Gonioscopy.org

http://www.gonioscopy.org/

Glaucoma & Thyroid disease

The prevalence of self-reported glaucoma was significantly higher among [respondents] who reported a history of thyroid problems [6.5%] compared with those who did not [4.4%]

Hypothyroidism "may lead to the deposition of mucopolysaccharides in the trabecular meshwork, which increases IOP as well as aqueous outflow resistance"

Work up for Optic Neuropathy

Lab tests to r/o nfectious, inflammatory or nutritional problems:

• CBC
• C-reactive protein (GCA)
  
• ESR (GCA)
  
• Platelet count
• Lyme titer (infectious)
  
• ANA with reflex titer (rheumatologic)
• ACE (sarcoid)
  
• RPR (syphillis/infectious)
• FTA-ABS (syphillis/infectious)
• Vitamin B₁₂ (nutritional)
• Folic acid (nutritional)
• Methylmalonic acid (occult vitamin B₁₂ deficiency)

Neuroimaging:

• MRI (preferred) or CT scan
  

Differentials:

• a young patient complaining of sudden vision loss will more likely have an optic neuritis (ON)
• a middle-aged person would more likely have nonarteritic anterior ischemic optic neuropathy (NAION).
• an older patient with the same complaint would more likely have arteritic anterior ischemic optic neuropathy (AAION) associated with giant cell arteritis (GCA).
• NAION: no pain, “disk-at-risk” appearance in the fellow eye (small, crowded optic disc with little or no cupping that is predisposed to the ischemic process of NAION), less pale nerve
  
• AAION: pain with eye movements, optic nerve dema usually associated with hemorrhages during the acute phase, more pale nerve
  
• AAION and GCA symptoms: jaw claudication, scalp tenderness, fatigue, loss of appetite and fever.
• ON: pain on eye movement; you will see either a normal optic disc (retrobulbar optic neuritis) or disc swelling without hemorrhages (papillitis).
• Multiple sclerosis (MS) symptoms: weakness, numbness, pares-thesias or any other neurologic symptoms.
  
• Traumatic optic neuropathy: pallor of the neuroretinal rim suggests a longstanding or chronic process
  
• Structural abnormality or mass: non-acute, nonglaucomatous optic neuropathy; patient is in need of neuro-imaging to look for either a structural abnormality such as a mass or abnormal enhancement indicating an inflammatory process, or some form of disruption of the blood-brain barrier.
• GCA: A CBC, ESR, C-reactive protein and platelet count must be performed on patients over the age of 50
  

Ocular Side Effects Of Systemic Medications

http://www.revoptom.com/index.asp?ArticleType=SiteSpec&page=osc/105682/lesson.htm

Sinusitis

Clinical Features
- stuffy nose, followed by the slow onset of increased sinus pressure

- malaise, toxicity, headache, possibly a slightly elevated temperature, and usually a normal WBC count.

- as the disease progresses over two to three days, symptoms become more pronounced and severe.

- associated pain to the eye and orbit is a constant, dull ache with no throbbing. It may worsen if the patient bends over, coughs or strains.

- patients with chronic sinusitis usually have: allergic rhinitis, which is signaled by itchy/watery eyes, seasonal variation in symptoms and a family history of the disorder.

- acute sinusitis symptoms: facial pain or tenderness, colored nasal discharge, headache, decreased sense of smell, maxillary toothache, cough (usually daytime), fever, malodorous breath and occasional periorbital swelling. Less common findings include middle ear effusion, swelling of the face and nasal bleeding.²⁴

- ethmoid sinusitis: headache is a prominent symptom, located either behind or between the eyes with radiation to the temporal region. The eyes may be tender to pressure, and extreme tenderness on palpation of the medial and superior aspects of the orbit may be present. The patient may experience discomfort with eye movement.

- frontal sinusitis: may cause a frontal headache, which radiates behind the eyes to the vertex of the skull. The pain is generally constant and tends to feel like a pressure sensation. There is also point tenderness on the undersurface of the medial aspect of the superior orbital rim, which is the floor of the frontal sinus. Often, the pain is not present in the early morning after a night of rest. It usually appears one or two hours after waking, increases for three or four hours and becomes less severe in the late afternoon or evening. Apply finger pressure upward toward the floor of the sinus, where the sinus wall is thin, or perform palpation directly over the frontal sinus. Swelling caused by tumors or retained secretions (mucoceles) may cause a downward bulge in the floor of the frontal sinus. Transillumination of the frontal sinuses is done by placing a light source below the supraorbital rim, under the floor of the frontal sinus, at the upper inner angle of the orbit. This technique helps assess light transmission into the lower forehead.

- sphenoid sinusitis: causes pain at the occiput or vertex, yet frontotemporal, retro-orbital or facial pain is more common. It may also travel from the orbit to the mastoid area. The pain is described as constant, and if it occurs retrobulbarly, quite severe. This type of severe retro-orbital pain can cause photophobia and tearing.

- maxillary sinusitis: 10% of maxillary sinusitis is generally secondary to dental root infection. Simultaneous finger pressure over both maxillae exemplifies differences in tenderness.Perform transillumination by placing the light source over the middle of the infraorbital rim.

Examination and Testing
- thorough patient history and physical examination to establish either acute or chronic sinusitis
- an evaluation of vision, pupils, extraocular muscle function, exophthalmometry, slit lamp and funduscopy helps identify any secondary periorbital, orbital or ocular complications
- evaluation of the head and neck should be performed.

Amaurosis Fugax

-Most commonly caused by emboli thrown from the carotid artery or the heart; this eventually causes occlusion of the retinal arteriole system and/or an occlusive event anywhere else in the body.

-Patients usually have a history of hypertension, diabetes or hypercholesterolemia; danger of cerebral vascular accident (CVA) in addition to ocular sequelae.

-patients must be referred to the emergency room to rule out emboli actively being thrown from the carotid artery, cardiac valves or aortic arch.

-If a patient with these symptoms is 56 or older, one must consider giant cell arteritis (GCA)

-Other conditions, such as antiphospholipid antibody syndrome and systemic lupus erythematous, may also result in arteriole occlusion

-A central artery occlusion of less than 24 hours might be aided by intervention, including lowering IOP, performing ocular massage and attempting vasodilation by increasing carbon dioxide levels in the blood (this is accomplished by having the patient breathe into a paper bag).

-r/o weakness, numbness, headache or speech difficulty

-lab w/u:

• emergent complete blood count (CBC) with differential
• prothrombin time (PT)
• partial thromboplastin time (PTT) tests
• platelets
• carotid duplex
• echocardiogram

-start on ASA

-educate to report immediately to the ER if any non-recovering vision loss or peripheral weakness or numbness