Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2920_Библиотеки_им_академика_М_И_Перельмана
.pdf
278 EXOPHTHALMOS
https://t.me/medicina_free
Drugs associated with erythema
Suspect drug-induced erythema in any patient who develops this sign within 1 week of starting
a drug. Erythematous lesions can vary in size, shape, type, and amount, but they almost always
appear suddenly and symmetrically on the trunk and inner arms. The following drugs can produce erythematous lesions:
◆ allopurinol
◆ anticoagulants
◆ anticonvulsants
◆ antimetabolites
◆ antituberculotics
◆ barbiturates
◆ cephalosporins
◆ chlordiazepoxide
◆ codeine
◆ corticosteroids
Some drugs—particularly barbiturates, hormonal contraceptives, salicylates, sulfonamides,
and tetracycline—can cause a “fixed” drug eruption. In this type of reaction, lesions can appear
in any body part and flake off after a few days, leaving a brownish purple pigmentation. Repeated drug administration causes the original lesions to recur and new ones to develop.
P
EDIATRIC POINTERS
Many newborns develop a pink papular rash
(erythema toxicum neonatorum) that starts
within the first 4 days after birth and spontaneously disappears by the 10th day. Neonates
and infants can also develop erythema from
infections and other disorders. For instance,
candidiasis can produce thick white lesions
over an erythematous base on the oral mucosa as well as diaper rash with beefy red erythema.
Roseola, rubeola, scarlet fever, granuloma
annulare, and cutis marmorata also cause erythema in children.
G
ERIATRIC POINTERS
Many elderly patients have well-demarcated
purple macules or patches, usually on the back
of the hands and on the forearms. Known as actinic purpura, this condition results from blood
◆ co-trimoxazole
◆ diazepam
◆ erythromycin
◆ gentamicin
◆ griseofulvin
◆ hormonal
contraceptives
◆ indomethacin
◆ iodide bromides
◆ lithium
◆ nitrofurantoin
◆ NSAIDs
◆ penicillin
leaking through fragile capillaries. The lesions
disappear spontaneously.
P
ATIENT COUNSELING
Teach patients with a chronic disease, such as
SLE or psoriasis, about the character of their
typical rashes so they can be alert to any flareups of their disease. Also, advise such patients
to avoid sun exposure and to use sunblock
when appropriate.
◆ phenothiazines
◆ phenytoin
◆ quinidine
◆ salicylates
◆ sulfonamides
◆ sulfonylureas
◆ tetracyclines
◆ thiazides
Exophthalmos
[Proptosis]
Exophthalmos—the abnormal protrusion of one
or both eyeballs—may result from hemorrhage,
edema, or inflammation behind the eye; extraocular muscle relaxation; or space-occupying
intraorbital lesions and metastatic tumors. This
EXOPHTHALMOS 279
https://t.me/medicina_free
sign may occur suddenly or gradually, causing
mild to dramatic protrusion. Occasionally, the
affected eye also pulsates. The most common
cause of exophthalmos in adults is dysthyroid
eye disease.
Exophthalmos is usually easily observed.
However, lid retraction may mimic exophthalmos even when protrusion is absent. Similarly,
ptosis in one eye may make the other eye appear exophthalmic by comparison. An exophthalmometer can differentiate these signs by
measuring ocular protrusion.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by asking when the patient first noticed
exophthalmos. Is it associated with pain in or
around the eye? If so, ask him how severe it is
and how long he has had it. Then ask about recent sinus infection or vision problems. Take
the patient’s vital signs, noting fever, which may
accompany an eye infection. Next, evaluate the
severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthal-
mos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer
formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with
and without correction, and evaluate extraocular movements. Palpate the patient’s thyroid for
enlargement or goiter.
EXAMINATION TIP
Detecting
unilateral
exophthalmos
If one of the patient’s eyes seems more
prominent than the other, examine both
eyes from above the patient’s head. Look
down across his face, gently draw his lids
up, and compare the relationship of the
corneas to the lower lids. Abnormal protrusion of one eye suggests unilateral exophthalmos.
Remember: Don’t perform this test if you
suspect eye trauma.
M
EDICAL CAUSES
◆ Cavernous sinus thrombosis. This disorder
usually causes sudden onset of pulsating unilateral exophthalmos. Accompanying it may be
eyelid edema, decreased or absent pupillary reflexes, limited extraocular movement, and impaired visual acuity. Other features include high
fever with chills, papilledema, headache, nausea, vomiting, somnolence and, rarely, seizures.
◆ Dacryoadenitis. Unilateral, slowly progres-
sive exophthalmos is the most common sign of
dacryoadenitis. Assessment may also reveal
limited extraocular movement (especially on elevation and abduction), ptosis, eyelid edema
and erythema, conjunctival injection, eye pain,
and diplopia.
◆ Foreign body in the eye. When a foreign
body enters the eye, exophthalmos may accompany other signs and symptoms of ocular trauma, such as eye pain, redness, and tearing.
◆ Hemangioma. Most common in young
adults, this orbital tumor produces progressive
exophthalmos, which may be mild or severe
and unilateral or bilateral. Other signs and
symptoms include ptosis, limited extraocular
movement, and blurred vision.
◆ Hodgkin’s disease. In this disorder, unilater-
al exophthalmos may develop gradually along
with eyelid edema, diplopia, and a palpable eyelid mass. More characteristic findings include
painless swelling of one or more lymph nodes,
intermittent fever, weight loss, fatigue, malaise,
night sweats, hepatosplenomegaly, and
pruritus.
◆ Lacrimal gland tumor. Exophthalmos usu-
ally develops slowly in one eye, causing its
downward displacement toward the nose. The
patient may also have ptosis and eye deviation
and pain.
◆ Leiomyosarcoma. Most common in people
ages 45 and older, this tumor is characterized
by slowly developing unilateral exophthalmos.
Other effects include diplopia, impaired vision,
and intermittent eye pain.
280 EYE DISCHARGE
https://t.me/medicina_free
◆ Leukemia. When leukemia causes intraor-
bital hemorrhage, mild to moderate bilateral exophthalmos and lacrimal gland enlargement
also result. Associated signs and symptoms include bleeding tendency, fever, arthralgia, pallor, weakness, hepatosplenomegaly and, possibly, lymphadenopathy.
◆ Lymphangioma. Hemorrhage of this con-
genital tumor causes unilateral or bilateral exophthalmos, among other signs.
◆ Neuroblastoma. This highly malignant tu-
mor, the most common extracranial solid tumor
of childhood, may produce exophthalmos.
◆ Ocular tuberculosis. Occasionally, this rare
disease causes progressive exophthalmos accompanied by ptosis, painless eyelid edema and
erythema, and enlarged lacrimal glands. Examination may reveal yellow or white fat deposits
on the cornea and small white nodules in
the iris.
◆ Optic nerve meningioma. This tumor usu-
ally produces unilateral exophthalmos and a
swollen temple. Impaired visual acuity, visual
field deficits, and headache may occur.
◆ Orbital cellulitis. Commonly the result of si-
nusitis, this ocular emergency causes sudden
onset of unilateral exophthalmos, which may be
mild or severe. Orbital cellulitis may also produce eye pain, conjunctival injection, tearing,
eyelid edema and erythema, a purulent discharge, and limited extraocular movement as
well as fever, headache, and malaise.
◆ Orbital choristoma. A common sign of this
benign tumor, progressive exophthalmos may
be associated with diplopia and blurred vision.
◆ Orbital emphysema. Air leaking from the
sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation.
◆ Orbital pseudotumor. Progressive unilat-
eral exophthalmos characterizes this uncommon disorder. Limited extraocular movement,
eyelid edema, eye pain, and diplopia may also
occur.
◆ Parasite infestation. Usually, this disorder
causes painless progressive exophthalmos in
one eye that may spread to the other eye. Associated findings include limited extraocular
movement, diplopia, eye pain, and impaired
visual acuity.
◆ Scleritis (posterior). Gradual onset of mild
to severe unilateral exophthalmos is common in
scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.
◆ Thyrotoxicosis. Although a classic sign of
this disorder, exophthalmos is absent in many
patients. It’s usually bilateral, progressive, and
severe. Associated ocular features include ptosis, increased tearing, lid lag and edema, photophobia, conjunctival injection, diplopia, and decreased visual acuity. Other findings include an
enlarged thyroid, nervousness, heat intolerance,
weight loss despite increased appetite, sweating,
diarrhea, tremors, palpitations, and tachycardia.
S
PECIAL CONSIDERATIONS
Exophthalmos usually makes the patient selfconscious, so provide privacy and emotional
support. Protect the affected eye from trauma,
especially drying of the cornea. However, never
place a gauze eye pad or other object over the
affected eye; removal could damage the corneal
epithelium. If a slit-lamp examination is indicated, explain the procedure to the patient. If necessary, refer him to an ophthalmologist for a
complete examination. The cause of exophthalmos determines the therapy. Prepare the patient
for blood tests, such as a thyroid panel and a
white blood cell count.
P
EDIATRIC POINTERS
In children around age 5, a rare tumor—optic
nerve glioma—may cause exophthalmos. Rhabdomyosarcoma, a more common tumor, usually
affects children between ages 4 and 12 and produces rapid onset of exophthalmos. In HandSchüller-Christian syndrome, exophthalmos typically accompanies signs of diabetes insipidus
and bone destruction.
Eye discharge
Usually associated with conjunctivitis, an eye
discharge is the excretion of any substance other than tears. This common sign may occur in
one or both eyes, producing scant to copious
discharge. The discharge may be purulent,
frothy, mucoid, cheesy, serous, clear, or white
and stringy. Sometimes, the discharge can be
expressed by applying pressure to the tear sac,
punctum, meibomian glands, or canaliculi.
An eye discharge commonly results from inflammatory and infectious eye disorders but
may also occur in certain systemic disorders.
(See Sources of eye discharge.) Because this sign
may accompany a disorder that threatens vision, it must be assessed and treated immediately.
EYE DISCHARGE 281
https://t.me/medicina_free
EXAMINATION TIP
Sources of eye discharge
An eye discharge can come from the tear sac, punctum, meibomian glands, or canaliculi. If the
patient reports a discharge that isn’t immediately apparent, you can express a sample by pressing
your fingertip lightly over these structures. Then characterize the discharge, and note its source.
Superior canaliculus
Tear sac (within
bony orbit)
Inferior
canaliculus
H
ISTORY AND PHYSICAL
Punctum (visible
without special
manipulation)
EXAMINATION
Begin your evaluation by finding out when the
discharge began. Does it occur at certain times
of day or in connection with certain activities? If
the patient complains of pain, ask him to show
you its exact location and to describe its character. Is the pain dull, continuous, sharp, or stabbing? Do his eyes itch or burn? Do they tear excessively? Are they sensitive to light? Does he
feel like something is in them?
After taking vital signs, carefully inspect the
eye discharge. Note its amount, color, and consistency. Then test visual acuity, with and without correction. Examine external eye structures,
beginning with the unaffected eye to prevent
cross-contamination. Observe for eyelid edema,
entropion, crusts, lesions, and trichiasis. Next,
ask the patient to blink as you watch for impaired eyelid movement. If the eyes seem to
bulge, measure them with an exophthalmometer. Test the six cardinal fields of gaze. Examine
the eye for conjunctival injection and follicles
and for corneal cloudiness or white lesions.
Meibomian glands
(behind and perpendicular
to eyelids)
M
EDICAL CAUSES
◆ Canaliculitis. This uncommon chronic disor-
der causes a scant purulent discharge, usually
from the lower canaliculus of one eye. The eye
is red and irritated, and its punctum bulges a
bit.
◆ Conjunctivitis. Five types of conjunctivitis
may cause an eye discharge with redness, hyperemia, foreign-body sensation, periocular
edema, and tearing.
In allergic conjunctivitis, a bilateral ropey dis-
charge is accompanied by itching and tearing.
Bacterial conjunctivitis causes a moderate pu-
rulent or mucopurulent discharge that may form
sticky crusts on the eyelids during sleep. The
discharge is commonly greenish white and usually occurs in one eye. The patient may also experience itching, burning, excessive tearing,
and the sensation of a foreign body in the eye.
Eye pain indicates corneal involvement. Preauricular adenopathy is uncommon.
Viral conjunctivitis, which is more common
than the bacterial form, usually produces a
serous, clear discharge and preauricular
282 EYE DISCHARGE
https://t.me/medicina_free
adenopathy. The history includes a runny nose,
an upper respiratory tract infection, or recent
contact with a person who had these signs. Onset is usually unilateral.
Fungal conjunctivitis produces a copious, thick,
purulent discharge that makes the eyelids crusty
and sticky. Also characteristic are eyelid edema,
itching, burning, and tearing. Pain and photophobia occur only with corneal involvement.
Inclusion conjunctivitis causes a scant mucoid
discharge—especially in the morning—in both
eyes, accompanied by pseudoptosis and conjunctival follicles.
◆ Corneal ulcers. Both bacterial and fungal ul-
cers produce a copious, purulent unilateral eye
discharge and crusty, sticky eyelids. Severe
pain, photophobia, and impaired visual acuity
may also occur.
Bacterial corneal ulcers are also characterized
by an irregular gray-white area on the cornea,
blurred vision, unilateral pupil constriction, and
conjunctival injection.
Fungal corneal ulcers are also characterized
by conjunctival injection and eyelid edema and
erythema. A painless, dense, whitish gray central ulcer develops slowly and may be surrounded by progressively clearer rings.
◆ Dacryoadenitis. This disorder may cause a
moderate purulent discharge associated with
temporal eye pain, conjunctival injection, and
severe eyelid edema and erythema. However,
its most characteristic sign is unilateral exophthalmos.
◆ Dacryocystitis. A lacrimal sac infection may
produce a scant but continuous purulent discharge that’s easily expressed from the tear sac.
Additional signs and symptoms include excessive tearing, pain, and tenderness near the tear
sac. Eyelid inflammation and edema are most
noticeable around the lacrimal punctum.
◆ Erythema multiforme major (Stevens-
Johnson syndrome). Ocular effects of this disorder include a purulent discharge, severe eye
pain, entropion, trichiasis, photophobia, and decreased tear formation. Also typical are erythematous, urticarial, bullous lesions that suddenly
erupt over the skin.
◆ Herpes zoster ophthalmicus. This disorder
yields a moderate to copious serous eye discharge accompanied by excessive tearing. Examination reveals eyelid edema and erythema,
conjunctival injection, and a white, cloudy
cornea. The patient also complains of eye pain
and severe unilateral facial pain that occurs
several days before vesicles erupt.
◆ Keratoconjunctivitis sicca. Better known as
dry eye syndrome, this disorder typically causes
a copious and continuous mucoid discharge
and insufficient tearing. Accompanying signs
and symptoms include eye pain, itching, burning, a foreign-body sensation, and dramatic
conjunctival injection. The patient may also
have difficulty closing his eyes.
◆ Meibomianitis. In this disorder, applying
pressure on the meibomian glands may produce
a continuous frothy, soft, foul-smelling, cheesy
yellow eye discharge. The eyes also appear
chronically red, with inflamed lid margins.
◆ Orbital cellulitis. Although exophthalmos is
the most obvious sign of this disorder, a unilateral purulent eye discharge may also be present.
Related findings include eyelid edema, conjunctival injection, orbital pain, impaired visual acuity, limited extraocular movement, headache,
and fever.
◆ Pemphigus. This rare disorder may cause a
thick, mucuslike discharge; eye pain, burning,
and irritation; and blurred vision. Initially, the
patient may develop unilateral or bilateral conjunctivitis that’s unrelieved by treatment; later,
entropion and, occasionally, corneal ulceration
may occur.
◆ Psoriasis vulgaris. Usually, psoriasis vul-
garis causes a substantial mucoid discharge in
both eyes, accompanied by redness. The characteristic lesions it produces on the eyelids may
extend into the conjunctivae, causing irritation,
excessive tearing, and a foreign-body sensation.
◆ Trachoma. A bilateral eye discharge occurs
in this disorder along with severe pain, excessive tearing, photophobia, eyelid edema, redness, and visible conjunctival follicles.
S
PECIAL CONSIDERATIONS
Apply warm soaks to soften crusts on the eyelids and lashes. Then gently wipe the eyes with
a soft gauze pad. Carefully dispose of all used
dressings, tissues, and cotton swabs to prevent
the spread of infection. Also, be sure to sterilize
ophthalmic equipment after use. Teach the patient how to avoid contaminating the unaffected
eye.
Explain any ordered diagnostic tests, including culture and sensitivity studies to identify the
infectious organism.
P
EDIATRIC POINTERS
The prophylactic eye medication (silver nitrate),
no longer commonly used with neonates, causes eye irritation and discharge. In children, dis-
EYE PAIN
https://t.me/medicina_free
283
charges usually result from eye trauma, eye infection, or upper respiratory tract infection.
P
ATIENT COUNSELING
Inform patients with bacterial or viral conjunctivitis that these disorders are contagious. Tell
those with bacterial conjunctivitis to avoid contact with other people for 24 hours after receiving antibiotic treatment; not to share towels,
pillows, or cosmetic eye products; and not to
wear contact lenses until the conjunctivitis resolves. Tell patients with allergic conjunctivitis
that this type of inflammation isn’t contagious.
Eye pain
[Ophthalmalgia]
Eye pain may be described as a burning, throbbing, aching, or stabbing sensation in or around
the eye. It may also be characterized as a foreign-body sensation. This sign varies from mild
to severe; its duration and exact location provide clues to the causative disorder.
Eye pain usually results from corneal abrasion, but it may also be due to glaucoma or other eye disorders, trauma, and neurologic or systemic disorders. Any of these may stimulate
nerve endings in the cornea or external eye,
producing pain.
EMERGENCY INTERVENTIONS If the
patient’s eye pain results from a chemical
burn, remove contact lenses (if present) and
irrigate the eye with at least 1 L of normal saline
solution over 10 minutes. Evert the lids and wipe
the fornices with a cotton-tipped applicator to
remove any particles or chemicals. Eye pain from
acute angle-closure glaucoma is an ocular
emergency requiring immediate intervention to
decrease intraocular pressure (IOP). If drug treatment doesn’t reduce IOP, the patient will need
laser iridotomy or surgical peripheral iridectomy
to save his vision.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient’s eye pain doesn’t result from a
chemical burn or from acute angle-closure
glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a
sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find
out when it began. Is it worse in the morning or
late in the evening? Ask about recent trauma or
surgery, especially if the patient complains of
severe pain that developed suddenly. Does he
have headaches? If so, find out how often and at
what time of day they occur.
During the physical examination, don’t ma-
nipulate the eye if you suspect trauma. Carefully
assess the eyelids and conjunctivae for redness,
inflammation, and swelling. Then examine the
eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any
discharge. (See Examining the external eye, page
284.)
M
EDICAL CAUSES
◆ Acute angle-closure glaucoma. Blurred
vision and sudden excruciating pain in and
around the eye characterize this disorder; the
pain may be so severe that it causes nausea,
vomiting, and abdominal pain. Other findings
are halo vision, rapidly decreasing visual acuity,
and a fixed, nonreactive, moderately dilated
pupil.
◆ Astigmatism. Uncorrected astigmatism com-
monly causes headaches and eye fatigue,
aching, and redness. This disorder occurs in
both older and younger people.
◆ Blepharitis. Burning pain in both eyelids is
accompanied by conjunctival injection and an
itching, sticky discharge. Related findings include a foreign-body sensation, eyelid ulcerations, and loss of eyelashes.
◆ Burns. In chemical burns, sudden severe eye
pain may occur with erythema and blistering of
the face and eyelids, photophobia, miosis, conjunctival injection, blurring, and inability to
keep the eyelids open. In ultraviolet radiation
burns, moderate to severe pain occurs about
12 hours after exposure along with photophobia
and vision changes.
◆ Chalazion. A chalazion causes localized ten-
derness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.
◆ Conjunctivitis. Some degree of eye pain and
excessive tearing occur in four types of conjunctivitis. Allergic conjunctivitis causes mild,
burning, bilateral pain accompanied by itching,
conjunctival injection, and a characteristic
ropey discharge.
Bacterial conjunctivitis causes pain only when
it affects the cornea. Otherwise, it typically produces burning, a foreign-body sensation, a purulent discharge, and conjunctival injection.
If the cornea is affected, fungal conjunctivitis
may cause pain and photophobia. Without
284 EYE PAIN
https://t.me/medicina_free
EXAMINATION TIP
Examining the external eye
For patients with eye pain or other ocular
symptoms, examination of the external eye
forms an important part of the ocular assessment. Here’s how to examine the external eye.
First, inspect the eyelids for ptosis and incomplete closure. Also, observe the lids for
edema, erythema, cyanosis, hematoma, and
masses. Evaluate skin lesions, growths,
swelling, and tenderness by gross palpation.
Are the lids everted or inverted? Do the eyelashes turn inward? Have some of them been
lost? Do the lashes adhere to one another or
contain a discharge? Next, examine the lid
margins, noting especially any debris, scaling,
lesions, or unusual secretions. Also, watch for
eyelid spasms.
Now gently retract the eyelid with your
thumb and forefinger, and assess the conjunctiva for redness, cloudiness, follicles, and blisters or other lesions. Check for chemosis by
pressing the lower lid against the eyeball and
noting any bulging above this compression
point. Observe the sclera, noting any change
from its normal white color.
Next, shine a light across the cornea to detect scars, abrasions, or ulcers. Note any color
corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.
Viral conjunctivitis produces itching, red eyes;
a foreign-body sensation; visible conjunctival
follicles; and eyelid edema.
◆ Corneal abrasions. This type of injury typi-
cally produces a foreign-body sensation, excessive tearing, photophobia, and conjunctival
injection.
◆ Corneal erosion (recurrent). In this disor-
der, severe pain occurs on waking and continues throughout the day. Accompanying the pain
are conjunctival injection and photophobia.
◆ Corneal ulcers. Both bacterial and fungal
corneal ulcers cause severe eye pain. They may
also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In
addition, bacterial corneal ulcers produce a
grayish white, irregularly shaped ulcer on the
cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and
changes, dots, or opaque or cloudy areas.
Also, assess the anterior eye chamber, which
should be clean, deep, shadow-free, and filled
with clear aqueous humor.
Inspect the color, shape, texture, and pattern
of the iris. Then assess the pupils’ size, shape,
and equality. Finally, evaluate their response to
light. Are they sluggish, fixed, or unresponsive?
Does pupil dilation or constriction occur only
on one side?
Eyelid
Pupil
Iris
Conjunctiva
Sclera
erythema, and a dense, cloudy, central ulcer
surrounded by progressively clearer rings.
◆ Dacryoadenitis. Temporal pain may affect
both eyes in this disorder. Associated findings
include exophthalmos, conjunctival injection,
severe eyelid erythema and edema, and a purulent eye discharge.
◆ Dacryocystitis. Pain and tenderness near the
tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling
around the lacrimal punctum.
◆ Episcleritis. Deep eye pain occurs as tissues
over the sclera become inflamed. Related effects
include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.
◆ Erythema multiforme major. This disorder
commonly produces severe eye pain, entropion,
trichiasis, purulent conjunctivitis, photophobia,
and decreased tear formation.
◆ Foreign bodies in the cornea and con-
junctiva. Sudden severe pain is common in this
condition, but vision usually remains intact.
EYE PAIN
https://t.me/medicina_free
285
Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark
speck on the cornea, and dramatic conjunctival
injection.
◆ Glaucoma. Open-angle glaucoma may
cause mild aching in the eyes as well as loss of
peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Acute
angle-closure glaucoma may cause severe pain
and pressure over the eye, blurred vision, halo
vision, decreased visual acuity, and nausea and
vomiting.
◆ Herpes zoster ophthalmicus. Eye pain oc-
curs with severe unilateral facial pain, usually
several days before vesicles erupt. Other signs
include red, swollen eyelids; excessive tearing;
a serous eye discharge; conjunctival injection;
and a white, cloudy cornea.
◆ Hordeolum (stye). This lesion usually pro-
duces localized eye pain that increases as the
stye grows. Eyelid erythema and edema are also
common.
◆ Hyphema. Occurring after eye injury or
surgery, hyphema accompanies sudden pain in
and around the eye. Orbital and eyelid edema,
conjunctival injection, and visual impairment
may also occur.
◆ Interstitial keratitis. Associated with con-
genital syphilis, this corneal inflammation produces eye pain with photophobia, blurred vision, prominent conjunctival injection, and
grayish pink corneas.
◆ Iritis (acute). Moderate to severe eye pain
occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.
◆ Keratoconjunctivitis sicca. This condition—
known as dry eye syndrome—causes chronic
burning pain in both eyes, itching, a foreignbody sensation, photophobia, dramatic conjunctival injection, and difficulty moving the
eyelids. A copious mucoid discharge and inadequate tearing are typical.
◆ Lacrimal gland tumor. This neoplastic le-
sion usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.
◆ Migraine headache. Migraines can produce
head pain so severe that the eyes also ache.
Nausea, vomiting, blurred vision, and light and
noise sensitivity may also occur.
◆ Ocular laceration and intraocular foreign
bodies. Penetrating eye injuries usually cause
mild to severe unilateral eye pain and impaired
visual acuity. Eyelid edema, conjunctival injec-
tion, and an abnormal pupillary response may
also occur.
◆ Optic cellulitis. This disorder causes dull,
aching pain in the affected eye, some degree of
exophthalmos, eyelid edema and erythema, a
purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity
and fever.
◆ Optic neuritis. In this disorder, pain in and
around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but
improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.
◆ Orbital floor fracture. Sometimes called a
blowout fracture, this injury causes eye pain,
dramatic eyelid edema and, possibly, enophthalmos and diplopia.
◆ Orbital pseudotumor. This disorder causes
deep, boring eye pain and diplopia in about 50%
of patients. However, prominent exophthalmos
and lateral ocular deviation are more characteristic. Eyelid edema and limited extraocular
movement may also occur.
◆ Pemphigus. In this disorder, bilateral eye
pain and irritation may be accompanied by
blurred vision and a thick discharge. Blisters
may develop on the conjunctiva alone or may
extend to the nasal, oral, and vulvar mucous
membranes as well as the skin.
◆ Scleritis. This inflammation produces severe
eye pain and tenderness, conjunctival injection,
bluish purple sclera and, possibly, photophobia
and excessive tearing.
◆ Sclerokeratitis. Inflammation of the sclera
and cornea causes pain, burning, irritation, and
photophobia.
◆ Subdural hematoma. Following head trau-
ma, a subdural hematoma commonly causes
severe eye ache and headache. Related neurologic signs depend on the hematoma’s location
and size.
◆ Trachoma. Along with pain in the affected
eye, trachoma causes excessive tearing, photophobia, an eye discharge, eyelid edema and erythema, and visible conjunctival follicles.
◆ Uveitis. Anterior uveitis causes sudden se-
vere pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.
Posterior uveitis causes insidious onset of
similar features, plus gradual blurring of vision
and distorted pupil shape.
Lens-induced uveitis causes moderate eye
pain, conjunctival injection, pupil constriction,
and severely impaired visual acuity. In fact, the
patient usually can perceive only light.
286 EYE PAIN
https://t.me/medicina_free
O
THER CAUSES
◆ Treatments. Contact lenses may cause eye
pain and a foreign-body sensation. Ocular
surgery may also produce eye pain, ranging
from a mild ache to a severe pounding or stabbing sensation.
S
PECIAL CONSIDERATIONS
To help ease eye pain, have the patient lie down
in a darkened, quiet environment and close his
eyes. Prepare him for diagnostic studies, including tonometry and orbital X-rays.
P
EDIATRIC POINTERS
Trauma and infection are the most common
causes of eye pain in children. Be alert for nonverbal clues to pain, such as tightly shutting or
frequently rubbing the eyes.
G
ERIATRIC POINTERS
Glaucoma, which can cause eye pain, usually
affects older patients, becoming clinically significant after age 40. It usually occurs bilaterally
and leads to slowly progressive vision loss, especially in peripheral visual fields.
P
ATIENT COUNSELING
Tell the patient to seek medical help for eye
pain, and stress the importance of meticulous
compliance with drug therapy to prevent an increase in IOP.
D
https://t.me/medicina_free
Decerebrate posture
[Decerebrate rigidity,
abnormal extensor reflex]
Decerebrate posture is characterized by adduction (internal rotation) and extension of the
arms, with the wrists pronated and the fingers
flexed. The legs are stiffly extended, with forced
plantar flexion of the feet. In severe cases, the
back is acutely arched (opisthotonos). This sign
indicates upper brain stem damage, which may
result from primary lesions, such as infarction,
hemorrhage, or tumor; metabolic encephalopathy; head injury; or brain stem compression associated with increased intracranial pressure
(ICP).
Decerebrate posture may be elicited by noxious stimuli or may occur spontaneously. It may
be unilateral or bilateral. With concurrent brain
stem and cerebral damage, decerebrate posture
may affect only the arms, with the legs remaining flaccid. Or, decerebrate posture may affect
one side of the body and decorticate posture the
other. The two postures may also alternate as
the patient’s neurologic status fluctuates. Generally, the duration of each posturing episode correlates with the severity of brain stem damage.
(See Comparing decerebrate and decorticate
postures, page 198.)
EMERGENCY INTERVENTIONS Your first
priority is to ensure a patent airway. Insert
an artificial airway and institute measures to prevent aspiration. (Don’t disrupt spinal alignment if
you suspect spinal cord injury.) Suction the patient
as necessary.
Next, examine spontaneous respirations. Give
supplemental oxygen, and ventilate the patient
with a handheld resuscitation bag if necessary. Intubation and mechanical ventilation may be indicated. Keep emergency resuscitation equipment
handy, but be sure to check the patient’s chart for
a do-not-resuscitate order.
H
ISTORY AND PHYSICAL
EXAMINATION
After taking vital signs, determine the patient’s
level of consciousness (LOC). Use the Glasgow
Coma Scale (GCS) as a reference. Decerebrate
posturing indicates the second-lowest measure
of motor response, according to the GCS. Patients exhibiting this abnormal posturing have a
decreased LOC and may be in a comatose state.
Evaluate the pupils for size, equality, and response to light. Test deep tendon reflexes
(DTRs) and cranial nerve reflexes, and check for
doll’s eye sign.
Next, explore the history of the patient’s
coma. If you’re unable to obtain this information, look for clues to the causative disorder,
such as hepatomegaly, cyanosis, diabetic skin
changes, needle tracks, or obvious trauma. If a
family member is available, find out when the
patient’s LOC began deteriorating. Did it occur
abruptly? What did the patient complain of before he lost consciousness? Does he have a
history of diabetes, liver disease, cancer, blood
clots, or aneurysm? Ask about any accident or
traumatic injury responsible for the coma.
197
Соседние файлы в папке Библиотека им академика М.И. Перельмана