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
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
Examination Visual Fields Evert eyelids-local anaesthetic (Amethocaine) aids thorough eye exam Eye movements “H” CN III, IV, VI palsies, fatigability (myasthenia)
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
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
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
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.
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
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)
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
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”
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
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
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
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
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
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
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
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)
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
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
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)
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
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
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.
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
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
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
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
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