Eye emergencies


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Important eye emergencies in the ED

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  • Equipment: Morgan Lens Ophthalmoscope Fluorescein Eye drops-Amethocaine/Tropicamide Tonopen Ref process at Cabrini
  • Conjuctiva-Bulbar, Palpebral
  • palpebral conjunctiva lines the lids
  • Normal ICP
  • Bowie-L eye permanently dilated pupil from trauma at child
  • RELATIVE AFFERENT PUPILLARY DEFECT: L light in R eye, L constricts, light swings to L eye, L dilates since reduced light transmission on L
  • Presumed glaucome
  • Forrest Whitaker-congenital ptosis
  • Eye emergencies

    1. 1. Eye Emergencies Dr Dane Horsfall Emergency PhysicianCabrini Emergency Department
    2. 2. Overview Eye Anatomy/Terminology History/Examination Red Eye Acute visual loss Eye Trauma
    3. 3. Anatomy
    4. 4. Anatomy
    5. 5. Terminology Keratitis = inflammation of cornea Blepharitis = inflammation of the eyelid Iritis = inflammation of Iris Uveitis = inflam of uvea, (middle layer-iris, ciliary body and choroid)  Anterior uveitis (most common) – inflam. iris and ciliary body aka “Iritis”  Intermediate uveitis – inflam. ciliary body  Posterior uveitis – inflam. choroid  Diffuse uveitis - all
    6. 6. History/Examination Glasses? Contact Lenses? Previous eye conditions/trauma/surgery/med s Visual Acuity  Snellen chart x/y  X is distance from chart (ie 6 metres)  Y is smallest font size read  Eg Normal 6/6, just top line 6/60  Vision less than 6/60 count no. of fingers/hand movements/light perception  Pin hole corrects refractory error to 6/9 or better
    7. 7. Examination Visual Fields Evert eyelids-local anaesthetic (Amethocaine) aids thorough eye exam Eye movements “H” CN III, IV, VI palsies, fatigability (myasthenia)
    8. 8. Examination Ophthalmoscopy: dark, dioptric to zero, pt focus on corner of room  Pupils  Reflex  Symmetry  Cornea  Lens  Humour  Retina-Fundoscopy-dilate pupil-Tropicamide  Can use cobalt blue light with fluorescein
    9. 9. Examination Slit Lamp-where is it?  Lateral canthus at black line on frame  Pt to look at examiners R ear when examining R eye  Joystick to focus  Cobalt blue light for fluorescein-NOT green light filter. But Fluorescein dye appears green under blue light
    10. 10. Painful Red Eye Case:  65yo F, 1/52 increasing R unilateral eye pain assoc n/v, Dx as migraine  o/e  visual acuity reduced  hazy cornea  fixed mid-dilated pupil  hard eyeball
    11. 11. Acute Angle ClosureGlaucoma Females in 60-70s, esp. Asians/Eskimos, +ve FHx defined as  > 2 of  ocular pain,  nausea/vomiting,  intermittent blurred vision with halos  and at least 3 of:  conjunctiva injection  corneal epithelial oedema = hazy  mid-dilated non-reactive pupil  IOP >21 mmHg can be >60 mmHg  shallower chamber in the presence of occlusion.
    12. 12. Acute Angle ClosureGlaucoma Aqueous humor  produced by ciliary body (posterior chamber)  passes thu pupil into ant chamber drained via trabecular meshwork and canal of Schlemm in the angle. Contact between the lens and the iris blocks flow, pressure in posterior chamber - iris bows forward closing angle – reduce drainage Precipitated by dilated pupil- darkness, stress, medications (anticholinergic, sympathomimetic) Chronic open angle- no pain no attacks-slow progressive vision loss
    13. 13. Acute Angle ClosureGlaucoma Intra-ocular pressure measurement: Normal 10-20mmHg  Goldman applanation tonometer: attached to the slit lamp  Storz/Schiotz Tonometer  Tono-Pen handheld electronic contact tonometer ($3000)
    14. 14. Acute Angle ClosureGlaucoma Mx Ophthal. referral  Acetazolamide 500mg IV  Topical beta-blocker  Topical steroid  Analgesics/Anti-emetics/Supine  Once pressure-induced ischemic paralysis of the iris resolves around 1 hour post initial Rx then:  Pilocarpine: a miotic (constricts pupil) – opens angle, should be administered every 5 mins for 30 mins  Laser peripheral iridotomy performed 24-48 hours after IOP is controlled is definitive treatment
    15. 15. Famous Eyes Who’s eyes are they?
    16. 16. Painful Red Eye Case:  45yo F with unilateral red, painful eye  PHx Crohn’s Disease  o/e blurred vision, perilimbal injection,  Slit lamp  “floaters/debris in anterior chamber”
    17. 17. Acute Anterior Uveitis (Iritis) Unilateral, painful red eye, blurred vision, photophobia, and tearing Peri-limbal injection, worse closer to limbus: (conjunctivitis= worse further from limbus) Visual acuity may be decreased Examine anterior chamber with Slit lamp  Increase in protein content of aqueous causes an effect known as “flare”, looks “smokey”  White or red blood cells may be observed in the anterior chamber  Severe cases - inflam. cells accumulate as sediment in ant. chamber = Hypopyon
    18. 18. Iritis Causes  50% idiopathic  Assoc  CTD (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome, psoriatic arthritis, sarcoidosis)  Infections: Herpes, syphilis, TB, toxoplasmosis, histoplasmosis, CMV, Candida  Trauma Mx Referral: steroids and cycloplegics, antimicrobials.
    19. 19. Painful Red Eye Herpes simples – dendritic ulcers Rx topical Acyclovir Bacterial Ulcer or Acanthamoebal ulcer: amoeba assoc contact lens Mx urgent Ophthal ref. ? admit/antimicrobials
    20. 20. Painful Red Eye - Eyelid Chalazion - eyelid cyst inflam. of blocked meibomian gland -usually painless and larger. Rx warm compresses/antis/usually resolve can inject steroids/surgically remove Stye – infection (staph) of the sebaceous glands at base of the eyelashes. Rx warm compress, pull out eyelash, antis Blepharitis – inflam. eyelid can be infective. Rx warm wet compress/ antis Herpes Zoster – vesicular rash, can cause infection of all parts of eye. Nasociliary branch involvement predicts serious complications: ocular inflam. and corneal denervation. Mx Opthal ref, Acyclovir
    21. 21. Painful Red Eye Conjunctivitis  Viral - recent URTI, clear, watery discharge  Allergic –pruritus, clear, watery discharge  Bacterial – pus, swab, staph/strep/ gonococcal/chlamydia,  Rx Chlorsig
    22. 22. Red Eye Scleritis:  Inflam sclera- localized, nodular, or diffuse  Vision may be impaired  Sclera thick, discoloured  Severe pain  Assoc with CTD (esp RA) and Vasculitis  Mx Analgesia, Ophthal ref steroids/ immunosuppressant Pterygium :  raised yellow, fleshy lesion at limbus, may be inflamed  Asymptomatic or redness, swelling, itching, irritation, blurred vision  r/f UV, FHx, Male  Mx lubricant, sunglasses, refer - surgery
    23. 23. Famous EyesWho’s eyes are they?
    24. 24. Case 60yo M Sudden, painless loss of vision L eye, previous partial/intermittent loss of vision over a few days PHx IHD, HT, DM L eye light perception only, relative afferent pupillary defect Fundus: pale, arteries/veins narrowed
    25. 25. Central Retinal ArteryOcclusion Embolism  Most commonly cholesterol, cardiac (assoc HT,DM) can be calcific, bacterial, Giant cell arteritis Amaurosis Fugax : transient loss of vision lasting seconds to minutes, can precede  Mx Urgent ophthal referral  Decrease intra-ocular pressure  Acetazolamide/Anterior chamber paracentesis  Move clot  Pulsed ocular compression  Anticoagulate  Intra-arterial fibrinolysis
    26. 26. Central Retinal Vein Occlusion Sudden painless loss of vision R/F: age, HT, DM, prothrombotic disorders Types: Non-ischaemic and Ischaemic Signs: Decreased visual acuity, Relative Afferent pupillary Defect, abnormal red reflex Fundus haemorrhage (“Stormy sunset”) Mx Ophthal referral  Anticoag, aspirin  Surgery incl. Laser photocoagulation
    27. 27. Optic Neuritis Vision loss (esp. colour) over hours-days, pain with eye movements, central scotoma Usually unilateral, F 18-45yo may be 1st presentation of demyelinating disease-MS Swollen optic disc May have other neurology Mx Ophthal referral, IV IV steroids
    28. 28. Giant Cell Arteritis AKA Arteritic Ischaemic Optic Neuropathy Females, 60’s Profound unilateral visual loss Check for  Jaw claudication  Headache  Scalp tenderness  Polymyalgia Rheumatica in 50% Fundus: disc oedema ESR >60mm/hr Rx Ophthal referral, Prednisolone
    29. 29. Retinal Detachment Result of retinal hole with seepage of fluid between retina and choroid R/F age, trauma Signs  flashing lights, floaters  Vision loss may be filmy, cloudy, irregular, or curtainlike  Visual field defects Mx Ophthal ref., Repair  Laser therapy  Cryotherapy  Intraocular gas (ie, pneumatic retinopexy) tamponades retina  Intraocular repair
    30. 30. Famous Eyes Who’s eyes are they?
    31. 31. Eye Trauma
    32. 32. Corneal injuries Corneal Abrasion  Sensation of foreign body, light sensitivity, tearing  Local drops (Amethocaine 0.5%)  Fluorescein with blue light  Rx Chlorsig (drops/ointment) Corneal Flash burns  Arc welding/UV lamp  Red, painful, tearing  LA, Fluorescein  Rx Chlorsig
    33. 33. Corneal foreign body Dirt/glass/metal (rust ring) Velocity of impact Signs of penetration Removal  Local  25G needle, lateral approach using slit lamp  Dental burr for rust ring (adherent rust ring may loosen with Chlorsig/patch for 24hrs as the cornea heals, may recall pt)
    34. 34. Chemical burns Acids: toilet/pool cleaner, battery fluid Alkalis (more harmful): lime, mortar/plaster, drain cleaner, oven cleaner, ammonia Immediate Mx: LA copious irrigation with fluid-bag of N/Saline + Morgan Lens until pH 7.5, test aquity Degree of vascular blanching (esp at limbus) proportional to severity of burn Chlorsig, Ophthal. referral
    35. 35. Blunt Trauma - Haemorrhage Subconjunctival Hemorrhage  usually benign, if spont. Check BP/ Coags  If cant see post border ?Orbital # Hyphaema: blood in anterior chamber  If >1/3 = damage to drainage angle, risk glaucoma  Mx shield/patch/semi- recumbent/rest +/- sedation/admission no NSAIDs, Ophthal. Ref.  Recurrent bleeding in 10% esp with early mobilization Hemorrhage vitreous or retina, can be accompanied by a retinal detachment. Iris damage can result in poor pupil reactivity = Traumatic mydriasis. Misleading Neuro signs Lens can be damaged or dislocated and a cataract may develop
    36. 36. Blunt trauma - Orbital blowoutfracture Usually inferior wall since weakest Signs:  Diplopia/Ophthalmoplegia from muscle entrapment. Tethering of inferior rectus prohibits the upward movement of the globe.  Proptosis from swelling or retrobulbar hemorrhage and later Enophthalmos from loss of volume  Infraorbital nerve entrapment- numb cheek/upper teeth  Epistaxis 30% incidence of a ruptured globe in conjunction with orbital fractures. (Wilkins RB, Havins WE. Current treatment of blow-out fractures. Ophthalmology. May 1982;89(5):464-6)
    37. 37. Blowout Fracture Mx  Repair: Indicated if significant diplopia or cosmetically unacceptable enophthalmos. Most surgeons will wait 10 to 14 days following the trauma to allow for resolution of the associated edema and hemorrhage  Medical : if no diplopia/enophthalmos  o antis/no nose blowing/? steroids
    38. 38. Ruptured Globe May be from blunt or penetrating trauma Occurs at thinnest part:  Limbus (Visible with slit lamp)  Insertions of the extra-ocular muscles (reduced eye movements, loss red reflex from vitreous haemorrhage)  Around the optic nerve Signs:  Pupil : peaked, teardrop- shaped, or otherwise irregular  Seidel’s Sign  Enophthalmos (recession of the globe within the orbit)  Exophthalmos from retrobulbar hemorrhage
    39. 39. Ruptured Globe Ix: CT most sensitive Mx : Anti-emetics/analgesics/prophylactic antibiotics/tetanus/fast  Urgent Ophthal. referral always requires surgical intervention.  ? Suxamethonium in open globe injury controversial, weigh up risk to airway Mx and theoretical risk of ocular extrusion and ask opthal.
    40. 40. Penetrating Eye Trauma Easily missed since may seal over and abnormal signs may be subtle High risk with high velocity eg metal striking metal and glass Leave bodies insitu until surgery Signs:  Distorted pupil  Cataract  Prolapsed black uveal tissue on the ocular surface  Vitreous hemorrhage.  Seidel’s Sign  Shallow/flat anterior chamber or bubbles in anterior chamber Mx as for ruptured globe
    41. 41. Lid Lacerations Require Ophthal. ref. if:  Torn lid margins - must be closed accurately  Lacrimal ducts damage  Any suspicion of a foreign body or penetrating eyelid injury  Mx refer/Tetanus/iv antis/ antiemetics/shield eye
    42. 42. Famous Eyes Who’s eye’s are they?
    43. 43. Golden Rules Always check visual acuity Always attempt to open eye early and examine pupil/acuity etc in trauma Beware Dx unilateral conjunctivitis until more serious disease is excluded Don’t D/C pt with LA drops - impedes healing, further injury may occur to anaesthetized eye. Don’t start Steroid drops without ophthalmology r/v
    44. 44. References Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com Handbook of ocular disease, 2000 - 2001 Jobson Publishing, www.revoptom.com/handbook/hbhome.htm P T Khaw et al, Clinical review “ABC of Eyes- Injury to the eye” BMJ 2004;328:36-38 (3 January) Cameron et al, Textbook of Adult Emergency Medicine, Second Ed, Churchill Livingston, 2004 Eye Emergency Manual, NSW Ophthalmology Service, 2007 Retinal Detachment, G Larkin , Apr 7, 2008 www.emedicine.com Acanthamoeba, N Crum-Cianflone, Jun 30 2008, www.emedicine.com Facial Trauma, Orbital Floor Fractures (Blowout), A Cohen, Dec 18 2006, www.emedicine.com Glaucoma, Acute Angle-Closure, A Darkeh, Oct 3 2007, www.emedicine.com Scleritis, T Gaeta, Apr 14 2008 www.emedicine.com Wilkins RB, Havins WE. Current treatment of blow-out fractures. Ophthalmology. May 1982;89(5):464-6