Chapter 27

Ophthalmology

1 What is the hallmark of conjunctivitis?

Hyperemia of the conjunctival vessels.

2 Distinguish among allergic, viral, and bacterial conjunctivitis in terms of signs and symptoms and treatment

ETIOLOGY	SIGNS AND SYMPTOMS	TREATMENT
ALLERGIC	ITCHING, BILATERAL, SEASONAL, LONG DURATION	VASOCONSTRICTORS OR TOPICAL ANTIHISTAMINES/MAST CELL STABILIZERS
Viral∗	Preauricular adenopathy, highly contagious (look for affected contacts); clear, watery discharge	Supportive, hand washing to prevent spread
Bacterial	Purulent discharge; classic in neonates	Topical antibiotics ± systemic antibiotics

^∗The number-one viral cause is adenovirus.

3 What are the three common causes of neonatal conjunctivitis?

Chemical, Neisseria gonorrhoeae, and Chlamydia trachomatis.

4 What causes chemical conjunctivitis? How do you recognize it?

Chemical conjunctivitis is caused by the silver nitrate (or erythromycin) drops that are given to all newborns to prevent gonorrhea conjunctivitis. The drops may cause a chemical conjunctivitis (with no purulent discharge) that appears within 12 hours of instilling the drops and resolves within 48 hours. Chemical conjunctivitis is always the best guess if the conjunctivitis develops in the first 24 hours of life.

5 How can you distinguish gonorrheal from chlamydial conjunctivitis?

In cases of suspected gonorrheal conjunctivitis, look for symptoms of gonorrhea in the mother. The infant has an extremely purulent discharge starting between 2 and 5 days after birth. Infants who were given prophylactic drops should not develop gonorrheal conjunctivitis. Treatment involves systemic ceftriaxone or cefotaxime.

In cases of chlamydial (inclusion) conjunctivitis, the mother often reports no symptoms. The infant has mild-to-severe conjunctivitis beginning between 5 and 14 days after birth. Oral erythromycin is recommended for chlamydial conjunctivitis or pneumonia; topical therapy for chlamydial conjunctivitis is not effective.

6 If you forget everything else about neonatal conjunctivitis, what point should you remember to help you distinguish among the three discussed causes?

The varying time frames during which they present.

7 True or false: Conjunctivitis frequently causes loss of vision

False. Other than transient blurriness (caused by tear film debris) that resolves with blinking, conjunctivitis should not affect vision. If vision is affected, think of other, more serious conditions.

8 Define glaucoma. What are the risk factors for developing it? What are the two general types?

Glaucoma is best thought of as ocular hypertension (or elevated intraocular pressure, measured with a tonometer); its effects include visual field defects and blindness. The risk factors are age older than 40 years, black race, and positive family history. The two main types are open-angle and closed-angle glaucoma.

9 Describe the physical findings of open-angle glaucoma. How common is it? How is it treated?

Open-angle glaucoma causes 90% of the cases of glaucoma; it is painless and does not have acute attacks. The only signs are elevated intraocular pressure (usually 20 to 30 mm Hg), a gradually progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on funduscopic examination). Treatment may involve several different classes of medications, including beta blockers, prostaglandins, alpha adrenergic agonists, carbonic anhydrase inhibitors, cholinergic agonists, as well as laser therapy and surgery.

10 How does closed-angle glaucoma present? What should you do if you recognize it?

Closed-angle glaucoma presents with sudden ocular pain, seeing halos around lights, red eye, high intraocular pressure (greater than 30 mm Hg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil. It is an ophthalmologic emergency. Treat the patient immediately with pilocarpine, oral glycerin, and/or acetazolamide to break the attack. Definitive surgery (peripheral iridectomy) is used to prevent further attacks. In rare cases, anticholinergic medications can trigger an attack of closed-angle glaucoma in a susceptible, previously untreated patient. Medications do not cause acute attacks in patients with open-angle glaucoma or in patients with surgically treated closed-angle glaucoma.

11 How do steroids affect the eye?

Steroids, whether topical or systemic, can cause glaucoma and cataracts. Topical ocular steroids can worsen ocular herpes and fungal infections. For the Step 2 examination, do not give topical ocular steroids, especially if the patient has a dendritic corneal ulcer that stains green by fluorescein. Such an ulcer represents herpes.

12 Define ultraviolet keratitis. How is it treated?

Exposure to ultraviolet light can cause keratitis (corneal inflammation) with pain, foreign body sensation, red eye, tearing, and decreased vision. Patients have a history of welding, using a tanning bed or sunlamp, or snow-skiing (“snow-blindness”). Treat with an eye patch (for 24 hours) and topical antibiotic. You can reduce pain with an anticholinergic eye drop that causes paralysis of the ciliary muscle (cycloplegia).

13 What pediatric rheumatologic condition is commonly associated with uveitis?

Uveitis is common in juvenile rheumatoid arthritis (especially the pauciarticular form). Patients with juvenile rheumatoid arthritis need periodic ophthalmologic examination to check for uveitis.

14 What is the most common cause of painless, slowly progressive loss of vision?

Cataracts, especially in older adults. Treatment is surgical removal of the affected lens and replacement with an artificial lens.

15 What should cataracts in a neonate suggest?

Cataracts in a neonate may indicate a TORCH (toxoplasmosis, other, rubella, cytomegalovirus, and herpes simplex virus) infection or an inherited metabolic disorder (the classic example is galactosemia).

16 What changes in the retina and fundus are seen in diabetes and hypertension?

Diabetes is associated with dot-blot hemorrhages, microaneurysms, and neovascularization of the retina. Hypertension is associated with arteriolar narrowing, copper/silver wiring, and cotton-wool spots. Papilledema may be seen with severe hypertension and should alert you to the presence of a hypertensive emergency.

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