Ectropion/Entropion Chalazion Hordeolum 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 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 () 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  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/ 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  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 causing “cupping” and increased cup-to-disc ratio. OPEN CLOSED  Closed angle glaucoma is an EMERGENCY

 S/SX: painful , 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