PANCE Blueprint EENT (7%)

Disorders of the Eye (PEARLS)

NCCPA™ PANCE EENT Content Blueprint Disorders of the eye

osmosis Osmosis
Conjunctivitis
ReelDx Virtual Rounds (Conjunctivitis )
Patient will present as → a 6-year-old boy complaining of itchy eyes. The mother states that she has noted that he has been tearing and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. On exam, there is marked redness, tearing, and eyelid edema of both eyes.

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
Patient presents as → a 78-year-old man who complains of slowly progressive vision loss over the last several years. He describes his vision as if he is looking through “dirty glass” and reports seeing a white halo around lights. On physical exam, there is clouding of the lens and no red reflex.

Blurred vision over months or years, halos around lights. Clouding of the Lens (versus clouding of cornea = glaucoma)

  • Risk factors: aging, hypoparathyroid, steroid use, lovastatin

DX: is by fundoscopy "black on red background⇒ cataract appears dark against the red reflex on exam

  • Slit-lamp to magnify, difficult to see the fundus

Tx: Surgical removal is definitive

Corneal ulcer
Patient will present as → a 34-year-old contact lens wearer with severe pain, redness, and photophobia. Eyes are injected with cloudy discharge unilaterally. A dense corneal infiltrate is visible with fluorescein staining. 

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

DX: Fluorescein stain is diagnostic

  • Corneal cultures should be obtained before starting antibiotics

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

Pterygium
ReelDx Virtual Rounds (Pterygium)
Patient will present as → a 65-year-old male Hispanic farmworker who is brought to you by his concerned wife. She reports he has had this “thing” on his left eye for years and refuses to seek care. He denies pain or discharge from the affected eye. Physical exam reveals an elevated, superficial, fleshy, triangular-shaped fibrovascular mass in the inner corner/nasal side of the left eye.

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

DX: This is a clinical diagnosis

TX: Only surgically remove when vision is affected

Dacryocystitis
Patient will present as → a 12-year-old with severe unilateral right eye pain and pressure. On physical exam, there is swelling, redness, tearing, and drainage from the outermost part of the affected right eye.

Dacryoadenitis

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

DX: The diagnosis is based on clinical observation ⇒ CT orbits if chronic

TX:  cannulation of the duct, stenting, surgery

Dacryocystitis

DX: The diagnosis is based on clinical observation ⇒ CT orbits if chronic

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

Blepharitis
Patient will present as → a 34-year-old female with crusting, scaling, red-rimming of the eyelid, and eyelash flaking along with dry eyes. The patient has a history of seborrhea and rosacea.

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

DX: Diagnosis is usually by slit-lamp examination

  • Chronic blepharitis that does not respond to treatment may require a biopsy to exclude eyelid tumors that can simulate the condition

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

  • Daily lid wash with baby shampoo
Chalazion
Patient will present as → a 52-year-old male with a foreign-body sensation in the right eye. Over the last 3 weeks, he has had gradually increasing painless swelling around the right lower eyelid. Your examination shows a nontender discrete nodule on the right lower eyelid. There is no evidence of injection or discharge and her visual acuity is normal.

chalazion is a sterile painless (non-infectious) granuloma of the internal meibomian sebaceous gland, painless "cold" lid nodule

DX: Diagnosis is clinical

  • Will present as a hard, nontender eyelid swellingoften NOT very red
  • Unlike a hordeolum (stye), a chalazion tends to have a more gradual onset, is less painful, and affects the middle part of the eyelid

TX: Warm compresses, and eyelid hygiene

  • Injection of corticosteroid or incision + curettage may be necessary for large chalazion that is affecting vision
Ectropion
Patient will present as  a 72-year-old with complaints of dry eyes coupled with excessive tearing. On exam, the conjunctiva appears red and the left eyelid is turned outward.

Ectropion (eversion of the eyelid) occurs when the eyelid turns outward exposing the palpebral conjunctiva, conjunctiva will appear red from air exposure and inflammation

DX: Diagnosis is clinical (the eyelid turns out)

TX: Tear supplements and ocular lubricants at night

  • Definitive treatment is surgery
Entropion
Patient will present as → a 75-year-old with a foreign body sensation and tearing of his right eye. On physical exam you note a red, irritated, right eye in association with an inverted eyelid.

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

DX: Diagnosis is clinical (eyelids turn in)

TX: Tear supplements and ocular lubricants at night

  • Definitive treatment is surgery
Hordeolum
ReelDx Virtual Rounds (Hordeolum )
Patient will present as → a 15-year-old male with pain, redness, and swelling of the upper eyelid for the last 3 days. There are no visual changes or photophobia. Examination reveals a tendererythematous, and outward-pointing edema of the right eyelid.

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

DX: The diagnosis is clinical

TX: Warm compress and topical antibiotics

  • A hordeolum that does not respond to hot compresses can be incised with a sharp, fine-tipped blade
  • Systemic antibiotics (eg, dicloxacillin or erythromycin 250 mg PO QID) are indicated when cellulitis accompanies a hordeolum
Nystagmus
ReelDx Virtual Rounds (Nystagmus)
Patient will present as → a 46-year-old male with an involuntary, rapid, and repetitive movement of both eyes side to side.

Involuntary, jerking movements of the eyes

DX: Caloric reflex test in which one ear canal is irrigated with warm or cold water or air. The temperature gradient provokes the stimulation of the horizontal semicircular canal and the consequent nystagmus.

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 (ReelDx)
ReelDx Virtual Rounds (Optic neuritis )
Patient will present as → a 47-year-old school teacher with a cough, hemoptysis, fever, chills, and weight loss that has persisted since he returned from a summer trip to China. A chest radiograph is concerning for infection and a sputum culture is positive for acid-fast organisms. Treatment for this patient’s condition is begun. Three weeks later the patient returns to the clinic with decreased visual acuity for one day in his right eye. He also reports pain in the eye with movement but no other symptoms. The patient has a family history of glaucoma, diabetes mellitus, factor V Leiden and stroke. On physical examination, when a penlight is shined into the affected eye there is no pupillary constriction in either eye. 

Acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements

DX: Fundoscopy ⇒ inflammation of the optic disc

  • MRI will confirm demyelination

TX: IV corticosteroids

  • Refer to neurology for evaluation of Multiple Sclerosis
Papilledema (ReelDx)
ReelDx Virtual Rounds (Papilledema)
Patient will present as → a 57-year-old male with a history of hypertension who complains of an acute onset of intermittent headaches and blurred vision of the right eye.

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

DX: Diagnosis is by ophthalmoscopy with further tests, usually brain imaging and sometimes subsequent lumbar puncture, to determine the cause

  • MRI or CT scan of the head looking for a cause. Focus on finding intracranial pathology = tumor or bleed, cerebral edema, CSF outflow obstruction, or overproduction
  • Increased opening pressure with lumbar puncture confirms increased intracranial pressure

TX: Treat underlying cause

Orbital cellulitis (ReelDx)
ReelDx Virtual Rounds (Orbital cellulitis)
Patient will present as →  a 2-year-old who arrives at the ED with a swollen and erythematous eyelid, proptosis, pain with movement of the eye, and an inability to adduct or abduct his eye.

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

DX: history, clinical exam, and focused assessment of extraocular muscles

  • The imaging modality of choice for the diagnosis of orbital cellulitis is CT with contrast
  • CBC and blood culture may be standard in some settings

TX: Hospitalization and IV broad-spectrum antibiotics

Macular degeneration
Patient will present as → a 62-year-old male who arrives for his follow-up visit for chronic central visual loss. He describes a phenomenon of wavy or distorted vision that has deteriorated rather quickly. The patient is frustrated because he “just can’t drive anymore” and he is “having difficulty seeing words when he reads.” When looking at a specific region of the Amsler grid, he reports a dark “spot” in the center, with bent lines. On the fundoscopic exam, you note areas of retinal depigmentation along with the presence of yellow retinal deposits

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, neovascularization. New abnormal vessels grow under the central retina which leaks and bleed causing retinal scarring.

DX: funduscopic findings are diagnostic; color photographs, fluorescein angiography, and optical coherence tomography assist in confirming the diagnosis and in directing treatment.

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
Patient will present as → a 65-year-old man complaining of a sudden unilateral vision loss which he describes as “a curtain or dark cloud lowering over my eye.” This was preceded by small moving flashing lights, and floaters. The fundoscopic exam reveals a detached superior retina.

Separation of the retina from the pigmented epithelial layer causing the detached tissue to appear as a flap in the vitreous humor

  • Can occur spontaneously or secondary to trauma or extreme myopia
  • Vertical curtain coming down (curtain of darkness) across the field of vision may sense floaters or flashes at the onset, loss of vision over several hours (acute and painless)
  • Myopia (nearsightedness) is a risk factor for the development of retinal detachment
  • Retinal detachment usually presents with defects in the peripheral visual field

DX: is by fundoscopy

  • Retinal detachment is visualized on fundoscopy as crinkling of retinal tissue and changes in vessel direction
  • Ultrasonography may help determine the presence and type of retinal detachment if it cannot be seen with funduscopy

TX: Retinal detachment is an ophthalmologic emergency

  • Stay supine (lying face upward) with head turned towards the side of the detached retina
  • Consult ophthalmologist
  • Pneumatic retinopexy is a procedure for the management of retinal detachment that involves cryoretinopexy followed by injection of an air bubble in the vitreous
Retinopathy
Patient will present as → a 64-year-old diabetic patient who is being seen for a routine health screening. On fundoscopic exam, you see cotton wool spotshard exudatesblot and dot hemorrhagesneovascularizationflame hemorrhages, A/V nicking

Caused by systemic disorders, including diabetes, hypertension, preeclampsia-eclampsia, blood dyscrasias, and HIV disease -may affect the retina

  • Diabetic retinopathy falls into two main classes: nonproliferative (early) and proliferative (late, advanced)
  • Prolonged hyperglycemia causes basement membrane thickening, decreased pericytes (hyperproliferation), microaneurysms, and neovascularization
  • Leading cause of blindness in adults

Nonproliferative type (an early form of the disease)

Proliferative type (most severe, abnormal blood vessel growth)

  • Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease
  • At this stage, circulation problems deprive the retina of oxygen. As a result new, fragile blood vessels can begin to grow in the retina and into the vitreous. The new blood vessels may leak blood into the vitreous, clouding vision
  • Fundoscopic exam (abnormal growth of vessels) neovascularization

TX:  control of blood glucose and BP

  • Ocular treatments: retinal laser photocoagulation, intravitreal injection of antivascular endothelial growth factor drugs (eg, ranibizumab, bevacizumab), intraocular corticosteroids, vitrectomy, or a combination
  • If diabetic get yearly dilated ophthalmoscopic examination
Blowout fracture (ReelDx)
ReelDx Virtual Rounds (Blowout fracture)
Patient will present as → a 13-year-old who was hit in the right eye by a baseball. The area is ecchymotic and swollen. He complains of pain, rated 6 out of 10. On physical exam, the patient has eyelid swelling, decreased visual acuity, enophthalmos (sunken eye), and anesthesia/paresthesia in the gums and upper lips.

History of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye)

  • Pain with EOM, epistaxis, erythema/ecchymosis, “raccoon eyes”
  • Anesthesia/paresthesia in the gums, upper lips, and cheek indicate damage to the infraorbital nerve

DX: diagnosed with CT scan

TX: Prompt ophthalmic referral ⇒ treatment with surgery

  • Antibiotics to prevent infection
Corneal abrasion (ReelDx)
ReelDx Virtual Rounds (Corneal abrasion)
Patient will present as → a 10-year-old boy who was hit in the right eye with a piece of bark that was thrown on the playground. He developed sudden onset of eye pain, photophobia, tearing, and blurring of vision. He claims there is “something stuck in my eye.” On physical examination, there is significant conjunctival injection.

Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection

DX: fluorescein staining - increased absorption in the devoid area

TX: Antibiotic eye ointment, no patching

Globe Rupture
Patient will present as → a 15-year old male with no significant PMHx is brought to the emergency department by his coach after being struck in the right eye by a baseball. The patient reports pain in the right eye with complete loss of vision. On physical examination, you note scleral buckling and the visual acuity testing reveals light perception only.

Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma

  • Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury
  • The vitreous and/or aqueous humour drain through the site of the rupture causing the eye to deflate (sunken appearance)
  • Immediate ophthalmology consultation

DX: CT scan: non-contrast 1 to 2 mm cuts axial and coronal through the orbits

TX: Avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry

  • Requires referral to ER or emergent ophthalmologist
  • Do not remove any protruding foreign bodies
  • Begin IV antibiotics with Vancomycin PLUS either ceftazidime or fluoroquinolone
  • Avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye
  • A Fox eye shield or other rigid devices (bottom of a polystyrene foam cup) should be placed over the affected eye
  • Surgical repair should be expedited
Hyphema (ReelDx)
ReelDx Virtual Rounds (Hyphema )
Patient will present as → a 14-year-old who sustained blunt trauma to his right eye after being struck by a baseball. He complains of blurry vision. On physical exam, you note unequal pupils, injected conjunctiva/sclera, and blood in the anterior chamber of the right eye.

Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris) and may cover 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
  • Usually from blunt/penetrating trauma ⇒ ensure no other type of injury (skull fracture, orbital fracture)

DX: orbital CT if indicated + ophthalmology consult

TX: usually, blood is reabsorbed over days/weeks

  • Elevate head at night at 30 degrees, acetaminophen for pain, patch/shield
  • May use beta-adrenergic blockers or carbonic anhydrase inhibitors
  • Surgery if high pressure/persistent bleeding
  • NSAIDs contraindicated (may increase bleeding)
Retinal vascular occlusion
Patient will present as → a 74-year-old man with sudden vision loss in his right eye. He has a medical history of hypertension and coronary artery disease and new-onset atrial fibrillation. On physical exam, a carotid bruit is auscultated. His visual acuity is light perception. Confrontational visual fields reveal a dense scotoma, and a penlight examination shows an afferent pupillary defectDilated funduscopic examination shows retinal whitening with a cherry-red spot in the fovea.

Central retinal artery occlusion (cherry-red spot, ischemic retina)

  • Flow-through CRA occluded
  • Atherosclerotic thrombosis, embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis
  • Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax)

DX: Fundoscopy

  • Look for perifoveal atrophy (cherry-red spot) and pale opaque fundus with red fovea and arterial attenuation
    • Arteriolar narrowing, separation of arterial flow, retinal edema, ganglionic death leads to optic atrophy and pale retina
  • Rule out carotid artery stenosis by carotid ultrasound

TX: Emergent ophthalmologic consult - 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
  • Workup and management of atherosclerotic disease
  • Irreversible damage to the retina after 90 min; Poor prognosis

Central retinal vein occlusion (blood and thunder fundus)

  • Sudden, painless, unilateral vision loss. Blurred vision or complete visual loss
  • Most common in ages 50+, associated with HTN, primary open-angle glaucoma (POAG), diabetes, hyperlipidemia, hyperviscosity states (polycythemia, leukemia)
  • Usually occurs secondary to a thrombotic event

DX: Funduscopy: retinal hemorrhages in all quadrants, optic disc swelling; blood and thunder retina (dilated veins, hemorrhages, edema, exudates)

TX: vision resolves with time (partially); workup for thrombosis

  • Neovascularization treated with intravitreal injection of VEGF inhibitors

Amaurosis fugax
Patient will present as → an 82-year-old man who presents to the emergency department complaining of vision loss in his left eye. He states that it suddenly appeared as if a curtain was coming down over his left eye. It resolved after five minutes, and his vision has returned to normal. He has a history of coronary artery disease and type 2 diabetes.

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

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

  • Laboratory tests should also be ordered to investigate some of the more common systemic causes including a CBC, ESR, lipid panel, EKG, and blood glucose level
  • Noninvasive carotid duplex ultrasound studies are recommended to identify carotid artery disease if ophthalmic and laboratory findings are inadequate for explanation

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
Patient will present as → a 5-year-old male is brought by his parents and referred by his teacher for suspected decreased vision in his left eye. His mother had not noticed any vision problems. He has had normal growth and development. On exam, the patient has an abnormal vision screen of the left eye and red reflex asymmetry. 

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

DX: screening to detect amblyopia in all children younger than five years of age

  • Screening includes vision risk assessment at all health maintenance visits and vision screening at three, four, and five years of age

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
Patient with open-angle glaucoma present as →  a 47-year-old African American male presents for an ophthalmic examination. Medical history is significant for hypertension and type II diabetes mellitus. On slit-lamp examination, there is cupping of the optic disc, with a cup-to-disc ratio > 0.6. Tonometry reveals intraocular pressure of 45 mmHg (normal is 8-21 mmHg). Peripheral field vision loss is noted on the visual field exam.

Patient with acute angle-closure glaucoma will present with → a 60-year-old Asian American woman presents with sudden ocular pain. She reports she was visiting the planetarium when the pain started and when she walked outside she saw halos around the street lights. The pain was so bad that she began to vomit. She reports her vision is decreased. Physical examination reveals conjunctival injection, a cloudy cornea, and pupils

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

DX: confirmed by tonometry demonstrating increased intraocular pressure

  • May demonstrate cupping of the optic nerve
  • All patients should be screened at age 40 - may present for routine fundoscopy with a cup to disk ratio > 0.5 (<0.5 is normal). This is suggestive but not diagnostic of glaucoma so you will progress to the next step which is tonometry
    • Perform tonometry (IOP testing): pressure > 21 mmHg is concerning but not diagnostic - proceed to the next step which is peripheral field testing
    • Peripheral field testing and optic disc changes confirm the diagnosis in normal pressure glaucoma

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
Patient will present as → a 42-year-old white female complaining of a severely painful right eye. The pain is a constant, boring pain that worsens at night and in the early morning hours and radiates to the face and periorbital region. Additionally, she reports a headachewatering of the eye, and ocular redness.

Inflammation of the sclera associated with systemic immunologic disease, such as rheumatoid arthritis

  • It causes significant eye pain (severe, deep pain)

DX: On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment

  • Labs should include screening for systemic immunologic diseases - ANCAs, ANA, CRP, ESR, Lyme, RA, ACE, RPR, etc.

TX: Refer the patient for prompt evaluation by an ophthalmologist

  • Treatment involves topical and sometimes systemic corticosteroids
Strabismus (ReelDx)
ReelDx Virtual Rounds (Strabismus )
Patient will present as → a 3-year-old girl brought to you by her mother who is worried about her daughter’s “lazy eye.” She reports that her daughter’s symptoms are exaggerated when she has a cold. Past medical history is negative for trauma or headaches. The patient has an asymmetric corneal light reflex and the cover/uncover test reveals a right-sided esotropia. You refer the patient to a pediatric ophthalmologist.

Strabismus is defined as any form of ocular misalignment

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

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