PANCE Blueprint EENT (9%)

Disorders of the Eye (PEARLS)

The NCCPA™ EENT PANCE and PANRE Content Blueprint covers 24 topics under the category diseases of the eye

Blepharitis Eyelid changes: crusting, scaling, red-rimming of eyelid and eyelash flaking along with dry eyes and associated seborrhea and rosacea
Blowout fracture (ReelDx) 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
Cataract 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. Fundoscopy "black on red background." Surgical removal is definitive.
Chalazion A 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
Conjunctivitis (ReelDx) Viral: copious watery discharge, scant mucoid discharge. Adenovirus (most common). Self-limiting associated with URI

Bacterial:  Pt 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: red eyes, itching and tearing, usually bilateral, cobblestone mucosa on the inner/upper eyelid

Corneal abrasion (ReelDx) Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection, fluorescein dye - increased absorption in devoid area, antibiotic eye ointment, no patching. 
Corneal ulcer  Contact lense wearers, caused by deep infection in the cornea by bacteria, viruses or fungi. White spot on surface of cornea that stains with fluorescein: round "ulceration" versus "dendritic" pattern like herpes
Dacryoadenitis Dacryoadenitis is inflammation of the nasolacrimal duct or the nasolacrimal gland (supratemporal)

Dacryocystitis is infectious obstruction of nasolacrimal duct (inferomedial region)

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
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
Ocular Foreign body Metallic foreign bodies may leave a rust ring, irrigation and removal with sterile swab. Intraocular foreign bodies require immediate surgical removal by an ophthalmologist
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 central loss)

Acute angle closure glaucoma: Iris against lens, dark environment, acute loss of vision, nausea, and vomiting. Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil, this is an ophthalmic emergency

Hordeolum (stye) (ReelDx) 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.
Hyphema (ReelDx) an-vitreouschamberTrauma 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. Treatment: elevate head at night, acetaminophen for pain, patch/shield. Surgery if high pressure or persistent bleeding
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 – slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY)= yellow retinal deposits.
  • Wet macular degeneration: hemorrhage, neovascuration. New abnormal vessels grow under central retina which leak and bleed causing retinal scarring.
Nystagmus (ReelDx)
  • Down/upbeat: CNS dysfunction
  • Vestibular (horizontal): labyrinth or vestibular nerve dysfunction
  • Gaze-evoked: most common and often benign
Optic neuritis (ReelDx) 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. Fundoscopy: Inflammation of the optic disc. Associated with multiple sclerosis.
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. Hospitalization and IV broad-spectrum antibiotics.
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. Treat underlying cause.
Pterygium (ReelDx) Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in inner corner/nasal side of the eye). Only surgically remove when vision is affected
Retinal detachment Vertical curtain coming down across the field of vision may sense floaters or flashes at onset, loss of vision over several hours. Asymmetric red reflex. Consult ophthalmologist. Stay supine (lying face upward) with head turned towards the side of the detached retina.
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.
Retinopathy Leading cause of blindness most common is diabetic retinopathy. Proliferative type is most severe. Fundoscopic exam Cotton wool spots, hard exudates, blot and dot hemorrhages, neovascularization, flame hemorrhages, A/V nicking (the phenomenon where, on examination of the eye, a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing)
Strabismus (ReelDx) Strabismus is defined as any form of ocular misalignment, The cover/uncover test is used to diagnose strabismus, Exotropia: out-turning of eyes, Esotropia: in-turning of eyes. Patch exercises, if untreated after age two, amblyopia results.
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