Ophthalmology for the Internist Robert F. Nash D.O. November 2006.
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Transcript of Ophthalmology for the Internist Robert F. Nash D.O. November 2006.
Ophthalmology for the Ophthalmology for the InternistInternist
Robert F. Nash D.O.Robert F. Nash D.O.
November 2006November 2006
Ophthalmology for the InternistOphthalmology for the Internist
Physical ExamPhysical Exam
Red EyeRed Eye
Acute Loss of VisionAcute Loss of Vision
Complications of Systemic DiseasesComplications of Systemic Diseases
Physical ExamPhysical Exam
Visual AcuityVisual Acuity
Confrontation visual Confrontation visual fieldfield
External InspectionExternal Inspection
Conjunctiva and Conjunctiva and sclera inspectionsclera inspection
Extraocular MusclesExtraocular Muscles
Pupillary ReactionsPupillary Reactions
Cornea and iris Cornea and iris inspectioninspection
Anterior chamber Anterior chamber examexam
Lens clarityLens clarity
Ophthalmoscopic Ophthalmoscopic ExamExam
Red EyeRed Eye
Ophthalmology for the Ophthalmology for the InternistInternist
Part IPart I
Red EyeRed Eye
ConjuctivitisConjuctivitis
Corneal InjuryCorneal Injury
Subconjunctival HemorrhageSubconjunctival Hemorrhage
IritisIritis
EpiscleritisEpiscleritis
ScleritisScleritis
TraumaTrauma
Acute angle-closure glaucomaAcute angle-closure glaucoma
ConjunctivitisConjunctivitis
Chemical conjunctivitis- EmergencyChemical conjunctivitis- Emergency– FLUSH-FLUSH-and FLUSHFLUSH-FLUSH-and FLUSH– Then, do your H&PThen, do your H&P– Acid v. BaseAcid v. Base
Viral v. Bacterial conjunctivitisViral v. Bacterial conjunctivitis– Difficult to distinguishDifficult to distinguish
Purulent discharge- more common with bacterial etiologyPurulent discharge- more common with bacterial etiologyPre-auricular lymphadenapathy- more common with viral Pre-auricular lymphadenapathy- more common with viral etiologyetiologySexually activeSexually active
ConjunctivitisConjunctivitis
AllergicAllergic– TreatmentsTreatments
BlepheritisBlepheritis– SeborrheaSeborrhea– BacterialBacterial
Corneal InjuryCorneal Injury
Sharp pain, improves with Topical Sharp pain, improves with Topical anesthetic, worse with blinkinganesthetic, worse with blinking
Foreign body sensationForeign body sensation
Foreign Body v KeratitisForeign Body v Keratitis
Fluorescein to locate pathologyFluorescein to locate pathology
KeratitisKeratitis
Inflamed corneaInflamed cornea– Contact misuseContact misuse– UV damageUV damage– Dry eyesDry eyes– Viral causesViral causes
TreatmentTreatment
Subconjunctival HemorrhageSubconjunctival Hemorrhage
Solitary red spot usually unilateral and Solitary red spot usually unilateral and always painlessalways painless
Causes:Causes:– CoughCough– AnticoagulationAnticoagulation– HypertensionHypertension– VomitingVomiting
IritisIritisInflammation or iris and/or cilary bodiesInflammation or iris and/or cilary bodies
Predisposing Factors:Predisposing Factors:
– HLA B27 HLA B27
– Ankylosing spondylitis, Ankylosing spondylitis,
– Reactive arteritis (Reiters syndrome), Reactive arteritis (Reiters syndrome),
– psoriatic arteritis, psoriatic arteritis,
– irritable Bowel disease irritable Bowel disease
– Crohn's diseaseCrohn's disease
– Multiple Sclerosis (HLA B15), Multiple Sclerosis (HLA B15),
– Sarcoidosis, Sarcoidosis,
– systemic Lupus Erythematosussystemic Lupus Erythematosus
– Lyme diseaseLyme disease– Juvenile Idiopathic arteritisJuvenile Idiopathic arteritis– Sexually transmitted diseases Sexually transmitted diseases – Cat Scratch diseaseCat Scratch disease– Toxoplasmosis, toxocardiaToxoplasmosis, toxocardia– Presumed Ocular Histoplasmosis Presumed Ocular Histoplasmosis
syndromesyndrome– Lyme diseaseLyme disease– whipples diseasewhipples disease– valley fevervalley fever– TuberculosisTuberculosis– LeptospirosisLeptospirosis– Rocky Mountain Spotted fever.Rocky Mountain Spotted fever.
IritisIritis
HPI: Pain, blurry vision, PhotophobiaHPI: Pain, blurry vision, Photophobia
PE: Sluggish, smaller pupil, “Cilary Flush”, PE: Sluggish, smaller pupil, “Cilary Flush”, Vessels do not blanch or move with swabVessels do not blanch or move with swab
Inflammatory cells seen with slit lampInflammatory cells seen with slit lamp
Treatment: CorticosteroidsTreatment: Corticosteroids
Consult : OphthalmologyConsult : Ophthalmology
EpiscleritisEpiscleritis
Inflammation of superficial layer of scleraInflammation of superficial layer of sclera
HPI: Red eye, sudden onset, without any HPI: Red eye, sudden onset, without any known cause, minimal discharge with known cause, minimal discharge with some discomfortsome discomfort
PEPE
Treatment: NSAIDSTreatment: NSAIDS
ScleritisScleritis
Strong association with system diseasesStrong association with system diseases– Rheumatoid arteritisRheumatoid arteritis– Chronic infectionsChronic infections– Connective tissue diseaseConnective tissue disease
PainPain
Treatment: systemic steroidsTreatment: systemic steroids
Consult: OphthalmologyConsult: Ophthalmology
Acute angle closure GlaucomaAcute angle closure Glaucoma
5% of all Glaucoma5% of all GlaucomaPrecipitated by dilation of pupilPrecipitated by dilation of pupilHPI: Eye pain, blurry vision, Haloes, Nausea and HPI: Eye pain, blurry vision, Haloes, Nausea and vomiting, Headachevomiting, HeadachePEPE– Shallow anterior chamberShallow anterior chamber– Pupil fixedPupil fixed– Cornea hazinessCornea haziness– Eye feels firmEye feels firm
Acute angle closure GlaucomaAcute angle closure Glaucoma
TreatmentTreatment– Pilocarpine – MioticPilocarpine – Miotic– Laser surgery - IridectomyLaser surgery - Iridectomy
Consult - OphthalmologyConsult - Ophthalmology
Red Eye Differential Diagnosis
Viral Conjunctivitis
Bacterial Conjunctivitis
Chemical Conjunctivitis
Corneal Injury
Episcleritis Scleritis IritisAngle closure Glaucoma
Redness Diffuse Diffuse DiffuseLocal ordiffuse
LocalizedLocalized or diffuse
Surrounding cornea
Surrounding cornea
PainDiscomfort
Discomfort
+/- + + + + +
Visual Acuity
Normal Normal Normal +/- Normal Normal Blurred Decreased
Discharge Watery + Watery + - - - -
Pupil Normal Normal Normal Normal Normal Normal SmallOften dilated orfixed
Acute Vision LossAcute Vision Loss
Ophthalmology for the Ophthalmology for the InternistInternist
Part IIPart II
Acute Vision LossAcute Vision Loss
GlaucomaGlaucoma
Iritis Iritis
Corneal UlcerCorneal Ulcer
HyphemaHyphema
HypopionHypopion
Vitreous HemorrhageVitreous Hemorrhage
Retinal detachmentRetinal detachment
Retinal vascular Retinal vascular occlusionocclusion
Optic NeuritisOptic Neuritis
Optic NeuropathyOptic Neuropathy
PapilledemaPapilledema
CVACVA
All require Ophthalmologic All require Ophthalmologic ConsultConsult
See above…See above…
GlaucomaGlaucoma
IritisIritis
Corneal UlcerCorneal Ulcer
Bacteria v. FungalBacteria v. Fungal
Severe eye painSevere eye pain
Can be seen on cornea as a white spotCan be seen on cornea as a white spot
Topical Broad spectrum antibioticsTopical Broad spectrum antibiotics
HyphemaHyphema
Blood in anterior chamberBlood in anterior chamber
Easily seen: red air-fluid levelEasily seen: red air-fluid level
Traumatic cause most commonTraumatic cause most common
Usually self limited Usually self limited
Eye pressure must be monitoredEye pressure must be monitored
HypopionHypopion
Leukocytes in anterior chamberLeukocytes in anterior chamber
Penetrating trauma to eyePenetrating trauma to eye
AntibioticsAntibiotics
Consult OphthalmologistConsult Ophthalmologist
Vitreous HemorrhageVitreous Hemorrhage
Extravasation of blood into potentional Extravasation of blood into potentional spaces in and around the vitreous bodyspaces in and around the vitreous body
Blood blocks red reflexBlood blocks red reflex
Vitreous HemorrhageVitreous Hemorrhage
Causes:Causes:– Proliferative Diabetic retinopathy (31.5-54%)Proliferative Diabetic retinopathy (31.5-54%)– Retinal tears (11.4-44%)Retinal tears (11.4-44%)– Trauma (12-18.8%)Trauma (12-18.8%)– Neovascularization (3.5-16%)Neovascularization (3.5-16%)– Posterior vitreous Detachment with retinal vascular Posterior vitreous Detachment with retinal vascular
tears (3.7-11.7%)tears (3.7-11.7%)– Proliferative sickle cell retinopathyProliferative sickle cell retinopathy– Macroaneurysm (0.6-4.3%)Macroaneurysm (0.6-4.3%)
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Vitreous HemorrhageVitreous Hemorrhage
May cause retinal damage, floaters, and May cause retinal damage, floaters, and glaucomaglaucoma
Treat the underlying causeTreat the underlying cause
May require surgical removal of bloodMay require surgical removal of blood
Retinal DetachmentRetinal Detachment
Lifetime risk: 1 in 300Lifetime risk: 1 in 300
Causes:Causes:– Sarcoid iritisSarcoid iritis– Severe hypertensionSevere hypertension– NeoplasmNeoplasm– FibrosisFibrosis
Retinopathy (DM)Retinopathy (DM)
TraumaTrauma
– Posterior Vitreous detachmentPosterior Vitreous detachment
Retinal DetachmentRetinal Detachment
HPI: painless, curtain sensation, flashes of HPI: painless, curtain sensation, flashes of lightlightTreatment: Treatment: – Laser surgeryLaser surgery– Scleral bucklingScleral buckling– Posterior vitrectomyPosterior vitrectomy– Pneumatic retinopexyPneumatic retinopexy
Prognosis: Good, if macula is not involvedPrognosis: Good, if macula is not involved
Retinal Arterial OcclusionRetinal Arterial Occlusion
CausesCauses– EmboliEmboli– TIATIA– VasculitisVasculitis– Must check Carotid circulationMust check Carotid circulation
SuddenSuddenPainlessPainlessCurtain sensationCurtain sensationCherry red spot – Fovea against the white retinaCherry red spot – Fovea against the white retinaHollenhorst PlaquesHollenhorst Plaques– Glistening yellow flakesGlistening yellow flakes
Permanent or temporary (Amaurosis Fugax)Permanent or temporary (Amaurosis Fugax)
Retinal Arterial OcclusionRetinal Arterial Occlusion
TreatmentTreatment– Ballot eye 10 sec cyclesBallot eye 10 sec cycles– Paracentesis of anterior chamberParacentesis of anterior chamber
Optic NeuritisOptic Neuritis
Inflamed nerveInflamed nerve
MSMS
May have pain behind eyeMay have pain behind eye
PE:PE:– May have optic nerve pallorMay have optic nerve pallor– Pupil light reflex abnormalityPupil light reflex abnormality– Tenderness with ROMTenderness with ROM
MRIMRI
Treatment: IV GlucocorticoidsTreatment: IV Glucocorticoids
Note: 30-50% will develop MS within 15 years of diagnosisNote: 30-50% will develop MS within 15 years of diagnosis
Optic NeuropathyOptic Neuropathy
Giant Cell arteritisGiant Cell arteritis– Jaw ClaudicationJaw Claudication– Over 60Over 60– MalaiseMalaise– HeadacheHeadache– FeverFever– Scalp tendernessScalp tenderness– Weight lossWeight loss– Polymyalgia Polymyalgia
RheumaticaRheumatica
TraumaTrauma– Disruption of vascular Disruption of vascular
supply to optic nervesupply to optic nerve– Nerve impingementNerve impingement
Giant Cell arteritisGiant Cell arteritis
8-15% of all Temporal arteritis patients 8-15% of all Temporal arteritis patients develop acute loss of visiondevelop acute loss of vision
If suspectedIf suspected– Sed rateSed rate
>50>50– SteroidsSteroids– Temporal artery biopsyTemporal artery biopsy
Traumatic Optic NeuropathyTraumatic Optic Neuropathy
Poor prognosisPoor prognosis
May try steroids, surgeryMay try steroids, surgery
CVACVA
May cause acute vision loss due to optic May cause acute vision loss due to optic nerve infarct or cerebral infarctnerve infarct or cerebral infarct
May cause partial vision loss unilaterally or May cause partial vision loss unilaterally or bilaterallybilaterally
Ophthalmologic Complications Ophthalmologic Complications of Systemic Diseaseof Systemic Disease
Ophthalmology for the Ophthalmology for the InternistInternistPart IIIPart III
Ophthalmologic Complications of Ophthalmologic Complications of Systemic DiseaseSystemic Disease
Hypertension: A-V nickingHypertension: A-V nicking
Diabetes Mellitus: Diabetic RetinopathyDiabetes Mellitus: Diabetic Retinopathy
Syphilis: Marcus-Gunn pupilSyphilis: Marcus-Gunn pupil
Intracranial Edema: Papillary EdemaIntracranial Edema: Papillary Edema
Hyperthyroidism: ExophthalmosHyperthyroidism: Exophthalmos
Herpes Zoster: VesiclesHerpes Zoster: Vesicles
CMV Infection: Cotton wool spotsCMV Infection: Cotton wool spots
ReferencesReferencesAlward WL. Medical Management of Glaucoma. NEJM 1998; 339:1298-1307.Alward WL. Medical Management of Glaucoma. NEJM 1998; 339:1298-1307.
Uptodate, 2006Uptodate, 2006
Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan. 2005Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan. 2005
LECOM note server, Crane W. Acute Visual Loss, Eye in Systemic DZ, and The Red Eye.LECOM note server, Crane W. Acute Visual Loss, Eye in Systemic DZ, and The Red Eye.
Donahue S. Evaluation and management of red eye. Patient Care Dec 30, 2001: 36-44.Donahue S. Evaluation and management of red eye. Patient Care Dec 30, 2001: 36-44.
Hara JH. The Red Eye: Diagnosis and Treatment. Amer Family Phys 1996; 54(8): 2423-Hara JH. The Red Eye: Diagnosis and Treatment. Amer Family Phys 1996; 54(8): 2423- 2430.2430.
Havener WH. Synopsis of Ophthalmology. 1975: Chapter 10: Diagnosis and management of the Red Eye.Havener WH. Synopsis of Ophthalmology. 1975: Chapter 10: Diagnosis and management of the Red Eye.
Patel SJ. Ocular Manifestations of Autoimmune Disease. Amer Family Phys 2002; 66(6):Patel SJ. Ocular Manifestations of Autoimmune Disease. Amer Family Phys 2002; 66(6): 991-998.991-998.
Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000;Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000; (2): CD001211.(2): CD001211.
Question 1Question 1
Which of the following components of a Which of the following components of a Physical exam is first?Physical exam is first?
a)a) Visual AcuityVisual Acuity
b)b) Confrontation visual fieldConfrontation visual field
c)c) External InspectionExternal Inspection
d)d) Conjunctiva and sclera inspectionConjunctiva and sclera inspection
Answer 1Answer 1
Which of the following components of a Which of the following components of a Physical exam is first?Physical exam is first?
a)a) External InspectionExternal Inspection
b)b) Confrontation visual fieldConfrontation visual field
c)c) Visual AcuityVisual Acuity
d)d) Conjunctiva and sclera inspectionConjunctiva and sclera inspection
Question 2Question 2
When a patient is believed to have a When a patient is believed to have a chemical conjunctivitis, the first thing to chemical conjunctivitis, the first thing to do is?do is?
a)a) Physical examPhysical exam
b)b) Visual acuityVisual acuity
c)c) Flush eye immediatelyFlush eye immediately
d)d) Obtain a HistoryObtain a History
Answer 2Answer 2
When a patient is believed to have a When a patient is believed to have a chemical conjunctivitis, the first thing to do chemical conjunctivitis, the first thing to do is?is?a)a) Physical examPhysical exam
b)b) Visual acuityVisual acuity
c)c) Flush eye immediatelyFlush eye immediately
d)d) Obtain a HistoryObtain a History
Question 3Question 3
Patient presents with “deep eye pain”, Patient presents with “deep eye pain”, blurry vision, Photophobia. Sluggish, blurry vision, Photophobia. Sluggish, smaller pupil, and “Cilary Flush” on PE. smaller pupil, and “Cilary Flush” on PE. Vessels do not blanch or move with a Vessels do not blanch or move with a swab. What is the probable diagnosis?swab. What is the probable diagnosis?
a)a) Bacterial conjunctivitisBacterial conjunctivitisb)b) Subconjunctival hemorrhageSubconjunctival hemorrhagec)c) IritisIritisd)d) Acute angle closure glaucomaAcute angle closure glaucoma