MSKAP Extravaganza: The Eye, the Ear, and Randoms!

1. MSKAP Extravaganza:The Eye, the Ear, and Randoms! November 2013 Alison Landrey Richard Pinckney Halle Sobel

2. A 23-year-old man is evaluated for a 3-day history of redness and itchiness of the right eye. He had an upper respiratory tract infection 3 days before the eye symptoms began. Each morning he has awoken with crusting over the lids. He is otherwise healthy, with no ocular trauma or recent medical problems. • On physical examination, he is afebrile, blood pressure is 122/72 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Right eye conjunctival injection is present, with some crusting at the lids. Bilateral vision is 20/20. Pupils are equally round and reactive to light. • Which of the following is the most appropriate management of this patient? • Cool compresses to the affected eye • Oral antihistamine • Topical antibiotics • Topical corticosteroids

4. A 23-year-old man is evaluated for a 3-day history of redness and itchiness of the right eye. He had an upper respiratory tract infection 3 days before the eye symptoms began. Each morning he has awoken with crusting over the lids. He is otherwise healthy, with no ocular trauma or recent medical problems. • On physical examination, he is afebrile, blood pressure is 122/72 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Right eye conjunctival injection is present, with some crusting at the lids. Bilateral vision is 20/20. Pupils are equally round and reactive to light. • Which of the following is the most appropriate management of this patient? • Cool compresses to the affected eye • Oral antihistamine • Topical antibiotics • Topical corticosteroids

5. The Red Eye • How long are people with conjunctivitis contagious? • What is the treatment for viral conjunctivitis? • Typically no pain, cornea is clear, pupil is normal. IOP is normal.

6. The Red Eye • Why should you care? • Most common eye condition seen in primary care. • What should the history and physical focus on?

7. The Red Eye • What are other causes of the red eye? • Who needs referred emergently to an ophthalmologist?

8. TheRedEye • Glaucoma • Orbital Disease • Scleritis • Uveitis • Conjuncitivitis • Keratitis (HSV) • Subconjuctival Hematoma • Corneal Conditions • Chalazion, stye

10. The Red Eye • Uveitis: urgent referral • The presence of ciliary flush • Presents with pain, photophobia and blurred vision

11. The Red Eye

12. The Red Eye • Episcleritis • Superficial inflammation of the superficial vessels of the episclera • Typically no pain, no visual changes, no tearing, resolves without treatment

15. The Red Eye • Scleritis: emergent referal • Inflammation of the fibrous layer of the eye underlying the conjunctiva and episclera Severe, dull pain, may have awoken a patient from sleep; may be visual loss

16. A 76-year-old woman is evaluated for a 1-day history of headache, left eye pain, nausea and vomiting, seeing halos around lights, and decreased visual acuity of the left eye. She has type 2 diabetes mellitus, hypertension, and atrial fibrillation. Medications are metformin, digoxin, metoprolol, hydrochlorothiazide, and warfarin. • On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 104/min, and respiration rate is 16/min. Visual acuity wearing glasses is 20/40 (right eye) and 20/100 (left eye). The left eye has conjunctival erythema. The right pupil is reactive to light, the left pupil is sluggish and constricts in response to light from 6 mm to 4 mm. On palpation of the ocular globe, the left globe feels firm as compared with the right. • Which of the following is the most likely diagnosis? • Acute angle-closure glaucoma • Central retinal artery occlusion • Ocular migraine • Temporal arteritis

17. A 76-year-old woman is evaluated for a 1-day history of headache, left eye pain, nausea and vomiting, seeing halos around lights, and decreased visual acuity of the left eye. She has type 2 diabetes mellitus, hypertension, and atrial fibrillation. Medications are metformin, digoxin, metoprolol, hydrochlorothiazide, and warfarin. • On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 104/min, and respiration rate is 16/min. Visual acuity wearing glasses is 20/40 (right eye) and 20/100 (left eye). The left eye has conjunctival erythema. The right pupil is reactive to light, the left pupil is sluggish and constricts in response to light from 6 mm to 4 mm. On palpation of the ocular globe, the left globe feels firm as compared with the right. • Which of the following is the most likely diagnosis? • Acute angle-closure glaucoma • Central retinal artery occlusion • Ocular migraine • Temporal arteritis

18. Acute-Angle Glaucoma • What is the pathophysiology? • Halos, severe pain (may present as a headache), decreased visual acuity, elevated IOP, pupil mid-dilated

20. A 70-year-old man is evaluated for a 6-month history of low energy and decreased libido. He is not in a depressed mood and is still interested in daily activities. He has glaucoma and hypertension. Over the past year his vision has decreased and his ophthalmologist has adjusted his medications repeatedly. His current medications are timolol drops, latanoprost drops (a prostaglandin analogue), dorzolamide drops (a topical carbonic anhydrase inhibitor), lisinopril, and amlodipine. • On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 138/84 mm Hg, pulse rate is 48/min and regular, and respiration rate is 12/min. BMI is 28. Other than bradycardia, the results of the physical examination are normal. An electrocardiogram shows only sinus bradycardia. • Which of this patient's medications should be discontinued? • Amlodipine • Dorzolamide • Latanoprost • Lisinopril • Timolol

21. A 70-year-old man is evaluated for a 6-month history of low energy and decreased libido. He is not in a depressed mood and is still interested in daily activities. He has glaucoma and hypertension. Over the past year his vision has decreased and his ophthalmologist has adjusted his medications repeatedly. His current medications are timolol drops, latanoprost drops (a prostaglandin analogue), dorzolamide drops (a topical carbonic anhydrase inhibitor), lisinopril, and amlodipine. • On physical examination, temperature is 37.6 °C (99.7 °F), blood pressure is 138/84 mm Hg, pulse rate is 48/min and regular, and respiration rate is 12/min. BMI is 28. Other than bradycardia, the results of the physical examination are normal. An electrocardiogram shows only sinus bradycardia. • Which of this patient's medications should be discontinued? • Amlodipine • Dorzolamide • Latanoprost • Lisinopril • Timolol

22. Glaucoma Treatment • How does timolol work? • Local drugs can have systemic effects. • How do carbonic anydrase inhibitors work for glaucoma?

23. A 70-year-old woman is evaluated for a 3-month history of vision problems. She reports that objects may appear blurry or distorted, particularly in the central field. She has difficulty reading and recognizing faces. She has no eye pain or recent eye trauma. She is a smoker. She is on no medications. • On physical examination, vital signs are normal. Funduscopic findings are shown :shown . The remainder of the eye examination is normal. • Which of the following is the most likely diagnosis? • Age-related macular degeneration • Cataracts • Primary open angle glaucoma • Retinal detachment

25. A 70-year-old woman is evaluated for a 3-month history of vision problems. She reports that objects may appear blurry or distorted, particularly in the central field. She has difficulty reading and recognizing faces. She has no eye pain or recent eye trauma. She is a smoker. She is on no medications. • On physical examination, vital signs are normal. Funduscopic findings are shown :shown . The remainder of the eye examination is normal. • Which of the following is the most likely diagnosis? • Age-related macular degeneration • Cataracts • Primary open angle glaucoma • Retinal detachment

26. Q 29 • A 55-year-old man is evaluated for a 1-day history of seeing flashing lights, “squiggly” lines, and floating objects in his left eye followed by loss of vision at the outer periphery of the eye shortly after having breakfast this morning. He now describes seeing what looks like a curtain coming down in that location. He has myopia requiring prescription glasses. • On physical examination, vital signs are normal. Vision in the right eye is 20/100 uncorrected and 20/40 with glasses. Vision in the left eye is 20/100 uncorrected and 20/40 with glasses. Pupils are equally reactive to light and accommodation. There is no conjunctival injection. Findings on funduscopic examination are shown :shown . • Which of the following is the most likely diagnosis? • Central retinal artery occlusion • Central retinal vein occlusion • Ocular migraine • Retinal detachment • Temporal arteritis

28. Q 29 • A 55-year-old man is evaluated for a 1-day history of seeing flashing lights, “squiggly” lines, and floating objects in his left eye followed by loss of vision at the outer periphery of the eye shortly after having breakfast this morning. He now describes seeing what looks like a curtain coming down in that location. He has myopia requiring prescription glasses. • On physical examination, vital signs are normal. Vision in the right eye is 20/100 uncorrected and 20/40 with glasses. Vision in the left eye is 20/100 uncorrected and 20/40 with glasses. Pupils are equally reactive to light and accommodation. There is no conjunctival injection. Findings on funduscopic examination are shown :shown . • Which of the following is the most likely diagnosis? • Central retinal artery occlusion • Central retinal vein occlusion • Ocular migraine • Retinal detachment • Temporal arteritis

29. A 19-year-old woman is evaluated for a 1-week history of left ear canal pruritus, redness, and pain. She swims 1 mile each day and has recently started wearing plastic ear plugs to keep water out of her ears while swimming. • On physical examination, she is afebrile, blood pressure is 98/66 mm Hg, pulse rate is 62/min, and respiration rate is 16/min. She appears healthy and in no distress. There is pain with tugging on the pinna and compression or movement of the tragus. The left ear canal is shown :shown . With irrigation, the left tympanic membrane appears normal. There is no preauricular or cervical lymphadenopathy. • Which of the following is the most likely diagnosis? • A Acute otitis externa • B Delayed-type hypersensitivity reaction to ear plugs • C Malignant otitis externa • D Otitis media

31. A 19-year-old woman is evaluated for a 1-week history of left ear canal pruritus, redness, and pain. She swims 1 mile each day and has recently started wearing plastic ear plugs to keep water out of her ears while swimming. • On physical examination, she is afebrile, blood pressure is 98/66 mm Hg, pulse rate is 62/min, and respiration rate is 16/min. She appears healthy and in no distress. There is pain with tugging on the pinna and compression or movement of the tragus. The left ear canal is shown :shown . With irrigation, the left tympanic membrane appears normal. There is no preauricular or cervical lymphadenopathy. • Which of the following is the most likely diagnosis? • A Acute otitis externa • B Delayed-type hypersensitivity reaction to ear plugs • C Malignant otitis externa • D Otitis media

32. Otitis Externa • Symptoms: • ear fullness • Exacerbated by jaw motion • Exam Findings • Canal erythema and edema, purulent debris • TM may be erythematous as well (but not bulging) • Pain with movement of tragus or pinna • Treatment • Polymyxin/cortisporin drops OR topical fluoroquinolones (e.g. ofloxacin)

33. A 29-year-old man is evaluated for the gradual onset of right-sided hearing loss. He reports a continuous high-pitched ringing in his right ear that has been present for 3 to 4 months. • On physical examination, vital signs are normal. When a vibrating 512 Hz tuning fork is placed on the top of his head, it is louder in the left ear. When placed adjacent to his right ear, it is heard better when outside the ear canal than when touching the mastoid bone. Otoscopic examination is normal bilaterally. Neurologic examination is normal other than right-sided hearing loss. • Which of the following is the most appropriate management of this patient? • Biofeedback therapy • Immediate treatment with oral corticosteroids • MRI of the posterior fossa and internal auditory canal • Otolith repositioning maneuver

35. Weber and Rinne • Weber: fork on forehead • Lateralizes to unaffected side in sensorineural hearing loss, affected side in conductive • Rinne: fork on mastoid then held over ear canal • If heard better on mastoid: suggests conductive loss

36. *if hearing loss with pain or drainage -> more likely conductive *If hearing loss with vertigo or tinnitus -> more likely sensorineural • Conductive • Cholesteatoma • Foreign body, cerumen • Infection • otosclerosis • Sensorineural • acoustic neuroma/schwannoma (unilateral, sometimes with tinnitus and vertigo) • Menieres (unilateral with vertigo, tinnitus) • SSNHL (unilateral, <3 days, often idiopathic • Presbycusis (bilat, gradual) • Drug induced (bilat: loop diuretics, AGs, chemo) • Autoimmune (bilateral progressive) • Noise induced

37. B A C

38. Acoustic Neuroma Visual

39. A 29-year-old man is evaluated for the gradual onset of right-sided hearing loss. He reports a continuous high-pitched ringing in his right ear that has been present for 3 to 4 months. • On physical examination, vital signs are normal. When a vibrating 512 Hz tuning fork is placed on the top of his head, it is louder in the left ear. When placed adjacent to his right ear, it is heard better when outside the ear canal than when touching the mastoid bone. Otoscopic examination is normal bilaterally. Neurologic examination is normal other than right-sided hearing loss. • Which of the following is the most appropriate management of this patient? • Biofeedback therapy • Immediate treatment with oral corticosteroids • MRI of the posterior fossa and internal auditory canal • Otolith repositioning maneuver Asymmetric Sensorineural hearing loss not clearly due to menieres should be evaluated with MRI to exclude acoustic neuroma, meningioma

40. A 72-year-old woman is evaluated for sudden hearing loss in the left ear with moderate ringing that started yesterday. She has no vertigo or dizziness. • On physical examination, vital signs are normal. Otoscopic examination is initially obscured by cerumen bilaterally. Once cerumen is removed, the tympanic membranes appear normal and there is some redness in the canals bilaterally. When a 512 Hz tuning fork is placed on top of the head, it is louder in the right ear. When placed adjacent to the left ear, it is heard better when outside the ear canal than when touching the mastoid bone. Neurologic examination is normal other than left-sided hearing loss. • Which of the following is the most appropriate management of this patient? • Acyclovir • Neomycin, polymyxin B, and hydrocortisone ear drops • Triethanolamine ear drops • Urgent audiometry and referral

41. A 72-year-old woman is evaluated for sudden hearing loss in the left ear with moderate ringing that started yesterday. She has no vertigo or dizziness. • On physical examination, vital signs are normal. Otoscopic examination is initially obscured by cerumen bilaterally. Once cerumen is removed, the tympanic membranes appear normal and there is some redness in the canals bilaterally. When a 512 Hz tuning fork is placed on top of the head, it is louder in the right ear. When placed adjacent to the left ear, it is heard better when outside the ear canal than when touching the mastoid bone. Neurologic examination is normal other than left-sided hearing loss. • Which of the following is the most appropriate management of this patient? • Acyclovir • Neomycin, polymyxin B, and hydrocortisone ear drops • Triethanolamine ear drops • Urgent audiometry and referral

42. Sudden sensorineural hearing loss • If no obvious cause on exam (infection, cerumen), urgent referral to ENT • Prednisone may have some benefit in reversing hearing loss

43. A 66-year-old woman is evaluated for several months of a “whistling” or “swishing” sound in her right ear. She notes that it gets faster and louder when she exercises and thinks it is timed to her heartbeat. She does not notice any hearing loss, dizziness, or vertigo. • On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 138/84 mm Hg, and pulse rate is 84/min. Auditory acuity to normal conversation appears normal, and otoscopic examination is unremarkable bilaterally. Neurologic examination is normal. • Which of the following is the most appropriate next step in the management of this patient? • Audiometry • Auscultation over the right ear, eye, and neck • Trial of a sound-masking device • Trial of a nasal corticosteroid spray

44. A 66-year-old woman is evaluated for several months of a “whistling” or “swishing” sound in her right ear. She notes that it gets faster and louder when she exercises and thinks it is timed to her heartbeat. She does not notice any hearing loss, dizziness, or vertigo. • On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 138/84 mm Hg, and pulse rate is 84/min. Auditory acuity to normal conversation appears normal, and otoscopic examination is unremarkable bilaterally. Neurologic examination is normal. • Which of the following is the most appropriate next step in the management of this patient? • Audiometry • Auscultation over the right ear, eye, and neck • Trial of a sound-masking device • Trial of a nasal corticosteroid spray

45. Pulsatile Tinnitus • Concern for vascular etiology • Stenosis or AVM • Eustachian Tube Dysfunction can also uncommonly cause pulsatile tinnitus • Look for middle ear effusion on exam, ask about significant nasal congestion, evidence of conductive hearing loss • Of note: nonpulsatile tinnitus Is most commonly due to sensorineural hearing loss ->audiometry appropriate

46. A 72-year-old man is evaluated in the emergency department for a 12-hour episode of dizziness, described as a “spinning sensation” when he opens his eyes. He has nausea without vomiting, has had no loss of consciousness, no palpitations, and no other neurologic symptoms. He requires assistance to walk. He prefers to keep his eyes closed but has no diplopia. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had an upper respiratory tract infection 2 weeks ago. Medications are hydrochlorothiazide, lisinopril, simvastatin, and metformin. • On physical examination, vital signs are normal. There are no orthostatic changes. Results of a cardiovascular examination are normal. He has no focal weakness. He cannot stand without assistance. Vertical nystagmus occurs immediately with the Dix-Hallpike maneuver. It persists for 90 seconds and does not fatigue. Electrocardiogram is consistent with left ventricular hypertrophy and shows no acute changes. • Which of the following is the most appropriate next step in management? • CT scan of the head without contrast • MRI with angiography of the brain • Otolith repositioning • Trial of vestibular suppressant medication

47. Vertigo: 1) What features distinguish vertigo from other causes of dizziness? 2) What are two general categories of vertigo? the Dix Hallpike helps distinguish Peripheral (horizontal nystagmus) vs. Central (vertical)

48. Peripheral • BPPV (transient with head movement) • Vestibular neuronitis (postviral inflammation with nausea, persistant severe sx) • Acute labyrinthitis (with hearing loss) • Menieres • Central (<1% of vertigo) • Acoustic neuroma (esp if hearing loss concurrent) • Migraine • Posterior circulation cerebrovascular disease (infarct or ischemia) (consider if risk factors) -> MRA if vascular cause suspected • Head trauma (get hx of coagulopathy • Brain lesion (mets, toxoplasmosis, CNS lymphoma – hx of cancer, HIV)

49. A 72-year-old man is evaluated in the emergency department for a 12-hour episode of dizziness, described as a “spinning sensation” when he opens his eyes. He has nausea without vomiting, has had no loss of consciousness, no palpitations, and no other neurologic symptoms. He requires assistance to walk. He prefers to keep his eyes closed but has no diplopia. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had an upper respiratory tract infection 2 weeks ago. Medications are hydrochlorothiazide, lisinopril, simvastatin, and metformin. • On physical examination, vital signs are normal. There are no orthostatic changes. Results of a cardiovascular examination are normal. He has no focal weakness. He cannot stand without assistance. Vertical nystagmus occurs immediately with the Dix-Hallpike maneuver. It persists for 90 seconds and does not fatigue. Electrocardiogram is consistent with left ventricular hypertrophy and shows no acute changes. • Which of the following is the most appropriate next step in management? • CT scan of the head without contrast • MRI with angiography of the brain • Otolith repositioning • Trial of vestibular suppressant medication

50. A 48-year-old man is evaluated for a 2-day history of episodic dizziness with nausea. He noted the onset abruptly and compares the feeling to “being on a roller coaster.” His most severe episodes occurred while arising from bed and when parallel parking his car. The symptoms lasted 30 to 40 seconds and were followed by two episodes of emesis. He has no recent fever, headache, tinnitus, hearing loss, double vision, dysarthria, weakness, or difficulty walking. He had a similar episode 5 years ago. Medical history is significant for depression. His only medication is citalopram. • On physical examination, vital signs are normal. Results of cardiac and neurologic examinations are normal. The Dix-Hallpike maneuver precipitates severe horizontal nystagmus after about 20 seconds. With repeated maneuvers, the nystagmus is less severe. • Which of the following is the most likely diagnosis? • Benign paroxysmal positional vertigo • Cerebellar infarction • Meniere disease • Vestibular neuronitis