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Eye Emergencies        Dr Dane Horsfall    Emergency PhysicianCabrini Emergency Department
Overview   Eye Anatomy/Terminology   History/Examination   Red Eye   Acute visual loss   Eye Trauma
Anatomy
Anatomy
Terminology   Keratitis = inflammation of    cornea   Blepharitis = inflammation of    the eyelid   Iritis = inflammati...
History/Examination   Glasses? Contact Lenses?   Previous eye    conditions/trauma/surgery/med    s   Visual Acuity    ...
Examination   Visual Fields   Evert eyelids-local    anaesthetic (Amethocaine)    aids thorough eye exam   Eye movement...
Examination   Ophthalmoscopy: dark, dioptric to zero, pt focus on    corner of room     Pupils       Reflex       Symm...
Examination   Slit Lamp-where is it?     Lateral canthus at black line on frame     Pt to look at examiners R ear when ...
Painful Red Eye   Case:       65yo F, 1/52 increasing        R unilateral eye pain        assoc n/v, Dx as        migrai...
Acute Angle ClosureGlaucoma   Females in 60-70s, esp. Asians/Eskimos, +ve FHx   defined as       > 2 of         ocular...
Acute Angle ClosureGlaucoma   Aqueous humor     produced by ciliary body         (posterior chamber)     passes thu pup...
Acute Angle ClosureGlaucoma   Intra-ocular pressure    measurement: Normal    10-20mmHg     Goldman applanation        t...
Acute Angle ClosureGlaucoma   Mx Ophthal. referral       Acetazolamide 500mg IV       Topical beta-blocker       Topic...
Famous Eyes   Who’s eyes are they?
Painful Red Eye   Case:       45yo F with unilateral        red, painful eye       PHx Crohn’s Disease       o/e blurr...
Acute Anterior Uveitis (Iritis)   Unilateral, painful red eye, blurred vision,    photophobia, and tearing   Peri-limbal...
Iritis   Causes       50% idiopathic       Assoc           CTD (ankylosing spondylitis, inflammatory bowel            ...
Painful Red Eye   Herpes simples –    dendritic ulcers Rx    topical Acyclovir   Bacterial Ulcer or    Acanthamoebal ulc...
Painful Red Eye - Eyelid   Chalazion - eyelid cyst inflam. of    blocked meibomian gland -usually    painless and larger....
Painful Red Eye   Conjunctivitis     Viral - recent URTI,      clear, watery discharge     Allergic –pruritus,      cle...
Red Eye   Scleritis:       Inflam sclera- localized, nodular, or        diffuse       Vision may be impaired       Scl...
Famous EyesWho’s eyes are they?
Case   60yo M Sudden, painless    loss of vision L eye,    previous    partial/intermittent loss of    vision over a few ...
Central Retinal ArteryOcclusion   Embolism       Most commonly cholesterol,        cardiac (assoc HT,DM) can be        c...
Central Retinal Vein Occlusion   Sudden painless loss of vision   R/F: age, HT, DM,    prothrombotic disorders   Types:...
Optic Neuritis   Vision loss (esp. colour) over hours-days,    pain with eye movements, central scotoma   Usually unilat...
Giant Cell Arteritis   AKA Arteritic Ischaemic Optic    Neuropathy   Females, 60’s   Profound unilateral visual loss  ...
Retinal Detachment   Result of retinal hole with    seepage of fluid between    retina and choroid   R/F age, trauma   ...
Famous Eyes   Who’s eyes are they?
Eye Trauma
Corneal injuries   Corneal Abrasion       Sensation of foreign body, light        sensitivity, tearing       Local drop...
Corneal foreign body   Dirt/glass/metal (rust ring)   Velocity of impact   Signs of penetration   Removal       Local...
Chemical burns   Acids: toilet/pool cleaner,    battery fluid   Alkalis (more harmful): lime,    mortar/plaster, drain c...
Blunt Trauma - Haemorrhage   Subconjunctival Hemorrhage        usually benign, if spont. Check BP/         Coags       ...
Blunt trauma - Orbital blowoutfracture   Usually inferior wall since weakest   Signs:        Diplopia/Ophthalmoplegia f...
Blowout Fracture   Mx       Repair: Indicated if        significant diplopia or        cosmetically unacceptable        ...
Ruptured Globe   May be from blunt or    penetrating trauma   Occurs at thinnest part:       Limbus (Visible with slit ...
Ruptured Globe   Ix: CT most sensitive   Mx : Anti-emetics/analgesics/prophylactic    antibiotics/tetanus/fast       Ur...
Penetrating Eye Trauma   Easily missed since may seal over and abnormal signs may    be subtle   High risk with high vel...
Lid Lacerations   Require Ophthal. ref. if:     Torn lid margins - must      be closed accurately     Lacrimal ducts da...
Famous Eyes   Who’s eye’s are they?
Golden Rules   Always check visual acuity   Always attempt to open eye early and    examine pupil/acuity etc in trauma ...
References   Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com   Handbook of ocular disease, 2000 - 2001 Jobson Pu...
Eye emergencies
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Eye emergencies

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Important eye emergencies in the ED

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Eye emergencies

  1. 1. Eye Emergencies Dr Dane Horsfall Emergency PhysicianCabrini Emergency Department
  2. 2. Overview Eye Anatomy/Terminology History/Examination Red Eye Acute visual loss Eye Trauma
  3. 3. Anatomy
  4. 4. Anatomy
  5. 5. 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
  6. 6. 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
  7. 7. Examination Visual Fields Evert eyelids-local anaesthetic (Amethocaine) aids thorough eye exam Eye movements “H” CN III, IV, VI palsies, fatigability (myasthenia)
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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.
  12. 12. 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
  13. 13. 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)
  14. 14. 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
  15. 15. Famous Eyes Who’s eyes are they?
  16. 16. 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”
  17. 17. 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
  18. 18. Iritis Causes  50% idiopathic  Assoc  CTD (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome, psoriatic arthritis, sarcoidosis)  Infections: Herpes, syphilis, TB, toxoplasmosis, histoplasmosis, CMV, Candida  Trauma Mx Referral: steroids and cycloplegics, antimicrobials.
  19. 19. Painful Red Eye Herpes simples – dendritic ulcers Rx topical Acyclovir Bacterial Ulcer or Acanthamoebal ulcer: amoeba assoc contact lens Mx urgent Ophthal ref. ? admit/antimicrobials
  20. 20. 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
  21. 21. Painful Red Eye Conjunctivitis  Viral - recent URTI, clear, watery discharge  Allergic –pruritus, clear, watery discharge  Bacterial – pus, swab, staph/strep/ gonococcal/chlamydia,  Rx Chlorsig
  22. 22. Red Eye Scleritis:  Inflam sclera- localized, nodular, or diffuse  Vision may be impaired  Sclera thick, discoloured  Severe pain  Assoc with CTD (esp RA) and Vasculitis  Mx Analgesia, Ophthal ref steroids/ immunosuppressant Pterygium :  raised yellow, fleshy lesion at limbus, may be inflamed  Asymptomatic or redness, swelling, itching, irritation, blurred vision  r/f UV, FHx, Male  Mx lubricant, sunglasses, refer - surgery
  23. 23. Famous EyesWho’s eyes are they?
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Giant Cell Arteritis AKA Arteritic Ischaemic Optic Neuropathy Females, 60’s Profound unilateral visual loss Check for  Jaw claudication  Headache  Scalp tenderness  Polymyalgia Rheumatica in 50% Fundus: disc oedema ESR >60mm/hr Rx Ophthal referral, Prednisolone
  29. 29. 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
  30. 30. Famous Eyes Who’s eyes are they?
  31. 31. Eye Trauma
  32. 32. Corneal injuries Corneal Abrasion  Sensation of foreign body, light sensitivity, tearing  Local drops (Amethocaine 0.5%)  Fluorescein with blue light  Rx Chlorsig (drops/ointment) Corneal Flash burns  Arc welding/UV lamp  Red, painful, tearing  LA, Fluorescein  Rx Chlorsig
  33. 33. 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)
  34. 34. 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
  35. 35. 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
  36. 36. 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)
  37. 37. 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
  38. 38. 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
  39. 39. 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.
  40. 40. 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
  41. 41. 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
  42. 42. Famous Eyes Who’s eye’s are they?
  43. 43. 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
  44. 44. 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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