Professional Documents
Culture Documents
Survival Guide
2014-2015
Introduction
Table of Contents
Ophthalmology Survival Guide ................................................................................................................................................................. 1
Introduction ............................................................................................................................................................................................ 2
Table of Contents ................................................................................................................................................................................... 3
UIHC Layout ......................................................................................................................................................................................... 6
Driving Directions to UIHC ................................................................................................................................................................... 7
On-Call tips: When seeing a patient...................................................................................................................................................... 8
On-Call tips: Documentation and follow up ....................................................................................................................................... 11
On-Call tips: Odds and Ends ............................................................................................................................................................... 15
Corneal Drawing .................................................................................................................................................................................. 16
Symptoms as a Clue To Cause of a Red Eye ....................................................................................................................................... 18
Superficial Keratitis - Differential Diagnosis Based on Distribution ................................................................................................... 20
Corneal Abrasion/ Foreign Body ......................................................................................................................................................... 21
Corneal Ulcer ....................................................................................................................................................................................... 22
How to Culture a Corneal Ulcer .......................................................................................................................................................... 24
Chemical Injury ................................................................................................................................................................................... 26
Trauma ................................................................................................................................................................................................. 27
Hyphema .............................................................................................................................................................................................. 28
Post-Op PKP Management .................................................................................................................................................................. 32
Classification of the Anterior-Chamber Angle .................................................................................................................................... 34
Laser Settings ....................................................................................................................................................................................... 36
Guide to Fundus Drawing .................................................................................................................................................................... 40
Retina Studies ...................................................................................................................................................................................... 41
Bilateral Optic Disc Edema.................................................................................................................................................................. 42
Anisocoria ............................................................................................................................................................................................ 44
Dilating a Child .................................................................................................................................................................................... 48
Using the Retcam ................................................................................................................................................................................. 48
Ophthalmology Survival Guide
Page 3
UIHC Layout
The Buildings of the Hospital are in alphabetical order (by last name) from North to South.
Boyd Tower (BT) - aka General Hospital
Roy Carver (RC)
John Colloton (JC)
John Pappajohn (JP)
Pomerantz Family Pavilion (PFP)
Elevators A, B, C
Elevators D, E
Elevators F, G, H
Elevators I, J
Elevators K, L, M
The wards are named by floor number, then building, then often as West or East. When you get off the elevator and start walking
down one of the wards, the first nurses' station you come to will be the "West" nurses' station, and if you keep going you will come to
the "East" nurses' station
The key to knowing where you are is the elevators. They are in alphabetical order, starting with Elevator A in Boyd Tower down to
Elevator M in Pomerantz Family Pavilion.
Burn Unit
Call Room Ophtho
CT Scanner
CVICU
East Room
ER
Main OR
Med Psych
Microbiology
MICU
Molecular Ophtho lab
MRI/Reading Room
Neuro/Neuro-surg
NICU
Ocular Path
Ophtho Inpatient
Peds Eye Inpatient
Pharmacy, Outpatient
Pharmacy, Main
PICU
Radiology Reading Room
SICU
Specimen Control
Floor
8 JC
7 JC
3 JC
4 JC
8 JC
1 RC
5 JC/JP
4 SE (Gen. Hospital)
6 BT
5 RC
4 Med Labs
Lower Level JC
6JCW
6 JP
2 MRC
3 RC
2 or 3 JCW
2 PFP
1 Gen Hospital
7 JP
3 JC
5 JP
6 RC
Elevator:
G (H)
H
H
G (H)
D
D
G (H)
C
A
E
Main Cafeteria
1 Gen Hospital
G or F
G (H)
I
BB
D (**There is a slit lamp on 3 RC, Room #2)
G (H)
K
C
I
F
I
E
Offer to see every patient who calls. Even if you don't think the situation is emergent, it's still wise to let patient decide not to
come in right away.
Never hesitate to call for help.
Document, Document, Document. Take photos whenever possible.
Although there are many things wed rather do than be stuck on-call, it an amazing opportunity to learn.
Above all, help your fellow residents out whenever you can. Remember, we are in this together.
*Hint - To administer medications in the ER, enter these into current visit orders. To print a prescription in the ER, enter this into the
discharge orders similar to what you would in clinic. Generally the ER attending or resident will do all of the during visit and after
visit ordersyou just need to let them know your recommendations at the end of the visit.
B. Staffing
Staffing can be a difficult and frustrating part of call. You will find some faculty prefers to staff most inpatient consults and others
prefer to simply sign off on your notes. In general our more junior faculty want to be more hands-on with on call issues and our more
senior faculty prefer, well, to not. If there are any questions about an individual faculty preference, ask your senior.
Officially, all inpatient consults are supposed to be staffed by a fellow or attending within 24 hours. Unofficially, there are three types
of consult patients.
1. Complicated Complicated patients should be discussed or seen by the senior resident. It is our policy that faculty only be
contacted by the senior resident. In these patients, the senior residents will usually contact the faculty that night and discuss staffing.
Sometimes, staffing can occur the next day in the facultys clinic. It is permissible for the first year resident to contact a fellow
directly regarding the staffing of complicated patients if the first year resident has become proficient in the examination of that
particular type of patient. Otherwise, they should be discussed or seen by the senior resident first.
2. Uncomplicated Uncomplicated patients can often be discussed with the senior resident over the phone. If the senior resident
feels staffing can wait for 24 hours, an e-mail can be sent to the on call faculty asking if they would like to staff these patients or if
they would prefer to just sign off on the note. On some services, it is standard practice to e-mail the fellow (such as the case of an
uncomplicated orbital fracture) in order to ask them about staffing.
3. Really Uncomplicated On rare occasion, you will be asked to see a post-op corneal abrasion or something like a subconjunctival
hemorrhage in a patient recently intubated on Coumadin. In these cases, it is often unnecessary for these patients to be staffed and
also unfair for the patient to be billed for these consults. If this is the case, it is permissible to ask the consulting service not to order
an official consult and to document a short note into EPIC.
*Hint Progress notes do not need to be cosigned and can be used for really uncomplicated patients.
C. Follow-up
After receiving permission from a fellow or attending to schedule a follow up in their clinic, leave a message with scheduling by
calling 2-0098 and leave the patients name, MRN, chief complaint, clinic to be seen in, and time period to be seen. Alternatively, it is
sometimes easier to email the ophthalmology schedulers (OphthalmologySchedulers@healthcare.uiowa.edu). The nice thing about
email is that they generally send a reply when the follow-up has been scheduled. The bad thing is that they may not get to an email
until later in the morning so I would avoid this option if a patient needs to be scheduled for an appointment the same day.
Inpatient follow-up can be easily documented by creating a new progress note. This does not have to be co-signed. You are
responsible for follow-up on inpatients in these cases:
-
The inpatient did not require subspecialty care but have eye issues that need follow-up (you may be following for weeks)
The patient was unable to be dilated at the time of the initial consultation. In this case you need to contact the primary service to
see when they can be dilated, then perform the DFE and document your findings as a progress note in EPIC.
The patient was seen by a subspecialty service by they requested you follow-up on issues.
D. Miscellaneous
-
Often notes can be started while a patient is dilating and finished shortly after performing the dilated exam.
A note will not appear in the co-signers inbox until the note is accepted.
In general, notes should be completed before the senior resident or fellow arrives on the scene. If a note is shared, it can be
viewed by the senior resident from home, prior to completion
Ophthalmology Survival Guide
Page 12
Medication refills should be done under Telephone Encounters as well. Refills and new medications can often be sent using eprescribe.
Miscellaneous EPIC
#1 Kaleidoscope (Ophth Exam is a tool given to all Ophthalmology LIPs as part of our privileges for all active outpatient visits.)
Because Kaleidoscope can only be used one time per visit, there are a few caveats to remember:
You still must create visits by calling the ER for patients we are going to see directly in the clinic after hours. If you do not do this,
there will most likely not be a tab for documenting the clinic visit. If there is one, it is likely from a previous visit and changes to
Kaleidoscope may change the previous exam.
#2 Most faculty feel that it is satisfactory to use text templates or free text for inpatients or ER consults if you do not wish to use
Kaleidoscope. So until Kaleidoscope becomes available in the inpatient settings, you may for now use the consult template for seeing
inpatients and ER patients without creating outpatient encounters. This way your consultants can easily find your note in the inpatient
setting.
In summary:
Inpatient Consults
1.
2.
3.
ER Consults
1.
2.
3.
ER attending as cosigner
Call scheduling or email ophthalmology schedulers to schedule follow-ups
Consider follow up locally if patient has local eye care provider
No-man's land (consults you are called with between 7:30AM and 8AM)
This is an issue that is a source of frustration for us all, as we all have clinical duties to report to, and the issue of whom your third
year is and who the attending on call is sometimes become hazy when consultations are begun around 8AM. There is no official
policy around these consults. Suggestions are as follows:
1. You should evaluate the patient if you think that this can be reasonably accomplished prior to the beginning of clinic at 8:45 AM.
Try to be efficient and get this done so it doesn't get left for your colleagues. If there is no way you will be able to see the patient and
finish your evaluation prior to 9AM, the consult should get passed off to the day consult service for inpatients, or to the general clinic
resident if the patient is in the ED.
2. If the patient is unavailable (getting a scan, in the OR, etc) you should pass the patient off to the day consult service for inpatients or
to the general clinic resident if the patient is in the ED.
3. The day consult service will only see patients after 1PM. If there is any question of an inpatient with a possible true ophthalmic
emergency that you are called with in the AM, you should definitely see the patient regardless of your pending clinical duties (advise
your clinic attending of the situation though!), or ask your third year what to do if you have obligations you cannot miss.
Ophthalmology Survival Guide
Page 13
4. Staffing: If staffing is needed, first discuss the situation with your third year backup. If he/she is in the OR or unavailable, call the
attending who was on overnight directly to see how he/she would like it to be handled. They may choose to request that the consult be
staffed by someone else, but this decision does not involve you. If the patient will definitely require subspecialty staffing, contact the
fellow on the respective subspecialty service instead of the on-call attending (after discussion with your third year).
The last shuttle is 12:15 am. If your car is still at Finkbine then, you will have to walk there or call Hospital Security for a
personal ride (6-2658).
You can park in Parking Ramp IV (connected to Pomerantz) from 4:30 pm to 7:30 am weekdays and all day on weekends for free
if you display your Finkbine card. Just write your name and card number (e.g. 1077) on you ramp ticket. If you don't have a
Finkbine placard, but have parked in one of the ramps while on call, you can write the following on the back of your parking slip:
the words Call Back, Your Name, Your signature. This is called the Call Back program. If you have any problems with the
staff in the parking ramp questioning this, you can direct them to the following number: 5-8312 (parking dispatch, which is open
24-7). If you do this, you will not be charged. But if you are unlucky enough to have an early morning call patient that runs into
the next clinic day, you will have to move your car or pay the regular rate after 8:00 am ($17/day).
Additionally, you can park across the street from the hospital (next to Stadium) from 4:30pm to 7:30am on weekdays and all day
on weekends for free (without having a Finkbine pass).
If you have a quick in and out after business hours you can try to park under the glass awning (valet area) out front, but residents
have occasionally been ticketed for parking there if they stayed long enough. Also, it is best to tell the patients who are coming in
to park in the ramp (they will be charged). They can park under the awning out front at their own risk.
II. Food
Dining Dollars: Ophthalmology resident physicians can utilize their dining support monies to purchase food in the cafeterias with
their ID badges. The amount of food purchased and the time of day will be at the house staff members discretion, and if the preset amount is depleted before the annual deadline of June 30, the resident will be responsible for the cost of any additional food
purchases for the remainder of the academic year. Ophthalmology Residents will receive $300 for the 2014-2015 academic year.
You must have payroll deduct activated before you can use dining dollars. When you hand your badge to the cashier, be sure you
indicate dining dollars. If you do not, they will payroll deduct.
The staff cafeteria and the visitors cafeteria are the main full service food areas with the largest selection of hot and cold foods.
Marketplace (first floor near Elevator C) is open 24 hours. Other options, see: http://www.uihealthcare.org/food-and-nutrition/
Hours:
Breakfast
Lunch
Dinner
Night
Weekends
6:30-10:30
10:45-2:00
4:30-7:00
-----
6:30-2:00
Melrose (5PFP):
7:00-9:00
10:30-3:30
-----
-------
-------
Corneal Drawing
Less used now that we are with EPIC, but good to know!
A. Color code used in clinical corneal drawings (see color guide in cornea exam rooms)
B. Basic Outline: Left, frontal view:
1. Draw a circle about 30 mm in diameter to represent the corneal limbus (black).
2. Add pupil as a landmark (brown).
3. Indicate location of cross-section by a line through frontal view (black). Right, slit view:
4. Draw a freehand cross-section outline to show variations in corneal thickness (black)
C. Pattern of corneal pathology.
Left, frontal view: 5. Use sclerotic scatter and broad tangential illumination to outline all opacities (blue).
Right, slit view: 6. Add a line to indicate epithelium (black), leaving defects where ulcers are apparent.
D. Details of corneal pathology.
Left, frontal view: 7. refine opacities into scar (black), degeneration (black), infiltrate (orange), and edema
(blue).
8. Add labels if helpful.
Right, slit view: 9. Draw opacities in epithelium, stroma, and Descemet's membrane at appropriate level.
10. Add labels if helpful.
E. Other corneal findings.
Left, frontal view: 11. Add vessels (red), pigment (brown), and posterior deposits (orange, brown).
Right, slit view: 12. Add vessels (red), pigment (brown), and posterior deposits (orange, brown)
F. Anterior chamber and lens.
Left, frontal view: 13. Add abnormalities of anterior chamber (hypopyon, orange), iris (anterior and
posterior synechiae, brown), and lens (posterior subcapsular cataract, green).
Omit those that clutter the drawing.
Right, slit view: 14. Show the relation between abnormalities of anterior chamber, iris, and lens.
G. Vital stain
Left, frontal view: Take photographs before vital staining (if desired).
15. Sketch in stain with fluorescein (green) or rose bengal (red). Make a separate sketch of needed.
16. Measure lesions with continuously variable slit height or reticle from an identifiable limbal landmark.
Right, slit view: 17. Add staining with fluorescein (green) or rose bengal (red. HSV. Herpes Simplex Virus.
See also:
Waring GO, Laibson PR. A Systematic Method of Drawing Corneal Pathologic Conditions. Arch Ophthalmol
1977;95:1540-1542.
Possible Cause
Itching
Allergic conjunctivitis
Scratchy Sensation
Burning
Localized lump or
tenderness
Hordeolum, chalazion
Ocular Pain
Photophobia
Mucoid discharge
Watery discharge
Purulent discharge
The following is used with permission: van Heuven WAJ, Zwaan J. Decision Making in Ophthalmology: an
Algorithmic Approach. Mosby, 2000.
Corneal Ulcer
History: Trauma, previous corneal abnormalities, CL wear and details (type of lens, solutions, wear time, sleep
in CL, hot tub/lake exposure, previous corneal ulcer, nasal/oral/genital ulcerations, systemic diseases).
Exam: Check corneal sensation (decreased sensation can suggest herpetic keratitis). Measure the size and
extent of the ulcer (stromal loss with an overlying epithelial defect)
Ancillary Studies: Usually no need to ECHO very rare corneal ulcer will lead to endophthalmitis if bad
enough may cause hypopyon and vitreous cell, but just treat the corneal ulcer to start.
Management: Infection is assumed to be bacterial until proven otherwise.
Criteria to evaluate the response to therapy:
1. Margin of infiltrate
2. Density
3. Hypopyon
4. Discharge
5. Symptoms: pain, etc.
6. Epithelial defect
Indication for Steroid: rule of thumb add after 48 hrs of appropriate tx for gm pos, 72 hrs for gm neg
1. To reduce inflammation after adequate coverage
2. Reduction of scar formation especially at or near visual axis
3. Tectonic changes: marginal thinning, etc.
Treatment:
1. Cycloplegic
2. Topical antibiotic
Low risk of visual loss <1mm, non-staining peripheral infiltrate, minimal AC rxn and discharge
Non CL: Fluoroquinolone QID -6x/day
CL: Fluoroquinolone Q2 hours-QID
Borderline risk 1-1.5 mm diameter peripheral infiltrate, or any smaller infiltrate with epi defect, mild
AC rxn, and moderate discharge
Fluoroquinolone q1hr around the clock
Vision threatening
Large, >1.5mm diameter ulcer, or any infiltrate with moderate to severe AC rxn, purulent
discharge, or involving the visual axis
Fortified tobramycin or gentamicin (15 mg/ml) q1hr alternating with fortified cefazolin (50 mg/ml)
or vancomycin (25 mg/ml) q1hr
Or fluoroquinolone gtt q 5min x 3 doses, then q15min for 2-6 hrs, then q30min around the clock
Atypical mycobacterial: amikacin (10 mg/ml) gtt q2hr for 1 week then qid for 2 months
Treatment can be adjusted according to the culture and sensitivity results. If improving, the antibiotic
3.
regimen is gradually tapered.
4. If not, re-culture.
Ophthalmology Survival Guide
Page 22
Please refer to eyerounds.org How to a Corneal Culture video tutorial by Dr. Watts.
http://eyerounds.org/video/Cornea-Culture.htm
In Cornea Clinic, the first workroom (by front desk) has a small fridge in which youll find:
o Blood agar (for aerobic bacteria)
o Chocolate agar (for Hemophilus and N. Gonorrhea)
o Thioglycolate broth short tube of broth (for anaerobic bacteria)
o Tryptone Soy Broth (TSB) tall tube of broth (for aerobic bacteria)
o Potato dextrose white slant tube (fungus)
o Lowenstein-Jensen green slant tube (mycobacterium)
o HSV tubes (one little eppendorf tube, one tube with pink viral culture media).
From the supply cart, collect:
o Glass slides
o Slide folder/holder
o Tube rack
o Sharpie (for labeling glass slides)
o Lab slips
o Specimen bags
o Jewelers forceps
In any of the exam rooms, youll find:
o Topical anesthetic
o Calcium alginate swabs
o Tear strips
Set Up:
1. Gather all the supplies listed above
2. Print patient labels (this is done through EPIC and can be printed after hours at the computer in the Nurses
Station).
** to print labels: click on the Epic button in the top corner of the screen, choose Patient Care, and then
Patient Labels.
3. Tape a label onto the 2 agar plates, 4 tubes, slide folder, and specimen bag
4. Tape the 2 glass slides into the folder and use the sharpie to mark the location of the sample (mark on the back of
the slide)
5. Line up your tubes in the tube rack and open 7 swabs
Procedure
(see http://eyerounds.org/video/Cornea-Culture.htm tutorial by Dr. Chris Watts for more details)
Complete EPIC orders (in SmartSet box type: Corneal Ulcer) and print out a copy of the order requisite.
The requisite should be placed with the specimens in a biohazard bag.
For HSV culture and PCR. Complete EPIC orders. A separate lab printout (outside lab) will print. The culture
and PCR will go in separate bags. They will eventually be sent to the hygienic lab through our micro lab.
After hours you need to bring the specimen to microbiology 6BT at elevator A.
Record the patients name and MRN on the cornea white board, along with the drops the patient was started
on.
Chemical Injury
Initial Therapy:
Irrigation x 15-30 minutes using Morgan lens or until pH is normal (may require several liters).Outcome related to
duration of contact between the chemical agent and the eye. Alkali usually worse than acidic.
Hint: compare pH paper result with your own tears
May need to sweep fornices to clean debris
Debridement of necrotic corneal/conj epithelium to allow proper re-epithelialization- do not do this on your own
Medical Therapy:
Wagoners alkaline chemical injury protocol:
Check for epi defect, IOP, VA, perilimbal ischemia
**Amount of therapy dictated by degree of limbal ischemia a judgment call**
Acute phase:
TOPICAL RX
Corticosteroids Q1-4H
Medroxyprogesterone Q2H (compounded by pharmacy)
Ascorbic acid Q2-4H (compounded by pharmacy)
Sodium citrate Q2-4H (compounded by pharmacy)
Prophylactic antibiotics
Cycloplegia
IOP control
SYSTEMIC RX
Doxycycline 100mg BID
Sodium ascorbate 2 grams BID
BANDAGE CONTACT LENS for large epithelial defect if patient admitted and/or likely to follow-up in clinic.
Corticosteroids
Doxycycline
Citrate
Strongly decrease
Progestational
steroids
Mildly
Mildly
Moderately
Mildly
decrease
Strongly
decrease
Strongly
Decrease
Mildly
Decrease
No direct effect
Decrease
No direct effect
Decrease
No direct effect
Decrease
No direct effect
Collagen synthesis
Strongly
No effect
No effect
No effect
Matrix remodeling
decrease
Strongly decrease
No effect
No effect
No effect
Neovascularization
Mild
Moderate
No effect
No effect
Decrease
Decrease
Inflammation
Collagenase
Epithelial
migration
Trauma
OPEN GLOBE
First, confirm the globe is open. Often a patient will be billed as open globe on the outside but is not
Do not check IOP if there is concern for an open globe
Call 3rd year after confirmation of open globe
Things to be done while waiting for 3rd year
- 400mg IV moxifloxacin or equivalent
- IV zofran if there is any nausea (want to prevent valsalva)
- fox shield no pressure on globe
- ask about last meal, last tetanus shot. Give tetanus shot update if needed
- fill out consent
- can call main OR if 3rd year requests: 3-6400 (schedule as class B priority)
- page anesthesia (3911) all cases will be general anesthesia
- call bed placement at 4-5000 (admit to 3RCE)
- admission orders (smart set EYE:ADMIT TO OPTHALMOLOGY INPATIENT)
- if placing OR procedure orders use eye trauma order set, general anesthesia, no retrobulbar
EYELID LACERATION REPAIR
Simple
- close skin: 5-0 fast absorbing (if sure patient will follow up, can consider 7-0 vicryl or 6-0 prolene)
Complex / deep
- consider CT if fat prolapse (septum violated)
- close with 4-0 or 5-0 vicryl for deep sutures
Hyphema
Definition: Layered blood in the anterior chamber. Microhyphema: suspended RBCs only.
History: Mechanism & time of the injury, use of antiplatelet or anticoagulant therapy, Sickle cell (always suspect if
African American)
Exam: r/o open-globe, Va, IOP, Slit lamp (note and sketch character, extent, color of hyphema, measure dimensions),
check for NVI, DFE *Avoid gonioscopy during the first week.
Ancillary Studies: Ultrasound or CT scan, Sickle cell work up. If you have no view to the back, a gentle B-scan is
appropriate, but be very gentle!
Goals
1. Prevent secondary hemorrhage (greatest risk in first 5 days)
2. Control elevated IOP (occur in about 1/3 of patients)
3. Minimize complications: corneal blood stain, optic atrophy, glaucoma.
Outpatient treatment
1. To be seen daily in the next four days.
2. Bed rest with head elevation as much as possible.
3. Scopolamine 1% TID (for cycloplegia and prevention of pupillary block/synechiae)
4. Prednisolone acetate 1% QID at minimum
5. Control IOP
Indications for Hospitalization
1. Present of or high risk for secondary hemorrhage
a. Presenting Va of 20/200 or worse
b. Initial hyphema greater than 1/3 A/C
c. Use of antiplatelet or anticoagulant
d. Positive sickle cell trait or anemia
e. Delayed medical attention greater than 24 hours
2. Noncompliant patient, parents, or both
3. Hyphemas more than 50%
4. Penetrating ocular trauma
5. Suspected child abuse
Indications for Surgery:
1. Most hyphemas, including total hyphemas, should be treated medically for the first 4 days.
2. Microscopic corneal blood staining (at any time)
3. IOP >50 mmHg despite maximum medical mgmt for >5days, or >35 mmHg for 7 days (to prevent optic atrophy)
4. Total hyphema or >75% of A/C present for 6 days with IOP >24 mmHg (to prevent corneal blood staining)
5. Hyphemas >50% retained longer than 8 days (to prevent peripheral anterior synechiae)
6.Sickle-cell trait or sickle-cell disease patients with hyphema of any size and IOP > 35 mmHg > 24 hours
Patient Instructions
1. Watch for decrease vision (secondary hemorrhage) or pain (elevated IOP)
2. Avoid antiplatelet or anticoagulant
3. No strenuous physical activities for 2 weeks after injury. Patients should not resume normal activities before 4 weeks
after injury.
References:
1.
Gottsch JD. Hyphema: diagnosis and management. Retina. 1990;10 Suppl 1:S65-71. PMID: 219138
2.
Crouch ER Jr, Crouch ER. Management of traumatic hyphema: therapeutic options. J Pediatr Ophthalmol Strabismus. 1999
Sep-Oct;36(5):238-50. PMID: 10505828
ENDOPHTHALMITIS
Important: MUST CALL PHARMACY FOR INTRAVITREAL ANTIBIOTICS: 6-6162 or 6-4300
Types:
1. Exogenous
Post-operative: Acute < 6 weeks, Delayed > 6 weeks. Incidence is 0.1% post uncomplicated CE
Post-traumatic
Contiguous infections
2. Endogenous need medicine or ID consult to aid in finding source
History: Intraocular surgery or injections, trauma, septicemia/systemic symptoms, IV drug abuse, microbial keratitis
Exam: Va/ IOP/ Slit lamp/ DFE/echo
Signs and Symptoms: Decreased Va, photophobia, chemosis/lid edema, hypopyon (non-shifting), corneal edema/
infiltrate, vitreous cell, periphlebitis, inflammation greater than the usual clinical course.
Differential Diagnosis: TASS, retained lens material, inflammatory conditions, aseptic endophthalmitis
Factors determining outcome:
1) Time to diagnosis
2) Time to treatment (hence, do an efficient exam and get the antibiotics to the vitreous ASAP)
3) Organisms
Acute post-operative: staph epidermidis
Delayed post-operative: Propionibacterium acnes
Bleb associated: Haemophilus or Streptococcus species
Post traumatic: bacillus
Management:
Endophthalmitis Vitrectomy Study (EVS): study pertains to cataract surgery, careful in extrapolating to other patients
Patients: Endophthalmitis within 6 wks after CE
Results: HM or better: Tap and Inject
LP: immediate vitrectomy
IV antibiotics do not make any difference
Have ready:
EPIC orders for microbiology and for antibiotics. Call pharmacy ASAP (inpatient pharmacy is 6-3040) and ask them
to tube the medications to tube station 510 (eye clinic by the nurses station)
Gram stain and culture plates, Culture media
For vit tap use 25 gauge needle
For vit inject use 30 gauge needle
Antibiotics:
Vancomycin: 1mg/ 0.1 ml intravitreal (overfill syringe to 0.5 ml); 25mg/1.0 ml subconj.
Ceftazidime: 2mg/0.1ml intravitreal; 25 mg/0.5ml subconj
PCN allergic: Gentamycin 200 mcg/0.1ml
Pharmacy to call for Intravitreal antibiotics (once they are ordered in EPIC you also have to call the appropriate
pharmacy): You can ask them to tube them to the appropriate location (eye clinic is tube station 510)
ASC patients (M-F 6am-5pm)
ASC
67813
OR patients (M-F 6am-10pm)
OR
36485
ER patients (M-F 10am-6pm)
ER
45228 (pg 4577)
ER patients (M-F 6pm-10am, Sat/Sun)
7JP
64300
All inpatients
4JP
67985
Clinic patients
Pomerantz 46902
Ophthalmology Survival Guide
Page 30
POM#3-6:
Remove sutures if necessary to improve Ks/MRx. If pt has useful vision (i.e.-20/60) and is happy with MRx,
try it b/c taking more sutures may cause more problems.
We like to wait to take sutures til 6 months, but will do it as early as 3 months if the GHJ edema is resolved.
Please record Ks before and after sutures are removed.
We generally remove a suture only if there is more than 3 D of MRx astigmatism.
At POM#6 reduce PF to BID
POM#12:
Reduce PF to QD
POM#16-18
Can consider removing all sutures if there is problem (like really weird topography) especially if you are
anticipating needing to do PRK or LASIK or AKs. By this point, you may have the patient see staff at UIHC if
necessary. Patients that are 1-2 years can still have graft dehiscence at the slit lamp. So consent the patient
before you do this.
Remember that contact lenses are your friend.
Remember that anisometropia can be fixed with piggyback IOLs
We do not cut back on PF at the same visit where we remove sutures b/c epi defects are a risk factor for
rejection, so we stagger the two.
Any problems, call the fellowsimple phone calls can save much time and pain.
from van Heuven WAJ, Zwaan J. Decision Making in Ophthalmology: an algorithmic approach. Mosby, 2000.
Used with permission from Mosby.
Laser Settings:
Argon LPI
Size: 50m
Duration: 0.02-0.2sec
Power: 1 W
Wavelength: Argon blue green
Contact lens: Abraham, Wise
YAG LPI
Size: Fixed
Duration: Fixed nanoseconds
Power: 1-2mJ
Wavelength: YAG
Contact lens: Abraham, Wise, Lasag CGI
ALT
Size: 50m
Duration: 0.1sec
Power: 200-1200mW
Wavelength: Argon green or blue-green
Contact lens: Goldmann 3-mirror
SLT
Pretreat: Brimonidine Tartrate 0.2%, Proparacaine HCl 0.5%
Size: 400m
Post-treatment: Check IOP one hour after procedure
Duration: set
Rx: +/- Prednisolone acetate (either 16d taper or QID x 4 days)
Energy: 0.5-1.2mJ
Follow-up: 6 weeks
Wavelength: 532nm Nd: YAG
Contact lens: Goldmann 3-mirror or Latina
Argon Laser Iridoplasty
Size: 200-500m
Duration: 0.2-0.5sec
Power: 150-300mW
Wavelength: Argon blue-green
Contact lens: None, Goldmann 3-mirror
Transpupillary Cyclophotocoagulation
Size: 50-200m
Duration: 0.1-0.2sec
Power: 500-1000mW
Application: 3-5 per ciliary body process
Circumference treated: Up to 180 degree
Endophotocoagulation
Size: Fixed 20-guage probe
Duration: 0.1-0.2sec
Power: 500-1000mW
Application: 3-5 per ciliary body process
Circumference treated: 180 degree-360 degree
Noncontact Nd:YAG Transscleral Cyclophotocoagulation
Size: Fixed 70m
Duration: 10-20msec
Power: 4-8 J
Applications :32
Circumference Treated: 360 degrees
Contact Nd:YAG Transscleral Cyclophotocoagulation
Size: Fixed, quartz probe
Duration: 0.5-0.7msec
Power: 4-9 J
Applications:32
Circumference Treated: 360 degrees or 270 degrees, sparing superonasal quadrant
Contact Semiconductor Diode Laser Cyclophotocoagulation
Size: Fixed, quartz probe
Duration: 2 sec
Power: 1750-2000 mW
Applications: 17-24
Circumference Treated: 270-360 degrees
Laser Suture Lysis
Size: 50m-100m
Duration: 0.02-0.05sec
Power: 250-500mW
Wavelength: Argon green, Krypton red
Contact lens: Hoskins, Ritch
Diabetic Retinopathy
PRP:
Size: 200microns Superquad, 350microns Rodenstock, 500microns Pancake/Goldmann
Duration: 20ms (titrate as needed)
Power: 200mW
Increase: +50mW increments
Wavelength: Argon green
CL: Rodenstock, Pancake, Goldmann, Superquad
Macular Edema
Focal Laser:
Size: 50-200m
Duration: 0.1sec
Power: 100mW
Ophthalmology Survival Guide
Page 37
CNVM
Laser Photocoagulation
Size: 200-500m
Duration: 0.2-0.5sec
Power: 200mW
Increase: +50mW increments
Wavelength: Argon green, Krypton red
Contact lens: Yanuzzi, Pancake
Retinal Angioma Photocoagulation
Size: 200-500m
Duration: 0.2-0.5sec
Power: 180mW
Wavelength: Argon green, Dye yellow
Contact lens: Goldmann, Rodenstock
Red
Detached retina
Macular edema
Retinal veins
Attached retina
Retinal arteries
Brown
Green
Yellow
Hemorrhage in retina
Retinal Breaks
Retinal pigmentation
Choroidal pigmentation when seen
through attached retina
Choroidal pigmentation seen
through detached retina
Opacities in media, including
vitreous hemorrhage
Chorioretinal exudation
Retina Studies
Diabetic Retinopathy Study (DRS):
Questions: Does PRP decrease severe visual loss (SVL; 20/800 or > 6 lines loss) in patients who meet high risk
criterion (HRC)?
Results: >50% reduction in the rate of SVL in patients with HRC
Non Proliferative Diabetic Retinopathy (NPDR):
A. Mild: at least one microaneurysm (Heme/Ma < std. photo 2A) not met B,C,D
B. Moderate: H/Ma std. photo 2A/ CWS/HE, VB and/or IRMA not met C,D
C. Severe: H/Ma in all 4 quadrants or
VB in 2 or more quadrants > std. photo 6B or
IRMA > std. photo 8A in at least 1 quadrant
D. Very Severe: Any 2 or more of C above.
Proliferative Diabetic Retinopathy (PDR):
A. Early: new blood vessels on the disc or elsewhere and definition not met by HRC
B. High risk: Must have 3 out of the 4 criterion:
1. New blood vessels
2. NVD
3. NVD > std photo 10A (1/3 - 1/2 DA) or NVE > 1/2 DA
4. pre-retinal or vitreous hemorrhage.
*if hemorrhage obscures visualization of the retina, then new vessels are assumed to cover that area not visualized.
B. Confirmed DRS that optimal timing for initiating PRP is at stage of high risk PDR
C. Aspirin use (650 mg Qday) was neither helpful nor harmful in diabetic retinopathy.
Grade 0 (Normal)
radial arrangement of peripapillary nerve fiber layer without axon bundle tortuosity
blurring of superior and inferior poles is disregarded
rarely, a major vessel may be obscured (especially superior pole)
Grade 3 (moderate)
Grade 4 (severe)
from Lee AG, Brazis PW. Clinical pathways in neuro-ophthalmology: an evidence-based approach. Thieme, 1998
Anisocoria
Anisocoria that increases in dim light and diminishes in brighter light is either physiologic or caused by
Horner's syndrome, a loss of sympathetic innervation to the dilator muscle.
(Modified with permission from Thompson HS: The pupil, in Hart WM Jr (ed): Adler's Physiology of the eye: clinical applications (9th ed). St.
Louis: Mosby Year Book, 1992. p 439.)
Anisocoria that increases in bright light is indicative of a weak iris sphincter or parasympathetic lesion on the
side that does not dilate well.
(Modified with permission from Thompson HS: The pupil, in Hart WM Jr (ed): Adler's Physiology of the eye: clinical applications (9th ed). St. Louis: Mosby Year
Book, 1992. p 439.)
Carotid-cavernous fistula (CCF): If you suspect a CCF, order the following imaging sequences:
MRI brain with and w/o contrast
MRA brain time of flight
MRA head/neck with contrast
Ophthalmology Survival Guide
Page 45
from van Heuven WAJ, Zwaan J. Decision Making in Ophthalmology: an algorithmic approach. Mosby, 2000.
Permission to use pending. If denied, this image will be deleted.
Ophthalmology Survival Guide
Page 46
from Lee AG, Brazis PW. Clinical pathways in neuro-ophthalmology: an evidence-based approach. Thieme, 1998.
Permission to use this image is pending. If this request is denied, image will be deleted.
Ophthalmology Survival Guide
Page 47
Dilating a Child
Premies -- 2 months of age
Cyclomydril (cyclopentolate/phenylephrine) 1 gtt x2, five minutes apart
Available in the peds clinic and the NICU
2 months 1 year
Cyclogyl 0.5% (cyclopentolate) 1 gtt x2, five minutes apart
+/- phenylephrine for dark irides
Available in the peds clinic and the NICU
Over 1 year
Cyclogyl 1% (cyclopentolate) 1 gtt x2, five minutes apart
+/- phenylephrine for dark irides
** Remember consults regarding a peds patient must be seen with a senior resident
** Non-accidental trauma cases need photo documentation and to be staffed with attending
** To make arrangements for peds follow-up or to schedule appointment you can email: pediatric ophthalmology
triage or personally stop by pediatric clinic
** If you are carrying the day-call pager and it is regarding a consult on a pediatric patient, check with pediatric
scheduling and staff before accepting
Postoperative Troubleshooting
General:
It is a good idea to see all post-op patients who call.
Contact the attending surgeon if appropriate. Level of contact will vary between
attending so when in doubt ask senior resident or try to contact personally.
Cataract Extraction:
Be mindful of the possibility for endophthalmitis, elevated IOP, or Toxic
Anterior Segment Syndrome (TASS)
Penetrating Keratoplasty: graft failure
Primary: occurs immediately post-op and reflects faulty donor tissue. High dose
topical steroid but may need re-grafting
Secondary:
Rarely occurs within 2 wks but may occur as late as 20 yrs post PK
1/3 of grafts experience rejection but 1/3 of patient with rejection never
report symptoms
Symptoms: decreased vision, mild pain, redness, photophobia
Signs: epithelial rejection line, sub-epithelial infiltrates, iritis (especially
when accompany by increase graft thickness), KP, endothelial rejection line
(Khodadoust line), NV extending onto the graft
Treatment:
1. Topical steroid:
Endothelial rejection: PF q1hr while awake; dexamethasone 0.1%
ointment qhs
Epithelial rejection: PF qid, or twice the current dose, whichever is
more
2. Consider cycloplegic agents
3. Consider systemic steroid (PO or IV)
4. Control IOP if increased
5. Close follow up
Loose/ broken sutures:
Suture can be cut with a pre-bended needle (in Cornea clinic)
Grasp knotted end with forceps and pull firmly
Vigamox or Zymar qid x 4 days
PF qid x 4 days then resume previous dose
Retina:
Take all eye or head pain seriously
Think about increased IOP, this should be ruled out before prescribing pain med
Examine patient and discuss with senior or retina fellow at minimum
Plastics:
DCR/stenting: Ask the patient to tape the loose stent to the nose. Return to next plastic clinic
Conformers: if conformer falls out, try to replace with a larger one (found in main OR), otherwise,
replace conformer, patch eye, and follow up in oculoplastics clinic in the next 1-2 days.
Glaucoma:
Seidel Test is your friend
Presentations
Differential Diagnosis
Aqueous Misdirection
Pupillary Block
Suprachoroidal Hemorrhage
Tight suture
Acute angle closure
(as of 6/22/13)
Illinois
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/70 in one or both eyes
20/71 - 20/100 in one or both eyes
No restrictions
No driving when headlights are required
Bioptic telescope required unless living in a town with a population of
3000 or less
- Must achieve 20/40 or better with no more than a 3x telescope
- Requires a vision specialist statement indicating the individual has had
the telescope a minimum of 60 days and has been trained to use the
telescope when driving
- Requires a behind the wheel test
- Must be approved by a medical review board
- No night driving allowed with a bioptic telescope
License denied
Iowa
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/70 in one or both eyes
20/71 20/199 in one or both eyes
No restrictions
No driving when headlights are required
- Behind the wheel testing can be requested via discretionary review
process to gain privilege to drive when headlights are required.
Discretionary issuance
- Requires a vision specialist statement indicating the individual is
visually competent to drive
- Requires a behind the wheel test
- The behind the wheel testing is used to determine maximum speed,
distance from home and whether ok to drive when headlights are
required
- If VA < 20/100, must also be approved by a medical review board
- If VA is <20/100 in the left eye, will be required to have a left and right
outside mirror
License denied
Bioptic Telescopes: Not allowed to achieve the visual acuity standards noted above
Visual Field: (uninterrupted is not specified)
> 140 degrees binocular
No restrictions
Discretionary issuance
- Requires a vision specialist statement indicating the individual is
visually competent to drive
- Requires a behind the wheel test
Iowa uses a vision standard for licensure. This standard states that the individual is legally qualified to drive, until their
license comes up for renewal, regardless of whether their visual acuity or visual field becomes impaired during the
interval between licensing renewal. Although individuals with acquired visual impairments are legally qualified to drive
until their license is up for renewal, civil liability exposure exists if they continue to drive with the knowledge that they
would no longer visually qualify to drive, if they attempted to renew their license. If the Iowa Department of
Transportation becomes aware that a person has experienced a decrease in their visual acuity or visual field, the DOT will
arrange for a re-evaluation to see if the person is capable of continuing to safely operate a motor vehicle.
For additional information: http://www.iamvd.com/ods/index.htm
To print a copy of the driving form:
https://forms.iowadot.gov/BrowseForms.aspx?category=2
No restrictions
Discretionary issuance
License denied
Bioptic Telescopes: Not allowed to achieve the visual acuity standards noted above
Visual Field: (uninterrupted is not specified)
>55 degrees in each eye or 85 degrees monocular
70-109 degrees binocular or monocular
<70 degrees binocular or monocular
No restrictions
Discretionary issuance
License denied
Missouri uses a vision standard for licensure. This standard states that the individual is legally qualified to drive, until
their license comes up for renewal, regardless of whether their visual acuity or visual field becomes impaired during the
interval between licensing renewal. Although individuals with acquired visual impairments are legally qualified to drive
until their license is up for renewal, civil liability exposure exists, if they continue to drive with the knowledge that they
would no longer visually qualify to drive, if they attempted to renew their license. If the Missouri Motor Vehicle
Department becomes aware that a person has experienced a decrease in their visual acuity or visual field, the DOT will
arrange for a re-evaluation to see if the person is capable of continuing to safely operate a motor vehicle.
For additional information: http://www.dor.mo.gov/mvdl/drivers/dlguide/
To print a copy of the driving form:
http://dor.mo.gov/forms/index.php?formName=&category=2&year=&searchForms=Search+Forms - choose form 999
Minnesota
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/70 in one or both eyes
20/71 - 20/99 in one or both eyes
< 20/100
No restrictions
Speed restrictions
- May also have time of day and radius from home restrictions
Discretionary issuance
- Requires a vision specialist statement indicating the individual is visually
competent to drive
- Requires a behind the wheel test
- May have speed, time of day and radius from home restrictions
License denied
Ophthalmology Survival Guide
Page 54
Bioptic Telescopes: Not currently allowed to achieve the visual acuity standards noted above
Visual Field: (uninterrupted is not specified)
No restrictions
Discretionary issuance - vehicle may require left and right outside mirrors, in
addition to speed, radius from home and time of day restrictions
License denied
Minnesota uses a vision standard for driving. This standard states that it is the individuals legal responsibility to notify the Minnesota
Driver and Vehicle Services office when they becoming aware that they have reduced visual acuity or visual field limitations that may
disqualify them from further driving.
For additional information: http://www.dps.state.mn.us/dvs/index.html
To print a copy of the driving form: https://dps.mn.gov/divisions/dvs/forms-documents/Pages/drivers-license-forms.aspx - select form
PS30338
Nebraska
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/60 in one or both eyes
20/60-20/70
20/70 in one or both eyes
< 20/71 in one or both eyes
No restrictions
No driving when headlights are required
If blind in fellow eye, license will be denied
No driving when headlights are required and speed limitations
License denied
Bioptic Telescopes: Are allowed to achieve the visual acuity standards noted above
Visual Field: (uninterrupted is specified)
> 140 degrees binocular or monocular
1390120 degrees binocular or monocular
100-119 degrees binocular or monocular
< 100 degrees binocular or monocular
No restrictions
Vehicle must have left and right outside mirrors
No driving when headlights are required
- Radius from home and speed limitations
License denied
Nebraska uses a vision standard for licensure. This standard states that the individual is legally qualified to drive, until
their license comes up for renewal, regardless of whether their visual acuity or visual field becomes impaired during the
interval between licensing renewal. Although individuals with acquired visual impairments are legally qualified to drive
until their license is up for renewal, civil liability exposure exists, if they continue to drive with the knowledge that they
would no longer visually qualify to drive, if they attempted to renew their license. If the Nebraska Department of Motor
Vehicle becomes aware that a person has experienced a decrease in their visual acuity or visual field, the DOT will
arrange for a re-evaluation to see if the person is capable of continuing to safely operate a motor vehicle.
For additional information: http://www.dmv.state.ne.us/examining
To print a copy of the driving form: http://www.dmv.state.ne.us/examining/forms#vision
South Dakota
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/60 in one or both eyes
Bioptic Telescopes: Not allowed to achieve the visual acuity standards noted above
Visual Field:
Not considered
South Dakota uses a vision standard for licensure. This standard states that the individual is legally qualified to drive,
until their license comes up for renewal, regardless of whether their visual acuity or visual field becomes impaired during
the interval between licensing renewal. Although individuals with acquired visual impairments are legally qualified to
drive until their license is up for renewal, civil liability exposure exists, if they continue to drive with the knowledge that
they would no longer visually qualify to drive, if they attempted to renew their license. If the South Dakota Department
of Public Safety becomes aware that a person has experienced a decrease in their visual acuity or visual field, the DOT
will arrange for a re-evaluation to see if the person is capable of continuing to safely operate a motor vehicle.
For additional information or to print a copy of the driving form: http://www.state.sd.us/dps/dl/Applications/main.asp
Wisconsin
Visual Acuity:
> 20/40 in one or both eyes
20/41-20/100 in one or both eyes
No restrictions
Discretionary issuance
- Requires a vision specialist statement of visual acuity
- May require a behind the wheel test
- May result in speed, time of day and radius from home restrictions
License denied
Bioptic Telescopes: Not allowed to achieve the visual acuity standards noted above
Visual Field: (uninterrupted is not specified)
> 140 degrees binocular
No restrictions
139-40 degrees binocular or monocular
Discretionary issuance
- Requires a vision specialist statement of visual field
- May require a behind the wheel test
- May result in speed, time of day and radius from home restrictions
< 40 degrees binocular or monocular
License denied
Wisconsin uses a vision standard for licensure. This standard states that the individual is legally qualified to drive, until
their license comes up for renewal, regardless of whether their visual acuity or visual field becomes impaired during the
interval between licensing renewal. Although individuals with acquired visual impairments are legally qualified to drive
until their license is up for renewal, civil liability exposure exists, if they continue to drive with the knowledge that they
would no longer visually qualify to drive, if they attempted to renew their license. If the Wisconsin Department of
Transportation becomes aware that a person has experienced a decrease in their visual acuity or visual field, the DOT will
arrange for a re-evaluation to see if the person is capable of continuing to safely operate a motor vehicle.
For additional information or to print a copy of the driving form:
http://www.dot.wisconsin.gov/drivers/drivers/apply/vision.htm
Additional Information
--The DOT does make accommodations for the functionally illiterate. An auditory, computer generated voice, test can be
provided or the individual can bring someone with them to read the test.
--As part of the author's work up, we ask the following questions. Do you drive? If yes, what type of driving do you do?
Do problems with your sight cause you to be fearful when you are driving? During the past 6 months, have you made any
driving errors? Is your driving ability affected by your vision?
Ophthalmology Survival Guide
Page 56
--For individuals that are visually impaired who wish to be licensed or to have the privileges of his or her license
expanded, a letter from a vision specialist is required and must state, "It is my professional opinion that (patient name) has
the visual ability to operate a motor vehicle". The author would also recommend that the letter state "I am requesting that
a hearing officer provide (patient name) with a behind the wheel evaluation to see if he/she can acquire/maintain the
privilege of operating a motor vehicle".
--A letter can replace the Vision Specialist Form 430032 (Iowa) if all of the information from the departmental vision
form is included. This information includes:
0. The patient's full name and address
1. Visual acuity OD, OS, and OU, both uncorrected, corrected, and with new prescription when appropriate.
2. The visual fields for the right and left eye measure nasally and temporally.
3. A statement concerning whether the eye specialist feels the individual is visually competent to drive
4. A statement concerning privileges, whether they be general, daylight only, or limited
5. If limited, the amount of limitations
6. Should vision be rechecked sooner than 2 years
7. The date of the examination, which needs to be within 30 days of the individual's attempt to be licensed or re-licensed.
--The Iowa DOT does allows eye care practitioners (MD, DO and OD) to report to the department the identity of a person
who has a physical or mental condition which may render that person incompetent to operate a motor vehicle safely. The
physician is to make reasonable efforts to notify the person in writing of the nature and reason for the report to the DOT.
The physician has no duty to make a report or to warn third parties. The reporting physician is immune from any
liabilities, civil or criminal, which may otherwise be incurred or imposed as a result of the report.
--The author feels it is important for the practitioner to counsel those individuals, whose vision has decreased significantly
from the time they were licensed, about their increased potential for personal liability if they are involved in an accident.
For those individuals whose vision changes after they are licensed, the author would recommend that they be re-evaluated
by the DOT to see if they are still capable of continue to safely operate a motor vehicle.
Combination Drugs:
Timolol-Dorzolamide (Cosopt): Blue/white cap
Timolol-Brimonidine (Combigan): Navy cap
Other drops:
Antibiotics: TAN CAP
Steroids: PINK OR WHITE CAP
NSAIDS: GRAY CAP
Mydriatics: RED CAP
Miotics: GREEN CAP
Abbreviations
2xIOL secondary IOL
2xOAG secondary open angle glaucoma
4x 4 prism diopter test
5FU 5-fluorouracil
A applanation tonometry
A scan 1 dimensional U/S exam of length of eye
A/V arteriole/venule ratio (normally 2:3)
A1 Atropine 1%
ABK aphakic bullous keratopathy
ABMD anterior basement membrane dystrophy
AC anterior chamber, accommodative convergence
AC/A accomodative convergence to accommodation ratio
ACE angiotensin converting enzyme
ACh Acetylcholine
ACIOL anterior chamber intraocular lens implant
AD autosomal dominant
AFB Acid Fast Bacilli
AG Amsler grid
AI accommodative insufficiency
AIBSE acute idiopathic blind spot enlargement
AIDS acquired immune deficiency syndrome
AION anterior ischemic optic neuropathy
AK astigmatic keratotomy, actinic keratosis
ALK automated lamellar keratoplasty
ALT argon laser trabeculoplasty
AMD age-related macular degeneration
AMP acid mucopolysaccharide
AMPPE acute multifocal placoid pigment epitheliopathy
AN1 autosomal dominant familial aniridia
AN2 sporadic nonfamilial aniridia and Wilms' tumor (Miller's Syndrome, WAGR)
AN3 autosomal recessive aniridia (Gillespie's Syndrome)
ANA anti-nuclear antibodies
ANCA antineutrophil cytoplasmic antibodies
ANGAU acute nongranulomatous anterior uveitis
Ap applanation tonometry (Goldmann slit lamp)
APD afferent pupillary defect (Marcus-Gunn)
APUD amine precursor uptake and decarboxylation system
AR autorefraction, autosomal recessive
ARC abnormal retinal correspondence
ARI aldose reductase inhibitor
ARMD age-related macular degeneration
ARN acute retinal necrosis
ARNS Atropine retinoscopy
ARP Argyle Robertson Pupil
AS ankylosing spondylitis
ASB apostilb
ASC anterior subcapsular cataract
astig astigmatism
AT artificial tears
ATR astig against the rule astigmatism
AVM arterio-venous malformation
AZT azidothymidine (Zidovudine)
B scan 2 dimensional U/S exam of eye
B9 benign
band keratopathy
BAT Brightness Acuity Tester
Ophthalmology Survival Guide
Page 59
RF rheumatoid factor
rhabdo rhabdomyosarcoma
RHT right hypertropia
RK radial keratotomy
RLF retrolental fibroplasia (now ROP)
RLL right lower lid
RNS dilated retinoscopy
ROP retinopathy of prematurity (was RLF)
RP retinitis pigmentosa
RPE retinal pigment epithelium
RPED (see PED)
RRD rhegmatogenous RD
RT retinal thickening, retinal tear
RUL right upper lid
SAH subarachnoid hemorrhage
SB scleral buckle
SBEB scleral buckle with encircling band
SCC squamous cell carcinoma
SCH subconjunctival hemorrhage
SDH subdural hematoma
SE soft exudates (CWS), side effects
SEI subepithelial infiltrates
SK seborrheid keratosis
SLACH soft lens-associated corneal hypoxia syndrome
SLE slit lamp exam or systemic lupus erythematosis
SLK superior limbic keratoconjunctivitis
SN superonasal
SO superior oblique, sympathetic ophthalmia
SPCAS short posterior ciliary arteries
SPEP serum protein electrophoresis
sph spherical correction
SPK superficial punctate keratitis
SR superior rectus
srf subretinal fluid
SRK Sanders-Retzlaff-Kraff formula
SRNVM subretinal neovascular membrane
SRT Sorbinil Retinopathy Study
SS scleral spur
ST superotemporal
SVL severe visual loss
SVP spontaneous venous pulsations
T tonometry, IOP
Tl longitudinal relaxation time: time required for the next bulk magnetization to realign itself along the original axis.
T1/2 Timoptic 0.5%
T2 transverse relaxation time: mean relaxation time based on the interaction of hydrogen nuclei within a given tissue.
TA temporal arteritis (GCA)
TB tuberculosis
TCN tetracycline
TEM transmission electron microcopy
TF trachomatous inflammation-follicular (WHO)
TGF transforming growth factor
TI trachomatous inflammation --intense (WHO), transillumination
TM trabecular meshwork
tobra tobramycin
Tp tonopen
TPPV trans pars plana vitrectomy
Trab trabeculectomy
TRD tractional RD
TRIC Trachoma Inclusion Conjunctivitis
TS tuberous sclerosis, Tay-Sach's disease, trachomatous scarring (WHO)
Ophthalmology Survival Guide
Page 66
Phone Lists
UIHC Frequently Used Numbers
3RCW: 6-3660 3RCE: 6-3680
Create Pt Encounter: 6-2547
ER: 6-2233
ASC: 6-7876
ASC (specific OR): 6-61xx (xx = room #)
Main OR: 3-6400
Main OR (specific OR): 6-66xx (xx= room #)
Bed Placement: 4-5000
Eye Clinic Fax: 6-0363
Nurses station Fax: 319-384-5619
Eye Clinic Tube: 510
Day call pgr: 3314
Radiology pgr (notify of request after hours): 3205
Chart control after hours pgr: 3292
Scheduling:
2-0098 (voice mail)
6-2852 (for patients)
Phone
3-7617
5098
5270
3703/5225
4713
5101
CONTACT LENS
CORNEA/EXTERNAL
ECHOGRAPHY
GLAUCOMA
LOW VISION
MOL (MOLECULAR OPHTH
5102
LAB)
4410
NEURO-OPHTHALMOLOGY
OCULOPLASTICS
OPHTH PROCEDURE SUITE
5258
PATHOLOGY (OCULAR)
PEDIATRIC
OPHTH/STRABISMUS
5227
RETINA
VASCULAR (8:00 - 12:00 noon )
5273
VASCULAR (12:00 - 5:00 pm)
VITRECTOMY
Administration
Billing (Eye Department only)
Business Office (First Floor, GH)
4302/5275 Chart Control (Eye Med Records)
COMS (Coll. Ocular Melanoma
4305
Study)
Comprehensive Clinic
3314
Technicians
4832
ERG Lab
Eye Bank
Eye Bank Lab **after 5:00, call
**
356-1616
FRONT DESK (Eye Reception)
5265
Library (C.S. O'Brien)
Macular Degeneration, Center for
Nurse's Station (Minor Room)
Nursing Supervisor
3314
4591
4621
4298
5272
4254
3702
Perimetry
Photofile
Photograph Reading Center
(PRC)
Photography
Photography Copy Room
Pupil Lab
6-2916
6-7449
6-2901
6-2380
6-8301
5-8270
6-2548
6-2590
6-2853
5-7095
6-2859
6-2951
6-2921
6-7445
3-6557
6-2866
3-6345
6-2211
6-2952
6-3940
3-7617
4-9381
6-2871
6-2874
6-2864
6-2191
4-9270
6-2853
6-3544
3-7617
6-2918
6-7440
6-2390
6-0500
3-6400
6-2853
6-0381
319-5890592
6-4551
6-2339
6-0453
6-0392
6-4400
6-8299
Pager
#
Clinical Faculty
Billing #
Area of
Service
6677
E057
Oph Imaging
3835
3742
4147
3041
9011
4940
3707
8241
8098
8329
5403
3398
3736
7021
E898
Plastics
K313
Glaucoma
L746
Retina
K314
Plastics
E646
Peds/Rsch
E381
Glau/MOL
C115
Retina
G696
Retina/IRL
A883
Cornea
G664
Cornea
B350
Vascular
H425
Comp
Perimetry/Vis Fields
C921
Neuroop/VA
H759
*Pathology
A370
Riverside/VA
Comp/Cornea
E820
H462
Glaucoma
G552
Peds Oph
G944
Contact Lens
E333
Neuro/VA
E503
Peds Oph
E331
Retina/Rsch
Visiting
Neuro-op
H646
Comp/VA
A676
Peds Oph
H524
Retina
B321
Peds Oph
G503
Optometry
G721
Plastics
H672
Contact Lens
G313
Retina
K540
MOL/Ret
A738
OcPath
B133
Neuro-op
G314
Neuro-Op
E458
Cornea
L603
*Neuro-op
Vision Rehab
Area of Service
*Secondary appointments
*Glaucoma Genetics
*Biophysics
*Biochemistry
Bioinformatics
*Bioinformatics
VA-Neuro-op
Glaucoma Genetics
Billing
#
Pager
FELLOWS
4915
Retina
Plastics
Glaucoma
Retina
Retina
4651
5959
3318
1823
4916
4545
3346
4596
4845
5100
4844
Pager #
Service
Peds Oph
Cornea
Neuro-op
Retina
Oph Gene
G778
G782
G997
G795
G968
G966
W558
G003
G991
G020
G974
2015
2015
2015
2015
2016
2015
2015
2015
2015
2016
2015
Retina
G778
2015
Retina-med
RESIDENTS
Billing #
Date of
Completion
THIRD YEAR
4601
4616
4618
4622
3203
R937
R939
R940
R942
W053
2015
2015
2015
2015
2015
7747
8624
2118
7764
2273
Carter, P. Christi, MD
Beebe, Johanna D., MD
Kirkpatrick, Chris A., MD
Niles, Philip I., MD
Phillips, David L., MD
W127
W139
W311
W235
W324
2016
2016
2016
2016
2016
8257
8265
1614
8318
8319
Christiansen, Steven M, MD
Flanary, William E., MD
Haugsdal, Jaclyn M., MD
Lenci, Lucas T., MD
Parekh, Prashant K., MD
W459
W460
W610
W461
W324
2017
2017
2017
2017
2017
4130
4531
4572
4923
4953
SECOND YEAR
FIRST YEAR
Cell Biology
Bioinformatics
Biology & Pharmacology
*Peds-Genetics
*Med Imaging Analysis
Photosensory Biology
Stem Cell Biology
NAMES
FACULTY
Last
First
pager
Abrmoff
Allen
Boldt
Carter
Drack
Fingert
Michael
Richard
Culver
Keith
Arlene
John
6677
3835
4147
3041
9011
4940
Folk
James
3707
Gehrs
Goins
Greiner
Johnson
Karen
Kenneth
Mark
A. Tim
8241
8098
8329
3398
Kardon
Randy
7021
Kitzmann
Kwon
Larson
Longmuir
Longmuir
Mahajan
Oetting
Olson
Russell
Shriver
Sindt
Sohn
Syed
Thurtell
Wall
Anna
Young
Scott
Reid
Susannah
Vinit
Thomas
Richard
Stephen
Erin
Chris
Elliott
Nasreen
Matthew
Michael
3852
3579
3031
5887
3869
5940
7312
3443
7013
2203
1236
7012
2438
5228
9-339-6054
carries
pager
when
NOT OnCall?
yes
sometimes
yes
sometimes
sometimes
no
Prefers
pager
sometimes
sometimes
sometimes
yes
cell best
after hrs
sometimes
no
sometimes
sometimes
sometimes
sometimes
sometimes
sometimes
always
sometimes
no
no
no
no
Prefers cell
1st choice
contact
phone #
2nd choice
contact
phone #
is this a
cell
phone?
is this a cell
phone?
319-325-5775
319-631-9446
319-512-9454
319-330-3842
319-631-9032
319-512-9625
yes
yes
yes
yes
yes
yes
358-7405
338-6871
319-430-0506
337-3214
354-0375
Lab office
no
no
yes (wife's)
home
no
335-7508
337-3083
no
319-325-2399
yes
319-331-7922
319-400-9250
916-307-3454
319-936-7545
yes
yes
yes
yes
358-1488
337-3117
319- 499-1632
358-1488
no
no
home
no
319-321-6132
yes
--
--
319-321-2865
319-621-2068
319-855-8028
319-325-0954
319-331-6838
pager
338-7278
351-0750
339-4824
786-385-8468
319-213-2719
310-779-3848
319-631-1718
216-543-0865
319-430-7979
yes
yes
yes
yes
yes
no
no
no
no
yes
yes
yes
yes
yes
yes
319-321-4825
354-3508
354-0892
339-9322
339-9322
338-1621
319-541-4081
319-331-7693
319-430-9712
-351-7455
-354-3986
-624-2268
Y-husbands
home
home
home
no
no
yes
yes
yes
-no
-no
-No
FELLOWS
Almeida
Baker
David
Meredith
Chambers
Megan
Chin
Elshatory
Huckfeldt
Ko
Shams
Raecker
Rivera
Roybal
Eric
Yasser
Rachel
Ashley
Pari
Matthew
Enrique
Nate
Weed
Matt
Hager
Perry
Sacher
Vislisel
Welder
Jonathan
C. Blake
Bradley
Jesse
Jeffrey
4915 Retina
5959 plastics
no
rarely
319-930-9046
612-940-8629
yes
yes
319-359-1294
609-647-1229
4651 glaucoma
not always
614-256-0999
yes
Pager>husband
4916 Retina
4845 Retina
3346 Med retina
4545 Peds
5267 plastics
5100 cornea
3318 Neuro-op
4844 Retina
3501 Oph
genetics
no
no
no
no
not always
rarely
no
no
510-414-8646
585-738-3766
314-306-5883
319-471-1836
319-400-9995
319-504-5514
787-525-5976
505-235-4005
yes
yes
yes
yes
yes
yes
yes
yes
none
585-738-5145
314-406-2400
--507-358-2339
787-525-5976
--
no
Y-husband's
952-2125762
-Wifes cell
Y-husbands
--yes-wifes
yes, wifes
--
no
801-400-4753
yes
801-318-7150
yes-wifes
4601
4616
4618
4622
3203
no
sometimes
no
sometimes
sometimes
yes
yes
yes
yes
yes
N/A
360-708-1061
314-324-0433
N/A
480-228-3367
-yes- wifes
yes- wifes
-wifes cell
3rd Yr RESIDENTS
512-618-1742
858-414-9912
847-791-1881
319-310-0589
515-290-9633
rd
Hager
rd
rd
rd
rd
nd
nd
nd
nd
nd
st
st
st
st
st
3 year
(512) 618-1742
Perry
Blake
(858) 414-9912
Sacher
Brad
(847) 791-1881
Vislisel
Jesse
(319) 310-0589
Welder
Jeff
(515) 290-8633
Carter
Christi
(903) 330-5139
Beebe
Hanna
(307) 630-4374
Kirkpatrick
Chris
(608) 333-7300
Niles
Phil
(716) 725-9531
Phillips
David
(217) 653-3448
Christiansen
Steve
(801) 602-2086
Flanary
Will
(603) 306-6868
Haugsdal
Jaci
(641) 590-3282
Lenci
Luke
(573) 745-9115
1 year
Parekh
Prashant
(305) 389-1134
Intern
Clark
TJ
(641) 420-2763
Intern
McConnell
Lindsay
(319) 321-7476
Intern
Miller
Matt
(801) 645-1971
Intern
Myers
Lori
(812) 381-1676
Intern
Risma
Tyler
(507) 254-5666
3 year
3 year
3 year
3 year
2 year
2 year
2 year
2 year
2 year
1 year
1 year
1 year
1 year
FAQ
"I had eye surgery the other day and my eye is watery."
- Some degree of irritation and watering is normal after eye surgery. Are you having an
increase in redness? Are you having pain in the eye? Is your vision getting worse? If any of these
are true, you should come in tonight so that I can take a look, since I can't rule out an infection or
high pressure in the eye over the phone.
- (NOTE: Have a very low threshold for bringing in a postoperative patient who calls with a
concern)
"I've had glaucoma surgery and my eye is red. I think I have pink eye."
- Patients that have had trabeculectomy are at increased risk of infection inside the eye. If
you've had a trabeculectomy, you should come in tonight to make sure your bleb and your eye
aren't infected. It could be simple conjunctivitis, but you need to come in so we can make sure.
"I had retina surgery earlier this week and my eye has been hurting. It hurts right above
my eyeball, and I feel sick to my stomach. Can you prescribe something for the nausea?"
- I'm concerned that the pressure in your eye may be elevated, which can happen after eye
surgery, especially retina surgery. I want you to come in tonight to be seen.
"I had endothelial transplant (DMEK, /DSAEK) and now I see a large floater on top
portion of my vision.
- As the AC bubble reabsorbs the meniscus involves the visual axis. No need to worry as
long as symptoms fit what you expect with the dynamics of a floating bubble.
"I had an intravitreal injection today and my eye is tearing, red, and painful."
- It is normal for the eye to be red after an injection. Tearing and pain after the injection is
usually due to the toxicity of the iodine and numbing medication. This usually improves very
quickly over the course of 12-24 hours with rest, Tylenol and artificial tears. If this does not
improve (in 12-24h) or gets worse in any way, call back so we can see you.
"My conformer fell out. Do I need to come in?"
- Place the conformer somewhere safe. We will schedule an appointment to replace it
within a week.
"My bandage contact lens fell out. Do I need to come in?"
- You can attempt to carefully put it back in yourself or with help if you are comfortable
doing so. If the eye feels uncomfortable, increase lubrication. If the eye is still uncomfortable or
if the lens was placed for a corneal wound leak, we can arrange for you to be seen tomorrow to
replace it or you can see a local eye care provider if you live a long distance away.
"My nasolacrimal duct stent is coming out. Do I need to come in?"
- You can carefully feed it back into the tear duct with your fingers if you feel comfortable
doing so. Otherwise, tape the protruding end to your cheek and we will arrange to see you
tomorrow to replace it.
"Outside provider: I have a patient with an orbital fracture, do they need to be seen?"
- At UIHC, we examine all orbital fractures acutely. Please transfer them to our ETC
evaluation.
Ophthalmology Survival Guide
Page 76
Notes