Ophthalmological

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. 

Deep Dive

• Bacterial Conjunctivitis (emDOCs)

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. 

Deep Dive

• Blepharitis (Merck Manual)

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.

Deep Dive

• Ocular Foreign Body (WikEM)

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. 

Deep Dive

• Globe Rupture (WikEM)

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.

Deep Dive

• Orbital Cellulitis (emDOCs)