Post on 30-Dec-2015
EmergencyOphthalmology
EmergencyOphthalmology
justin chatten-Brown, MDCCRMC Emegency Departmentjustin chatten-Brown, MDCCRMC Emegency Department
Objectives
• Learn examination of the eye, and slit- lamp basics
• Diagnose and be able to rule out eye emergencies
• Know how to treat basic conditions
• Know when to refer, and on what timescale
Etiologies of the Red or Painful Eye
• Infection• Orbital Cellulitis
• Severe Iritis/Uveitis
• Hypopyon
• Herpetic keratitis
• Preseptal cellulitis
• Bacterial conjunctivitis
• Viral conjunctivitis
Etiologies of the Red or Painful Eye
• Primary Ophthalmologic Disease• Acute Glaucoma
• Optic Neuritis
• Allergy• Blepharitis
• Allergic Conjunctivitis
Etiologies of the Red or Painful Eye
• Trauma• Corneal abrasions
• Corneal foreign bodies
• Subconj Hemorrhage/Hyphema
• Penetrating Orbital Trauma
• Acute Retinal Detachment
• Chemical Burns• Alkali worse than acid
History is Key
• SymptomSymptom ThinkThink
• ItchingItching AllergyAllergy
• Scratchiness/ burningScratchiness/ burning lid, conjunctival, lid, conjunctival, corneal disorders, corneal disorders, including foreign body, trichiasis, dry eye including foreign body, trichiasis, dry eye
• Localized lid tendernessLocalized lid tenderness Hordeolum, Hordeolum, ChalazionChalazion
• Foreign Body Sensation Foreign body, Foreign Body Sensation Foreign body, rule out traumarule out trauma
History is Key
• SymptomSymptom ThinkThink
• Intense deep painIntense deep pain Iritis, scleritis, Iritis, scleritis, sinusitis, acute glaucomasinusitis, acute glaucoma
• PhotophobiaPhotophobia Corneal abrasion, Corneal abrasion, iritis, acute glaucoma iritis, acute glaucoma
• Halo VisionHalo Vision Acute glaucoma, Acute glaucoma, corneal edemacorneal edema
• Floaters, halos, lines Retinal Floaters, halos, lines Retinal Detachment Detachment or “veil” visual loss or “veil” visual loss
Exam
• Visual acuities
• Gross Examination
• Proptosis, EOM, lid malfunction
• Lids/Lashes (evert)
• irregularities in pupil size or speed of reaction (APD, anisocoria)
Exam• Examine Anterior to Posterior on Slitlamp
• Conjunctiva (palpebral & bulbar) for injection, discharge (scant/profuse; purulent/serous)
• Corneal irregularities, opacities, foreign bodies
• Iris and lens, noting depth of anterior chamber, pupillary anomalies
• Measure intraocular pressures with Tono-pen if indicated
Exam
• Fluorescein stain and Examine with Cobalt Blue Light
• “streaming” on Seidel test- Penetrating trauma
• corneal abrasion or ulcer
• Dendrites- herpetic keratitis
Eye Disorders Anatomical Approach
• Lid Disorders
• Conjunctivitis/Corneal Disorders
• Uveitis/Iritis and Glaucoma
• Retinal Disorders
• Systemic Disorders
Lid Disorders
Hordeolumstaph infection glands of
Zeiswarm compresses and topical abx
Chalazion Meibomian gland infection same
BlepharitisStaph or seborrhea of the lid margin
same + lid scrubs with baby shampoo/H2O
Corneal Lesions
• Conjunctivitis
• Localized Opacities
• Generalized Haziness (corneal edema)
• Keratitic precipitates
Conjunctivitis
Chemical Allergic ViralBacteria
l
History exposurehay
fever, asthma
ill contacts
Distribution
depends bilateralmore often bilateral
often unilater
al
Discharge Clear Mucous Clear Purulent
Treatment FLUSH!!!
anti-histamine
s, systemic + gtt
symptomatic (except with Herpetic Keratitis
-> can result in vision loss)
Abx (Ocuflox
, Polytrim
)
Neonatal Conjunctivitis
Type Gonococcal Chlamydia
Onset 48 hours post-partum4-7 days post-
partum
Signs/SxsSevere purulent dc,
chemosis
pseudomembranes, less purulent, eyelid edema
Dx Gram stain Giemsa, ab stain
TreatmentSystemic CTX, PCN G, Top Erythromycin
Topical and oral erythromycin; Treat parents
too!!
Chemical Injury
• Strong bases more dangerous than strong acids, as is progressive
• Treatment is copious irrigation with NS, towards temple away from unaffected eye, and under lids
• Check pH with litmus, and irrigate until pH neutralized
• If obvious damage, emergent ophtho referral
Corneal Ulcer•Always urgent referral•Often have trauma history, contact lens users•Suspect fungal infection if trauma with organic matter•Culture and gram stain•Antibiotics +/- antifungals
Herpes Keratitis
Herpetic Dendrites•may have ulcers/vesicles•can result in visual loss•urgent Ophtho referral•Treatment: topical and systemic antivirals
Uveitis/Iritis• Keratitic precipitates
• Cellular deposits on cornea found in iritis (anterior chamber inflammation), along with “cell and flare”
• Idiopathic, traumatic, or associated with systemic disease
• Urgent referral
• Treatment differs on type of iritis/uveitis- steroids and cycloplegics
Chamber Anatomy• Aqeous humor from ciliary process (post chamber) through pupil to ant chamber
• Drains through trambecular network into Canal of Schlemm, and to scleral plexus
Acute Angle Closure Glaucoma
•Etiology: Contact between the iris and trabecular meshwork, obstructs outflow of aqueous humor
•Symptoms: Intense eye pain, blurred vision, halos, HA, vomiting, photophobia• Findings:
• Pupils mid- dilated and unresponsive• Scleral injection• Corneal edema•EMERGENT REFERRAL!!!
Pupillary Abnormalities
• Unaffected in conjunctivitis
• Constricted, possibly irregular in iritis due to spasm
• Fixed and mid-dilated in acute angle closure
• Can be irregular in penetrating trauma
Preseptal Cellulitis
• Soft tissue infection ANTERIOR to orbital septum
• Possibly secondary to sinus infection, trauma or simple cellulitis
• Consider CT scan orbit to assess for orbital cellulitis, subperiosteal or orbital abscess
Preseptal Cellulitis
• Treat with IV antibiotics (Unasyn)
• Admit moderate to severe for observation and to ensure no progression
• 12 Hour recheck for mild disease
Orbital Cellulitis• Differentiate from preorbital cellulitis: • proptosis• impaired motility (pain)• decreased vision• optic disc edema• afferent pupillary defect
• Complications• Meningitis in ~ 2%• Cavernous sinus thrombus• Optic nerve damage
Eye Trauma
• With any history of eye trauma, must rule out penetrating globe injury
• Seidel’s test is positive if streaming fluoroscein
• Do not put pressure on globe...stat ophtho consult if positive test
Eye Trauma “Bloody Eye”
Subconjunctival Hemorrhage
•Resolve Spontaneously•No treatment needed
Hyphema•Blood in anterior chamber•Emergent/Urgent referral
Retinal Detachment
• Separation of neurosensory retina from retinal pigment epithelium
• Multiple Etiologies• Rhegmatogenous • Tractional (including trauma)
• Exudative
Retinal Detachment• Symptoms
• Flashes (photopsia), floaters, loss of peripheral vision
• Signs
• Afferent pupillary defect
• Lower IOP
• Vitreous opacities
• Convex corrugated/undulating surface