Disease
Cause
Symptoms
Diagnosis
Treatment
Picture
Notes
Optic Neuritis
**Multiple Sclerosis
•
Ischemic optic neuropathy (Giant Cell
Arteritis)
•
Infection (meningitis, encephalitis, syphilis)
(Viral)
•
Develops between 20
-
40 (mean age of 30)
•
most are female (2/3rds)
•
Patho: T cell activation > release of
cytokines and other inflammatory agents >
edema in the myelinated nerve sheaths >
myelin breakdown
•
Pain eye movements
•
Unilateral (monocular) loss
of vision
developing over
hours to a few days
•
Decreased color vision •
Visual field loss (usually
central)
•
+ afferent pupillary defect(if
other eye not involved)
•
Papillitis w/hyperemia of
disc, blurring of disc
margins, distended veins
(1/3 of pts)
•
Refer to ophthalmology
•
MRI of brain and orbits •
*brain MRI advisable in every
patient with a first attack of optic
neuritis due to chance of multiple
sclerosis, in those whose vision
recovery doesn’t occur, or there
are atypical features (continued
deterioration of vision or
persisting pain after 2 wks)
Lumbar Puncture: not essential
but considered in atypical cases
•
Other testing: erythrocyte
sedimentation rate, ANA (if
relevant clues to an alte rnative dx)
•
IV corticosteroids (methylprednisolone)
-
first
line
•
Immunomodulatory therapies (immune
globulin)
•
Can follow with oral prednisone (usually if
vision worse than 20/100) but not common
practice
•
Refer urgently for ophthalmologic and/or
neurologic assessment **Vision usually
improves over 2
-
3 weeks
•
Corneal
Abrasion
Trauma (fingernails, paws, branches, foreign
body, contact lenses)
Severe pain/FB sensation
•
Photophobia
•
Erythema•
Exclude penetrating trauma or
infectious infiltrate
through H&P
•
Get visual acuity FIRST •
Analgesia (proparacaine or
tretracaine) if needed then
fluorescein stain exam
•
Topical antibiotics
(Erythromycin,
trimethoprim
-
polymyxin B, Ciprofloxacin)
•
Cycloplegics if large (cyclopentolate,
homatropine)
•
Daily f/u
until healed
•
Tetanus prophylaxis •
Pain control
(NSAIDs, Opioids)
•
Emergent Referral
Corneal infiltrate, white spot, or opacity
suggestion ulceration
•
Foreign body that cannot be removed
(this isn’t always an emergent referral)
•
Hypopyon (pus in the anterior chamber) •
Urgent Referral
A larger epithelial defec t •
Purulent discharge
•
A drop in vision of mo re than one to two
lines on a Snellen chart
•
An infant or child with p ersistent
discharge or unwillingness to keep the
eye open
•
Corneal abrasion that has not heale d
after three to four days
•
Corneal
Foreign Body
"something in my eye"
•
FB under eyelid
: instill anesthetic
(proparacaine 0.5%) and evert the
lid > If FB present can remove by
passing a wet sterile cotton tip
applicator over it
•
Corneal FB
: examine the eye with
slit lamp or with a hand flashlight,
using oblique illumination > FB
may be made more apparent by
instilling fluorescein > Removed
with a sterile wet cotton tipped
applicator or hypodermic needle
or burr > Bacitracin oint should
then be instilled
•
Test visual acuity before treatment
•
Once FB removed cornea starts healing within
24 hours
•
Tell patient to return promptly for increased
pain, redness or impaired vision
•
Refer
: urgently if FB can’t be removed or
corneal infection suspected
•
* Do not give anesthetic gtts to patient
because they are toxic to the corneal
epithelium and can lead to further injury
without patient knowing
*consider intraocular FB if patient gives
history of something hitting the eye
(usually by hammering on metal or using
grinding equip) and no corneal FB is seen,
a corneal or scleral wound is present, or
marked vision loss or media opacity. Refer
emergently to ophthalmologist
Corneal Ulcer
Bacteria
(Staph, Strep, Pseudomonas)
•
Viruses
(HSV, adenovirus)
•
Fungal (rare) •
Vitamin A deficiency•
Pain
•
Photophobia
•
Decreased vision •
Discharge •
FB sensation
•
Corneal infiltrate (round,
white spot)
•
Conjunctival hype remia
•
Meiosis
•
Chemosis •
Fluorescein stain and slit lamp
exam
•
May need cultured•
Cycloplegics
•
Bacterial
: moxifloxacin (small ulcers) or
tobramycin and cefazolin (significant ulcers)
•
HSV: ganciclovir, valacyclovir, or acyclovir •
Fungal
: natamycin e or amphoter icin B
•
Bacterial
Keratitis
Improper contact lens wear (greatest risk
factor)
•
Dry ocular surface •
Topical corticosteroid use and/or
immunosuppression
•
FB sensation
•
Trouble keeping eye open
(sign of active corneal
process)
•
Corneal opacity, infiltrate,
ulceration
•
Red eye •
Photophobia
•
Mucopurulent d/c •
Limbic flushing •
Mostly clinical
•
Can get corneal scrapings for
culture and gram stain (performed
by ophthalmologist)
•
Abx eye gtts
(fluoroquinolone) applied hourly
for 24
-
48 hours x 2 weeks
•
Cycloplegic gtts•
Don’t patch eye
•
*warrants evaluation by an
ophthalmologist same day
HSV Keratitis
HSV
-
1 or HSV
-
2
•
Viral latency (trigeminal ganglion)
•
Can be reactivated by stress, trauma,
fever, UV exposure, and other infections
•
Unilateral
•
Pain
•
Photophobia •
Visual blurring
•
Watery discharge
•
Conjunctival inj ection near
the limbus
(ciliary flush)
•
Dendritic lesion
•
Usually clinical
•
Three types of testing: Viral
culture, detection of viral antigen
(ELISA/ELVIS), detection of viral
DNA (PCR)
•
Topical antiviral agents
(Ganciclovir, Acyclovir)
•
Oral antivirals
(Acyclovir)
•
Use of topical glucocorticoids are effective but
need to used with caution (best done by
ophthalmologist)
•
Herpes Zoster
Opthalmicus
Varicella Zoster reactivation
within the
trigeminal ganglion/nerve
•
Frontal branch
most frequently involved
•
Headache, malaise, fever
•
Unilateral pain/tingling in
affected eye/forehead/scalp
•
Vesicular eruption along the
dermatome
•
Vesicular lesions on the nose
(
Hutchinson’s sign
) indicate
high risk of HZO
•
Conjunctivitis •
Lid droop
•
Corneal involvem ent
(keratitis)-Corneal dendrites
•
Anterior uveitis, increased
IOP, nerve palsies, retinal
necrosis, corneal scarring
are common sequelae
•
Antivirals
(oral or topical)
•
Topical steroid drops•
Anterior
Uveitis
Inflammation of uveal tract
•
Infections- Bacterial, viral, fungal, and
parasitic (HSV, CMV, Toxoplasmosis,
Syphilis, West Nile)
•
Systemic immune-mediated disease (40%) •
Inflammatory disease (Ankylosing
spondylitis, Reactive arthritis,
Inflammatory Bowel Disease)
-
Drug hypersensitivity reactions
(Fluoroquinolones, Bisphosphonates,
Immunotherapy)
-
Unilateral,
deep, aching pain
•
Decrease in visual acuity •
Ciliary injectio n or diffusely
red
•
Cornea may be slig htly
cloudy
•
Pupil usually small and may
become irregular (miosis)
•
Photophobia (consensual) •
Slit lamp and dilated fundus exam
Keratitic precipitates (white
cells on endothelium)
•
Inflammatory cells and flare
within the aqueous of
anterior chamber
(hypopyon)
•
•
Refer to ophthalmology
•
Infectious: antiviral agents, abx •
Noninfectious: topical glucocorticoi d
(prednisolone); mydriatics (scopolamine)
•
Includes the iris (iritis) or ciliary body
(cyclitis) or both (iridocyclitis)
Urgent & Emergent Eye
Wednesday, April 5, 2023 8:06 AM
Urgent Emergent Eye Page 1
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