Allergic rhinitis, 477.9
Bell’s palsy, 351.0
Central and branch retinal artery obstruction, 362.30
Conjunctivitis, 372.30
Corneal abrasion, 918.1
Diabetic retinopathy, 362.01
Epiglottitis, 464.30
Epistaxis, 784.7
Glaucoma, 365.9
Otitis externa, 380.10
Otitis media, 382.9
Pharyngitis, 462.0
Retinal detachment, 361.9
Sinusitis, 473.9
Temporomandibular joint disorder, 524.60
Trigeminal neuralgia (tic douloureux), 350.1
Vertigo, 780.4
I. Definition
A. Common, generally acute, painful inflammation with or without infection of the conjunctiva (palpebral or bulbar), but not involving the cornea or deeper structures of the eye
B. Can be chronic, but most cases are acute, and many are infectious
II. Etiology/predisposing factors
A. Spread by direct inoculation via fingers or droplets
B. Bacterial
1. Staphylococcus aureus
2. Pseudomonas
3. Haemophilus influenzae
4. Streptococcus pneumoniae
5. Moraxella
6. Gonorrhea and chlamydia
C. Viral
1. Commonly adenovirus
2. Herpes virus (may be vision threatening)
D. Allergens/hypersensitivity to
1. Pollen
2. Dust
3. Contact lenses
4. Dyes
5. Ophthalmic drops
E. Trauma (chemical and ultraviolet flash burns)
F. Keratoconjunctivitis sicca (dry eye)
G. Parasitic infestation (pediculosis pubis)
H. Systemic infection
1. Reiter’s syndrome
2. Behçet’s syndrome
3. Temporal arteritis
I. May accompany other eye disorders
1. Keratitis
2. Uveitis
3. Acute angle-closure glaucoma
J. Medication adverse effects (e.g., antihistamines, anticholinergics)
K. Environmental insults (wind, heat, sun)
III. Subjective findings
A. Redness or excessive tearing (sense of a foreign body in the eye)
B. Swelling or itching
C. History of allergenic/infectious/traumatic exposure
D. Discharge
IV. Physical examination findings
A. Visual acuity (See V., Laboratory/Diagnostic Findings.)
B. Edema of external eye or lid
C. Extraocular movement (EOM), visual fields, pupillary response, cornea, and anterior chamber are usually normal. The presence of photophobia rules out conjunctivitis.
D. Conjunctival injection/swelling (chemosis)/foreign body
1. While wearing gloves, evert the upper lid by rolling it externally along the cotton end of a swab, and inspect for foreign bodies or papillary changes.
a. Normal internal lid is pink and smooth.
b. With injection, “bumpy” flesh or cobblestone appearance (i.e., giant papillary conjunctivae) indicates tissue changes induced by chronic irritation, as from
i. Poor hygiene
ii. Improper use of extended wear contacts
2. Examine for obvious foreign body.
E. Drainage may be purulent or serous. If intent is to culture, a specimen should be taken before drops or irrigation is instilled.
V. Laboratory/diagnostic findings
A. Decreased visual acuity may indicate a more serious condition.
B. Consider culture of secretions: Giemsa’s stain for possible infection with chlamydia or gonorrhea
VI. Management
A. To rule out corneal abrasion or foreign body
1. Instill topical anesthetic (2 drops tetracaine [Pontocaine], 0.5%, or proparacaine, 0.5%).
2. Stain the eye with fluorescein with the use of drops or paper.
3. Examine under ultraviolet light or slit lamp.
B. Bacteria
1. Topical antibiotic ophthalmic solutions or ointments
a. Gentamicin, 3 mg/ml solution or 3 mg/g ointment, 1 to 2 drops every 4 hours while awake for 5 days; if severe, may be increased to 2 drops every 1 to 2 hours
b. Neomycin (Neosporin), polymyxin, or sulfacetamide sodium (Sodium Sulamyd), 10% solution, 1-2 drops into affected eye every 2 to 3 hours while awake for 5 to 7 days
c. Ofloxacin (Ocuflox) 0.3% solution, 1 to 2 drops into affected eye for 2 days, then 4 times a day for up to 5 additional days (total 7 days)
2. Note: A 15% potential for an adverse reaction to neomycin-containing products (Neosporin) has been reported.
C. In the presence of other systemic disease, treat the underlying condition accordingly (e.g., otitis media: typically treated with synthetic penicillin with or without clavulanate or a macrolide regimen).
D. Chlamydia
1. Oral tetracycline or erythromycin, 250 mg 4 times a day, or doxycycline, 100 mg twice daily, for 3 to 4 weeks or
2. Single dose of azithromycin
3. Local antibiotics generally are not indicated.
E. Gonorrhea
1. Ceftriaxone, 1-2 g parenterally daily for 5 days, and erythromycin or bacitracin ointment, 4 times a day for 7 days
2. Note: Gonococcal conjunctivitis should be confirmed by Gram’s stain and culture.
3. Patients suspected of ophthalmic infection should be immediately referred to an ophthalmologist because of the risk of corneal perforation.
F. Allergy
1. Vernal type occurs seasonally (typically in the spring) and affects adolescents and young adults predominantly. Atopic keratoconjunctivitis affects older adults more commonly and may manifest with lid structural changes and blepharitis (with or without bacterial infection).
2. Over-the-counter naphazoline 0.05% or antazoline 0.5% (Albalon-A, Vasocon-A), 2 drops every 2 to 4 hours and as needed
3. H1-receptor antagonists (levocabastine hydrochloride 0.05%), ketorolac tromethamine, 2 drops every 6 hours, or ketotifen 0.025%, 2 drops 2 to 4 times a day. Topical mast cell stabilizers, cromolyn, vasoconstrictors, and antihistamines should be considered for vernal type. Oral prescription antihistamine (loratadine [Claritin], 10 mg daily, Allegra or Zyrtec) or over-the-counter diphenhydramine (Benadryl), 25-50 mg PO every 6 to 8 hours
4. Ophthalmic corticosteroids should be considered for acute exacerbations. Note: Cataracts, glaucoma, and worsening of infections such as herpes may occur with use of steroids.
5. If allergy to contacts or contact solution is suspected, discontinue agent and refer to ophthalmologist. Change in contact type or cleaning solution (e.g., hydrogen peroxide based), discontinuance of one or both, or simply a more judicious cleaning protocol may be indicated.
CORNEAL ABRASION
I. Definition
Disruption of the epithelium of the cornea (the clear, anterior covering of the eye)
II. Etiology/incidence/predisposing factors
A. Usually associated with chemical, burn, or mechanical trauma (including foreign body)
B. Very common
C. Result of outdoor activity, occupational hazards (e.g., welding, painting, construction)
III. Subjective findings
A. Intense pain associated with the vast sensory nerve supply of the eye
B. A sense of foreign body in the eye
C. Report of redness or discharge of the conjunctiva
D. History of decreased visual acuity
E. Complaint of tearing
F. Photophobia
IV. Physical examination findings
A. Decrease in visual acuity
1. Except in trauma involving emergency need for irrigation of the eye, visual acuity should be the initial measure of vision.
2. When a Snellen chart is unavailable, gross evaluation such as a finger count can be used.
3. Instill a topical anesthetic such as tetracaine (Pontocaine) ophthalmic drops (1-2 drops).
B. Inspect for other signs of trauma (foreign body) by everting the lid.
1. Note positive findings with location.
2. See preceding section, IV.D., Conjunctivitis, for lid eversion procedure.
C. Fluorescein staining of the cornea
1. May reveal disruptions in the corneal epithelium
2. Appears as increased uptake (pooling) of dye when the area is illuminated by a Wood’s lamp or ultraviolet (blue) light
V. Management
A. Apply antibiotic ointment (preferred by many clinicians and patients) or solution such as
1. Gentamicin ophthalmic ointment 3 mg/g 2 or 3 times a day, or solution 3 mg/ml, 1 to 2 drops into affected eye every 2 to 3 hours while awake or
2. Sulfacetamide sodium, 10% ointment, applied as small amount to affected eye every 3 to 4 hours and at bedtime for 5 to 7 days, or solution, 1 to 2 drops every 2 to 3 hours for 1 to 3 days
3. Cycloplegic or mydriatic drops (e.g., Atropisol, Isopto, Mydriacyl) may be prescribed for 24 hours (until recheck by clinician) to promote analgesia and healing. Caution: Adverse effect of ciliary and papillary dilatation is increased ocular pressure. Do not use in patient with angle closure conditions.
B. Apply a soft eye patch or a soft contact lens bandage. Dressing should be removed within 24 hours by clinician.
C. Update tetanus immunization if indicated.
D. Reevaluate in 24 hours, at which time healing should be complete.
E. Refer to ophthalmologist for removal of foreign bodies or for failed initial management.
DIABETIC RETINOPATHY
I. Definition
Ocular disease of the retina resulting from systemic diabetes
II. Etiology/incidence/predisposing factors
A. Most common cause of blindness in the U.S.
B. Inhibition of aldose reductase pathways results in increased blood flow and pressure, thereby diminishing the integrity of the blood–retina barrier.
1. Entry of large cells into the extracellular space of the retina causes macular edema.
2. Microaneurysms, intraretinal microvascular leaking, and hemorrhage may result, leading to scarring and proliferation of new capillary vessels and ischemia of existing retinal vasculature.
3. Smoking, uncontrolled hyperglycemia, and hypertension are associated with greater risk.
IV. Physical examination findings
A. Funduscopic examination may reveal exudates (hard or soft) and microaneurysms seen as dot and flame hemorrhagic markings.
B. Hard, bright-yellow markings may be noted arising from lipid transudation via leaky capillaries.
C. Soft exudates produced by infarcted nerve tissue appearing as pale yellow, irregular, cotton-wool spots may be present.
V. Laboratory/diagnostic findings
A. Retinopathy is associated with poor glycemic control.
B. Sustained glucose levels exceeding 130 mg/dl have been associated with an increase in microvascular complications.
C. Hypertension increases risk.
VI. Management
A. Refer to ophthalmologist.
1. Macular edema can be ascertained only via stereoscopic examination or by fluorescein angiography.
2. Visual acuity is not a sufficient indicator of retinopathy.
B. Laser photocoagulation for focal macular edema
C. Vitrectomy and laser therapy as indicated
D. Tight glycemic control is paramount.
E. Management of blood pressure
F. Smoking cessation
RETINAL DETACHMENT
I. Definition
Separation of the neural retina from the choroid after trauma, hemorrhage, increased intraocular pressure, or transudation of fluid
II. Etiology/incidence/predisposing factors
A. Trauma
B. Intraocular/intracerebral mass
C. Uveitis (inflammation of the iris)
D. Annually, 10 per 100,000 persons suffer a retinal detachment without rhegmatogenous tear.
E. In all, 1% to 3% of patients undergoing cataract surgery suffer a retinal detachment.
F. Associated with chronic disease
III. Subjective findings
A. Painless visual changes, floaters, blurred vision, light flashes
B. As detachment becomes pervasive, a “curtain” may obscure part or all of the field of vision.
C. Large detachments may produce a Marcus Gunn pupil (afferent pupil that reacts more consensually than directly).
V. Management
A. Immediate referral to an ophthalmologist for evaluation and treatment such as
1. Diathermy
2. Cryotherapy
3. Scleral buckling
4. Photocoagulation
B. If the detachment is a result of traumatic insult, patch the eye with a metal shield (i.e., Fox’s eye shield).
CENTRAL AND BRANCH RETINAL ARTERY OBSTRUCTION
I. Definition
A. Abrupt blockage of the central retinal artery or its branches, causing sudden visual loss or loss of visual fields
B. Permanent partial or complete visual loss may ensue without immediate intervention.
II. Etiology/predisposing factors
A. Causes
1. Thrombosis
2. Embolism
3. Arteritis of the central retinal artery
B. Associated with
1. Migraine
2. Advancing age
3. Use of oral contraceptives
4. History of vasculitis
III. Subjective findings
A. Sudden, painless, gross visual loss (monocular) or visual field loss. Amaurosis fugax (ipsilateral, intermittent monocular blindness) is associated with ipsilateral carotid disorder and is a harbinger of impending stroke.
B. Visual loss may be central (if fovea is affected) or peripheral.
IV. Physical examination findings
A. Partial dilatation of the pupil, which is sluggishly reactive to direct light but may have a normal consensual response
B. Funduscopic examination
1. May reveal a pale, opaque fundus and a characteristic “cherry-red spot” at the fovea
2. Arterial vessels may appear pale and bloodless.
V. Laboratory/diagnostic findings
A. Elevated erythrocyte sedimentation rate associated with giant cell arteritis
B. Hyperlipidemia is associated with venous occlusions.
C. Presence of antiphospholipid antibodies
VI. Management
A. Immediate consultation with an ophthalmologist
B. Intermittent digital massage of the anterior chamber by gentle pressure over the eyelid may be sight-saving. If an embolus can be dislodged, retinal ischemia can be relieved.
C. Consider rebreathing CO2 per air-tight mask or bag to decrease alkalosis.
D. Consider IV anticoagulant (e.g., heparin, 10,000 units)
E. Treatment of underlying comorbidities such as carotid and cardiac disease causing emboli, hypertension, migraine, oral contraceptive use, thrombophilia, and so forth
GLAUCOMA
I. Definition
A. Disorder of progressive visual loss. Typically, peripheral vision decreases first.
B. Often caused by increased intraocular pressure that leads to partial or complete blindness
II. Etiology/incidence/predisposing factors
A. Primarily of two types
1. Chronic open-angle (wide) (most common) or
2. Acute or chronic closed-angle (narrow)
B. Primary open-angle glaucoma accounts for nearly two thirds of all cases.
C. Two other types exist:
1. Congenital glaucoma (primary)
2. Secondary or induced glaucoma, resulting from
a. Prolonged steroid use
b. Uveitis
c. Cataracts
d. Tumor
e. Trauma
D. Obstruction of the outflow of aqueous humor from the ciliary body through the trabecula and the canal of Schlemm produces increased intraocular pressure, which leads to atrophy of the optic nerve head.
E. Affects approximately 2% of the population
III. Subjective findings
A. In open-angle glaucoma, visual changes occur slowly, with decreasing peripheral vision noted over time.
1. Photophobia and visual blurring may occur.
2. Headache and halos around lights are atypical, although a unilateral headache in conjunction with visual changes on the same side as the headache may occur.
B. In secondary glaucoma, such as occurs with ophthalmic corticosteroid use, elevated intraocular pressure may be produced in just 2 weeks.
C. In acute closed-angle glaucoma, symptoms develop rapidly.
1. The patient complains of intense eye pain and visual disturbances (halos around lights), with nausea and vomiting.
2. Note: Although pain is common with closed-angle glaucoma, painless variants may be distinguished only by a fixed pupil.
IV. Physical examination findings
A. Inspect for external signs such as redness, tearing, lid deformities, proptosis, or ptosis, and for corneal clouding.
B. A “hard eye” may be palpated in acute glaucoma.
C. Observe changes in pupillary response, reactivity, symmetry, and accommodation.
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