Treatment

Vasoconstrictors if needed

Supportive, hand washing (prevents spread)

Ibpieai antibiotics

Neonatal conjunctivitis is usually due to one of three causes:

1. Chemical: silver nitrate (or erythromycin) drops are given prop.hylactical.ly to all new borns to prevent gonorrheal conjunctivitis. Tire drops may cause a chemical conjunctivitis (with no purulent discharge) that develops within 12 hours of instilling the drops and. re solves within 48 hours (pick this answer if conjunctivitis occurs in the first 24 hours of life).

2. Gonorrheal: look for symptoms of gonorrhea in the uioiUvr.'i !«• infant has an t'xUcmdy purulent discharge at 2- 5 days of ojjc.Treatment: is topical (e.g., erythromycin ointment). Infants that are given prophylactic: drops should not get gonorrheal conjunctivitis.

3. Chlamydial (inclusion conjunctivitis): the mother often reports no symptoms. The infant has mild-to-severe conjunctivitis beginning at 5--14 days of age. Patients must be treated with topical and systemic antibiotics (oral erythromycin usually is used) to prevent chlamydial pneumonia (a common complication). Prophylactic eyedrops do not effectively prevent chlamydial conjunctivitis.

Important points:

1. 11 you forget everything else, remember the age at which the three diseases present.

2. Conjunctivitis involves no loss of vision (other than transient bhi.iTi.ness due to tear libit debris that resolves with blinking). If loss of vision is present, think of other, more serious conditions.

Glaucoma; best thought of as ocular hypertension wi th its resultant: effects. Risk factors are age

> 40, race (black), and family history. Two types:

1. Open angle: although it is traditional to talk about painful attacks, they are rare. Open-angle glaucoma causes 90% of cases of glaucoma, is pninJcss, and does not involve acute attacks.

Tlie only signs are elevated intraocular pressure (usually 20-30 mrnHg), a gradually progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on fun-doscopic exam).Treat with several different types of medications (beta blockers, prostaglandin [latanoprost 1, aceta/.olamide, pilocarpine) or surgery.

2. Closed angle: presents with sudden ocular pain, haloes around lights, red eye, high intraocular pressure (> 30 mrnHg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil. Treat immediately with pilocarpine drops, oral glycerin, and ac.etazolamr.de to break the attack.Then use surgery to prevent further attacks (peripheral iridectomy). In rare cases, anticholinergic medications may cause, an attack of closed-angle glaucoma in a susceptible, previously untreated patient. Medications do not cause glaucoma attacks in open-angle glaucoma or patients previously treated surgically for closed-angle glaucoma.

Important points:

1. Steroids, whether topical or systemic, can cause glaucoma and cataracts. Topical steroids can worsen ocular herpes and fungal infections. For board purposes, do not give topical steroids (especially if the patient has a dendritic corneal ulcer stained green by fluorescein).

2. Exposure to ultraviolet light can cause keratitis (corneal inflammation) with resultant pain, foreign body sensation, red eye, tearing, and decreased vision. Patients have a history of welding, using a tanning bed or sunlamp, or snow-skiing ("snow-blindness"). Treat with an eye patch (24 hours), topical antibiotic, and possibly with an anticholinergic (cycloplegic agent that reduces pain).

3. Uveitis is common in juvenile rheumatoid arthritis (especially the pauciarticular form). Patients need periodic ophthalmologic examination to check for uveitis.

4. Cataracts are the most common cause of a painless, slowly progressive loss of vision. Treatment is surgical. Cataracts in a neonate should make you think of TORCH infections or an inherited metabolic disorder (e.g., galactosemia).

5. Know the retinal and fundus changes seen in diabetes (dot-blot hemorrhages, microaneurysms, neovascularization) and hypertension (arteriolar narrowing, copper/silver wiring, cotton wool spots, papilledema with, severe hypertension).

Background diaiietic retinopathy with exudate, hemorrhages, and edema (clot and blot). (From Vander JF, Gatilt JA: Ophthalmology Secrets, Philadelphia, Hanley & Belfus, 199!t, with permission.)

6. Diabetes is the number-one cause of blindness in adults under 55. Senile macular degeneration (look for macular d rusen) is the most common cause of blindness in adults over age 55. Glaucoma is the number-one cause of blindness in blacks of any age and the number-three overall cause of blindness.

7. Treatment for proliferative diabetic retinopathy (with neovascularization) is application, of a laser beam lo the periphery of the whole retina (panretinal photocoagulation), Focal laser treatment is common for nonproliferative retinopathy with, macular edema; the lasers applied only to the affected area.

Be able to differentiate orbital cellulitis; from preorbital cellulitis, (preseptal cellulitis). Both may involve swollen lids, fever, chemosis, and a history of facial laceration, trauma, insect bite, or sinusitis. Ophthalmoplegia, proptosis, severe eye pain, or decreased visual acuity indicates orbital cellulitis (a medical emergency).The most" common bugs in both are Strqitococcuspneumoniae, Haemophilus influenzae type b, and staphylococci/streptococci with a history of trauma. Complications of orbital cellulitis include extension into the skull, vein thromboses, and blindness. Treat either condition with blood cultures and administration of broad-spcctmm antibiotics to cover the likely bugs until culture results are known. Inpatient IV antibiotics are needed for orbital cellulitis.

With chemical burns to the eye (acid or alkaline), the key to management is copious irriga tion with the closest source of water, The longer you wait;, the worse the prognosis. Do not get additional history in this instance. Alkali burns have a worse prognosis, because they tend to penetrate more deeply into the eye.

Hordeolum (stye) is a painful, red lump near the lid margin, treat with warm compresses. Chalazion is a painless lump away from the lid margin. Treat with warm compresses. If the compresses do not work, use incision and drainage for both conditions.

Herpes simplex keratitis usually starts with conjunctivitis and a vesicular lid eruption, then progresses to the classic dendritic keratitis (seen with fluorescein—know what: this looks like). Treat with topical antivlrals (e.g., idoxuridine, trifluridinc). Corticosteroids arc; contraindicated with dendritic keratitis, because they may make the condition worse-

Ophthalmic herpes zoster should be suspected with involvement of the ti p of the nose and/or medial eyelid with a typical zoster dermatomal pattern.Treat with, oral acyclovir. Complications include uveitis, keratitis, and glaucoma.

Central retinal artery occlusion presents with sudden (within a few minutes), painless, unilateral loss of vision. The fundoscopic appearance is classic (know it!). No treatment is satisfactory. The most: common cause is emboli from carotid, plaque or the heart, but look for coexisting symptoms of temporal arteritis (elderly patients with, jaw claudication, tortuous temporal artery, markedly elevated erythrocyte sedimentation rate, and co-existing polymyalgia rheumatica symptoms of proximal m uscle pain and stii fhess). If temporal arteritis is suspected, start corticosteroids immediately before confirming the diagnosis with, a temporal artery biopsy. The patient may lose vision in the other eye if you wait to confirm the diagnosis.

Central retinal vein occlusion also presents with sudden (within a few hours), painless, unilateral loss of vision. The fundoscopic appearance is classic (know it!). No treatment is satisfactory.The most common causes are hypertension, diabetes mellitus, glaucoma, and in creased blood, viscosity (e.g., leukemia). Complications (vision loss, glaucoma) are related to neo v ascul ar i zati on.

Retinal detachment causes a sudden (instant), painless, unilateral loss of vision. History usually includes "floaters" and seeing flashes of light. Often described as a "curtain or veil coming down in front of my eye." This history should prompt immediate referral to an ophthalmolo gist. Surgery to reattach the retina may save the patient's sight;.

In elderly patients, both macular degeneration and cataracts cause painless loss of vision, often bilateral, but one side may be worse than the other. Know what the red reflex looks like in a patient with a cataract and what the fundus looks like in a patient with macular degenera tion (macular drusen).Treat cataracts with surgery. Macular degeneration currently has no treatment.

Drusen are the byproduct of retinai metabolism and manifest as focal yellow-white deposits (Jeep to the retinal pigment epithelium. They serve as a marker of nonexudative age-related macular degeneration. (From Vander JF, Gault JA: Ophthalmology Secrets. Philadelphia, Hanley & ßßlfus, 1998, with permission.)

Drusen are the byproduct of retinai metabolism and manifest as focal yellow-white deposits (Jeep to the retinal pigment epithelium. They serve as a marker of nonexudative age-related macular degeneration. (From Vander JF, Gault JA: Ophthalmology Secrets. Philadelphia, Hanley & ßßlfus, 1998, with permission.)

Optic neuritis and papillitis present with a fairly quick (over hours to days), painful (unless retrobulbar), unilateral or bilateral loss of vision. If loss of vision bilateral in a 20 40-year-old woman, think of multiple sclerosis; the same applies to mtcrnuclear ophthalmoplegia. Worry about tumor if the patient is male and has signs of intracranial hypertension or other neuro logic deficits. Lyme disease and syphilis are rare causes. Disc margins may appear blurred on fimdoscopie exam, just as in papilledema.

Note: Know your visual pathway lesions and location, just as for Step I (e.g., homonymous hemianopia, bitemporal hemianopia). The most commonly tested example is bitemporal hemianopia, which usually is due to a pituitary tumor.

Ophthalmologic cranial nerve (CN) palsies: usually due to vascular complications of diabetes and hypertension. Most cases resolve on their own within 2 months. In patients under 40, patients with other neurologic deficits or severe pain, and any patient who does not improve within 8 weeks, get: an MRI because benign causes are less likely:

1. Oculomotor (CN 3): the eye is down and out and can move only laterally. In cases due to hypertension or diabetes mellitus, the pupil is normal. Close observation is all that is needed; the condition resolves on its own in several weeks. A pupil that is "blown" (dilated, nonreactive) is a medical emergency; the most likely cause is an aneurysm or tumor. Get an MRI and/or magnetic resonance or cerebral angiogram.

2. Trochlear (CN 4): when the gaze is medial, the patient cannot look down.

3. Abducens (CN 6): the patient cannot look laterally with the affected eye.

4. CN .5 and 7 palsies also affect the eye because of corneal drying (loss of corneal blink reflex).

Children with a "lazy eye" or strabismus (deviation of the eye, usually inward) that persists beyond 3 months need ophthalmologic referral.The condition does not resolve and may cause blindness (amblyopia) in the affected eye. For this reason, visual screening must be done in pediatric patients; the visual system is still developing after birth until the age of 7 or 8. If one eye. does not see well or is turned outward, the brain cannot fuse the two different images that it sees and suppresses the bad eye, which will not develop the proper neural connections. Thus, the eye will never see well and cannot be corrected with glasses (neural rather than refractive problem).

Presbyopia: between the ages of 40 and 50 years, the lens loses its ability to accommodate. Patients need, bifocals or reading glasses for near vision. Presbyopia is a normal part of aging.

Important points:

1. Pelvic fracture is the fracture with the highest mortality rate. Patients can bleed to death. If the patient is unstable, consider heroic measures such as military antishock trousers and external fixator.

2. For any fracture, always do a neurologic and vascular exam distal to the fracture site to see if there is any neurologic or vascular compromise. Either may be an emergency.

3. For any fracture, get two x -ray views (usually anteroposterior and lateral) of the site, and consider x-rays of the joint above and below the fracture site.

4. Open fracture (compound fracture): skin is broken over the fracture site. Closed fracture: skin is intact over the fracture site,

5. For open fractures (lacerated skin), give antibiotics (cefazolin or cefazohn/gentamicin if the laceration is large or contaminated), do surgical debridement, give tetanus vaccine, lavage fresh wounds (< 8 hours old), and do an open reduction and internal fixation.The main complication in open fractures is infection.

Compartment syndrome: usually occurs after fracture, crush injury, burn, or other trauma or as a reperfusion injury (e.g., after revascularization procedure).The most common site is the calf. Symptoms and signs include pain on passive movement (out of proportion to injury), paresthesias, cyanosis or pallor, firm-feeling muscle compartment, bypesthesia or numbness (decreased sensation and two-point discrimination), paralysis (late, ominous sign), and elevated compartment pressure (> 30 -4-0 mmHg).The diagnosis usually is made clinically without a need to measure pressure. Compartment syndrome is an emergency, and quick action can save an otherwise doomed limb. Pulses are usually palpable or detectable with Doppler ultrasound. Treatment is an immediate fasciotomy; incising the fascial compartment relieves the pressure. Untreated, the condition progresses to permanent nerve damage and muscle necrosis. The clas sic clinical scenarios associated with compartment syndrome are supracondylar elbow fractures in children, proximal/midshaft tibial fractures, electrical burns, arterial or venous disruption, and revascuiarization procedures.

Open vs. closed reduction:

1. Reasons to do open reduction m Intraarticular fractures or articular surface malalignment m Open (compound) fractures m Nonunion or failed closed reduction

■ Compromise of blood supply a Multiple trauma (to allow mobilization at earliest possible point) ■a Extremity function requiring perfect reduction (e.g., professional athlete)

Z. Closed reduction should be done for all other fractures.

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