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Eye DDX Clin III student copy

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Disorders of the Eyes
Additional Reading:
Article posted: Vision Loss in Older Adults
The Patient History: Chapter 16 - Red Eye
Special exams
●Fluorescein
●stain for object in eye or damage to cornea
●more superficial exam of the eye
●Tonometry
●Determines intraocular pressure (15.5mmHg is
normal)
●Used to dx glaucoma
●Slit lamp exam
●10-20X magnification
●Used to dx various eye conditions
3
Eye Pain
Usually indicates inflammation of one of 3 structures
➢ Keratitis
➢ Iritis
➢ Uveitis
➢ Acute angle closure glaucoma
What are common causes of pain? Infx, trauma &
increased intraocular pressure
Examination:
➢ Careful examination of cornea, anterior chamber, iris
and retina is mandatory
➢ Assess visual acuity
VINDICATING IT
●Idiopathic
● Cluster headache (plus intense, unilateral, tearing and
rhinitis, shorter, frequently re-occuring, restless)
●Inflammatory
● Hordeolum infx, chalazion, interstitial keratitis, iritis,
scleritis, dacryoadenitis, optic neuritis (MS can have
this)
●Infectious
● Herpes simplex and zoster
● Sinusitis, dental abscesses
●Mechanical/trauma
● Foreign body, corneal abrasion, glaucoma, eyestrain
RED EYE
●Anatomical Differential
● Eyelids and Lacrimal Sac
Dacrocystitis(inflammed lacrimal sac – obstructs flow of tears),
Blepharitis, Hordeolum, Entropion/Ectropion
● Conjuctiva
● Bacterial, Viral, Allergic, N. gonorrhea, Chemical, Subconjunctival
hemorrhage
● Anterior Chamber
● Hypemia (increased superficial vascularization)
● Sclera
● Epi/Scleritis, Keratitis, Corneal abrasion, Herpetic keratitis
● Orbit
● Periorbital cellulitis, Orbital cellulitis
● Uveal Tract
● Iritis
● Glaucoma - Acute closed angle glaucoma
●
6
Red Flags Causes of Red Eye
7
Red Flag Causes of Red Eye
8
Conjunctivitis
Infectious
➢ Bacterial, viral*m/c adenovirus specifically, chlamydial,
fungal parasitic
Non-infectious
➢ Allergic asthma, dermatitis, irritant
➢ Toxic
➢ Secondary to another disorder: dacryocystitis,
dacryoadenitis, cellulitis, Kawasaki disease
Allergic conjunctivitis
●Atopic
●Giant papillary conjunctivitis(mechanical irritation,
often contacts, of conjunctiva)
●Vernal – end up with cobblestone appearance of
conjunctiva. Can have corneal ulcers and keratitis
● occurs in children lasts 5-10 days then resolves
● Seasonal
Iatrogenic:
● Topical antibiotics gentomyosin, sulphonamides ect
Sx/Sn: eye itching b/l, tearing with stringy discharge,
eye fullness sensation, conjunctival hyperemia,
marked chemosis swelling of the conjunctiva
Viral Conjunctivitis
Most common cause of conjunctivitis (80%)
Common cause of swimming pool conjunctivitis
Signs and symptoms:
●Serous discharge, lid edema
●Associated with URI
●Palpable and tender preauricular nodes
●Severe pharyngitis
●Mild to no pain, mild itching
●Fever
●Initially unilateral may progress to opposite eye w/in 24-48 hrs
●Highly contagious for up to 12 days
● Associated with which virus? Adenovirus (M/C), varicella zoster,
herpes simples, ebstein barr virus, influenza
● Why should you care? Complications? Dif consequences
depending on the virus type. Ensure it is viral.
14
Herpetic Infection
● HSV or HVZ
● Immediate referral to Opthamologist
● S&Sx
● pain, photophobia diffuse or ciliary injection
● dendrites seen on fluorecein staining
● may cause inflammation and scarring of the cornea
and in some cases the retina and optic nerve are
involved
● chronic outbreaks may cause glaucoma, cataract
formation, double vision and scarring of the cornea
15
es-pictures
16
Cornea.html
17
Bacterial conjunctivitis
●Newborns
● What are common causes?chemical prophylaxis (M/C of
conjunctivitis erythromycin drops at birth to prevent
gonorrhoea)
● Gonorrheal infx: bilateral mucopurulent discharge that
comes back even if you wipe it away.
●Children
● Streptococcus pneumoniae
● H influenza
● Staphylococcus species
● Moraxella species
●Adults
● Staph, Strep, E. coli, Pseudomonas, Moraxella,
Chlamydia, Gonorrheal
Bacterial Conjunctivitis
●Usually occurs suddenly
● Unilateral → to opposite eye within 2-5 days
●Mucopurulent discharge
●Matting of lashes in the a.m
●Significant irritation with stinging sensation or foreign
body sensation
●Eyelid edema
●Variable conjunctival injection
●Visual acuity not affected
●Complications: Blepharitis, External hordeolum,
conjunctival scarring and blindness (clap)
Blepharitis
●Most common Inflammation of the eyelids
●Anterior (outside of eyelid)
● Affects base of eyelashes
● Associated with Staph or seborrhea
●Posterior (inner eyelids)
● Affects meibomian gland openings
● Associated with rosacea and seborrheic dermatitis
Blepharitis
●Signs and symptoms
● Bilateral
● Pruritus
● Local irritation and burning/ not painful
● Inflammation of eyelid margin
● Moderate lid swelling
● Lower eyelid more affected
● Soft oily yellow skin scaling
Keratitis
●Corneal inflammation or Infection
●Etiology
● Eye trauma
● Infection
● Secondary to scleritis
Keratitis
●Signs and symptoms
● Moderate to severe eye pain** know differences b/w
conditions
● Moderate to severe to foreign body sensation
● Blurred vision
● Watery to mucopurulent eye discharge
● Photophobia
● Eye tearing
● Painful red eye, with ciliary flush
● Pupils are equal, cornea appears cloudy
Staphylococcal Keratitis
Uveitis
●Inflammation of the choroid layer:
● Iris (iriditis)
● Iris+ciliary body (iridocyclitis)
● Posterior compartment (posterior uveitis)
● Endophlalmitis – really bad, rare, often bacterial infection of
entire eye
●In general, divided into anterior and posterior uveitis
● Often anterior divided into granulomatous and nongranulomatous inflammation…
●
Even though “granulomatous” refers to etiologies that cause
granulomas and classical granulomas sometimes aren’t found in the
eye
Uveitis - history
●Anterior uveitis:
● Acute – Pain, redness, photophobia, excessive tearing, and
decreased vision; pain generally develops over a few hours
or days except in cases of trauma
● Chronic - Primarily blurred vision, mild redness; little pain or
photophobia except when having an acute episode
●Posterior uveitis:
● Blurred vision, floaters
● Symptoms of anterior uveitis (pain, redness, and
photophobia) absent
●
Symptoms of posterior uveitis and pain suggest anterior chamber
involvement, bacterial endophthalmitis, or posterior scleritis
Uveitis
●Etiology:
● for anterior (about 90%): idiopathic, seronegative
spondyloarthropathies/IBD, sarcoidosis, JIA, lupus,
AIDS, herpes, tubular interstitial nephritis
●
Most common are idiopathic, and autoimmune
● For posterior: a lot of infections:
● Toxoplasmosis and CMV infections are common
● Cat scratch disease
● Autoimmune/sarcoidosis causes can also cause posterior
Uveitis
●Not very common – about 17-52
cases/100,000/year… 90% are an anterior uveitis
●It’s not common, so why do we care?
● Can cause a lot of different complications:
● Macular edema and destruction
● Glaucoma
● Corneal damage
● cataracts
Uveitis Labs
•
•
•
•
•
CBC
Urinalysis
ESR
CRP
Basic Metabolic panel
• 2nd line labs
• TB Skin test
• HLA-B27
• Rapid Plasma Reagin (RPR)
• Which imaging is indicated? Chest x ray
Orbital Inflammation
●Orbital cellulitis
● Inflammation + infection of tissues posterior to the orbital
septum
● Bacterial in origin – common causes are Staph aureus, Strep
pneumo, and H. influenza
●
Bacteria seeded from skin or from sinuses, or from a pre-existing
peri-orbital cellulitis
● Nasty complications
● 11% rate of vision loss
● Small minority of cases (1%) with cavernous sinus thrombosis
(which has a 50% mortality)
● Small minority will result in intracranial abscesses or meningitis
Orbital inflammation
●Orbital cellulitis:
● Signs/symptoms
●
●
●
●
●
●
Proptosis (exopthalmos)
Pain on eye movement
Elevated intraocular pressure
Fever, headache
Edema of the eyelid
Conjunctivitis
● Treated with antibiotics
Glaucoma
● In open angle glaucoma, the aqueous humor has
complete physical access to the trabecular meshwork,
and the elevation in intraocular pressure results from an
increased resistance to aqueous outflow in the open
angle.
● In angle closure glaucoma, the peripheral zone of the
iris adheres to the trabecular meshwork and physically
impedes the egress of aqueous from the eye.
Acute angle-closure glaucoma
●Glaucoma
● Increased intraocular pressure with optic nerve injury
●Risk factors
● Increasing age
● Far sightedness
● Family hx
● Angle closure glaucoma in contralateral eye
● Pupillary dilation
Acute angle closure glaucoma
●Etiologies
● Opthalmic anticholinergic agents
● Systemic medications – antidepressants, sulfa based
medications, topiramate
●Acute Symptoms (Usual presentation)
● Decreased visual acuity, severe vision loss in hours to
days
● Photophobia
● Headache
● Extreme deep eye pain
● Nausea and vomiting
● Halos
● Usually unilateral
Acute angle-closure glaucoma
●Signs
● Decreased visual acuity
● Mildly dilated pupil
● Increased IOP – 25-50 mmHg
● Eye redness; Ciliary injection
● Conjunctival edema
● Corneal edema (cloudy, “steamy” hazy)
● Optic disc cupping
39
Open Angle Glaucoma
●Most common type of glaucoma
● Seen mostly in older patients (rarely in people under 40
yrs of age)
●Risk Factors
● Black race – 4 fold increase
● First Degree relative with glaucoma
● DM
● Severe Nearsightedness
● Eye injury
●
Eye trauma, uveitis, steroids
Pterygium
●Growth on the surface of the conjunctiva
●Starts at the inner canthus and enlarges laterally to
cover portion of cornea
●Etiology: UV light exposure, low humidity, dust, wind
●Pinguecula
● Only involves conjunctiva, no cornea involement
●Symptoms: foreign body sensation, tearing, dry and
itchy eyes, persistent redness.
43
Differential Diagnosis of Red Eye
Conjunctivitis
Acute Iritis
Acute AngleClosure
Glaucoma
Keratitis
Discharge
Bacteria
Virus
Allergic
No
No
Profuse tearing
Pain
No
++ (tender globe)
+++ (nausea)
++ (on blinking)
Photophobia
No
+++
+
++
Blurred vision
No
++
+++
Varies
Pupil
Normal
Smaller
Fixed in middilation
Same or smaller
Injection
Conjunctiva
Ciliary flush
Diffuse
Diffuse
Cornea
Normal
Keratic
precipitates
Cloudy
Infliltrate, edema,
epithelial defects
IOP
Normal
Varies
Increased
Normal or
increased
Anterior chamber
Normal
+++ cells and flare Shallow
Other
Large, tender pre-
Posterior
Colored halos
Cells and flare or
normal
Transient or sudden visual loss
●Optic neuritis
●Anterior ischemic optic neuropathy
●Posterior ischemic optic neuropathy
●Toxic optic neuropathy
●Retinal detachment
●Transient Ischemic Attack
●Classic migraine
●Stroke
●Vitreous degeneration
Chronic Visual loss
●Cataract
●Glaucoma
●Maculardegeneration
●Diabetic retinopathy
●Melanoma
RETINAL DETACHMENT
Separation of the neurosensory retina from the retinal pigment
epithelium
●Rhegmatogenous retinal detachment is associated with a fullthickness retinal defect
● develop after the vitreous collapses structurally, and the
posterior hyaloid exerts traction on points of abnormally
strong adhesion to the retinal internal limiting membrane.
● Liquefied vitreous humor seeps through the tear and gains
access to the potential space between the neurosensory
retina and the retinal pigment epithelium
● Most common type
● Causes:
●
●
●
Age
Cataract surgery
Inflammation in posterior chamberie uveitis
RETINAL DETACHMENT
●Non-rhegmatogenous retinal detachment,
exudative type = retinal detachment without
retinal break
● may complicate retinal vascular disorders associated
with significant exudation and any condition that
damages and permits fluid to leak from the choroidal
circulation beneath the retina
●
Causes:
● Trauma, hypertension, tumors, autoimmune disease…
many causes
RETINAL DETACHMENT
●Non-rhegmatogenous retinal detachment, tractional
type = contractile membranes in and around the retina
pull the neurosensory retina away from the RPE
● Can be viewed as scar formation that separates the
retina from the pigment epithelium
● Second most common type after rhegmatogenous
● Causes: diabetes, retinal ischemia, eye trauma
Retinal Detachment
51
Retinal Detachment – Clinical
features
●Initial symptoms commonly include the sensation of a
flashing light (photopsia) related to retinal traction and
often accompanied by a shower of floaters and vision
loss
●Over time, the patient may report a shadow in the
peripheral visual field
● may spread to involve the entire visual field in a matter
of days
● described as cloudy, irregular, or curtainlike.
54
RETINAL VASCULAR DISEASE Diabetes Mellitus
●Review the effects of hyperglycemia on the lens and iris:
● Cataracts
● Neovascular membranes that can cause glaucoma
● The retinal vasculopathy of diabetes mellitus may be
classified into
● background (preproliferative) diabetic retinopathy
● proliferative diabetic retinopathy
●Prognosis & Epidemiology
● 65,000 per year contract proliferative DR in US
● 8000 people in the US become blind per year from DR;
leading cause of new cases of blindness
Background (preproliferative)
diabetic retinopathy
Pathology
●The basement membrane of retinal blood vessels
is thickened.
●Microaneurysms are an important manifestation of
diabetic microangiopathy
●Macular edema
●Hemorrhagic exudates
Diabetic retinopathy – clinical
features
●In the initial stages patients are generally asymptomatic; in
the more advanced stages of the disease, however,
patients may experience:
● floaters, blurred vision, distortion, and progressive visual
acuity loss
●Signs, from early to late, include microaneurysms (quite
early), hemorrhages (dot and flame), retinal edema, hard
exudates, cotton-wool spots, macular edema (common
cause of vision impairment)
●Proliferative is late – characterized by new vessels,
hemorrhages, fibrovascular membranes, retinal
detachment, and macular edema
58
59
Optic Neuritis – retrobulbar optic
neuropathy
●Inflammation of the optic nerve
●Etiologies
● Posterior uveitis
● Optic nerve vascular lesions
● Encephalomyelitis
● Tumor – optic nerve glioma, neurofibromatosis,
meningioma
● Fungal infections
● Medications
Optic Neuritis
● Usually presents in young individuals
● Symptoms
● Pain behind affected eye
● Impaired vision – one or both eyes
● Signs
● Abnormal pupil light reflex
● Extra ocular movements painful
● Pressure on globe pressure
A 55 year old woman presented with acute onset of redness in her left eye which she
noted upon awakening in the morning. She had no pain, ocular discharge photophobia,
blurry vision, or history of blunt trauma. On examination, she was normotensive. Her
pupils were equal and reactive and her corrected vision was 20/20
62
63
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