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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2611_Библиотеки_им_академика_М_И_Перельмана.pdf
196
▲
Figure 7–4. Periocular contact dermatitis due to eye
CMDT 2025
CHAPTER 7
drop preservative.
must be considered when there is a systemic medical contraindication to the use of the drug. Ophthalmic solutions
of the nonselective beta-blockers, eg, timolol, may worsen
bradycardia, HF, or asthma. Phenylephrine eye drops may
precipitate hypertensive crises and angina. Adverse interactions between systemically administered and ocular
drugs should also be considered. Using only 1 or 2 drops at
a time and a few minutes of nasolacrimal occlusion or eyelid closure ensures maximum ocular efficacy and decreases
systemic side effects of topical agents.
An antibiotic instilled into the eye can sensitize the
patient to that drug and cause an allergic reaction upon
subsequent systemic administration. Potentially fatal anaphylaxis is known to occur in up to 0.3% of patients after
intravenous fluorescein for fluorescein angiography. Anaphylaxis also has been reported after topical fluorescein.
ADVERSE OCULAR EFFECTS OF
SYSTEMIC DRUGS
Systemically administered drugs produce a wide variety of
adverse effects on the visual system. Table 7–3 lists the
major examples. The likelihood of most complications is
rare, but if visual changes develop while a patient is being
6. Systemic Effects of Ocular Drugs
The systemic absorption of certain topical drugs (through
the conjunctival vessels and lacrimal drainage system)
treated with these medications, the patient should be referred
to an eye care professional for an eye examination. Screening
for toxic retinopathy is recommended in patients receiving
long-term chloroquine or hydroxychloroquine therapy.
Table 7–3. Adverse ophthalmic effects of systemic drugs (selected list).
Medications Possible Ophthalmic Side Effects
Respiratory medications
Anticholinergic bronchodilators (eg, ipratropium) Angle-closure glaucoma due to mydriasis, blurring of vision due to cycloplegia,
Sympathomimetic bronchodilators (eg, salbutamol) and
decongestants (eg, ephedrine)
Cardiovascular system medications
Amiodarone Corneal deposits (vortex keratopathy), optic neuropathy, thyroid eye disease
Amlodipine Chemosis (conjunctival edema)
Anticoagulants Conjunctival, retinal, and vitreous hemorrhage
Carbonic anhydrase inhibitors (eg, acetazolamide,
methazolamide)
Chlorthalidone Angle-closure glaucoma due to ciliary body swelling
Digoxin Disturbance of color vision, photopsia, optic neuropathy
Furosemide Angle-closure glaucoma due to ciliary body swelling
Phosphodiesterase type 5 inhibitors (eg, sildenafil,
tadalafil, vardenafil)
Statins Extraocular muscle palsy (myasthenic syndrome)
Thiazides (eg, indapamide) Angle-closure glaucoma, nearsightedness, xanthopsia (yellow vision), band
Gastrointestinal medications
Anticholinergic agents Angle-closure glaucoma due to mydriasis, blurring of vision due to cycloplegia,
H2-blockers Retinal vascular occlusion, optic neuropathy, retrobulbar optic neuritis
Urinary tract medications
Alpha-adrenoceptor-antagonists (eg, doxazosin, prazosin,
tamsulosin, terazosin)
dry eyes
Angle-closure glaucoma due to mydriasis
Nearsightedness, angle-closure glaucoma due to ciliary body swelling
Color vision changes, nonarteritic anterior ischemic optic neuropathy
keratopathy due to hypercalcemia, macular edema
dry eyes
Intraoperative floppy iris syndrome
(continued)
DISORDERS OF THE EYES & LIDS
CMDT 2025
197
Table 7–3. Adverse ophthalmic effects of systemic drugs (selected list).
Medications Possible Ophthalmic Side Effects
Anticholinergic agents Angle-closure glaucoma due to mydriasis, blurring of vision due to cycloplegia,
Finasteride Floppy iris syndrome during intraocular surgery
Pentosan polysulfate sodium Maculopathy
Phosphodiesterase type 5 inhibitors (eg, sildenafil,
tadalafil, vardenafil)
CNS medications
Amphetamines Widening of palpebral fissure, blurring of vision due to mydriasis, elevated
Anticholinergic agents including preoperative medications Angle-closure glaucoma due to mydriasis, blurring of vision due to cycloplegia,
Aripiprazole Nearsightedness
Diazepam Nystagmus
Haloperidol Capsular cataract
Lithium carbonate Proptosis, oculogyric crisis, nystagmus
MAO inhibitors Nystagmus, visual hallucinations, diplopia, myasthenia gravis
Morphine/opioids Miosis, visual hallucinations, diplopia, dry eye
Neostigmine Nystagmus, miosis
Olanzapine Angle-closure glaucoma due to mydriasis
Phenothiazines (eg, chlorpromazine) Pigmentary deposits in conjunctiva, cornea, lens, and retina; oculogyric crisis
Phenytoin Nystagmus
Quetiapine Floppy iris syndrome during intraocular surgery
Retigabine Ocular pigmentation and retinopathy
Risperidone, paliperidone Floppy iris syndrome during intraocular surgery
SNRIs (eg, venlafaxine) Angle-closure glaucoma, mydriasis, dry eye
SSRIs (eg, paroxetine, sertraline) Angle-closure glaucoma, ischemic optic neuropathy, cataract
Thioridazine Corneal and lens deposits, retinopathy, oculogyric crisis
Topiramate Angle-closure glaucoma due to ciliary body swelling, nearsightedness,
Tricyclic agents (eg, imipramine) Angle-closure glaucoma due to mydriasis, blurring of vision due to cycloplegia,
Triptans (eg, sumatriptan, zolmitriptan) Angle-closure glaucoma due to ciliary body swelling, nearsightedness
Vigabatrin Visual field constriction, cone dystrophy
Zonisamide Angle-closure glaucoma due to ciliary body swelling, nearsightedness
Obstetric drugs
Sympathomimetic tocolytics Angle-closure glaucoma due to mydriasis
Hormonal agents
Aromatase inhibitors (eg, anastrozole) Dry eye, vitreoretinal traction, retinal hemorrhages
Cabergoline Angle-closure glaucoma
Female sex hormones Retinal artery occlusion, retinal vein occlusion, papilledema, cranial nerve
Tamoxifen Crystalline retinal and corneal deposits, altered color perception, cataract, optic
dry eyes
Color vision changes, nonarteritic anterior ischemic optic neuropathy
intraocular pressure
dry eyes
Chlorpromazine causes floppy iris syndrome during intraocular surgery
macular folds, anterior uveitis, corneal edema
dry eye
palsies, ischemic optic neuropathy
neuropathy, macular edema, retinal pigmentary change
(continued)
(continued)
198
CMDT 2025
CHAPTER 7
Table 7–3. Adverse ophthalmic effects of systemic drugs (selected list).
Medications Possible Ophthalmic Side Effects
Immunomodulators
Alpha-interferon Retinopathy, keratoconjunctivitis, dry eyes, optic neuropathy
Corticosteroids Cataract (posterior subcapsular); susceptibility to viral (herpes simplex),
Cyclosporine Posterior reversible leukoencephalopathy
Fingolimod Macular edema, retinal vein occlusion
NSAIDs Corneal opacity, vortex keratopathy, periorbital edema, dry eye
Tacrolimus Optic neuropathy, posterior reversible leukoencephalopathy
Antibiotics
Chloramphenicol Optic neuropathy
Clofazimine Crystalline deposits (conjunctiva, cornea, iris)
Ethambutol Optic neuropathy
Fluoroquinolones Diplopia, retinal detachment
Isoniazid Optic neuropathy
Linezolid Optic neuropathy
Rifabutin Uveitis
Streptomycin Optic neuropathy, epidermal necrolysis
Sulfonamides Nearsightedness, angle-closure glaucoma due to ciliary body swelling
Tetracycline, doxycycline, minocycline Papilledema
Antivirals
Cidofovir Uveitis
Antimalarial agents
Chloroquine, hydroxychloroquine Retinal degeneration principally involving the macula, vortex keratopathy
Quinine Retinal toxicity, pupillary abnormalities
Amebicides
Diiodohydroxyquinoline Optic neuropathy
Chemotherapeutic agents
Bortezomib Chalazia
Chlorambucil Optic neuropathy
Cisplatin Optic neuropathy
Docetaxel Lacrimal (canalicular) obstruction
Fluorouracil Lacrimal (canalicular) obstruction
MEK inhibitors: trametinib, selumetinib, cobimetinib,
pimasertib
Vincristine Optic neuropathy
Chelating agents
Deferoxamine, deferasirox Retinopathy, optic neuropathy, lens opacity
Penicillamine Ocular pemphigoid, optic neuropathy, extraocular muscle palsy (myasthenic
Oral hypoglycemic agents
Chlorpropamide Refractive error, epidermal necrolysis, optic neuropathy
Thiazolidinediones (glitazones) Increase in diabetic macular edema
bacterial, and fungal infections; steroid-induced glaucoma; idiopathic
intracranial hypertension; central serous retinopathy
Multifocal serous retinal detachment, retinal vein occlusion, cystoid macular
edema
syndrome)
(continued)
(continued)
DISORDERS OF THE EYES & LIDS
CMDT 2025
199
Table 7–3. Adverse ophthalmic effects of systemic drugs (selected list).
Medications Possible Ophthalmic Side Effects
Vitamins
Vitamin A Papilledema
Vitamin D Band-shaped keratopathy
Rheumatologic agents
Chloroquine, hydroxychloroquine Retinal degeneration principally involving the macula, vortex keratopathy
Gold salts Deposits in the cornea, conjunctiva, and lens
NSAIDs (eg, ibuprofen, naproxen, indomethacin) Vortex keratopathy (ibuprofen, naproxen), corneal deposits (indomethacin),
Penicillamine Ocular pemphigoid, optic neuropathy, extraocular muscle palsy (myasthenic
Salicylates Subconjunctival and retinal hemorrhages, nystagmus
Dermatologic agents
Dupilumab Conjunctivitis
Retinoids (eg, isotretinoin, tretinoin, acitretin, and
etretinate)
Bisphosphonates
Alendronate, pamidronate Scleritis, episcleritis, uveitis
If no baseline abnormalities are present, screening should
be repeated annually beginning after 5 years. More fre-
retinal degeneration principally involving the macula (indomethacin)
syndrome)
Papilledema, blepharoconjunctivitis, corneal opacities, decreased contact lens
tolerance, decreased dark adaptation, teratogenic ocular abnormalities,
idiopathic intracranial hypertension, optic neuritis
before alpha-adrenoreceptor antagonist treatment is
started, if possible.
quent screening is necessary in patients treated with doses
greater than 5.0 mg per kg measured body weight per day
of hydroxychloroquine or greater than 2.3 mg/kg/day of
chloroquine, in patients with kidney or macular disease, or
in those taking tamoxifen.
Patients receiving long-term systemic corticosteroids
are at increased risk for several ocular complications,
ocular complications including serous retinal detachment,
cystoid macular edema, and retinal vein occlusion. Patients
receiving MEK inhibitors should have a complete eye exami-
nation at baseline before the initiation of these medications
and should be referred for an eye examination if blurred or
reduced vision develops while taking MEK inhibitors.
(continued)
The chemotherapeutic MEK inhibitors are associated with
including glaucoma, cataract, and central serous retinopathy. They should be referred to an eye care professional for
an eye examination at baseline before starting corticosteroids and at any time if reduced or blurry vision develops.
An ophthalmologist should be informed whether a
patient is taking or has ever taken alpha-adrenoreceptor
antagonists (such as tamsulosin) before cataract surgery
because these medications increase the risk of intraoperative floppy iris syndrome, which can make cataract surgery
more challenging. Cataract surgery should be completed
Arora S et al. Retinal toxicities of systemic anticancer drugs.
Surv Ophthalmol. 2022;67:97. [PMID: 34048859]
Park SSE et al. Dealing with floppy iris syndrome. Curr Opin
Ophthalmol. 2022;33:3. [PMID: 34711714]
Somisetty S et al. The impact of systemic medications on retinal
function. Asia Pac J Ophthalmol (Phila). 2023;12:115. [PMID:
36971705]
Yusuf I et al. Hydroxychloroquine-induced retinal toxicity. Front
Pharmacol. 2023;14:1196783. [PMID: 37324471]
200
CMDT 2025
Otolaryngology Disorders
Elliott D. Kozin, MD
Rosh Sethi, MD
8
º
DISEASES OF THE EAR
HEARING LOSS
ESSENTIALS OF DIAGNOSIS
»
Hearing loss is generally categorized as either
conductive or sensorineural.
»
Diagnostic evaluation routinely includes
audiologic testing.
» Classification & Epidemiology
Lawrence R. Lustig, MD
loss that manifests as a gradually progressive, predomi-
den sensorineural hearing loss, often called idiopathic
sudden sensorineural hearing loss, is considered an
otologic emergency and may be treatable with oral or
intratympanic corticosteroids if delivered within several
weeks of onset. Long-term severe to profound sensorineu-
A. Conductive Hearing Loss
B. Sensorineural Hearing Loss
Table 8–1. Hearing loss classification.
Classification Vocal Equivalent Decibel (dB) Range
Normal Soft whisper 0–20 dB
Mild Soft spoken voice 20–40 dB
Moderate Normal spoken voice 40–60 dB
Severe Loud spoken voice 60–80 dB
Profound Shout > 80 dB
OTOLARYNGOLOGY DISORDERS
» Evaluation of Hearing (Audiology)
hears better than the other ear. In the Rinne test, the tuning
201
DISEASES OF THE AURICLE
Every patient who reports hearing loss should be referred
for audiologic evaluation unless the cause is easily remediable (eg, cerumen impaction, otitis media). Immediate audio-
» Hearing Amplification
DISEASES OF THE EAR CANAL
1. Cerumen Impaction
cleansing and no hygiene measures are recommended. Ceru-
202
2. Foreign Bodies
CMDT 2025
CHAPTER 8
» Clinical Findings
» Treatment
3. Otitis Externa
ESSENTIALS OF DIAGNOSIS
»
Otalgia.
»
Erythema, edema, and purulence of the external
auditory canal skin.
»
Patients who are immunocompromised or have
diabetes are at risk for “malignant” otitis externa
(osteomyelitis of the skull base).
» General Considerations
Aspergillus), which grow in the presence of excessive mois-
▲
Figure 8–1. Malignant otitis externa in a 40-year-old
woman with diabetes mellitus, with typical swelling and
honey-colored crusting of the pinna. Both the external
auditory canal and temporal bone were involved in the
pseudomonal infection. (Used, with permission, from E.J.
Mayeaux Jr, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr,
Chumley H. The Color Atlas of Family Medicine, 2nd ed.
McGraw-Hill, 2013.)
OTOLARYNGOLOGY DISORDERS
otitis externa in patients who are immunocompromised or
have diabetes must be referred for specialty evaluation.
203
6. Neoplasia
resolve on therapy, a malignancy should be suspected and
biopsy performed. This disease carries a very high 5-year
4. Pruritus
5. Exostoses & Osteomas
DISEASES OF THE EUSTACHIAN TUBE
1. Eustachian Tube Dysfunction
ESSENTIALS OF DIAGNOSIS
»
Aural fullness.
»
Discomfort with barometric pressure change.
»
Retracted eardrum.
204
chian tube”) is a relatively uncommon, although quite
CMDT 2025
CHAPTER 8
3. Barotrauma
2. Serous Otitis Media
ESSENTIALS OF DIAGNOSIS
»
Negative pressure from eustachian tube obstruction causes transudation of fluid into the middle
ear and stasis.
»
Dull and hypomobile tympanic membrane.
Tympanic membrane perforation is an absolute contrain-
dication to diving, as the patient will experience an unbal-
OTOLARYNGOLOGY DISORDERS
DISEASES OF THE MIDDLE EAR
1. Acute Otitis Media
ESSENTIALS OF DIAGNOSIS
»
Otalgia.
»
Purulent fluid of the middle ear.
»
Erythema and hypomobility of tympanic
membrane.
» General Considerations
usually precipitated by a viral upper respiratory tract
infection that causes eustachian tube obstruction. This
205
▲
Figure 8–2. Acute otitis media with effusion of right
ear, with multiple air-fluid levels visible through a
translucent, slightly retracted, nonerythematous
tympanic membrane. (Used, with permission, from Frank
Miller, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr,
Chumley H. The Color Atlas of Family Medicine, 2nd ed.
McGraw-Hill, 2013.)
zae, and Streptococcus pyogenes.
» Clinical Findings
» Treatment
2. Chronic Otitis Media
ESSENTIALS OF DIAGNOSIS
»
Chronic otorrhea with or without otalgia.
»
Tympanic membrane perforation with conductive
hearing loss.
»
Often amenable to surgical correction.