Urgencias retinales en oftalmologia , criterios y conceptos de urgencia

2. Presentacion
• Disminucion de Agudeza Visual Abrupta (total o parcial )
Intermitente
Uni O bilateral
• Dolor
• Alteraciones de Campo visual
• Alteraciones Timicas

3. Presentacion
• Asociacion Signos Oculares
Miosis, midriasis , diplopia , paralisis
o paresias musc.extraoculares ,
Reflejos pupilares alterados,
Imflamacion escleral , Uveitis ,
• Asociacion Patologias
Sistemicas
Diabetes , HTA , Enf. Coronaria,
Colagenopatias ,Inmunodeficiencias ,
Neoplasias , Pat .Autoinmunes ,
Panvasculares
• Asociacion de Sintomas
PERDIDA DE VISION , DOLOR

4. Vascular
• Émbolos
• Trombos
• Vasculitis
• Malformaciones vasculares

5. Infecciosa
 Endógena
 Exógena • Postraumática
• Postquirurgica

6. Traumática
• Contusional
• Lacerante
• Penetrante
• Perforante

7. • Hipertensión arterial
• Diabetes
• Colagenopatías
• Reumatológicas
• Enf . Desmielinizantes
Sistémica
(Secundaria)

8.  Agudeza visual Cy S/C y Ph.
 Examen Externo
 Reflejos Pupilares
 Movimientos Oculares
 Biomicoscopia
 Presion ocular.
 Gonioscopia (según el caso )
 Oftalmoscopia Binocular Indirecta
 Campo Visual por Confrontacion

9. URGENCIA INMEDIATA : menos de 12 horas
URGENCIA DIFERIDA : 13 a 48 horas.
PRIORIDAD Atencion : 3 a 15 dias
Atencion Consultorio externo programada

10. Eur J Ophthalmol. 2008 May-Jun;18(3):445-9.
Testing the reliability of an eye-dedicated triaging system: the RESCUE.
Rossi T1, Boccassini B, Cedrone C, Iossa M, Mutolo MG, Lesnoni G, Mutolo PA.
Abstract
PURPOSE:
To calculate the reliability of an eye-dedicated triaging system named Rome Eye Scoring System for Urgency and Emergency (RESCUE).
METHODS:
There were four coding parameters: pain, redness, loss of vision, and risk of open globe. Each parameter is assigned a score, the sum of which
allows color coding. There were 1000 consecutive patients divided into urgent (U) or non-urgent (NU) based upon diagnosis, need for
treatment, hospitalization, and/or follow-up visit. Correlation between RESCUE triage scoring as assigned by the nurse on presentation and
urgency as estimated retrospectively was calculated. Accuracy, sensitivity, and specificity have been calculated. False positives (FP) have been
defined as patients assigned a RESCUE green or yellow code while retrospectively judged NU and false negatives (FN) have been defined as
patients assigned a white code despite being considered U.
RESULTS:
Of 1000 patients, 332 (33.2%) were classified as U and 668 (66.8%) NU. The difference in RESCUE scoring between U and NU patients was
significant (p<0.001), as well as the correlation between RESCUE scoring and urgency status. Accuracy was 95% with 9.3% FP and 2.7% FN.
Sensitivity was 90.7% and specificity 97.2%. Positive predictive value was 94.6%, and negative predictive value was 95.2%. All 32 hospitalized
patients and 147/198 (74.2%) patients given a return appointment properly received a yellow or green code.
CONCLUSIONS:
RESCUE accuracy, sensitivity, and specificity yield encouraging results, confirming the system''s ability to properly spot the most urgent cases.
The concept of urgency in ophthalmology can be difficult to establish; nonetheless, an eye-dedicated triage
can help in properly prioritizing urgent patients.

11. • Perdida de Vision Monocular
• Examen Oftalmologico
• Signos asociados
• Isquemia Ocular
• Isquemia Cerebral

12. • Embolos en la Arteria Carotida +++
• Embolos en Corazon o Aorta
• Insuficiencia vascular por ateroesclerosis ( Aorta – Ojo )
• Hipoperfusion por cambios posturales o arritmias cardiacas
• Hipercoagulabilidad / hiperviscocidad sanguinea.
• Migrañas

13. Patología < 12 hs 13- 48 hs 72 hs a 15 días
Migraña ------- -------- Neuroftalmologia
Émbolos Ecocardio,Doppler
Carotideo y vasos
Cuello, hemograma
Completo , Ers ,
factores Coagulantes,
Lipidograma, glucemia
Cardiólogo
Papiledema Neuroftalmologia
RMN

14. Amaurosis Fugax Enfermedad Carotidea Emboligena
u Oclusiva
Marcador de Aumento de Riesgo
• Parkin PH, Kendall BE, Marshall J, McDonald WI: Amaurosis
fugax: Some aspects of management. J Neurol Neurosurg
Psychiatry 1982;45:l-6
• Muerte por infarto de
miocardio
• Precursor de Infarto cerebral
y TIA
Muuronen A, Kaste M: Outcome of 314 patients with transient
ischemic attacks. Stroke 1982;13:24-31
• Morax PV, Aron Rosa D, Gautier JC: Symptoms et signes
ophthalmologique des stenoses et occlusions carotidiennes.
Bull Soc Ophthalmol Francois 1970;l:169-174

15. Embolic
• Carotid bifurcation thromboembolism
• Great vessel or distal internal carotid artery atheroembolism
• Cardiac emboli (valve, mural thrombi, intracardiac tumor)
• Drug abuse-related intravascular emboli
Hemodynamic
• Extensive atheromatous occlusive disease
• Inflammatory arteritis (Takayasu's disease)
• Hypoperfusion (cardiac failure; acute hypovolemia; systemic
• diseases disturbing blood viscosity, coagulability, or content)
Ocular
• Anterior ischemic optic neuropathy
• Central or branch retinal artery occlusion (often embolic)
• Central retinal vein occlusion
• Nonvascular causes (hemorrhage, pressure, tumor, congenital)
Neurologic
• Brainstem, vestibular, and oculomotor
• Optic neuritis, optic nerve or chiasm compression
• Papilledema
• Multiple sclerosis
• Migraine
• Psychogenic Causes of Transient Monocular Blindness

16. Algoritmo
Diagnostico
Algoritmo
Tratamiento

17. ● Oclusion Vascular retinal
● Neuropatia Optica
● Lesion vascular cerebral
● Histeria

18. • Muy mala vision
• Ocurre en segundos o minutos
• Defecto pupilar
• Obstruccion de Arteria Central Retinal
• Obstruccion de Vena Central Retinal
• Variantes de Rama Arterial y Venosa

19. • 1: 100.000
• 75 % -- AV menor a 20/400
• Indolora
• 74 % de embolos son colesterol y calcio ( carotida )
• Pueden ser bilaterales

20. • Hipertension arterial
• Enf. Valvular cardiaca
• Isquemias cardiacas
• Diabetes
• Enfermedad Carotidea
• Enfermedad coronaria
• TIA
• Infarto miocardio
• Enf . Renal

21. Menores de 50 años
• HiperHomocistinemia
• Alt .factor V de leiden
• Deficiencias de Antirombina, Mutaciones geneticas
protrombina
• Sindrome antifosfolipidico
• Enf. Celulas falsiformes
• Vasculitis
• Uso de Anticonceptivos Orales
• Sindromes paraneoplasicos
• Proteina C y S

22. Eye (Lond). 2016 Jun 3. doi: 10.1038/eye.2016.111.
Associations of retinal artery occlusion and retinal vein occlusion to
mortality, stroke, and myocardial infarction: a systematic review.
Woo SC1, Lip GY1,2, Lip PL3.
Author information:
1University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK.
2Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
3Birmingham and Midland Eye Centre, City Hospital, Birmingham, UK.
Abstract
Retinal vascular events are perceived to be related to various cardiovascular complications. We conducted a systematic review to assess the relationship between
retinal artery/vein occlusions (RAO/RVO) and the incidence of mortality, stroke, and myocardial infarction (MI). A comprehensive electronic literature search
selected 93 relevant studies between 1992-2015: 16 articles qualified for inclusion (7 for mortality rate and MI, 11 for stroke). No published articles examined
associations of RAO to mortality or MI, but only to stroke. Because of the heterogeneity of studies, no meta-analysis was performed. The association with
mortality risk was highest at ~34.7% in RVO subgroup; whereas for MI, the risk was comparatively lower at 3.9-5.7% for RVO. There was no significant
difference in stroke rate when comparing central and branch RVO subgroups (6.5%), but was significantly higher at 19.6-25% in RAO. There is a positive
association of retinal vascular events to mortality, stroke, and MI. RAO is associated with a higher risk of stroke. Given that RAO and RVO patients would
generally present to ophthalmologists, their high cardiovascular risk should include a referral for cardiovascular assessment as part of their management
protocol.Eye advance online publication, 3 June 2016; doi:10.1038/eye.2016.111.

23. ● Cardiopatia (ecocardiograma)
● Obstruccion carotidea (doppler)
● Historia de ACV (MRI)
● Arteritis temporal (Sedimentacion)

24. Placa de Hollenhorst

25. Bilateralidad

27. ¨ El tiempo es Tejido ¨
240 minutos ----------- ideal antes 97 minutos
Hayreh SS, Zimmerman MB, Kimura A, Sanon A.
Central retinal artery occlusion.Retinal survival time.
Exp Eye Res. 2004;78:723736.

28. • Hipertension
• Diabetes
• Hiperlipidemias
• Disproteinemias
• Poligloburia
• Discrasias sanguineas (drepanocitos)
• Glaucoma

29. • Isquemica
• NO isquemica ( 70 % )
Presentacion

30. Factores predisponentes para TVC
Alteraciones hematologicas
a) Alt. Funcional
• Hemoglobinopatias Falciforme
• Alt.. Coagulacion
• Deficit Proteina C,S y antitrombina III
• Ac Antifosfolipidos
b) Alt .Cantidad
• Policitemias
• DBT
• Paraproteinemias ( mieloma multiple, crioglobulinemia, etc )
Alteraciones vasculares
a ) Compresion extrinseca
• Arterioesclerosis Arteria central Retinal
• Glaucoma Angulo abierto
• Tumor Orbitario
b) Alt. Pared vascular ( imflamacion )
Sarcoidosis , Sifilis , HIV , arteritis temporal .

32. Patologia <12 13-24 hs 2 a 15 dias
Arteria CO2 , paracentesis
Masaje
Ecocardio
Doppler Carotideo
Cardiologia
Tpa
Rutina completa .
ERS Alta . Esteroides
Completar
hematologico
Descartar vasculitis
VENA Heparina ?
Trombolisis ?
Cardiologia
Rutina
Angiografia
OCT Retinologo
Buscar trombofilia

33. ● Desprendimiento de Retina
● Hemorragia vitrea
● Lesion Macular Aguda
● Oclusion Aguda de Arteria O Vena Central de Retina
● Vitreitis

34. Eye (Lond). 1996;10 ( Pt 4):456-8.
Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary
for posterior vitreous detachment?
Dayan MR1, Jayamanne DG, Andrews RM, Griffiths PG.
PURPOSE:
The aim of the study was to determine whether patients presenting with an isolated posterior vitreous detachment require follow-up to identify retinal breaks not apparent
at presentation and whether some histories are more predictive of associated serious posterior segment pathology.
METHODS:
The notes of 295 patients presenting to eye casualty with flashes and/or floaters were reviewed.
RESULTS:
One hundred and eighty-nine patients (64%) had isolated posterior vitreous detachments, 49 (16.6%) had retinal detachments and 31 (10.5%) had flat retinal tears. Three
new breaks (3.3% of all tears found, 1.9% of review appointments) were identified only at follow-up. Although a subjective reduction in vision and a history of less than 6
weeks' duration were strongly predictive of retinal breaks, the large group of patients presenting with floaters alone (124/295, 42%) still harboured a significant proportion
(26.7%) of the retinal breaks.
CONCLUSIONS:
A follow-up visit for patients with an isolated posterior vitreous detachment can be justified to detect the small percentage of asymptomatic retinal breaks. Although a
subjective reduction of vision is the symptom most predictive of serious posterior segment pathology, it would be unsafe to identify particular subgroups of patients alone
for careful examination.
Uncomplicated posterior vitreous detachment may develop into a retinal tear within six weeks
Patients with uncomplicated posterior vitreous detachment should be re-examined by an
ophthalmologist at six weeks, as 3.4% will have a new retinal tear.

36. Tomado del Preferred Practice Pattern
American Academy of Ophtalmology

37. Tomado del Preferred Practice Pattern
American Academy of Ophtalmology

38. • 10-18 casos cada 100.000 hab.
• De estos 20-40 % luego cirugia catarata.
• 10 % trauma
• Bilateralidad 1,7 %.
• Aumento del 10 % riego de DR ,luego de DR no
traumatico en el otro ojo.
• DR secundario a extraccion refractiva de
Cristalino en pacientes Miopes altos 2-8 %
• No incrementa el riesgo de DR los lentes
faquicos.

40. Vogt-Koyanagi-Harada

41. Patologia < 12 hs 13- 48 hs 72 hs a 15 dias
Desgarro > 1 hs severo
traccion borde
elevado o
multiples
NO severo y
unico
Reposo .y
posterior Tto
Agujero trofico ,
operculo libre
,pigmentacion .
Desp. Retina Reciente
Macula on off /
menos de 72 hs
Total o > de 72 hs
de perdida de
vision
Dialisis Inf. Temp
DR cronico
PVR
DR traccional
Desp. Retina
Exudativo
VKH o secundario
a tumor

42. ● Perdida suele ser gradual en horas
● Puede ser parcial iniciandose con miodesopsias
o total
● Siempre esta comprometido el reflejo rojo

44. Patologia < 12 hs 13- 48 hs 72 hs a 15 dias
Desgarro visible Laser o crio ----------------------
---
----------------------
---
HV denso Ecografia Ecografia Diabetes , HTA ,
Vascular ,
trauma
HV denso Desgarro o DR
visible por eco
Work up para
Laser o cirugia
vitreoretinal

45. Br J Ophthalmol. 2016 Feb 11.
Visual recovery after retinal detachment with macula-off: is surgery
within the first 72 h better than after?
Frings A1, Markau N1, Katz T2, Stemplewitz B1, Skevas C1, Druchkiv V1, Wagenfeld L1.
AIMS:
To investigate the influence of lag time between the onset of central visual acuity loss and surgical intervention of macula-off retinal detachment.
METHODS:
This retrospective case series examined all consecutively treated eyes with primary macula-off retinal detachment at the University Hospital Hamburg
(Germany) from February 2010 to February 2015. Records of 1727 patients operated by six surgeons were reviewed. Eighty-nine eyes (5.2%) from 89
patients met the inclusion and exclusion criteria. The main outcome measure studied was final visual acuity as a function of symptom duration of macula-
off detachment. Secondary outcome measures studied were influence of age and surgical technique. Symptom duration was defined as the time from the
onset of loss of central vision to surgical intervention.
RESULTS:
After 10 days no clinically relevant difference was seen in final visual acuity. Eyes with symptom duration of 3 days or less achieved best final visual acuity
(p<0.001). Age and preoperative visual acuity had no influence while vitrectomised eyes had better outcome compared with those with scleral buckling.
CONCLUSIONS:
Our study suggests that 1. After 10 days of central visual acuity loss, the final visual outcome is clinically comparable and independent of
further delay of surgery up to 30 days. 2. Eyes treated up to 3 days after onset of loss of central vision have better final
visual acuity than eyes with longer lag time. However, we did not find statistically significant differences within the first 3 days. 3. Surgery
for macula-offretinal detachment may therefore most likely not be postponed without compromising the patient's visual prognosis.
KEYWORDS:
Rehabilitation; Retina; Treatment Surgery; Vision

46. ● Perdida de vision central (lectura)
● Metamorfopsia
● Anamnesis y forma de vision orientan diagnostico

47. ● Coroidopatia serosa central
● Hemorragia macular
● Agujero macular
● Corioretinitis
● Membrana Neovascular Coroidea

48. Central Serosa
Macroaneurisma
Hemorragia Macular
MNV

49. Patologia < 12 hs 13- 48 hs 72 hs a 15 dias
Agujero Macular Oct En traccional
.Servicio Retina
Oct en completo
Servicio retina
Pucker macular OCT. Servicio retina
MNV Coroidea < 2 dias Oct y Rfg
FAF, Servicio Retina.
Oct y rfg ,
Servicio retina
Coroideopatia
Central serosa
Rfg y Oct ,
Servicio retina
Toxoplasmosis Tto sistemico y
evaluacion RFG
Hemorragia Macular Ver causa Vitrectomia o
Yag subhialoideo ?

50. • Agente Etilogico
Familia Herpes Varicela Zoster (H.simplex , Epstein Bar, CMV )
• Diagnostico
Forma clinica y curso evolutivo

51. • Focos de Retinitis necrotizantes homogeneos
perifericos
• Rapida progresion
• Diseminacion circumferencial
• Vasculitis arteriolar OCLUSIVA.
• Panuveitis AGUDA .
Manifestacion Clinica

52. 1 º Fase ( 1y 2 semana )
• Uveitis anterior y placas Necrosis Retinal y Vasculitis oclusiva.
2º Fase ( 3 y 4 semana )
• Vitreitis y extension Lesion retinal. Disminucion AV .severa . Neuritis Optica
3º Fase ( 2 a 3 mes )
• Desprendimiento de Retina
Fases Uveitis

53. Segmentoposterior
Triada diagnostica
• Necrosis Retinal
• Vasculitis Oclusiva
• Vitreitis
Asociacion 65 % casos con Neuritis optica retrobulbar o papilitis
Bilateralidad 30 -60 % casos

55. Consecuencias

58. Tratamiento
Tratamiento Ocular
• Vitrectomia mas Panfotocoagulacion con Aceite de Silicon .
• Inyecciones Intravitreas de Antivirales
Sistemico
Acyclovir : 10 mg/kg IV x 10-14 dias seguido de
Valacyclovir :1000 mg via oral x 6 semanas

59. • Perdida Vision tenue a Profunda
• Perdida en horas o dias
• Defecto pupilar aferente
• Dolor orbitario (mov.oculares)
• 18-45 años
• Unilateral (>)

60. ● Viral (Joven)
● Sifilis (adulto)
● Esclerosis multiple
● Isquemica (mayor)

65. ●Aterosclerosis
●Arteritis temporal

66. Patologia <12 hs 13-24 hs 3 a 15 dias
Niño RNM, Hem, sed,
prot c
Neurologia
Adulto FTAABS
RNM
Neurologia
Mayor 60a Sedimentacion,
Neurologia
Reum, cardiolgo,
neuro, doppler
carotideo