Ocular emergency & differential diagnosis

Dr.Bakhtiar Q.Hamasalh Jaf

Ocular emergencies these require urgent consultation to an ophthalmologist

• gonococcal conjunctivitis

• corneal ulcer• acute iritis• acute angle closure

glaucoma• trauma, especially

intraocular foreign bodies, lacerations

• chemical burns• orbital cellulitis• central retinal artery

occlusion (CRAO)• retinal detachment• endophthalmitis• giant cell arteritis

conjunctivitis

corneal ulcer

• is a condition in which there is destruction of some portion of both the epithelium and the underlying stroma of the cornea.

• Clinically it appears as a saucer-shaped yellowish grey pit, which stains green with fluorescein

Acute congestive angle-closure glaucoma

• Severe corneal oedema • Complete angle closure( Shaffer grade 0)

• Dilated, unreactive, vertically oval pupil

• Shallow anterior chamber

• Ciliary injection

Signs

Treatment of Acute Congestive

Angle-Closure Glaucoma

2 .Hyperosmotic agents - if appropriate• Oral glycerol 1-1.5 g/kg of 50% solution in lemon juice• Intravenous mannitol 2g/kg of 20% solution

3 .Topical therapy• Pilocarpine 2% to both eyes• Beta-blockers• Steroids

1 .Acetazolamide 500 mg i.v.

4 .YAG laser iridotomy• To both eyes when cornea is clear

Acute Endophthalmitis

Endophthalmitis is a purulent inflammation of the entire uveal tract, although the adjacent tissues may be secondarily affected.Symptoms.—The patient usually complains of severe irritation in the eye, though pain is not very marked. Excessive lacrimation, photophobia and marked-diminution of vision are very common.SignsThe eye is severely injected and red.The conjunctiva becomes chemotic.Keratic precipitates on the back of the cornea.The aqueous becomes turbid with many cells circulating through it

Treatment

• Intensive local and systemic antibiotic therapy must be given.

• Local atropine, steroid and application of_heat are very useful.

• systemic steroid in an attempt to suppress the inflammatory reaction.

• Vitrectomy and intraocular injection of antibiotics, e.g. gentamycin may become sight saving therapeutic regimen.

• When perception of light is lost, enucleation of the eyeball should be consider

PANOPHTHALMITIS• intense purulent inflammation of the three coats of the eye. The

eyeball is filled with pus, and the entire uveal tract is infiltrated with inflammatory cells, mainly WBC

• Symptoms.—The symptoms are usually severe :1. Fever and general febrile symptoms. 2. Headache and vomiting. 3. Severe pain in the eye. 4. Complete loss of vision.

• Signs.— : - Swelling of the eyelids with intense congestion of the eyeball. A small degree of proptosis. Chemosis of the conjunctiva. Haziness of the cornea.Anterior chamber and vitreous filled with pus.Loss of accurate projection of light, due to retinal detachment.The eyeball may finally perforate or the pus may escape through the anterior ciliary region and eventually the eyeball shrinks.

Treatment

• early use of intensive systemic and local antibiotic may prevent the panophthalmitis.

• treatment may be supplemented with systemic steroids to reduce inflammatory reactions.

• The administration of analgesics to control pain, and the application of local heat to improve the blood flow are usually recommended in severe cases.

• Loss of light perception is an indication for evisceration of the eyeball.

ORBITAL CELLULITIS : is an acute inflammation of the fatty-cellular tissue of the orbit.Etiology : spread of infection from the neighbouring sinuses especialy ethmoid,erysipelas of the face, lacrimal abscess, stye or suppurating chalazionClinical Picture: General.—Fever, malaise and prostration , cerebral symptoms.Ocular.:(a) Severe pain in the orbit which increases during ocular movements.(b) Lid oedema, (c) Chemosis of the conjunctiva.(d) Proptosis which is axial and irreducible.(e) Limitation of ocular movements usually in all directions causing diplopia.(f) Fundus examination :engorged retinal veins & papillitis

Treatment of Orbital Cellulitis swab of conjunctival sac for culture and sensitivity. Vigorous systemic and local use of broad spectrum antibiotic drugs. Local heat by frequent hot bathing is very beneficial. If abscess formation is suspected, early incision is recommended.

Ocular Injuries

• Chemical injuries• Thermal injuries.• Mechanical injuries:

• Blunt trauma (Non-penetrating ).• Penetrating trauma

Anterior SegmentPosterior SegmentAdnexaOrbital Structures

• Anterior Segment– Conjunctiva– Cornea– Iris– Lens

• Posterior Segment– Vitreous– Retina– Optic nerve

• Orbital Structures– Extraocular muscles– Bony walls

• Blow out fracture

Trauma to conjuctiva

Subconjunctival Hemorrhage ?

Corneal FB

• Types of FB– Inert– Irritent– Organic

• Managment

• Anesthetize eye• Remove FB

– Cotton swab (don’t worsen abrasion!)– Kimura spatula– needle tip

Foreign Body Treatment

Hyphema

HyphaemaTrauma

closed penetratingPost-surgical anterior chamber IOL implantationtumours

retinoblastoma iris tumours

juvenile xanthogranuloma.Rubeosisdiabetic retinopathy,central retinal vein occlusion,chronic ocular ischaemia,sickle cell disease, absolute glaucoma,intraocular tumour.

Orbital Wall Fracture

• IRRIGATE• Check pH• Minor

– E-mycin ointment– 1 day follow-up eye doc

• Major– Same day eval by eye doc

Chemical Treatment

• Moderate blunt injury• Photophobia• Lid bruising/edema• Subconj heme or injection• Pupil sluggish• Eval by eye doc

Traumatic Iritis

CENTRAL RETINAL ARTERY OCCLUSION CRAO

Etiology: 1.Spasm of the arterial wall, generally hypertensive in origin.2. Embolization is the most common cause of obstruction to

the retinal circulation from : vegetation in SBEC Degenerative changes of arterial wall e.g.

arteriosclerosis or atherosclerosis

3. Inflammation of the vessel wall, e.g. giant-cell arteritis.

Clinical feature of CRAOSymptomsComplete occlusion: of the CRA results in sudden and

complete blindness (NPL). Branch occlusion: produces localized effects confined to the

area of the retina supplied by this branch.Signs of Arterial Occlusion

-milky-white appearance of the retina and cherry-red spot at the macula.

-retinal arteries are attenuated and the veins are slightly filled with blood.

-vision rapidly diminishes to just perception of light ("P.L.") or complete loss of vision ("N.P.L.").

• Prompt & urgent treatment is essential. treatment is effective only if given within the first few minutes of occlusion.. Attempts urgently to relieve any arterial spasm or to dislodge the causative embolus into a less important branch. No return of good central vision if the obstruction lasted over 6 hours. Blindness always occurs if the obstruction has lasted for 24 hours.

Treatment

central retinal vein occlusion -Etiology1. Arteriosclerosis and hypertension in elderly people2. Increased blood viscosity, as polycythaemia.3. Diabetic retinopathy causing phlebosclerosis and sluggish

capillary and venous4. Infective phlebitis.5. The infiltration of the wall of the vein by leucocytes leading to

narrowing of the lumen of the vein or to clot formation. 6. Pre-existing chronic simple glaucoma.7. An orbital cellulitis may damp the venous return from the eye.

-usually middle-aged and arteriosclerotic -sudden diminution of vision down to PL or HM-positive central scotoma.-defective vision is often noticed by the patient when waking up in the morning, because the occlusion often takes place during sleep when the circulation becomes sluggish, the general blood pressure is lowered.

Symptoms of Venous Occlusion

Signs of Central Retinal Vein Thrombosis• no external signs except that the pupillary

reaction to direct light may be a little sluggish.

• ophthalmoscopic picture is very characteristic :

The fundus appears splashed with haemorrhages radiating from the disc in all directions. The retinal veins are grossly distended and tortuous. and patches of white exudates.

• The arterioles are slightly narrowed and may be concealed by oedema and haemorrhages. Patches of white exudate may appear among the haemorrhages.

• The treatment• The primary systemic causative conditions

should always receive appropriate attention. Unfortunately, there is no effective treatment once the blockage has become fully established. If the patient is seen within a few hours of the onset of symptoms,

the administration of anticoagulants may be effective in maintaining the circulation and preventing the spread of the thrombotic process. Steroids

If fluorescein angiography reveals widespread capillary occlusion and retinal ischaemia, panretinal laser photocoagulation is of benefit in treating the retinal complications of the ischaemic response and aborting the development of neovascular glaucoma and rubeosis iridis.

RETINAL DETACHMENTRetinal detachment, or more accurately retinal separation, is a condition in which the sensory retina is separated from the underlying pigment epithelium at the line of cleavage between the layer of visual receptors and the pigment epithelium, with an accumulation of fluid in the potential

space between them.The fluid may accumulate between the sensory retina and the retinal pigment epithelium by any of the following

mechanisms:

Differential diagnosis of ocular and visual symptoms

Visual symptoms

Poor distance visual acuity

Uncorrected refractive error, especially myopiaKeratoconusMedia opacityAmblyopia (lazy eye) stimulus deprivation anisometropic strabismicOptic neuropathy Maculopathy Albinism

Night blindness (nyctalopia)peripheral retinal degenerations,nutritional (vitamin A deficiency, dietary/absorptive defect),congenital stationary night-blindness (CSNB),advanced glaucoma,following extensive laser PRP,juvenile Batten's disease.Photophobiaanterior uveitis,anterior cortical lens opacity,albinism,achromatopsia,buphthalmos,drugs and toxins,psychogenic.

Transient monocular visual loss (amaurosis fugax)retinal arteriolar embolization: carotid atheroma other proximal arteriopathy (aneurysm, AV malformation, stenosis) cardiac arrhythmiapapilloedema (obscurations last a few seconds)giant cell arteritiselevated IOPaccelerated hypertension and eclampsia

Bilateral transient visual losssyncope,low output cardiac failure,cardiac arrhythmia.

Sudden monocular visual lossgiant cell arteritis (AION)central retinal artery occlusion,central retinal vein occlusion,vitreous haemorrhage,optic neuritis,toxic optic neuropathy (methanol, tobacco/alcohol, quinine),optic nerve trauma,retinal detachment.

Red eyeConjunctivitis Injection(entire conjunctiva), pain(itching, foreign body sensation), cornea(clear), discharge(purulent and mucopurulent), pupil(normal), vision(normal)KeratitisInjection(most intesely circumcorneal), pain(ache & foreign body sensation), cornea(cloudy), discharge(purulent), pupil(unaffected or miosed), vision(reduced)EpiscleritisInj.(deep to conj.), pain(pricking to mild ache), cornea(clear), no discharge, normal pupil & vision.Anterior uveitisInj(most intense circumcorneal), aching photophobia, cornea may be dull, no discharge, miosed or irregular pupil, normal or reduced vision.Acute glaucomaInj.( Most intense circumcorneal), severe pain, cloudy cornea, no discharge, fixed mid-dilated pupil, vision severely reduced.

References

Clinical ophthalmology KanskiParson’s diseases of the eye

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