Are antibiotics necessary for the treatment of a hordeolum?

Usually not.  Hordeola which are caused by obstruction of the oil-producing meibomian glands tend to be self-limited and often resolve spontaneously within a week or perhaps earlier with the frequent application of warm compresses.

Although there have been no clinical trials to prove benefit, topical antibiotics are recommended by some sources to - in theory - prevent secondary infection of other meibomian glands.  Systemic antibiotics should be administered for secondary cellulitis.


Source

Ferri: Ferri's Clinical Advisor 2011, 1st ed.

Greenberg, M.  "Diagnosis: A Hordeolum"  Emergency Medicine News.  2002 June.

Lindsley, K.  et al.  "Interventions for acute internal hordeolum."  Cochrane Database Syst Rev.  2010 Sept.

Wald, ER.  "Periorbital and orbital infections"  Infect Dis Clin North Am.  2007 June.

Yanoff & Duker: Ophthalmology, 3rd ed.

Determining whether a patient's transient visual deficit was monocular or binocular is often harder than it seems. Here's a helpful hint to help figure it out.

If the patient alternately covered each eye during the attack and can clearly describe what was seen out of each eye, then you have it easy. However, unfortunately many patients don't do this.

A helpful clue in this scenario is to ask the patient whether reading was impaired during the attack. If it was impaired, this suggests that the visual loss was binocular rather than monocular.


Source

Givre, S. and Van Stavern, G. "Amaurosis fugax" Up to Date. 18 Jan 2010.

Identify the pathology on these retinal photographs. What is the patient's chief complaint?

Identify the pathology on these retinal photographs. What is the patient's chief complaint?

Right Eye

Left Eye

This patient has a branch retinal artery occlusion in the right eye.  Note the pale color below the midline of the right retina.  The left retina is normal.  The patient complained of loss of vision in the superior field of the right eye.  Recall, ocular optics:

Source

Image, Right Eye: http://www.eyehealthnutrition.com/retinal-artery-occlusions.html

Image, Left Eye: http://webeye.ophth.uiowa.edu/dept/service/photo/cfundus.htm

Image, Ocular Optics:http://www.sumanasinc.com/webcontent/animations/content/visualpathways.html

What is the oblique flashlight test?

It is a quick way to estimate the depth of the anterior chamber of the eye without use of a gonioscope.

A light is held parallel to the iris. If a shadow is cast, the angle is narrow. If there is no shadow, the angle is open.

Source

Mahadevan, S.V. and Garmel, G.  An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department.

Match the retinal image on the left with the corresponding ultrasound image on the right.

scroll down for answer 

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Source

Image Source: http://www.virginiaretina.org/diabetic_retinopathy.html

Image Source: http://www.eyeatlas.com/box/64.htm

Image Source: http://www.sonoguide.com/smparts_ocular.html

What are the causes of anterior chamber hyphema?

• trauma (most common, 70-80%)
• spontaneous (tumors, blood dyscrasia, blood thinners, postsurgical, neovascularization of the iris)

Source

5-minute Emergency Medicine Consult.

Patient presents with unequal pupils. What is your diagnosis?

Some additional info regarding the patients history and physical:

1. Acute onset.  Driver's license does not demonstrate that this is a chronic physiologic anisocoria. 
2. Anisocoria is greater in light than dark.  Abnormal pupil is the larger one. 
3. There is no ptosis or extraocular muscle palsies.  Third nerve palsy is unlikely. 
4. No recent eye trauma.  Iris appears intact on slit-lamp examination.  Iris sphincter muscle damage is unlikely. 
5. Denies getting any mydriatic substance in the eye ie atropine, scopolamine patch, ipratropium bromide, pseudoephedrine.  Unlikely pharmacologically induced. 

A physical exam maneuver was performed and a presumed diagnosis made.  What is the test and diagnosis? Scroll down for answer.

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Abnormal pupil had no reaction to light but a slow constriction to prolonged near stimulation (looking at thumb), a light-near dissociation.  Diagnosis: Adie's tonic pupil.   To learn more about this entity, click here.

Source

Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease

Practical Neurology DVD Review

Image source: https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJqnAA4APhM7xTgXm6h5i6QJ0H-RABpqH3LQn8UYQEu197ouNyvg33oHQhFUonpvKuuT9lJRHJoi73sKEQsOl-gf5OLGX_XNzK-DzX0CfdV781GrmjryQFFhp3LF96DCYNkSS8g_sLH1Ml/s400/Anisocoria.jpg

How can your clinical diagnosis of optic neuritis be confirmed?

Although the diagnosis of optic neuritis is often made on clinical grounds, gadolinium-enhanced MRI can help confirm the diagnosis. Optic nerve inflammation can be demonstrated in 95% of patient who have optic neuritis on gadolinium-enhanced MRI.


Source

Vortmann, M. and Schneider, J. "Acute Monocular Visual Loss" Emergency Medicine Clinics of North America. 2008.

What is the visual prognosis for retinal detachment?

Depends on the type.

1. For a rhegmatogenous retinal detachment where fluid from the vitreous cavity passes through a retinal break into the subretinal space to cause separation of the neural retina from the underlying retinal pigment epithelium, prognosis depends on the extent of damage to the macula. If the macula becomes detached, only about 50% end up with 20/40 vision or better despite surgical repair. In eyes with no macular detachment present, 90% can be expected to have 20/40 vision or better following surgery.

2. For an exudative retinal detachment where the neural retina is elevated secondary to the accumulation of subretinal fluid in the absence of a retinal break, prognosis is dependent upon the underlying cause (ie. neoplasm, inflammatory disease, congenital abnormalities) and whether or not it is reversible. In general, the retina tolerates exudative subretinal fluid better than fluid from rhegmatogenous retinal detachment. Therefore, provided the mechanism of fluid accumulation can be altered, good visual outcome can result even for relatively longstanding macular detachments.


Source

Yanoff & Duker: Ophthalmology, 3rd ed.

Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease

A tip on removing embedded corneal foreign bodies ...

Decrease the number of moving parts:

a) place your hand on the patient's cheek or nasal bridge so that unexpected movements on the part of the patient will not result in large movements of the removal device

b) instruct patient to keep forehead in continual contact with the slit lamp's cross bar

c) instruct patient to gaze at an object in the distance to further stabilize the eye


Source

Roberts: Clinical Procedures in Emergency Medicine, 4th ed

What is the mechanism of traumatic mydriasis? Treatment? Prognosis?

Blunt injury to the orbit may cause small tears to the iris sphincter muscle resulting in dilation or mydriasis. Treatment is supportive and the condition often resolves spontaneously.


Source

Bord, S. and Linden, J. "Trauma to the Globe and Orbit" Emerg Med Clin N Am. v 26. 2008.

What is the prognosis of an isolated cranial nerve III palsy caused by ischemia from microvascular disease in the vasa nervosa?

Good. After several weeks, most patients regain full function of their ocular muscles.

For a nice review of ocular nerves and their respective functions, check out this awesome website.


Source

Goodwin, J. "Oculomotor Nerve Palsy" Emedicine. 2 Dec 2008.

Yanoff & Duker: Opthalmology, 3rd ed.

What is commotio retinae? How is it treated?

Commotio retinae is a bruise to the retina secondary to blunt trauma. No effective treatment for commotio retinae is known.

It is important to distinguish (on your own; or with the help of an ophthalmologist) this entity from a retinal tear which can also present with decreased visual acuity following ocular trauma but which requires emergent repair.


Source

Albert: Albert & Jakobiec's Principles & Practice of Ophthalmology, 3rd ed.

Name the condition which can cause tunnel vision and is the third leading cause of blindness in the US behind cataracts and macular degeneration.

Glaucoma.


Source

Manual of Ocular Diagnosis and Therapy. 2002.

How do you treat this red eye?

Notables on H + P:

• severe pain, can't sleep, insidious onset over past several days


• history of rheumatoid arthritis


• visual acuity 30/20


• no lid edema or ocular discharge


• globe tender to palpation


• PERRL, no afferent pupillary defect


• no floroscien uptake


• blood vessels don't move with pressure applied from Q-tip


• blood vessels don't blanch with application of topical phenylephrine


• anterior chamber clear


• ocular pressure 18 mm Hg


• posterior ocular exam unremarkable

Scroll down for answer

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Scleritis

• opthalmology consult


• mild: oral NSAIDs


• refractory cases or evidence of scleral thinning (exposing underlying choroid): NSAIDs + oral corticosteroids/other immunosupressive drugs


• evaluate for potential complications: uveitis, keratitis or glaucoma


• evaluate for underlying systemic cause: rheumatoid arthritis (most common), Wegener's granulomatosis, systemic lupus erythematosus, inflammatory bowel disease, polyarteritis nadosa, infectious etiologies (herpes, Lyme, HIV)

Source

Dargin, J MD and Lowenstein, R MD. "The Painful Eye." Emergency Medicine Clinics of North America. 2008. 199-216.

Image: Dr. Frederick A. Jakobiec, eyepathologist.com

What is the treatment for primary angle closure glaucoma?

Primary angle closure glaucoma = iris acutely bulges forward obliterating angle between cornea and iris, closing off outflow of aqueous humor through canal of Schlemm

Treatment:

• topical timolol 0.5% - non-selective beta-blocker that reduces aqueous humor production. Systemic absorption and adverse effects may occur.


• topical pilocarpine 1% - 2% - stimulates cholinergic receptors in eye causing miosis which decreases resistance to aqueous humor outflow


• topical alpha-2 agonist (apraclonidine 1.0%) - reduces aqueous humor formation


• IV acetazolamide - carbonic anhydrase inhibitor that decreases aqueous humor production. Don't use in patients with sulfa allergy.


• ophthalmologic consultation for definitive treatment

Note: these treatments do not necessarily apply to primary open angle glaucoma, secondary open angle glaucoma or secondary angle closure glaucoma.

Source

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.

What causes visual floaters?

Visual floaters can be described as bubbles, strings, bundles of filaments which float within the visual field of one eye.

They are caused by small, benign inclusions in the vitreous.

They increase with age and may be permanent once present.

The sudden appearance of numerous floaters is a whole different ball game and may suggest retinal detachment.

Source

Tasman, W. et al. Duane's Ophthalmology. Lippincott Williams and Wilkins. 2008.