620 Adult I Eyes - Dunphy, Winland-Brown, Porter & Thomas

Dry eye is more prevalent in

Hispanic and Asian populations pg 245

Dry eye occurs due to

mechanical abnormalities
lacrimal gland malfunction
mucin deficiency pg 245

Epiphoria is

excessive tearing pg 245

The most important thing for the clinician to know in the case of eye pain, and in dealing with eye problems in general is

referral to an opthalmologist pg 246

The most common condition of red eye is

viral conjunctivitis pg 246

bacterial conjunctivitis has a

thick purulent discharge, crust eyelids in the morning pg 247

bacterial conjunctivitis occurs more commonly during the

fall and winter pg 247

preauricular lymph nodes are not palpable in

bacterial conjunctivitis, allergic conjunctivitis, iritis, and acute glaucoma pg 247

in viral conjunctivitis, preauricular lymph nodes are

palpable pg 247

allergic conjunctivitis discharge is

stringy, mucoid pg 247

allergic conjunctivitis symptoms of conjunctival abnormalities are

itching and burning, mild,and diffuse pg 247

viral conjunctivitis discharge is

watery pg 247

allergic conjunctivitis occurs more commonly during the

fall and spring, sneezing and rhinorrhea are common pg 247

acute glaucoma presents with

severe pain, the anterior chamber may appear narrow with penlight exam, the pupil is mid-dilated nonreactive or sluggish, nausea, vomiting and headache may be present pg 247

a patient between ages 50-85 presents with sudden onset of severe eye pain, vomiting, headache, the conjunctiva may be injected, steamy cornea, pupil may be fixed, partially dilated, narrow chamber angle. Does this require urgent treatment?

yes - symptoms of Acute glaucoma pg 248

a patient usually older than 40 but may occur in younger patients presents with decreased peripheral field of vision, decreased central vision is a later sign, increased intraocular pressure, increased cu-to-disc ratio. Does this require urgent treatment?

Usually no - symptoms of Chronic glaucoma pg 248

Should any patient newly diagnosed with diabetes be referred to an opthalmologist?

Yes pg 272

bacterial conjunctivitis is usually caused by

Streptococcus pneumoniae,
Haemophilus influenzae,
group A Streptococcus
S. aureua
pseudomonads pg 259

Bacterial conjunctivitis should be treated with

broad spectrum topic agents pg 259

chlamydial conjunctivitis is a leading cause of blindness in developing nations and should by treated with systemic antibiotics in addition to topical agents. The drug of choice is

Azithromycin 1g as single dose or doxycycline 100mg bid x7 days. Treat the sexual partner simultaneously pg 259

herpes simplex conjunctivitis requires

systemic or topical agents and should be referred to an opthalmologist pg 259

viral conjunctivitis does not require

antibiotics unless there is a 2nd infection, use lubrication for comfort pg 259

Medications for Allergic conjunctivitis are

Mast cell stabilizers - lodaxamide, nedocromil 2%, pemirolast 0.1%
Antihistamine - emedastine 0.05%, Levocabastine 0.05%
Combination mast-cell & antihistamines
Nonsteroidal antiinflammatory pg 258

iritis requires

prompt attention by an opthalmologist pg 261

a Pterygium commonly is seen at

3 and 9 oclock in the eye position pg 262

A patient presents with sudden eye pain and blurred vision. Has nausea and vomiting. Reports seeing rainbow halos around lights, there is corneal cloudiness, with diffuse conjunctival hyperemia. The pupil of the affected eye will be moderately dilated and

acute closed-angle glaucoma and should be referred immediately to an opthalmologist pg 262

Cataracts are classified as

Type I - visual acuity better than 20/40 in the affected eye(s)
Type II - visual acuity of 20/40 or worse in the affected eye(s)
pg 265

normal intraocular pressure is typically

8-21mm Hg pg 269
10-20 mm Hg pg 270

acute angle-closure glaucoma IOP can occur as high as

40-80 mm Hg pg 269

systemic steroids may interfere with

glaucoma control pg 272

diabetic retinopathy is a

noninflammatory disorder of the retina that develops in patients with diabetes pg 272

diabetic retinopathy is divided into three stages,

background diabetic
preproliferative diabetic
proliferative diabetic
pg 273

background diabetic retinopathy,

microaneurysms, intraretinal hemorrhage, macular edema, and lipid deposits may be apparent pg 273

As the preproliferative diabetic disease progress,

nerve fiber layer infarctions (cotton wool spots), venous beading and dilation, edema and in some cases extensive retinal hemorrhage will be noted
pg 273

all diabetic patients should be seen by an opthalmologist at least

annually pg 273

patients with background retinopathy should be followed up with the opthalmologist every

six months pg 273

patients with proliferative retinopathy should be followed up with the opthalmologist every

3-4 months pg 273

patients with active proliferative retinopathy should be followed up with the opthalmologist every

8 weeks pg 273

Lisinopril is the only pharmacologic agent found to

slow the progression of diabetic retinopathy pg 273

The American Diabetes Association sets an acceptable level of
HgbAIC at

less than 7% pg 273

A hallmark of macular degeneration is

visual difficulties in low light pg 275

If a patient with bacterial conjunctivitis wears contacts,

it is important to treat her with a more broad-spectrum antibiotic drop, such as macrolide. handout

Up to 1/2 of potentially fatal sebaceous cell carcinomas resemble

chronic, benign inflammatory disease such as a chalazion and blepharoconjunctivitis pg 251

carcinomas may mimic

styes or chalazions pg 251

Eye Conditions requiring immediate referral:

Severe or sudden vision loss
Eye pain
Corneal ulceration
Trauma
Foreign body
Herpetic infection of the eye (ppt in week 2)

Inflammation of the conjunctiva
Highly contagious
Direct contact with secretions
S/S
Redness
Purulent or mucopurulent discharge
Unilateral at onset
Eyelids "glued" shut in morning
Eyelid edema

bacterial conjunctivitis (ppt in week 2)

Major Pathogens in Acute Bacterial Conjunctivitis In Adults

Gram-Positive Organisms
Staphylococcus aureus
Streptococcus species
Gram-Negative Organisms
Escherichia coli
Pseudomonas species
Moraxella species (ppt week 2)

Major Pathogens in Acute Bacterial Conjunctivitis in Children

Gram-Positive Organisms
Streptococcus pneumoniae
Staphylococcus aureus
Gram-Negative Organisms
Haemophilius Influenzae
Moraxella species (ppt week 2)

preauricular lymph nodes are palpable in

Viral conjunctivitis pg 247

Presentation
Painless or mild discomfort
"gritty"
Watery to serous discharge
Unilateral at onset then bilateral w/in 1-2 days
Preauricular lymphadenopathy
Treatment
Adenovirus is most common pathogen
Antihistamine
Lubricant drops
Cool compresses
Often tre

viral conjunctivitis (ppt week 2)

Prevention and education regarding conjunctivitis

Bacterial & Viral conjunctivitis are contagious
24 hours of therapy prior to school, daycare etc.
Good handwashing
Washcloths, pillowcases in laundry
Proper contact use
No contacts X 1 week
New contacts, eye makeup etc. (ppt, week 2)

A palpable preauricular node is usually present
Treatment - Doxycycline 100mg BID x 7-10 days or Azithromycin 1 gram po in combination with topicals

Chlamydia Conjunctivitis (ppt week 2)

Reduction of visual acuity
Ciliary flush
Photophobia
Severe foreign body sensation that prevents the pt from opening eye
Fixed pupil
Severe headache/nausea
Corneal opacity

Eye - Red flags (ppt week2)

S/S:
eye pain
hesitant or unable to open eye
Foreign body sensation
Important to identify situation leading to abrasion - scratching the eye, trauma, or contact lens irritation

Corneal abrasion (ppt week 2)

Visual Acuity
Penlight & fundoscopic exam
Check for pupillary response
Foreign body
Direct trauma
Fluorescein stain and use cobalt blue filter

Eye assessment (ppt week 2)

No tetracaine needed if patient is not photophobic
Will permanently stain clothing
Ulcers fluoresce distinctive round lesions
Abrasions may be singular or multiple with an "ice rink" appearance
Foreign bodies fluoresce around FB and the center is dark
Rin

Fluorscein Stain (ppt week 2)

Treat all contact lens wearers with a red eye as a corneal ulcer. Close follow up and eye drops of either tobramycin or quinilones. No contacts. Do not patch.
No steroid eye drops unless Opthalmology consult obtained and recommends.
Corneal abrasions trea

Treatment (ppt week 2)

Common history
Burning, itching
Feels like something is in the eye
Crusting of eyelids/lashes
Warm compresses 5-10 mins bid
Scrub lash with diluted baby shampoo bid
Treatment
Bacitracin
Erythromycin
Azithromycin drops

Blepharitis (ppt week 2)

Acutely presenting, erythematous, tender lump within the eyelid
Involves infection or inflammation of hair follicles of the eyelashes along the eyelid margin
Caused by blocked meibomian gland or infection in sebaceous glands of the eyelash

Hordeolum (ppt week 2)

Pimple or abscess in either upper or lower lid
External. Next to eyelash
Internal. Under eyelid
Painful swelling
Develop suddenly

Hordeolum presents as (ppt week 2)

Treatment
Warm compresses 15mins/ 4x per day
Do NOT squeeze or pop stye
Antibiotic drops if persistent/ edema of eyelid

Hordeolum treatment consists of (ppt week2)

Prevention
Good handwashing
Proper contact lense care
Take off eye makeup each night

Prevention of Hordeolum consists of (ppt week 2)

A hordeolum that does not resolve and eventually forms granulation tissue
Slow-developing, painless, hard mass
Pea-sized nodule within the eyelid, typically top eyelid

Chalazion (ppt week 2)

A Chalazion is

Not an infection.
Blocked meibomian gland.
Develop over weeks to months.
Typically self-limiting
If persistent - refer to opthamology. (ppt week 2)

Tasks of an APRN

Learn the patient's history/history of present illness
Perform the physical exam
Appropriate use/interpretation of tests
Appropriate choice of therapies
Consider need for consultation and/or collaboration
Negotiate decisions with the patient
Evaluate outc

In treating a patient with allergic conjunctivitis, the most appropriate treatment option is:

Opthalmological antihistamines

One distinguishing characteristic between conjunctivitis and iritis is:

A ciliary flush

An acutely presenting, erythematous, tender lump within the eyelid is called:

Hordeolum

In assessing a client with bacterial conjunctivitis, the nurse practitioner finds:

Minimal itching, moderate tearing, and profuse exudate.