On Call Survival Guide

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Ophthalmology

Survival Guide

2014-2015


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Introduction

No doubt about it, starting a residency is very difficult. As a new first-yearresident, the recurrent theme seems to be "I wish I had known this sooner"or "I wish someone had told me that." This guide is designed to do justthat. It is to be a quick stop for information. We intend for it to be as

concise and practical as possible. References are provided whenappropriate. Obviously, it is not complete by any stretch of imaginationand you will definitely need to consult the abundant reference materialsavailable in our great C.S. O'Brien Library. This is designed to be afoundation on which we hope you will build. We review the manual on ayearly basis in order to make it as up-to-date as possible. As you gothrough the year please, think about additions or deletions that may be

appropriate and suggest these changes for future editions.

Two key things to remember when youre starting call:

1)Dont blind anyone if you are ever unsure what to do (Should I goin or not?) err on the side caution. Just see the patient.

2)Youre never alone theres always back-up available. Every seniorresident has at one time been a first-year.

Welcome to Iowa! As you will soon find out, this is a great departmentwith a profound and far-reaching legacy of ground-breaking research andexcellent patient care. You are now a part of that family and werehappy to have you!

Iowa City, July 2014

Ophthalmology Survival GuidePage 2


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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



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Postoperative Troubleshooting ............................................................................................................................................................ 49

Things To Remember From Internship ................................................................................................................................................ 51

Driving with a Visual Impairment (as of 6/22/13) .............................................................................................................................. 52

Generic Names, Brand names & Cap Colors ....................................................................................................................................... 58

Abbreviations ....................................................................................................................................................................................... 59

Phone Lists ........................................................................................................................................................................................... 68

Basic Phrases In Spanish ..................................................................................................................................................................... 73

FAQ ..................................................................................................................................................................................................... 76

Notes .................................................................................................................................................................................................... 78



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UIHC Layout

The Buildings of the Hospital are in alphabetical order (by last name) from North to South.

Boyd Tower (BT) - aka General Hospital Elevators A, B, CRoy Carver (RC) Elevators D, EJohn Colloton (JC) Elevators F, G, HJohn Pappajohn (JP) Elevators I, JPomerantz Family Pavilion (PFP) 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 walkingdown 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 tothe "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 toElevator M in Pomerantz Family Pavilion.

Floor Elevator:

Burn Unit 8 JC G (H)

Call Room Ophtho 7 JC H

CT Scanner 3 JC H

CVICU 4 JC G (H)

East Room 8 JC D

ER 1 RC D

Main OR 5 JC/JP G (H)

Med Psych 4 SE (Gen. Hospital) C

Microbiology 6 BT A

MICU 5 RC E

Molecular Ophtho lab 4 Med Labs

MRI/Reading Room Lower Level JC G or FNeuro/Neuro-surg 6JCW G (H)

NICU 6 JP I

Ocular Path 2 MRC BB

Ophtho Inpatient 3 RC D (**There is a slit lamp on 3 RC, Room #2)

Peds Eye Inpatient 2 or 3 JCW G (H)

Pharmacy, Outpatient 2 PFP K

Pharmacy, Main 1 Gen Hospital C

PICU 7 JP I

Radiology Reading Room 3 JC F

SICU 5 JP I

Specimen Control 6 RC E

Main Cafeteria 1 Gen Hospital C

On-call room: 7404 JCP



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Driving Directions to UIHC

Driving distances, in miles, from regional cities include:

Des Moines: 110Chicago: 220Omaha: 245

Milwaukee: 260St. Louis: 260Kansas City: 290Minneapolis: 300

Driving from the North (Eastern Iowa Airport):

Take Interstate 380 SouthAt mile marker 0, Interstate 380 South becomes Highway 218 SouthTake Highway 218 South for 3 miles to exit 93 (Melrose Avenue)Turn left onto Melrose AvenueTake Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins Drive

Turn left onto Hawkins Drive, and the Hospital is immediately on the rightFollow signs to valet parking or appropriate parking ramp

Driving from the East (Quad Cities Airport):

Take Interstate 80 West to exit 242 (1st Avenue Coralville)At stoplight, turn left onto 1st AvenueTake 1st Avenue for 1.3 miles to 4th stoplight at 2nd Street (Coralville Strip)Turn left onto 2nd StreetTake 2nd Street for 0.4 miles to 1st stoplight at Hawkins DriveTurn right onto Hawkins DriveTake Hawkins Drive for 0.6 miles, and the Hospital will be on the left

Follow signs to valet parking or appropriate parking ramp

Driving from the South:Take Highway 218 North to exit 93 (Melrose Avenue)Turn right onto Melrose AvenueTake Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins DriveTurn left onto Hawkins Drive, and the Hospital is immediately on the rightFollow signs to valet parking or appropriate parking ramp

Driving from the West:Take Interstate 80 East to exit 239A (Highway 218)

Take Highway 218 South for 3 miles to exit 93 (Melrose Avenue)Turn left onto Melrose AvenueTake Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins DriveTurn left onto Hawkins Drive, and the Hospital is immediately on the rightFollow signs to valet parking or appropriate parking ramp



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On-Call tips: When seeing a patient

Patients call us because they are worried and in need of help. Listen to them carefully.

1. 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 tocome in right away.

2. Never hesitate to call for help.3. Document, Document, Document. Take photos whenever possible.4. Although there are many things wed rather do than be stuck on-call, it an amazing opportunity to learn.

5. Above all, help your fellow residents out whenever you can. Remember, we are in this together.

I. Telephone calls from patients

A. Identify

1. Chief complaint

2. Pertinent ocular symptoms

a. Visual change

b. Pain

c. Redness

d. Onset and duration

e. Discharge

B. General Rule: If in doubt, bring the patient in.

1. Good idea to offer to see all patients

2. "It is difficult to assess your problem without examining you. I would be happy to see you as soon as you can get here."

3. Obtain patient information (KEY!!)

a. Name (fullname, proper spelling)

b. Individual identifiers (D.O.B., Hometown, Hospital # if known)

c. Telephone number ask for cell phone if possible

d. Seen previously at this clinic? Attending?

4. Set a time for arrival/appointment. If urgent tell them to come immediately and not to eat or drink if symptoms suggest apossible retinal detachment/globe injury/need for emergent surgery.

5. Established patients may come directly to the eye clinic; patients new to UIHC must go to the ED first. Tell the patientthat the eye clinic will be locked. They will need to use the phone at the door to call the operator and ask for the eyedoctor on call.

6. Request medical records if last seen in pre-EPIC era.

a. Page 131-3292 and ask them to STAT charts to the eye clinic.

7. Document calls and follow-up plans for patients who cannot/will not come in that you feel need to be seen.

II. Telephone calls from outside physicians and ERs

A. Additional injuries? Is the patient stable?

1. Isolated globe trauma or eye problems decide if they can been managed in eye clinic or should be managed in ER.

2. Possibly unstable or other injuries transfer patient to UIHC through the ER. Facilitate communication between thereferring physician/ER and UIHC ER (6-2233) so transfer can be arranged and the patient accepted. Ask the ER topage you once the patient has arrived.

B. Obtain referral information

1. Physician name and phone number

2. Referring physician should be kept informed (dictated letter +/- phone call)

C. Request medical records (from transferring physician and old UIHC records as above)

D. Special instructions

Isolated open globe see Trauma section, open globe



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III. Seeing patients on call in the clinic

A. Make sure patient is stable take immediately to ER if unstable

B. Screen and take history

C. If situation is urgent and you need to dilate - check Va, Ta, pupils for RAPD, SLE for iris neovascularization, narrowangles first and then dilate before completing the history.

D. See the patient and form an assessment and plan before calling the senior resident

1. Do your best tough at first!!

2. Don't be afraid to call. If any questions, check with your back-up.

3. Early in the year, always run patients by the senior resident later you will be able to manage more on your own.All patients going to the OR must being admitted and need to be seen by the senior resident.

E. If things seem emergent or there has been a dramatic change in visual acuity call the senior resident right away beforedilation. They may want to come in to verify an RAPD early in the year.

F. If a patient appears surgical (i.e. open globe, canalicular laceration, lid margin laceration )

1. Call back-up early

2. Last meal?? - keep NPO

3. Tetanus

4. History and physical

5. Consent form

6. Call anesthesia for pre-op evaluation (131-3911)

7. Call OR for available time (3-6400)

8. Call bed placement (4-5000)

G. Admissions (corneal ulcer, endophthalmitis)

1. Call back-up early

2. History and physical; Consent

3. If the patient needs to be admitted post-op, get the admission orders ready

4. Call nurse supervisor (Adult: 131-3313; Pediatric: 131-3925) to arrange admission

H. CT/MRI/X-ray: For patients being seen in clinic1. Page the radiology resident on-call to ensure the proper protocol is being ordered

2. Put the orders in EPIC.

3. If giving contrast check BUN/Creatinine

4. Transport the patient to radiology

* If you know a patient may need imaging, it is sometimes helpful to have the patients come through the ER rather than clinic.

IV. Seeing patients on the floor or in the ER

A. Think about what you may need for your exam

B. Stock the call bag for your journey You should re-stock the call bag after each call and recharge instruments thatneed it. Place used instruments in the appropriate area in the nurses station. A comprehensive list of suppliesshould be located in the call bag to instruct you on what should be refilled / replaced. Remember to help each other outand to respect the call bag!!! Its home is in the room across from the nurses station.

1. acuity card

2. indirect ophthalmoscope

3. Finhoff with neutral density filters

4. tonopen and covers

5. drops fluorescein, proparacaine, tropicamide, phenylephrine (different if a childplease refer to page 48)

6. near card with +3.00 and +1.75 spherical lenses

7. 90/20 D lens

8. portable slit lamp

9. other supplies as indicated by consult



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C. Essential parts of your exam:

1. Check for RAPD

2. Visual acuity in each eye eye chart or near with appropriate add (loose lenses in call bag)

3. Motility

4. View of optic nerve and posterior pole

5. Ocular exam specific to trauma

a. sub-conj heme !360 SCH and you cannot see sclera be cautious of occult open globe

b. hyphema/hypopyon

c. iridodialysis, traumatic mydriasis

d. pigmented tissue visible anywhere

e. periorbital ecchymosis/edema (need for canthotomy/cantholysis!)

f. infraorbital paresthesia

g. orbital rim step-offs

h. lacerations

i. subcutaneous emphysema

j. telecanthus or rounding of medial canthus (medial wall fracture)

k. facial asymmetry

l. forced ductions if limited motilitym. if suspicious of an open globe do not check IOP

6. Find out what ENT, G-Surg, Neuro Surg, Ortho, etc. plan to do with a multiple trauma patient to coordinateservices and plan OR time if necessary.

7. Review CT scans

8. If the patient looks surgical and other services are moving fast, let the senior know right away. Otherwise, do theabove prior to calling the back-up.

V. Miscellaneous

A. Diurnal pressure checks

1. Glaucoma tech will notify you of diurnal curve patients

2. You are responsible for 7PM, 10PM, and 7AM IOP checks3. Communicate with your patient at the 7 PM check

a. Where to meet usually call from front door

b. "I'm on call and may be tied up, but will try to be as punctual as possible"

c. if you anticipate an excessive wait, call your back up

B. S/P vitrectomy patients

1. Retina fellow may call for IOP check

2. Communicate directly with the retina fellow on post-op patients

3. Never take lightly a retina patient complaining of head or eye pain! (May indicate endophthalmitis)

C. Retinal detachments, retinal holes, etc.

1. Call retina fellow pager directly for evaluation of definiteRD referrals after working it up. If unclear of what

youre seeing, call your senior first prior to fellow. Remember: the B-scan is your friend!



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On-Call tips: Documentation and follow up

A. Visit Types and Documentation

There are three types of patients seen on call with subtle differences in the way documentation is initiated and co-signed.

1. Clinic patients These are patients who have previously been seen in our department such as post-op patients who need to be seenafter hours. In order to document on these patients in EPIC, an encounter must be created by calling the ER at 356-2547. You willneed to tell the ER the patients name, MRN, faculty on call, and type of encounter comprehensive clinic. If the faculty on-call isnot a comprehensive ophthalmologist, the encounter may display the exam type of a sub-specialty such as neuro-op or peds.Sometimes, Kaleidoscope doesnt get initiated at all in this situation. Although the ER should be able to enter this correctly, I havefound that if you substitute a comprehensive faculty name when asked for the on-call doctor, the encounter almost always loadscorrectly. The appropriate on-call faculty will still need to sign the note so it shouldnt cause unnecessary liability.

To view the patients encounter after the ER has created it, open Patient Station in EPIC and then type in the patients MRN. Then,while in Pt Station, click on the newly created encounter.

You will now be able to enter a clinic note just as you would in general clinic using the ophthalmology exam and the comprehensiveclinic note template. There is an ophthalmology exam activity on the navigator bar on the left once you are in the patientsencounter. You can use this (just as you would in clinic), to enter your exam. Just be sure that when you select your consult notetemplate, that you select the eye Kaleidoscope consult note template to pull your in your Kaleidoscope exam information. This

should be used for consult notes as well.

Clinic notes will need to be co-signed. This will generally be directed to the faculty on-call unless you have spoken to a fellow orfaculty about the patient or the patient was seen or will be seen by a fellow or faculty within 24 hours.

2. Inpatient consults These are patients on the floor who have an official consult entered into EPIC. When you are paged aboutthese patients, you should remind the consulting team to enter an official consult order into EPIC. You will also want to ask if thesepatients can be dilated if needed. These patients may be found by using either Patient Station or the Pt Lists tab. Under the Pt Liststab, patients can be found by floor under System Lists -> Consults -> Ophthalmology

When the correct encounter is opened, click on the consult tab. Click Consult Note to open the clinic note text box. This prompts youto link it to the ophthalmology consult order if it has been placed.

The Consults SmartText should appear in the consult note. Choose Eye Consult Note from the list. Under Objective, select whetherthe exam was performed in the clinic or at the bedside. You can either free text an exam or type .eyeconsultinpatient for an examtemplate SmartPhrase. You can type F2 to quickly navigate through the blanks in the exam template.

Inpatient consults will also need to be co-signed using the same guidelines as for clinic patients. See the staffing section below formore information. It is a rule of thumb to discuss or email the senior resident about all inpatient consults since faculty will need to bemade aware of the consult. (Anytime you need to talk to faculty, the senior should be aware of the patient first.)

3. ER patients These are patients the ER is consulting you on OR patients our department have never seen before OR patients whoyou feel you may need ER assistance for things such as imaging, medication, sedation, or for security reasons.

*Hint Patients with Medicaid who are not from Iowa will not be covered and should be directed to an appropriate facility in their

own state.It is not your job to ask about insurance, rather make sure the call center transferring service looks into these details.

The ER will create encounters for these patients. If you are sending the patient to the ER, you should let them know bycalling 6-2547. These patients can be found by using Pt Station or Pt Lists under ETC.

*Hint To view the ER grease board, log in as ETC instead of Ophthalmology LIP, but always document as an Ophthalmology LIP.

An ER consult can be documented just like an inpatient consult. These notes must be cosigned as well. Many patients can becosigned by the ER attending unless the patient is to be seen by a fellow or faculty soon.



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*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 othersprefer 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 moresenior 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 typesof consult patients.

1. Complicated Complicated patients should be discussed or seen by the senior resident. It is our policy that faculty only becontacted 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 fellowdirectly regarding the staffing of complicated patients if the first year resident has become proficient in the examination of thatparticular 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 residentfeels 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 ifthey 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 subconjunctivalhemorrhage in a patient recently intubated on Coumadin. In these cases, it is often unnecessary for these patients to be staffed andalso 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 orderan 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 issometimes easier to email the ophthalmology schedulers ([email protected]). The nice thing aboutemail 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 emailuntil 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 areresponsible 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 tosee 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

- Notes should be completed shortly after seeing a patient on call.

- 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 beviewed by the senior resident from home, prior to completion



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- Telephone conversations should be documented under Telephone Encounters.

- Medication refills should be done under Telephone Encounters as well. Refills and new medications can often be sent using e-prescribe.

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 toKaleidoscope 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 useKaleidoscope. So until Kaleidoscope becomes available in the inpatient settings, you may for now use the consult template for seeinginpatients and ER patients without creating outpatient encounters. This way your consultants can easily find your note in the inpatientsetting.

In summary:Inpatient Consults

1. Template consult note2. Attending on call or fellow cosigner3. All inpatient follow-ups must be text templates or free text.

ER Consults

1. ER attending as cosigner2. Call scheduling or email ophthalmology schedulers to schedule follow-ups3. Consider follow up locally if patient has local eye care provider

After hours clinic visits

1. Call ER to create a visit (356-2547)2. Kaleidoscope or clinic note template where appropriate3. Attending on call or fellow is co-signer4. Call scheduling or email ophthalmology schedulers to schedule follow-ups.

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 thirdyear is and who the attending on call is sometimes become hazy when consultations are begun around 8AM. There is no officialpolicy 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 andfinish your evaluation prior to 9AM, the consult should get passed off to the day consult service for inpatients, or to the general clinicresident 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 orto 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 ophthalmicemergency that you are called with in the AM, you should definitely see the patient regardless of your pending clinical duties (adviseyour clinic attending of the situation though!), or ask your third year what to do if you have obligations you cannot miss.



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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 theattending who was on overnight directly to see how he/she would like it to be handled. They may choose to request that the consult bestaffed by someone else, but this decision does not involve you. If the patient will definitely require subspecialty staffing, contact thefellow on the respective subspecialty service instead of the on-call attending (after discussion with your third year).



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On-Call tips: Odds and Ends

II. Food

Dining Dollars: Ophthalmology resident physicians can utilize their dining support monies to purchase food in the cafeterias withtheir ID badges. The amount of food purchased and the time of day will be at the house staff members discretion, and if the pre-set 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 youindicate 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

Main Cafeteria (1RC): 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 ----- ------- -------

I. Parking

On weeknights, try to get your car from Finkbine early. It is best to head straight out as soon as you can after clinic (5:00pm) if you do not have conference or patients already coming.

The Hospital Cambus schedule: Night Pentacrest Schedule:

4:45-6:00 -- every 5 minutes 7:00-8:45 -- every 15 minutes6:05-6:45 -- every 10 minutes 9:15-12:15 -- every 30 minutes

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 apersonal 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 freeif you display your Finkbine card. Just write your name and card number (e.g. 1077) on you ramp ticket. If you don't have aFinkbine 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 thestaff in the parking ramp questioning this, you can direct them to the following number: 5-8312 (parking dispatch, which is open24-7). If you do this, you will not be charged. But if you are unlucky enough to have an early morning call patient that runs intothe 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 dayon 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 residentshave occasionally been ticketed for parking there if they stayed long enough. Also, it is best to tell the patients who are coming into park in the ramp (they will be charged). They can park under the awning out front at their own risk.



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Corneal Drawing



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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 andposterior 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 stainLeft, 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 Ophthalmol1977;95:1540-1542.



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Symptoms as a Clue To Cause of a Red Eye

Symptom Possible Cause

Itching Allergic conjunctivitis

Scratchy Sensation Dry eyes, foreign body in the eye, blepharitis

Burning Lid, conjunctival or corneal disorders

Localized lump ortenderness

Hordeolum, chalazion

Ocular PainIritis, keratopathy, glaucoma, scleritis, infection, orbitalcellulitis, corneal abrasions, myositis, optic neuritis

Photophobia Iritis, keratopathy, glaucoma, corneal abrasions

Mucoid discharge Allergic conjunctivitis, chlamydial infection

Watery discharge Viral conjunctivitis, chemical irritants

Purulent discharge Bacterial conjunctivitis, corneal ulcer, orbital cellulitis

The following is used with permission: van Heuven WAJ, Zwaan J.Decision Making in Ophthalmology: anAlgorithmic Approach. Mosby, 2000.



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Superfic ial Keratitis - Differential Diagnosis Based on Distribution



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Corneal Abrasion/ Foreign Body

History:Mechanism of injury/ Tetanus status

Exam:Va/ IOP/ Slit lamp/ Evert eyelids/ Inspect fornices/ measure dimension of lesion/ DFE

Ancillary Studies:If there is a potential of intraocular foreign body, think about Echo or CT scan (1.5 mm fine

cuts-0.006 mm3 metallic FB, 1.5 mm3 glass, may miss organic/wood)

Signs and Symptoms:Decreased Va; Photophobia; Cell & Flare; Corneal edema/ infiltration;

Management:Topical anesthetic will make life easy for everybody. Use lid speculum if necessary.

Abrasion:

Dirty (i.e. CL induced or from a tree branch, etc.)

No patching!

If there is infiltrate, treat as corneal ulcerIf there is no infiltrate, moxifloxacin or gatifloxacin QID at minimum, if bad Q1 hour

Consider cycloplegic (will aid in pain control)

Monitor daily until there is complete resolution. Consider steroid if lesion is in visual

axis only after the infection is adequately treated. (rarely starting steroid on call, first visit)

Clean

Be very cautious with using bandage contact lens, unless you want to be accountable dont risk it

Antibiotic coverage (usually as above Qday minimum)

Consider hypertonic NaCl drops or ointment for persistent or recurrent erosions

Foreign body:Irrigation:May want to try this first.Needle:Under low to medium magnification/ stabilize your hand/ needle is held parallel to corneal surface/bevel faces the practitioner.Burr:round metal head that spins to help remove FB also removes healthy stroma do not use over thevisual axis. This overall is less preferred to needle.Rust ring:Complete removal of a rust ring is not necessary and doing so may damage additional tissue. Ascells repopulate, the rust ring will move anteriorly and resolve.Post procedure Care:Antibiotic: fluoroquinolone qid to 6x/day+/-CycloplegiaNo patchingFollow-up in 1-2 days (most epithelial defects heal in 24-48 hours)

Patients Instructions:Signs and Symptoms of infection; discussion of safety goggles



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Corneal Ulcer

History:Trauma, previous corneal abnormalities, CL wear and details (type of lens, solutions, wear time, sleepin 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 andextent 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 badenough 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 loss1.5mm diameter ulcer, or any infiltrate with moderate to severe AC rxn, purulentdischarge, or involving the visual axis

Fortified tobramycin or gentamicin (15 mg/ml) q1hr alternating with fortified cefazolin (50 mg/m

or vancomycin (25 mg/ml) q1hrOr 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

3.Treatment can be adjusted according to the culture and sensitivity results. If improving, the antibioticregimen is gradually tapered.

4. If not, re-culture.



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If patient has a positive fungal corneal culture:

1. Make sure patient is on topical anti-fungala. topical voriconazole 1% q2h while awake x 1 week, then qidb. amphoteracin 0.15% as 2nd line (qid if donor rim culture positive, q1h if corneal culture is positive)

2. Make sure patient is on oral antifungal:a. voriconazole 200 mg bidb. fluconazole 200 mg bid as 2nd line

3. For EK (DSAEK/DMEK) patient: Follow-up with Cornea in 1 week for intracameral voriconazole

4. Email attending and fellow to inform them of the cutlure result

Fungal:

Natamycin (50mg/ml) gtt q1-2hr WA, q2hr at night

Amphotericin B(1.5mg/ml) gtt q1hr (good for Candida)

Itraconazole po 400mg loading dose then 200 mg qd

Miconazole or clotrimazole (1-10mg/ml) gtt q1hr (for Aspergillus)

Acanthamoeba:

Cholorohexidine (CHX) 0.02% gtt q 1hr

Polyhexamethyl biguanide (PHMB) 0.02% gtt q 1hrItraconazole 400mg po x 1, then 200 mg po qd

Herpes Simplex Virus:

Trifluorotymidine (Viroptic) 1% 9 times/day or Vidarabine (Vira-A) ung 5 times/day (can be very toxithe epithelium) or acyclovir PO 800 mg 5x/day or Valtrex 1000 mg TID

Herpes Zoster Virus: acyclovir 800 mg PO 5x/day; famciclovir 500 mg tid; or valcyclovir 1000 mg PO ti7 to 10 days. If severe acyclovir 5-10 mg/kg IV q8h for 5-10 days



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How to Culture a Corneal Ulcer

When to culture:

Infiltrate >1-2mm with an epithelial defect

Central or paracentral ulcers

Significant tissue loss

Presence of hypopyon

Unusual organisms suspected by history or examination Lack of response to empiric therapy

Postoperative eye

What youll need & where youll find it:

Please refer to eyerounds.org How to a Corneal Culturevideo 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 slideso Slide folder/holder

o Tube racko Sharpie (for labeling glass slides)o Lab slipso Specimen bagso Jewelers forceps

In any of the exam rooms, youll find:

o Topical anesthetico Calcium alginate swabso Tear strips

Set Up:

1. Gather all the supplies listed above2. 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 bag4. 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



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Procedure(see http://eyerounds.org/video/Cornea-Culture.htmtutorial by Dr. Chris Watts for more details)

Apply topical anesthesia

For each sample (other than HSV) saturate swab with TSB prior to scrapingo Each scraping should be used to inoculate only one medium

o None of these swabs are broken off in the media. Just swirl them around their respective tubes or streakon media.

First collect the samples for HSVo Hold tear strip with Jewelers and obtain a sample of patients tear film. Try not to touch theeyelid/conj/cornea. Does not have to soak the strip -> a little bit will do.

o Use cotton swab to sample ulcer, stir around in pink media, do not break swab in media.

Next, inoculate the blood and chocolate agar plates

o Streak the surface to produce a row of separate inoculation marks (Cs)o Do not penetrate the agar

Then, smear two slides for gram stain

Inoculate the 2 slant tubes

Finally, inoculate the 2 broth cultureso Transfer the sample from the swab into the broth by pushing the swab to the bottom of the tube

If Concerned about Acanthamoeba

Confocal prior to culture (debate if this needs to be done on-call)

In addition to abovementioned culture, perform epithelial scraping and place the scraping in small tube withSaccomano fixative

o Saccomano fixative is a green liquid above the sink in the confocal room

o Small tubes are above the sink too.o These get sent to PATHOLOGY, not micro. After hours leave in specimen pick-up.

Off to the Lab

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 startedon.



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Chemical Injury

Initial Therapy:Irrigation x 15-30 minutes using Morgan lens or until pH is normal (may require several liters).Outcome related toduration of contact between the chemical agent and the eye. Alkali usually worse than acidic.

Hint: compare pH paper result with your own tearsMay 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 Progestational

steroids

Doxycycline Citrate

Inflammation Strongly decrease Mildly

decrease

Mildly

decrease

Moderately

Decrease

Collagenase Mildly

Decrease

Strongly

Decrease

Strongly

Decrease

Mildly

Decrease

Epithelial

migration

No direct effect No direct effect No direct effect No direct effect

Collagen synthesis Strongly

decrease

No effect No effect No effect

Matrix remodeling Strongly decrease No effect No effect No effect

Neovascularization Mild

Decrease

Moderate

Decrease

No effect No effect



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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 3rdyear after confirmation of open globe

Things to be done while waiting for 3rdyear

- 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 3 rdyear 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

Full thickness, lid margin- close tarsal plate (5-0 vicryl)- vertical mattress sutures x 2 at lid margin

Lid laceration with canalicular involvement- confirm with probe or irrigation- suspect with any laceration medial to puncta- usually repair in the OR within 24-48 hours

- patient does not always need to go to the OR that night. Call plastics and discuss with them



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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 ifAfrican 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 isappropriate, 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 dailyin 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 both3. 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 weeksafter injury.



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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. 1999Sep-Oct;36(5):238-50. PMID: 10505828



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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 CEPost-traumatic

Contiguous infections2. 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/echoSigns 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 diagnosis2) Time to treatment (hence, do an efficient exam and get the antibiotics to the vitreous ASAP)3) Organisms

Acute post-operative: staph epidermidisDelayed post-operative: Propionibacterium acnesBleb associated: Haemophilus or Streptococcus speciesPost 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 themto tube the medications to tube station 510 (eye clinic by the nurses station)Gram stain and culture plates, Culture mediaFor vit tap use 25 gauge needleFor 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 subconjPCN allergic: Gentamycin 200 mcg/0.1ml

Pharmacy to call for Intravitreal antibiotics (once they are ordered in EPIC you also have to call the appropriatepharmacy): You can ask them to tube them to the appropriate location (eye clinic is tube station 510)ASC patients (M-F 6am-5pm) ASC 67813OR patients (M-F 6am-10pm) OR 36485ER patients (M-F 10am-6pm) ER 45228 (pg 4577)ER patients (M-F 6pm-10am, Sat/Sun) 7JP 64300All inpatients 4JP 67985Clinic patients Pomerantz 46902



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Post-Op PKP Management

MEDSPreop:If PKP alone, Pilo 1% and Quinolone x 3 q 5 min +/- AcularIf PKP/CE/IOL, then dilating gtts + Quinolone +/- AcularIntraop:

IV Solumedrol 250mg unless diabetic125 mg if mild diabetes (NIDDM) and check postop sugar or no IV steroidsSubconj Ancef 50 and Decadron 5 at end of case. Vanco if PCN allergicPostop:Start with Pred Forte 1% and Fluroquinolone 6x/day

POD#1:Make sure wound is Seidel neg and IOP is okayIf large epi defect, use BCL

POW#1:

If epithelium healed, d/c quinolone. If epitheliopathy or delayed healing, consider Doxy 100 mg BID for fewweeks.Check IOP/wound/pachy.If epi defect, return 1 week, if not, return 3 weeks.Decrease PF to QIDRemove sutures only if loose/broken.

POM#1:Surface should be ok.Measure pachy/IOP/KsTry MRx if you want

Cont PF QIDReturn 1 month.Remove sutures only if loose/broken.

POM#2:Surface should be ok.Measure pachy/IOP/KsTry MRx if you wantReduce PF to TIDReturn 1 month.Remove sutures only if loose/broken.

POM#3:Measure pachy/IOP/KsConsider selective suture removal based on Ks ONLY IF GRAFT HOST JUNCTION EDEMA IS GONE.Cont PF TIDUse Quinolone QID for 4 days if sutures are removed.If no sutures are removed, try MRx or wait for GHJ edema to resolve. Rtn 1-2 mo.If sutures are removed, return 1 month.



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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#16-18Can consider removing all sutures if there is problem (like really weird topography) especially if you areanticipating needing to do PRK or LASIK or AKs. By this point, you may have the patient see staff at UIHC ifnecessary. Patients that are 1-2 years can still have graft dehiscence at the slit lamp. So consent the patientbefore you do this.

Remember that contact lenses are your friend.

Remember that anisometropia can be fixed with piggyback IOLsWe do not cut back on PF at the same visit where we remove sutures b/c epi defects are a risk factor forrejection, so we stagger the two.Any problems, call the fellowsimple phone calls can save much time and pain.



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Classification of the Anterior-Chamber Angle

Spaeth System for Grading Angle Widths:

A (Anterior): iris inserts anterior to Schwalbes lineB (Behind Schwalbes line): anterior to posterior limits of the trabecular meshworkC (Sclera): posterior to the sclera spurD (Deep): into the ciliary bodyE (Extremely deep): into the ciliary body

Angular Width:Estimated angle (expressed in degrees) formed between a line tangential to the trabecular meshwork and a line tangential to the irissurface about one third of the way from the periphery

Iris configuration:F: flatS: steep curvature or bombeP: plateau

Van Herick System(good for estimate but you should do gonioscopy exam whenever possible)

Grade of angle Depth of peripheral chamber4 > corneal thickness

3 -1/2 corneal thickness2 corneal thickness1 < corneal thicknessslit Dangerously narrow



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from van Heuven WAJ, Zwaan J.Decision Making in Ophthalmology: an algorithmic approach. Mosby, 2000.

Used with permission from Mosby.



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Laser Settings:

Argon LPI Pretreat:Pilocarpine HCL 2% & Brimonidine Tartrate 0.2%, proparacaineSize: 50m Post-treatment:Check IOP one hour after procedureDuration: 0.02-0.2sec Rx:Prednisolone acetate (either 16d taper or QID x 4 days)Power: 1 W Follow-up:If needed in other eye: 2 weeks, otherwise 1 mo f/uWavelength: Argon blue greenContact lens: Abraham, Wise

YAG LPISize: FixedDuration: Fixed nanosecondsPower: 1-2mJWavelength: YAGContact lens: Abraham, Wise, Lasag CGI

ALTSize: 50mDuration: 0.1sec

Power: 200-1200mWWavelength: Argon green or blue-greenContact lens: Goldmann 3-mirror

SLT Pretreat:Brimonidine Tartrate 0.2%, Proparacaine HCl 0.5%Size: 400m Post-treatment:Check IOP one hour after procedureDuration: set Rx: +/-Prednisolone acetate (either 16d taper or QID x 4 days)Energy: 0.5-1.2mJ Follow-up:6 weeksWavelength: 532nm Nd: YAGContact lens: Goldmann 3-mirror or Latina

Argon Laser IridoplastySize: 200-500mDuration: 0.2-0.5secPower: 150-300mWWavelength: Argon blue-greenContact lens: None, Goldmann 3-mirror

Transpupillary CyclophotocoagulationSize: 50-200mDuration: 0.1-0.2secPower: 500-1000mW

Application: 3-5 per ciliary body processCircumference treated: Up to 180 degree



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EndophotocoagulationSize: Fixed 20-guage probeDuration: 0.1-0.2secPower: 500-1000mWApplication: 3-5 per ciliary body processCircumference treated: 180 degree-360 degree

Noncontact Nd:YAG Transscleral Cyclophotocoagulation

Size: Fixed 70mDuration: 10-20msecPower: 4-8 JApplications :32Circumference Treated: 360 degrees

Contact Nd:YAG Transscleral CyclophotocoagulationSize: Fixed, quartz probeDuration: 0.5-0.7msecPower: 4-9 JApplications:32

Circumference Treated: 360 degrees or 270 degrees, sparing superonasal quadrant

Contact Semiconductor Diode Laser Cyclophotocoagulation

Size: Fixed, quartz probeDuration: 2 secPower: 1750-2000 mWApplications: 17-24Circumference Treated: 270-360 degrees

Laser Suture LysisSize: 50m-100m

Duration: 0.02-0.05secPower: 250-500mWWavelength: Argon green, Krypton redContact lens: Hoskins, Ritch

Diabetic Retinopathy

PRP:Size: 200microns Superquad, 350microns Rodenstock, 500microns Pancake/GoldmannDuration: 20ms (titrate as needed)Power: 200mWIncrease: +50mW increments

Wavelength: Argon greenCL: Rodenstock, Pancake, Goldmann, Superquad

Macular Edema

Focal Laser:

Size: 50-200mDuration: 0.1secPower: 100mW



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Increase: +50mW incrementsWavelength: Argon greenContact lens: Goldmann, Yanuzzi, Pancake

Diffuse Macular Edema

Laser Grid Treatment:

Size: 100-200mDuration: 0.1sec

Power: 100mWIncrease: +50mW incrementsWavelength: Argon greenContact lens: Goldmann, Yanuzzi, Pancake

BRVO Macular Edema

Laser Treatment:Size: 100-200mDuration: 0.1secPower: 100mWIncrease: +50mW increments

Wavelength: Argon greenContact lens: Goldmann, Yanuzzi, Pancake

BRVO Neovascularization

Laser Treatment:

Size: 200-500mDuration: 0.1secPower: 200mWIncrease: +50mW incrementsWavelength: Argon greenContact lens: Rodenstock

CNVM

Laser PhotocoagulationSize: 200-500mDuration: 0.2-0.5secPower: 200mWIncrease: +50mW incrementsWavelength: Argon green, Krypton redContact lens: Yanuzzi, Pancake

Retinal Angioma PhotocoagulationSize: 200-500mDuration: 0.2-0.5secPower: 180mWWavelength: Argon green, Dye yellowContact lens: Goldmann, Rodenstock



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Retinal Telangiectasis Photocoagulation

Size: 200-500mDuration: 0.2-0.5secPower: 150mWWavelength: Argon green, Dye yellowContact lens: Goldmann, Rodenstock

Juxtafoveal Retinal Telangiectasis

Size: 50-100mDuration: 0.05-0.1 secPower: 150mWWavelength: Argon greenContact lens: Goldmann

Choroidal Cavernous Hemangioma Photocoagulation

Size: 300-1000mDuration: 0.2-0.5secPower: 150mWIncrease: +50mW increments

Wavelength: Argon green, Krypton red, Argon blue-green, Dye yellowContact lens: Rodenstock, Goldmann, Pancake

Retinal Break TreatmentSize: 200-400mDuration: 0.1-0.2secPower: 150mWIncrease: +10-20mW incrementsWavelength: Argon green, Krypton redContact lens: Goldmann, 4-mirror, Panfundus



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Guide to Fundus Drawing

Chart contains three concentric circles. Inner circlerepresents equator, middle circle represents ora serrata, and

outer circle represents region of ciliary processes. Band

between middle and outer circles is pars plana of ciliary body.

Small circle in center of chart represents disc.

(Right) Standard key to colors in fundus sketch.

Blue Detached retina

Macular edema

Retinal veins

Red Attached retina

Retinal arteries

Hemorrhage in retina

Red Lined With Blue Retinal BreaksBlack Retinal pigmentation

Choroidal pigmentation when seenthrough attached retina

Brown Choroidal pigmentation seenthrough detached retina

Green Opacities in media, includingvitreous hemorrhage

Yellow Chorioretinal exudation

The color concepts above apply to fundus drawings in EPIC.

On-call, you can use epic drawing tool or you can find fundus drawing paper at the retina front desk.

If you hand draw something on-call that you would like to include in the chart, put the patients sticker oridentifying information on the paper and turn it into the nurses station to be scanned.



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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 riskcriterion (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.

Early Treatment Diabetic Retinopathy Study (ETDRS):

A. Defined Clinically Significant Macular Edema (CSME):

1. retinal thickening within 500 mm (1/3 DD) of center or

2. hard exudate (HE) within 500 mm of center if adjacent to thickened retina or

3. retinal thickening at least 1 DA in size, at least part of which is within 1 DD of center

*Va is not included in the definition of CSME and FFA is not required for diagnosis but will aid treatment. Macular laser treatment in

CSME reduces risk of doubling of the visual angle over 3 year period. The goal is to prevent worsened not to improve vision in the

future.

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.

Diabetic Retinopathy Vitrectomy Study (DRVS):

Results:Type I diabetes with severe vitreous hemorrhage benefits from early vitrectomy (1-6 months afteronset of VH) as compare to late (1 year). No benefit for Type II or mixed.



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Bilateral Optic Disc Edema

Use papilledema only when secondary to elevated ICPSee images of papilledema grading posted by Drs. Pham and Wall on Eyerounds.orghttp://eyerounds.org/cases/papilledema-grading.htm

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 1(early disc swelling)

blurring of nasal border (obscured by swollen peripapillary nerve fiber layer) radial arrangement of nerve fiber layer is disrupted temporal margin is flat and distinct (especially within papillomacular bundle)

subtle grayish halo around disc with a temporal gap

Grade 2(early disc swelling)

elevation of nasal circumference blurring of temporal margin complete halo concentric or radiating retino-choroidal folds may be present

Grade 3(moderate)

elevation of temporal circumference

increased diameter of nerve head circumpapillary halo has irregular outer fringe with finger-like extensions elevated borders totally obscure >1 segments of the major retinal vessels

Grade 4(severe)

elevation of entire nerve with obliteration of cup OR compression of cup into a slit OR total obscuration of a segment of the central retinal artery or vein

Grade 5(severe - transitional stage towards progressive atrophy)

anterior expansion dominates over lateral expansion nerve assumes a smooth, dome-shaped protrusion narrow and smoothly demarcated halo major retinal vessels climb steeply over dome surface segments of vessels may or may not be obscured by overlying swollen axons



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from Lee AG, Brazis PW. Clinical pathways in neuro-ophthalmology: an evidence-based approach. Thieme, 1998



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Anisocor ia

Anisocoria that increases in dim light and diminishes in brighter light is either physiologic or caused byHorner'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.)



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Anisocoria that increases in bright light is indicative of a weak iris sphincter or parasympathetic lesion on theside 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 YearBook, 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



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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.



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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.



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Dilating a Child

Premies -- 2 months of ageCyclomydril (cyclopentolate/phenylephrine) 1 gtt x2, five minutes apartAvailable in the peds clinic and the NICU

2 months 1 yearCyclogyl 0.5% (cyclopentolate) 1 gtt x2, five minutes apart

+/- phenylephrine for dark iridesAvailable in the peds clinic and the NICU

Over 1 yearCyclogyl 1% (cyclopentolate) 1 gtt x2, five minutes apart+/- phenylephrine for dark irides

Using the Retcam

For call purposes, the retcam is generally used for photo-documentation of positive findings in pediatric consults,particularly non-accidental trauma

The retcam is located in the peds procedure room or the orthoptist office. The key to the room (your Z key will not work)is located in a small pull-out drawer to the left of Angelas desk.Make sure you have Genteal gel and proparacaine drops available.To turn on:

1. power button below central unit of the computer2. actual computer button3. light source to the camera

Password is: Retcam12 (case sensitive)Enter patient information, attending, select new session, ignore selecting eye, by convention start with OD first

Can save using either the foot pedal or with mouseEnd session and review to ensure images are adequate and saveYou will have to bring the RetCam to photography for them to transfer the images to OIS

** 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 ophthalmologytriage 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



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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 betweenattending so when in doubt ask senior resident or try to contact personally.

Cataract Extraction:

Be mindful of the possibility for endophthalmitis, elevated IOP, or ToxicAnterior Segment Syndrome (TASS)

Penetrating Keratoplasty: graft failure

Primary: occurs immediately post-op and reflects faulty donor tissue. High dosetopical 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 neverreport symptoms

Symptoms:decreased vision, mild pain, redness, photophobia

Signs:epithelial rejection line, sub-epithelial infiltrates, iritis (especiallywhen 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 ismore

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 medExamine patient and discuss with senior or retina fellow at minimum



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Plastics:

DCR/stenting:Ask the patient to tape the loose stent to the nose. Return to next plastic clinicConformers: 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 Testis your friend

Presentations Differential Diagnosis

High IOP/ flat Chamber

Aqueous Misdirection

Pupillary Block

Suprachoroidal Hemorrhage

High IOP/ normal ChamberTight suture

Acute angle closure

Low IOP/ flat ChamberWound/ Bleb leak

Over filtration

Post-op IOP spikes

Signs/symptoms:Painusually achy that radiates to brow or around eye or headache, nausea/vomiting, red eye, corneal edema (resolvesquickly with decrease in IOP), "halos" around lights from edema

Think etiology:Pupillary block (phakic or not?--if the patient is aphakic you could still potentially get block from the anterior vitreousface); related to surgery: hyphema, endophthalmitis, ciliary body swelling (retinal laser), silicone oil, ciliary body orchoroidal effusion; steroid induced --usually not before 3 weeks of use

Treatment:

Topicals:CosoptBrimonidine

Systemic:Diamox 500 mg not sustained release for acute, can switch to sustained release once IOP is under controlCan do IV if availableMannitol (20%) 1g/kg

Procedures:LPI indicated for papillary block only

Anterior chamber paracentesisBurp wound



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Things To Remember From Internship

(be thankful that we can consult services that manages these issues)

PainPOTylenol 500mg Q4-6 hours (limit 4g in a day)Tylenol with codeine Q4-6 hours up to 2 tabsOxycodone/acetaminophen = Lortab = Vicodin doses: 5, 7.5, 10 comes with 500 mg Tylenol 1-2 tabs q4-6 hours

Oxycodone 5-10mg Q4-6H (no Tylenol)Longer acting: MS Contin (long acting oral morphine)

IVMorphine 1-2mg Q2-4H, this is a small doseDilaudid (Heavy D) 0.5 to 1mg Q2-4H -- be carefulPCA (morphine then Dilaudid)

Nausea

Ondansetron (Zofran) 4mg Q4-8H PO or IV (efficacy of 4mg identical to 8mg)CompazinePhenergan (IV can cause severe ischemia/necrosis)Reglan (bowel motility agent)

Scopolamine patchDexamethasone (prior to leaving OR)

SleepBenadryl (watch out in the elderly) 25-50mg Q6H prnAmbien 5-10mg QHSTrazadone 25-50mg QHS

AgitationZyprexa (Zydis) 2.5-5mg Q6HQuetiapine (Seroquel) 50mg x1Lorazepam (Ativan) (Watch out in elderly) 0.5-1mg IVExtreme agitation: Haldol 5mg/Ativan 2mg IM

ConstipationColace/Senna (100mg BID/2mg Qday)de-bulker + motility agentMilk of MagnesiaMiralax or MetamucilDulcolax suppFleets or Tap water enemaMagnesium citrateGolytely

HyperglycemiaNovolog (good short acting) sliding scale (EPIC smartset under ISS)NPH (better basal insulin for acute setting than Lantus)

Hypertensionhome meds taken?IV for acute crisisB blockers -- labetalol, metoprololHydralazine -- 10mg IV push to start (seems to work better than metoprolol)

HypotensionIV fluids -- bolus NS (crystalloid) 500ml to 1L depending on cardiac and renal functionMay need to intubate to resuscitateICU if needed



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Driving with a Visual Impairment (as of 6/22/13)

Mark E. Wilkinson, O.D.Director, Vision Rehabilitation Service

UIHC Department of Ophthalmology and Visual Sciences

Almost daily, individuals with visual impairments confront eye care professionals with questions concerning operating amotor vehicle. These individuals fall into three categories:

Teenagers with congenital or acquired visual impairment

Adults with congenital or acquired visual impairment who have never driven

Adults with acquired visual impairment who will become non-drivers because of decreased visual acuity

Visual Field/Visual Acuity Standards for Driving

Illinois

Visual Acuity:

> 20/40 in one or both eyes No restrictions 20/41-20/70 in one or both eyes No driving when headlights are required

20/71 - 20/100 in one or both eyes 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 hadthe telescope a minimum of 60 days and has been trained to use thetelescope when driving- Requires a behind the wheel test- Must be approved by a medical review board- No night driving allowed with a bioptic telescope

< 20/100 in one or both eyes License denied

Visual Field: (uninterrupted is not specified) > 140 degrees binocular or monocular No restrictions

139 -105 degrees binocular with at least oneeye having a monocular field of at least 70degrees temporal and 35 degrees nasal Vehicle must have left and right outside mirrors

< 105 degrees binocular or monocular License denied

Illinois uses a vision standard for driving. This standard states that it is the individuals legal responsibility to notify theIllinois Secretary of States office within 10 days of becoming aware that they have reduced visual acuity or visual fieldlimitations that may disqualify them from further driving.

For additional information or to print a copy of the driving form:http://www.dmv.org/il-illinois/disabled-drivers.php#Vision-Impairments



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Iowa

Visual Acuity:

> 20/40 in one or both eyes No restrictions 20/41-20/70 in one or both eyes No driving when headlights are required

- Behind the wheel testing can be requested via discretionary reviewprocess to gain privilege to drive when headlights are required.

20/71 20/199 in one or both eyes Discretionary issuance- Requires a vision specialist statement indicating the individual isvisually 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 arerequired- If VA < 20/100, must also be approved by a medical review board- If VA is 140 degrees binocular No restrictions < 140 degrees but >110 degrees

binocular or >100 degrees monocular Will be required to have a left and right outside mirror


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Iowa Dark Window Exemption

Effective July 4, 2012

ADMINISTRATIVE RULE 761-450.7(3)The dark window exemptions will no longer be granted from the minimum standard of transparency. A motor vehiclefitted with a front windshield, a front side window or a front side wing window with less than 70 percent but not less than35 percent light transmittance before July 4, 2012, may continue to be maintained and operated after July 4, 2012, so longas the vehicle continues to be used for the transport of a passenger or operator and the dark window exemption which

documented a medical need for such reduced transparency, was signed by the persons physician before July 4, 2012. Theexemption must be carried at all times in the vehicle to which it applies. At such time the vehicle is no longer used for thetransport of the passenger or operator that is the subject of the exemption, the exemption expires and may notbe used onany replacement vehiclepurchased after July 3, 2012.The owner of the vehicle to which the exemption applied mustreturn the vehicle to conformance with the minimum standard of transparency within 60 days of expiration of theexemption.

Missouri

Visual Acuity: > 20/40 in one or both eyes No restrictions

20/41-20/160 in one or both eyes Discretionary issuance < 20/160 in one or both eyes 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 No restrictions

70-109 degrees binocular or monocular Discretionary issuance 20/40 in one or both eyes No restrictions

20/41-20/70 in one or both eyes Speed restrictions- May also have time of day and radius from home restrictions

20/71 - 20/99 in one or both eyes Discretionary issuance- Requires a vision specialist statement indicating the individual is visuallycompetent to drive- Requires a behind the wheel test- May have speed, time of day and radius from home restrictions

< 20/100 License denied



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Bioptic Telescopes:Not currently allowed to achieve the visual acuity standards noted above

Visual Field: (uninterrupted is not specified) > 105 degrees binocular or monocular No restrictions < 105 degrees binocular or monocular Discretionary issuance - vehicle may require left and right outside mirrors, in

addition to speed, radius from home and time of day restrictions 20/40 in one or both eyes No restrictions

20/41-20/60 in one or both eyes No driving when headlights are required

20/60-20/70 If blind in fellow eye, license will be denied 20/70 in one or both eyes No driving when headlights are required and speed limitations

< 20/71 in one or both eyes License denied

Bioptic Telescopes: Are allowed to achi

On Call Survival Guide

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