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

Ophthalmology for the Internist Physical Exam Red Eye Acute Loss of Vision Complications of Systemic Diseases

Physical Exam Visual Acuity Confrontation visual field External Inspection Conjunctiva and sclera inspection Extraocular Muscles Pupillary Reactions Cornea and iris inspection Anterior chamber exam Lens clarity Ophthalmoscopic Exam

Red Eye Ophthalmology for the Internist Part I

Red Eye Conjuctivitis Corneal Injury Subconjunctival Hemorrhage IritisEpiscleritisScleritisTrauma Acute angle-closure glaucoma

Conjunctivitis Chemical conjunctivitis- Emergency –FLUSH-FLUSH-and FLUSH –Then, do your H&P –Acid v. Base Viral v. Bacterial conjunctivitis –Difficult to distinguish Purulent discharge- more common with bacterial etiology Pre-auricular lymphadenapathy- more common with viral etiology Sexually active

Conjunctivitis Allergic –Treatments Blepheritis –Seborrhea –Bacterial

Corneal Injury Sharp pain, improves with Topical anesthetic, worse with blinking Foreign body sensation Foreign Body v Keratitis Fluorescein to locate pathology

Keratitis Inflamed cornea –Contact misuse –UV damage –Dry eyes –Viral causes Treatment

Subconjunctival Hemorrhage Solitary red spot usually unilateral and always painless Causes: –Cough –Anticoagulation –Hypertension –Vomiting

Iritis Inflammation or iris and/or cilary bodies Predisposing Factors: –HLA B27 –Ankylosing spondylitis, –Reactive arteritis (Reiters syndrome), –psoriatic arteritis, –irritable Bowel disease –Crohn's disease –Multiple Sclerosis (HLA B15), –Sarcoidosis, –systemic Lupus Erythematosus –Lyme disease –Juvenile Idiopathic arteritis –Sexually transmitted diseases –Cat Scratch disease –Toxoplasmosis, toxocardia –Presumed Ocular Histoplasmosis syndrome –Lyme disease –whipples disease –valley fever –Tuberculosis –Leptospirosis –Rocky Mountain Spotted fever.

Iritis HPI: Pain, blurry vision, Photophobia PE: Sluggish, smaller pupil, “Cilary Flush”, Vessels do not blanch or move with swab Inflammatory cells seen with slit lamp Treatment: Corticosteroids Consult : Ophthalmology

Episcleritis Inflammation of superficial layer of sclera HPI: Red eye, sudden onset, without any known cause, minimal discharge with some discomfort PE Treatment: NSAIDS

Scleritis Strong association with system diseases –Rheumatoid arteritis –Chronic infections –Connective tissue disease Pain Treatment: systemic steroids Consult: Ophthalmology

Acute angle closure Glaucoma 5% of all Glaucoma Precipitated by dilation of pupil HPI: Eye pain, blurry vision, Haloes, Nausea and vomiting, Headache PE –Shallow anterior chamber –Pupil fixed –Cornea haziness –Eye feels firm

Acute angle closure Glaucoma Treatment –Pilocarpine – Miotic –Laser surgery - Iridectomy Consult - Ophthalmology

Acute Vision Loss Ophthalmology for the Internist Part II

Acute Vision Loss GlaucomaIritis Corneal Ulcer HyphemaHypopion Vitreous Hemorrhage Retinal detachment Retinal vascular occlusion Optic Neuritis Optic Neuropathy PapilledemaCVA

All require Ophthalmologic Consult

See above… GlaucomaIritis

Corneal Ulcer Bacteria v. Fungal Severe eye pain Can be seen on cornea as a white spot Topical Broad spectrum antibiotics

Hyphema Blood in anterior chamber Easily seen: red air-fluid level Traumatic cause most common Usually self limited Eye pressure must be monitored

Hypopion Leukocytes in anterior chamber Penetrating trauma to eye Antibiotics Consult Ophthalmologist

Vitreous Hemorrhage Extravasation of blood into potentional spaces in and around the vitreous body Blood blocks red reflex

Vitreous Hemorrhage Causes: –Proliferative Diabetic retinopathy ( %) –Retinal tears ( %) –Trauma ( %) –Neovascularization (3.5-16%) –Posterior vitreous Detachment with retinal vascular tears ( %) –Proliferative sickle cell retinopathy –Macroaneurysm ( %) Subarachnoid Hemorrhage

Vitreous Hemorrhage May cause retinal damage, floaters, and glaucoma Treat the underlying cause May require surgical removal of blood

Retinal Detachment Lifetime risk: 1 in 300 Causes: –Sarcoid iritis –Severe hypertension –Neoplasm –Fibrosis Retinopathy (DM) Trauma –Posterior Vitreous detachment

Retinal Detachment HPI: painless, curtain sensation, flashes of light Treatment: –Laser surgery –Scleral buckling –Posterior vitrectomy –Pneumatic retinopexy Prognosis: Good, if macula is not involved

Retinal Arterial Occlusion Causes –Emboli –TIA –Vasculitis –Must check Carotid circulation SuddenPainless Curtain sensation Cherry red spot – Fovea against the white retina Hollenhorst Plaques –Glistening yellow flakes Permanent or temporary (Amaurosis Fugax)

Retinal Arterial Occlusion Treatment –Ballot eye 10 sec cycles –Paracentesis of anterior chamber

Optic Neuritis Inflamed nerve MS May have pain behind eye PE: –May have optic nerve pallor –Pupil light reflex abnormality –Tenderness with ROM MRI Treatment: IV Glucocorticoids Note: 30-50% will develop MS within 15 years of diagnosis

Optic Neuropathy Giant Cell arteritis –Jaw Claudication –Over 60 –Malaise –Headache –Fever –Scalp tenderness –Weight loss –Polymyalgia Rheumatica Trauma –Disruption of vascular supply to optic nerve –Nerve impingement

Giant Cell arteritis 8-15% of all Temporal arteritis patients develop acute loss of vision If suspected –Sed rate >50 –Steroids –Temporal artery biopsy

Traumatic Optic Neuropathy Poor prognosis May try steroids, surgery

CVA May cause acute vision loss due to optic nerve infarct or cerebral infarct May cause partial vision loss unilaterally or bilaterally

Ophthalmologic Complications of Systemic Disease Ophthalmology for the Internist Part III

Ophthalmologic Complications of Systemic Disease Hypertension: A-V nicking Diabetes Mellitus: Diabetic Retinopathy Syphilis: Marcus-Gunn pupil Intracranial Edema: Papillary Edema Hyperthyroidism: Exophthalmos Herpes Zoster: Vesicles CMV Infection: Cotton wool spots

References Alward WL. Medical Management of Glaucoma. NEJM 1998; 339: Uptodate, 2006 Phillpotts B. Hemorrhage, Vitreous.Emedicine. Jan 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: Hara JH. The Red Eye: Diagnosis and Treatment. Amer Family Phys 1996; 54(8): 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): Sheikh A. Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2000; (2): CD

Question 1 Which of the following components of a Physical exam is first? a)Visual Acuity b)Confrontation visual field c)External Inspection d)Conjunctiva and sclera inspection

Answer 1 Which of the following components of a Physical exam is first? a) External Inspection b) Confrontation visual field c) Visual Acuity d) Conjunctiva and sclera inspection

Question 2 When a patient is believed to have a chemical conjunctivitis, the first thing to do is? a)Physical exam b)Visual acuity c)Flush eye immediately d)Obtain a History

Answer 2 When a patient is believed to have a chemical conjunctivitis, the first thing to do is? a) Physical exam b) Visual acuity c) Flush eye immediately d) Obtain a History

Question 3 Patient presents with “deep eye pain”, blurry vision, Photophobia. Sluggish, smaller pupil, and “Cilary Flush” on PE. Vessels do not blanch or move with a swab. What is the probable diagnosis? a)Bacterial conjunctivitis b)Subconjunctival hemorrhage c)Iritis d)Acute angle closure glaucoma