Transcript Ophthalmology for the Internist

Ophthalmology for the
Internist
Robert F. Nash D.O.
November 2006
Ophthalmology for the Internist
Physical Exam
Red Eye
Acute Loss of Vision
Complications of Systemic Diseases
Physical Exam
Visual Acuity
Confrontation visual
field
External Inspection
Conjunctiva and
sclera inspection
Extraocular Muscles
Pupillary Reactions
Cornea and iris
inspection
Anterior chamber
exam
Lens clarity
Ophthalmoscopic
Exam
Red Eye
Ophthalmology for the
Internist
Part I
Red Eye
Conjuctivitis
Corneal Injury
Subconjunctival Hemorrhage
Iritis
Episcleritis
Scleritis
Trauma
Acute angle-closure glaucoma
Conjunctivitis
Chemical conjunctivitis- Emergency
– FLUSH-FLUSH-and FLUSH
– Then, do your H&P
– Acid v. Base
Viral v. Bacterial conjunctivitis
– Difficult to distinguish
Purulent discharge- more common with bacterial etiology
Pre-auricular lymphadenapathy- more common with viral
etiology
Sexually active
Conjunctivitis
Allergic
– Treatments
Blepheritis
– Seborrhea
– Bacterial
Corneal Injury
Sharp pain, improves with Topical
anesthetic, worse with blinking
Foreign body sensation
Foreign Body v Keratitis
Fluorescein to locate pathology
Keratitis
Inflamed cornea
– Contact misuse
– UV damage
– Dry eyes
– Viral causes
Treatment
Subconjunctival Hemorrhage
Solitary red spot usually unilateral and
always painless
Causes:
– Cough
– Anticoagulation
– Hypertension
– Vomiting
Iritis
Inflammation or iris and/or cilary bodies
Predisposing Factors:
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HLA B27
Ankylosing spondylitis,
Reactive arteritis (Reiters syndrome),
psoriatic arteritis,
irritable Bowel disease
Crohn's disease
Multiple Sclerosis (HLA B15),
Sarcoidosis,
systemic Lupus Erythematosus
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Lyme disease
Juvenile Idiopathic arteritis
Sexually transmitted diseases
Cat Scratch disease
Toxoplasmosis, toxocardia
Presumed Ocular Histoplasmosis
syndrome
Lyme disease
whipples disease
valley fever
Tuberculosis
Leptospirosis
Rocky Mountain Spotted fever.
Iritis
HPI: Pain, blurry vision, Photophobia
PE: Sluggish, smaller pupil, “Cilary Flush”,
Vessels do not blanch or move with swab
Inflammatory cells seen with slit lamp
Treatment: Corticosteroids
Consult : Ophthalmology
Episcleritis
Inflammation of superficial layer of sclera
HPI: Red eye, sudden onset, without any
known cause, minimal discharge with
some discomfort
PE
Treatment: NSAIDS
Scleritis
Strong association with system diseases
– Rheumatoid arteritis
– Chronic infections
– Connective tissue disease
Pain
Treatment: systemic steroids
Consult: Ophthalmology
Acute angle closure Glaucoma
5% of all Glaucoma
Precipitated by dilation of pupil
HPI: Eye pain, blurry vision, Haloes, Nausea and
vomiting, Headache
PE
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Shallow anterior chamber
Pupil fixed
Cornea haziness
Eye feels firm
Acute angle closure Glaucoma
Treatment
– Pilocarpine – Miotic
– Laser surgery - Iridectomy
Consult - Ophthalmology
Red Eye Differential Diagnosis
Viral
Bacterial Chemical
Corneal
Conjunctiv Conjunctiv Conjunctiv
Injury
itis
itis
itis
Local or
Localized Surroundi Surroundi
Localized
diffuse
or diffuse ng cornea ng cornea
Diffuse
Pain
Discomfor Discomfor
+/t
t
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Visual
Acuity
Normal
Pupil
Normal
Diffuse
Iritis
Redness
Discharge Watery
Diffuse
Episcleritis Scleritis
Angle
closure
Glaucoma
Normal
Normal
+/-
Normal
Normal
Blurred
Decreased
+
Watery
+
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Small
Often
dilated or
fixed
Normal
Normal
Normal
Normal
Normal
Acute Vision Loss
Ophthalmology for the
Internist
Part II
Acute Vision Loss
Glaucoma
Iritis
Corneal Ulcer
Hyphema
Hypopion
Vitreous Hemorrhage
Retinal detachment
Retinal vascular
occlusion
Optic Neuritis
Optic Neuropathy
Papilledema
CVA
All require Ophthalmologic
Consult
See above…
Glaucoma
Iritis
Corneal Ulcer
Bacteria v. Fungal
Severe eye pain
Can be seen on cornea as a white spot
Topical Broad spectrum antibiotics
Hyphema
Blood in anterior chamber
Easily seen: red air-fluid level
Traumatic cause most common
Usually self limited
Eye pressure must be monitored
Hypopion
Leukocytes in anterior chamber
Penetrating trauma to eye
Antibiotics
Consult Ophthalmologist
Vitreous Hemorrhage
Extravasation of blood into potentional
spaces in and around the vitreous body
Blood blocks red reflex
Vitreous Hemorrhage
Causes:
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Proliferative Diabetic retinopathy (31.5-54%)
Retinal tears (11.4-44%)
Trauma (12-18.8%)
Neovascularization (3.5-16%)
Posterior vitreous Detachment with retinal vascular
tears (3.7-11.7%)
– Proliferative sickle cell retinopathy
– Macroaneurysm (0.6-4.3%)
Subarachnoid Hemorrhage
Vitreous Hemorrhage
May cause retinal damage, floaters, and
glaucoma
Treat the underlying cause
May require surgical removal of blood
Retinal Detachment
Lifetime risk: 1 in 300
Causes:
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Sarcoid iritis
Severe hypertension
Neoplasm
Fibrosis
Retinopathy (DM)
Trauma
– Posterior Vitreous detachment
Retinal Detachment
HPI: painless, curtain sensation, flashes of
light
Treatment:
– Laser surgery
– Scleral buckling
– Posterior vitrectomy
– Pneumatic retinopexy
Prognosis: Good, if macula is not involved
Retinal Arterial Occlusion
Causes
– Emboli
– TIA
– Vasculitis
– Must check Carotid circulation
Sudden
Painless
Curtain sensation
Cherry red spot – Fovea against the white retina
Hollenhorst Plaques
– Glistening yellow flakes
Permanent or temporary (Amaurosis Fugax)
Retinal Arterial Occlusion
Treatment
– Ballot eye 10 sec cycles
– Paracentesis of anterior chamber
Optic Neuritis
Inflamed nerve
MS
May have pain behind eye
PE:
– May have optic nerve pallor
– Pupil light reflex abnormality
– Tenderness with ROM
MRI
Treatment: IV Glucocorticoids
Note: 30-50% will develop MS within 15 years of diagnosis
Optic Neuropathy
Giant Cell arteritis
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Jaw Claudication
Over 60
Malaise
Headache
Fever
Scalp tenderness
Weight loss
Polymyalgia
Rheumatica
Trauma
– Disruption of vascular
supply to optic nerve
– Nerve impingement
Giant Cell arteritis
8-15% of all Temporal arteritis patients
develop acute loss of vision
If suspected
– Sed rate
>50
– Steroids
– Temporal artery biopsy
Traumatic Optic Neuropathy
Poor prognosis
May try steroids, surgery
CVA
May cause acute vision loss due to optic
nerve infarct or cerebral infarct
May cause partial vision loss unilaterally or
bilaterally
Ophthalmologic Complications
of Systemic Disease
Ophthalmology for the
Internist
Part III
Ophthalmologic Complications of
Systemic Disease
Hypertension: A-V nicking
Diabetes Mellitus: Diabetic Retinopathy
Syphilis: Marcus-Gunn pupil
Intracranial Edema: Papillary Edema
Hyperthyroidism: Exophthalmos
Herpes Zoster: Vesicles
CMV Infection: Cotton wool spots
References
Alward WL. Medical Management of Glaucoma. NEJM 1998; 339:1298-1307.
Uptodate, 2006
Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan. 2005
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.
Hara JH. The Red Eye: Diagnosis and Treatment. Amer Family Phys 1996; 54(8): 2423- 2430.
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): 991-998.
Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000; (2): CD001211.
Question 1
Which of the following components of a
Physical exam is first?
a)
b)
c)
d)
Visual Acuity
Confrontation visual field
External Inspection
Conjunctiva and sclera inspection
Answer 1
Which of the following components of a
Physical exam is first?
a) External Inspection
b) Confrontation visual field
c) Visual Acuity
d) Conjunctiva and sclera inspection
Question 2
When a patient is believed to have a
chemical conjunctivitis, the first thing to
do is?
a)
b)
c)
d)
Physical exam
Visual acuity
Flush eye immediately
Obtain a History
Answer 2
When a patient is believed to have a
chemical conjunctivitis, the first thing to do
is?
a) Physical exam
b) Visual acuity
c) Flush eye immediately
d) Obtain a History
Question 3
Patient presents with “deep eye pain”,
blurry vision, Photophobia. Sluggish,
smaller pupil, and “Cilary Flush” on PE.
Vessels do not blanch or move with a
swab. What is the probable diagnosis?
a)
b)
c)
d)
Bacterial conjunctivitis
Subconjunctival hemorrhage
Iritis
Acute angle closure glaucoma