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ref: AAFP Monograph 194, July 1995. Cynthia Bradford.
- 6th: lateral rectus, look to side
- 4th: superior oblique, look down
- 3rd: all the rest
cornea: superficial layer heals well in 24-48 hours, middle stroma
heals slowly over weaks, scars.
visual field defects
- bitemporal hemianopsia: optic chiasm, pituitary tumor
- upper homonymous hemianopsia: lesion in Meyers loop, at temporal horn of lateral
- if metallic object, do x-ray to check for retention
- contact lens: tobramycin ointment, no patch, f/u 24h
- cyclogyl (cyclopentate) .5-1.0% 1 gtt -- lasts 6-24 h, onset .5-1 hour or homatropine 2%
BID-TID for comfort and NSAID PO
- erythromycin ophthalmic ointment, tobrex if large defect
- patch > 1 cm or for comfort, or children aged 3-7 (wont leave eye alone)
- recheck daily if patched, else for healing at 2-3 days
- loss or distortion of central vision, or marked difference of acuity between eyes
- sudden loss of peripheral vision
- flashes of light or floaters (ischemia), sudden cobweb or stringy floaters (detachment)
- curtain across eyes (ischemia)
- halos about lights (glaucoma)
- double vision
- intermittent dimming of vision
- cornea > 11 mm in newborn (congenital glaucoma)
- red eye with Red Eye Danger Signs
- dandruff or crust along lashes and erythema of lid margins
- lid hygeine twice daily for a looong time
- soak for 2-3 minutes
- dilute baby shampoo for upper and lower lid margins
- bacitracin or erythro ophthalm ointment at night for one week per month
- doxycyc 100 BID if severe case
- if multiple ulcer, consider staph coverage. Watch periorbital cellulitis.
- acute angle-closure glaucoma: halos about lights, red painful eye, pain over brow,
blurred vision, nausea and vomiting
- amblyopia (apparent) can be due to retinoblastoma
- atraumatic 6th nerve palsy in child has 50% pontine glioma risk
- black spots on red reflex: cataract
- giant cell arteritis: "odd facial/head sensations", severe temporal headaches,
jaw claudication, weight loss/weakness/anorexia.
- nasolacrimal duct obstn/dacrocystitis: refer if not relieved by 1 year or severe
symptoms. If acute dacrocystitis in child, rx. Augmentin for H flu
- odd pupils
- Marcus Gunn: better consenusal response to light than direct response. Due to afferent
defect from optic nerve disease (MS)
- Adies tonic pupil: dilated pupil poorly responsive to light, constricts with 1/8 %
- Horners: ptosis, miosis, anhidrosis. Oculosymp gateway defect (lung tumor)
- Argyll Robertson: small irregular pupil that reacts to accomod but not to light.
- optic neuritis: gradual (hours to days) visual loss, unilateral, pain on eye movement,
globe tenderness, pupillary and visual field defects, abnormal color vision.
- retinitis pigmentosa - lose cones, then rods. Night vision loss > tunnel vision and
- sporadic inirida in newborn has 30% risk Wilms tumor
- strabismus: refer if persist > 6 weeks
- very severe conjunctivitis with copious purulent discharge: think GC, refer (IV abs)
- white reflex in newborn: retinoblastoma
Pediatric: Strabismus and More
also see separate attachment
- blurred vision (keratitis, glaucoma, Iritis)
- ciliary flush - perilimbal conjunctival injection (Iritis)
- corneal opacification or epithelial disruption (bacterial keratitis)
- abnormal pupil: nonreactive, small/irregular. (glaucoma, iridocyclitis, Iritis)
- increased intraocular pressure
- colored halos (acute angle-closure glaucoma)
- pain (glaucoma, Iritis, bacterial keratitis)
- Aus sign: sharp pain in covered (red) eye when uncovered eye is illuminated (Iritis)
- photophobia (iridocyclitis, Iritis)
Iritis and Herpes Zoster Opthalmicus (refer)
- Herpes Zoster Opthalmicus first branch of Trigeminal nerve (V1). Look for lesions
at tip of nose. HZO has conjunctivitis as well, but iritis is the serious complication.
Refer for steroid drop therapy.
- other causes of Iritis: ank spond, IBD, syphilis, sarcoid, Reiters, psoriasis,
- on some use joystick turn to raise and lower
- slit width chg tells depth
- green light shows blood
- move chin up and down so canthus lines up with mark (to start)
- light 45 deg temporal, direct medial
- initial exam: slit max ht, min width
- fluorescein: blue filter, beam 3-4 mm
- ant chamber (iritis, hyphema): narrow, 3-4 mm ht. High power, focus between cornea &
lens. Focus light on lens to backlight matter in anterior chamber.
- amblyopia: decreased vision in one or both eyes with no apparent abnormality
- chalazion: obstructed meibomian gland (warm compress 10 minutes QID, may use PO abs) --
if no response x 4 weeks do surgery
- pinguecula/pterygium: benign neoplasms of conjunctiva. Pinguecula is raised
yellowish-white near cornea at 3 or 9 oclock. Pterygium is fleshy growth that may
spread onto cornea -- hot, dry climates.
- ecropion: outward turning of lower lid
- entropion: inward turning of lid
- episcleritis: benign, recurrent. localized inflamm, red-purple, below conjunctiva that
doesnt repond to vasoconstrictors.
- slceritis: deep red inflammation, sometimes nodular. Very painful. More purple.
- esotropia: eye turns inwards (medial)
- hordeolum: stye
- hyphema: layered blood in ant chamber
- hypopon: layered WBC in ant chamber (severe intraocular inflammation)
- internuclear opthalmoplegia: delayed adduction on lateral gaze, MS.
- keratitis: inflamm of the cornea (Herpes shows dendritic fluorescein stain) Bacterial
keratitis (corneal ulcer) is painful red eye, purulent drainage, corneal opacity.
- miosis: constriction, from parasymp via ciliary ganglion
- mydriasis: dilation of pupil
- proptosis (exophthalmos): one eye 3 mm > than other
- uveal tract: iris, ciliary body, choroid
- anterior uveitis: iridocyclitis (iris/iritis and ciliary
- post uveitis: choroiditis
- iritis produces ciliary flush: redness around the limbus
central retinal artery occulsion
a) acute unilateral visual loss, afferent pupilary defect, swollen optic nerve, narrow
retinal arteries, cherry-red spot on fovea
b) vasodilate by rebreathing into paper bag, topical beta blockers, acetazolamide IV,
- topical anaesthesia then 10 minutes saline irrigation
emergent rx of angle-closure glaucoma (no ophth. available)
- pilocarpine 2% q10min for 1 hr
- timoptic q30min for 1 hr
- Diamox 500 mg PO or IV
- Glycerin 50% (isosorbide 50% if diabetic) 3ml/kg over ice with lemon juice
- diagnostic: neo-synephrine 2.5%, 3 hrs
- therapeutic: homatropine, 48 hrs
- midriacyl: 2 hours
- cyclogyl 1%: 12-24 h
- scopolamine: 2 w
- atropine: 2-4 w
Author: John G. Faughnan.
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