Opthalmologic Emergencies Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02.

Opthalmologic Opthalmologic EmergenciesEmergencies

Dave Dyck R3Dave Dyck R3

Preceptor: Dr. Bryan YoungPreceptor: Dr. Bryan Young

Sept. 26/02Sept. 26/02

Objectives:Objectives:

• Briefly review ocular anatomy and Briefly review ocular anatomy and examexam

• Recognize pathology (yeah – Recognize pathology (yeah – pictures!)pictures!)

• Discuss treatment optionsDiscuss treatment options

• Discuss areas of controversyDiscuss areas of controversy

• Slit lamp reviewSlit lamp review

Ocular Anatomy:Ocular Anatomy:

Eye Exam:Eye Exam:

• Visual acuityVisual acuity

• PupilsPupils

• MotilityMotility

• Confrontation visual fieldsConfrontation visual fields

• Anterior segmentAnterior segment

• Posterior segmentPosterior segment

• Intraocular pressureIntraocular pressure

Visual Acuity:Visual Acuity:

• Perform at 20 feet (6 meters) Perform at 20 feet (6 meters)

• Range from 20/15 to 20/400 then counting Range from 20/15 to 20/400 then counting fingers, hand movements, light perception, fingers, hand movements, light perception, and no light perceptionand no light perception

• Near vision uses a reading card at 14 inchesNear vision uses a reading card at 14 inches

• OD= right eye; OS= left eye; OU= both eyesOD= right eye; OS= left eye; OU= both eyes

• If vision< 20/20 use pinhole to check for If vision< 20/20 use pinhole to check for correctable refractive errorscorrectable refractive errors

Pupils:Pupils:

• Size and reaction to lightSize and reaction to light

• Swinging flashlight testSwinging flashlight test– Afferent pupillary defectAfferent pupillary defect

•Differential= retinal detachment, central Differential= retinal detachment, central retinal artery or vein occlusion, optic neuritis, retinal artery or vein occlusion, optic neuritis, optic neuropathyoptic neuropathy

•Cataract, hyphema, vitreous hemmorhage, Cataract, hyphema, vitreous hemmorhage, corneal ulcer, and iritis are associated with corneal ulcer, and iritis are associated with decreased vision but not an afferent pupillary decreased vision but not an afferent pupillary defectdefect

Pupils cont.Pupils cont.

• DilatedDilated– Third nerve palsyThird nerve palsy– TraumaTrauma– Adie’s pupilAdie’s pupil– Drug induced (dilating drops)Drug induced (dilating drops)– Acute glaucomaAcute glaucoma

Pupils cont.Pupils cont.

• ConstrictedConstricted– Drug inducedDrug induced– IritisIritis– Horner’s syndromeHorner’s syndrome

* Anisocoria >4mm seen in 19% of * Anisocoria >4mm seen in 19% of normalsnormals

Motility:Motility:

Confrontation Visual Fields:Confrontation Visual Fields:

To help localize lesions to the retina, To help localize lesions to the retina, optic nerve, optic chiasm, or visual optic nerve, optic chiasm, or visual cortexcortex

Anterior Segment:Anterior Segment:

• Lids, puncta, conjunctiva, sclera, Lids, puncta, conjunctiva, sclera, cornea, anterior chamber, and lenscornea, anterior chamber, and lens

• FluoresceinFluorescein– Remove contact lensesRemove contact lenses

Posterior Segment:Posterior Segment:

• Vitreous, disc, vessels, macula, and Vitreous, disc, vessels, macula, and peripheral retinaperipheral retina

• Through dilated pupil UNLESS Through dilated pupil UNLESS shallow anterior chamber (or hx of shallow anterior chamber (or hx of angle closure glaucoma), iris angle closure glaucoma), iris supported intraocular lens (rare), supported intraocular lens (rare), head injury, ruptured globehead injury, ruptured globe

Optic Disc:Optic Disc:

• Normally slightly oval in the vertical Normally slightly oval in the vertical meridian, central depression (cup), meridian, central depression (cup), various pigmentationvarious pigmentation

• Cup-to-disc ratio <0.5Cup-to-disc ratio <0.5

• Distinct disc marginsDistinct disc margins

Intraocular Pressure:Intraocular Pressure:

• Normal < 23 mmHg.Normal < 23 mmHg.

• Acute angle glaucoma often > 40 Acute angle glaucoma often > 40 mmHg.mmHg.

• Tonopen- easyTonopen- easy

• Schiotz tonometry (Roberts)Schiotz tonometry (Roberts)

• Applanation tonometryApplanation tonometry

• Air-puff tonometryAir-puff tonometry

Case 1: 66y lady watching TV tonight in a Case 1: 66y lady watching TV tonight in a dark room. Took 50mg Benadryl for itch dark room. Took 50mg Benadryl for itch increased eye pain with dec. visionincreased eye pain with dec. vision

Glaucoma:Glaucoma:

• Imbalance of aqueous humor Imbalance of aqueous humor production and drainage leading to production and drainage leading to increased intraocular pressure increased intraocular pressure optic neuropathyoptic neuropathy

Types:Types:

• Primary angle closure glaucomaPrimary angle closure glaucoma

• Secondary angle closure glaucomaSecondary angle closure glaucoma

• Primary open angle glaucomaPrimary open angle glaucoma

• Secondary open angle glaucomaSecondary open angle glaucoma

Acute Angle Closure Acute Angle Closure Glaucoma:Glaucoma:• Symptoms: Redness, severe pain, Symptoms: Redness, severe pain,

headache, photophobia, decreased vision, headache, photophobia, decreased vision, halos, +/- N/Vhalos, +/- N/V

• Signs: Increased IOP, acute anterior Signs: Increased IOP, acute anterior angle, corneal edema, conjunctival angle, corneal edema, conjunctival injection, non-reactive or sluggish mid-injection, non-reactive or sluggish mid-dilated pupildilated pupil

• More common if history of far-sightedness More common if history of far-sightedness (Hyperopia), Asian/Eskimo descent(Hyperopia), Asian/Eskimo descent

Treatment:Treatment:

• Pilocarpine 2% - 1 drop q15 min until Pilocarpine 2% - 1 drop q15 min until pupillary constriction. (+ 1 drop q6h in pupillary constriction. (+ 1 drop q6h in unaffected eye for prophylaxix)unaffected eye for prophylaxix)

• Timolol 0.5% - 1 drop (works within 30-Timolol 0.5% - 1 drop (works within 30-60min)60min)

• Apraclonidine HCl 1% - 1 dropApraclonidine HCl 1% - 1 drop• Diamox – 250-500mg po q6h or 500mg IVDiamox – 250-500mg po q6h or 500mg IV• If not < 35mmHg in 30-60 minutes give If not < 35mmHg in 30-60 minutes give

Mannitol 20% - 2-7ml/Kg IV or isosorbide Mannitol 20% - 2-7ml/Kg IV or isosorbide 1-1.5g/Kg po1-1.5g/Kg po

Treatment cont.Treatment cont.

• Opthamology : for peripheral Opthamology : for peripheral iridectomy or laser iridotomyiridectomy or laser iridotomy

• When to refer urgently for surgery?When to refer urgently for surgery?

• When to expect a pressure drop with When to expect a pressure drop with medications?medications?

• What is a satisfactory pressure drop?What is a satisfactory pressure drop?

Primary Open-Angle Primary Open-Angle Glaucoma:Glaucoma:• Most common cause of blindness in NAMost common cause of blindness in NA

• Due to increased aqueous humor Due to increased aqueous humor outflow through the trabecular outflow through the trabecular meshworkmeshwork

• Insidious, slowly progressive, bilateral, Insidious, slowly progressive, bilateral, painless vision loss (peripheral) ie. NOT painless vision loss (peripheral) ie. NOT AN EMERGENCYAN EMERGENCY

• Increased cup-to-disc ratioIncreased cup-to-disc ratio

Fundoscopic lesions:Fundoscopic lesions:

Case 2:Case 2:

• 58 y male presents 58 y male presents with acute vision with acute vision loss in L eye x 90 loss in L eye x 90 minutes. minutes.

Central Retinal Artery Central Retinal Artery Occlusion:Occlusion:

• Painless, ages 50-70, vasculopathic hxPainless, ages 50-70, vasculopathic hx

• R/O glaucomaR/O glaucoma

• Signs= Decreased visual acuity, Signs= Decreased visual acuity, afferent pupillary defect, pale fundus afferent pupillary defect, pale fundus with cherry-red foveawith cherry-red fovea

• Experimentally, 100min until Experimentally, 100min until irreversible ischemiairreversible ischemia


• Digital global massage (5sec on –5sec Digital global massage (5sec on –5sec off)off)

• Increase PCO2 by breathing into paper Increase PCO2 by breathing into paper bag for 10min every hour vs Carbogenbag for 10min every hour vs Carbogen

• IV acetozolamide + ASAIV acetozolamide + ASA• R/O and Treat glaucomaR/O and Treat glaucoma• Emergent Opthamology referral and Emergent Opthamology referral and

outpatient Cardiologyoutpatient Cardiology• R/O neuritis 2% (ESR, hx, etc)R/O neuritis 2% (ESR, hx, etc)

Case 3: 60 y male with Case 3: 60 y male with painless blurry vision r eyepainless blurry vision r eye

Branch Retinal Artery Branch Retinal Artery Occlusion:Occlusion:

• Same treatment as for CRAOSame treatment as for CRAO

Case 4:Case 4:

• 60 y female with 60 y female with vision loss L eyevision loss L eye

Central/Branch Retinal Vein Central/Branch Retinal Vein Occlusion:Occlusion:

• Symptoms: variable vision loss, Symptoms: variable vision loss, usually painlessusually painless

• Signs: ischemic (neovascular Signs: ischemic (neovascular glaucoma) or non-ischemic (macular glaucoma) or non-ischemic (macular edema with leaking capillaries) edema with leaking capillaries) Dilated tortuous veins, retinal Dilated tortuous veins, retinal hemmorhages and disc edemahemmorhages and disc edema


• ExpectantExpectant

• Referral to Opthomology within 24 Referral to Opthomology within 24 hrs to R/O neovascular glaucomahrs to R/O neovascular glaucoma

Case 5:Case 5:

• 55 y myopic male 55 y myopic male with light flashes with light flashes and complete and complete vision loss acutely vision loss acutely 2hrs ago in L eye. 2hrs ago in L eye. No painNo pain

Retinal Detachment:Retinal Detachment:

• Separation of the inner neuronal Separation of the inner neuronal retina layer from the outer retinal retina layer from the outer retinal pigment epithelial layerpigment epithelial layer

• 3 types:3 types:– i. rhegmatogenousi. rhegmatogenous– ii. Exudativeii. Exudative– iii. Tractionaliii. Tractional

Rhegmatogenous:Rhegmatogenous:

• Due to tear/hole in the neuronal layer Due to tear/hole in the neuronal layer causing vitreous fluid to enter and causing vitreous fluid to enter and separate the 2 retinal layersseparate the 2 retinal layers

• Often due to vitreous gel pulling on Often due to vitreous gel pulling on retina as one ages or related to retina as one ages or related to traumatrauma

• Men, myopia, age>45 Men, myopia, age>45

Exudative:Exudative:

• From blood/fluid leakage from From blood/fluid leakage from vessels within the retinavessels within the retina

• HT, eclampsia, CRVO, papilledema, HT, eclampsia, CRVO, papilledema, vasculitis, choroid tumorvasculitis, choroid tumor

Tractional:Tractional:

• Due to fibrous band formation in the Due to fibrous band formation in the vitreous and the contraction of these vitreous and the contraction of these bandsbands

Retinal Detachment:Retinal Detachment:

• Symptoms: light flashes, floaters, Symptoms: light flashes, floaters, variable vision loss depending on variable vision loss depending on macular involvement (cloudy or macular involvement (cloudy or curtainlike), painlesscurtainlike), painless

• Signs: area out of focus on Signs: area out of focus on fundoscopyfundoscopy

• Cannot be ruled out by direct Cannot be ruled out by direct fundoscopyfundoscopy


• Emergent opthamologic consultationEmergent opthamologic consultation

• When?When?

Case 6:Case 6:

• 72 y IDDM female 72 y IDDM female with 2hr hx of with 2hr hx of “cobwebs” L eye “cobwebs” L eye leading to marked leading to marked decrease in vision decrease in vision nownow

Vitreous Hemmorhage:Vitreous Hemmorhage:

• Bleeding into the preretinal space or Bleeding into the preretinal space or vitreous cavityvitreous cavity

• Usually due to diabetic retinopathy or Usually due to diabetic retinopathy or retinal vessel tears secondary to vitreous retinal vessel tears secondary to vitreous collapse but various other causescollapse but various other causes

• Symptoms: initially floaters or cobwebs Symptoms: initially floaters or cobwebs with subsequent vision losswith subsequent vision loss

• Fundoscopy findings are widely variable Fundoscopy findings are widely variable (reddish haze to black reflex)(reddish haze to black reflex)

Vitreous hemmorhage:Vitreous hemmorhage:

• If afferent pupillary defect present If afferent pupillary defect present retinal detachment likely behind retinal detachment likely behind hemmorhagehemmorhage

• Treatment: bedrest, elevate HOB, Treatment: bedrest, elevate HOB, avoid ASA and refer to opthomology avoid ASA and refer to opthomology

Case 7:Case 7:

• 75y male with 75y male with progressive vision progressive vision loss x years with loss x years with acute worsening acute worsening central vision central vision today. No pain. today. No pain.

Macular Hemmorhage:Macular Hemmorhage:

• Refer to opthomology Refer to opthomology

Macular Disorders:Macular Disorders:

• Loss of central vision with preservation of Loss of central vision with preservation of peripheral vision, central vision distortion, peripheral vision, central vision distortion, abnormal retinal changes at maculaabnormal retinal changes at macula

• Due to trauma, radiation, inflammation, Due to trauma, radiation, inflammation, vascular disease, toxins, genetics, vascular disease, toxins, genetics, idiopathicidiopathic

• DrusenDrusen

• NeovascularizationNeovascularization

• *no afferent defect and optic nerve normal*no afferent defect and optic nerve normal

Drusen:Drusen:

Macular Star:Macular Star:

ER role:ER role:

• Recognition primarily and referral to Recognition primarily and referral to opthamology for fluorescein opthamology for fluorescein angiogram within 24-48 hrsangiogram within 24-48 hrs

Non-Penetrating Ocular Non-Penetrating Ocular Trauma:Trauma:

• Orbit and globeOrbit and globe

• Cornea and conjunctivaCornea and conjunctiva

• Anterior chamber and irisAnterior chamber and iris

• LensLens

• Posterior SegmentPosterior Segment

Case 8:Case 8:

• 22y male hit in L 22y male hit in L eye with puck. eye with puck. Vision slightly Vision slightly blurry (20/60) and blurry (20/60) and decreased up gaze. decreased up gaze. Tender inferior Tender inferior orbit.orbit.

Orbital Wall Fractures:Orbital Wall Fractures:

• Orbital floor is weakest point and orbital Orbital floor is weakest point and orbital tissues may prolapse inferiorly tissues may prolapse inferiorly enopthalmos, ptosis, diplopia, aneasthesia enopthalmos, ptosis, diplopia, aneasthesia of ipsilateral cheek/upper lip, and of ipsilateral cheek/upper lip, and decreased up gazedecreased up gaze

• Medial orbital wall # into ethmoid sinus Medial orbital wall # into ethmoid sinus (look for orbital emphysema)(look for orbital emphysema)

• Globe injuries in 10-25%Globe injuries in 10-25%• Facial x-rays (imperfect)Facial x-rays (imperfect)

– Teardrop signTeardrop sign– AF levelAF level


• Consultation with plastic surgery for Consultation with plastic surgery for possible surgical repairpossible surgical repair

• Abx unnecessary unless involved Abx unnecessary unless involved sinus previously infectedsinus previously infected

• Avoid nose blowing (dec Avoid nose blowing (dec emphysema)emphysema)

Retrobulbar Hemmorhage:Retrobulbar Hemmorhage:

• Hemmorhage in potential space Hemmorhage in potential space surrounding globe may increase surrounding globe may increase intraorbital pressure and cause CRAO.intraorbital pressure and cause CRAO.

• Symptoms=proptosis, visual loss, Symptoms=proptosis, visual loss, increased IOPincreased IOP

• Signs= CRAOSigns= CRAO• Dx= above + orbital CT scanDx= above + orbital CT scan• Tx=immediate optho consult, IV mannitol Tx=immediate optho consult, IV mannitol

+/-lateral canthotomy or anterior chamber +/-lateral canthotomy or anterior chamber paracentesisparacentesis

Complications:Complications:

• Infection, hemmorhage, injury to Infection, hemmorhage, injury to globeglobe

• RareRare

• Canthotomy wounds heal well Canthotomy wounds heal well without suturing or significant without suturing or significant scarringscarring

Case 9: 22y male in MVACase 9: 22y male in MVA

Globe Rupture:Globe Rupture:

• Most common at EOM insertions into Most common at EOM insertions into sclera or at limbussclera or at limbus

• Pain and decreased visionPain and decreased vision

• Examination: various = teardrop Examination: various = teardrop pupil (iris plugging limbal hole), pupil (iris plugging limbal hole), distortion of anterior chamber, othersdistortion of anterior chamber, others

Diagnosis:Diagnosis:

• Hx/Px +/- CT or U/SHx/Px +/- CT or U/S

• FluoresceinFluorescein

• Avoid tonometryAvoid tonometry


• Protective shield, avoid manipulation, Protective shield, avoid manipulation, NPO, tetanus, IV Abx, urgent NPO, tetanus, IV Abx, urgent opthalmologyopthalmology

• Avoid succ or use defasciculator if Avoid succ or use defasciculator if must use itmust use it

Case 10: 32 y male with drain Case 10: 32 y male with drain cleaner in eyecleaner in eye

Alkali burns:Alkali burns:

• Liquefaction necrosisLiquefaction necrosis

• Severe injury= (severity judged by Severe injury= (severity judged by degree of corneal whitening)degree of corneal whitening)


• Prehospital- copious irrigation with Prehospital- copious irrigation with clean water x 15 min prior to clean water x 15 min prior to transport. Bring in chemicaltransport. Bring in chemical

• Hospital- topical anaesthesia, lid Hospital- topical anaesthesia, lid retraction and 2L continuous retraction and 2L continuous irrigation NS. Continue until pH=7.4-irrigation NS. Continue until pH=7.4-7.6. Remove foreign bodies. Urgent 7.6. Remove foreign bodies. Urgent optho consult.optho consult.

Complications:Complications:

• Perforation, scarring and corneal Perforation, scarring and corneal neovascularization. Lid adhesions, neovascularization. Lid adhesions, glaucoma, cataracts, and retinal glaucoma, cataracts, and retinal damagedamage

Neovascularization:Neovascularization:

Acid burns:Acid burns:

• Less devastatingLess devastating

• Coagulation necrosis Coagulation necrosis precipitates precipitates tissue proteins to limit depth of injurytissue proteins to limit depth of injury

• If pH>2 If pH>2 usually min damage usually min damage unless very high concentration or unless very high concentration or long duration of exposurelong duration of exposure

• Treatment as for alkali burnsTreatment as for alkali burns

Miscellaneous exposures:Miscellaneous exposures:

• Treat as if acid/alkaliTreat as if acid/alkali

• Superglue= If eyelids sealed shut in Superglue= If eyelids sealed shut in normal position normal position leave alone. If leave alone. If eyelids in abnormal position eyelids in abnormal position may may require surgery. Optho should see require surgery. Optho should see both in consultationboth in consultation

Thermal Burns:Thermal Burns:

• Eyelid usually worse than globeEyelid usually worse than globe

• If superficial treat with irrigation and If superficial treat with irrigation and Abx ointment. If deeper Abx ointment. If deeper as above as above + involve optho+ involve optho

Case 11: 16y male scratched in Case 11: 16y male scratched in eyeeye

Corneal Abrasion:Corneal Abrasion:

• Symptoms: pain, photophobia, Symptoms: pain, photophobia, foreign body sensation, dec vision.foreign body sensation, dec vision.

• Signs: injected conjunctiva, Signs: injected conjunctiva, fluorescein defectfluorescein defect


• R/O foreign body and herpes keratitis R/O foreign body and herpes keratitis (evert lids, use slit lamp)(evert lids, use slit lamp)

• Refer immed if pain not relieved with top Refer immed if pain not relieved with top anaesthetics or if large abrasion esp if in anaesthetics or if large abrasion esp if in central field of visioncentral field of vision

• Cycloplegics (cyclogyl 1%)Cycloplegics (cyclogyl 1%)• Abx drops (sulfacetamide 10%, polytrim, Abx drops (sulfacetamide 10%, polytrim,

ocuflox, etc)ocuflox, etc)• Patch vs no patch (Kaiser 1995; Hart 1997; Patch vs no patch (Kaiser 1995; Hart 1997;

Patterson 1996)Patterson 1996)• If no patch give topical NSAID for pain If no patch give topical NSAID for pain

control eg ketorolac 0.5% QIDx3dcontrol eg ketorolac 0.5% QIDx3d

Contact lens related Contact lens related abrasions:abrasions:

-remove contact lens-remove contact lens

-gram neg coverage (gentamycin, -gram neg coverage (gentamycin, ocuflox)ocuflox)

-cycloplegic-cycloplegic

-don’t patch-don’t patch

-may require opth follow-up so that a -may require opth follow-up so that a corneal ulcer doesn’t developcorneal ulcer doesn’t develop

Follow-up:Follow-up:

• Bring back in 24 hrs or not?Bring back in 24 hrs or not?

• Optho follow-up?Optho follow-up?

Case 12: 38 y male feels Case 12: 38 y male feels something got in his eye while something got in his eye while chopping woodchopping wood

Corneal foreign body:Corneal foreign body:

• Dx.=topical aneasthetic and slit lamp Dx.=topical aneasthetic and slit lamp examexam

• r/o intraocular foreign bodyr/o intraocular foreign body

• Treatment= irrigation or needle Treatment= irrigation or needle removal (25 guage) and then as for removal (25 guage) and then as for abrasionabrasion

• Rust ring removalRust ring removal

Case 12: 42y male with acute Case 12: 42y male with acute redenning of eye after rubbing redenning of eye after rubbing it. No other sxit. No other sx

Subconjunctival Subconjunctival Hemmorhage:Hemmorhage:

• Treatment= reassurance, cool Treatment= reassurance, cool compressescompresses

• Resolves in 2-3 weeksResolves in 2-3 weeks

Case 13: 22y male struck in Case 13: 22y male struck in eye by squash balleye by squash ball

Hyphema:Hyphema:

• Blood in anterior chamberBlood in anterior chamber

• Due to disruption of blood vessels in the iris Due to disruption of blood vessels in the iris or ciliary body (trauma or spontaneous)or ciliary body (trauma or spontaneous)

• Typically lasts 4-6 days if uncomplicatedTypically lasts 4-6 days if uncomplicated

• Classification:Classification:– Grade 1 = less than 1/3 of ant chamber filled Grade 1 = less than 1/3 of ant chamber filled

(72%)(72%)– Grade 2 = 1/3 to ½ (20%)Grade 2 = 1/3 to ½ (20%)– Grade 3 = greater than ½ (5%)Grade 3 = greater than ½ (5%)– Grade 4 = complete filling of ant chamber (3%)Grade 4 = complete filling of ant chamber (3%)

““eight ball hyphema”eight ball hyphema”

ComplicationsComplications

• Glaucoma 1/3 (esp if Sickle Cell Glaucoma 1/3 (esp if Sickle Cell Anemia)Anemia)

• Rebleeding 4-38% usually at 2-5 Rebleeding 4-38% usually at 2-5 daysdays

• Corneal staining 2-5%Corneal staining 2-5%

Management:Management:

• Document VA, pupils, IOP, aff Document VA, pupils, IOP, aff pupillary defect (eight ball)pupillary defect (eight ball)

• Slit lamp and complete eye exam to Slit lamp and complete eye exam to r/o other injuriesr/o other injuries


• ShieldShield• Rest, elevate HOB, no Rest, elevate HOB, no

straining/bending/valsalvastraining/bending/valsalva• No near viewing activities eg readingNo near viewing activities eg reading• Control IOP (avoid acetazolamide in Sickle Control IOP (avoid acetazolamide in Sickle

Cell Anemia)Cell Anemia)• Stop anticoagulation and avoid ASA/NSAIDsStop anticoagulation and avoid ASA/NSAIDs• Steroids controversial – leave up to opthoSteroids controversial – leave up to optho• Systemic antifibrinolytics (aminocaproic acid) Systemic antifibrinolytics (aminocaproic acid)

– controversial (dec rebleeding but inc N/V)– controversial (dec rebleeding but inc N/V)• Cycloplegics ok and tx corneal abrasions w Cycloplegics ok and tx corneal abrasions w

abxabx


• To admit or not?To admit or not?– No answer in literatureNo answer in literature– Growing opinion to allow grade 1-11 Growing opinion to allow grade 1-11

hyphemas with controlled IOP to be hyphemas with controlled IOP to be treated at home with close optho follow-treated at home with close optho follow-up dailyup daily

Indications for Surgery:Indications for Surgery:

• Uncontrolled increased IOPUncontrolled increased IOP

• Persistent total/near total hyphema x Persistent total/near total hyphema x daysdays

• Prolonged clot durationProlonged clot duration

• Corneal blood stainingCorneal blood staining

• Surgery required in 5% Surgery required in 5%

Traumatic Iridocyclitis:Traumatic Iridocyclitis:

• Contusion to iris/ciliary body Contusion to iris/ciliary body ciliary ciliary spasmspasm

• Photophobia and deep eye painPhotophobia and deep eye pain

• Exam= ciliary flush, anterior chamber Exam= ciliary flush, anterior chamber cells (WBCs and protein)cells (WBCs and protein)

• Tx=long acting cycloplegics x7-10 daysTx=long acting cycloplegics x7-10 days

• Steroids may be given by opthoSteroids may be given by optho

Case 14: 12y boy 2 wk f/u post Case 14: 12y boy 2 wk f/u post hyphemahyphema

Iridodialysis:Iridodialysis:

• Tearing of the iris root from the Tearing of the iris root from the ciliary bodyciliary body

• ED tx- only if hyphema presentED tx- only if hyphema present

• May require non-urgent surgical May require non-urgent surgical correctioncorrection

Case 16: Tall thin 32y male Case 16: Tall thin 32y male presents with diplopic vision L presents with diplopic vision L eye after minor eye traumaeye after minor eye trauma

Lens Lens subluxation/dislocation:subluxation/dislocation:

• Due to trauma, Marfan’s, Due to trauma, Marfan’s, homocystinuria, and tertiary syphilishomocystinuria, and tertiary syphilis

• Tx.= optho referralTx.= optho referral

Anterior chamber lens Anterior chamber lens dislocation:dislocation:

Penetrating Trauma:Penetrating Trauma:

Case 17:18y male hit in eye by Case 17:18y male hit in eye by TV remoteTV remote

Lid lacerations:Lid lacerations:

• What can ED do?What can ED do?– Simple horizontal and oblique partial Simple horizontal and oblique partial

thickness lacerationsthickness lacerations

Complex lid lacerations Complex lid lacerations needing referral (24 hrs):needing referral (24 hrs):

• Lid marginsLid margins

• Canalicular system involvement Canalicular system involvement (medial lower eyelid)(medial lower eyelid)

• Levator or canthal tendon Levator or canthal tendon involvementinvolvement

• Lacs with tissue lossLacs with tissue loss

Conjunctival, Corneal, Scleral Conjunctival, Corneal, Scleral lacerations and punctures:lacerations and punctures:

• Conjunctival lac: small,superficialConjunctival lac: small,superficial no suturing, topical abx. O/Wno suturing, topical abx. O/W opthooptho

• Corneal lac: Dx.= fluorescein flow. Tx Corneal lac: Dx.= fluorescein flow. Tx as for globe rupture. as for globe rupture.

• Scleral lac: Dx and Tx as for globe Scleral lac: Dx and Tx as for globe rupturerupture

Case 17:Case 17:

Orbital and Intraocular Foreign Orbital and Intraocular Foreign Body:Body:

• May have normal physical exam. May have normal physical exam. Therefore high index of suspicion is Therefore high index of suspicion is crucial.crucial.

• Low threshold for plain orbital plain Low threshold for plain orbital plain films or orbital CT scan if non films or orbital CT scan if non radioopaque substanceradioopaque substance

• Tx=opthoTx=optho

Case 18: 70y male 3days post Case 18: 70y male 3days post L cataract surgery. Increased L cataract surgery. Increased pain and dec. vision.pain and dec. vision.

Endophthalmitis:Endophthalmitis:

• Infection involving the deep Infection involving the deep structures of the eyestructures of the eye

• Tx=early diagnosis, IV abx (Vanco + Tx=early diagnosis, IV abx (Vanco + 33rdrd gen antipseudomonal ceph. +/- gen antipseudomonal ceph. +/- clinda), prompt optho referral for clinda), prompt optho referral for intravitreal abx, vitreous intravitreal abx, vitreous tap/vitrectomy, and possible steroids.tap/vitrectomy, and possible steroids.

Non-traumatic red eye (other Non-traumatic red eye (other than glaucoma)than glaucoma)

Conjuncitivitis key points:Conjuncitivitis key points:

• Bilateral findings less likely bacterialBilateral findings less likely bacterial

• Gonococcus only bacterial Gonococcus only bacterial conjunctivitis with a preauricular conjunctivitis with a preauricular nodenode

• Always fluorescein eyes to r/o herpes Always fluorescein eyes to r/o herpes lesionslesions

• Never prescribe steroids from ERNever prescribe steroids from ER

Treatments:Treatments:

• Allergic: cool compresses, remove Allergic: cool compresses, remove allergens, medsallergens, meds

• Viral (non-herpetic): cool compresses, Viral (non-herpetic): cool compresses, reassurance, some advocate for reassurance, some advocate for prophylactic abx (adenovirus may take 3 prophylactic abx (adenovirus may take 3 weeks to resolve)weeks to resolve)

• Bacterial: warm compresses, Na Sulamyd, Bacterial: warm compresses, Na Sulamyd, tobramycin, polymyxin, or erythro tobramycin, polymyxin, or erythro (chloramphenical); if o/w healthy avoid (chloramphenical); if o/w healthy avoid topical fluoroquinolones. Culture if non topical fluoroquinolones. Culture if non responders. (gonococcusresponders. (gonococcus systemic tx, systemic tx, ocular lavage, topical erythro, notification).ocular lavage, topical erythro, notification).

Treatment cont.Treatment cont.

• No evidence comparing one abx to No evidence comparing one abx to another, but good evidence that abx another, but good evidence that abx ameliorate symptoms faster than ameliorate symptoms faster than placebo.placebo.

(Sheikh & Hurwitz, 2001)(Sheikh & Hurwitz, 2001)

Case 19:Case 19:

Herpetic Herpetic keratoconjunctivitis:keratoconjunctivitis:

• Tx.= trifluridine 1% 8x/day, acyclovir Tx.= trifluridine 1% 8x/day, acyclovir 400mg 5x/day (no clinically 400mg 5x/day (no clinically significant evidence), new topical significant evidence), new topical acyclovir ointment 5x/dayacyclovir ointment 5x/day

Case 20:Case 20:

Herpes Zoster Opthalmica:Herpes Zoster Opthalmica:

• PO acyclovir 600-800mg 5x/day or PO acyclovir 600-800mg 5x/day or famcyclovir 500mg po tid.famcyclovir 500mg po tid.

• Start within 72 hrsStart within 72 hrs

• +/- po prednisone under guidance of +/- po prednisone under guidance of opthamologyopthamology

Disorders of Lids and Ocular Disorders of Lids and Ocular Soft Tissues:Soft Tissues:

Case 21:Case 21:

Hordeolum:Hordeolum:

• Localized, nodular acute infection of Localized, nodular acute infection of an eyelid (staph aureus most an eyelid (staph aureus most common)common)

• Can point to either skin or Can point to either skin or conjunctival sideconjunctival side

• Tx=warm compresses 4-6x/day, Tx=warm compresses 4-6x/day, topical abx. I&D if largetopical abx. I&D if large

Case 22:Case 22:

Chalazion:Chalazion:

• Chronic inflammatory process Chronic inflammatory process develops after incomplete resolution develops after incomplete resolution of a meibomian glandof a meibomian gland

• Conjunctival or skin sideConjunctival or skin side

• Non-tenderNon-tender

• Tx as for hordeolum (most resolve on Tx as for hordeolum (most resolve on own) Sx if still present x3-4 wksown) Sx if still present x3-4 wks

Case 23:Case 23:

Dacrocystitis:Dacrocystitis:

• Acute infection of lacrimal sac from Acute infection of lacrimal sac from Nasolacrimal obstructionNasolacrimal obstruction

• Staph aur.Staph aur.

• May express pus from punctaMay express pus from puncta

• Tx. Po abx and hot compresses, Tx. Po abx and hot compresses, massagemassage

Case 24:Case 24:

Preseptal Cellulitis:Preseptal Cellulitis:

• Hx URTI, eyelid trauma, external eye Hx URTI, eyelid trauma, external eye infectioninfection

• Normal vision, no proptosis, normal Normal vision, no proptosis, normal ocular motility, no pain with eye ocular motility, no pain with eye movementsmovements

• Staph, strep, heamophilusStaph, strep, heamophilus

• PO/IV Abx and optho referral to r/o PO/IV Abx and optho referral to r/o orbital involvmentorbital involvment

Case 25:Case 25:

Orbital Cellulitis:Orbital Cellulitis:

• Pain, decreased vision, +/- diplopiaPain, decreased vision, +/- diplopia

• Proptosis, limited EOM, Dec visual Proptosis, limited EOM, Dec visual acuity, +/- afferent pupillary defectacuity, +/- afferent pupillary defect

• w/u=CT scan, blood/eye c&sw/u=CT scan, blood/eye c&s

• Tx= admit, broad spectrum Abx. Tx= admit, broad spectrum Abx. Consider mucormycosisConsider mucormycosis

Blepharitis:Blepharitis:

• Chronic conditionChronic condition

• Due to staph infection or seborrheic Due to staph infection or seborrheic gland inflammationgland inflammation

• Tx=warm compresses, eyelid scrubs Tx=warm compresses, eyelid scrubs (diluted baby shampoo) erythro (diluted baby shampoo) erythro ointment & chronic eyelid hygeine. ointment & chronic eyelid hygeine. PO doxycycline added in severe PO doxycycline added in severe casescases

Case 26:Case 26:

Phlyctenule:Phlyctenule:

• R/O foreign bodyR/O foreign body

• Due to hypersensitivity rxn to Due to hypersensitivity rxn to antigen such as staph or TBantigen such as staph or TB

• CXR/mantoux as outpt -CXR/mantoux as outpt -refer to refer to optho for ? Topical steroidsoptho for ? Topical steroids

• Tx coexistant blepharitisTx coexistant blepharitis

Case 27:Case 27:

Episcleritis:Episcleritis:

• ““Salmon pink” hue of the superficial Salmon pink” hue of the superficial layer of the eye between layer of the eye between conjunctiva/scleraconjunctiva/sclera

• Usually idiopathicUsually idiopathic

• 1/3 tender, 2/3 sectoral1/3 tender, 2/3 sectoral

• Tx. Outpatient referral to optho for Tx. Outpatient referral to optho for topical steroids only if severe.topical steroids only if severe.

Case 28:Case 28:

Scleritis:Scleritis:

• More painful, often bilateralMore painful, often bilateral

• 50 % have systemic dx (Crohns, UC, 50 % have systemic dx (Crohns, UC, collagen vasc dx, sarcoid, etc)collagen vasc dx, sarcoid, etc)

• Simple vs nodular (immobile nodules Simple vs nodular (immobile nodules with q tip) vs necrotizingwith q tip) vs necrotizing

• Tx: NSAIDs, Optho referral for Tx: NSAIDs, Optho referral for steroids and systemic w/usteroids and systemic w/u

Case 29:Case 29:

Iritis:Iritis:

• Redness, photophobia, tearing and Redness, photophobia, tearing and decreased visiondecreased vision

• Ciliary flush and pupillary constrictionCiliary flush and pupillary constriction• Slit lamp= anterior chamber rxn with Slit lamp= anterior chamber rxn with

WBCs, flare (protein leakage), and WBCs, flare (protein leakage), and keratic precipitateskeratic precipitates

• Always fluorescein to r/o Always fluorescein to r/o abrasion/herpesabrasion/herpes

• Tx=cycloplegics & Topical NSAIDs and Tx=cycloplegics & Topical NSAIDs and referral to optho for steroidsreferral to optho for steroids

Dry Eyes:Dry Eyes:

Summary:Summary:

• Always do a complete eye exam with Always do a complete eye exam with documentation of acuity and documentation of acuity and fluoresceinfluorescein

• Never prescribe steroids from ERNever prescribe steroids from ER

• Very low threshold to x-ray orbitsVery low threshold to x-ray orbits

• When in doubt consult your When in doubt consult your opthomologistopthomologist

ENDEND

Opthalmologic Emergencies Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02.

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Transcript of Opthalmologic Emergencies Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02.