Opthalmology

 

Eye anatomy & physiology

Opthalmic glossary

eyeglossary.net
from opthlalmology made ridiculously easy steven goldberg

amaurosis fugax transient loss of vision from retinal ischemia due to vasospasm or embolic obstruction of an arteriole

aphakia absence of lens.

asthenopia eyestrain (blurred vision, diplopia, headache) from excessive use of the eye.

blepharochalasis loose overhanging skin fold in upper lid.

Bruch’s membrane the membrane separating the pigment epithelium and choroid.

cataract lens opacity.

chalazion inflammation of a meibomian gland.

coloboma a developmental defect in the closure of the eye cup, leading to a gap in the inferior region of the retina and/or iris.

conjunctiva the thin transparent vascular membrane overlying the sclera and continuingon the under surface of the lids, in direct apposition to the tear film.

cycloplegia paralysis of accommodation.

dermatochalasis puffiness of skin in the upper lid with aging, commonly due to herniation of orbital fat.

diopter a unit referring to the converging (plus) or diverging (minus) ability of a lens.

diplopia double vision.

drusen small round yellow spots just outside the pigment epithelium, a benign degenerative condition. When in the optic nerve head, drusen appear as bumpy rapioca like excrescences, which should not be confused with papilledema.

dry eye syndrome irritation secondary to decreased tearing, as in Sjogrens syndrome may be treated with ocular lubricants like methylcellulose (Adsorbotear) and polyvinyl alcohol (Liquifilm tears).

episcleritis inflammation of the connective tissue lying between sclera and conjunctiva.

esotropia crossed eyes.

exotropia wall eyes

fornix the region where conjunctiva overlying the eye folds back to become the conjunctiva underlying the lid.

fundus the posterior area of the retina, particularly the area within view of the ophthalmoscope.

Goldmann perimeter a refined device for plotting visual field defects using lights of varying size and brightness.

hemianopia loss of vision in half of a visual field.

injection marked prominence of small vessels.

iridectomy surgical removal of iris tissue.

keratitis inflammation of the cornea.

limbus the junction zone between cornea and sclera.

lipaemia retinalis yellowcream coloring of retinal vessels due to markedly excessive lipids in the blood.

microphthalmia small eye.

myokymia twitching of eyelids, a benign transient condition possibly related to fatigue or tension; occurs unilaterally.

neovascularization formation of new blood vessels.

photophobia pain on exposure to bright light.

pinguecula a benign yellowish, soft, slightly elevated area found nasal or lateral to the cornea, typically nasal.

ptosis droopy lid.

quadrantopia loss of vision in one quandrant of a visual field.

slit lamp a specialized microscope for viewing the eye externally and internally; has attachments to alter the size, shape, brightness, and angulation of the light beam, and usually contains a tonometer for measuring intraocular pressure.

stye an inflamed pimple along the lid margin, representing an infection of a hair follicle or a small local gland.

superior colliculus the curved roof of the rostral midbrain, associated with various visual reflexes.

synechiae adhesions secondary to inflammation.

tangent screen a black screen designed to test for visual field defects by introducing test objects of various sizes in different positions of the visual field.

trachoma a viral disease of the eye in which follicles arise in the upper lid conjunctiva, followed by vascular invasion and scarring of the cornea, beginning at its 12 o’clock position.

trichiasis inward turning of eyelashes against the eye, often causing ocular irritation

visual field the extent of what the eye sees when looking forward.

Wilson’s disease a familial disorder of copper metabolism with cirrhosis of the livernand degeneration in the basal ganglia of the brain. Copper deposits in the lens (copper cataracts) and the peripheral cornea, as a greenishbrown ring (Kayser-Fleisher ring).

xerophthalmia drying and clouding of the cornea with vitamin A deficiency.

Eye examination

Acuity
Absolutely essential even if only a rough guide. Can the patient count fingers and perceive objects in all four quadrants of the visual field?
Ensure that the eyelids are sufficiently open during test.

Inspection
Examine ocular structure from anterior to posterior: lids, bony orbit, conjunctiva, cornea. anterior chamber, iris, etc.

Light
A strong beam is essential and is more effective if concentrated as by a good pencil torch and shone obliquely.

Magnification
A convenient type is a binocular loupe fixed to a headband which can fit over spectacles if necessary leaving the hands
free. A Xl0 hand loupe provides greater magnification but its use requires practice.

Opthalmoscopy
for examining the posterior segment of the eye
Its use is facilitated by dilation of the pupil (after the likelihood of glaucoma has been excluded).
When examining myopic eyes do so with the patient wearing his spectacles.

FLUORESCEIN
Shows up cerneal epithelial lesions stain green in blue light.

Other equipment which may be required are sterile disposable hypodermic needles, cotton wool buds, epilation (block ended) forceps, sterile saline with IV giving set. eye pads,1 inch strapping (micropore), wire lid speculae.

The following should always be available in single dose units:
LA Drops Benoxinate or Ophthaine
Analgesic Diclofenac
Mydriatic Dilating Drops Homatropine 2%
Miotic Constricting Drops Pilocarpine 4%
AB Ointment and/or Drops Chloramphenicol or Sulphacetamide

Unless 24 hour prescribing is readily available. there should also be a supply of:
Systemic Antibiotic: Ampicillin (Penbritin)
Local Steroid Drops: Betamethasone
Steroid/Antibiotic Ointment: Betamethasone and Neomycin
Idoxuridine Drops: (Kerecid)
Acetazolamide 250mg tablets.

When examining closely. sit or stand on the same side of the patient as the eye under scrutiny. When carrying out treatment
it is most convenient to do so sitting at the head of a couch or reclining chair. with the patient lying supine. fixing his gaze on an object above his head.

CHILDREN are sometimes surprisingly co-operative. and such measures as sedation and general anaesthesia must be judged according to the urgency of the situation. In an emergency, such as cement inside the lids. if necessary wrap the child up in a blanket to prevent struggling, the arms should be separate inside the layers of blanket and. with an assistant steadying the head ‘and body, lay the child supine on a couch or the floor.

It may be difficult to separate the eyelids. and Casualty Departments should have a pair of curved wire lid speculae for this purpose, as well as sterile saline for irrigation by means of an I.V. giving set. or an undine, after liberal instillation of local anaesthetic drops.
While the child is restrained there will be an opportunity to check the cornea for abrasions or foreign bodies; treatment for this may be given immediately. or if necessary deferred in favour of a general anaesthetic later.

Acuity near/far with and without glasses/pinhole
Colour Vision Ishihara Charts
RAPD

Specialist Eye Examination

 

Opthalmoscopy

Fundoscopy
DM/FT Disc Medial Fovea Temporal

 

Fundoscopy
Condition Features Changes
Papilloedema disc hyperaemia, obliteration of cup, congestion of veins, loss of pulsations haemorrages radiating from disc malignant hypertension
raised ICP
CRVO, CO2 retention
Papillitis similar to papilloedema retrobulbar neuritis
Optic atrophy pale disc, blurred edgepale disc sharp edge papilloedemaretrobulbar neuritis, optic nerve pressure, DM, RVO
Myelinated Nerve Fibres streaky irregular white patches adjacent to disc margin normal variant
Angioid Streaks streaks across retina resembling blood vesels Pagets
Pseudoxanthoma elasticum Hyperphosphataemia Acromegaly
DM Background Venous dilatation and tortosity
Microaneurysms
Blot Haemorrhages
Soft Exudaes
DM Proliferative New vessel formation
Vitreous haemorrhage
Retinal detatchment
retinitis proliferans
Hypertension Irregular arteriolar lumen with increased light reflexAV nipping Grade 1Grade 2
Hypertension (accelerated) Flame Haemorrhages + hard exudatesPapilloedema Grade 3Grade 4
Anaemia pallor, engorged vessels, flame haemorrhages wooly exudates any severe anaemia especially PA and leukaemia
Aids to clinical examination Hayes and MacWalter CL 1986

Soft (cotton wool) exudates = poorly demarcated superficial ischemic areas with necrosis of the retina or localised oedema in the nerve fibre layers – indicate onset of accelerated hypertension and are reversible with good control.  Hard exudates are small deep deposits of lipids with well defined borders. they persist much longer than soft exudates.

Causes of exudates

  • Hypertension
  • DM
  • SLE
  • Leukaemia
  • severe anaemia

Optic Nerve CN2

  • AFRO
  • Acuity
  • Fields
  • Reflexes (light/accomodation)
  • Optic Disc (papilla)
  • Disc CCCP colour contour cupping papilloedema

Optyse and WA panoptic opthalmoscope

WA Panoptic

Optyse

 

Slit lamp

Visual acuity

Visual acuity tedmontgomery.com

Snellen chart

Snellen chart mdsupport.org

Refractive disorders

Contact lenses

Contact lenses merckmanuals.com

Refractive surgery

Refractive surgery merckmanuals.com

Colour vision

Eye clinic tests and procedures

Eye exam mayoclinic.com

Orthoptist

Orthoptics Oxford Eye hospital

Eye surgery

Referral guidelines eye conditions

Oxford NHS referral guidelines

Eye triage

Emergency
Sudden loss of vision with history of trauma
Impaled or penetrating foreign object
Severe contusions with evidence of increased intraocular pressure
Hyphema
Iris tears

Urgent
Traumatic mydriasis (dilation of pupil) with blurred vision or diplopia
Severe lid lacerations
Disturbance in vision in patient with history of glaucoma
Actinic injuries

Nonurgent
Ptosis
Soft tissue edema, ecchymosis without vision change
Eye Trauma Hyphaema
Hyphemas usually are the result of blunt trauma to the eye which results in a tear in the iris vasculature or subconjunctival hemorrhage.

Signs and Symptoms
Blood in the anterior chamber More difficult to detect in brown eyes than in blue eyes.
Decreased vision and increased pain
Due to increased intraocular pressure and distension of intraocular structures.

Interventions
Sit the patient in an upright position to assist in detecting the pooled blood
Patch bilaterally Immobilizes eyes and provides for resolution in hyphemas of 50% or less.
Depending on the size of the hyphema, surgical intervention may be necessary.(4)
Monitor for rebleeding, especially in the first five days after the trauma

Eyelid bruising does not necessarily indicate damage to vital structures. but important points must be elucidated:
(a) CAN THE PATIENT SEE? If necessary. open swollen lids digitally.
(b) IS THE EYEBALL INTACT? Check the integrity of the cornea, depth of anterior chamber and whether or not it contains blood (hyphaema).
Compare the pupil to the opposite side; does it react? Is there a red reflex through the pupil?
(c) OCULAR POSITION AND MOVEMENT: protrusion may indicate a retrobulbar haemorrhage, or the eye may be sunk back in the socket-enophthalmos, suggesting a” blowout” fracture of the bony orbit. which may also cause restriction ofocular movement and diplopia due to impaction of extraocular muscles in the fracture.
(d) BONY MARGIN: Irregularity of the bony margin may be palpated.
Always X-RAY: If “blowout” is suspected ask for tomograms.
OTHER INJURIES may require more urgent treatment. in which case it may be expedient to call the ophthalmologist to a casualty or orthopaedic department. Fractures of the bony margin may require the opinion of a faciomaxillary surgeon.
Rx Refer to eye department if signs indicate.

All patients presenting with eye injuries should have Visual Acuity recorded at each visit.
Patients with painful eye conditions should be prescribed oral analgesics, not LA drops.
Where the eye may have suffered penetration by a FB X-Ray of the Orbits should be performed.

Retinal Detachment Medscape

Chemical Burns

Welders Flash injury

Opthalmic Red Flags
chlamydial conjunctivitis (erythromycin/tetracycline/ung + po),
hyphemas (? intraocular pressure?),
subtle retinal detachment
intraocular foreign bodies (e.g. hammering metal against metal),
iridocyclitis,
optic neuritis (multiple sclerosis?)
periorbital/orbital cellulitis,
blowout or depressed fractures ? subconjunctival hemorrhage with no lateral and/or medial white sclera?, check eye movements diplopia?; infraorbital hypothesia?, subcutaneous or orbital emphysema?, CT scan required?).

do not use topical ophthalmic steroids (always refer; topical steroids can result in corneal perforation)
do not give topical ophthalmic anaesthetics for home use (well, maybe a “few” drops to go, e.g. abrasion of cornea, welding flash burn/may prevent a premature return visit)

Avoid delicate corneal treatment unless the eye/hand is reasonably steady – G.A. if necessary.
Avoid mydriatics whenever glaucoma is suspected-the condition might be aggravated (check AC depth).
Avoid local STEROID ocular therapy unless specifically indicated: it exacerbates herpes simplex keratitis.
Avoid excessive use of local anaesthetic drops for painful corneal conditions: this may delay healing.
GIST

Sudden visual loss refer immediately
temporal arteritis consider prednisolone 80 mg stat
acute angle closure glaucoma consider pilocarpine 4% drops every 5 mins
migraine consider referral if atypical or unsure of diagnosis

Painful and red: often need referral: glaucoma, herpes simplex, foreign body, abrasion.
Painful not red: often seen in general practice: stress, refractive error, beware GCA, retrobulbar neuritis.
Red not painful: conjunctivitis, subconjunctival haemorrhage. Temporal artery + fever = giant cell arteritis
Cloudy cornea and pupil dilation = glaucoma.

Flashers and floaters

Black spots or shapes suddenly occurring, and remaining in the patient’s sight often cause worry and annoyance. most are of little significance.

Sudden loss of vision

Anterior Ischaemic Optic Neuropathy (Temporal Arteritis)

Elderly headache jaw claudication temporal tenderness polymyalgia
Disc swollen
Check ESR Treat urgent hight dose steroids

CRO

also seen in TA/GCA above plus AF, infective endocarditis hypertension and disseminated atherosclerosis.

Bright “cherry red” spot on fovea + swollen optic disc
Arteries are attenuated +/- straky haemorrhages arounf=d the vessels
Veins are narrow
Optic disc is pale and atrophied
No light perception. APD
Check for carotid bruits
Refer for urgent treatment to prevent optic nerve atrophy
Rx IV diamox (acetazolomide) occular massage AC paracentesis

CRVO
= CRV thrombosis?
Venous congestion and numderous haemhoerrages with retinal oedema and papilloedema ( true papilloedema usually bilateral and affects vision late, CRVO unilateral and vision is affected early) =/- microaneurysms and collateral vessesls
CF large optic disc stormy sunset with engorged veins
No definitive Rx Perpheral vision may improve in 6-12 m
Causes
Hypertension
DM
Hyperviscosity syndrome (myeloma, myeloproliferative disorders)

Iritis acute anterior uveitis

Uveitis/Iritis is an inflammation of the uveal tract, which contains the iris, cilary body, and choroid. Usually affects the anterior portion of the uveal tract and is categorized as iritis. It can be caused by inflammation, infection, or trauma. Symptoms include decreased vision, photophobia, pain with direct and consensual light reflex, red eye, and excessive tearing.

Inflammation of the iris which is occasionally associated with systemic disease such as spondylitis.
The most severe cases are usually recurrences.The eye becomes painful for no apparent reason over a day or two with photophobia and circumcorneal redness. often without visual disturbance (but it may be grossly reduced in severe cases).
Close inspection may reveal Keratic Precipitates. linear aggregations of inflammatory cells on the internal surface of the cornea.
There may be an hypopyon.
The pupil is usually normal or small, sometimes irregular.
The anterior chamber is of normal depth and contains inflammatory cells which are not normally visible.
R Dilate pupil with mydriatic drops. local steroid drops hourly. Always refer.

Acute glaucoma

http://hacking-medschool.com/acute-glaucoma

http://youtu.be/73D63azw0GU

Temporal arteritis (opthalmology)

Elderly patients with C.R.A. occlusion
History of headache, scalp tenderness and jaw claudication +/- PMR
ESR grossly elevated
Start high dosage steroids immediately to protect the OTHER eye from a similar catastrophe.

Central retinal artery occlusion CRAO

http://youtu.be/08wRyNCpTDU

sudden, unilateral, painless profound loss of vision,
commoner in arteriosclerotic patients
asent or reduced pupil reaction to direct light
Pale retina +/- red spot at the macula.
Refer stat – immediate treatment (within the hour) may re-establish circulation – needle decompression, ocular massage, IV heparin (5-10,000 units), tPA

Central retinal vein occlusion CRVO

monocular decrease in vision ? engorged veins and retinal hemorrhages ? refer immediately.

???A relatively small haemorrhagic disturbance in this area causes severe CENTRAL visual defects.
In YOUNG MYOPES this can occur spontaneously and be visible ophthalmoscopically.
In the ELDERLY haemorrhage and exudate may occur, and either may predominate in the appearance of this arteriopathic lesion. known as DISCIFORM DEGENERATION. Refer.

Gradual reduction of vision may be “Suddenly” discovered by the patient who closes the good eye for some reason.
Scattered flame shaped haemorrhages throughout the retina. and congested veins. One quadrant only may be affected.
Check BP. Refer. Secondary glaucoma is a late complication. and should be suspected in patients who have had a
CR. V. T. followed some WEEKS later by pain.

 

Retinal detachment

Flashers (flashing lights)
Floaters (looking through frogspawn)
Field Defect (half visual field like a curtain)
Lie patient flat (if cant see down below and sees flashing lights suggests upper detatchment)

@@@ Vitreous haemorrhage

http://youtu.be/rALSIg6Os8g

Diabetics with neovascularisation
Seen also in retinal detachment and bleeding disorders
Spontaneous absorption
Rx Photocoagulation of new vessels

Coles
Gradual Loss of Vision
Cerebral vascular accidents may involve the visual pathways.
The patient is usually arteriosclerotic.

Patients with sudden loss of one half of the visual field of EACH eye often report it as blindness “in one eye”. Testing by confrontation soon reveals the true defect which is caused by a lesion in the opposite cerebral hemisphere to the side of the field defect. This need not be accompanied by other neurological
signs but often is. Quadrantanopia may be found.

This rare occurrence is caused by vertebrobasilar artery insufficiency. There is no apparent ocular lesion but the patient cannot see. and usually no treatment is possible. Always refer to a neurologist.
Attacks of complete or partial painless loss of vision in one eye, which may sometimes be associated with transient neurological symptoms affecting the opposite side of the body. Due to carotid insufficiency.
Reduced carotid pulsation may be palpated. A bruit may be heard with a stethoscope.
Rx Refer, Carotid artery surgery may be possible. in order to prevent permanent damage.

This may occur when the balance of the extraocular muscles is upset, Palsies of the 3rd .4th and 6th cranial nerves can occur suddenly, with or without other neurological signs and symptoms. These defects may be transient. Always measure blood pressure and check urine for sugar.
If diplopia is intolerable cover one eye.

This may be present as pain in the ocular region or head. accompanied by double vision due to involvement of cranialnerves to extraocular muscles. Refer.

Partial or complete vitreous haemorrhage may occur from trauma and is diagnosed by a dull or absent red reflex throughthe pupil (it may accompany hyphaema). It usually clears. but further damage inside the eye may be revealed. Rest. Refer.
Eye Trauma Penetrating Injuries
Penetrating Trauma/Ruptured Globe
Penetrating trauma is usually observed in conjunction with impalement injuries from knives, pencils, knitting needles, or bullet wounds. A ruptured
globe is also seen, particularly in the elderly trauma victim, as a result of blunt trauma to a very thin region of the globe at the limbus or below the rectus.(1)
These penetrating injuries sever nerves and muscles of the eye with or without rupture of the globe itself. If the floor of the anterior cranial fossa is
penetrated, the frontal lobe of the brain is readily injured; meningitis, brain abscess, internal carotid artery tears, or hemorrhage can result. Retinal
detachment with painless “light flashes” and blurred vision often accompanies trauma (contusions) to the globe.

Signs and Symptoms
Loss of vision
Extreme pain and anxiety
Visible impaled or penetrating object, e.g. knife, knitting needle
Visible hemorrhage
Extrusion of vitreous or aqueous humor
Decrease in intraocular pressure

Interventions
Immobilize impaled or penetrating obje,s:ts immediately to prevent further damage to intraocular structures and surrounding tissue
Elevate head of bed to decrease intraocular pressure
Patch or bandage bilaterally
Instill NO medications if the trauma is perforating
Facilitate an ophthalmology consult
Prepare for admission to the hospital
Prepare for immediate surgical intervention
Eye Trauma Chemical Burns
Alkali ocular burns
? require prolonged irrigation prn (hours, days), for liquefaction necrosis. Wood ashes are alkaline, and can result in permanent ocular damage
? ocular alkali burns are also associated with automobile air-bag activation

Chemical burns of the eye occur primarily in industrial settings. Acid and alkali burns cause destruction of epithelial tissues and the conjunctiva with
subsequent scarring. Organic irritants such as pesticides and brake fluid usually cause edema of the cornea and conjunctiva but damage is usually
temporary. Proper identification of the chemical agent involved, its concentration, degree and duration of exposure and prehospital care administered
are critical,as well as whether the injured eye was irrigated at the time of injury with large amounts of water. Acid burns tend to penetrate tissue
slowly or superficially, but can result in vision loss if not adequately treated.
Alkaline substances are proteolytic and continue to burn, destroy, or lyse tissue resulting in ischemia and necrosis until they are removed.

ALKALI (lime) damage to the cornea is devastating. If any chemical enters an eye. irrigate PROFUSELY immediately, if necessary plunge head into a basin of water and force lids apart. Local anaesthetic drops facilitate irrigation which can be carried out most efficiently with saline from an IV giving set.
If delay in referral is unavoidable. instil mydriatic drops and , antibiotic ointment after thorough irrigation-analgesics may be necessary

Signs and Symptoms
Severe pain
Opaque cornea may be present
Interventions
As indicated in “Nursing .Care of Eye Trauma” plus:
Irrigate immediately with running water or normal saline. Be careful not to contaminate opposite eye, irrigate from inner to outer canthus for 30-60
minutes with lids open for acid burns and 60 minutes for alkali.
Assist with/remove any foreign objects
Check pH of eye surface periodically until the pH is 7.3-7.7 and again ten X minutes after irrigation is discontinued. Z
Instill prescribed topical anesthesia intermittently to diminish pain and increase ease of irrigation.
Instill prescribed antibiotic drops
Patch as indicated
Instill prescribed cycloplegic drops to relieve ciliary spasm and mydriatic agents to dilate pupils.
Facilitate ophthalmology consult, revaluate visual acuity and injury.

Vitreous opacities

http://youtu.be/4FJYeEGl98g

These vitreous opacilies are usually due to small haemorrhages. and may be seen through an ophthalmoscope. sometimes they may be found to be associated with flat retinal holes.
x Refer. This trealable condilion. if ignored. might later lead to the much more serious retmal detachment. Accompanying symptoms of flashes of light make the diagnosis more likely.
Spontaneous haemorrhage into the vitreous is a complication of diabetic retinopathy and some other condiltons (but thecommonest cause is trauma). It may cause loss of vision.There is a reduced or absent red reflex through the pupil. The patient should rest and be referred.

If gradually increasing think vitreos degeneration lens opacity or corneal scar

If sudden onset with flashing =/- decreased vision think vitreos detatchment, disc embolus, blocked blood vessel or retinal detachment

2 weeks post cataract surgery with CF may indicate infection vitreous detacment or haemorrhage or retinal detachment Check RAPD and dilate to examine retina

Orbital cellulitis

S.pyogenes, S.aureus
Ophthalmic emergency. Refer stat.

Orbital Cellulitis is an infection deep into the orbital septum and it can be life-threatening.
It is usually caused by S. pneumoniae, S. aureus, and Haemophilius influenzae, is usually associated with a sinus infection.
Patients typically present with pain, fever, and impaired EOM.
Impairment of EOM is a very important sign in differentiating between Periorbital cellulitis and orbital cellulitis.
Decreased visual acuity is a late finding. If this is not treated it can progress into cavernous sinus thrombosis, which is a life-threatening infection that spreads from the infected sinus to the orbital area.

http://www.youtube.com/watch?v=6YT6GAbkGKY

Cautionary Tale

Hypopion

Hypopion = pus in the anterior chamber
Hyphaema = blood in the anterior chamber

May result from infection at the site of a foreign body or an ulcer due to corneal exposure. Requiries immediate treatment to prevent intraocular extension.

There may be a circumscribed yellowish white patch in the cornea plus pus in the anterior chamber with a fluid level
Eye is very red especially close to the cornea.

CULTURE if possible before starting treatment
Antibiotic therapy. half hourly drops topically and systemically in maximum dosage.
Dilate the pupil with as many instillations of mydriatic drops as are necessary i.e. every quarter of an hour until pupil is dilated – it may be stuck down to the lens (posterior synechiae).

http://youtu.be/Yjdi6gXUlq8

Eye trauma

Blunt trauma
Deceleration Injuries – RTAs, sports injuries – can cause substantial damage as the vessels and nerves are torn from delicate eye structures.
Penetrating injuries – missiles, bullets, knives, explosion debris, broken glasses, hard contact lenses, letter bombs, fireworks, exploding car batteries and soft drink bottles, and aggressive recreational sports activities. Penetrating injuries are also more frequently seen in the elderly person who has been subjected to severe blunt trauma.
Chemical burns another type of penetrating injury, may damage the eyes, lids, and surrounding structures.

Concurrent Injuries
Due to the location of the eyes, eye trauma is frequently seen concurrently with head and facial trauma. It is critical to recall that actual life-threatening injuries MUST be treated before turning attention to the care of a painful, traumatized eye.
Severe, penetrating trauma to or near the eye can easily penetrate the fragile facial/sinus bones and cause direct injury to the brain, sever the optic nerve or extraocular muscles (without obvious external trauma to the visible sclera or anterior chamber), damage the lower lid, and/or disrupt the lacrimal apparatus. If the supportive tarsal plate is traumatized, the shape of the upper lid is altered significantly. Even when the lid is not completely penetrated, assessment of damage to underlying structures especially the cornea is necessary. Also lateral zygomatic or medial ethmoid orbital fracture can result in ligament avulsion.

Other Significant Facts
The assessment of eye injuries should NOT be forced in the field. The lids should NOT be forced open without the judicious and appropriate use of prescribed topical anaesthetic agents to facilitate opening of the lids and examining the eye without further injury. Additionally, the patient with eye injuries should not leave the emergency care setting without a complete exam of eye injuries.
Because eye injuries can quickly and easily result in diminished or lost vision and the inability to function in one’s occupational field, these injuries are a high priority for intervention. The examination of a swollen eye, deferred for several days, may contribute to serious injury or vision loss in both eyes.

PATHOPHYSIOLOGY AS A BASIS FOR SIGNS AND SYMPTOMS
Contusion of the soft tissue of the orbit with edema, bleeding, and discoloration of the lids results in one of the most frequently and readily encountered signs of eye trauma, the contused or “black” eye.
Soft tissue lacerations,especially of the lids, result from either blunt trauma to the thin skin of the lids as they decelerate on the underlying bone or from penetrating trauma. Ptosis seen in eye trauma frequently results from an upper lid injury, laceration of the levator palpebral superioris tendon, or accompanying gross oedema.

diplopia can occur from dislocated lens, optic nerve lesions, or retinal hemorrhage diplopia/double vision can be bilateral or unilateral.
Bilateral diplopia can result from contusion, tears, or trapping of the extraocular muscles (damaged cranial nerves III, IV, or VI) or limited globe movement associated with fractures, hematomas, or foreign bodies.
Unilateral diplopia results from a subluxed lens, oedema, haematoma in the orbit, macular oedema, or superior oblique or rectus muscle damage.

Blindness can occur in anterior or posterior chamber bleeds from trauma from optic nerve injuries, or globe destruction.

Sudden or immediate blindness can result from a hyphaema which fills the anterior chamber with blood, vitreous hemorrhage, severed optic nerve with or without basilar skull fracture, .globe disruption with extruded contents, occipital injury, or intracerebral hemorrhage

Blindness with an onset within hours of the trauma is associated with corneal ulceration, central retinal artery occluion from dressings or patches that are too tight, and retinal detachmeot. Blindness with a late onset is usually caused by retinal detachment, ocular infection, or traumatic cataracts

If on gentle palpation the globe feels soft the eye may be extruding through a lacerated conjunctiva. Vitreous or aqueous humor may be visible on or extruding from lacerations of the globe itself.

Blood levels seen inside the cornea result from anterior chamber bleeds. With the effect of gravity, the blood settles or “levels” when the patient sits upright.

A grossly pink or red eye is seen in subconjunctival hemorrhage as blood collects between the conjunctiva and sclera. While the condition may be frightening to the patient, the injury is generally not vision-threatening.

Pain is associated with most eye trauma. It results from irritation to the lid or globe by minute or large foreign objects, from extensive edema. or from underlying fractures.

NURSING CARE OF EYE TRAUMA
History
What was the mechanism of injury?
How the injury occurred identifies the risk of other concurrent injuries
Was the patient wearing eye protection such as goggles?
Protective eyewear serve as a barrier to protect and to slow the velocity of potentially penetrating foreign objects,
Was a foreign object involved? Is it still in the eye?
Was the foreign object metal, wood, or glass?
Metal objects are of particular concern as rust rings can form in the cornea from iron fragments. The iron rust ring formation may further impede vision as well as cause corneal deterioration if not removed.
Was the patient’s vision normal prior to this injury, and how is the vision now? Is it present, blurred, or double? Was onset gradual or acute?
Is there pain with bright light?(photophobia)

Does the patient usually wear corrective lenses, glasses, or soft/hard contact lenses?
Were they on or in at the time of the injury and are they on or in now?
Shattered spectacles may become foreign objects to penetrate the eye. Contact lenses should be removed as soon as possible.
Does the patient use eye medications, have a history of eye problems, hypertension, diabetes, or glaucoma?

Physical Assessment
INSPECTION
Note lid edema and ecchymosis
Observe ptosis
Assess lacerations
Identify gross trauma to the sclera, iris, and cornea
Identify gross/visible foreign objects
Note scleral and conjunctival redness, lacerations, tearing, and proptosis/enophthalmus or esotropia/exotropia
Note blepharospasm or blinking
Assess extraocular movements (EOMs), all six directions bilaterally
Assess pupil size, equality, shape, and direct and consensual response to light
PALPATION
Gently palpate eye and surrounding area for pain or tenderness
Obviously traumatized globe or eye with a penetrating or foreign object should NEVER be palpated as this increases the danger of penetration and/or increased intraocular .pressure.
Assess for anesthesia, caused by damage to the supraorbital nerve
Palpate for tenderness, crepitus, depression of frontal bone structures, and notching of the supraorbital ridge which indicate an increased risk of eye trauma

Diagnostic Procedures
XRAY often necessary to identify the presence of or extent of penetration by a foreign body.
OTHER
It is often necessary to obtain an order for topical anesthesia to enable the patient to cooperate with diagnostic exams.
Visual acuity with and without corrective lenses for each eye
This can be done by testing if and how clearly the patient can:
1) visualize bright light and finger motion or a moving object, 2) count the number of fingers held up by the examiner, and 3) read a wall mounted Snellen chart
or hand held Snellen card.
Visual fields from all directions with and without corrective lenses
These findings assist in documenting the presence of weak, torn, or paralyzed muscles.
Fluorescein stain identifies de-epithelialized areas made visible under cobalt bluelight. Abraded or lacerated areas show up as a green.

Slit lamp exam
This exam identifies hyphemas and foreign bodies in the anterior chamber.

Nursing Diagnoses
Actual
Pain, acute, related to tissue injury
Self-care deficit related to impaired response to visual stimuli
Self-concept, disturbance in: role performance, related to possibility of permanent damage to vision
Potential
Anxiety, related to diminished or lost vision
Expected Outcomes
Pain will be controlled as evidenced by:
Patient will rate pain on a 1-10 scale as decreased or absent
Absence of autonomic response to pain
Patient will perform activities of daily living at highest level possible.
Patient will verbalize understanding of alterations in role performance
necessary 10 function a1 desired level.
Patient will report decreased anxiety and/or demonstrate decreased restlessness.

Interventions
Apply prescribed topical anesthesia (tetracaine, proparacaine, butacaine, ophthetic) to prevent blepharospasm, to facilitate adequate assessment, and to diminish discomfort for traumatic injuries.
Immobilize visible pen·~trating objects to prevent further damage
Cover/patch BOTH eyes with a light dress~g to prevent eye motion and further pain and injury
NO pressure should be placed on the globe dUring this procedure since pressure can induce further damage or bleeding. The patch should be
taped from the medial forehead to lateral cheek area and secured tightly enough to prevent blinking.
Elevate head of bed. Instruct patient not to bend forward as this can increase intra=ocular pressure and thus cause pain and additional damage
to the eye.
Additional Interventions
Reassure and continue to orient patient to surroundings to decrease
anxiety and increase cooperation with treatment
Ensure one staff person or significant other remains with patient.
Facilitate referral to ophthamologist if there is blurred vision.
corneal clouding, hyphaema, or changes in extraocular muscle function, penetration
Patch eye if topical anesthetic has been instilled for protection of the eye until anesthesia wears off
Apply cool packs after assessment and initial interventions to decrease soft tissue edema and associated discomfort
Instruct about prevention of future injuries

Interventions to Prevent Complications
Place NO ocular steroids on eye tray to prevent misuse. These should be used only by an ophthalmologist as they may induce infections and glaucoma.
Use new tube/bottle of medication with each patient to prevent cross contamination
Fluorescein strips rather than drops are preferred for the same reason.
Do-not send topical anesthesia home with patient Continued use can promote breakdown of the corneal epithelium.
Instruct the patient to wear sunglasses to decrease photophobia and associated discomfort and excess tearing
Instruct patient not to squeeze eyelids as this increases discomfort and potential for injury
Keep eyes moist to prevent drying and exposure keratitis
Lubricating ointments should be placed within the lower lid margins priorto patching.

Tetanus immunization as indicated
Administer prescribed antibiotics to prevent infection in penetrating injuries
Administer prescribed antibiotics and steroids to prevent sympathetic opthalmia which can develop in the uninjured eye after unilateral penetrating eye trauma If not treated immediately, this can cause bilateral panuveitis, possibly an autoimmune response, which is a vision-threatening complication.

Ongoing Assessment
Monitor primary survey for life-threatening crises
Monitor pain for changes in characteristics, intensity, or location
Monitor vision for decrease or sudden’ loss
Assess globe for extrusion of contents especially after change in body position

Blunt Trauma

Periorbital contusion or  “black eye” is usually a benign injury.  Symptoms include ecchymosis of the lids, usually healing in 2-3 weeks.

Orbital fractures involve the orbital floor or the orbital rim.  A fracture of the orbital rim is called a “blowout fracture”.  It is a serious injury and is usually caused by direct blunt trauma to the eye causing an increase in the intraocular pressure to the point where the orbital floor fractures.    It is diagnosed by history and observations of periorbital ecchymosis, subconjunctival hemorrhage, periorbital edema, a sunken eye, an upward gaze, and complaints of diplopia.  These are usually non emergent unless there is visual impairment or associated globe injury.

Hyphema is when bleeding occurs into the anterior chamber.  Blood vessels of the iris rupture and leak into the clear aqueous fluid of the anterior chamber. A large clot can obstruct aqueous outflow and lead to secondary glaucoma.  Symptoms are pain, photophobia, and blurred vision.  A hyphema can be hard to see in dark colored eyes.

Subconjunctival hemorrhage is a harmless ocular condition usually caused by coughing, sneezing, or valsalva maneuvers.  A small blood vessel underneath the conjunctiva ruptures and bleeds. It is painless and a bright red patch can be seen on the sclera.

Penetrating Trauma

Periorbital wounds are injuries to the eyelids and surrounding periorbital tissue.  Check for globe injury and foreign bodies. Treat with routine wound care and suturing.

A ruptured globe is a major ocular emergency.  It presents as an unusually deep or shallow anterior chamber, altered light perception, hyphema, and sometimes vitreous hemorrhage, the pupil takes a teardrop shape with the tip pointing to the perforation.  Eye pain, and nausea are reported.

Impaled objects must be stabilized immediately which can be done with an eye shield. The other eye is patched to decrease eye movement. General anesthesia or aggressive pain management must be done.  Administer antiemetics to prevent retching.

Superficial Trauma

Corneal abrasions occur when a foreign body scratches, abrades, or denudes the epithelium.  Tearing, eyelid spasms, pain, foreign body sensation, and photophobia can occur.

Conjunctival/cornea foreign bodies are mostly caused by a dust particle.  Symptoms include photophobia, excessive tearing, and pain.  The goal is to remove the foreign body.

Intraocular foreign bodies are small and easily overlooked.  They are commonly caused by small fragments of metal or other small projectile.  Discomfort, decreased visual acuity, or a cat eye shaped pupil can occur.

Occular burns are an immediate threat to vision and can be broken down into three categories:

Chemical burns are the most urgent ocular emergency.
Acidic burns can cause immediate damage to the cornea by denaturing the tissues.  The cornea appears white and opaque.  No further damage is done once the initial contact is over because the acid is neutralized on contact.
Alkalali burns cause the cornea to opacify but continue to penetrate and damage the eye until removed.  Copious irrigation is required until pH is 7.5-8.

Thermal burns affect the eyelids but not usually the globe due to the reflex of the lid to close. These burns are treated like other burns.

Radiation burns are caused by ultraviolet or infrared light.  Ultraviolet radiation is absorbed by the cornea and produces keratitis and conjunctivitis.  Pain, tearing, photophobia, and foreign body sensation usually occur 8-12 hours after exposure.

Hyphaema

Hyphaema Medscape

http://youtu.be/28yfqXA2dcs

Haemorrhage in the anterior chamber after trauma.
Blood is usually absorbed within a few days without treatment.
However, patients are admitted to hospital for rest and observation because of the possibility of a secondary haemorrhage and glaucoma, which can occur within several days of the original injury.

Iris / lens damage

IRIS DAMAGE
Sphincter rupture with a distorted or dilated pupil or
iridodialysis

Lens Dislocation
http://youtu.be/rSTkziZ6YhA

No treatment: refer cataract which may develop later

http://youtu.be/UFJjqV73fpY

commotio retinae
Penetrating injuries involving the lens cause cataract.

Corneal/subtarsal FB

Easily missed/overlooked diagnosis.
Suspect from history; a piece of grit entered the eye and is not seen on ordinary inspection. Very irritable eye.
The patient is asked to open eyes and look downwards. Evert the eyelid by grasping the lashes and pulling them down. round and up while depressing the upper margin of the tarsal plate with a matchstick or glass rod.
The F.B, is seen on the conjunctiva and can be wiped off with a finger tip or cleanswab.
Corneal staining may reveal multiple scratches or large ulcer.

Often extremely painful. History usually relevant. metal grinding. etc.
F. B. visible on anterior surface of cornea.
x Instil local anaesthelic drops 2 or 3 limes. Steady eyelids of supine patient wilth one hand. and insist on his fixing gaze on adefinile object above. Remove F.B. with sterile hypodermic needle.

Special Note
If a rust deposit remains. or the F.B. is deeply embedded. do NOT scratch much: leave it and refer to an eye department:it is often easier to remove rust after 1 or 2 days. Very deep metallic F. B.s may require removal by magnet.
After Treatment
If the F.B. was only lightly embedded. it may not be necessary to pad the eye and bring the patient back; insert antibiotic ointment.
If the eye is sore. instil mydriatic drops.
If the F.B. left a large crater it will heal faster if the eye is padded for a day or two. and the patient should be seen again to make sure that healing is progressing. especially if the central part of the cornea is involved.

EYE pads
Some consideration should always be given to the problem of padding an eye: it is only advised when there is a painful defect
in the corneal epithelium which heals more quickly under a closed lid. and is more comfortable. Eye pads may cause greatINCONVENIENCE (drivers) and unless correctly applied may actually make conditions worse. quite apart from being useless. It may be more expedient to leave an eye unpadded and tell
the patient to go home and that the eye will heal quicker if kept shut.
Antibiotic ointment is always inserted after F.B. removal. If an eye pad is advised. then it is placed over tulle gras on the closed lids. and held on by a diagonal piece of strapping (micropore or Sellotape). A crepe bandage is then applied, just firm enough to prevent the patient from opening this eye
Padding is carried out daily until the corneal epithelial defectis nearly healed. If the eye remains irmable. continue mydriatic drops as well. Antibiotic ointment should be used twice daily for a further few days.

Corneal abrasion

Painful condition may be caused by trauma from such injuries as overlong contact lens wear. manipulation, or by a finger nail or twig poked into the eye. There is profuse lacrimation and it is often necessary to instil local anaesthetic drops in order to examine the eye. Fluorescein may be helpful in determining its extent.
R Treatment is the same as that described after removal of corneal foreign body: if the defect is slight. no pad. antibiotic ointment only. If the eye is very Sore, instil mydriatic drops, antibiotic ointment and pad. Large abrasions usually take less than 48 hours to heal if properly padded. Analgesics may be necessary.

This is a recurring corneal epithelial defect, usually in an area of cornea damaged previously, which may wake the patient atnight, presumably dUe to a reduced tear secretion causing a weak patch of epithelium to be shed, Treat as for any corneal abrasion.
STFB
Presence usually suspected from history; a piece of grit entered the eye and is not seen on ordinary inspection. Very irritable eye.
The patient is asked to open eyes and look downwards. Evert the eyelid by grasping the lashes and pulling them down. round and up while depressing the upper margin of the tarsal plate with a matchstick or glass rod. The F.B, is seen on the conjunctiva and can be wiped off with a finger tip or cIeanswab.
Insert antibiotic ointment.

CORNEAL ABRASION
Often extremely painful. History usually relevant. metal grinding. etc.
F. B. visible on anterior surface of cornea.
x Instil local anaesthelic drops 2 or 3 limes. Steady eyelids of supine patient wilth one hand. and insist on his fixing gaze on adefinile object above. Remove F.B. with slerile hypodermic needle.

Special Note
If a rust deposit remains. or the F.B. is deeply embedded. do NOT scratch much: leave it and refer to an eye department:it is often easier to remove rust after 1 or 2 days. Very deep metallic F. B.s may require removal by magnet.
After Treatment
If the F.B. was only lightly embedded. it may not be necessary to pad the eye and bring the patient back; insert antibiotic ointment.
If the eye is sore. instil mydriatic drops.
If the F.B. left a large crater it will heal faster if the eye is padded for a day or two. and the patient should be seen again to make sure that healing is progressing. especially if the central part of the cornea is involved.

EYE pads
Some consideration should always be given to the problem of padding an eye: it is only advised when there is a painful defect
in the corneal epithelium which heals more quickly under a closed lid. and is more comfortable. Eye pads may cause greatINCONVENIENCE (drivers) and unless correctly applied may actually make conditions worse. quite apart from being useless. It may be more expedient to leave an eye unpadded and tell
the patient to go home and that the eye will heal quicker if kept shut.
Antibiotic ointment is always inserted after F.B. removal. If an eye pad is advised. then it is placed over tulle gras on the closed lids. and held on by a diagonal piece of strapping (micropore or Sellotape). A crepe bandage is then applied, just firm enough to prevent the patient from opening this eye
Padding is carried out daily until the corneal epithelial defectis nearly healed. If the eye remains irmable. continue mydriatic drops as well. Antibiotic ointment should be used twice daily for a further few days.

This painful condition may be caused by trauma from such injuries as overlong contact lens wear. manipulation, or by a finger nail or twig poked into the eye. There is profuse lacrimation and it is often necessary to instil local anaesthetic drops in order to examine the eye. Fluorescein may be helpful in determining its extent.
R Treatment is the same as that described after removal of corneal foreign body: if the defect is slight. no pad. antibiotic ointment only. If the eye is very Sore, instil mydriatic drops, antibiotic ointment and pad. Large abrasions usually take less than 48 hours to heal if properly padded. Analgesics may be necessary.

This is a recurring corneal epithelial defect, usually in an area of cornea damaged previously, which may wake the patient atnight, presumably dUe to a reduced tear secretion causing a weak patch of epithelium to be shed, Treat as for any corneal abrasion.

Intraocular foreign body

IOFB @ EyeWiki.com

Always suspect this potentially blinding condition when there is a suggestive HISTORY such as injury while using a hammerand chisel-even when the eye looks relatively normal. The entry wound may be surprisingly difficult to see.
The F.B. may be visible anywhere in the eye, but it may be obscured by cataract formation in a damaged lens.
ALWAYS X-RAY TO EXCLUDE IOFB even if only a remote possibility. The chances of blindness and losing the eye increase rapidly while the F.B, remains. Usually they are metallic, often ferrous or steel allowing removal with the aid of a magnet.
Corneal Ulcer
Corneal ulcers
? herpes zoster?, herpes simplex?
L herplex gtts prn, refer.

Welding flash / arc eye

Superficial Keratitis caused by UV light
Welders, “Sun lamp” users and Corneal Laser Surgery patients.
Pain, watering and photophobia after an initial delay of a few hours.
Fluorescein reveals pitted corneal surface.
Rx Local anaesthetic drops +/- topical diclofenac +/- mydriatic drops if the condition is severe.
Give frequent antibiotic ointment and send patient home to bed. to keep eyes shut.
Usually heals within 12 hours.

Chemical burns to eye

should be treated by copious irrigation of the conjunctival sac until the pH becomes and remains neutral. Particulate debris (eg cement dust) should be removed. Alkaline burns can be particularily troublesome as they tend to be deeper and more extensive than others.

Commotio retinae and retinal haemorrhages

Retinal bruising/haemorrhage as a result of blunt or contra-coup injury.
May be seen as whitish areas of oedema (commotio) and haemorrhages which may be bright red droplet shaped preretinal or more usually, intraretinal streaks or petechiae.
Particularly serious if the MACULA is involved: damage here may result in permanent visual impairment.
Great care is taken to exclude holes in the retina or a dialysis which can lead to detachment. Patients in whose eyes this type of damage is suspected should be rested kept quiet and be referred soon.

Eyelid problems

Eyelid Disorders: Diagnosis and Management AAFP 1998

Blepharitis

Often chronic, may be acute. Lid margins crusted and sore.
Rx Local antibiotic ointment. Combined steroid and antibiotic ointment may be more effective.

Allergic inflammation is usually iatrogenic (local atropine and antibiotics are the commonest causes).
The skin is red, itchy and eczematous with exaggerated wrinkles.
Rx Stop treatment. Local steroid ointment to skin. If severe. systemic antihistamine.
Inform patient of details and record prominently in notes.

Stye and chalazion

Chalalazion

Round hard, discreet lump, usually within the tarsal plate. Granuloma of lipid-secreting meibomian gland There may be associated inflammation.
Incision and curettage may be necessary, and this should be carried out when inflammation has cleared by previous treatment with local antibiotic ointment and systemic antibiotic if severe.
Recurrent chalazia may occur in association with blepharitis and acnerosacea.

Stye
A stye is an infection of a lash follicle and may be easily confused with an infected chalazion. It can be treated with hot compresses and topical antibiotic ointment.
A pointing” boil” on lid margin. Hot bathing, local antibiotic ointment. If necessary give systemic antibiotic. If recurrent check urine for glycosuria.

Entropion ectropion

Entropion
http://youtu.be/y5qMqhHOtNQ
This is a frequent cause of inflamed eyes in elderly persons, The margin of the affected lower lid is rolled inwards, with thelashes abraiding the cornea, which may stain with fluorescein. A vicious circle is set up, spasm of the lids and corneal irritation consequent one upon the other.
Rx Strap lid with 1 inch strapping applied first to the lid. just below the lashes, drawn downwards. the other end pressedfirmly onto the malar skin. This usually curtails the condition. Insert antibiotic ointment and refer. Corrective surgery is usually necessary.

Ectropion
http://youtu.be/rFvrae-nNFk
The lid margin is turned outwards. often with a sagging lower lid, with unsightly exposed conjunctiva. Watering occurs because tears cannot drain through the everted punctum, The eyelid skin may become macerated and secondarily infected.
Rx Antibiotic ointment. Surgery is usually necessary.

Trichiasis
Ingrowing eyelashes are a common cause of corneal irritation and if the condition is chronic, as in post-trachomatous scarring, then corneal ulceration and visual impairment can occur.
Epilation may be sufficient, but, if the condition is recurrent then electrolysis of the offending lashes should be arranged. Other treatment may include surgery to correct the position of the lid margin.

http://youtu.be/R8Dtu_FGlq8

Syringoma

see also milia and xanthelesma

BCC eyelid/orbit

BCC eyecancer.com

BCC medscape

Dry eyes

Tear film

Epiphora

Causes
Overproduction of tears, eg due to corneal irritation from an ectropion (out-turning of the eyelid) or entropion (in-turning of the eyelid).
These conditions usually need surgical correction, but topical lubricants can provide temporary reilief.
Patients with entropion, whose in-turning eyelashes are causing abrasion of the cornea, may be helped by taping the eyelid into mild ectropion.
Ectropions and entropions usually affect the lower eyelids.
Overproduction of tears for another reason, eg hayfever, blepharitis, corneal foreign body.

Impaired drainage from a partially blocked nasolacrimal duct.
Approximately 20% of neonates have imperforate or stenosed ducts and produce ocular discharge which simply consists of mucus and is not infected. Parents should be reassured that most children are better by the time they reach the age of 1 year. They should be advised to massage their baby’s lacrimal sac four times a day. Topical antibiotics are only indicated if there is evidence of infective conjunctivitis.

The nasolacrimal duct can also become stenosed with age (age-related lacrimal drainage obstruction). These patients may have intermittent swelling
of their lacrimal sacs (lacrimal sac mucocoele) and are more likely to develop dacryocystitis.
Surgery is possible for patients with troublesome symptoms.

Nasolacrimal duct obstruction

http://youtu.be/oYxOBv6zj_A

Dacrocystitis

Periorbital Infections @ Medscape

Inflammation of the lacrimal sac with obstruction. Usually there is a history of watering eye. This painful condition occurs more commonly in babies and old people. There may be a sticky discharge on the lids and a tense fluctuant swelling at the side of the bridge of the nose. Gentle digital pressure may express pus through the lacrimal puncta.
Systemic antibiotic. Incision and drainage may be necessary if the inflammation is pointing, but if possible this is AVOIDED in favour of elective DCR operation later (Dacryocystorhinostomy, creation of a new drainage route through to the nose).

Dacroadenitis lacrimal sac infection

The patient will present with inflammation medially, over the lacrimal sac. There may be a previous history of excess watering of the affected eye, due to a partially blocked nasolacrimal duct. Systemic and topical antibiotics are necessary and the patient will need to be referred if their symptoms do not settle quickly because there is a danger that a lacrimal sac abscess may form.

Bacterial conjunctivitis

Conjunctivitis is an inflammation of the mucous membrane lining the inner surface of the eye or conjunctiva. This is typically caused by allergies, irritants, bacteria, or viral infection.
Diffuse redness of the conjunctiva with discharge, little pain,no disturbance of vision.
Culture in babies, and in any case if severe.

Usually bacterial. but occasionally viral and if so may be highly contagious, Warn patient to be scrupulous about handwashing and the use of face toweIs at home (or school).
Rx Antibiotic drops and ointment. Use drops half hourly if severe

Sufferers should be prescribed topical antibiotics if the infection is severe (usually chloramphenicol) and be advised to clean their eyelids and eyes with cooled boiled water twice a day. The bottle containing the topical antibiotics should not touch the eye when it is being applied. Artificial tears can help to soothe the eye.
Without treatment, symptoms may be marked for about a week, then resolve over the course of 2-3 weeks. Conjunctivitis is highly contagious and patients should not share towels, facecloths or pillowcases and should wash their hands every time they touch their eyes.

Allergy to topical antibiotics can develop: this usually presents with itching and eyelid oedema and is the most common cause for apparent ‘nonresolution’.
The patient often shows an initial improvement when the antibiotic is first prescribed, before deteriorating again. Symptoms commonly resolve within 24 hours of stopping treatment.

Conjunctivitis occurring in contact lens wearers can be potentially sight-threatening.
Patients with mild infection with no visual loss are usually treated in primary care, but need to be followed up carefully and referred if it does not improve within a few days. The patient should not use lenses for at least 1 week after the infection has fully resolved and will need a fresh pair when they do resume wear.
Contact lens wearers (particularly those who don’t clean their lenses often enough) may develop a protozoal infection called Acanthamoeba keratitis. This usually presents with ocular pain or ‘aching’. Swabs are negative and symptoms are more pronounced than signs. Such patients should be referred

Beware Iritis and uveitis (more painful with visual disturbance), acute glaucoma, foreign bodies or burns
Visual loss, or disturbance including visual haloes (glaucoma)
Severe pain (iritis uveitis)
Photophobia (ditto)
Gonococcal conjunctivitis (profuse purulent discharge) or chalmydial conjunctivitis in young adults and neonates REFER all conjunctivitis occurring within 3 weeks of birth.

Do not prescribe (or advise) chloramphenicol if pregnant breastfeeding or with FH, if immunosuppressed or with personal or FH of blood dyscrasias..

Detailed examination including Acuity and inspection under the eyelid and  after staining
Prompt irrigation prior ro transit for chemical splashes and burns
Consider alternative diagnoses eg FB  especially with unilateral conjunctivitis

Bacterial conjunctivitis
Acute bacterial conjunctivitis is  (pinkeye )and is very common occurring  at any age but most commonly in children due to their poor hand washing or hygiene habits.  Staphylococcus aureus is the most common microorganism – Others include Streptococcus pneumonia and Haemonphilus influenza (more often in children).  Careful hand washing and using disposable towels helps prevent the spread of the eye infection.

Viral conjunctivitis
Many different viruses such as adenovirus 3,7, and 8, herpes simplex virus type 1 and, chickenpox and measles can cause viral conjunctivitis.  The patient may present with excessive tearing, photophobia or complaints of the sensation of a foreign body in the eye.  Adenovirus conjunctivitis can be contracted in a contaminated swimming pool or as with other forms of conjunctivitis through direct contact.

Allergic conjunctivitis
Allergic conjunctivitis is caused by allergens, such as pollen, grass, smoke, animal dander, ocular solution, contact lenses, makeup, or air pollutants.  It can be mild or severe sometimes causing significant swelling.  The classic sign of allergic conjunctivitis is itching and papillae which look like cobblestone bumps located in the conjunctiva of the upper eyelid which result from swollen lymph tissue in the conjunctiva membrane.  The patient may also complain of burning, redness, and tearing.  Artificial tears may assist in washing allergen from the eyes medications may also be prescribed.

Chlamydia conjunctivitis
Adult inclusion conjunctivitis is caused by the oculogenital type of Chlamydia.  This is a relatively benign type of conjunctivitis and is typically successfully treated with topical treatment; however the patient is at greater risk of developing more Chlamydia infections as well as other sexually transmitted diseases.  These patients should be evaluated further and placed on systemic antibiotics.

At birth newborns have a one- time instillation of tetracycline or erythromycin ointment into the eyes to prevent gonococcal and Chlamydia conjunctivitis.

Conjunctivitis associated with chicken pox
Varicella infrequently involves the eyes, but can inflame any part of the anterior segment of the eye. Most commonly lesions involve the conjunctival surface, appearing as white blister-like domes of 1-2mm with surrounding dilated capillaries. The lesions are asymptomatic, and clear as the varicella resolves. Occasionally it can lead to crusting on the lid margin which can be a mechanical irritation to the cornea leading to abrasion.

Discharge and Follow Up Considerations
Caution the patient against rubbing the eye, it could spread the infection to the other eye or another individual
Treatment for bacterial conjunctivitis is not mandatory and the condition may clear with simple eye hygiene. The tears themselves contain natural bacteriocidals.
There is no need to exclude children from school or nursery (Health Protection Agency)
Proper hand washing techniques, avoid sharing towels, washcloths or pillows, and use of tissue or disposable wipes
Demonstrate instillation of eye drops and ointment bottle tip should not touch eye or eyelashes
If conjunctivitis from gonorrhea or Chlamydia infection  is suspected or confirmed refer eye clinic + GUM and educate and review methods of safe sex
Avoid chemical irritants, eye makeup, and contacts until infection has cleared
Apply warm compresses to affected eye or eyes
Advice re allergen avoidance/reduction for allergic conjunctivitis.
Ophthalmologist referral if infection is severe or any doubt re diagnosis

Allergic conjunctivitis

Rx
oral or topical antihistamines (such as azelastine).
Topical mast cell stabilisers such as sodium cromoglicate are also used, but may take up to 2 weeks to work.

This can occur with rapid and alarming chemosis (oedema of the conjunctiva) as a response to pollens and animal dander, usually in an atopic patient.
Rx Steroid eye drops hourly. Antistin Otrivine eye drops hourly.
It usually subsides quite quickly but referral may be necessary

http://youtu.be/mCZPTOy-S-E

Keratitis and dendritic ulcer

http://youtu.be/xbVruHai87I

Keratitis is a generic term for inflammation of the cornea. The cornea becomes light sensitive, red, and painful, with profuse tearing. It can be caused by a corneal ulcer, bacteria, or fungus. Exposures to ultraviolet light, corneal injury secondary to contact lens use, viral infections, or blepharitis are risk factors for keratitis. Patients usually present with conjunctivitis, pain, photophobia, mucopurulent discharge, and decreased vision. Pus in the anterior chamber may be seen.

Dendritic ulcer
Commonest cause in U.K. is deep extension of herpes simplex (trachoma is the main cause in hot dry countries and is seen in immigrants to this country.)
The affected pan of the cornea loses its transparency due to oedema and/or white infiltrate. The eye is usually inflamed and vision impaired.
If the condtion becomes chronic the scar may become vascularized.
This serious condition should be referred promptly. If delay is unavoidable dilate pupil and give antibiotic drops or ointment.Variable history of irritation, redness, watering and photophobia: for days or weeks. The patient may have suffered from cold sores of the lips.
Fluorescein staining reveals branching figure on corneal surface.
Rx (lD.V.) Idoxuridine drops 2 hourly. All cases should be referred promptly: further treatment may include carbolization
or cryotherapy-debridement of the affected epithelium: If the eye is sore give mydriatic drops. Do not give local steroids. If steroids have been used inadvertently refer at once.

Viral Keratoconjunctivitis is an acute conjunctivitis and keratitis that is usually caused by adenovirus.  Patients usually present with redness, tearing, and pain to the eye.  Photophobia usually starts several days later.  The eyelids and conjunctiva become swollen as well.  Children may also present with fever, pharyngitis, and diarrhea.

Herpes Simplex Virus can affect the eyelids, conjunctiva, and the cornea.  Symptoms include watery discharge, burning, and a foreign body sensation.  Vesicular lesions are seen on the skin and the conjunctiva appears inflamed.

Exposure keratitis

Due to failure of the eyelids to close over cornea-may result in dangerous situation in comatose patients, facial palsy anddysthyroid exophthalmos. Efforts must be made to protect

Cornea. Red Eye.
Rx Antibiotic ointment liberally applied will usually provide protection. but other steps may be necessary to avoid corneal ulceration.
Patients with FACIAL PALSY may be helped by a temporary tarsorrhaphy (joining lids together) by strapping or a stitch, and this may later be made permanent.

In the absence of its sensory nerve supply the cornea is particularly liable to Keratitis which may become severe quiterapidly. Often there is a history which gives a clue to the diagnosis such as treatment for Trigeminal Neuralgia. If a painless red eye develops in such a patient treat with mydriatic and antibiotic. and refer: tarsorrhaphy may be necessary

Pterygion

http://youtu.be/BnS-FS3UeIQ

Unilateral/bilateral triangular lesions beginning outside the limbus on the nasal aspect of the eye encroaching onto the cornea.

Probably caused by excess UV light.

Present with redness, soreness and dryness (exacerbated by sunlight, wind, air-conditioning and smoke), or concerns re cosmetic appearance Visual disturbance is uncommon.

Most pterygia can be managed in primary care with advice on avoidance of sunlight, smoke, etc, and can be prescribed topical lubricants. Some patients may need referral for excision.

Pingeculia

http://youtu.be/T62PkzE7Gjs

small bilateral grey, white or yellowish nodules that occur at the 3 o’clock and 9 o’clock positions of the eye, just outside the limbus and which are usually found in elderly patients.

Squamous cell carcinoma of the conjunctiva
very rare and presents as a unilateral irregular, rounded lesion, with a rough uneven surface.

Xanthelesma

Raised waxy yellow plaques due to deposition of cholesterol in the dermis and subcutaneous around the eyelids esp inner canthus.
May signal raised cholesterol or cholesterol may be normal

Causes

  • Familial hypercholesterolaemia
  • Prolonged obstructive jaundice
  • Hypothyroidism
  • Nephrotic syndrome
  • DM

May manifest in other body sites as xanthomas
– eruptive xanthomas – firm raised papules with pale yellow centres over buttocks, elbows knees and dorsum of arms – found in FH, alcohol xs, and DM.
-palmar/planar xanthomas in palmar and digital vreases in type 3 hyperlipidaemia
-tendon xanthomas extensor tendons at back of hands or achilles and patellar in FH

Arcus senilis

mayoclinic.com arcus-senilis

Ophthalmic shingles

Herpes Zoster Opthalmicus
shingles in the ophthalmic division of the trigeminal nerve.
Fever, fatigue, and malaise often occur before an eruption of the vesicles.
It appears as a unilateral rash over the forehead, upper eyelid, and nose.

Patients with lesions require oral antiviral treatment for up to 7 days after rash onset.

Treatment
Aciclovir 800mg five times a day, or valaciclovir 1g three times daily for seven days
plus aciclovir eye ointment to be applied five times daily.

Refer ophthalmologist
If there is a red eye or other signs of ocular involvement, an urgent ophthalmological opinion must be obtained.

Usually affects elderly, but can occur in patients of any age. Pain in the ocular region may precede the rash by several days, it is sometimes severe and initially difficult to diagnose.
The skin eruption occurs in the area supplied by the ophthalmic division of the Trigeminal Nerve on one side, this includes theeyelids. forehead, scalp and side of the nose.
The degree of pain, skin and ocular involvement is variable.
The vesicles become pustules which coalesce and form scabs over the affected area. There may be signs of secondary bacterial inflammation with erythema and oedema.
The eye may become involved at any stage, usually when the skin eruption is at its worst. The eyeball may be red and painful, and vision disturbed: Keratitis, Iritis and Secondary Glaucoma are fairly frequent ocular complications, and to recognize them it is often necessary to separate grossly inflamed eyelids digitally in order to inspect the eye:
The main features to assess are the BRIGHTNESS OF THE CORNEA, and WHETHER OR NOT THE EYE IS INFLAMED. If in any doubt call an Ophthalmologist. Sometimes these patients are too ill to be moved.

Rx If the eye is involved, mydriatic drops and steroid and antibiotic ointment should be inserted at least twice a day.
While the skin is oozing, calamine lotion may help to dry it. Application of steroid and antibiotic, either in an ointment or by a spray, is soothing.
The scabs should be left for several days after they have dried, until they” fall” off.
Systemic antibiotic is usually given during the early stages of the eruption if secondary infection is feared.
Neuralgic pain may be severe and require quite high dosage of analgesics.

http://youtu.be/2CfNVKvMLGM

Subconjunctival haemorrhage

http://youtu.be/_8BHSZtJKjQ

May be traumatic or more usually spontaneous.
Urine and blood pressure should be checked.
If recurrent haemorrhages occur haematological investigation may be indicated.

Cataracts

Cataract surgery

Cataract surgery

Glaucoma

Primary Chronic glaucoma     open angle glaucoma
Primary Acute glaucoma       angle closure glaucoma

Secondary glaucoma can occur in many other ocular conditions such as hyphaema and iritis.

Chronic glaucoma

(open-angle glaucoma)

Acute glaucoma

(angle closure glaucoma /narrow angle glaucoma)

Fluid cannot leave the eye because of the shape of the shallow anterior chamber-which is a vital diagnostic feature: the iris and pupil are close up behind the cornea.
It usually occurs in the elderly. females more commonly. with pain, redness and reduced vision.
Besides the shallow A.C., the cornea is hazy due to oedema, pupil fixed and semi-dilated, and the eyeball feels hard when palpated.

? headache, nausea, vomiting, severe eye pain, red eye, steamy cornea, mid-dilated and non-reactive pupil,
and of course, increased intraocular pressure (marble hard eye?, tonometry). The patient may present with a
headache ± nausea, vomiting, and not complain of a painful eye.
L ABC’s, supportive care, plus the following:
? pilocarpine 2% gtts q30 minutes.
? diamox® 500mg I.V.
? mannitol 20% 500cc I.V.
? immediate ophthalmology referral for surgical intervention

DIGITAL PALPATION
carried out by placing your two forefinger tips onto the patients closed upper lid, and gently feeling the consistency of the eye while steadying the hands by the middle fingers on the patien!”s brow.
Compare with the other eye (and a normal subject); the hardness of an acutely glaucomatous eye should be apparent.
Rx Miotic drops. Pilocarpine 4% every 5 minutes for 1 hour. Diamox 500 mg orally.
Refer immediately. but if delay is unavoidable continue pilocarpine drops 2 hourly and Diamox 250 mg 4 times a day until the patient reaches the Eye Dept. Surgery is always carried out for this form of glaucoma but usually after the attack has been controlled by medical therapy. Analgesics may be necessary.

Glaucoma treatments

Treatment of glaucoma
Prostaglandin analogues
FIRST CHOICE: LATANOPROST
Latanoprost eye drops 50micrograms/ml
Dose: apply one drop once daily, preferably in the evening
A combination preparation of Latanoprost 50micrograms/ml and Timolol (as maleate) 0.5% eye drops (Xalacomâ) is available for those patients where both drugs are indicated. Latanoprost is a prostaglandin analogue recommended for treatment of patients intolerant or unresponsive to other drugs. Travoprost is an alternative to latanoprost not requiring refrigeration.

Beta-blockers
FIRST CHOICE: TIMOLOL MALEATE
Timolol (as maleate) eye drops 0.25%, 0.5%, long-acting eye drops 0.25%, 0.5% (Timoptol®-LA)
Dose: Standard eye drops, apply twice daily. Long-acting eye drops, apply once daily.

Systemic absorption of timolol (and other topical beta- blockers) may induce bronchospasm in sensitive individuals and they should not be used in asthmatics or a history of obstructive airway disease, unless no alternative treatment is available. In such cases, the risk of inducing bronchospasm should be appreciated and appropriate precautions taken. Eye drops containing beta-blockers are also contra-indicated in patients with bradycardia, heart block or uncontrolled heart failure.

Carbonic anhydrase inhibitors
FIRST CHOICE: DORZOLAMIDE
Dorzolamide eye drops 2% (Trusopt®); dorzolamide 2% with timolol (as maleate) 0.5% eye drops (Cosopt®)
Dose: Used alone, apply 3 times daily; with topical beta-blocker, apply twice daily
Brinzolamide eye drops 10mg/ml (Azopt®); brinzolamide 10mg/ml with timolol (as maleate) 5mg/ml eye drops (Azarga®?)
Dose: Used alone, apply twice daily increased to 3 times daily if necessary; with topical beta-blocker, apply twice daily

Dorzolamide and brinzolamide are used as adjuncts to beta-blockers or alone in patients unresponsive to beta-blockers or if beta-blockers are contra-indicated. Dorzolamide and brinzolamide are contraindicated in patients with severe renal impairment (eGFR less than 30mL/min).

Sympathomimetics
FIRST CHOICE: BRIMONIDINE
Brimonidine eye drops 0.2%
Dose: Apply one drop twice daily

Brimonidine is used as an adjunct to beta-blockers or alone in patients unresponsive to beta-blockers or if beta-blockers are contra-indicated. Approximately 15% of patients started on bromonidine will develop ocular allergic reactions with an onset between 3 and 9 months in the majority of patients. Patients with dry eyes appear to have an increased risk of developing an allergic reaction with brimonidine, therefore brimonidine should be avoided in patients with dry eyes. Brimonidine has been reported to cause drowsiness and may affect performance of skilled tasks.

Glaucoma surgical treatments

Glaucoma surgical treatments

Macular degeneration AMD AMRD

Leading cause of blindness in the UK (2.3% of people over 65).
Cause is unknown but is related to age female sex smoking FH sunlight exposure and diet low in vitamins and minerals.
Central vision is affected, with peripheral vision remaining intact.

Wet and Dry Macular Degeneration
Dry AMD 90% is a Chronic, slowly-progressing disease (90%)
In Wet AMD 10% there is choroidal neovascularisation with urgent risk of haemmorrhage particularly around the macula caused by by Vascular endothelial Growth factor
Treatment for wet AMD is via laser phototherapy or drugs according to fairly strict NICE/local guidelines

Patients with known dry AMD should be asked to test their eyes regularly (eg on alternate days) by covering up each eye in turn and looking at a straight object such as a door frame or crossword.
If straight lines look curved, they should see a doctor as soon as possible; this may indicate the onset of wet AMD or use the Amsler Grid
Urgent referral is important, because ideally treatment with photodynamic therapy should take place within 2 weeks of the onset of symptoms.

High-dose vitamins A, C, E and zinc and copper supplements help to reduce progression of DRY MRD disease from occurring;
Antioxidants (Vitamin C 500mg, Vitamin E 400IU, beta-carotene 15mg) OR zinc (80mg) OR both.
these are found in multivitamin preparations such as ICAPS® or OCUVITE®, Visivite Original Ocuvite Preservision Viteyes AREDS Formulation.

ARMD Wet

http://youtu.be/j9YgAeKxqd8

Drugs for the treatment of wet ARMD

  • Ranibizumab (Lucentis) approved by NICE for a subset of patients with wet AMRD
  • Bevacizumab (Avastin)
  • Pegaptanib (Macugen)

Macular oedema and retinal detatchment

http://www.youtube.com/watch?v=9Lxu3cUguM0&feature=related

Apart from myopia, trauma is the other cause of detachment in young people, and it may be the cause of this condition at any age. The main symptom is an increasing visual field defect. coming on several days after the trauma, which may possibly have been to the head rather than directly to the eye.
The detached area of retina is spatially opposite to the field defect, and it appears grey and ballooned with dark tortuous blood vessels. rather than the usual pink appearance of retina and choroid.

MACULAR INVOLVEMENT. which may, or may not be suspected according to visual acuity. is the vital factor: all retinal detachments require surgery and if the macula can be preserved then the prognosis is good, and referral most urgent.
Rx All cases should be seen by an ophthalmologist as soon as possible; if delay is unavoidable a case must be kept in bed until he can travel to the eye clinic.
Retinal detachment may occur spontaneously in HIGH MYOPES of any age and in old people, and after cataract extraction. It is especially likely if the retina of the OTHER eye has been detached. Previous floaters and flashes of light may be valuable diagnostic symptoms. Treatment is always surgical.

CRANIAL NERVE INJURY
After a head injury a patient may regain consciousness to find blindness in one eye, which is total, with no direct pupillary light response. The eye may appear otherwise normal. This condition may be due to damage to the optic nerve, probably inside the bony optic canal which leads from the back of the orbit.
Usually no treatment is advised but neurosurgical or ophthalmological advice should be sought as soon as possible.

INJURY
A fixed dilated pupil in one eye of an unconscious patient after head injury may indicate III nerve involvement due to a space occupying lesion such as an extradural haemorrhage. Fixed dilated pupils in both eyes indicate profound coma. Both conditions require urgent neurosurgical opinion.
Eye Trauma Lacerations
Eyelids
The most serious are those involving the lid margin. particularly at the medial end of the lower lid where the lower lacrimal canaliculus may be involved.
Repair of the lid margin requires meticulous care to avoid ‘notching’, and other defortmities such as malposition of the evelashes and unsightlv cosmetic defects. It may be necessary to approximate conjunctiva, tarsal plate and skin separately. It is important to assess the extent of eyelid lacerations very carefully-very extensive defects can cause exposure of the cornea which should then be protected by frequent application of eye ointment.

Conjunctiva
Usually not serious , but extensive laceration will require suturing. Do not try to remove ingrained dirt in the conjunctival wound too vigorously.

Corneal and Scleral Lacerations
Lacerations of the outer coat of the eyeball may allow:
EXTRUSION OF INTRAOCULAR CONTENTS
a potentially disastrous condition requiring immediate surgery, usually due to flying glass fragments.
Dark coloured uveal tissue, iris or ciliary body. may be incarcerated in the wound, and the anterior chamber may be collapsed. Do nothing to the eye, prevent semi·conscious patient from rubbing itjudge degree of “ocular” emergency in relation to OTHER body injury and, if possible, co-ordinate various medical attention to SINGLE general anaesthetic. Refer.

Diabetic retinopathy

Diabetic retinopathy BMJ 2010;341:c5400

1 Background (BDR)
Microaneurysms with tortuous and congested veins -no Rx review annually
Dot and blot haemorrhages
Hard Exudates – waxy with well defined edges
Rx nil review annually

2 Preproliferative
cotton wool spots (soft exudates) – marker for ischaemia
Maculopathy hard yellow (lipoprotein) exudates urgent same day laser Rx
macula oedema laser Rx to decrease visual loss
ischaemic maculopathy no RX

3 Proliferative
– neovascularisation – new vessel fornmation over the disc and along the nerves =/- macular oedema. Risk of bleeding and scarring with retinal traction Rx panretinal photocoagulation
– Pre retinal haemorrhages
– Subhyaloid haemorrhages – boat shaped vitreous haemorrhages
– Retinal detatchment

Hypertensive retinopathy

http://youtu.be/FVe89MebNX8
but see comments

Hypertensive Retinopathy
Grade 1 arterial narrowing increased light reflex
Grade 2 vessel irregularity AV nipping
Grade 3 soft exudates flame haemorrhages
Grade 4 above + papiiloedma

Neuro-opthalmology

 

Squint (strabismus) and occular palsies

Deviation of the eye from the optical axis
Concomitant = non-paralytic = muscle imbalance – may be convergent or divergent latent or manifest
Comitant = paralytic = paralysis of one or more ocular muscle usually due to lesion of 3rd 4th or 6th cranial nerves causing limitation of movement and increasing diplopia in the field of action of the affected muscle

Eye Movements
Muscle Action Nerve Palsy
Medial Rectus Adducts CN3 Occulomotor eye down & out with lid palsy & dilated pupil (DM will not affect pupil)sudden onset painful diplopia cant look up and out or down and in = post comm artery aneurysm SAHsudden onset in child with ptosis & lateral diverging eye = posterior communicating artery aneurysm???
Inferior Rectus Depresses + extrorts +adducts CN3 Occulomotor
Superior Rectus Elevates +intorts + adducts CN3 Occulomotor
Inferior Oblique Extorts + elevates + abducts CN3 Occulomotor
Superior Oblique Intorts + depresses + adducts CN4 Trochlear CN 3 (??4) Superior Oblique eye goes down and out on accomodation (???)
Lateral Rectus Abducts CN6 Abducens limited lateral deviation of affected eye may be convergent squint = brain tumour stroke

Diplopia

Childhood squint

Convergent squint common in hypermetropes not wearing glassses

Visual field defects

Visual Field Defects
Field loss Site of lesion
total loss in one eye optic nerve or retina
bitemporal hemianopia optic chiasma – pituitary and suprasellar tumours
non congruous hemianopia optic tract
upper homonymous quadrantopia optic radiation (temporal)
lower homonymous quadrantopia optic radiation (parietal)
homonymous hemianopia lesions in optic tract optic radiations or cerebral cortex with lossof function in the right or left halves of both visual fields opposite to the side affected
if light reflex is preserved lesion is between midbrain and occipital lobe – if lost between optic chiasm and mid-brain
homonymous hemianopia with macular sparing occipital cortex
inattention hemianoia parietal lobe
enlarged blind spot early papilloedema
concentric field constriction late papilloedema
central scotoma + poor acuity papillitis, retrobulbar neuritis, B12 deficiency toxins pressure on optic nerve from tumourchoroidoretinitis
Aids to Clinical Examination 1986 Hayes and McWalter C

Pupil abnormalities

http://youtu.be/jgVJyEOXVvM

Patients showing bilateral abnormal pupils-dilated (LS.D.Amphetamine) or constricted (Morphine and Pethidine) and/orabnormal eye movements must be suspected of intoxication.

Argyll Robertson Pupil
Small Irregular unequal pupils
Accomodation reflex intact but does not react to direct or consensual light (or miydriatic drugs)
May be Ptosis and depigmmentation and atrophy of the iris

Due to lesion of the ciliary ganglion

  • – syphilis
  • – DM
  • – Orbital injury
  • – hereditary neuropathy
  • – sarcoid

Holmes Adie Pupil
Large pupil with absent light reflex and slow accomodation reflex. Unilateral. Young women. Absent or reduced tendon reflexes.

Marcus Gum Pupil

Pseudblindness
This is the last differential diagnosis! Often difficult to prove. and left to ophthalmologist or neurologist to elucidate.
The eyes look normal. pupils react to light. and when symptoms are uniocular the “affected” eye can usually be tricked into seeing.

RAPD

Ptosis

drooping of the upper eyelids

Horners

http://youtu.be/JBVGh0gyyYc

Nystagmus

Involuntary rhythmic oscillations of the eyes
pendular nystagmus
– equal in speed and amplitude in both directions (albinism, blindness)
jerking nystagmus
– quick and slow phases of unequal direction (quick phase defines direction of nystagmus)
vertical nystagmus
brainstem disease
horizontal nystagmus
vestibular lesions eg acoustic neuroma – slow phase is towards diseased side
Phasic nystagmusalcoholism barbiturate poisoning
Cerebellar nystagmus

Papilloedema

Signs Raised ICP Early Late
Level of conciousness Requires increased stimulation
subtle orientation loss
restlessness and anxiety
sudden quietness
unrousable
Pupils pupil changes
one pupil constricts then dilates – unilateral hippus
both pupils sluggish
unequal pupils
Fixed and dilated or “blown”
Motor Response sudden weakness
motor changes
pronator drift
Profound weakness
Vital Signs Increased bp Increased systolic BP
profound bradycardia
abnormal resps

Papilloedema

  • Engorgement of retinal veins
  • Blurring of disc margins
  • Redder disc with loss of physiological cupping

Causes

  • raised ICP
  • Malignant hypertension
  • CRVO
  • Optic Neuritis Papillitis Hypercapnia
  • Hypoparathyroidism

Swelling of the optic disc in one or both eyes is a serious sign.especially if there are neurological symptoms.
It is often difficult to distinguish between unusually pink optic discs. often seen in long sighted eyes. and true papilloedema.
Small haemorrhages are a valuable clue, and the swollen disc edges cannot be defined

Papilloedema may be caused by raised intracranial pressure. in which case it is usually bilateral. Vision may be normal, but field defects and other neurological signs may be found.Hypetension may cause papilloedema. All cases should be referred without delay.

Optic neuritis

Optic Atrophy
May be primary (due to MS, Tabes Dorsalis, B12 defiiciency, tobacco, methy alcohol or familial cerebellar ataxia) or secondary to disease causing papilloedema ( brain tumour, TA, CRAO)

 

Thyroid eye disease

Proptosis and exopthalmos
Thyrotoxicosis
Retroorbital tumours or cellulitis
Cvernous sinus thrombosis

Signs
Lid retraction with wide palbebral fissure
Lid Lag
Bruit over eyeball
Retinitis Pigmentosa
AR (usually – can bbe AD or sex-linked) inherited condition causing progressive tunnnel vision and blindness
Superficial exudates surrounded bt black pigmented margins.

Choroiditis
Exudates of various size appearing as white opaque areas surrounded by black pigmented margin
Causes
TB
Sarcoid
Toxoplasmosis

Visual impairment and blindness

Blind Registration
Patients who wish to be registered as blind need to have form CVI (formerly BD8) completed by an ophthalmologist.
Most people who have vision of <3/60 Snellen qualify.
People who have vision of between 3/60 and 6/60 with a very contracted field of vision are also eligible, as are those with vision >6/60 with a very contracted field of vision, especially if the contraction is in the lower part of the field.
Patients with homonymous hemianopia or bitemporal hemianopia should not be certified as blind if their central vision is >6/18 Snellen, but they can usually be registered as being partially sighted.

Many of these patients will benefit from being referred to the Low Vision Clinic at their local hospital; they may be offered free low vision aids through the Hospital Eye Service.
Social Services involvement is also important, in terms of helping the patient to remain at home and to arrange mobility training.
Partially sighted patients are eligible for Social Services assistance as well, but may not qualify for the same financial benefits.
People can apply to the Guide Dogs for the Blind Association for their own guide dog.

source GPCSG

Preservatives and sensitisers in ophthalmic preparations

MIMS Table Preservatives and Potential Sensitisers in Ophthalmic Preparations

Opthalmic prescribing

Administration
Drops should be discarded 28 days after opening.
When patients are administering more than one preparation at the same time of the day, they should be advised to allow a five-minute interval before administering the next drug. Without this period, the drugs are diluted and overflow occurs. If one of these drops causes stinging, this should be instilled last as stinging drops cause tears to be secreted. Where an ointment and drops are required at the same time of day, the ointment should always be the last medication administered.
The potential for systemic side effects of topically administered drugs should be remembered (eg beta blockers).

Antibacterial preparations
Chloramphenicol drops 0.5%, ointment 1%
Dose: Eye drops, apply 1 drop at least every 2 hours then reduce frequency to 3 – 4 times daily as infection is controlled and continue for 48 hours after healing.
Eye ointment, apply either at night (if drops used during the day) or 3 to 4 times daily (if eye ointment used alone).
Fusidin viscous drops 1% m/r bd
Fusidic acid viscous eye drops are useful for staphylococcal infections and can be administered twice daily. However, they are significantly more expensive and have a narrower spectrum of action than chloramphenicol preparations. The CSM has not recommended any change to current practice following a report highlighting the rare but serious incidences of bone marrow hypoplasia with chloramphenicol. However, it may be wise to avoid the use of chloramphenicol in patients with a family history of blood dyscrasias and to avoid prolonged courses of treatment.

Antivirals
Aciclovir ointment 3% 5 times daily (continue for at least 3 days after complete healing).

Topical corticosteroids
Betamethasone sodium phos drops 0.1%, ointment 0.1% Apply eye drops every 1 to 2 hours until controlled, then reduce frequency, eye ointment 2 to 4 times daily or at night when used with eye drops.

Other anti-inflammatory preparations
Sodium cromoglycate eye drops 2% qds
Topical corticosteroids should normally only be used under expert supervision. Prescribers must be certain of diagnosis before prescribing topical corticosteroids as their use may aggravate dendritic ulcers caused by herpes simplex. Bacterial, fungal and amoebic infections may pose similar hazard. In patients predisposed to simple glaucoma, a ‘steroid glaucoma’ may be produced. In addition, a ‘steroid cataract’ may also occur following prolonged use. Sodium cromoglicate eye drops and ointment are available OTC.

Mydriatics and cycloplegics
Tropicamide eye drops 0.5%, 1% 1 drop as necessary.
Cyclopentolate eye drops 0.5%, 1%
Atropine eye drops 0.5%, 1%

Darkly pigmented iris is more resistant to pupillary dilatation and caution should be exercised to avoid overdosage. Mydriasis may precipitate acute angle-closure glaucoma in a very few patients, usually age over 60 years and hypermetropic (long-sighted), who are predisposed to the condition because of a shallow anterior chamber. Patients should be warned not to drive for 1-2 hours after mydriasis.
Tropicamide is appropriate for diagnostic use and in the screening of diabetics by non-ophthalmologists. It should be used with caution in patients over the age of 50 who are hypermetropic (long-sighted).
Cyclopentolate and atropine should be used according to ophthalmologist’s advice.

Treatment of glaucoma
Prostaglandin analogues
Latanoprost eye drops 50micrograms/ml one drop once daily, preferably in the evening
A combination preparation of Latanoprost 50micrograms/ml and Timolol (as maleate) 0.5% eye drops (Xalacom) is available for those patients where both drugs are indicated. Latanoprost is a prostaglandin analogue recommended for treatment of patients intolerant or unresponsive to other drugs. Travoprost is an alternative to latanoprost not requiring refrigeration.

Beta-blockers
Timolol (as maleate) eye drops 0.25%, 0.5%, long-acting eye drops 0.25%, 0.5% (Timoptol®-LA)
Dose: Standard eye drops, apply twice daily. Long-acting eye drops, apply once daily.
Systemic absorption of timolol (and other topical beta- blockers) may induce bronchospasm in sensitive individuals and they should not be used in asthmatics or a history of obstructive airway disease, unless no alternative treatment is available. In such cases, the risk of inducing bronchospasm should be appreciated and appropriate precautions taken. Eye drops containing beta-blockers are also contra-indicated in patients with bradycardia, heart block or uncontrolled heart failure.

Carbonic anhydrase inhibitors
Dorzolamide eye drops 2% (Trusopt®); dorzolamide 2% with timolol (as maleate) 0.5% eye drops (Cosopt®)
Used alone, apply 3 times daily; with topical beta-blocker, apply twice daily
Brinzolamide eye drops 10mg/ml (Azopt®); brinzolamide 10mg/ml with timolol (as maleate) 5mg/ml eye drops (Azarga®?)
Used alone, apply twice daily increased to 3 times daily if necessary; with topical beta-blocker, apply twice daily
Dorzolamide and brinzolamide are used as adjuncts to beta-blockers or alone in patients unresponsive to beta-blockers or if beta-blockers are contra-indicated. Dorzolamide and brinzolamide are contraindicated in patients with severe renal impairment (eGFR less than 30mL/min).

Sympathomimetics
Brimonidine eye drops 0.2% one drop twice daily
Used as an adjunct to beta-blockers or alone in patients unresponsive to beta-blockers or if beta-blockers are contra-indicated. Approximately 15% of patients started on bromonidine will develop ocular allergic reactions with an onset between 3 and 9 months in the majority of patients. Patients with dry eyes appear to have an increased risk of developing an allergic reaction with brimonidine, therefore brimonidine should be avoided in patients with dry eyes. Brimonidine has been reported to cause drowsiness and may affect performance of skilled tasks.

Local anaesthetics
Tetracaine (Amethocaine) minims 0.5%, 1% apply as required.
Produces profound anaesthesia and is suitable for use before minor surgical procedures, such as the removal of corneal sutures. Local anaesthetics significantly impede corneal healing and can cause corneal damage with prolonged application, therefore they must never be used for symptom relief in those with corneal abrasions or other ocular symptoms.

Diclofenac eye drops

Tear substitutes
Hypromellose eye drops 0.3% 3 to 4 times daily or more frequently (eg hourly) if necessary for adequate relief.
Lacri-Lube® eye ointment (white soft paraffin 57.3%, liquid paraffin 42.5%, wool alcohols 0.2%) Apply at night before sleep
Carbomer eye drops 0.2% apply 1 to 4 times daily as required.
All of these products are available OTC. In many cases hypromellose 0.3% drops will provide satisfactory relief of dry eyes although a more viscous preparation such as a carbomer 980 may be required.
Lacrilube® contains paraffin and may be used to lubricate the eye surface, especially in cases of recurrent corneal epithelial erosion. It may cause temporary visual disturbance and so is best suited for application before sleep.
However, it can be used as required during the day in cases of persistent corneal epithelial erosion.
Eye ointments containing paraffin should not be used during contact lens wear.
source NHS Tayside formulary

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