PANCE Blueprint EENT (7%)

Disorders of the Eye (PEARLS)

Conjunctivitis Viral conjunctivitis - copious watery discharge, scant mucoid discharge. Adenovirus (most common). Self-limiting associated with URI

Bacterial conjunctivitis - will present with purulent (yellow) discharge, crusting, usually worse in the morning. May be unilateral.

  • S. pneumonia, S. aureus – acute mucopurulent
  • M. catarrhalis, Gonococcal – copious purulent discharge, in a patient who is not responding to conventional treatment
  • Chlamydia– newborn, Giemsa stain - inclusion body, scant mucopurulent discharge

Allergic conjunctivitis - red eyes, itching and tearing, usually bilateral, cobblestone mucosa on the inner/upper eyelid

TX:

Bacterial: Treatment(s) in order of suggested use - the dose is 0.5 inch (1.25 cm) of ointment (preferable in children) deposited inside the lower lid or 1 to 2 drops instilled four times daily for five to seven days.

  1. Gentamicin/tobramycin (Tobrex): aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this agent
  2. Erythromycin ointment (E-Mycin) Chlamydia for newborns
  3. Trimethoprim and polymyxin B (Polytrim) This combination is used for ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic.
  4. Ciprofloxacin (Ciloxan)

Contact lenses use = pseudomonas tx=fluoroquinolone (ciprofloxacin / Ciloxan drops) 

  • Neisseria conjunctivitis warrants prompt referral and topical + systemic antibiotics
  • Chlamydial conjunctivitis systemic tetracycline or erythromycin x 3 weeks, topical ointments as well, assess for STD or child abuse

Viral: There is no specific antiviral agent for the treatment of viral conjunctivitis. Some patients derive symptomatic relief from topical antihistamine/decongestants. Warm or cool compresses may provide additional symptomatic relief.

Allergic conjunctivitis systemic antihistamines and topical antihistamines or mast cell stabilizers. (Naphcon-A, Ocuhist, generics)

  • epinastine (Elestat)
  • azelastine (Optivar)
  • Emedastine difumarate (Emadine)
  • Levocabastine (Livostin)
Cataract Blurred vision over months or years, halos around lights. Clouding of the Lens (versus clouding of cornea = glaucoma)

Tx: Surgical removal is definitive

Corneal ulcer Contact lens wearers, caused by deep infection in the cornea by bacteriaviruses or fungi.

Tx: Immediate referral - if immediate referral is not possible, it is reasonable to start topical ophthalmic antibiotics without delay

Pterygium
Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in the inner corner/nasal side of the eye).

  • Pterygium is associated with increased sun exposure and climates where there is wind, sand, and dust.

Tx: Only surgically remove when vision is affected

Dacryocystitis
Dacryoadenitis

  • Inflammation of the nasolacrimal duct or the nasolacrimal gland (supratemporal)

Tx:  cannulation of the duct, stenting, surgery

Dacryocystitis

Tx: systemic antibiotics: Clindamycin + 3rd gen. cephalosporin

Blepharitis Eyelid changes: crusting, scaling, red-rimming of eyelid and eyelash flaking along with dry eyes and associated seborrhea and rosacea

TX: Warm compresses, irrigation, lid massage, and topical antibiotics for flare-ups

  • Daily lid wash with baby shampoo
Chalazion chalazion is a sterile painless (non-infectious) granuloma of the internal meibomian sebaceous gland, painless "cold" lid nodule, versus hordeolum, which is a painful infectious "hot" nodule

TX: Warm compresses, and eyelid hygiene

  • Injection of corticosteroid or incision + curettage may be necessary for large chalazion that are affecting vision
Ectropion Ectropion (eversion of the eyelid) occurs when the eyelid turns outward exposing the palpebral conjunctiva, conjunctiva will appear red from air exposure and inflammation

TX: Tear supplements and ocular lubricants at night

  • Definitive treatment is surgery
Entropion Entropion (inversion of an eyelid) occurs when the eyelid turns inward. It is most commonly caused by age-related tissue relaxation, surgical correction is definitive

TX: Tear supplements and ocular lubricants at night

  • Definitive treatment is surgery
Hordeolum Painful, warm (hot), swollen red lump on the eyelid (different from a chalazion which is painless)

  • Think “H” for Hot = Hordeolum. Most common organism S.  aureus

TX: Warm compress and topical antibiotics

  • A hordeolum that does not respond to hot compresses can be incised wit a sharp, fine-tipped blade
  • Systemic antibiotics (eg, dicloxacillin or erythromycin 250 mg PO QID) are indicated when cellulitis accompanies a hordeolum
Nystagmus Involuntary, jerking movements of the eyes

TX: medications baclofen and gabapentin

  • Several therapeutic approaches, such as contact lenses, surgery, and low vision rehabilitation have also been proposed
  • Surgery: tenotomy
  • Physical therapy
Optic neuritis Acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements

  • Typically occurs over hours or days. Associated with multiple sclerosis
  • Fundoscopy: Inflammation of the optic disc

TX: IV corticosteroids

  • Refer to neurology for evaluation of Multiple Sclerosis
Papilledema Optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks

  • Causes include brain tumor/abscess, meningitis, cerebral hemorrhage, encephalitis, pseudotumor cerebri
  • Immediate neuroimaging to rule out mass lesion, then CSF analysis

TX: Treat underlying cause

Orbital cellulitis Decreased extraocular movement, pain with movement of the eye and proptosis, signs of infection

  • Often associated with sinusitis. Occurs more often in children than adults
  • CT Scan of orbits (confirmatory)

Tx: Hospitalization and IV broad-spectrum antibiotics

Macular degeneration Gradual painless loss of central vision. The macula is responsible for central visual acuity which is why macular degeneration causes gradual central field loss.

  • Metamorphopsia (distortion on Amsler grid)
  • Dry macular degeneration (85% of cases): atrophic changes with age – a slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY) = yellow retinal deposits.
  • Wet macular degeneration: hemorrhage, neovasculation. New abnormal vessels grow under central retina which leaks and bleed causing retinal scarring.

TX:

Wet age-related macular degeneration

  • VEGF inhibitors (e.g., bevacizumab)
  • Photodynamic therapy
  • Zinc and antioxidant vitamins

Dry age-related macular degeneration

  • Zinc and antioxidant vitamin
Retinal detachment Vertical curtain coming down across the field of vision may sense floaters or flashes at onset, loss of vision over several hours.

TX: Stay supine (lying face upward) with head turned towards the side of the detached retina

  • Consult ophthalmologist
Retinopathy Leading cause of blindness most common is diabetic retinopathy.

TX:  control of blood glucose and BP

  • Ocular treatments: retinal laser photocoagulation, intravitreal injection of antivascular endothelial growth factor drugs (eg, ranibizumabbevacizumab), intraocular corticosteroids, vitrectomy, or a combination
Blowout fracture History of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye).

  • Anesthesia/paresthesia in the gums, upper lips, and cheek due to damage to the infraorbital nerve

TX: Prompt ophthalmic referral. Treatment with surgery

Corneal abrasion Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection, fluorescein dye - increased absorption in devoid area

TX: Antibiotic eye ointment, no patching

Hyphema TX: Antibiotic eye ointment, no patching

Hyphema (ReelDx)Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye

TX: Elevate head at night, acetaminophen for pain, patch/shield. Surgery if high pressure or persistent bleeding

Retinal vascular occlusion Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax)

  • Embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis
  • Rule out carotid artery stenosis by carotid ultrasound
  • Look for the cherry red spot and pale opaque fundus with red fovea and arterial attenuation

TX: Optho emergency. Immediate treatment is indicated if occlusion occurred within 24 h of presentation

  • Reduction of intraocular pressure with ocular hypotensive drugs (eg, topical timolol 0.5%, acetazolamide 500 mg IV or PO)
  • Intermittent digital message over the closed eyelid or anterior chamber paracentesis
  • If patients present within the first few hours of occlusion, some centers catheterize the carotid/ophthalmic artery and selectively inject thrombolytic drugs
Amaurosis fugax Transient partial or complete loss of vision in one eye - The most common cause of amaurosis fugax is a cholesterol plaque emboli from a carotid artery plaque

  • Blockage of the central retinal artery leads to sudden, painless, monocular vision loss due to retinal hypoxia
  • Vision loss is classically described as a curtain coming down over one eye
  • Amaurosis fugax (an example of a TIA) occurs if the clot passes and the vision loss is transient. If the clot cannot pass, central retinal artery occlusion occurs

A fundus exam may reveal optic disk pallor, a cherry-red macula, and retinal edema

TX: If it does not resolve spontaneously, treatment is recommended within an hour of the occlusion

  • Treatment involves surgical decompression, but, if unavailable, digital massage of the globe and CO2 rebreathing should be initiated in an attempt to pass the clot
Amblyopia Amblyopia (lazy eye) is reduced visual acuity is not correctable by refractive means

  • It may be caused by strabismus (crossed eye); uremia; or toxins, such as alcohol, tobacco, lead, and other toxic substances

TX: Includes correction of refraction error as well as forced use of the amblyopic eye by patching the better eye or blurring with glasses or drops

Glaucoma Open-angle glaucoma: most common, aqueous outflow obstruction

  • > 40 y/o,  African Americans, often asymptomatic
  • Peripheral to central gradual visual loss (versus macular degeneration which is a central loss)

Acute narrow angle-closure glaucoma: Iris against lens, dark environment, acute loss of vision, nausea, and vomiting.

  • Classic triad: injected conjunctivasteamy cornea, and fixed dilated pupil, this is an ophthalmic emergency

TX:

Acute narrow angle-closure glaucoma

  • Acetazolamide IV is the first-line agent - decrease IOP by decreasing aqueous humor production
  • Topical beta blocker (ex. timolol) reduces IOP without affecting visual acuity
  • Miotics/cholinergics (ex. Pilocarpine, Carbachol)
  • Peripheral iridotomy is the definitive treatment

Chronic open-angle glaucoma

  • Prostaglandin analogs are 1st line (ex. latanoprost), Timolol
Scleritis Inflammation of the sclera associated with systemic immunologic disease, such as rheumatoid arthritis

  • It causes significant eye pain (severe, deep pain)
  • On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment

TX: Refer the patient for prompt evaluation by an ophthalmologist.

  • Treatment involves topical and sometimes systemic corticosteroids
Strabismus Strabismus is defined as any form of ocular misalignment

Tx: Patch exercises, if untreated after age two, amblyopia results

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