Ophthalmology

PANRE Review Brock Phillips, PA-C

I am not an ophthalmologist, optometrist or

certified eye guy of any sort - I am a

practicing UC/EM PA-C who frequently

evaluates eye/vision complaints, consults

Ophtho regularly and has taken an interest

in the topic. Eyes are fascinating!

Thanks to Joshua F. Smith, PA-C - who

originally created this lecture and

graciously allowed me to adapt it

Review A&P of the eye and topics covered

on PANRE Blueprint – buzzwords & key points

are noted in red

Score 100% on the ophthalmology questions!

Augment your clinical practice with a few

ophtho pearls, tips and tricks

Blepharitis

Blowout fracture

Cataract

Chalazion

Conjunctivitis

Corneal abrasion

Corneal ulcer

Dacryoadenitis

Ectropion

Entropion

Foreign body

Glaucoma

Hordeolum

Hyphema

Macular degeneration

Nystagmus

Optic neuritis

Orbital cellulitis

Papilledema

Pterygium

Retinal detachment

Retinal vascular occlusion

Retinopathy

Strabismus

Work from the outside inward…

Gross exam - photophobia, asymmetry,

doorknob DXs

Visual acuity

EOMs and visual fields

Periorbital eye, lids, lashes, glands & ducts

Conjunctiva, sclera & cornea

Iris & limbus

Pupillary size & response

Anterior chamber

Posterior chamber

Always check &

document visual

acuity! This is

considered to be

the “vital sign” of the

eye. You wouldn’t

skip a pulse ox on a

PNA pt, would you?!

Wall chart (20 ft.) vs.

handheld (14”)

Can’t see chart?

Counting fingers,

hand motion, light

Homonymous Hemianopsia

Heteronymous Hemianopsia (aka “Bitemporal")

Superior Quadrantanopsia

Monocular vision loss

http://openi.nlm.nih.gov/imgs/rescaled512/3223174_pone.0027095.g001.png

CN VI Palsy - limited lateral gaze

Inferior Rectus Entrapment –

limited downward gaze

When no light is present, both pupils are dilated

Presenting light in one eye will result in similar constriction in the opposite pupil

RAPD

(Relative Afferent Pupillary Defect)

Light in the affected eye causes paradoxical dilatation

Lids and

Conjunctiva Blepharitis

Ectropion/Entropion

Chalazion

Hordeolum

Dacryocystitis

Conjunctivitis

Pterygium

Chronic

inflammation of the

eye lids

Seborrhea

Bacterial infection

Red lids with scales

adhered to lashes

TX:

Baby shampoo lid

scrubbing

Topical ABX

Ectropion

Edges of the eyelid roll out due to:

Trauma

Advanced age

Facial palsy

Infection

Entropion

Eyelid edges are turned inward due to scarring or muscle spasm

TX: Surgery (blepharoplasty) if the above problems are symptomatic

Chalazion is a painless

cyst in the eyelid due

to blocked

meibomian gland

TX: warm compresses

or elective excision

Hordeolum (stye) is a

painful nodule or

pustule caused by

staph infection

TX: warm compresses

1st, topical ABX, I&D if

not better

Inflammation and/or infection of the lacrimal sac 2/2 obstruction of duct

Usually Staph aureus, Strep, Staph epidermidis or Candida

TX: ABX and warm compresses

Surgery if not better after conservative management (DCR)

Benign, slow

growing tissue of the

bulbar conjunctiva

Looks like a white

vascular triangle,

nasal side

Encroaches on the

cornea

Leave alone unless it

starts to impact

vision, then surgical

excision

Elevated yellow

mass on the

conjunctiva,

adjacent to the

cornea

Benign; caused by

sun exposure,

chronic trauma,

chronic dryness

Leave alone unless

bothersome, then

surgical excision

Conjunctivitis Allergic

Viral

Bacterial

HSV/Zoster

Inflammation of the conjunctiva due to environmental allergies

Nearly always bilateral

Itchy, red, irritated eyes with clear discharge/tearing

Cobblestoning of palpebral surfaces

Associated with other allergic symptoms Rhinorrhea

Congestion

Sneezing

TX: Topical antihistamine gtts

Oral antihistamines

Caused by adenovirus

Very contagious

Unilateral or bilateral

Often starts in one eye and transfers to the other

Conjunctival injection, clear to mucoid D/C, pre-auricular lymphadenopathy

TX:

Supportive including warm compresses and artificial tears, +/- ABX ointment

Hand/eye hygiene is important

Common pathogens include Staph. aureus

Strep. pneumoniae

Haemophilus sp.

Moraxella sp.

Also: Neisseria gonorrhoeae, Chlamydia trachomatis

Red eyes, matted & crusted lids/lashes, unilateral or bilateral copious purulent drainage

Gram stain may help diagnosis

Giemsa stain for chlamydia

TX: topical ABX ointment or gtts targeting organism, hygiene recs. IM/PO ABX for G/C conj.

Herpes Simplex or Varicella Zoster Virus

Most common cause of corneal blindness

Dendritic ulcers on cornea

observed on fluorescein staining

Zoster may manifest with lesions on tip of nose (”Hutchinson’s sign”)

TX: Topical or oral antivirals

AVOID topical steroids

Inflammation of iris, which is the

anterior portion of the uvea

Traumatic (delayed in onset)

vs. atraumatic(linked to

rheum/autoimmune/IBD)

S/SX of limbic flush, deeper

pain not alleviated by

tetracaine, consensual

photophobia, “cells and flare”

(WBCs in anterior chamber) on

slit lamp exam

TX’ed w/ steroid & dilating gtts

Commonly misdiagnosed as conjunctivitis! Don’t make this mistake!!!

Anterior

Chamber/Lens Corneal Abrasion

Corneal Ulcer

Cataract

Glaucoma

Hyphema

Abrasions only involve superficial epithelium Due to mechanical trauma

SX: pain, FB sensation, photophobia, tearing

Look on eye and under lid for residual foreign body - abrasion itself visible with fluorescein

Treatment ABX ointment/gtts (cover

pseudomonas in CTL wearers, organic/dirty material) and Tdap

Patching/bandage contact lens controversial

DO NOT give tetracaine/topical anesthetic for D/C

Ulcers involve the epithelium and stroma

Can be caused by: Trauma

Infection

Contact lenses

SX: Pain, photophobia,

tearing

Fluorescein staining shows epithelial defect with dense/hazy corneal infiltrate

TX: Refer to Ophtho

Avoid steroids (can lead to perforation)

Accumulation of protein within the lens causing opacity and decreased vision

Causes:

Aging, trauma, diabetes, systemic steroids

Signs: lens appears yellow and translucent, difficult to examine retina

SX:

Gradual vision loss, glare, double vision, spots

TX: extraction of lens with placement of intraocular lens

Increased intraocular

pressure (IOP ≥ 20) due

to inability of aqueous

humor to move through

trabecular network in

iris.

This pressure leads to

damage of the optic

nerve causing

“cupping” and

increased cup-to-disc

ratio.

OPEN CLOSED

Closed angle glaucoma is

an EMERGENCY

S/SX: painful red eye,

fixed/mid-dilated pupil,

vision loss, tearing, N/V

TX:

Emergent referral to Ophtho

IV acetazolamide, topical

beta blockers.

DO NOT DILATE EYES

Open angle glaucoma is chronic compared to

closed

SX: can cause gradual loss of vision progressing to

blindness. Usually asymptomatic at first. First SX is loss

of peripheral vision.

TX - topical drops including:

Prostaglandins (first line)

Beta blockers (timolol)

Alpha agonists (brimonidine)

Carbonic anhydrase inhibitors