Scleritis - Scleritis is a rare but emergent cause of a red eye. It is thought to be caused by an autoimmune response that can be idiopathic, triggered by infection or trauma, or secondary to underlying autoimmune dysregulation. In fact, it is estimated that up to half of all cases of scleritis have an underlying autoimmune disorder such as IBD, SLE, granulomatosis with polyangiitis (Wegener's granulomatosis), or scleroderma. There are two main types of scleritis: anterior and posterior.
-Anterior scleritis: involvement of the sclera anterior to the extraocular muscle insertion. There are three variants: Diffuse (most common and most treatable), nodular (presents with tender nodules), and necrotizing (most severe and destructive).
-Posterior scleritis: involvement of the sclera posterior to the extraocular muscle insertion. This is rarer than anterior scleritis and difficult to detect due to its more posterior location. It is associated with retinal detachment, angle closure glaucoma, and vision loss.
#Clinical #Ophth #Scleritis
Fusarium Eye Infections - Keratitis and Endophthalmitis
Fungal Keratitis is an infection of the cornea that is most commonly caused by trauma to eye from stick/thorn/plant
• Up to 1/3 of fungal keratitis infections will result in corneal deformation and invasion into deeper eye structures
• S/sx include eye pain & redness, eye discharge, blurry vision, photophobia, excessive tearing
• In 2006, CDC investigated Fusarium keratitis outbreak a/w contact lens solution (PMID: 16617289)
Fungal Endophthalmitis is infection of the vitreous and/or aqueous humors
• Devastating infection and may lead to irreversible blindness w/in hours-days of symptom onset
• Can either be exogenous *most common* (microbes from external source are introduced into eye)
• Or endogenous (hematogenous seeding during fungemia)
• Symptoms can include floaters and subtle decrease in vision progressing to vision loss - important to remember that eye pain can be minimal or absent!
#Fusarium #Eye #Infections #Keratitis #Endophthalmitis #ocular #ophthalmology #diagnosis
Red Eye - Differential Diagnosis Framework
What?
Redness in the eye can be caused by many conditions and injuries that can lead to irritation, blood in the eye, or swelling of blood vessels.
Common Causes:
• Conjunctivitis, corneal abrasions, etc., that usually affect superficial eye structures, lid or lashes
Dangerous Causes:
• Usually affect deeper structures like the sclera, anterior and posterior chambers, nerves, and vessels
Alarm (Emergent):
• Acute angle closure glaucoma
• Hyphema
• Hypopyon
• Bacterial keratitis
• Acute endophthalmitis
• Herpes ophthalmicus
• Orbital cellulitis
• Globe trauma
• Chemical injury
Urgent:
• Scleritis
• Herpes keratitis
• Uveitis
Time to Think:
• Conjunctivitis (most common)
• Blepharitis
• Subconjunctival hemorrhage
• Episcleritis
Ocular Emergencies Without a Red Eye:
• Optic neuritis
• Retinal detachment
• Central retinal artery occlusion
• Central retinal vein occlusion
Conjunctiva:
• Conjunctivitis (bacterial, viral, allergic)
• Episcleritis
• Scleritis (+ Photophobia)
• Hemorrhage
Lids/Lashes:
• Hordeolum
• Chalazion
• Blepharitis
Cornea:
• Abrasion (+ Photophobia)
• Contact lens overwear
• Foreign body
• Infectious keratitis (bacterial, viral)
Lens:
• Acute angle closure glaucoma
Anterior Chamber/Uvea/Iris:
• Iritis
• Hyphema
• Hypopyon
• Uveitis (+ Photophobia)
• UVEA: comprised Iris, Ciliary body, Choroid
Questions to Ask:
• Unilateral or bilateral symptoms + duration?
• Trauma?
• Discharge?
• Photophobia?
• Is the eye painful?
• Globe rupture
• Foreign body
• Uveitis/Ulcer
• Narrow angle glaucoma
• Keratitis (Herpes keratitis, herpes zoster ophthalmicus, UV)
• Scleritis
• Is the eye painless?
Painless conditions include:
• Hyphema
• Conjunctivitis
• Conjunctival hemorrhage
• Is there any subjective vision loss?
Complete vision loss is very rare:
• End stage endophthalmitis
• Narrow angle closure glaucoma
• Is there partial visual loss or blurriness?
• Corneal ulcer
• Keratitis
• Hyphema
• Contact lens use?
#Red #eye #Conjunctivitis #ocular #differential #diagnosis #ophthalmology #painful #painless
Seesaw nystagmus
-> eye move in an opposed vertical fashion (one goes up while the other goes down) with same direction torsion of the eyes. (eye moving up intorts, eye moving down extorts)
The wave form can be either pendular (seesaw) or jerk (semi seesaw).
Seesaw nystagmus is a sequence of abnormal eye movements in which one eye moves up as the other moves down. In addition to the alternating opposed vertical movements, there is rotation (torsion) of the eyes. The eyes rotate synchronously with the up and down movements, both eyes rotating in the same direction; the eye moving up intorts, and the eye moving down extorts.
There are many etiologies of SSN including: most commonly parasellar masses, mesodiencephalic disease, brainstem stroke, head trauma, lack or loss of crossing fibers in the optic chiasm, multiple sclerosis, arnold-chiari malformation, congenital, whole brain irradiation, and intrathecal methotrexate.
Video by Kathleen B. Digre, M.D. - Moran Eye Center
#Seesaw #nystagmus #ophthalmology #clinical #video #eye #ocular #PhysicalExam
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Bitot's Spots- A 4-year-old boy was brought by his father to the ophthalmology clinic with a 1-year history of enlarging white deposits in both eyes and decreased night vision. On examination, the conjunctivae of both the right eye (Panel A) and the left eye (Panel B) appeared dry and wrinkled, with foamy, cream-colored deposits near the outer corners... The ocular findings were consistent with Bitot’s spots, which are accumulations of keratin, often intermixed with an overgrowth of Corynebacterium xerosis, that result from epithelial metaplasia caused by vitamin A deficiency. Vitamin A deficiency can also cause blindness, as a result of corneal ulceration with scarring, and particularly night blindness, as a result of dysfunction of rod photoreceptor cells... #NEJM #clinical #photo #ophth #bitot #spots #Corynebacterium #xerosis #keratin
Acute Closed Angle Glaucoma: Pathogenesis and Clinical Findings
OPHTHALMIC EMERGENCY: Early detection is essential, but most patients who present with early glaucoma are asymptomatic.
• The disease must be ruled out in patients who present with a red eye and are acutely ill
• Colored halos around bright lights are a key symptom of prodromal episodes
Epidemiology
• Significant cause of blindness in North America and the most frequent cause of blindness among African Americans
• Incidence increases in patients of advancing age and in patients with a family history
• Occurs in small eyes (often hypermetropic), which thus have shallow anterior chambers
Anatomic abnormalities (i.e thinner ciliary bodies, shallow ACD, small axial length) -> crowding of ocular structures
-> Increased resistance to the flow of aqueous humour from the posterior to anterior chamber
-> Increased pressure gradient bows iris forward
-> Iridocorneal angle closure
-> Prolonged Increased IOP leads to optic nerve damage & blindness
Signs / Symptoms / Complications:
• Consolidation of obstruction
• Corneal edema & clouding
• Visual field defects (scotomas of various shapes, generally with central sparring)
• Loss of vision
• Photophobia
#Acute #ClosedAngle #Glaucoma #pathophysiology #ophthalmology
Floaters - Differential Diagnosis Framework
What?
Vitreous Floaters:
• Microscopic collagen fibers within the vitreous that tend to clump and cast shadows on the retina, appearing as floaters to the patient.
• Acute-onset flashes and floaters with visual field defect are suggestive of retinal detachment.
Described by Patients As:
• Black spots or specks in the vision
• Spots in the eyes
• Straight and curved lines
• Cobwebs
• Strings
• "O" or "C"-shaped blobs
Retinal Detachment:
Symptoms: Sudden
• Unilateral flashing lights
• Floaters
Risk factors for floaters:
• Myopia
• Cataract surgery
• Retinal lattice degeneration
• Retinal breaks
• Positive family history
• Have had inflammation (swelling) inside the eye
Flashes DDX:
Ophthalmic:
• Posterior vitreous detachment
• Retinal tear/hole
• Retinal detachment
• Optic neuritis - photopsia on eye movement, retrobulbar pain
Non-Ophthalmic:
• Migraine - scintillating scotomas, colored lights, bilateral, evolves over 5 to 30 minutes before resolving with onset of a headache, normal visual acuity
• Postural hypotension - bilateral temporary dimming of vision and light-headedness
• Occipital tumors/Occipital lobe disorders
• Vertebrobasilar transient ischemic attacks
Floaters DDX:
Ophthalmic:
• Vitreous syneresis
• Vitreous hemorrhage
• Posterior vitreous detachment
• Retinal detachment
• Vitritis
• Tear film debris
• With time the vitreous, begins to liquify (Vitreous syneresis) and contract.
• As the vitreous contracts, it peels away from the retina (posterior vitreous detachment)
• 50% of 65-year-olds will have a PVD in one or both eyes.
• A person developing a PVD in one eye is likely to develop a PVD in the other eye within the following 18 months.
• Sometimes, as the vitreous pulls away from the retina, a retinal tear or detachment may occur.
#Floaters #Differential #Diagnosis #Ocular #ophthalmology
Adie’s Tonic Pupil on Physical Exam
A young female was referred in for a sudden onset anisocoria. Her ocular exam was essentially unremarkable with the exception of anisocoria (OS>OD) that was most prominent in bright light conditions (top image) and slightly reduced near vision in the left eye. She was otherwise healthy and had no history of recent illness or trauma.
Typical evaluation of anisocoria begins with emphasis on where the anisocoria is most prominent. In this case, the asymmetry was most prevalent (greater than 3mm in this case) with bright or direct light, suggesting the parasympathic nervous system isn’t working correctly.
Adie’s tonic pupil denotes anisocoria worse in bright lights with light near dissociation (meaning the pupil still constricts when accommodating). It is generally unilateral and affects young females most commonly. The etiology is usually unknown but assumed to be damage to the ciliary ganglion which is responsible for the post ganglionic parasympathetic control of the iris sphincter. Clinical confirmation involves diluted pilocarpine (approximately 0.125%) instilled in both eyes. Because the postganglionic synapse is hypersensitive to acetylcholine, the affected eye will constrict while the unaffected eye will remain the same (image 4). Over time, the affected pupil will become smaller in size relative to the other pupil, occasionally it can occur bilaterally. Syphilis should be suspected in those rare bilateral cases.
Failure of the pupil to respond to diluted pilocarpine typically warrants retesting before proceeding to 1% pilocarpine which if positive (constriction) would suggest oculomotor nerve palsy.
Bennett & Bloom Eye Center @anterior_seg_rocks
#Adies #Tonic #Pupil #anisocoria #clinical #video #ophthalmology #physicalexam #neurology
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