Acute Dacryocystitis
1. Obstruction of nasolacrimal duct with secondary infection of the nasolacrimal sac. Usually Staph.
2. Redness, pain, swelling at medial canthus (tender nodule). Medial canthal fullness. Epiphora. Mild pre-septal cellulitis.
3. Warm compresses. System Abx (keflex, augmentin). May require I&D for epiphora.
Acute Closed Angle Glaucoma
1. Partial or total obstruction of the anterior chamber angle, which blocks the trabecular network. Can occur when iris gets pushed against the lens, shutting off the drainage angle. After long periods of dilated pupil (movie theater).
2. Severe pain and blurred vision. Halos around lights. Nausea. Abdominal pain. Eye is red, cornea steamy, and pupil is mid-dilated and non reactive. Corneal edema. IOP > 21mmHg.
3. Iridectomy. Acetazolamide. Hyperosmotic agent. Topical agent.
Acanthamoeba Keratitis
1. Ubiquitous protozoa found in ponds, pools, and streams. Cyst or active form can infect through breaks in epithelium.
2. Blurred vision, pain (often out of proportion of findings). Small, patchy subepithelial infiltrates. Punctuate or pseudo-dendritic keratitis. May develop ring infiltrate with stromal opacification. Perineuritis.
3. Corneal scrape biopsy w.silver stain - stains cysts. Culture on non-nutrient agar w/E. coli overlay. Brolene, PMHB, Clotrimazole (these are pool cleaners!)
Bacterial Keratitis
1. Corneal epithelial defect. Risk factors of contact wearers, trauma or ocular surface disease, corneal hypoesthesia, steroid use, immunosuppressed. Contact lens typically caused by Pseudomonas. Marginal ulcer typically staph or other gram +. Gram - more aggressive.
2. FBS, tearing, photophobia, blurred vision, eyelid edema, discharge. Staining of cornea w/flourescein. White infiltrate surrounding ulcer.
3. Stop contact lens wear. If infiltrate refer to Ophtho. Topical Abx - Fortifieds every hour alternating or 4th gen fluoroquinolone ever 2 hours if peripheral and small.
Blepharitis (anterior)
1. Involves the eyelid skin, eyelashes, and glands of Zeiss/Moll. Ulcerative due to infection of Staph, or seborrheic dermatitis. Posterior results from infl. of Meibomian gland and may be result of staph or primary glandular dysfunction (assoc. w/acne rosacea).
2. Itching, burning, mild FBS, tearing and crusting around eyes upon waking. Mild photophobia. Eyelid margins erythematous, thickened w/crust and debris w/in lashes. Hyperemia and telangiectasia of anterior lid margin.
3. Anterior - clean lids w/baby shampoo. Abx ointment bacitracin or erythromycin. Posterior - oral Abx Doxycycline.
Cataract
1. Protein of the lens discolors and clouds the lens with age. Can be congenital. Several different types including from trauma. Risk factors include age, smoking, EtOH, Diabetes Mellitus, systemic corticosteroid use (WILL get cataract if use prednisone).
2. Pt. typically complains of slowly progressive, painless visual impairment. Seen on exam as opacity behind pupil and possibly lost red retinal reflex.
3. Surgical lens replacement.
Chalazion
1. Subacute, non tender and usually painless nodule involving OBSTRUCTION of the Meibomian gland.
2. Eyelid swelling and erythema, then evolves into painless rubbery, nodular lesion. Points inside the lid.
3. Warm compress x 15 min x 4/day. Topical Abx only if infection present (bacitracin/erythromycin). If persists more than 4 wks may require I&D.
Chronic Open Angle Glaucoma
1. Most common type of glaucoma. Optic nerve atrophy (cupping) AND visual field loss resulting from IOP that is too high for a particular nerve. Predisposing family history, steroid use, surgeries, race, hypertension, myopia.
2. Onset usually insidious and asymptomatic w/visual field loss not noticed until late in the disease. Prevalence in AA and over 65 YOA. IOP MAY be > 21.
3. Surgery. Beta blockers (Timolol), Alpha 2 Agonists (Alphagan), and Miotics.
Bacterial Conjunctivitis
1. Gram + : Staph aureus, Strep pneumoniae. Gram - : Haemophilus influenzae, Moraxella catarrhalis, Gonococcal. Gonococcal can lead to corneal ulceration, perforation, and possible endopthalmitis.
2. Redness and PURULENT DISCHARGE in one or both eyes. Eye stuck shut in morning classic sign. Purulent discharge continues throughout day. Usually reappears w/in 5 min if wiped away.
3. Broad spectrum Abx - Erythromycin, Sulfacetamide, or Fluoroquinolone eye drops. Gonococcal requires corneal scraping and systemic treatment.
Viral Conjunctivitis
1. Very contagious. From HSV, HZV, Adenovirus, echo, Coxsackie, Molluscum, Chlamydia. Spreads through ocular and respiratory secretions.
2. Usually affects one eye first and second within a few days. Lids may be swollen, conjunctiva usually hyperemic and edematous, with WATERY discharge. Palpable preauricular lymph node strongly supports diagnosis.
3. No treatment needed. May use eye lubricant drops. Frequent hand washing.
Allergic Conjunctivitis
1. Caused by pollen, animal dander, dust.
2. Stringy, MUCOUS discharge. ITCHING, tearing, nasal congestion. Bilateral dilation of conjunctival blood vessels, with varying degrees of chemosis.
3. OTC Antihistamine/decongestant.
Pinguecula
1. Harmless, yellowish triangular nodule in the bulbar conjunctiva on either side of the iris.
2. Appears with aging, first on nasal and then on temporal side.
3. None.
Pterygium
1. Benign, degenerative conjunctival lesion often seen in hot, dusty climates, in people who spend long periods outdoors exposed to UV light. Develops over years and asymptomatic.
2. Hyperemia confined largely to raised, yellowish, fleshy plaque usually on nasal side. Vision unaffected unless extends into paracentral cornea.
3. None. Artificial tears often provide adequate relief.
Hordeolum
1. A staph abscess in the glands of Zeiss or Moll. Internal hordeolum is Meibomian gland abscess that points into conjunctival surface of lid.
2. Localized, red, swollen, acutely tender area on upper or lower lid.
3. Usually drain spontaneously after one week of warm compresses x15min x 4/day. I&D if resolution does not begin w/in 48 hrs. Abx (bacitracin or erythromycin) to eyelid every 3 hours may help during acute stage.
Ectropion
1. Usually involves lower lid and is turning out (eversion) of lid margin. Usually result of age.
2. May present with corneal exposure, tearing, keratinization of the palpebral conjunctiva, and visual loss.
3. Lubrication and moisture shields. Surgery.
Entropion
1. Degeneration of lid fascia or result of extensive scarring of conjunctiva or tarsus. Inward turning (inversion) of lid margin.
2. Hyperemia. FBS if lashes contact cornea/conjunctiva.
3. Surgery. Botox for temporary correction.
Corneal Ulcer
1. Can be caused by bacteria, fungus, acanthamoeba, viral, trauma.
2. Photophobia, hyperemia, pain, decreased vision. Focal white opacity seen in corneal stroma = infiltrate w/ stromal loss = ulcer. Cannot see through infiltrate. Corneal edema, hypopyon. Scrape at edge of ulcer.
3. Lubrication. Topical Abx QID - polytrim/gatifloxacin/moxiflxacin.
Anterior Uveitis
1. Presence of inflammatory cells and proteinaceous flare in the anterior chamber of the eye. Exact pathophys unknown. Associated with ankylosing spondylitis, Reiter's syndrom, IB disease, psoriasis. Causes breakdown of blood-ocular barrier.
2. Red, painful, w/photophobia. Possible decrease in vision. Ciliary flush and mitotic pupil. Sometimes floaters.
3. 50-60% idiopathic. Topical steroids - only from an OpHthamologist!; cyclopegia.
Herpes Simplex Keratitis
1. From HSV.
2. First vesicles appear then after several hours coalesce into a dendritic pattern. Progress into central epithelial defect. FBS, photophobia, tearing. Corneal psuedo-dendrites (lack terminal bulbs), nummular keratitis. Decreased corneal sensation (cotton wisp test).
3. Acyclovir. Debridement w/viral culture.
Fungal Keratitis
1. Caused by filamentous fungus - fusarium, aspergilllus, or by candida. Common in tropical climates/agrarian societies. Contact lens wearers at increased risk.
2. FBS, tearing, photophobia, blurred vision. eyelid edema. Infiltrate appears grey/white with feathery borders. May have satellite lesions. Hypopyon (settling in bottom of cornea) common. Corneal scrape with GMS stain.
3. Antifungals (usually w/Abx) natamycin for filamentous and amphotericin for candida. Epithelial debridement every 2-3 days for natamycin. Treatment may be 6-9 months.