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Neuro Ophthalmology Presentation
Wednesday, September 15, 2010
Orbit SEQs
The Orbit
Preseptal Cellulitis
• infection of soft tissue anterior to orbital septum
Etiology
• usually follows periorbital trauma or dermal infection
Clinical Features
• tender, swollen and erythematous lids
• may have low-grade fever
• normal visual acuity, pupils, extraocular movements (EOM)
• no exophthalmos or RAPD
Treatment
• systemic antibiotics (Suspect H. influenza in children; S. aureus or Streptococci in adults)
• warm compresses
Orbital Cellulitis
• inflammation of orbital contents posterior to orbital septum
• common in children, but also in the aged and immunocompromised
Etiology
• usually secondary to sinus/facial/tooth infections or trauma
Clinical Features
• decreased visual acuity, pain, red eye, headache, fever
• lid erythema, tenderness, and edema with difficulty opening
• conjunctival injection and chemosis (conjunctival edema)
• proptosis, limitation of ocular movements (ophthalmoplegia) and pain with
movement
• RAPD, optic disc swelling
Treatment
• admit, IV antibiotics, blood cultures, orbital CT
• surgical drainage of abscess
• follow closely
Complications
• orbital apex syndrome, cavernous sinus thrombosis, meningitis, blindness
Finding Preseptal Cellulitis Orbital Cellulitis
Fever May be present Present
Lid edema Moderate to severe Severe
Chemosis Absent or mild Moderate or marked
Proptosis Absent Present
Pain on eye movement Absent Present
Ocular mobility Normal Decreased
Vision Normal Diminished ± diplopia
RAPD Absent May be seen
Leukocytosis Minimal or moderate Marked
ESR Normal or elevated Elevated
Additional findings Skin infection Sinusitis, dental abscess
Preseptal Cellulitis
• infection of soft tissue anterior to orbital septum
Etiology
• usually follows periorbital trauma or dermal infection
Clinical Features
• tender, swollen and erythematous lids
• may have low-grade fever
• normal visual acuity, pupils, extraocular movements (EOM)
• no exophthalmos or RAPD
Treatment
• systemic antibiotics (Suspect H. influenza in children; S. aureus or Streptococci in adults)
• warm compresses
Orbital Cellulitis
• inflammation of orbital contents posterior to orbital septum
• common in children, but also in the aged and immunocompromised
Etiology
• usually secondary to sinus/facial/tooth infections or trauma
Clinical Features
• decreased visual acuity, pain, red eye, headache, fever
• lid erythema, tenderness, and edema with difficulty opening
• conjunctival injection and chemosis (conjunctival edema)
• proptosis, limitation of ocular movements (ophthalmoplegia) and pain with
movement
• RAPD, optic disc swelling
Treatment
• admit, IV antibiotics, blood cultures, orbital CT
• surgical drainage of abscess
• follow closely
Complications
• orbital apex syndrome, cavernous sinus thrombosis, meningitis, blindness
Finding Preseptal Cellulitis Orbital Cellulitis
Fever May be present Present
Lid edema Moderate to severe Severe
Chemosis Absent or mild Moderate or marked
Proptosis Absent Present
Pain on eye movement Absent Present
Ocular mobility Normal Decreased
Vision Normal Diminished ± diplopia
RAPD Absent May be seen
Leukocytosis Minimal or moderate Marked
ESR Normal or elevated Elevated
Additional findings Skin infection Sinusitis, dental abscess
Ocular Emergencies
Urgent referal to an Ophthalmologist
- intraocular foreign body
- lid/globe lacerations
- corneal ulcer
- gonococcal conjunctivitis
- orbital cellulitis
- chemical burns
- acute iritis
- acute angle-closure glaucoma
- entral retinal artery occlusion (CRAO)
- retinal detachment
- endophthalmitis
- temporal arteritis (AION)
- Any case of severe ocular trauma
- Any case of acute visual loss
Important Examination Topics
Referactive errors (myopia, hypermetropia astigmatism presbyopia)
Lids (entropion, ectropion, ptosis, Chalazion, stye, Basal cell ca Blepharitis)
Conjunctiva (conjunctivitis bacterial, viral, phylectenular, vernal catarrah, trachoma, pterygium pingecula)
Cornea (corneal ulcer, bacterial , viral, fungal, acanthamoebic, trophic, exposure, disciform keratitis keratoconus)
uvea (causes signs, symptoms and treatment of uveitis acute and chronic)
lens ( cataract, subluxation)
Glaucoma ( POAG PNAG causes of secondary glaucoma congenital glaucoma)
Dry eye (causes and treatment)
proptosis (causes, treatment options)
blunt trauma eye (effects, blow out fracture )
Chronic dacryocystitis causes of watering diagnosis treatment
central retinal venous oclusion
disc odema papllodema causes features
optic neuritis causes features treatment
retinal detachment
effects of diabetes on the eye
effects of hypertension on the eye
age related macular degeneration
central serrous retinopathy
retinitis pigmentosa
retinoblastoma
causes of leukocoria
episclerits/ scleritis causes treatment
causes of diplopia
squint (definition, classification, cover uncover test, alternate cover test investigations treatment amblyopia treatment of amblyopia)
Nerve palsies (causes features teatment)
optic atrophy causes
light reflex pathway
vitamin a deficency
orbital cellulitis
orbital pseudotumor
painful red eye
causes of reduced vision sudden and gradual
Red Eye Differential Diagnosis
| Acute Conjunctivitis | Acute Bacterial Keratitis/ Ulcer | Acute Anterior Uveitis | Acute Congestive Glaucoma | |
| Chief complaints | Redness,discharge,foreign body sensation | Redness, watering, pain, photophobia, reduced vision if central | Redness,Pain, photophobia,reduction in vision | Redness, Pain, photophobia, gross reduction of vision nausea/vomiting |
| Vision | Normal | Normal (reduced if lesion central) | Mild to moderately reduced | Severely reduced |
| Conjunctiva | conjunctival congestion | circumcorneal congestion | circumcorneal congestion | circumcorneal congestion |
| Cornea | Clear | Opacity | Generalized Haze (KPs) | Very Hazy (Epithelial Odema) |
| Anterior Chamber | Normal Depth | Normal depth (in severe cases aqueous Cells, aqueous Flare, Hypopyon ) | Normal depth or Shallow (if Iris Bombe) Aqueous Cells, Aqueous Flare, Hypopyon, | View hazy due to corneal edema Shallow anterior chamber |
| Iris | Normal | Normal | Muddy Iris Iris Bombe, Peripheral anterior synechae(PAS) | Congested |
| Pupil | Round, Regular, Normal reaction, | Round, Normal reaction | Miosed, Irregular, Sluggish Reaction Posterior Synechae, seclusio pupillae, Oclusio pupillae, | Mid-dilated, vertically oval, Non Reacting |
| IOP | Normal | Normal | Normal (High in secondary angle closure glaucoma or low in cilliary shut down) | Very High (stony hard) |
| Treatment | Broad spectrum Antibiotic eye drops analgesics dark glasses | Strong Antibiotic eye drops and Sub conjunctival injections to cover both gram positive and gram negative organisms Atropine Analgesics Dark glasses | Strong Steroid eye drops Atropine eye drops t.i.d Analgesics orally Dark glasses | Inj Mannitol 300 ml i.v. in 40 mts stat Tab Acetazolamide 2 stat then q.i.d Pilocarpine eye drops q.i.d Anti-emetics i.v. Analgesics orally Beta Blocker eye drops b.i.d. Mild steroid eye drops q.i.d.
|
Viva Questions Neuro Ophthalmology
what are the causes of disc odema
what is papilledema
what are the stages of papilledema
what are the earliest signs of papilledema
what is pseudo-tumor cerebri
what are the causes of optic atrophy
what are the causes of III Nerve palsy
what are the features
what are the causes of IV nerve palsy
what are the features
what are the causes of VI nerve palsy
what are the features
What are the causes of optic neuritis
what are the features
what are the visual field defects on ON
what are the MRI sign in ON
what is RAPD
what is the treatment
What are the causes of pain in and around the eye
what is migraine
what are the features of classical migraine
what is the treatment
what is trigeminal neuralgia
treatment
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