Eye Ophthalmologic Emergencies.ppt

1. Ophthalmologic Emergencies
Division of Emergency Medicine
Stanford School of Medicine

2. Challenges of Eye Complaints
• Similar complaints (redness, pain, visual
changes) may represent benign or vision
threatening etiologies
• Rapid diagnosis and therapy can be vision
saving
• Visual loss is devastating for the patient and
physician
• Most residents are uncomfortable with eye
complaints

3. General Approach to Eye Complaints
• History
- onset, trauma, history of same, discharge,
perceived vision, field defects, associated
symptoms (halos, headaches), allergies
Physical Exam
- Visual acuity, general inspection (pupils, obvious
foreign bodies, discharge, lid eversion),
fundoscopy, visual fields, slit lamp (cornea,
anterior chamber)

4. Everting the eyelid

5. Common Eye Lid Disorders
• Blepharitis
- Acute or chronic eyelid
inflammation, causing crusting
of the lids (infectious vs.
allergic)
• Stye
- Acute staph infection of an
eyelid follicle
• Chalazion – meibomian gland
cyst (painless, non infectious)
often confused with a stye

6. Causes of the “Red Eye”
Symptoms Signs
Conjunctivitis Bilateral (usually)
Gritty feeling (not pain)
Stickiness
Conjunctival hyperemia
Swollen lids
Mucoid Discharge
Iritis Unilateral (usually)
Lacrimation
Photophobia (Pain!)
Blurred vision
Reduced Vision
Cliary injection
Constricted pupil
Flare in AC
Keratitis/Foreign Body/Abrasion Unilateral (usually)
Lacrimation
Photophobia (Pain!)
Blurred vision
Reduced vision
Ciliary injections
Localised corneal opacification,
abrasion or FB
Acute Glaucoma Unilateral (usually)
Lacrimation
Photophobia (Pain!)
Blurred vision
Headache, Halos, Vomiting
Reduced vision
Ciliary injection
Corneal edema
Dilated pupil
Raised IOP

7. Many causes of the “Red Eye”
• A middle-aged man comes in with
complaints of a painful red eye.
• He said the pain developed after coming out
of a movie theater. “It feels like a
migraine” (headache, nausea, vomiting)
“The lights have halos around them”
• What’s the probable diagnosis?

8. Acute Angle Closure Glaucoma
• What are findings on
physical exam?
– Visual acuity:
– Conjunctiva:
– Cornea:
– Pupil:
– Anterior chamber:

9. What is the anterior chamber

10. Shallow anterior chamber
• How can you
demonstrate a
shallow anterior
chamber?
• OBLIQUE
FLASHLIHGHT
TEST

11. Acute Angle Closure Glaucoma
• What is a normal
intra-ocular
pressure (IOP)?
• How do you
measure the IOP?

12. Another “Red Eye”
• Patient presents whose
right eye is red, painful and
very sensitive to light.
• When you shine the
penlight in her left eye, it
causes her pain in the right
(affected) eye.
• What diagnosis does it
suggest?

13. Iritis
• What might you find on
examination of the
anterior chamber by slit
lamp?
– Headlights in the fog
– Dust in a sunbeam

14. Cell and Flare

15. My baby’s got pink eye
• A patient in a big hurry comes in to
see you. She is disheveled and
scantily dressed. She says, “my
baby’s got the pink eye
• She has a 5 day old infant with a
bilateral eyelid swelling and a thick
purulent discharge from both eyes.

16. My baby’s got the pink eye
• Should you just give her the
antibiotic drops?
• What’s the diagnosis?
• Where did the baby get the
infection?
• Does mom need to be
treated?

17. Eye pain and FB sensation
• A middle-aged man complains of a
foreign body sensation in the left eye
• Fluoroscein staining of the cornea
reveals the following lesions. Diagnosis?
• Should we initiate therapy with steroids?
• Complications?
• Stain everyone!

18. Red painful eye in a contact lens wearer
• A patient who wears contact
lenses presents with a painful
red eye
• Diagnosis?
• Treatment?

19. Eye pain in a contact lens wearer
• Never patch a contact lens wearer
• Advisable to cover for Pseudomonas
in a contact lens wearer
• No benefit to pressure patching in
terms of rate of healing or pain
reduction

20. Painful eye. Diagnosis?

21. Another red eye
• A three-year old child
presents with erythema and
swelling around the left eye.
• The Pediatric resident says,
“It’s periorbital cellulitis;
start the kid on antibiotics
and send him home.”
• Are you comfortable with
that?

22. Sudden painless visual loss
• The nurse has an elderly man with a
history of CAD and TIA's who says he
can’t see anything out of his left eye.
The loss of vision was sudden and
painless.
• What diagnosis does this presentation
suggest?

23. Central retinal artery occlusion
(CRAO)
• How long before this visual
loss becomes permanent?
• Physical exam findings?
– Visual acuity/field:
– Pupillary exam:
– Retina:

24. • Doctor, I see flashes of
light and a curtain has
dropped over my right
lower visual field…
• Diagnosis?

25. • Doctor, I can’t see
well out of my right
eye. It’s hazy and
there are floaters…
• Diagnosis?

26. Traumatic Conditions
of the Eye

27. Poked in the eye!
• A young boy presents to the
ER after having been poked
in the eye by another student.
• He is being seen by a
resident who is just about to
measure the child’s intra-
ocular pressure when you
yell “STOP!!!!!!”
• Why are you so uptight?
• Now what should you do?

28. • Emergency Ophthalmology
Consultation
• Protect the eye
• Avoid eye manipulation
• NPO
• Prophylactic antibiotics
• Update Tetanus
• Antiemetics
• Analgesics, Sedation
• Avoid Succinylcholine?
Open Globe
Treatment

29. FB sensation
• A young male presents to the ER with foreign
body sensation to this left eye.
• He was pounding a nail and felt something get
into his eye.
• You examine patient and find that other than some
photophobia, his exam is normal.
• You are about to discharge him when the attending
says, hold on just a minute. What could you have
possibly missed?
• How do you make the diagnosis?

30. Positive Seidel’s
• You carefully examine
the patient and place
fluorescein in his eye.
You see the fluorescein
streaming.
• What is this called?
• What does it signify?

31. Drain cleaner in the eye
• A patient comes to the ER having
gotten some drain cleaner in her eye
and it's causing her a lot of pain.
• The triage nurse tells her the wait to
be seen is 1 hour and the patient
becomes irate and starts to leave.
• You happen to overhear this
conversation
• What should you do? Why?
• Treatment?
• How long?

32. Baseball versus eye
• A young male presents to
the ER after having been
hit in the eye with a
baseball. He says, "I keep
seeing double when I look
up".
• Diagnosis?
• Pathophysiology?
• Treatment?

33. BLOWOUT
FRACTURE
Symptoms:
• Diplopia
• Epistaxis
Signs:
• Crepitus/tenderness over orbital
rim or maxilla
• Periorbital subQ emphysema
• Limitation of EOM
• Enophthalmos
• Anesthesia of the ipsilateral
cheek and upper lip - WHY?
• Periorbital ecchymoses/swelling
Pathophysiolog
y

34. Blunt Trauma
• The patient may also have
a hyphema
• Make sure to look with a
slit lamp
• Some may be microscopic
- Blurred vision
- Risk of re-bleed, glaucoma

35. Blunt Trauma
• They may also have a
subconjunctival
hemmorhage or lens
dislocation.

36. Eyelid laceration
• A young child presents
to the emergency
department with a small
laceration of her left
upper eyelid.
• What's that protruding
from her laceration?
• What does it signify?

37. “Eyelids don’t have fat”
• Orbital fat usually protrudes
through septal lacerations
• Fat in the lid laceration
confirms the diagnosis
• High incidence of globe
penetration and intraocular
foreign bodies
• High risk for orbital cellulitis

38. Questions and Answers