Module 2

Saturday, 5 July 2014

9:48 AM

1. Causes of Red eye associated with photophobia?
Uveitis
Episcleritis
2. Causes of red eye associated with irregular pupils?
Iritis
Acute angle-closure glaucoma

Relationship between eye inflammation and back pain?

What causes of a red painful eye require urgent referral?
Acute glaucoma
Uveitis
o Acute irits
o Choroiditis
Corneal Ulcer
Herpes simplex keratitis
Microbial keratitis
Herpes zoster opthalmicus
Penetrating injury
Endopthalmitis
Orbital cellulitis
http://lib.myilibrary.com/Open.aspx?id=343763

How do you tell the difference between inflammatory back
pain and mechanical back pain?
Feature Inflammation Mechanical
History Insidious onset Precipitating injury/previous episodes
Nature Aching, throbbing Deep dull ache, sharp if there is root
compression
Stiffness Severe prolonged
Morning stiffness
Moderate, transient
Effect of rest exacerbates Relieves
Effect of
activity
Relieves exacerbates
Radiation More localised, bilateral or
alternating
Tends to be diffuse, unilateral
Intensity Night, early morning End of day following activity
http://lib.myilibrary.com/Open.aspx?id=343763
6. What are the important features of history and examination
when a patient presents with monoarticular joint pain?
Emergencies
o Hot or swollen joints
o Systemic symptoms
o Weakness
o Burning pain, numbness, paraesthesia

History

o Associated symptoms
Systemic complaints
Infectious cause
GI/GU complaints
Seronegative spondyloarthropathy
Recent travel to endemic areas
Examination
o Synovitis signs
Soft tissue swelling
Warmth over a joint
Joint effusion
o Fever suggests
Infectious arthritis
Postinfectious or reactive arthritis
Rheumatoid and Still's disease
Systemic rheumatic illness
Crystal induced arthritis
http://0-www.uptodate.com.library.newcastle.edu.au/contents/evaluation-of-the-
adult-with-monoarticular-pain?source=see_link#H12
Evaluation
o


What investigations should be considered for monoarticular
joint pain?
Imaging
o Radiographs
Rule out fracture or tumour
Can confirms presence of an effusion
Chondocalcinosis
Tophaceous erosions
Joint space narrowing
Joint aspiration
o Synovial fluid analysis
Inflammatory
Infection
Bloody
Crystalline
o Tests to be done
Visual inspection for
xanthochromia
Recent haemorrhage into a joint
Clear
Non-inflammatory
cloudy fluid
Inflammatory
Total leukocyte count and differential
Gram stain and culture
Crystal analysis
o Evaluation for septic arthritis
Synovial gram stain and culture
o Evaluation for crystal arthritis
Polarizing microscope
Other tests
o ESR and CRP
Inflammatory markers
o ANA
SLE
May be confusing
o RF
Suspicion of rheumatoid arthritis
o Anti-CCP
RF
o Synovial Biopsy
Useful in
TB
Fungus
Sarcoidosis
http://0-www.uptodate.com.library.newcastle.edu.au/contents/evaluation-of-the-
adult-with-monoarticular-pain?source=see_link#H12

What are the indications for a joint aspiration?
Evaluation for sepsis in a single inflamed joint
Initial confirmation of crystal arthritis by polarised light

How is the plan for investigation and management affected
by the presence of crystals or pus and/or bacteria in the
aspirated synovial fluid?
Septic Arthritis
Investigation
o Synovial fluid gram stain and culture
o Synovial fluid white cell count
o Blood culture
o White cell count
o ESR/CRP
o Radiograph
o U/S - effusion guidance
o MRI - associated osteomyelitis
Management
o Empirical antibiotic therapy immediately
Suspected gram positive
Should be suspected if there is nothing to suggest an alternate cause
Vancomycin
Followed by oral clindamycin
Joint aspiration to the point of dryness as required
Suspected ram negative
Third generation cephalosporin - ceftriaxone
Followed by cephalexin
Joint aspiration to dryness as required
Gout
Investigations
o Arthrocentesis with fluid analysis
Strongly negative birefringent needle-shaped crystals under polarised light
o Uric acid
o X-ray of affected joint
Typical tophaceous erosions
Management
o Short term
NSAIDS if no contraindiactions
Indometacin
Colchicine
Corticosteroid are last line, if everything else is contraindicated (renal
insufficiency)
o Long term
Prophylaxis is indicated
Recurrent attacks
Tophaceous gout
Radiographic changes and chronic destructive joint disease
Urate nephrolithasis
Patient preference
Allopurinol
Started 3-4 weeks after last exacerbation at 100mg/d
Should be increased over several weeks until the uric acid level is
<0.357mol/L
Pseudogout
Investigations
o Arthrocentesis with fluid analysis
Positive birefringent rhomboid crysta;s under polarised light
Often bloody
o X-rays
Linear, stippled radio-opaque deposits in fibrocartilage or hyaline articular
cartilage of joints
Clacified tendons
o Normal/elevated test
Serum calcium
Serum PTH
Iron studies
o Normal/decreased tests
Serum magnesium
Serum ALP
Management
o Monoarticular/oligo-articular disease
Intra-articular corticosteroids during an acute attack

http://bestpractice.bmj.com/best-practice/monograph/486/treatment/details.html
http://bestpractice.bmj.com/best-practice/monograph/13/treatment/step-by-
step.html
http://bestpractice.bmj.com/best-practice/monograph/370/treatment/step-by-
step.html

What is the management of osteoarthritis?
Consider: Physical therapy, medications, surgery,
occupational therapy/home modifications, social support

Nonpharmacological therapy
Weight loss
o Linear relationship between weight loss and reduced incidence of OA
o Suggests even slight weight loss is beneficial
Rest
o Associated with pain and other symptoms after prolonged use
o Rest for 12-24 hours is recommended
Any longer and run the risk of atrophy and joint immobility
Physical therapy
o Improves flexibility, supporting muscle strengthening
Improvement of functional outcome and pain scores
o These interventions are thought to 'unload' joints by improving the distribution of
mechanical forces during use.
Orthoses
o Canes and walkers
Reduces load at the hip by upto 50%
o Braces and splints
Valgus bracing of the knee reduce pain and improve function
Splints can be useful for OA of MCP and IP joints of the thumb
o Patellofemoral syndrome
Taping and braces are controversial methods of treatment
o Knee taping
Weekly application of tape over a base of hypoallergenic tape
Transverse suprapatellar location
Circumferential application over the infrapatellar or anserine bursa
May lead to minor skin irritation
Not enough to stop treatment
Exercise
o Exercise programs
Symptomatic relief
Increase range of motion
Increase strength
Reduce pain and increase motility
Joint protection
Low load exercise
Swimming
Cycling
Walking
Tai Chi
CVS warm up with stretching is reccomended
Also splints can help
Disability prevention
Improvement in pain and mobility
Reversal of muscle atrophy
Increased bone mineral density
Beneficial to overall health
o Aerobic vs resistance
Equal benefits
Single type of exercise in one session was more beneficial
Diet and vitamins
o Unclear
o Possible implications of Vitamins C,D,E
Heat and Cold
o Moist superficial heat
Produce analgesia by acting on free nerve endings
Decrease muscle spasm
o Modalities
Heat packs
Heating pads
Paraffin wax
o Ultrasound therapy
Based on the use of US waves to generate deep heat to enhance connective
tissue flexibility
Improve muscular contracture
Increase in ROM
Not recommended
o Cooling
Superficial cooling
Decreases muscle spasm
Increases threshold of pain
Modalities
Ice pacs
Local spray
Education and psychosocial support
o Assessment of coping mechanisms
Activity avoidance
Denial
Symptoms of depression
Antidepressant therapy
Counselling
o Education
In-depth discussion of disease
Physical limitations
Therapeutic options
Risks and benefits to different forms of treatment
o Self-management programs
Use principles of CBT
Other
o Chinese medicine
Herbs
Massage
Acupuncture
Relaxation techniques
o Mudpack therapy
Improves
Physiologic antioxidants in serum
Reduce oxygen radical damage on cartilage
Lower serum levels of
Prostaglanding E2
Leukotriene B4

Initial pharmacologic therapy
Initial treatment
o Non-inflammatory OA
Paracetamol
Patients with mild to moderate pain
Intermittient
Related to activity
Used on an as-needed basis
Persistent symptoms
Regular doses of upto 3g/day
o Inadequate response to paracetamol or inflammatory OA
Recommend oral
Non selective NSAID
COX-2 NSAID
Choice
Dependent upon
Adverse effect profile
Cost to patient
Type of OA
Patient preference regarding frequency of administration
Short to medium acting NSAID (naproxen)
Initially on an episodic basis for patients with non-inflammatory
OA
Takes 2-4 weeks to determine efficacy
Dose should be increased if there is inadequate control
Should be used on a continious basis
Change NSAID if not working after 2-4 weeks
Contraindicated or inadequate oral agents
o Topical
NSAID
Recommended in those who cannot tolerate oral NSAIDs
Capsaicin
As an adjunct
o Intra-articular glucorticoids
Indicated in
Symptoms of moderate or severe pain affecting one to a few joints
Monoarticular or oligoarticular inflammatory OA where NSAIDs are
contraindicated

Other pharmacologic therapy
o Resistant to intra-articular glucorticoids
Intra-articular hyaluronans
Preferred over long term opiods
o Resistant to NSAIDs and joint injections
Opiod analgesics
Only used in those where all other interventions have failed
Paracetamol and codeine
Paracetamol and tramadol
Oxycodone can be used for short term relief

Surgical therapy
Arthroscopic interventions
o Joint irrigation
Relieves pain through
Removing cartilagenous debris
Decreased burden on synovium
o Arthroscopic joint irrigation
Indicated in patients with refractory OA
Possibly placebo
o Arthroscopic debridement
Controversial
o Arthroscopic abrasion arthroplasty
Burring and drilling of sclerotic bone
Not been shown to be beneficial
o Arthroscopic synovectomy
Commonly used in patients with inflammatory arthritis
Indicated in those who are unresponsive to
Non-pharmacologic interbentions
NSAIDs
Intraarticular glucorticoid injections
Arthroscopic irrigation
Colchicine
Total joint arthroplasty
o Considered in patients with severe symptomatic OA who have failed to respond
to medical management
AND have difficulty with ADLs
o Should be performed before
Significant joint deformity
Joint instability
Contractures
Functional loss
Muscular atrophy
Joint resurfacing
o Alternative to hip replacement
o Preserves femoral neck
Replaces femoral head with metal prosthesis
o Metal acetabulum is introduced creating a metal-on-metal articular surface
Chondrocyte grafting
o Beneficial for selected patients with less severe, localized articular cartilage
defects.
Algorithm of treatment



How might your management of osteoarthritis be affected
by the presence of co-morbidities (consider both
psychosocial implications and polypharmacy)
Use of NSAIDs
o Hx of PUD or gsatroduodenal disease
Combine non-selective NSAID with a PPI or misoprostol
Coxib
o Asprin use
Avoid coxibs
Regular NSAID use should be avoided if possible
If no other option aspiring should be taken 2 hours before NSAID
o Warfarin or other chronic anti-coagulation therapies
Avoid use of non-selective NSAIDs
Platelet function inhibition
Cautiously use coxibs
o Increased risk of CVD
Restriction of all NSAIDs
o Risk of renal insufficiency
NSAIDs should be avoided in patients with stage 4-5

What are the causes of a cross-eyed appearance?
Acute causes - In adults
o Neoplasm
o Head trauma
o Intracranial aneurysm
o Hypertension
o Diabetes mellitus
o Atherosclerosis
o Hydrocephalus
o Multiple sclerosis
o Meningitis/engcephalitis
o Myasthenia gravis
o Sinus disease
o Chiari 1 malformation
o Ophthalmoplegic migraine
o Chemotherapy
Acute causes in infants/children
o Mononuclear visual impairment
o Orbital fractures
o Cellulitis
o Primary or metastatic tumours
o Meningitis
o Infiltrative processes
o Increased intracranial pressure
Emergent
o Cranial nerve paralysis
o Trapped ocular muscles
Congenital syndromes
o Goldenhar-Gorlin syndrome
o Kearns-Sayre syndrome
o Myotubular and mitochondrial myopathies
o Mobius syndrome
o Lambert-Eaton myasthenic syndrome
http://accessmedicine.mhmedical.com/content.aspx?bookid=690&sectionid=50910900
&jumpsectionID=50920816&Resultclick=2
http://accessmedicine.mhmedical.com/content.aspx?bookid=348&sectionid=40381587
&jumpsectionID=40393345&Resultclick=2
http://www.aoa.org/documents/optometrists/CPG-12.pdf
http://0-www.uptodate.com.library.newcastle.edu.au/contents/causes-of-horizontal-
strabismus-in-
children?source=search_result&search=Management+of+infantile+strabismus&selecte
dTitle=2~2

What are the management options for an infant or child
with a cross-eyed appearance?

Non-surgical management
Correction of refractive errors
o Correction with glasses or contacts
o May lead to realignment of eyes in
Accomodative esotropua
Intemittent exotropia
o In children needs to be measures under cycloplegia
Ambylopia treatment
o Should be treated before or with correction of strabismus
o Occlusion of good eye with a patch
Treatment of diplopia
o May be absent in children with strabismus due to suppression of the image
created by the non-fixating eye
Process of CNS where visual input of one eye is ignored
o Occlusion
Not a long-term soluition
To prevent development of ambylopia the occlusion should be limited to 2-
3 hours a day
o Prisms
Used in children with acute-onset strabismus to promote fusion and avoid
ambylopia
Do not change the position of the eyes - the eyes remain deviated
Work best in comitant strabismus and if the angle of deviation is small
Treatment of underlying cause
o Cranial nerve and supranuclear palsies
o Graves' disease
o Orbital fractures
o Myasthenia gravis

Surgical management
Should be considered in infantile strabismus
Principles to increase or decrease the function of a specific muscle
Common techniques
o Recessions
Movement of an insertion posteriorly on the eye
Weakens the muscle
o Resections
Removing a section of the muscle
Strengthens the muscle
o Adjustable sutures
Cases of post-op outcome is difficult to predict

How are patients managed in areas where there are no
resident ophthalmologists
Basic ophthalmology services are expected to be provided by the GP
Distribution
o 78% in capital cities
o 7.8% other major urban areas
o 12.9% Rural areas
o 0.8% remote areas
Substitution
o Optometrists are restricted to refraction services
o Currently not allowed to use Schedule 4 drugs
Services can be provided by city ophthalmologists supported by the Medical Specialist
Outreach Assistance program.
o Was established in 2000
o The government will provide $5million over four years
o
o Will provide funding to the society of ophthalmologists to administer specialists
willing to be part of MSOAP and to promote the availability of the service
o Primarily for cataract surgery in rural and remote areas
Also diabetic retinopathy
Rehabilitation of patients with vision loss
o Professionals supported
Ophthalmologists
Anaesthetists
Optometrists
Nurses assisting
GPs
Aboriginal Health workers
Orthoptists

References
http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-32-eye-and-vision-
health-rural-and-remote-australia.pdf