Em6

Front 1

Stye (External Hordeolum)

Back 1

Warm, wet compresses 4 times daily and erythromycin 0.5% ophthalmic ointment twice daily for 7 to 10 days

Front 2

Chalazion (Internal Hordeolum)

Back 2

same manner as a stye, although refractory lesions may improve with doxycycline

Front 3

Bacterial Conjunctivitis

Back 3

Non-contact lens wearers should receive topical polymyxin B-trimethoprim 10,000 units–1 mg/ml. Contact lens wearers should receive topical antibiotic coverage for Pseudomonas, such as ciprofloxacin, ofloxacin, or tobramycin (each 0.3%) The lens should be discarded and not replaced until the infection has completely resolved. In patients younger than 2 months, sulfacetamide 10% solution 1 drop every 2–3 h for 5 to 7 days may be used.

Front 4

A severe purulent discharge with a hyperacute onset (within 12–24 hours) should prompt an emergent consult with an ophthalmologist for ____?

Back 4

an aggressive workup for possible gonococcal conjunctivitis.

Front 5

Viral Conjunctivitis

Back 5

naphazoline/pheniramine 0.025%/0.3% 1 drop 3 to 4 times daily, as needed

Front 6

Allergic Conjunctivitis

Back 6

cool compresses 4 times daily, artificial tears 4 to 8 times daily, and naphazoline/pheniramine 0.025%/0.3% 1 drop 4 times daily. Diphenhydramine 25 mg PO 3 to 4 times daily may be helpful in moderate to severe cases. Severe cases may require a mild topical steroid such as fluorometholone 0.1% 1 drop 4 times daily for 7 to 14 weeks

Front 7

Herpes Simplex Virus

Back 7

trifluorothymidine 1% drops or vidarabine 3% ointment 5 times daily should be prescribed. In addition, erythromycin ophthalmic 0.5% ointment twice daily and warm soaks 3 times daily to skin lesions can help prevent secondary bacterial infections. If corneal involvement is present, then the trifluorothymidine 1% drops dosage must be increased to 9 times a day. If vidarabine 3% ointment is being used instead, the dosage remains 5 times daily. If an anterior-chamber reaction is present, a cycloplegic agent such as scopolamine 0.25% 1 drop 3 times daily can be used. Acyclovir 800 mg PO 5 times daily or famciclovir 500 mg 3 times daily for 7 to 10 days may be considered if the diagnosis is made within the first 3 days of the HSV outbreak.Topical steroids are to be strictly avoided. Refer to Oth in 3 mo

Front 8

Herpes Zoster Ophthalmicus

Back 8

Acyclovir 800 mg PO 5 times a day or famciclovir 500 mg 3 times daily for 7 to 10 days should be prescribed if the skin lesions are younger than 3 days. In addition, erythromycin 2% ointment and warm compresses should be applied to skin lesions. Ocular involvement requires erythromycin 0.5% ophthalmic ointment to the eye twice daily. For comfort, oral opioid analgesia, cycloplegic agents (scopolamine 0.25% 1 drop 3 times daily or cyclopentolate 1% 1 drop 3 times daily), and cool compresses are helpful.

Front 9

Endophthalmitis

Back 9

vancomycin 1 mg in 0.1 ml normal saline (N/S) and ceftazidime 2.25 mg in 0.1 ml N/S intravitreally (note not IV). Systemic antibiotics are added if bacteremia is suspected. Considerations include Clindamycin 600–900 mg IV q8h, Ceftazidime 2 g IV q8h, and Amikacin 7.5 mg/kg IV once, then 6 mg/kg q12h. Optional is the addition of steroids intravitreally or orally.

Front 10

Periorbital Cellulitis

Back 10

amoxicillin/clavulanate (40 mg/kg PO tid in children or 500 mg PO tid in adults). For children younger than 5 years or in the presence of comorbidities or toxicity in adults, hospital admission for IV ceftriaxone and vancomycin may be required.

Front 11

Orbital Cellulitis

Back 11

Ophthalmologic consultation and admission for cefuroxime 1 g IV q8h (vancomycin IV or a cephalosporin IV in penicillin-allergic patients) is required.

Front 12

Corneal Ulcer

Back 12

Topical ofloxacin 0.3% or ciprofloxacin 0.3% ophthalmic solution is used: 2 drops q 15 min for 6 h, then 2 drops q 30 min for the remainder of the day, then 2 drops q 1 h during the second day then 2 drops q 4 h for days 3 to 14. Topical cycloplegics, such as cyclopentolate 1% 1 drop 3 times daily, aid in pain relief. Eye patching is contraindicated because of the risk of Pseudomonas infection. An ophthalmologist should see the patient within 12 to 24 hours.

Front 13

Subconjunctival Hemorrhage

Back 13

It requires no treatment and usually resolves within 2 weeks.

Front 14

Conjunctival Abrasions

Back 14

Superficial conjunctival abrasions are treated with erythromycin 0.5% ophthalmic ointment twice daily for 2 or 3 days.

Front 15

Corneal Abrasion

Back 15

Proparacaine is preferred over tetracaine because it causes less pain upon administration and provides comparable anesthesia. A corneal abrasion will fluoresce green during a fluorescein stain examination when using the cobalt blue light on the slit lamp. A careful search for an ocular foreign body (including lid eversion) must be done in the presence of an abrasion. Once the diagnosis of a simple abrasion is made, a cycloplegic (cyclopentolate 1% or homatropine 5% 1 drop 3 times daily) likely will provide pain relief. Simple abrasions are treated with topical antibiotics (eg, tobramycin 0.3%, erythromycin 0.5%, or bacitracin/polymyxin ophthalmic ointment 3 times daily). Ciprofloxacin, ofloxacin, or tobramycin each 0.3% 1 drop every 4 hours may be used instead. Contact lens abrasions are at risk for Pseudomonas infection and should be treated with ofloxacin or ciprofloxacin 1 drop 4 times daily.

Front 16

Conjunctival Foreign Bodies

Back 16

Foreign bodies of the conjunctiva are removed under topical anesthesia with a moistened sterile swab. Eversion of the upper lid is performed to rule out foreign matter in the superior conjunctival fornix

Front 17

Corneal Foreign Bodies

Back 17

Superficial foreign bodies of the cornea are removed under slit lamp microscopy with a fine needle, an eye spud, or an ophthalmic burr. Topical anesthesia (eg, proparacaine) is used (also instilled in the unaffected eye to depress reflex blinking). For obvious reasons, this procedure should be attempted only in a sober, cooperative patient. A All patients should be referred to an ophthalmologist within 24 hours.

Front 18

Lid Lacerations

Back 18

Refer

Front 19

Blunt Ocular Trauma

Back 19

The care of the blunt trauma eye patient should be discussed with an ophthalmologist, and the patient should follow up with the ophthalmologist within 48 hours even if no significant injuries are initially found.

Front 20

Hyphema

Back 20

atropine 1% to prevent pupillary movement from tearing-damaged blood vessels. Increased intraocular pressure (IOP) is associated with hyphemas and can threaten sight. Therefore, after ruptured globe is excluded, IOP should be measured. If the IOP is greater than 30 mm Hg, timolol 0.5% 1 drop should be given. If increased IOP persists, apraclonidine 0.5% 1 drop should be added. Acetazolamide 500 mg PO is used in refractory cases. If the IOP is greater than 24 mm Hg in a sickle cell patient or in a patient with a spontaneous hyphema, timolol 0.5% 1 drop alone should be used because acetazolamide can cause red cells to sickle in the anterior chamber. Mannitol 1 to 2 g/kg IV may be used in either type of patient if initial measures are ineffective. In any case, emergent evaluation by an ophthalmologist is indicated. Because of the risk of rebleed in 3 to 5 days and the potential necessity of surgical intervention, any disposition decisions should be made by an ophthalmologist at the bedside, regardless of the size of the hyphema.

Front 21

Blowout

Back 21

ntibiotic prophylaxis (eg, penicillin 500 mg PO or cephalexin 250 mg PO 4 times daily for 10 days) is recommended due to sinus involvement. Isolated blowout fractures, with or without entrapment, require early referral to an ophthalmologist.

Front 22

Penetrating Trauma or Ruptured Globe

Back 22

Once a globe injury is suspected, any further manipulation or examination of the eye must be avoided. In such cases, the patient should be placed upright and kept non-PO. A protective metallic eye shield should be put in place, and a first-generation cephalosporin should be administered (cefazolin 1 g IV) with an antiemetic (to prevent Valsalva). Tetanus status should be updated. A CT of the orbit is the test of choice to screen for an intraocular foreign body. An ophthalmologist should be called immediately if a globe rupture or a penetrating injury is strongly suspected.

Front 23

Chemical Ocular Injury

Back 23

Acid and alkali burns are managed in a similar manner. The eye should be flushed immediately at the scene and sterile normal saline or Ringer lactate irrigation solution should be continued in the ED immediately upon arrival (even before visual acuities or patient registration) until the pH is normal (7.0). A topical anesthetic and a Morgan lens are used in this procedure.A cycloplegic (cyclopentolate 1% or homatropine 5%) 1 drop 3 times daily will alleviate ciliary spasm, and erythromycin 0.5% ophthalmic ointment applied every 1 to 2 hours while awake should be prescribed. Most patients will require opioid pain medications. If there are signs of a severe injury, such as a pronounced chemosis, conjunctival blanching, corneal edema or opacification, or increased IOP, the patient should be seen in the ED by an ophthalmologist.

Front 24

Cyanoacrylate (Super Glue or Crazy Glue) Exposure

Back 24

Cyanoacrylate glue easily adheres to the eyelids and corneal surface. Its primary morbidity stems from corneal injuries from the hard particles that form. Initial manual removal is facilitated by heavy application of erythromycin 0.5% ophthalmic ointment, with special care to avoid damaging underlying structures. After the easily removable pieces are removed, the patient should be discharged with erythromycin 0.5% ophthalmic ointment to be applied 5 times a day to soften the remaining glue. Complete removal of the residual glue can be accomplished by the ophthalmologist at a follow-up visit within 48 hours.

Front 25

Ultraviolet Keratitis

Back 25

Treatment is the same as for a corneal abrasion (cycloplegics, topical antibiotics, opioid analgesics).

Front 26

Acute Angle Closure Glaucoma

Back 26

Immediate medications to administer include: timolol 0.5% 1 drop, apraclonidine 0.5% 1 drop, or prednisolone acetate 1% 1 drop every 15 minutes for 4 doses and then every 1 hour. If IOP is greater than 50 mm Hg or if vision loss is severe, then acetazolamide 500 mg IV should be considered. If IOP does not decrease and vision does not improve in 1 hour, mannitol 1 to 2 g/kg IV should be given. Pilocarpine 1% to 2% 1 drop every 15 minutes for 2 doses in the affected eye and pilocarpine 0.5% 1 drop in contralateral eye may be given once the IOP is below 40 mm Hg as long as the patient has a natural lens in place.

Front 27

Optic Neuritis

Back 27

Optic neuritis refers to inflammation at any point along the optic nerve and presents with acute vision loss, with a particular reduction in color vision. It is often painful (>50%), especially with extraocular movements. A decrease in color vision can be diagnosed by the "red desaturation test."

Front 28

Central Retinal Artery Occlusion

Back 28

An ophthalmologist should be contacted immediately once the diagnosis is made. In an attempt to dislodge the embolus, firm pressure should be applied to the globe through closed eyelids for 15 seconds, followed by a sudden release. This may be repeated several times. Acetazolamide 500 mg IV or timolol 0.5% 1 drop is used to reduce IOP. Inhalation of carbogen (5% carbon dioxide and 95% oxygen) has not been demonstrated to improve outcomes. Further management should be directed by an ophthalmologist who may perform anterior-chamber paracentesis to lower IOP.

Front 29

Central Retinal Vein Occlusion

Back 29

This pattern is described as "blood-and-thunder fundus." IOP should be measured. There is no immediate treatment for central retinal vein occlusion, but predisposing drugs (eg, oral contraceptives or diuretics) should be discontinued. Ophthalmologic follow-up is required.

Front 30

Giant Cell Arteritis (Temporal Arteritis)

Back 30

If CGA is not treated, bilateral vision loss can develop. Therefore, if there is strong suspicion of GCA or vision loss is present, the patient should be admitted for methylprednisolone 250 mg IV every 6 hours. For less suspicious patients with no vision loss, they may be discharged with prednisone 80 to 100 mg/d PO with close follow-up. Steroids should not be delayed pending results of a biopsy. Antiulcer medications should be prescribed to be given with systemic steroids.

Front 31

Otitis Externa

Back 31

The treatment of OE includes analgesics, cleaning the EAC, acidifying agents, topical antimicrobials, and occasionally topical steroid preparations. Floxin otic 5 drops bid, Cortisporin otic suspension 5 drops tid-qid, and Cipro HC otic 3 drops bid are commonly used for 7 days to treat OE. If significant swelling of the EAC is present, a wick or piece of gauze may be inserted into the EAC to allow passage of topical medications.

Front 32

Acute Mastoiditis

Back 32

Emergent ENT consultation, cefotaxime 1.0 g IV q4h, and admission to the hospital are necessary. Surgical drainage ultimately may be required.

Front 33

Otitis Media

Back 33

A 10-day course of amoxicillin 250–500 mg q8h is the preferred initial treatment for OM. Alternative agents include trimethoprim/sulfamethoxazole, azithromycin, or cefuroxime. Cefuroxime or amoxicillin/clavulanate may be given for OM unresponsive to first-line therapy after 72 hours. Antibiotic coverage should be extended to 3 weeks for patients with OM with effusion. Analgesics should be prescribed for patients with any degree of pain. Patients should follow up with a primary care physician for reexamination and to assess the effectiveness of therapy.

Front 34

Foreign Bodies in the Ear

Back 34

Live insects should be immobilized with 2% lidocaine solution distilled into the ear canal before removal. Foreign bodies may be removed with forceps and direct visualization or with the aid of a hooked probe or suction catheter. Irrigation is often useful for small objects; however, organic material may absorb water and swell.

Front 35

Epistaxis

Back 35

1. A quick history should determine the duration and severity of the hemorrhage and the contributing factors (trauma, anticoagulant use, infection, bleeding diathesis, etc).

2. The patient should blow the nose to dislodge any clots.

3. A quick inspection is made to identify obvious anterior sources. A Frazier suction catheter will help keep the passage clear.

4. Cotton swabs or pledgets moistened with a topical anesthetic or vasoconstrictor are inserted into the nasal cavity with bayonet forceps. Four percent lidocaine provides excellent results when mixed with 1:1000 epinephrine, 1% phenylephrine, or 0.05% oxymetazoline.

5. Direct external pressure is then applied for 15 minutes. Active bleeding into the pharynx despite direct pressure suggests inadequate pressure, drainage from a clot in the posterior nasal cavity, or true posterior epistaxis.

6. If this approach fails, it should be repeated 1 or 2 more times. If still unsuccessful and the source of bleeding is anterior, an anterior pack may be inserted or local cautery may be attempted if the source of bleeding is easily identified and is a discrete area of bleeding.
Chemical cautery with silver nitrate is the standard of care for emergency department (ED) cautery of anterior epistaxis. After hemostasis is achieved, the mucosa is cauterized by firmly rolling the tip of a silver nitrate applicator over the area until it turns silvery-black. A small surrounding area also should be cauterized to control local arterioles. Overzealous use of cautery is discouraged because it may cause septal perforation and unintended local tissue necrosis.

8. Anterior nasal packing may be performed with gauze or commercial devices. One popular device is the Merocel nasal sponge (Merocel Corp, Mystic, CT), a compact, dehydrated sponge available in several lengths to control anterior and posterior epistaxes. The sponge is rapidly inserted along the floor of the nasal cavity and then expands upon contact with blood or secretions. A film of antibiotic ointment applied to the sponge will ease insertion and reduce chances of infection. After insertion, expansion is hastened by rehydrating the sponge with sterile water from a catheter-tipped syringe after the sponge has been inserted. A mixture of lidocaine and a topical vasoconstrictor also may be used to hydrate the sponge and provide topical anesthesia and vasoconstriction. The longer sponges used to control posterior hemorrhages have been associated with some morbidity and should be used only when indicated; they are not indicated for the control of isolated anterior epistaxis. A variety of commercially available nasal tampons can be used, some with inflatable balloons that can control anterior and/or posterior hemorrhage. All nasal packs are removed in 2 to 3 days by an ENT physician.

cephalexin 250–500 mg PO q6h or amoxicillin/clavulanate 250/125 mg PO q8h. Penicillin-allergic patients may be given clindamycin or trimethoprim/sulfamethoxazole.

Front 36

Nose Frx

Back 36

Intermittent ice application, analgesics, and over-the-counter decongestants are the normal treatment. Follow-up in 2 to 5 days for reexamination and possible fracture reduction is prudent.

The nose should be examined for a septal hematoma, which is a collection of blood beneath the perichondrium of the nasal septum. Septal hematomas appear as bluish, fluid-filled sacs (or grapelike clusters) on the nasal septum. If left untreated, a septal hematoma may result in abscess formation or necrosis of the nasal septum. The treatment is local incision and drainage with subsequent placement of an anterior nasal pack.

Front 37

Nasal Foreign Bodies

Back 37

Nasal foreign bodies should be suspected in patients with unilateral nasal obstruction, foul rhinorrhea, or persistent unilateral epistaxis. After topical vasoconstrictors and anesthetic agents have been used, the foreign body should be removed under direct visualization. Tools for removal include forceps, suction catheters, hooked probes, and balloon-tipped catheters. For pediatric patients, one technique is to apply positive pressure via a puff of air to the patient's mouth, with a finger occluding the unobstructed nostril. ENT consultation is required for any unsuccessful removal.

Front 38

Sinusitis

Back 38

Treatment includes nasal decongestant sprays, such as oxymetazoline or phenylephrine, for no longer than 3 days. Oral antibiotic choices for 10–14 day regimens include ampicillin 500–1000 mg tid, trimethoprim/sulfamethoxazole 160/800 mg bid, clarithromycin 1000 mg bid, cefdinir 600 mg per day, cefpodoxime 200 mg bid, cefprozil 250–500 mg bid, and amoxicillin/clavulanate 875 mg bid. Complications of sinusitis include osteomyelitis, meningitis, intracranial abscess, Pott's puffy tumor, periorbital cellulitis, orbital cellulitis, and cavernous sinus thrombosis.