PRINCIPLES OF OPHTHALMIC ASSESSMENT AND...
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PRINCIPLES OF
OPHTHALMIC
ASSESSMENT AND
MANAGEMENT IN THE
EMERGENCY DEPARTMENT
JUSTIN SHERWIN
WESTERN HEALTH
OPHTHALMOLOGY REGISTAR
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RESOURCES
www.ophthobook.com
www.rveeh.org.au
GOLDEN EYE RULES: Available from RVEEH websoie
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1 ALWAYS TEST AND
RECORD VISION
Wearing distance spectacles/contact lenses and without
Test each eye separately
A 1mm pinhole will improve acuity in refractive errors
Snellen chart (6 metres, or 3 metres in children)
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BASIC OCULAR
ASSESSMENT
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2 MORE MISTAKES IN
MEDICINE ARE MADE BY
NOT LOOKING THAN NOT
KNOWING
Good illumination and magnification (slit lamp optimal)
For examination of the fundus and if no head injury, use tropicamide 0.5 or 1.0% to dilate pupil (risk of precipitating angle closure crisis is low)
In children < 12 months:
‘Baby Drops’ 2.5% phenylephrine and 0.1% cyclopentolate
Older children:
Can use 2.5% phenylephrine and 1.0% cyclopentolate or tropicamide
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WHY DILATE?
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WHICH
OPHTHALMOSCOPE
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WHAT OPHTHALMOLOGISTS
USE
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IOP MEASUREMENT
Goldmann Applanation Tonometry:
GOLD STANDARD (if calibrated!).
Requires local anaeshesia and fluorosceine
I-Care: No anaesthesia required
Tonopen: Requires local anaesthesia
Manual palpation of closed eye
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TONOPEN
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I-CARE
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ACUTE ANGLE
CLOSURE GLAUCOMA
Cornea usually has a hazy appearance
Anterior chamber is shallow with irregular semidilated pupil
The affected eye is very tender and tense to palpation
Systemic symptoms include headache, nausea and vomiting
Urgent referral to ophthalmologist
- immediate consult by phone.
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ACUTE RED EYE
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3 EXAMINE THE PUPIL REFLEXES IF
VISUAL ACUITY IS ABNORMAL
WITH NO OBVIOUS
CAUSE
A relative afferent pupillary defect (RAPD) suggests an optic
nerve defect or a large retinal insult.
A unilaterally dilated pupil can be the first sign of a third
nerve palsy from intracranial aneurysm.
Other causes of abnormal pupils includes Horner’s
Syndrome (ptosis, miosis, anhydrosis), drugs,
trauma, angle closure glaucoma and uveitis
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4 VISUAL FIELD
EXAMINATION CAN
DIFFERENTIATE AN EYE
CAUSE FROM CENTRAL
CAUSE OF VISION LOSS
Horizontal defect in glaucoma, branch retinal artery or vein
occlusion, NAION
Bitemporal vertical defect suspect pituitary tumour
Homonymous vertical defect suspect intracranial lesion, CVA
? HOW TO CHECK VISUAL FIELDS
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5 NO CHILD IS TOO
YOUNG FOR AN EYE
EXAM
Check the red-reflex of every newborn
Refer any suspected squint immediately
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RED REFLEX
Normal red reflexes
Absent left red reflex
Abnormal left red reflex
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6 SUDDEN LOSS OR
BLURRING OF VISION IS
AN EMERGENCY
Always exclude temporal arteritis if > 50 years (headache, jaw claudication, scalp tenderness, constitutional symptoms, relative afferent pupil defect, raised ESR, CRP) because of immediate risk to other eye
Other COMMON causes:
- Retinal artery occlusion (‘stroke of the eye’)
- Retinal vein occlusion
- Vitreous and macular haemorrhage (many causes)
- Retinal detachment (vision loss preceded by floaters and flashes)
- Optic nerve ischaemia
- Optic neuritis
Distortion of vision may indicate macular disease
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SUDDEN VISION LOSS
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CLUES FROM HISTORY
Retinal Detachment: Flashes, Floaters, Field Defect, Reduced Vision, trauma, myopia (short-sighted), eye surgery
Retinal Artery Occlusion: Cardiovascular risk factors, painless
Retinal Vein Occlusion: Cardiovascular risk factors, painless, metamorphopsia
Optic neuritis: Young, female, Caucasian, neurological symptoms
GCA: pain, headache, JAW CLAUDICATION, nausea, weight loss, history of PMR
AACG: pain, haloes, blurred vision, red eye, LONG-SIGHTED, Asian
Vitreous haemorrhage: History of diabetes, floaters, painless
Macular haemorrhage/pathology: metamorphopsia, painless, history of AMD
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7 TRANSIENT
BLINDNESS CAN BE
SERIOUS
Temporal arteritis (GCA)
Carotid artery disease
Exclude migraine aura
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8 NEVER IGNORE NEW
ONSET DIPLOPIA
Binocular diplopia can be the first sign of temporal arteritis
or posterior communicating artery aneurysm.
DIPLOPIA
One eye or two
Intermittent v.s. constant
Horizontal vs. Vertical vs. Oblique
Have a low threshold for imaging (MRI most sensitive)
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9 ORBITAL CELLULITIS IS
A LIFE THREATENING
INFECTION
Pain on eye movement is often the first sign of orbital
involvement in a patient with lid swelling and redness.
Late signs include proptosis, diplopia, and relative afferent
pupillary defect (RAPD)
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10 HEADACHES ARE
RARELY DUE TO A
REFRACTIVE CAUSE
Ocular causes - examine for
- Acute angle closure crisis. Cloudy cornea, shallow AC
- Iritis: Cells/flare, posterior synechiae (abnormal pupil)
Extra-ocular causes - examine for
papilloedema, visual field defects and
temporal arteritis
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TRAUMA
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11 ALWAYS IRRIGATE
CHEMICAL BURNS
Immediately irrigate copiously with water for 15 minutes
(instill local anaesthesia to assist)
Immediate referral
Severity of burn is graded based on
degree of limbal ischaemia
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12 A PENETRATING EYE
INJURY IS AN
EMERGENCY
Cover with an eye shield, nil by mouth, and refer.
Do not instill any drops or ointment if penetrating injury
suspected.
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13 DO NOT REMOVE ALL
OCULAR FOREIGN
BODIES
Do not remove corneal foreign bodies that are deep central.
Do not remove penetrating foreign bodies
Suspect intraocular foreign body (IOFB) if history of
hammering or high-speed injury
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14 A CORNEAL
ABRASION SHOULD
IMPROVE IN 24 HOURS IF
THE CAUSE IS
REMOVED
Evert the eyelid to exclude foreign body and check
conjunctival fornices
Exclude corneal ulcer (white infiltrate, common in contact
lens wearer)
Use antibiotic ointment
Consider padding if pain is severe
Review daily until lesion heals
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15 EYE INJURY NEEDS
TO BE EXCLUDED IN
FACIAL AND LID INJURY
Eye lid lacerations require accurate apposition of the lid
margin do not excise eyelid skin
Beware of inner canthal injury to lacrimal drainage system
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16 BEWARE THE
UNILATERAL RED EYE
Common causes include foreign body (corneal/ sub-tarsal),
trauma, corneal ulcer, uveitis, acute glaucoma, herpes
simplex (HSV) keratitis or herpes zoster ophthalmicus (HZO)
(especially if nose involved).
in herpes simplex (HSV), it may be relatively painless, with a
history of recurrence increasing redness or reduction in
vision
In any patient with recent intraocular surgery is intraocular
infection (endophthalmitis) until proven otherwise
If cause uncertain refer
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17 RED EYE
EXAMINATION CAN
DETERMINE URGENCY
Test vision first as the combination of reduced vision and red eye is an
Emergency
Remove contact lens if present
Use local anaesthetic drops in examination of painful lesions, not for
continued pain relief.
Fluorescein highlights epithelial abrasions or ulcers
Redness maximal around cornea may indicate intraocular inflammation
Less urgent: tarsal gland infections, subconjunctival haemorrhage in
absence of trauma
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18 IRRITABLE EYES ARE
OFTEN
Dry eyes if they burn and sting
Blepharitis if lids are red and raw
Allergy if itchy
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19 CONJUNCTIVITIS IS
ALMOST ALWAYS
BILATERAL
Usually self limiting and will resolve without antibiotics
Swollen pre-auricular node suggests viral or chlamydial
cause
Always wash your hands after examination
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20 TOPICAL STEROID
USE SHOULD BE LIMITED
AND SUPERVISED
Topical steroid induced glaucoma can lead to blindness.
Do not allow prolonged use without ophthalmic supervision.
Topical steroids can promote herpes simplex corneal
ulceration and fungal infection
Systemic steroids can induce cataract