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Emergency ophthalmology


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Emergency Ophthalmology

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Emergency ophthalmology

  1. 1. An Ophthalmology Refresher Tiki Ewing Ophthalmology Registrar SCGH
  2. 2. Referrals • E-referrals checked daily • Details – why, what (include VA), when • Friday is AM clinic only – make referrals early • Is the patient well enough to come to clinic?
  3. 3. Examination • New pro-forma - please use it • Visual acuity (with distance glasses if uses or without), then with pinhole) • Pupils (please don’t dilate unless you are confident they are normal, or discussed if abnormal) • Movements • Colour vision (red saturations/eye handbook) • Confrontational fields
  4. 4. Slit Lamp Tips: • Practice makes perfect • You are most welcome to join us in clinic for practice sessions • Dilute the 2% fluorescein • Cobalt blue vs red free (green) • Looking for cells: 1x1mm2 beam, brightest light, high magnification
  5. 5. • IOP (post slit-lamp) • Fundoscopy Tonopen - Well anaesthetised eye - Sterile cover - Hold like a pencil, plan to patients cheek - Other hand lifts upper lid from orbital rim - NO PRESSURE on globe - If patient is squeezing in discomfort, can artificially raise IOP - 1295 : 95=accuracy
  6. 6. SERIOUS FEATURES • Visual acuity reduced • Significant pain  doesn’t significantly reduce with topical local • Patient’s only eye • Multiple eye drops/prolonged course • Recent surgery SERIOUS CONDITIONS Acute angle closure glaucoma Endophthalmitis Orbital cellulitis
  7. 7. 25yr old man, 1 week of red, discharging left eye, itchy and light sensitive
  8. 8. Adenoviral Conjunctivitis How to differentiate from other types • Burning, watery or mucopurulent D/C, painful pre-auricular lymph node, corneal involvement, pseudomembrane • 7 species of adenovirus, 54 serotypes, many, but not all cause conjunctivitis • Can survive on dry surfaces or in water for weeks • No known cure • Remains infective for up to 2 weeks
  9. 9. What about chlorsig • HEAVILY OVER USED Evidence: • Of cases GPs thought were bacterial conjunctivitis only 50% were • Randomised placebo controlled study in Kids (who are more likely to have bacterial conjunctivitis), chlorsig vs saline (blinded), cure within 7days in 85% chlorsig, 80% saline. • Evidence suggests managing conservatively with lubricants and cool compresses for 3 days, if not improving then consider it
  10. 10. 34yr old presents with a watery, red, aching eye, with photophobia
  11. 11. Uveitis/Iritis • Inflammation of the uveal tract • Immune mediated • Classification – Anterior – Intermediate – Posterior – Panuveitis Tips • PMHx relevant • Looks closely at pupil reactivity • Poor dilation • Extremely rare to be bilateral • Acutely photophobic
  12. 12. Herpetic Corneal Infections • HSV-1: Coldsores and Keratitis • HSV-2: Genital Herpes • VZV: Chicken pox, shingles, HZO HSV • Debridement, topical therapy (or oral, not both unless immunocompromised) • What about Steroids ?
  13. 13. Herpes Zoster Ophthalmicus
  14. 14. • Not all need referral • Hutchinson’s Sign • Eye involvement – Conjunctivitis – Keratitis (pseudodendrites) – Uveitis – Retinitis • Topical Antivirals have questionable role • Start PO antivirals early – reduces post herpetic neuralgia only – 800mg Aciclovir 5x or 1g Valtrex TDS (PBS covered)
  15. 15. Episcleritis • Sectoral inflammation of episcleral vessels (sometimes diffuse) • Mild-moderate tenderness over area • Can have fluorescein stain over area • Vision is NORMAL Treatment: artificial tears  Oral NSAIDs  topical steroids DDx • Scleritis – Older, known immune-mediated disease, deep severe pain, scleral as well as overlying vessel inflammation – No blanching with topical phenylephrine (2.5%)
  16. 16. Foreign Body Red Flags • ? Penetrating injury • Over visual axis • Residual material you are unable to remove • Infiltrate or AC reaction • Best outcome if as much of the rust ring is removed in first attempt • However if deep and central, can leave for it to migrate to surface
  17. 17. Corneal Infiltrate
  18. 18. 85yr old man Visual loss right eye “Salt rinse” this morning, now ? Left eye disturbance Wife terminal cancer VA: R CF, L 6/12 (NIPH)
  19. 19. 75year old lady Visual loss right eye overnight Painless CT head NAD Sent form JHC to SCGH ophthalmology for review ? Ocular cause
  20. 20. Posterior Vitreous Detachment • Occurs due to the liquefaction of vitreous gel with age • Occurs in 60% of 80yr olds • 20-30% have complications such as a retinal hole/tear or detachment • Risk factors crucial in our triaging (myope, Hx tear or detachment, recent eye surgery or trauma to eye, FHx) • You cannot adequately assess with a direct ophthalmoscope, these patients need referral
  21. 21. General Tips • Check visual acuity, use pinhole • Check optic nerve function • Check the cornea • Consider dilating • Please be honest