LL: Diplopia by Dr. Chady

• Binocular vs Monocular
• Bi – Double vision that resolves when the other eye is closed
  • DDx: Posterior circulation stroke, Cavernous Sinus Thrombosis, Compressive intracranial aneurysm, Botulism, MG

LL: Hematuria by Dr. Sawmiller

• DDx: microscopic vs macroscopic
• Micro : stones infection, viral illnesses, trauma, exercise, menstruation, renal disease, instrumentation
• Macroscopic: renal tumors, avm, aortocaval fistula, kidney stone, trauma, uti, STI
• Workup:
  • UA microscopy, CT urogram ( Ct A/P w/ and wo
  • MRI urography, noncon CT, US abd/pelvis, retrograde pyelogram
  • Cystoscopy
  • Asymptomatic hematuria – Cancer 
  • Trauma >50 RBC get ct scan to assess for injury
  • RUG in urethral injury or pelvic fractures

Ophthalmology Lecture

Vahid

• Visual acuity: near vision card, count fingers, hand motion (what direction is the hand moving), Light perception
• Pupils : Shape, size, direct response and consensual response
  • Anisocoria – CTA head/neck Horner syndrome (ptosis, miosis, anhidrosis), carotid dissection, pancoast tumor
  • Dark room, small pupil horner syndrome dissection pancoast
  • Bright room, large pupil, poor constriction of the big pupil
    • Wipes and plants vs 3rd nerve palsy
    • 3rd nerve palsy, MRI MRA

– EYE Pressure (IOP)

– eye drop pocket technique

– Tap central cornea, breath normally, normal below 22, ED 23-30 could be reasonable. 

– Hold eyelid against orbital rim

– Eye Movements

– entrapment – ischemia of the muscle

– Oculocardiac reflex – bradycardia n/v

– exotropia (outward), esotropia (inward) – call optho

– Amblyopia lazy eye – could be a brain problem

– Pain full eye

– corneal abrasion 

– flip upper eyelid if linear abrasions 

– Pinch eyelash, place cotton tip above the tarsal plate

– Tx: mechanism wood sticks, fingernail, contactlens – moxifloxacin 4x/day for 5 days

– Large, central moxifloxacin QID for 5 days

– Corneal foreign body – qtip preferred , 30 gauge needle bend to 75 degrees, bevel away from the eye, sweeping movement up and down not at the eye

– rust ring remove in the optho clinic – burr increases risk of scar

Cases

Nail glue on eye – erythromycin ointments 

Chemical injury

• Irrigate the eye
• Check pH and recheck pH
• pH should be 7.5

Corneal ulcer and hypopyon

• Infiltration, satellite lesions
• Acanthamoeba – swilling corneal ulcer

Blunt trauma

• Subconjunctival hemorrhage – resolves 2-3weeks
• Hyphema – traumatic rupture of iris blood vessel
  • High IOP – glaucoma and cornea staining 
  • African american patients with hyphema check for sickle cell at high risk of IOP
  • Needs close follow up Grade 1 & 2, call optho 3&4
  • IOP most important 
  • Ipressure lower drops

Traumatic Iritis 

• Happens 2 to 3 days after trauma 
• Traumatic mydriasis 
• Photophobia 

Retrobulbar hemorrhage 

• Orbital compartment syndrome – blood in the back of the eye 
• Needs lateral canthotomy and cantholysis (C&C)
• Proptotic , cant move, pupil big, vision blurry, chemosis
  • Lateral Canthotomy and cantholysis
    • Numb the eye, clamp cantho tendo with hemostat, hold eyelid with forcep and cut with iris or wescot scissors if you have
    • Inferior ramus of the lateral canthal tendon
    • Cut so the inferior eyelid can be pulled up to the limbus
    • Superior cantholysis (superior ramus) be careful to avoid lacrimal gland

Lacerations

• Simple- 
• Margin – optho does this repair 
• Canalicular laceration – laceration lateral near the medial punctum
  • Needs a stent oculplastics does

Globe rupture – penetrating trauma 

• No IOP, no fluorocene no drops
• CT w/o contrast
• Vanc and levaquin
• Tear drop pupil – iris protrudes
• Fly the eye place an eyeshield 

CRAO – central retinal artery occlusion

• Cherry red spot

• Activate code stroke
• < 8 hr activate code LVO
  • tPA intraarterial 

Giant Cell Arteritis 

• Anterior ischemic optic neuropathy
• Visual acuity RAPD Relative afferent pupillary defect , jaw claudication (do you get tired when chewing), proximal stiffness 
• ESR, CRP, CBC 
• High dose IV steroid

Chalazion (Stye)

• Warm compress
• Abx ointment 

Preseptal cellulitis and orbital 

• Orbital cellulitis – eye bulging, pupil changing, subperiosteal abscess 
• Risk factor – sinusitis 
• CT orbits with constrast

Conjectivits

• Viral vs bacterial 
• Allergic pataday eye drops
• Bacterial Purulent topical moxifloxacin 

Optic Neuritis 

• Color vision problems
• pixelated/static vision poorly reactive pupil 
• Painful eye movement up and inward
• MRI Brain/orbit

Acute Angle closure glaucoma

• pain , blurry, headache, n/v
• Mid dilated nonreactive to light
• IOP 30s/40s
• Recent nasal decongestant
• Tx: IOP lowering drops, IV diamox, IV mannitol 

Kids

• Red light reflex absent is bad
  • White reflex 
  • Urgent optho
  • Causes retinoblastoma, congenital cataract

• Eye hand book app

Slitlamp 

• Cell and flare
• 1mm , mag 1.6x, brightest light, 30degrees

Jimmy webb travels

• Angioedema 
• Trips abroad
  • Drake passage is where the pacific meets the atlantic 
  • World explorer is a big boat
  • No boat if you are on dialysis 
  • McGowan watches how people walk
    • She gives people fall risk bracelets
  • Cruise ship doc really good a sea sickness, diarrhea
  • Practicing emergency medicine physician expedition doctor – 3 to 4 weeks
  • Complicating factors that influence patient care
  • Jimmy organized 
  • Too much scopolamine causes naked running
  • Really good boot cleaning 
  • Really cool rocks in antarctica
  • Watch out for the bird flu
  • Really cool rocks in argentina 
  • Wilderness med education swiss alps put on by Utah
    • Chamonix
      • Mount Blanc highest mount in the Alps
        • There is a higher mountain western russian 
    • Rich Ingerstein wilderness med book 
    • Jimmy looks good in jorts
    • 2 french girls said there was a demon on the trail
      • It was an Ibex
    • Nex care tape is the best for blister
  • Lithuania
    • Formal global health elective