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EYE - Coggle Diagram
EYE
Blurred Vision
Myopia
image focuses in front of retina
Hyperopia
image focuses behind retina
Astigmatism
misshapen cornea (causes blurring and double imaging)
Amblyopia "lazy eye"
Refractive amblyopia -- anisometropia (one eye)
Refractive amblyopia -- isoametropia (both eyes)
Strabismus amblyopia
Deprivation amblyopia (i.e. cataract)
management: occlusion therapy, glasses, penalization therapy (atropine drops to blur good eye), optometric vision therapy
Strabismus
muscle weakness causes abnormal alignment in one eye (constant or intermittent)
esotropia -- visual axis converged
exotropia -- visual axis diverged
hyperdeviation -- visual axis elevated
hypodeviation -- visual axis depressed
management: strengthen eyes, reposition eye muscles, remove cataract
Presbyopia
difficulty adjusting focus when switching from near to distance vision, eye fatigue, headaches with close work
starts after age 40
management: reading glasses, prescription lenses (i.e. bifocal), surgery (conductive keratoplasty, photo refractive keratoplasty, lasik, lasek)
Retinoblastoma
malignant tumor of retina
white eye reflex
blurred vision, pattern deprivation, defocus
hereditary (multiple tumors both eyes) and non-hereditary (tumor in one eye)
management: cryotherapy, laser therapy, radioactive plaque, thermotherapy, chemotherapy, radiotherapy, surgery (eye removal)
Macular Degeneration
Congenital Cataracts
inherited
disease associated -- galactosemia
intrauterine infection -- Rubella
endocrine related -- diabetes
renal related -- Alport/Lowe syndromes
chromosome abnormality -- down's syndrome
neuromuscular -- myotonic dystrophy
trauma
management: glasses, surgery
Other disease
brain tumors
cerebral palsy
down syndrome
hydrocephalus
Systemic Disease
Vascular disorders
Hypertension
AV nicking
copper wiring
cotton wool spots
hemorrhages
risk factor for retinal vein and artery occlusion
arteriolar narrowing
Papiledema
disc is swollen with blurred edges
vessels obliterated
Central Retinal Artery Occlusion
pale retina
cherry red spot on fovea
sudden PAINLESS monocular vision loss
management: immediate ophtho consult, orbital massage, reduce IOP, vasodilator, stroke eval
Central Retinal Vein Occlusion
sudden PAINLESS monocular vision loss
blood and thunder
management: ophtho consult, anti-VEGF
Amaurosis Fugax
sudden, transient, PAINLESS vision loss of one or both eyes lasting seconds to 30 min
ischemia to retina or optic nerve
Diabetic Retinopathy
proliferative (abnormal growth of blood vessels; traction on retina --> retinal detachment)
non-proliferative (hemorrhages, exudates)
vessels are more leaky; hemorrhage
aneurysm
hard exudate
macular edema
Retinal Detachment
sudden PAINLESS vision loss
flashes/floaters
Retinal hemorrhage
Autoimmune
Keratoconjunctivitis Sicca
inflammation and damage due to decreased tear production
RA, Sjogren's syndrome, SLE
dryness, FB sensation, burning, photophobia
management: Restasis (Cyclosporine), lubrication, punctal occlusion
Uveitis/Iritis
inflammation of iris and ciliary muscle
red eye, pain, photophobia, headache, possible decreased vision, pupil irregularities
ciliary flush (engorged conjunctival vessels at corneal edge)
ankylosing spondylitis, JRA, reactive arthritis, IBD, syphilis, TB, herpes simplex, herpes zoster
management: ocular steroids, cycloplegia
Scleritis
red eye, tearing, photophobia, severe pain
inflammation of sclera
ankylosing spondylitis, SLE, RA, Polyarteritis Nodosa, Wegener's, post herpes zoster ophthlamicus, syphilis, gout
management: NSAIDs, systemic steroids
Optic neuritis
MS (#1), SLE, lyme disease, malignancy, syphilis
monocular vision loss, loss of color vision, worsening with eye movement
APD, decreased acuity, pain with eye movement
management: systemic corticosteroids
Grave's ophthalmopathy
retraction of lids and exposure of cornea and conjunctiva
gritty sensation, tearing, pain, blurry vision, diplopia
proptosis, lid retraction, lid lag
management: lubricants
Giant cell arteritis
Polymyalgia rheumatica
headache, jaw pain, engorged temporal artery, APD, swollen optic disc
sudden PAINLESS vision loss
management: high dose systemic corticosteroids
Neoplastic
Ocular melanoma
most common primary ocular tumor
asymptomatic, flashes/floaters, visual field defects
management: uveal tract radiation or chemotherapy
Metastatic Carcinoma
most common intraocular malignancy (lung and breast cancers)
Pituitary Tumors
compression of optic chiasm
bitemporal hemianopsia
headaches, visual disturbance, behavioral changes
Infection
CMV Retinitis and AIDS
PAINLESS blurred/decreased vision
management: antiviral (Valgancyclovir) and start HAART with ID
Aging
Open-Angle Glaucoma
overproduction of aqueous humor and/or reduced outflow
elevated IOP (>20) --> thinned, damaged optic disc (increased cupping)
asymptomatic, loss of peripheral vision, PAINLESS
RF: age, FHx, HTN, DM, myopia, AA, steroid use
management: beta blockers (Timolol), prostaglandins (Latanoprost), carbonic anhydrase inhibitor (Acetazolamide), laser therapy
Macular Degeneration
loss of central vision
degenerative disease of the central portion of the retina (macula)
RF: age, smoking, FHx, CVD, alcohol
Dry = drusen deposits
management: smoking cessation, antioxidants/vitamins, regular eye exams, visual aids
Wet = neovascularization and subretinal fluid collection
management: antioxidants/vitamins, intravitreal VEGF inhibitor
Cataract
opacity of the lens (protein no longer transparent)
difficulty with night driving due to glare, poor distance vision, reduced color
management: surgical lens replacement
RF: age, smoking, alcohol, sunlight, HIV/AIDS, systemic corticosteroid use, metabolic syndrome/DM
Red Eye
NON-Vision Threatening
Hordeolum
localized lid tenderness, swelling, erythema, localized lump at margin
management: warm compresses
Blepharitis
localized inflammation of lid margins at lash surfaces
types: staphylococcal/seborrhea, seborrhea/rosacea, mixed
lid burning/itching, crusting (mattering), sticky morning lashes, loss of lashes (notching), dry eyes
management: lid and face hygiene, moist compresses, lid massage, artificial tears, topical antibiotic ointment
Subconjunctival Hemorrhage
extravasated blood due to rupture of conjunctival vessels
spontaneous, straining, Valsalva, HTN
bright red blood patch (well-demarcated), normal vision, PAINLESS
management: reassurance b/c self-resolving
Dry Eyes
burning, gritty sensation, reflex tearing, minimal conjunctival erythema
aging, RA, Sjogren's, systemic medications, lack of blinking
management: artificial tears, lubricating ointment, Cyclosporine, ophtho referral
Corneal Abrasion
tearing, photophobia, initial FB sensation, blurred vision, small pupil, conjunctival erythema, Fluorescein stain defect
disruption of the corneal epithelium from trauma
management: cycloplegic drops, topical antibiotics, oral analgesic, follow up 24 hrs, refer to ophtho
Chalazion
management: refer to ophtho for excision
chronic stye, deeper lump, non-tender
Conjunctivitis
inflammatory process causing dilation of bulbar/palpebral conjunctival vessels
infectious:
bacterial
purulent discharge, lids matted shut in AM
starts in one eye
NOT itchy and NO vision changes
staphylococcus, streptococcus, H. influenzae
management: warm moist lid compresses, no contacts, topical antibiotic (erythromycin, trimethoprim, fluoroquinolones), refer to ophtho if no improvement or vision impairment, pain, tearing, photophobia
viral
watery serous discharge, pre-auricular lymph nodes, morning crusts, gritty/burning, starts unilateral and moves to other eye (usually)
adenovirus
most common form of acute red eye
highly contagious
associated URI symptoms (sore throat, fever, malaise, cough)
management: self-limited, refer to ophtho if pain, photophobia, decreased vision, or no resolution in 2 weeks
non-infectious:
allergic
watery stringy white mucus discharge, itching, burning, lid/conjunctival edema/erythema, bilateral, palpebral cobblestoning
hay fever/allergic rhinitis, asthma, eczema
cosmetics, products
management: oral antihistamines, topical H1 blocker/mast cell inhibitor, artificial tears, cool lid compresses, refer to ophtho and allergist
non-allergy
Dacryocystitis
infection/inflammation of the lacrimal sac secondary to nasolacrimal duct obstruction
management: dacryocystorhinostomy
Nasolacrimal Duct Obstruction
congenital (infants; unilateral tearing)
acquired (adults; tearing, discharge, mild conjunctivitis, erythema, edema, tenderness)
management: massage tear sac, probing irrigation, oral antibiotics
Pinguecula
focal elevation of conjunctiva
exposure to wind, dust, dry eye
yellow-white slightly raised lesion, asymptomatic
management: artificial tears, eye protection, topical anti-inflammatories or OTC vasoconstrictors
Pterygium
fibrovascular growth caused by UV light exposure
wing-shaped, nasally located, crosses limbus
management: artificial tears, eye protection, topical anti-inflammatories or OTC vasoconstrictors, refer to ophtho for surgical excision
Episcleritis
inflammation of the episcleral vessels
idiopathic, sometimes related to autoimmune disorders
acute onset, localized/segmental injection away from cornea, unilateral, mild pain, no discharge
management: refer to ophtho
Vision Threatening
Periorbital/Pre-septal Cellulitis
infection/inflammation of the anterior ocular structures (eyelids)
unilateral, edema, erythema, tender lids
vision, pupils, ocular motility NOT IMPAIRED
management: oral antibiotics, warm compresses, closely monitor
Scleritis
edema, local tenderness to touch, segmental focal erythema --> decreased vision --> deep intense severe pain
inflammation/degeneration of the sclera
RA, vasculitis
management: refer to ophtho (steroids)
Keratitis (corneal infection)
bacterial
secondary to progressive conjunctivitis, contact lens overuse, corneal abrasion, dry eyes
conjunctival/circumcorneal erythema, photophobia, decreased vision, FB sensation, purulent discharge, focal white corneal opacity
RF: contact lenses
management: ophtho referral stat
viral
herpes simplex, herpes zoster, adenovirus
conjunctival/circumcorneal erythema, tearing, watery discharge, decreased vision, FB sensation, vesicles on skin (if zoster), dendrites (if herpetic)
management: ophtho referral
exposure
inflammation of the conjunctiva/cornea due to incomplete lid closure
mild conjunctival erythema, burning sensation
management: lubricants, refer to ophtho if severe
Iritis
deep intense pain, photophobia, decreased vision, circumcorneal/circumlimbal redness (ciliary flush), small irregular pupil
inflammation of the iris and sometimes ciliary body
systemic inflammation, autoimmune, infectious
complications: glaucoma and cataracts
management: urgent ophtho referral
Acute Angle-Closure Glaucoma
deep intense pain, corneal edema, halo vision, severe ocular pain and frontal headache, nausea, vomiting, circumcorneal erythema, mid-dilated nonreactive pupil, cloudy cornea, decreased vision, photophobia
acute blockage of aqueous outflow channels causing increased IOP
dim light, pharmacologic agents, emotional stress
usually unilateral
management: refer to ophtho stat, Acetazolamide (PO or IV), topical Timolol, Pilocarpine, iridotomy (bilateral)
Orbital/Septal Cellulitis
infection/inflammation of the structures posterior to the orbital septum
edema, erythema, warmth, tenderness, chemosis, EOM PAINFUL AND IMPAIRED, proptosis, decreased vision, disc edema
management: hospitalization, ophtho and ENT consult, blood culture, orbital CT scan, IV antibiotics, surgical debridment
complications: meningitis, abscess, cavernous sinus thrombosis
Signs and symptoms needing referral:
decreased vision
ocular pain
photophobia
FB sensation
proptosis
corneal opacity/edema
corneal ulcers/dendrites
circumcorneal injection
abnormal pupil
Possible causes:
allergy
itching
infection
discharge
systemic conditions (inflammatory)
mechanical trauma
chemicals
Trauma
Emergency conditions
Alkali burns
immediate irrigation essential
management: instill topical anesthetic, use lid speculum, use GU bag or IV full open, stat ophtho consult
Open globe
obvious if large, eccentric or peaked pupil, pigmented mass on cornea, limbus or subconjunctival space, soft eye with indented cornea
management: stop exam, no topical meds, shield, CT, stat ophtho consult, antiemetics for N/V
Serious non-emergent injuries
Lid laceration
must rule out globe injuries
fat prolapse --> suspect penetrating injury or FB
management: close in layers lateral 2/3 upper/lower lid; refer to ophtho for medial 1/3 and injuries w/ significant tissue loss
Orbital fracture
compression of orbital rim, palpable step-off, flattened malar eminence, enophthalmus, epistaxis, upper lip/cheek numbness
management: repair elective (refer to ophtho and ENT)
Hyphema
grade by % AC filled with blood
must rule out perforating injury
sickle cell eval for non-Caucasian and asian pts
25% pts have other injuries like vitreous hemorrhage, subluxed lens and retinal damage
Minor non-emergent injuries
Corneal abrasion
Conjunctival/corneal FB
Subconjunctival hemorrhage
Vision Loss
Painful:
keratitis
corneal ulcer
corneal infection (HSV, VZV)
anterior uveitis/iritis
scleritis
endophthalmitis
acute angle closure glaucoma
temporal arteritis
optic neuritis
Painless:
retinal detachment
vitreous hemorrhage
CRAO
CRVO