Ophthalmology for the Internist Robert F. Nash D.O. November 2006.

Ophthalmology for the Ophthalmology for the InternistInternist

Robert F. Nash D.O.Robert F. Nash D.O.

November 2006November 2006

Ophthalmology for the InternistOphthalmology for the Internist

Physical ExamPhysical Exam

Red EyeRed Eye

Acute Loss of VisionAcute Loss of Vision

Complications of Systemic DiseasesComplications of Systemic Diseases

Physical ExamPhysical Exam

Visual AcuityVisual Acuity

Confrontation visual Confrontation visual fieldfield

External InspectionExternal Inspection

Conjunctiva and Conjunctiva and sclera inspectionsclera inspection

Extraocular MusclesExtraocular Muscles

Pupillary ReactionsPupillary Reactions

Cornea and iris Cornea and iris inspectioninspection

Anterior chamber Anterior chamber examexam

Lens clarityLens clarity

Ophthalmoscopic Ophthalmoscopic ExamExam

Red EyeRed Eye


Part IPart I

Red EyeRed Eye

ConjuctivitisConjuctivitis

Corneal InjuryCorneal Injury

Subconjunctival HemorrhageSubconjunctival Hemorrhage

IritisIritis

EpiscleritisEpiscleritis

ScleritisScleritis

TraumaTrauma

Acute angle-closure glaucomaAcute angle-closure glaucoma

ConjunctivitisConjunctivitis

Chemical conjunctivitis- EmergencyChemical conjunctivitis- Emergency– FLUSH-FLUSH-and FLUSHFLUSH-FLUSH-and FLUSH– Then, do your H&PThen, do your H&P– Acid v. BaseAcid v. Base

Viral v. Bacterial conjunctivitisViral v. Bacterial conjunctivitis– Difficult to distinguishDifficult to distinguish

Purulent discharge- more common with bacterial etiologyPurulent discharge- more common with bacterial etiologyPre-auricular lymphadenapathy- more common with viral Pre-auricular lymphadenapathy- more common with viral etiologyetiologySexually activeSexually active

ConjunctivitisConjunctivitis

AllergicAllergic– TreatmentsTreatments

BlepheritisBlepheritis– SeborrheaSeborrhea– BacterialBacterial

Corneal InjuryCorneal Injury

Sharp pain, improves with Topical Sharp pain, improves with Topical anesthetic, worse with blinkinganesthetic, worse with blinking

Foreign body sensationForeign body sensation

Foreign Body v KeratitisForeign Body v Keratitis

Fluorescein to locate pathologyFluorescein to locate pathology

KeratitisKeratitis

Inflamed corneaInflamed cornea– Contact misuseContact misuse– UV damageUV damage– Dry eyesDry eyes– Viral causesViral causes

TreatmentTreatment

Subconjunctival HemorrhageSubconjunctival Hemorrhage

Solitary red spot usually unilateral and Solitary red spot usually unilateral and always painlessalways painless

Causes:Causes:– CoughCough– AnticoagulationAnticoagulation– HypertensionHypertension– VomitingVomiting

IritisIritisInflammation or iris and/or cilary bodiesInflammation or iris and/or cilary bodies

Predisposing Factors:Predisposing Factors:

– HLA B27 HLA B27

– Ankylosing spondylitis, Ankylosing spondylitis,

– Reactive arteritis (Reiters syndrome), Reactive arteritis (Reiters syndrome),

– psoriatic arteritis, psoriatic arteritis,

– irritable Bowel disease irritable Bowel disease

– Crohn's diseaseCrohn's disease

– Multiple Sclerosis (HLA B15), Multiple Sclerosis (HLA B15),

– Sarcoidosis, Sarcoidosis,

– systemic Lupus Erythematosussystemic Lupus Erythematosus

– Lyme diseaseLyme disease– Juvenile Idiopathic arteritisJuvenile Idiopathic arteritis– Sexually transmitted diseases Sexually transmitted diseases – Cat Scratch diseaseCat Scratch disease– Toxoplasmosis, toxocardiaToxoplasmosis, toxocardia– Presumed Ocular Histoplasmosis Presumed Ocular Histoplasmosis

syndromesyndrome– Lyme diseaseLyme disease– whipples diseasewhipples disease– valley fevervalley fever– TuberculosisTuberculosis– LeptospirosisLeptospirosis– Rocky Mountain Spotted fever.Rocky Mountain Spotted fever.

IritisIritis

HPI: Pain, blurry vision, PhotophobiaHPI: Pain, blurry vision, Photophobia

PE: Sluggish, smaller pupil, “Cilary Flush”, PE: Sluggish, smaller pupil, “Cilary Flush”, Vessels do not blanch or move with swabVessels do not blanch or move with swab

Inflammatory cells seen with slit lampInflammatory cells seen with slit lamp

Treatment: CorticosteroidsTreatment: Corticosteroids

Consult : OphthalmologyConsult : Ophthalmology

EpiscleritisEpiscleritis

Inflammation of superficial layer of scleraInflammation of superficial layer of sclera

HPI: Red eye, sudden onset, without any HPI: Red eye, sudden onset, without any known cause, minimal discharge with known cause, minimal discharge with some discomfortsome discomfort

PEPE

Treatment: NSAIDSTreatment: NSAIDS

ScleritisScleritis

Strong association with system diseasesStrong association with system diseases– Rheumatoid arteritisRheumatoid arteritis– Chronic infectionsChronic infections– Connective tissue diseaseConnective tissue disease

PainPain

Treatment: systemic steroidsTreatment: systemic steroids

Consult: OphthalmologyConsult: Ophthalmology

Acute angle closure GlaucomaAcute angle closure Glaucoma

5% of all Glaucoma5% of all GlaucomaPrecipitated by dilation of pupilPrecipitated by dilation of pupilHPI: Eye pain, blurry vision, Haloes, Nausea and HPI: Eye pain, blurry vision, Haloes, Nausea and vomiting, Headachevomiting, HeadachePEPE– Shallow anterior chamberShallow anterior chamber– Pupil fixedPupil fixed– Cornea hazinessCornea haziness– Eye feels firmEye feels firm

Acute angle closure GlaucomaAcute angle closure Glaucoma

TreatmentTreatment– Pilocarpine – MioticPilocarpine – Miotic– Laser surgery - IridectomyLaser surgery - Iridectomy

Consult - OphthalmologyConsult - Ophthalmology

Red Eye Differential Diagnosis

Viral Conjunctivitis

Bacterial Conjunctivitis

Chemical Conjunctivitis

Corneal Injury

Episcleritis Scleritis IritisAngle closure Glaucoma

Redness Diffuse Diffuse DiffuseLocal ordiffuse

LocalizedLocalized or diffuse

Surrounding cornea

Surrounding cornea

PainDiscomfort

Discomfort

+/- + + + + +

Visual Acuity

Normal Normal Normal +/- Normal Normal Blurred Decreased

Discharge Watery + Watery + - - - -

Pupil Normal Normal Normal Normal Normal Normal SmallOften dilated orfixed

Acute Vision LossAcute Vision Loss


Part IIPart II

Acute Vision LossAcute Vision Loss

GlaucomaGlaucoma

Iritis Iritis

Corneal UlcerCorneal Ulcer

HyphemaHyphema

HypopionHypopion

Vitreous HemorrhageVitreous Hemorrhage

Retinal detachmentRetinal detachment

Retinal vascular Retinal vascular occlusionocclusion

Optic NeuritisOptic Neuritis

Optic NeuropathyOptic Neuropathy

PapilledemaPapilledema

CVACVA

All require Ophthalmologic All require Ophthalmologic ConsultConsult

See above…See above…

GlaucomaGlaucoma

IritisIritis

Corneal UlcerCorneal Ulcer

Bacteria v. FungalBacteria v. Fungal

Severe eye painSevere eye pain

Can be seen on cornea as a white spotCan be seen on cornea as a white spot

Topical Broad spectrum antibioticsTopical Broad spectrum antibiotics

HyphemaHyphema

Blood in anterior chamberBlood in anterior chamber

Easily seen: red air-fluid levelEasily seen: red air-fluid level

Traumatic cause most commonTraumatic cause most common

Usually self limited Usually self limited

Eye pressure must be monitoredEye pressure must be monitored

HypopionHypopion

Leukocytes in anterior chamberLeukocytes in anterior chamber

Penetrating trauma to eyePenetrating trauma to eye

AntibioticsAntibiotics

Consult OphthalmologistConsult Ophthalmologist


Extravasation of blood into potentional Extravasation of blood into potentional spaces in and around the vitreous bodyspaces in and around the vitreous body

Blood blocks red reflexBlood blocks red reflex


Causes:Causes:– Proliferative Diabetic retinopathy (31.5-54%)Proliferative Diabetic retinopathy (31.5-54%)– Retinal tears (11.4-44%)Retinal tears (11.4-44%)– Trauma (12-18.8%)Trauma (12-18.8%)– Neovascularization (3.5-16%)Neovascularization (3.5-16%)– Posterior vitreous Detachment with retinal vascular Posterior vitreous Detachment with retinal vascular

tears (3.7-11.7%)tears (3.7-11.7%)– Proliferative sickle cell retinopathyProliferative sickle cell retinopathy– Macroaneurysm (0.6-4.3%)Macroaneurysm (0.6-4.3%)

Subarachnoid HemorrhageSubarachnoid Hemorrhage


May cause retinal damage, floaters, and May cause retinal damage, floaters, and glaucomaglaucoma

Treat the underlying causeTreat the underlying cause

May require surgical removal of bloodMay require surgical removal of blood

Retinal DetachmentRetinal Detachment

Lifetime risk: 1 in 300Lifetime risk: 1 in 300

Causes:Causes:– Sarcoid iritisSarcoid iritis– Severe hypertensionSevere hypertension– NeoplasmNeoplasm– FibrosisFibrosis

Retinopathy (DM)Retinopathy (DM)

TraumaTrauma

– Posterior Vitreous detachmentPosterior Vitreous detachment

Retinal DetachmentRetinal Detachment

HPI: painless, curtain sensation, flashes of HPI: painless, curtain sensation, flashes of lightlightTreatment: Treatment: – Laser surgeryLaser surgery– Scleral bucklingScleral buckling– Posterior vitrectomyPosterior vitrectomy– Pneumatic retinopexyPneumatic retinopexy

Prognosis: Good, if macula is not involvedPrognosis: Good, if macula is not involved

Retinal Arterial OcclusionRetinal Arterial Occlusion

CausesCauses– EmboliEmboli– TIATIA– VasculitisVasculitis– Must check Carotid circulationMust check Carotid circulation

SuddenSuddenPainlessPainlessCurtain sensationCurtain sensationCherry red spot – Fovea against the white retinaCherry red spot – Fovea against the white retinaHollenhorst PlaquesHollenhorst Plaques– Glistening yellow flakesGlistening yellow flakes

Permanent or temporary (Amaurosis Fugax)Permanent or temporary (Amaurosis Fugax)

Retinal Arterial OcclusionRetinal Arterial Occlusion

TreatmentTreatment– Ballot eye 10 sec cyclesBallot eye 10 sec cycles– Paracentesis of anterior chamberParacentesis of anterior chamber

Optic NeuritisOptic Neuritis

Inflamed nerveInflamed nerve

MSMS

May have pain behind eyeMay have pain behind eye

PE:PE:– May have optic nerve pallorMay have optic nerve pallor– Pupil light reflex abnormalityPupil light reflex abnormality– Tenderness with ROMTenderness with ROM

MRIMRI

Treatment: IV GlucocorticoidsTreatment: IV Glucocorticoids

Note: 30-50% will develop MS within 15 years of diagnosisNote: 30-50% will develop MS within 15 years of diagnosis

Optic NeuropathyOptic Neuropathy

Giant Cell arteritisGiant Cell arteritis– Jaw ClaudicationJaw Claudication– Over 60Over 60– MalaiseMalaise– HeadacheHeadache– FeverFever– Scalp tendernessScalp tenderness– Weight lossWeight loss– Polymyalgia Polymyalgia

RheumaticaRheumatica

TraumaTrauma– Disruption of vascular Disruption of vascular

supply to optic nervesupply to optic nerve– Nerve impingementNerve impingement

Giant Cell arteritisGiant Cell arteritis

8-15% of all Temporal arteritis patients 8-15% of all Temporal arteritis patients develop acute loss of visiondevelop acute loss of vision

If suspectedIf suspected– Sed rateSed rate

>50>50– SteroidsSteroids– Temporal artery biopsyTemporal artery biopsy

Traumatic Optic NeuropathyTraumatic Optic Neuropathy

Poor prognosisPoor prognosis

May try steroids, surgeryMay try steroids, surgery

CVACVA

May cause acute vision loss due to optic May cause acute vision loss due to optic nerve infarct or cerebral infarctnerve infarct or cerebral infarct

May cause partial vision loss unilaterally or May cause partial vision loss unilaterally or bilaterallybilaterally

Ophthalmologic Complications Ophthalmologic Complications of Systemic Diseaseof Systemic Disease

Ophthalmology for the Ophthalmology for the InternistInternistPart IIIPart III

Ophthalmologic Complications of Ophthalmologic Complications of Systemic DiseaseSystemic Disease

Hypertension: A-V nickingHypertension: A-V nicking

Diabetes Mellitus: Diabetic RetinopathyDiabetes Mellitus: Diabetic Retinopathy

Syphilis: Marcus-Gunn pupilSyphilis: Marcus-Gunn pupil

Intracranial Edema: Papillary EdemaIntracranial Edema: Papillary Edema

Hyperthyroidism: ExophthalmosHyperthyroidism: Exophthalmos

Herpes Zoster: VesiclesHerpes Zoster: Vesicles

CMV Infection: Cotton wool spotsCMV Infection: Cotton wool spots

ReferencesReferencesAlward WL. Medical Management of Glaucoma. NEJM 1998; 339:1298-1307.Alward WL. Medical Management of Glaucoma. NEJM 1998; 339:1298-1307.

Uptodate, 2006Uptodate, 2006

Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan. 2005Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan. 2005

LECOM note server, Crane W. Acute Visual Loss, Eye in Systemic DZ, and The Red Eye.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.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-Hara JH. The Red Eye: Diagnosis and Treatment. Amer Family Phys 1996; 54(8): 2423- 2430.2430.

Havener WH. Synopsis of Ophthalmology. 1975: Chapter 10: Diagnosis and management of the Red Eye.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):Patel SJ. Ocular Manifestations of Autoimmune Disease. Amer Family Phys 2002; 66(6): 991-998.991-998.

Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000;Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000; (2): CD001211.(2): CD001211.

Question 1Question 1

Which of the following components of a Which of the following components of a Physical exam is first?Physical exam is first?

a)a) Visual AcuityVisual Acuity

b)b) Confrontation visual fieldConfrontation visual field

c)c) External InspectionExternal Inspection

d)d) Conjunctiva and sclera inspectionConjunctiva and sclera inspection

Answer 1Answer 1

Which of the following components of a Which of the following components of a Physical exam is first?Physical exam is first?

a)a) External InspectionExternal Inspection

b)b) Confrontation visual fieldConfrontation visual field

c)c) Visual AcuityVisual Acuity

d)d) Conjunctiva and sclera inspectionConjunctiva and sclera inspection


When a patient is believed to have a When a patient is believed to have a chemical conjunctivitis, the first thing to chemical conjunctivitis, the first thing to do is?do is?

a)a) Physical examPhysical exam

b)b) Visual acuityVisual acuity

c)c) Flush eye immediatelyFlush eye immediately

d)d) Obtain a HistoryObtain a History

Answer 2Answer 2

When a patient is believed to have a When a patient is believed to have a chemical conjunctivitis, the first thing to do chemical conjunctivitis, the first thing to do is?is?a)a) Physical examPhysical exam

b)b) Visual acuityVisual acuity

c)c) Flush eye immediatelyFlush eye immediately

d)d) Obtain a HistoryObtain a History


Patient presents with “deep eye pain”, Patient presents with “deep eye pain”, blurry vision, Photophobia. Sluggish, blurry vision, Photophobia. Sluggish, smaller pupil, and “Cilary Flush” on PE. smaller pupil, and “Cilary Flush” on PE. Vessels do not blanch or move with a Vessels do not blanch or move with a swab. What is the probable diagnosis?swab. What is the probable diagnosis?

a)a) Bacterial conjunctivitisBacterial conjunctivitisb)b) Subconjunctival hemorrhageSubconjunctival hemorrhagec)c) IritisIritisd)d) Acute angle closure glaucomaAcute angle closure glaucoma

Ophthalmology for the Internist Robert F. Nash D.O. November 2006.

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Transcript of Ophthalmology for the Internist Robert F. Nash D.O. November 2006.