Ophthalmological


Bacterial Conjunctivitis

Rapid Review

  • Background
    • Infection and inflammation of conjunctiva caused by bacteria (typically S. aureus). May be unilateral or affect both eyes. Commonly known as “pink eye”
    • Pseudomonas aeruginosa most common cause for contact lens wearers
  • Signs/Symptoms
    • Itchy eyes w/ discharge or crusting; usually worse in the morning; may say eyes are “glued shut” when waking up.
    • Exam will show red/pink eye with yellow, purulent discharge
  • Diagnosis
    • Clinical diagnosis
  • Treatment
    • Antibiotic eye drops (ex. gentamicin/tobramycin) or ointment (ex. erythromycin)
    • For contact lens wearers, use fluoroquinolone drops (ciprofloxacin)
  • Disposition
    • Discharge is appropriate for most patients. Ophthalmology follow-up up required if the patient is a contact lens wearer or if there is a lack of improvement despite antibiotics.
    • Admit patients with severe cases or those thought to be caused by gonorrhea.

Pearls

  • Patients with conjunctivitis will usually continue to be contagious for up to 2 weeks, despite antibiotic treatment.
  • Antibiotic drops are typically used for adults and older children, but ointment is preferable in young children due to better compliance. 

Video Credit: allornonelaw


Blepharitis

Rapid Review

  • Background
    • Acute or chronic inflammation of the eyelid margins, most commonly caused by dysfunctional meibomian gland or staph infection
    • Further divided into anterior and posterior blepharitis
  • Signs/Symptoms
    • Itchy/sore, tearing, blurry vision
    • Crusting at lid margins, eye flaking, red-rimming of eyelid
  • Diagnosis
    • Slit-lamp exam
  • Treatment
    • Warm compresses, irrigation, massage
    • Topical antibiotics (ex. erythromycin, bacitracin) if infection suspected
  • Disposition
    • Most patients can be discharged. Recommend ophthalmology follow-up for refractory cases. 

Pearls

  • Although typically caused by bacteria, blepharitis can sometimes be caused by viral pathogens such as herpes or VZV. These cases may require antivirals (acyclovir, valacyclovir)
  • Some cases of bleparitis may be chronic due to meibonmian gland dysfunction. There may be a role for oral antibiotics in these cases (ex. azithromycin or doxycycline) as this helps alter the composition of skin bacteria and meibominan gland secretion. 
Video Credit: Medical Centric


Corneal Foreign Body

Rapid Review

  • Background
    • Foreign material that becomes embedded on or in the corneal epithelium.
    • Commonly caused by grinding or hammering metal w/o eye protection.
  • Signs/Symptoms
    • Eye pain, tearing, foreign body sensation, blurred/decreased vision (rare)
    • (+) Seidel sign; suggests corneal perforation
  • Diagnosis
    • Slit lamp or X-ray
  • Treatment
    • Topical anesthetic, irrigation/cotton-swab
    • Deep foreign bodies and rust rings may require removal by ophthalmologist 
  • Disposition
    • Most patients can be discharged if the foreign body has been successfully removed and there was no penetration into the globe. Ophthalmology follow-up in 24 hours is required if a large defect or rust ring is left over.
    • Admit any patient with retained foreign bodies. Consult ophthalmology.

Pearls

  • Be especially careful with high impact metal projectiles (power tools, metal-on-metal impacts, weapons, etc.). These carry a greater risk of ocular involvement. 
  • Ultrasound may be useful for identifying intraocular foreign bodies, but should not be used for open globe injuries.
Video Credit: Larry Mellick


Globe Rupture

Rapid Review

  • Background
    • Full thickness corneal/scleral injury, causing compromise to the globe.  
    • Occurs when blunt or penetrating force is applied to the eye, causing an abrupt rise in intraocular pressure. This is a vision threatening emergency
  • Signs/Symptoms
    • Eye pain, tearing, limited extraocular movements, hyphema, extrusion of intraocular contents, teardrop-shaped pupil
  • Diagnosis
    • Clinical diagnosis; CT can may help identify fractures or foreign bodies
    • Do NOT perform tonometry (may worsen injury)
  • Treatment
    • Minimize intraocular pressure (pain control, nausea/vomiting control, antitussives, elevate head of bed). Update tetanus.
    • Emergent ophthalmologic consultation for surgical management
  • Disposition
    • Admission with emergent ophthalmologic consultation is required for all cases of globe rupture.

Pearls

  • Do not apply a gauze dressing alone to the eye (this adds very little protection). Protect the eye with a paper cup or commercial eye shield.
  • Once a globe rupture is identified or suspected, be sure to minimize further examination until it is time to repair. 
Video Credit: EM in 5


Orbital Cellulitis

Rapid Review

  • Background
    • Infection of the orbital tissues behind the eye. Most often a complication of sinusitis, but can also occur from orbital trauma or tooth/ear infections.
    • Most often affects children ages 7-12 years of age
  • Signs/Symptoms
    • Limited extraocular movement, proptosis, painful eye movements, fever
  • Diagnosis
    • Mostly clinical
    • CT scan of orbits can confirm diagnosis
  • Treatment
    • Broad-spectrum antibiotics (ex. Vancomycin + Zosyn)
    • Consult ophthalmology. May require surgical drainage.
  • Disposition
    • All cases of orbital cellulitis require admission.

Pearls

  • Orbital cellulitis is differentiated from preseptal cellulitis through involvement of the orbital septum, which will cause pain w/ extraocular movements, proptosis, and decreased ocular motility.
  • Several complications can arise from orbital cellulitis, including cavernous sinus thrombosis, meningitis, brain abscess, and orbital abscess.
Video Credit: Larry Mellick

Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021