Casualty

What conditions to expect

How to get help

History

Examination

Common (less serious) conditions

Rarer but more serious conditions

Helpful websites

The Eye in Casualty: a seminar

What conditions to expect: working in pairs, (2 minutes) think of:

• Common (less serious) conditions, e.g.

• Rarer but more serious conditions

If time, work out how you would refer, treat

Feedback…………what conditions to expect

• Common (less serious) conditions, e.g.– Conjunctivitis– Corneal abrasion– Foreign body– Blunt eye injury

• Rarer but more serious conditions– Acute glaucoma, acute uveitis– Central retinal artery occlusion– CVA– Giant Cell arteritis– Papilloedema– Retinal bleeding: maculopathy or diabetes– Severe trauma

• Common less serious– Conjunctivitis---------------– Corneal abrasion-----------– Foreign body---------------– Blunt eye injury------------

• Rarer serious conditions– Acute glaucoma,

acute uveitis– Central retinal artery occln– CVA-------------------------– Giant Cell arteritis---------– Papilloedema---------------– Retinal bleeding:

maculopathy or diabetes– Severe trauma--------------– Orbital cellulitis-----------

again in pairs, (2 minutes) think of best method of referral/treatment

• Common less serious– Conjunctivitis---------------– Corneal abrasion-----------– Foreign body---------------– Blunt eye injury------------

• Rarer serious conditions– Acute glaucoma,

acute uveitis– Central retinal artery occln– CVA-------------------------– Giant Cell arteritis---------– Papilloedema---------------– Retinal bleeding:

maculopathy or diabetes– Severe trauma--------------– Orbital cellulitis-----------

– diagnose/treat– diagnose/treat– diagnose/treat– diagnose/treat/refer

– diagnose, refer urgently

– diagnose, refer urgently– diagnose, refer urgently to RMO– diagnose, refer with diagnosis– refer to neurosurgeon (?via RMO)– diagnose, semi-urgent referral

– diagnose, start treatment, refer urgently

– urgent RMO/paediatrician

Feedback answers

Referral: severe problems/out of hours, Eye Casualty, City Hospital

Immediate

Chemical burn, plaster under upper lid

Irrigation+++

refer

Refer asap (even at night)

Severe trauma

GCA

CRAO

Acute glaucoma

Orbital cellulitis (to paediatrician for IV Rx?)

Trauma: examine gently/carefully

ESR

Hours (if present after 11pm, best to seek advice, some seennext morning)

Retinal detachment

Hypopyon uveitis

Corneal abscess

Most milder uveitis present in evening can be treated next day

Refer to eye clinic or to GP

(optometrist should check?)

Retinal vein occlusion

Macular haemorrhage

(Cataract

Dry eyes)

Treat in

A & E

•Conjunctivitis

•Corneal abrasion

•Foreign body

•Sub-tarsal

•Lid infections that may need flucloxacillin

Referral: severe problems/out of hours, Eye Casualty, City Hospital

Immediate Refer asap (even at night)

Hours (if present after 11pm, best to seek advice, some seennext morning)

Refer to eye clinic or to GP

(optometrist should check?)

Treat in

A & E

Chemical burn, plaster under upper lid

Severe trauma

GCA

CRAO

Acute glaucoma

Orbital cellulitis (to paediatrician for IV Rx?)

Retinal detachment

Hypopyon uveitis

Corneal abscess

Retinal vein occlusion

Macular haemorrhage

(Cataract

Dry eyes)

•Conjunctivitis

•Corneal abrasion

•Foreign body

•Sub-tarsal

•Lid infections that may need flucloxacillin

Irrigation++++

refer

Trauma: examine gently/carefully

ESR

Most milder uveitis present in evening can be treated next day

Will be many conditions you’re unsure of. Exclude more urgent problems; ring for advice.

History

Later………., as we go along

Examination

• Lids• Everting upper lid• Visual acuity • Visual fields• Pupils• Conjunctiva• Anterior chamber…later• Red reflex• Discs• Eye movements…later if time

Lids

• Pain & redness = inflammation

• Severe swelling = ? Orbital cellulitis

Lids: evert upper lid

Evert lid with cotton bud

Visual acuity

TNCEN

OTNC

LOXEWTYURNG

TYURNG

TYURNG

6/606/36

6/24

6/18

6/12

6/9

6/6

6/5

Visual fields

paper

Pupils

Red reflex

Check red reflex from 10 cm, focusing on iris

Check discs & retina

• Dim light• pupils, eyelids, red reflex • Patients look in distance, 15o up• Try not to obstruct sight in other eye,

otherwise examined eye will move.• Look 15o medially, to see the optic nerve first.• Going close increases field of view• Optic nerve first• Move along vessels• Find macula last (this will make pupils small)• Dilating pupil makes examination easier,

quicker and more complete. But it is time consuming, and is rarely needed to exclude papilloedema .

Examination……….in pairs, 5 minutes

• Eye movements

• Fields

• Pupils

• Red reflex

• discs

Slides, with a few questions

Lids

Conjunctivitis

Foreign body & cornea

Anterior segment (uveitis/glaucoma)

Retina

Optic nerve

Major trauma

Previous eye surgery

Give out quiz for later, in pairs, 2 minutes, what is the treatment/plan

Corneal abrasion Diagnose how…………

treat…………………

Foreign body Diagnose how…………


iritis findings……………………….

Refer? …comments……………

Acute glaucoma findings……………………….


Chemical burn Treat…………………………….

Which is worst chemical…………..

Lids

A chalazion

some ‘point’ with pus needing draining: some lid infections need systemic antibiotics

Severe infections like this orbital cellulitis need admission (often under paediatricians) and IV antibiotics

Corneal abrasion

Staining with fluorescein drops shows any active corneal lesion

Foreign body

Foreign body/rust

entropian

Foreign body

Foreign body & fluorescein drops

•Fluorescein drops do not sting and are comfortable for children (all other drops sting).

•Arc eye: wake up with pain at night, due to an ultraviolet (welding) flash earlier in the day.

Conjunctiva & anterior chamber

Conjunctivitis

No pain

Watery eye

Gritty, something in eye

Iritis/acute glaucoma

Achy eye

Tender

% fixed/sluggish pupil

Glaucoma..eye hard

Conjunctivitis

Conjunctivitis: no pain, red eyes, irritable, watery/ thin discharge (viral), itchy (possible allergic).

Conjunctivitis

Thick discharge = bacterial conjunctivitis

Treatment foreign body/conjunctivitis

Remove foreign body

Fluorescein excludes corneal ulcers

Chloramphenical drops qid (ointment tid), mild cases

Severer cases 2 hourly drops

Conjunctivitis is very infectious

Refer severe cases

Examples of nastier corneal problems

•Dendritic ulcer (acyclovir x5 day x 10d)

•Corneal abscess

•Giant papillary conjunctivitis

•pterygium

Pain & irritation

Ache Inflammation

(acute glaucoma, iritis, episcleritis etc)

Gritty scratchy eye, as though there is something there

Foreign body/abrasion/ulcer (=uneven surface)

Watery red eye

No pain

conjunctivitis

Severe knife like pain trigeminal neuralgia, spasms: history important

Iritis

• Achy eye, misty vision,

• Previous attacks lasting weeks, HLA B27 symptoms= iritis

Ciliary injection

Iritis cont.

‘dust’ particles = cells

‘smoke’= protein

Hypoyon in severe uveitis

Iritis cont.

Iritis cont.

Dilating pupil reveals adhesions: = posterior synechiae

Acute glaucoma

• Achy eye, misty vision

• Previous mild episodes with haloes

• Pupil fixed (sluggish), semi-dilated

• Eye feels hard

Press eye with 2 fingers..Try this on your own eye

normal shallow anteriorchamber

Acute glaucoma cont

Acute glaucoma cont (2)

Complete quiz now, in pairs,











feedback answers











History, pain, scratchy: examn chloramphenicol drops qid

History, pain, scratchy: examn chloramphenicol drops qid

Medical history, ache, misty vision, examn, : ciliary injection

Ocular history, ache, nausea, abdo pain, headache misty vision, examn, : semidilated, hard eye

Irrigate, fluoresceinammonia>alkalli>acid

Posterior segment: vision affected

Symptoms

Central vision

Central visual changes suggest macular disease: refer to Eye casualty same week

Sudden, most of sight, or part

TIA: retinal emboli, central/branch retinal artery occlusion

retinal artery occlusion

If within 3 hours of onset, can dislodge clot

(massage, IV diamox, AC paracentesis)

Refer ASAP, aspirin

ESR (10% are GCA)

Loss of sight over weeks/days/hours

• Retinal detachment, with flashes/floaters

• Ischaemic optic neuropathy (older patients)(%GCA with GCA symptoms)

• With pain on movement: optic neuritis (younger patients)

• Retinal vein occlusion

• Eye conditions: may lose top/bottom half of sight

Retinal detachment

1. Vitreous gel liquifies (floaters)

2. May pull retina if attached (flashes)

3. Causes a hole

4. Fluid enters hole

5. Retina peels off (more floaters, vision affected)

6. Dilate pupil, with careful look usually obvious, refer same day

Loss of sight over months

• Cataract

• Many other problems, dilate pupil…………

• red reflex

• Retina

• discs

Visual symptoms: quiz, in pairs, 2 minutes, what are the causes……….

Misty vision Aches…………

No ache…………………

Sudden onset visual loss ………………….

Specific symptoms Give examples……………………….

Loss of sight on one side What may be going on?………….…………………………………….

Episodes of visual loss ………………………………….Clues…………………………..

Blurred vision with flashes and floaters

……………………………….

Visual symptoms

Misty vision

If eye aches, acute glaucoma/uveitis

No ache, cataract/retinal disease etc

Sudden onset visual loss

Vascular

Specific symptoms

E.g. GCA, optic neuritis, HZO

Loss of sight on one side Differentiate eg right side of BOTH eyes (CVA), or ONE eye alone (eye disease)

Episodes of visual loss

TIAs: occur suddenly, resolves over minutes

Blurred vision with flashes and floaters

retinal detachment/vitreous haemorrhage

Eye general health: 1

• What is the history?– Vomiting

– Nausea

– Stomach not tender

– Headache?

– Sight GOOD

– Papilloedema

– Refer to RMO/neurosurgeon

healthy

• Loss of sight 2 days ago, one eye• Headaches 1 week• Shoulder pains months• Weight loss months• Jaw aches eating• unwell months• Test needed:• ESR high• Giant cell arteritis• (if eye OK, refer to RMO)


• Episcleritis• Scleritis• No steroid drops from casualty• Herpes zoster:

– IV antiviral if immunosuppressed


Eye & major trauma

Birmingham and Tamworth are increasingly violent. A careful eye exam will exclude problems. Sometimes the eye is impossible to examine (as lids are shut). Refer/ask on-call eye SPR to assess. Causes: fist, glass bottle, car windscreen.

Eye & major trauma: perforating

glass bottle, car windscreen, dart

Tetanus, antibiotic, refer (ring first), starve for operating

theatre

Eye & major trauma: blunt

Fist, foot, squash ball: blunt eye injury, refer many

Hyphaema:

% retinal detachment also

Eye & major trauma: blunt cont.

Fist, foot, squash ball: orbit injury

Double vision:

Globe itself fine, but floor of orbit fractured, and inferior rectus muscle tethered = blow out fracture

Eye & previous eye surgery

There are many possible problems after ocular surgery: refer, sometimes urgently

Visual fields

• Common conditions less serious, need to treat (includes antibiotics, chloramphenicol)

• Serious conditions: history provides a clue, but a careful examination through a dilated pupil and ophthalmoscope excludes most major pathology

• Generally provide an escape plan “see your doctor if it does not get better” etc

• Serious conditions always need expert advice

• Only really ‘immediate’ action is for chemical burn such as plaster under the lids…irrigate profusely.

• ASAP retinal artery occlusion, GCA

• Within hours..acute glaucoma

• Retinal detachment same day, operation next day often

• Many ‘none’ urgent conditions present; local optometrists help with less urgent

• RMO or nursing colleague can provide useful advice, as can on-call time in Eye Casualty

Summary

Casualty

Health & Medicine

Transcript of Casualty