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Ophthalmic Emergencies

Jamie W. Herrmann, DVM Ophthalmology Intern

Discussion Topics

v  What is an ophthalmic emergency?

v  Common reasons for presentation

v  Treatment of common diseases

§  Proptosis §  Acute eye pain §  “Red” eye §  “Cloudy” eye

§  “Bulging” or “swollen” eye §  Acute blindness §  Ocular & periocular trauma

Defining Ophthalmic Emergencies

v  “True” emergency §  Threatens integrity of the

globe or visual pathway

v  “Prefergency” §  What often comes in the door

§  Proptosis §  Glaucoma §  Lid laceration

§  Severe corneal injury §  Anterior lens luxation

§  Exophthalmos §  Blindness

§  Superficial ulcer §  Anterior uveitis

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v  Most ocular disease are urgent •  Visual pathway is extremely sensitive

Many ocular diseases look identical

Defining Ophthalmic Emergencies

Presenting Complaints for Common Ocular Emergencies

Red Eye §  Glaucoma §  Orbital disease

§  Scleritis §  Uveitis §  Conjunctivitis §  Keratitis (ulcers)

Cloudy Eye §  Glaucoma §  Anterior lens luxation §  Anterior uveitis

Acute Eye Pain §  Corneal ulcer §  Glaucoma §  Anterior lens luxation §  Anterior uveitis Bulging/swollen Eye

§  Glaucoma §  Buphthalmos §  Exophthalmos §  Hypersensitivity (periocular)

Acute Blindness §  Glaucoma §  Retinal disease

•  SARDS, detachment, etc. §  Optic neuritis §  Optic chiasm disease (tumor)

Proptosis Emergency

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Prognostic Indicators v  Presence of vision = good v  Normal PLR = good v  Damage to ≥ 3 extraocular

muscles = bad v  Hyphema = bad v  Desiccated cornea = bad

Overall Prognosis v  Brachycephalic dogs

§  Guarded (30% regain vision)

v  Any other animal §  Grave (pretty much 0%)

Proptosis Emergency

Treatment v  Globe reduction + tarsorrhaphy v  Topical antibiotics

§  Drops are easiest v  Systemic antibiotics

§  Torn conjunctiva and rectus muscles

v  Anti-inflammatories §  Prednisone is best

v  Analgesics §  Tramadol, gabapentin, etc.

v  E-collar

Proptosis Emergency

Correct placement of sutures is crucial

Proptosis Emergency

1) Dilute betadine 2) Lubricate 3) Lidocaine block

4) Pre-place sutures 5) Reduce globe 6) Tie sutures

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Proptosis Emergency

Corneal Ulcers

Causes of corneal ulcers

Decreased corneal

protection

Tear film problems - Quantitative KCS - Qualitative KCS

Eyelid problems - Lagophthalmos - CN VII paralysis - CN V paralysis - Ectropion

Increased epithelial cell

turnover

Endogenous - Entropion - Ectopic cilia - Distichia - Trichiasis - Eyelid tumors

Exogenous - Trauma - Foreign body - Infection - Herpesvirus

Schematic adopted from Slatter’s Fundamentals of Veterinary Ophthalmology, 5th Edition

Superficial Ulcer

Diagnostic Tests v  STT of both eyes v  Fluorescein stain v  +/- eye pressures

Urgency

Treatment v  Antimicrobial TID or more

§  Neo/poly/bac ointment §  Neo/poly/gram solution ($$$)

-  Pain control if needed -  1% Atropine (q12-24 hours)

-  Systemic NSAID -  E-collar if needed -  Re-evaluate in 5-7 days

Foreign material

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Deep Ulcer

Diagnostic Tests -  STT of contralateral eye -  Fluorescein stain -  +/- eye pressures

Emergency

Deep Ulcer

Treatment -  Antimicrobials (q 2-6 hours)

-  Fluoroquinolones -  +/- Cefazolin 5.55%

-  If lots of gram+ bacteria

-  Anti-proteolytics (q1 – 6 hours)

-  Serum -  1% EDTA

-  Pain control -  1% Atropine (q12-24 hours)

-  Systemic NSAID -  Tramadol

-  E-collar if needed -  Re-evaluate in 2-3 days

Emergency

Primary Glaucoma

Glaucoma Emergency

v  Common Signalment §  3-9 year old Cocker Spaniel,

Basset Hound, Mixed breed v  Clinical signs

§  Acute redness, pain, corneal edema

v  Emergency treatment §  Latanoprost §  Dorzolamide+timolol §  If no response

•  Aqueocentesis (27-30g needle) •  Mannitol IV at 1-2 g/kg

v  Prognosis §  guarded to poor

Alternate every 5 minutes for 30-45 minutes

Must rule out an anterior lens luxation before giving latanoprost

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Secondary Glaucoma

Glaucoma Emergency

v  Most common etiologies §  Anterior lens luxation

•  Terrier breeds §  Anterior uveitis (many DDx) §  Previous cataract surgery

•  Chronic low-grade uveitis

v  Clinical signs §  Chronic (maybe “acute”)

redness, pain, corneal edema

v  Emergency treatment §  Treat underlying cause §  Dorzolamide + timolol TID-QID

v  Prognosis §  Poor à difficult to lower IOP

Latanoprost contraindicated & will make anterior lens luxation worse

Diagnostic Tests

Anterior Lens Luxation Emergency

v  +/- STT v  Fluorescein stain v  Eye pressures

Treatment v  Trans-corneal reduction

§  If successful, give latanoprost q12 hrs for persistent miosis

v  Surgical extraction §  Required if manual reduction

not successful

Latanoprost contraindicated & will make anterior lens luxation worse

Anterior Lens Luxation Emergency

Trans-corneal reduction of an anterior lens luxation

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Clinical signs

Buphthalmos Not an

emergency

v  Chronic red eye v  High IOP v  Blind in affected eye v  Enlarged globe v  Lens subluxation

§  Aphakic crescent

Treatment v  Enucleation v  Exenteration v  Chemical cilary body

ablation

Exophthalmos

Orbital Abscess v  Acute and often painful v  Rapid response to therapy v  Often young age v  Stick chewer ?

Orbital Neoplasia v  Chronic, slowly progressive,

and typically non-painful v  Typically older age v  +/- decreased nasal air flow

Urgency

Exophthalmos

Orbital Abscess v  Acute and painful v  Rapid response to therapy v  Treatment

§  Clavamox or Simplecef x 3-4 weeks

§  Systemic NSAID x 2-3 weeks §  Lubrication if keratitis present

Urgency

2 weeks after therapy

Orbital Abscess

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Prognostic indicators v  Caused by orbital mass

•  Abscess, neoplasia, mucocele

v  Typically maintain vision v  Decreased retropulsion v  Globes are same size

Overall prognosis v  Caused by chronic glaucoma v  Blind & lose light perception v  Typically normal or near-

normal retropulsion v  Globes are different sizes

Exophthalmos vs Buphthalmos

Exophthalmos Buphthalmos

Urgency Anterior Uveitis

Diagnostic Tests v  +/- STT v  Fluorescein stain v  Eye pressures

§  Should be low •  ≤ 7 mmHg in affected eye •  ≥ 5 mmHg between eyes

§  If high teens, developing secondary glaucoma

v  +/- systemic workup

§  Not necessary on emergency

Uveitis photo

“Classic” Clinical Signs -  Episcleral injection - Miosis -  Corneal edema - Low IOP

Urgency Anterior Uveitis

Treatment v  Topical steroids TID-QID

§  Neo/poly/dex 0.1% §  Prednisolone acetate 1%

v  Atropine 1% q12-24 hours §  Be cautious if IOP is in teens

v  Systemic NSAIDs §  Corticosteroids not

recommended due to potential of infectious or neoplastic disease

v  +/- topical NSAIDs

“Classic” Clinical Signs -  Episcleral injection - Miosis -  Corneal edema - Low IOP

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Urgency Unilateral Hyphema

Diagnostic Tests v  +/- STT v  +/- fluorescein stain v  Eye pressures

§  If high teens, developing secondary glaucoma

v  Systemic workup §  Possibly rodenticide toxicity

Differential Diagnoses v  Coagulopathies v  Anterior uveitis v  Intraocular neoplasia v  Retinal detachment

Emergency Bilateral Hyphema

Diagnostic Tests v  +/- STT v  +/- fluorescein stain v  Eye pressures

§  If high teens, developing secondary glaucoma

v  Systemic workup §  Possibly rodenticide toxicity

Differential Diagnoses v  *** Coagulopathies *** v  Anterior uveitis v  Intraocular neoplasia v  Retinal detachment

Acute Blindness

Diagnostic Approach v  Assess Vision

§  Menace, maze test, cotton balls

§  Visual placing §  Dazzle reflex

•  Cortical response

v  Ophthalmic exam §  Opacity that impairs vision? §  Normal fundus? §  Normal PLRs?

v  Neurolocalization §  PLRs are most helpful

Urgency

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SARDS

Suggestive Findings v  Bilateral blindness v  History of:

§  Polyuria, polydipsia, polyphagia, weight gain

v  Dachshunds v  Normal fundus v  No neurologic disease

Not really an emergency

Diagnostic Tests v  Electroretinogram

§  Normal = brain disease

Sudden Acquired Retinal Degeneration Syndrome

Normal Canine Fundus

Retinal Detachment

Suggestive Findings v  Lack of menace response v  Marcus-Gunn pupil

§  Afferent denervation v  Anisocoria

§  Affected eye = larger pupil v  “Abnormal” fundus

Urgency

Diagnostic Tests v  Blood pressure measurement

§  Should be >200 mmHg v  Systemic workup

§  DDX: Systemic mycosis, toxoplasmosis, neoplasia, etc.

Marcus-Gunn Pupil

Retinal Detachment Normal Feline Fundus Retinal Detachment

Urgency

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Retinal Detachment Exudative Retinal Detachment

Urgency

Retinal Degeneration

Suggestive Findings v  Blindness in different

environment v  Signalment

§  Inherited in Shih Tzu, Miniature Poodle, Labrador

v  Night blindness v  +/- mydriasis v  +/- cataract formation v  “Abnormal” fundus

§  Hyper-reflective §  Small blood vessels

Diagnostic Tests v  Fundus evaluation

Not an emergency

Optic Neuritis

Suggestive Findings v  Unilateral or bilateral

blindness v  +/- neurologic disease v  Myrdiasis & absent PLRs

§  Pupils may be minimally responsive to light

v  May have dazzle reflex v  “Abnormal” fundus

Urgency

Diagnostic Tests v  Electroretinogram (normal)

v  Systemic work up v  MRI + CSF evaluation

Optic Neuritis

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Ocular & Periocular Disease Urgency

Diagnostic Tests v  +/- STT v  Fluorescein stain v  Tonometry v  +/- skull radiographs v  +/- CT Treatment v  Topical antibiotics (ointment) v  Systemic antibiotics v  Systemic anti-inflammatories

Prognosis v  Good with no intraocular damage v  Poor if hyphema present

Ocular & Periocular Trauma Urgency

Diagnostic Tests v  Good history v  +/- STT v  Fluorescein stain v  +/- Tonometry

Treatment v  Topical anti-inflammatories v  Systemic anti-inflammatories

§  Dexamethasone SP à IV

Prognosis v  Good to excellent

Hypersensitivity Reactions Not an emergency

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Questions?