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GEMC- Ocular Emgercencies- Resident Training

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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Ocular Emgercencies- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Ocular Emergencies Author(s): Joe Lex, MD, FACEP, FAAEM, MAAEM (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. Chambers of Horrors!! Eye Emergencies You Must Know Joe Lex, MD, FACEP, MAAEM Temple University School of Medicine Philadelphia, PA 3
  4. 4. The Basics Three major complaints: Change in vision Change in eye color Pain 4
  5. 5. History: Pain and Discomfort Anterior surface: burning, itching, tearing, foreign body sensation Orbital / periorbital: dull ache, pressure 5
  6. 6. History: Photophobia Hallmark of uveal inflammation (iritis, uveitis) Differentiate from “light sensitivity”: mild discomfort from bright lights 6
  7. 7. History: Discharge & Tears Discharge: primarily anterior surface disorders, like infection Tearing: reflex in origin, surface irritation from dysfunctional lubrication or injured epithelium 7
  8. 8. History: Visual Disturbance Blurred vision: anything from refraction error to occipital cortex Floaters: usually degenerative opacities within vitreous –Can be RBCs, WBCs, pigment granules in aqueous or vitreous 8
  9. 9. History: Visual Disturbance Glare or halo: light scatter from unclear ocular media –Mucinous tear film –Corneal edema / epithelial abnormality –Cataract –Vitreous haze 9
  10. 10. History: Double Vision Monocular: pathology within cornea or lens Binocular: ocular motility disturbance Horizontal: 3rd or 6th nerve palsy Vertical: after trauma, inferior rectus entrapment Double Vision 10
  11. 11. We’ll Try to Cover… Stye vs. chalazion Conjunctivitis vs. iritis vs. scleritis vs. episcleritis Vision loss – painful vs. painless Glaucoma Optic neuritis 15
  12. 12. We’ll Try to Cover… CRAO vs. CRVO Bell’s palsy Horner’s syndrome Minor trauma Major trauma Chemical burns 16
  13. 13. Eye Examination – 10 Part 1.Visual acuity 2.Lids, lashes, adnexa 3.Conjunctiva & sclera 4.Cornea 5.Pupil & iris 6. Anterior chamber & lens 7. EOM Motility 8. Visual fields 9. Slit lamp & IOP 10. Funduscopy 17
  14. 14. Eye Examination: General Start with peripheral and superficial Work to central and deep 18
  15. 15. 1. Visual Acuity 19
  16. 16. Herman Snellen Dutch ophthalmologist, February 19, 1834 – January 18, 1908 J.F. Lehmann, Wikimedia Commons 20
  17. 17. Visual Acuity 20 feet from chart Use green and red lines as reference Pinhole to correct Jeff Dahl, Wikimedia Commons 21
  18. 18. Visual Acuity Near-card also acceptable Hold 14 inches from eyes Presbyopics through bifocal 22
  19. 19. Visual Acuity – Pinhole Use pinhole if patient forgot glasses Nummer9, Wikimedia Commons 23
  20. 20. Visual Acuity – Pinhole Allows only passage of light perpendicular to lens –Light does not need to be bent prior to focusing onto retina Deficit corrects with pinholes  refractive problem 24
  21. 21. Visual Acuity – Documenting OD = oculus dexter = right eye OS = oculus sinister = left eye OU = oculus uterque = each eye OU = oculi uniti = both eyes Use + or – prn: 20/60-1, 20/40+2 25
  22. 22. Visual Acuity – Documenting Can’t read largest character on Snellen chart  count fingers Can’t count fingers  movement No movement  light perception –Document as NLP (no light perception) rather than “blind” or “unable to see” 26
  23. 23. 2. Lids, Lashes & Adnexa 27
  24. 24. Objectives Define blepharitis, and outline an appropriate treatment plan Identify and recognize clinical presentation and treatment for stye & chalazion Recognize and appropriately treat septal and preseptal cellulitis 28
  25. 25. Blepharitis Clubtable, Wikimedia Commons 29
  26. 26. Blepharitis Maolmhuire, Wikimedia Commons 30
  27. 27. Blepharitis Source Undetermined 31
  28. 28. Blepharitis Source Undetermined 32
  29. 29. Blepharitis – Angular Source Undetermined 33
  30. 30. Blepharitis Not serious: eye damage rare Lid cleaning: baby shampoo on Q-tip If needed: antibiotic cream 34
  31. 31. Bugs!! KostaMumcuoglu, Wikimedia Commons 35
  32. 32. Pediculosis / Pthiriasis Pediculosis: eyelid infestation by Pediculus humanus corporis (body) or capitus (head) Pthiriasis: eyelid infestation by Pthirus pubis (pubic louse, or crab louse) Both organisms are blood-suckers 36
  33. 33. Pediculosis / Pthiriasis Remove all visible organisms and nits (eggs) with forceps Pediculocidic medicated shampoo –Permethrin 1% Smother lice and nits with petroleum jelly or other bland ointments tid 37
  34. 34. Ptosis Stevenfruitsmaak, Wikimedia Commons 38
  35. 35. Drooping Lids Source Undetermined 39
  36. 36. Entropion Ectropion Source Undetermined Source Undetermined 40
  37. 37. Entropion 1.Senile: most common form 2.Congenital: typically effects upper eyelid 3.Spastic: neurologic, inflammatory or irritative process of eyelids 41
  38. 38. Entropion 4. Cicatricial: shortened tarsus secondary to ocular tissue scarring –Stevens-Johnson syndrome –Trachoma –Herpes zoster –Trauma –Chemical injuries or thermal burns 42
  39. 39. Entropion Source Undetermined 43
  40. 40. Ectropion Stretching with age, lower eyelid droops downward, turns outward Eyelid skin: thinnest skin in body Symptoms: sagging, dry, red, tearing, light and wind sensitivity Treatment: surgery 44
  41. 41. Ectropion Source Undetermined 45
  42. 42. Dacryocystitis Infection of tear sac between inner canthus of eyelid and nose Usually from blockage of tear duct May be related to malformation of tear duct, injury, eye infection, or trauma 46
  43. 43. Dacryocystitis – Findings Generally one eye Excessive tearing Tenderness, redness, swelling, discharge Red, inflamed bump on inner corner of lower lid 47
  44. 44. Dacryocystitis – Treatment Infants: gentle massage of area between eye and nose ± antibiotic drops or ointments Adults: above plus may need tear duct irrigation; surgery sometimes necessary 48
  45. 45. Dacryocystitis Source Undetermined 49
  46. 46. Dacryocystitis Source Undetermined 50
  47. 47. Dacryocystitis Source Undetermined 51
  48. 48. Stye (External Hordeolum) Acute staph infection of eyelash oil gland Location: lash line Appearance: small pustule Treatment: warm compresses, erythromycin ophthalmic ointment 52
  49. 49. Stye Source Undetermined 53
  50. 50. Stye Andre Riemann, Wikimedia Commons 54
  51. 51. Chalazion (Internal Hordeolum) Acute or chronic inflammation of eyelid due to blocked oil gland Red tender lump in lid Kotek1986, Wikimedia Commons 55
  52. 52. Chalazion (Internal Hordeolum) Treatment: 1.Warm moist compress 3-4 x a day 2.Erythromycin ophthalmic ointment to lid margins QID 3.(?)doxycycline 100 mg PO bid for 14 – 21 days if recurrent 4.Ophthalmology referral 4–6 weeks 56
  53. 53. Chalazion Poupig, Wikimedia Commons 57
  54. 54. Orbital Cellulitis (Post-Septal) 1.Extension from periorbital structures (paranasal sinuses, face, globe, lacrimal sac) 2.Direct inoculation of orbit from trauma or surgery 3.Hematogenous spread from bacteremia 69
  55. 55. Orbital Cellulitis (Post-Septal) Cardinal signs: proptosis and ophthalmoplegia Other findings: chemosis, fever, malaise,  vision, headache,  intraocular pressure, pain on eye movement, lid edema 70
  56. 56. Orbital Cellulitis (Post-Septal) Source Undetermined 71
  57. 57. Orbital Cellulitis (Post-Septal) Source Undetermined 72
  58. 58. Orbital Cellulitis (Post-Septal) Source Undetermined 73
  59. 59. Orbital Cellulitis (Post-Septal) Source Undetermined 74
  60. 60. Orbital Cellulitis (Post-Septal) Treatment Medical: appropriate antibiotics Surgical drainage if poor response to antibiotics (48 – 72 hours) or if CT scan shows completely opacified sinuses 75
  61. 61. Orbital Periorbital Source Undetermined Source Undetermined 76
  62. 62. Periorbital Cellulitis (Preseptal) Swelling,tenderness, redness around the eye No limitation of eye movement Less serious, more common than orbital cellulitis 77
  63. 63. Periorbital Cellulitis (Preseptal) Source Undetermined 78
  64. 64. 3. Conjunctiva & Sclera 92
  65. 65. Objective Identify and recognize the presentation and treatment for viral, bacterial, and allergic conjunctivitis Differentiate conjunctivitis from iritis, scleritis, and episcleritis 93
  66. 66. Pannus From Latin, "a piece of cloth“ Pathologically defined as superficial vascularization of cornea with infiltration of inflammatory- connective-granulation tissue Not a diagnosis, but a finding 94
  67. 67. Pannus Source Undetermined 95
  68. 68. Pannus Source Undetermined 96
  69. 69. Conjunctivitis Mucopurulent discharge Eyelids stuck in morning Inflamed conjunctiva: palpebral and bulbar, but stops at limbus Cornea clear 97
  70. 70. Conjunctivitis: Evaluation Fluorescein stain cornea to avoid missing abrasion, ulcer, dendrite P33tr, Wikimedia Commons 98
  71. 71. Conjunctivitis – Allergic Allergic: itch, burn, water Exam: injection, watery discharge, possible chemosis Treatment: cool compresses –Naphazoline (Clear Eyes®, Ocu- Zoline®, Allersol®, Vasoclear®) 99
  72. 72. Conjunctivitis – Allergic Histamine blocker: acute –Levocarbastine (Livistin®) Mast cell inhibitor: prevents future attacks –Lodoxamide (Alomide®) –Cromolyn Olopatadine (Patanol®): both 100
  73. 73. Conjunctivitis – Viral Often have history of exposure to “pink eye,” concurrent URI Exam: preauricular adenopathy, watery discharge, eyelid edema (especially with adenovirus) 101
  74. 74. Conjunctivitis – Viral Treatment: cool compresses Adenovirus: 2-3 weeks to clear, highly contagious Antibiotic ointment once or twice daily: prophylaxis against secondary bacterial infection 102
  75. 75. Conjunctivitis Joyhill09, Wikimedia Commons 103
  76. 76. Conjunctivitis red0_0eye, Wikimedia Commons 104
  77. 77. Conjunctivitis Rasbak, Wikimedia Commons 105
  78. 78. Conjunctivitis James Heilman, MD, Wikimedia Commons 106
  79. 79. Conjunctivitis – Bacterial Exam: yellow discharge, lids stuck in morning Extremely severe: gonococcus –Only bacterial with PAN Treatment: early generation antibiotic (sulfacetamide qid) 107
  80. 80. Conjunctivitis – Bacterial Avoid late generation broad spectrum (flouroquinolones): emerging resistance Non-responding: culture, adjust Gonococcal: ceftriaxone 108
  81. 81. Conjunctivitis – Bacterial Tanalai, Wikimedia Commons 109
  82. 82. Conjunctivitis – Gonococcal Centers for Disease Control and Prevention, Wikimedia Commons 110
  83. 83. Conjunctivitis – Gonococcal Source Undetermined 111
  84. 84. Conjunctivitis: Treatment No contact-lens  cheap antibiotic drops QID 5 – 7 days Contact-lens  fluoroquinolone (Ciloxan®, Ocuflox®) or aminoglycoside (Tobrex®) drops QID 5 – 7 days 112
  85. 85. Conjunctiva – Pale (Anemia) Source Undetermined 113
  86. 86. Subconjunctival Hemorrhage Common: minor trauma, cough, no apparent cause Frightening to see, no long-term sequelae Pain or vision loss suggests alternate diagnosis James Heilman, MD, Wikimedia Commons 114
  87. 87. Subconjunctival Hemorrhage Therealbs2002, Wikimedia Commons 115
  88. 88. Subconjunctival Hemorrhage Daniel Flather, Wikimedia Commons 116
  89. 89. Chemosis Swollen conjunctivae: sometimes lids can’t close Often related to allergic response, infection, severe exposure Other causes: angioedema, sleeping with eyes open 117
  90. 90. Chemosis Treatment: cool cloths, over-the- counter antihistamines, topical antihistamines Source Undetermined 118
  91. 91. Chemosis Source Undetermined 119
  92. 92. Chemosis Source Undetermined 120
  93. 93. Ciliary Flush  Uveal Tract University of Michigan Kellogg Eye Center, Wikimedia Commons 121
  94. 94. Ciliary Flush (More Later) EyeMD (Rakesh Ahuja, M.D.), Wikimedia Commons 122
  95. 95. Pterygium Jonathan Trobe, MD, University of Michigan Kellogg Eye Center, Wikimedia Commons 123
  96. 96. Pterygium José Miguel Varas, MD, Wikimedia Commons 124
  97. 97. Leukoplakia (precancer) Source Undetermined 125
  98. 98. Conjunctiva Jewelry Source Undetermined 126
  99. 99. Sclera – Jaundiced Sab3el3eish, Wikimedia Commons 127
  100. 100. Sclera – Jaundiced Centers for Disease Control and Prevention, Wikimedia Commons 128
  101. 101. Sclera – Blue (Osteogenesis Imperfecta) Herbert L. Fred, MD and Hendrik A. van Dijk, Wikimedia Commons 129
  102. 102. Scleritis Severe boring eye pain, may radiate to forehead, cheek, behind eye Red eye, light sensitivity,  vision 50% of patients have systemic autoimmune disease (rheumatoid arthritis, SLE, et al.) 130
  103. 103. Scleritis Kribz, Wikimedia Commons 131
  104. 104. Scleritis Source Undetermined 132
  105. 105. Scleritis Source Undetermined 133
  106. 106. Episcleritis Episcleral tissue between sclera and conjunctiva Acute mild-to-moderate discomfort with localized redness Self-limiting, no permanent damage No therapy needed: some patients may benefit from artificial tears 134
  107. 107. Episcleritis Asagan, Wikimedia Commons 135
  108. 108. Episcleritis Source Undetermined 136
  109. 109. 4. Cornea 137
  110. 110. Arcus Senilis (Gerontoxon) Common finding in elderly, of no pathological significance Formed by lipid deposition at periphery of cornea Also found in familial hyper- cholesterolemias 138
  111. 111. Arcus Senilis (Gerontoxon) Loren A Zech Jr and Jeffery M Hoeg, Wikimedia Commons 139
  112. 112. Arcus Senilis (Gerontoxon) Loren A Zech Jr and Jeffery M Hoeg, Wikimedia Commons 140
  113. 113. Arcus Senilis (Gerontoxon) Loren A Zech Jr and Jeffery M Hoeg, Wikimedia Commons 141
  114. 114. Kayser-Fleischer Ring Herbert L. Fred, MD, Hendrik A. van Dijk, Wikimedia Commons 142
  115. 115. Ultraviolet Keratitis Cornea “sunburned” by UV exposure “Snow blindness” or “welders flash” Presents 6 to 12 hours after UV exposure Very painful (“sand in the eyes”) Treat symptomatically 143
  116. 116. Ultraviolet Keratitis Source Undetermined 144
  117. 117. Ultraviolet Keratitis Source Undetermined 145
  118. 118. Corneal Abrasion Foreign body sensation: pain, photophobia,  visual acuity Topical anesthetic  complete relief (short-lived) Must examine for foreign body 146
  119. 119. Corneal Abrasion Proparacaine (Ophthetic®) 0.5% ester; onset 15 sec, lasts 20 min, not bacteriostatic Tetracaine 0.5% ester; lasts longer, more corneal toxicity Cocaine 1 – 4% ester solution 147
  120. 120. Proparacaine vs. Tetracaine Proparacaine = Ophthaine® Least irritating Onset 20 seconds Lasts 10 - 15 minutes $15 / bottle Tetracaine = Pontocaine® Stings a lot Onset 1 minute Lasts 15 - 20 minutes Both 0.5% solution 148
  121. 121. Corneal Abrasion – Findings Bulbar conjunctival injection Visual acuity should be normal Fluorescein + cobalt blue or Woods light: dye uptake where corneal epithelial cells damaged 149
  122. 122. Corneal Abrasion James Heilman, MD, Wikimedia Commons 150
  123. 123. Corneal Abrasion Source Undetermined 151
  124. 124. Corneal Abrasion Source Undetermined 152
  125. 125. Corneal Abrasion – Fingernail Source Undetermined 153
  126. 126. Poor Man’s Slit Lamp Source Undetermined 154
  127. 127. Tetanus and Eyes Cornea avascular, “tetanus prone” 38 cases reported between 1847 (sic) and 1993 33 involved perforated globe None in patient with simple corneal abrasion Benson WH. J Emerg Med 11:677, 1993 155
  128. 128. Corneal Abrasion Treatment: short-acting cycloplegic (Cyclogyl® 1%) Broad-spectrum antibiotic Early follow-up 156
  129. 129. Corneal Abrasion Eye patch: controversial –No benefit at follow-up DO NOT send topical anesthetics home with patient  ulcerations, perforation possible National Eye Institute, National Institutes of Health, Wikimedia Commons 157
  130. 130. Anesthetic Keratopathy Source Undetermined 158
  131. 131. Corneal Foreign Body Pain, foreign body sensation, red conjunctiva, tearing, lid spasm (blepharospasm) Excellent pain relief from topical anesthetic Definitive diagnosis: slit lamp 159
  132. 132. Corneal Foreign Body Source Undetermined 160
  133. 133. Corneal Foreign Body Source Undetermined 161
  134. 134. Corneal Foreign Body Source Undetermined 162
  135. 135. Corneal Foreign Body – Rust Source Undetermined 163
  136. 136. Corneal Foreign Body – Rust Source Undetermined 164
  137. 137. Spud Sarindam7, Wikimedia Commons 165
  138. 138. Magnet Burr Source Undetermined Source Undetermined 166
  139. 139. Pearls Evert eyelid to look for foreign bodies Fluorescein can permanently stain soft contact lenses 167
  140. 140. Lid Foreign Body Source Undetermined 168
  141. 141. Lid Foreign Body Source Undetermined 169
  142. 142. Lid Foreign Body Source Undetermined 170
  143. 143. Corneal Foreign Body Treatment Attempt flush  gentle stream Under magnification: removal with small-gauge needle or spud 171
  144. 144. Pearls Scratch from contact lens: use antibiotics –Infection, ulcers common –Cover Gram-negatives, especially pseudomonas 176
  145. 145. Pearls Avoid neomycin (Neosporin®): many people allergic Source Undetermined 177
  146. 146. NSAID Eyedrops Decrease cyclooxygenase activity  lower prostaglandin precursor  less prostaglandin synthesis NSAID + soft contact may give symptomatic relief, preserve binocular vision Salz JJ. J Refract Corneal Surg 1994 Nov-Dec; 10(6): 640-6 178
  147. 147. NSAID Eyedrops Diclofenac = Voltaren® ($48/5ml) Ketorolac 0.5% = Acular® ($45) 179
  148. 148. NSAID Eyedrops $9 / ml = $270 / ounce = $2160 / cup = $9000 / liter $37,854 / gallon 180
  149. 149. Cycloplegics / Mydriatics Cycloplegic paralyzes ciliary muscles that adjust lens shape –Relieves photophobia, pain Mydriatic causes pupil to dilate –Can cause acute narrow angle closure 181
  150. 150. Mydriasis Cycloplegia Duration Atropine 30 min 1 hr 14 days Homatropine 10 – 30 min 30 – 90 min 6 hr – 4 days Scopolamine 40 min 40 min 24 hr Cyclopentolate (Cyclogyl®) 15 – 30 min 15 – 45 min 24 hr Tropicamide (Mydriacyl®) 20 – 30 min 20 –25 min 4 – 6 hr 182
  151. 151. What Works Best? 401 patients with corneal abrasions Lubrication vs. homatrapine vs. NSAID drops vs. homatropine plus NSAID drops All outcomes: no difference among any groups Carley F. J Accid Emerg Med 18(4):273,2001 183
  152. 152. Corneal Ulcer Common cause: soft contacts Worse in extended wear Pain, tearing, light sensitive Exam: staining epithelial defect Slit lamp: possible hypopyon 184
  153. 153. Corneal Ulcer Treatment Fluoroquinolone drops every hour (Ciloxan®, Ocuflox®) Cycloplegic drops (Cyclogyl®) NO patch, rapid follow-up 185
  154. 154. Pseudomonas Keratitis Source Undetermined 186
  155. 155. Corneal Ulcer Source Undetermined 187
  156. 156. Corneal Ulcer Source Undetermined 188
  157. 157. Shingles / Herpes Keratitis Zoster of trigeminal nerve Vesicle on tip of nose  worry about cornea involvement (nasociliary nerve branch) Fluorescein  dendrites 189
  158. 158. Shingles / Herpes Keratitis Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center, Wikimedia Commons 190
  159. 159. Shingles / Herpes Keratitis Source Undetermined 191
  160. 160. Shingles / Herpes Keratitis Source Undetermined 192
  161. 161. Shingles / Herpes Keratitis Source Undetermined 193
  162. 162. Shingles / Herpes Keratitis Source Undetermined 194
  163. 163. Shingles / Herpes Keratitis Source Undetermined 195
  164. 164. Shingles / Herpes Keratitis Source Undetermined 196
  165. 165. Shingles / Herpes Keratitis STAT refer to ophthalmologist Oral anti-virals not helpful Some success with acyclovir ophthalmic 197
  166. 166. Contact Lens Jewelry Source Undetermined 198
  167. 167. 5. Pupil and Iris 199
  168. 168. Pupillary Reaction PERRLA: Pupils Equal Round Respond to Light & Accommodation About 25% of population has unequal pupils with no known etiology or pathological consequences 201
  169. 169. Pupillary Reaction Exam in semi-darkened room Have patient view distant object –Prevents accommodative and convergence from coming into play Anisocoria: reassess in varying light –If changes, more likely pathologic 202
  170. 170. Light Reflex View distant, then near target Watch both eyes to confirm equal, symmetrical responses If afferent arc intact, direct and consensual equal Do NOT shine light directly into eye; direct slightly inferior and upward 203
  171. 171. Heterochromia Iridis Tazztone, Wikimedia Commons 217
  172. 172. Iridodialysis Usually traumatic Photophobia, deep eye pain due to ciliary muscle spasm Continued pain after instillation of topical anesthetic Pain on accommodation 218
  173. 173. Iridodialysis Ciliary flush, cells and flare common Treatment: long-acting cycloplegia, topical steroid Consultation with ophthalmologist, but next-day follow-up okay 219
  174. 174. Iridodialysis Rakesh Ahuja, MD, Wikimedia Commons 220
  175. 175. Iridodialysis Petr Novak, Wikimedia Commons 221
  176. 176. 6. Anterior Chamber and Lens 222
  177. 177. Cells and Flare Cells: WBCs on the posterior cornea Flare: reflection of light on protein shed from inflamed iris or ciliary body Think of sunlight streaming through dust 223
  178. 178. Cells and Flare Source Undetermined 224
  179. 179. Hyphema Disruption of iris or ciliary body blood vessels Complaint: pain, photophobia,  visual acuity Findings: blood in anterior chamber 225
  180. 180. Hyphema Rakesh Ahuja, MD, Wikimedia Commons 226
  181. 181. Grade Size of Hyphema 0 Circulating RBCs only; no layering 1 Less than 1/3 2 1/3 to 1/2 3 1/2 to less than total 4 Total “eight ball” 227
  182. 182. Hyphema Source Undetermined 228
  183. 183. Hyphema Source Undetermined 229
  184. 184. Hyphema – Treatment Reliable patient, small hyphema: home therapy Elevate head of bed (30o – 45o) Limit eye movement (reading) Symptom relief 230
  185. 185. Hypopyon From Greek hupo “ulcer,” puon “pus” Pronounced hie PO pee on White cells (pus) in anterior chamber Causes: many Always an eye emergency 231
  186. 186. Hypopyon EyeMD (Rakesh Ahuja, M.D.), Wikimedia Commons 232
  187. 187. Hypopyon Source Undetermined 233
  188. 188. Hypopyon Source Undetermined 234
  189. 189. Subluxed Lens Blunt trauma causes disruption of zonule fibers Monocular diplopia, marked blurred vision Trembling or shimmering of iris with rapid eye movements 235
  190. 190. Subluxed Lens Anterior dislocation can manually block aqueous flow, precipitate acute glaucoma Marfan’s Syndrome 236
  191. 191. Subluxed Lens Source Undetermined 237
  192. 192. Subluxed Lens Source Undetermined 238
  193. 193. Marfan’s Syndrome Dissections Aneurysms Hernias Arachnydactyly Sunken chest Loose jointed Source Undetermined 239
  194. 194. Cataract Immature: some remaining clear areas Mature: completely opaque Hypermature: liquefied surface that leaks through the capsule 240
  195. 195. Cataract Difficulty seeing at night, halos around lights, sensitive to glare Most people have some clouding of lens after age 60 Age 65 – 74: 50% have cataract 75 and older: 70% have cataracts 241
  196. 196. Cataract Rakesh Ahuja, MD, Wikimedia Commons 242
  197. 197. Cataract Community Eye Health, Flickr 243
  198. 198. What the Patient Sees National Eye Institute, National Institutes of Health, Wikimedia Commons 244
  199. 199. Intraocular Lens Soerfm, Wikimedia Commons 245
  200. 200. Intraocular Lens – Displaced Source Undetermined 246
  201. 201. Phacoanaphylaxis Lens is “privileged space,” highly antigenic Ruptured lens  intense allergic reaction  endophthalmitis 247
  202. 202. Endophthalmitis – Streptococcus Source Undetermined 248
  203. 203. Endophthalmitis – Pseudomonas Source Undetermined 249
  204. 204. ANAG – Presentation Eye and facial pain Unilateral blurred vision Photopsiae: colored haloes around lights Nausea and vomiting (occasional) Visual acuity: often 20/80 or worse 250
  205. 205. ANAG – Findings Deep conjunctival and episcleral injection in a circumlimbal fashion Fixed, mid-dilated pupil Edematous or "steamy" cornea Shallow anterior chamber Elevated intraocular pressure 251
  206. 206. Cloudy Cornea Source Undetermined 252
  207. 207. Cloudy Cornea Source Undetermined 253
  208. 208. Mid-position Pupil Source Undetermined 254
  209. 209. Narrow Anterior Chamber Source Undetermined 255
  210. 210. Narrow Anterior Chamber Source Undetermined 256
  211. 211. Pale Optic Disc Source Undetermined 257
  212. 212. Measuring IOP Tonometry: IOP 30 to 60mm Hg or higher Schiotz® Goldman® Tonopen® 258
  213. 213. Schiotz Tonometer Community Eye Health, Flickr 259
  214. 214. Goldman Tonometer Jason7825, Wikimedia Commons 260
  215. 215. Tonopen® Source Undetermined 261
  216. 216. What the patient sees National Eye Institute, National Institutes of Health, Wikimedia Commons 262
  217. 217. ANAG Source Undetermined 263
  218. 218. ANAG – Treatment Shrink pupil (green): pilocarpine Miotics ineffective if pressures over 40mm Hg due to iris ischemia In that case, use beta-blocker and / or apraclonidine 264
  219. 219. ANAG – Treatment If no significant IOP reduction after 45 minutes: oral carbonic anhydrase inhibitor (acetazolamide) Also use hyperosmotic: 3-5 ounces oral glycerin or isosorbide over ice Check IOP every 15 minutes 265
  220. 220. ANAG – Treatment Once IOP below 40mm Hg: pilocarpine 2% and prednisolone acetate 1% every 15 minutes Safe to discontinue this regimen when IOP below 30mm Hg 266
  221. 221. 7. Extraocular Motility 267
  222. 222. Double Vision Monocular vs. Binocular Extraocular muscle testing –Six cardinal positions 268
  223. 223. Conjunctival Caput Medusa Source Undetermined 280
  224. 224. Cavernous Sinus Thrombosis Source Undetermined 281
  225. 225. 8. Slit Lamp Examination 282
  226. 226. Slit Lamp Examination PFrankoZeitz, Wikimedia Commons 283
  227. 227. Slit Lamp Examination U.S. Navy, Wikimedia Commons 284
  228. 228. 9. Funduscopic Examination 285
  229. 229. Acute Vision Loss Painful: ANAG, optic neuritis Painless –Central retinal artery occlusion (CRAO) –Central retinal vein occlusion (CRVO) –Temporal / giant cell arteritis –Retinal detachment 286
  230. 230. Funduscopic Exam Mikael Häggström, Wikimedia Commons 287
  231. 231. Optic Neuritis Women > men Rapid visual reduction, usually painful Color desaturation more common than acuity loss – bright reds look pink 288
  232. 232. Optic Neuritis – Disk Source Undetermined 289
  233. 233. Optic Neuritis – Disk Source Undetermined 290
  234. 234. Optic Neuritis Significance: may be first attack of multiple sclerosis Treatment: controversial ?steroids 291
  235. 235. CRAO Vascular occlusion of central retinal artery  retinal ischemic stroke Embolism from primary cardiac pathology Age: 50 – 70 292
  236. 236. CRAO – Physical Exam Funduscopic exam  pale edematous retina, fovea appears “cherry red” (only in comparison to pale retina) 293
  237. 237. CRAO – “Cherry Red” Spot Source Undetermined 294
  238. 238. CRAO – “Cherry Red” Spot Source Undetermined 295
  239. 239. CRAO – “Cherry Red” Spot Branch occlusion Source Undetermined Source Undetermined 296
  240. 240. CRAO – Treatment Dislodge / dissolve embolism Dilate artery to promote flow Reduce IOP to allow  perfusion gradient  pCO2 – rebreather 297
  241. 241. CRVO Leads to edema, hemorrhage, vascular leakage Vision loss can be minimal or severe Can be ischemic or nonischemic Loss may improve over time 298
  242. 242. CRVO – Physical Findings Varies: classically shows dilated, tortuous veins, retinal hemorrhage, disc edema Unilateral finding Prognosis: depends on size of lesion 299
  243. 243. CRVO Community Eye Health, Flickr 300
  244. 244. CRVO Source Undetermined 301
  245. 245. CRVO Source Undetermined 302
  246. 246. Retinal Detachment Rhegmatogenous: vitreous fluid dissects retinal layers Exudative: leakage of fluid from retinal vessels Traction: fibrous vitreous bands contract and pull retina away 308
  247. 247. Retinal Detachment NO pain May see flashing lights Vision “filmy,” “cloudy,” “like a curtain falling” Vision may be preserved if macula not involved 309
  248. 248. Retinal Detachment National Eye Institute, National Institutes of Health, Wikimedia Commons 310
  249. 249. Retinal Detachment Source Undetermined 311
  250. 250. Retinal Detachment Source Undetermined 312
  251. 251. Eye Trauma 313
  252. 252. Contusion  Black Eye Ecchymosis, swelling,  vision Visual acuity EARLY exam before swells shut Check extraocular muscles, eye grounds, cornea, etc. 314
  253. 253. Contusion  Black Eye Pavel Ševela, Wikimedia Commons 315
  254. 254. Contusion  Black Eye Treatment Symptomatic Cold compresses, elevate head of bed Resolution in 2 – 3 weeks 316
  255. 255. Beefsteak + Black Eye If it's cold, the raw steak will work, but it's the cold – not anything in the steak – which will stop the black eye. An ice bag is a much better – and cheaper – treatment. 317
  256. 256. Orbital Fractures Source Undetermined 318
  257. 257. Orbital Floor Fractures Weakest point: orbital floor –Infraorbital foramen Second weakest: medial wall Third weakest: lateral wall Strongest: supraorbital 319
  258. 258. Orbital Floor Fractures Orbital soft tissues can prolapse into maxillary sinus Enophthalmos, ptosis, diplopia, cheek anesthesia, limited upward gaze X-ray: “teardrop” sign 320
  259. 259. Orbital Floor Fractures Source Undetermined Source Undetermined 321
  260. 260. Orbital Floor Fractures Source Undetermined 322
  261. 261. Orbital Floor Fractures Source Undetermined 323
  262. 262. Retrobulbar Hemorrhage Blunt trauma Acute rise intraorbital pressure Central retinal artery occlusion Proptosis,  vision,  IOP Orbital CT  hematoma Treatment: canthotomy 324
  263. 263. Retrobulbar Hemorrhage Source Undetermined 325
  264. 264. Lateral Canthotomy Source Undetermined 326
  265. 265. Lateral Canthotomy Source Undetermined 327
  266. 266. Lateral Canthotomy Source Undetermined 328
  267. 267. Lateral Canthotomy Source Undetermined 329
  268. 268. Penetrating Ocular Trauma Common causes: BB pellet, lawn mower projectiles, hammering, knife, gunshot Give tetanus, IV cephalosporin STAT ophthalmology consult 330
  269. 269. Penetrating Ocular Trauma Shallow anterior chamber Hyphema Irregular pupil – “teardrop” Reduced visual acuity Can’t see posterior chamber 331
  270. 270. Penetrating Ocular Trauma Source Undetermined Source Undetermined 332
  271. 271. Penetrating Ocular Trauma Source Undetermined 333
  272. 272. Positive Seidel’s = Perforation Source Undetermined 334
  273. 273. Positive Seidel’s = Perforation Source Undetermined 335
  274. 274. Ruptured Globe Source Undetermined 336
  275. 275. Ruptured Globe Source Undetermined 337
  276. 276. Ruptured Globe Source Undetermined 338
  277. 277. Deflated Globe Source Undetermined 339
  278. 278. Penetrating Ocular Trauma Treatment Protective non-pressure eye shield STAT ophthalmology referral 340
  279. 279. Alkali Burns TRUE EMERGENCY Liquefactive necrosis  dissolves tissue IMMEDIATE irrigation with large amounts liquid until pH 7.4–7.6 341
  280. 280. Morgan Lens Source Undetermined 342
  281. 281. Morgan Lens Source Undetermined Source Undetermined 343
  282. 282. Nasal Cannula United States Patent Illustration, Wikimedia Commons 344
  283. 283. Irrigation Use neutral solution Use urine dipstick to check pH 345
  284. 284. Alkali Burn Secker, G.A., and Daniels, J.T., Wikimedia Commons 346
  285. 285. Alkali Burn Source Undetermined 347
  286. 286. Alkali Burn Source Undetermined 348
  287. 287. Lye Burn, Fresh Source Undetermined 349
  288. 288. Acid Burn Less devastating than alkali Coagulation necrosis (not liquefaction) Treatment: same as alkali, irrigate until neutral pH 350
  289. 289. Acid Burn Source Undetermined 351
  290. 290. Other Chemical Burn Initially treat all as acid or alkali After copious irrigation, treat as corneal abrasion 352
  291. 291. Chemical Burn: WP Source Undetermined 353
  292. 292. Superglue Cyanoacrylates used by ophthalmologists If lids stuck together, may leave as glue dissolves over several days 354
  293. 293. Thermal Burns Eyelids > globe 1o: irrigation, ointment 2o & 3o: ophthalmology consult Hot liquid splash, cigarette: treat as corneal abrasion Molten metal: can perforate 355
  294. 294. Class Color Anti-infective Tan Anti-inflammatory / steroid Pink Mydriatic and cycloplegic Red Nonsteroidal anti-inflammatory Gray Miotic Green Beta-blocker Yellow Beta-blocker combination Dark blue Adrenergic agonist Purple Carbonic anhydrase inhibitor Orange Prostaglandin analogue Turquoise 356
  295. 295. Fluorescein Stain Source Undetermined 357
  296. 296. Placing Drops Source Undetermined 358
  297. 297. Placing Ointments Community Eye Health, Flickr 359
  298. 298. Immediate Referral Acute glaucoma Corneal abscess / ulcer CRAO / CRVO Globe perforation / corneal laceration Chemical burn Scleritis 360
  299. 299. Referral Within 24 Hours Iritis / uveitis Corneal abrasion Foreign body Herpes Zoster with eye involvement Retinal detachment Orbital cellulitis 361
  300. 300. Referral Within One Week Persistent conjunctivitis Episcleritis Facial nerve palsy (unless severe corneal exposure then within 24 hours) 362
  301. 301. No Referral Needed Stye / chalazion Subconjunctival hemorrhage (unless associated with more significant trauma) Conjunctivitis 363

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