Case Studies in Urgent Eye Care Kelly D. Chung, M.D. Oregon Eye Specialists Suite 961

Eyelid Lesion A patient presents with the following eyelid lesion for 1-2 weeks.

1. Which of the following is NOT true of management of the lesion pictured above? a. Prescribe systemic antibiotics. b. Advise hot packs. c. Look for and treat associated rosacea and blepharitis. d. Injection of intralesional corticosteroids can be useful.

2. Which of the following associations are NOT true of the underlying etiology of the lesion? a. inspissations of the meibomian gland b. evaporative tear deficiency c. Staphylococcus aureus and Staphylococcus epidermidis are commonly found d. none of the above

3. Which of the following are treatments for chronic forms of the underlying disease? a. Doxycycline 100mg or tetracycline 1000mg orally b. Omega-3 fatty acids c. Hot packs / Lipiflow treatment d. Corticosteroid eye drops e. a through c f. All of the above

Meibomian gland anatomy

Inspissation at meibomian orifices

Rosacea

Collarettes

Lipiflow

Soap in eye This 68-year-old patient splashed liquid laundry soap in her eye and immediately began experiencing severe pain in this eye. She flushed the eye copiously with water and presented for examination. Fluorescein was placed in the eye producing the picture.

1. The most likely diagnosis is: a. endothelial dystrophy b. chemical corneal abrasion c. corneal erosion d. stromal haze/edema e. none of the above

2. Treatment could include: a. antibiotic solution b. dilating-cycloplegic drops c. a pressure patch d. analgesics by mouth e. all of the above

3. The long term result is expected to be: a. several lines of vision loss b. a permanent scar c. the possibility of recurrent erosions d. no possible late adverse results e. none of the above.

Piece of metal flew into eye A 28-year-old man reports that a few days ago while working at the mechanical shop where he is employed “a piece of metal” flew into his eye. He reports moderate pain and slightly blurred vision in that eye. On slit lamp examination, you find the above (on low and high magnification).

The most appropriate next step is: a. Remove the metallic foreign body at the slit lamp with a needle before a rust ring occurs. b. Start topical steroids/antibiotics immediately. c. Ophthalmology consult: For a complete dilated eye exam on both eyes, consideration of a diagnostic ultrasound or CT scan, and taking the patient to the operating room. d. This is a benign pigmented limbal lesion and should be followed conservatively.

Uveal prolapse

Metallic corneal foreign body

Everted lid with foreign body

Head trauma with loss of vision This 6-year-old boy fell from his bike and fell on his head hitting his right brow to the pavement. Loss of consciousness was not noted but child does not clearly remember the details of the accident. When he arrived home he noticed that he could not see out of his right eye. He was rushed to the hospital by parents and CT scan showed no evidence of injury. On exam the patient has hand motions vision in the right eye and has an afferent pupillary defect. Left eye has 20/20 vision. The remainder of the exam is negative aside from the echymosis over the right brow and temple.

1. What is the most likely diagnosis: a. third nerve palsy b. subarachnoid hemorrhage c. traumatic optic neuropathy d. amblyopia in right eye

2. Which test would be most helpful in confirming the diagnosis: a. CT scan with fine orbital cuts b. MRI scan with fine orbital cuts c. cocaine test d. visual field test

3. What is the next best step for this patient: a. observation b. intravenous steroid administration c. oral steroid administration d. patching the left eye

Conjunctivitis An 11-year-old female presents with the complaint of a foreign body sensation in both eyes for about one month. She has been using antihistamine and steroid drops. The appearance of her lower tarsal conjunctiva is as shown in the pictures above. Her vision is 20/20 in both eyes. Careful evaluation of the lower tarsus reveals multiple avascular, oval, pale elevations, some as large as 2 mm.

1. The tarsal conjunctival lesions are most likely to be: a. papillae b. follicles c. Drusen d. hordeola e. none of the above

2. The most important differential feature in determining the identity of these structures on the tarsus is: a. size b. color c. lack of central vascular core d. number e. none of the above

3. These tarsal lesions can be seen in: a. several types of acute and chronic conjunctivitis b. adenovirus c. Herpes simplex d. chlamydia trachoma e. all of the above

Follicular vs Papillary Conjunctivitis Causes of acute follicular conjunctivitis lasting three weeks or less: Adenovirus, Herpes simplex, Enterovirus 70, Coxsackie A24 Causes of chronic follicular conjunctivitis: Chlamydia trachoma, Inclusion conjunctivitis, Molluscum contagiosum, Parinaud’s oculoglandular syndrome Papillary conjunctivitis is usually due to an allergic response such as seasonal allergic conjunctivitis (hay fever) which is mild, self-limiting and episodic or the more serious and prolonged vernal conjunctivitis that begins between 5 and 10 years of age, usually in males and lasting up to 10 years. Giant papillary conjunctivitis can be seen as a reaction to soft contact lens wear.

Cataract surgery Your 78 y/o patient is in for a preoperative history & physical for upcoming cataract surgery.

Which of the following medications is it important for the surgeon to be aware of? a. Coumadin b.Flomax c.Inhaled or intranasal corticosteroids d.All of the above

What medical conditions may preclude cataract surgery? a.Inability to lay flat b.Morbid obesity c.Systemic infection d.Contraindication to general anesthesia e.a. and c.

Red eye Your 48 y/o male patient calls in stating he has a very red eye. The most common important easily missed diagnosis in a red eye is: a. Uveitis b. Subconjunctival hemorrhage c. Retinal detachment d. Scleritis

Important questions to ask are: Is there a blood red patch covering the white of the eye? Is there associated blurry vision? Is there associated deep pain or ache? Is there photophobia? Is it involving one or both eyes? Have you had eye surgery?

Uveitis

Subconjunctival hemorrhage

Episcleritis

Scleritis

Retinal detachment