Lecture notes from presentation by Dr Scott Czarnecki, 04 January 2017:
WHAT IS URGENT?
- Acute vision loss (<24h)
- Painful vision loss (<24h)
- Globe penetration (now)
- Flashes and floaters (<24h)
- Semi-urgent: HSV conjunctivitis, zoster ophthalmicus (24-48h)
- Ptosis and blown pupil (now)
Random ophtho pearls:
- For bacterial conjunctivitis, use Ocuflox or Polytrim. Don’t use tobra or gentamicin – these will just as often cause a chemical conjunctivitis as help!
- Bacterial conjunctivitis is actually pretty uncommon, vast majority of pink eyes are going to be viral.
- Cataract surgery is generally not indicated until vision is 20/40 or worse.
- Negative photopsias (loss of vision) are more concerning than positive photopsias (flashing lights), in general. More likely due to ischemia, CNS lesions or retinal disease.
Vitreous is what causes retinal tears – flashes and floaters should be seen by ophtho in 1-2 days to r/o retinal detachment.
Even prolonged use of nasal steroids (> 3 mos) should be screened for glaucoma and cataract – any prolonged steroid use can cause these side-effects.
Papilledema doesn’t exist in one eye only. However, optic nerve edema can (from, say, temporal arteritis.)
Tamsulosin (Flomax) – older patients should be seen by ophtho prior to being placed on tamsulosin – risk of floppy iris syndrome, so should have cataract surgery if vision compromise PRIOR to tamsulosin treatment.
- compromise of the red reflex with a diabetic cataract
- exudates (hard and soft), hemorrhages, microaneurysms, proliferative diabetic retinopathy
- these findings are very similar to what you see in uncontrolled hypertensives and pre-eclamptics!
- neovascularization of the iris (caused by ischemia of the eye) – advanced finding, very high risk of blindness
Hypertensive retinopathy can be distinguished from diabetic retinopathy at times by the presence of papilledema.
Arterial and Venous Disease
A-V nicking is the compression of retinal veins by overpressured arteries. The artery takes a “nick” out of the vein.
Any white in the retina (other than the optic nerve disc) is NOT normal. Suggestive of ischemia!
Opposite of the “white” of ischemia will be the diffuse “flame-like” hemorrhage from retinal vein occlusion caused by compression of the overlying artery. If central, the hemorrhages will be everywhere; if a branch retinal vein, just in the drained segment of the retina.
Cranial Nerve Disorders
- extraocular muscles PULL the eye, so whatever muscle is affected will not pull the eye as it should.
- Fourth cranial nerve palsy is more subtle (LR6, SO4) – pt will complain of a subtle diplopia.
- Ptosis: think 3rd nerve palsy; worry most about pupil-involving (blown pupil) third nerve palsy – this is a tumor until proven otherwise! They go to the ED to get a scan!
- Blown pupil + ptosis = tumor or stroke near CN III nucleus until proven otherwise.
Thyroid Eye Disease
- Hyperthyroidism will cause swelling and hypertrophy of EOMs, inferior affected most, causing deviation upward, decreased EOM.
- Should never see the sclera on the top or bottom of the iris.
- In severe cases, they will lose EOM altogether and proptosis to the point of eye extrusion.
- Any proptosis should be referred for evaluation by ophtho.
- Smoking worsens thyroid eye disease!
Cavernous Sinus Thrombosis
- The oculosympathetic plexus, CN III, IV, V and VI all go through the cavernous sinus.
- Tumors or clots in the cavernous sinus can crush or cause ischemia in these structures.
- Multiple cranial nerves affected at once is never a good thing.
- Compression of the optic chiasm will cause a homonymous hemianopsia.
- The farther back you go in the brain, the more congruous the visual fields are, and the more focal the visual loss will be.
Ischemic optic neuropathies usually get better. Tumor compression or traumatic neuropathies will not.
Toxocariasis: worm that infects the retina, from dogs and cats (don’t drink out of the dog bowl).
- If GCA is suspected, START THE PREDNISONE NOW at 80-100mg daily – they have about 7 days to get the temporal artery biopsy. Check an ESR ASAP.
- Any “funny blackouts in the vision” – get a sed rate.
- Any amaurosis symptoms – get a sed rate.
- Jaw pain or claudication – get a sed rate.
- Even if one eye is already blind, treat now – you’re saving the other eye.
- All AI diseases can affect the eye.
- Dry eye is the most common symptom of autoimmune diseases across the board.
- Scleritis: bright red scleral injection, there all the time, has a temporal boring pain (most common with RA, less common with sarcoid).
- Episcleritis: no temporal boring pain.
- Scleritis –> automatic rheum workup!
- Episcleritis is pretty common…
- Iritis: “everyone gets one free iritis in their lifetime,” but more than one, ID workup for syphilis, Reiter’s, rheum, sarcoid.
- Sarcoid causes “mutton fat” WBC globules in the inferior cornea.
- SLE: dry eyes, scleritis, autoimmune ulcerations of the cornea, retinal and optic neuropathy, cotton-wool spots (ischemic spots).
- Every JRA patient whether they have eye symptoms or not SHOULD see an ophthalmologist every 3-4 mos! They are at high risk of iritis (which can be asymptomatic).
HIV and CMV Retinitis
- HIV and CMV both love the eyes – cause retinitis.
- Most MS patients with sudden vision loss from optic neuritis will have an absolutely normal eye exam. This is a retrobulbar optic neuritis, so will not appear on the optic disc. May hurt when they move their eye.
Ischemic optic neuropathy will cause a white optic nerve – sometimes the whole, sometimes half. DDx: MS, stroke, infarct from meds (e.g., sildenafil).
Viagra can cause an optic neuropathy – esp far-sighted persons with small optic discs (“disk at risk”). These same patients are at higher risk for stroke of phenylephrine nasal sprays!
- Think about this in patients with a history of cold sores and a red eye. Especially if they don’t get better on antibiotic drops in 1-2 days.
- DO NOT PRESCRIBE STEROID DROPS – if you suspect iritis, give an NSAID anti-inflammatory, not a steroid!
Marfan’s Syndrome: ectropia lentis – displaced lens.
Wilson’s disease: Keyser-Fleischer rings and sunflower cataract.
Cat-scratch disease: can cause a star maculopathy from Bartonella.
Neurofibromatosis: can cause hamartomas in the iris and retinal gliomas on the optic nerve – NF patients should see an ophthalmologist, at least early in the course.
Chlamydia trachomatis: huge lymph nodules on the lid conjunctiva and PROFUSE purulent drainage. Can cause blindness in newborns from distortion of the lid and damage from the eyelashes rubbing.
Tuberous sclerosis: adenoma sebaceum, shagreen patch, ungual fibromas and ischemic retinopathy.
Von Hippel Lindau: will cause hemangiomas in the retina.