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Opthalmologic Emergencies. Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02. Objectives:. Briefly review ocular anatomy and exam Recognize pathology (yeah – pictures!) Discuss treatment options Discuss areas of controversy Slit lamp review. Ocular Anatomy:. Eye Exam:. Visual acuity

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opthalmologic emergencies

Opthalmologic Emergencies

Dave Dyck R3

Preceptor: Dr. Bryan Young

Sept. 26/02

objectives
Objectives:
  • Briefly review ocular anatomy and exam
  • Recognize pathology (yeah – pictures!)
  • Discuss treatment options
  • Discuss areas of controversy
  • Slit lamp review
eye exam
Eye Exam:
  • Visual acuity
  • Pupils
  • Motility
  • Confrontation visual fields
  • Anterior segment
  • Posterior segment
  • Intraocular pressure
visual acuity
Visual Acuity:
  • Perform at 20 feet (6 meters)
  • Range from 20/15 to 20/400 then counting fingers, hand movements, light perception, and no light perception
  • Near vision uses a reading card at 14 inches
  • OD= right eye; OS= left eye; OU= both eyes
  • If vision< 20/20 use pinhole to check for correctable refractive errors
pupils
Pupils:
  • Size and reaction to light
  • Swinging flashlight test
    • Afferent pupillary defect
      • Differential= retinal detachment, central retinal artery or vein occlusion, optic neuritis, optic neuropathy
      • Cataract, hyphema, vitreous hemmorhage, corneal ulcer, and iritis are associated with decreased vision but not an afferent pupillary defect
pupils cont
Pupils cont.
  • Dilated
    • Third nerve palsy
    • Trauma
    • Adie’s pupil
    • Drug induced (dilating drops)
    • Acute glaucoma
pupils cont10
Pupils cont.
  • Constricted
    • Drug induced
    • Iritis
    • Horner’s syndrome

* Anisocoria >4mm seen in 19% of normals

confrontation visual fields
Confrontation Visual Fields:

To help localize lesions to the retina, optic nerve, optic chiasm, or visual cortex

anterior segment
Anterior Segment:
  • Lids, puncta, conjunctiva, sclera, cornea, anterior chamber, and lens
  • Fluorescein
    • Remove contact lenses
posterior segment
Posterior Segment:
  • Vitreous, disc, vessels, macula, and peripheral retina
  • Through dilated pupil UNLESS  shallow anterior chamber (or hx of angle closure glaucoma), iris supported intraocular lens (rare), head injury, ruptured globe
optic disc
Optic Disc:
  • Normally slightly oval in the vertical meridian, central depression (cup), various pigmentation
  • Cup-to-disc ratio <0.5
  • Distinct disc margins
intraocular pressure
Intraocular Pressure:
  • Normal < 23 mmHg.
  • Acute angle glaucoma often > 40 mmHg.
  • Tonopen- easy
  • Schiotz tonometry (Roberts)
  • Applanation tonometry
  • Air-puff tonometry
slide18
Case 1: 66y lady watching TV tonight in a dark room. Took 50mg Benadryl for itch  increased eye pain with dec. vision
glaucoma
Glaucoma:
  • Imbalance of aqueous humor production and drainage leading to increased intraocular pressure  optic neuropathy
types
Types:
  • Primary angle closure glaucoma
  • Secondary angle closure glaucoma
  • Primary open angle glaucoma
  • Secondary open angle glaucoma
acute angle closure glaucoma
Acute Angle Closure Glaucoma:
  • Symptoms: Redness, severe pain, headache, photophobia, decreased vision, halos, +/- N/V
  • Signs: Increased IOP, acute anterior angle, corneal edema, conjunctival injection, non-reactive or sluggish mid-dilated pupil
  • More common if history of far-sightedness (Hyperopia), Asian/Eskimo descent
treatment
Treatment:
  • Pilocarpine 2% - 1 drop q15 min until pupillary constriction. (+ 1 drop q6h in unaffected eye for prophylaxix)
  • Timolol 0.5% - 1 drop (works within 30-60min)
  • Apraclonidine HCl 1% - 1 drop
  • Diamox – 250-500mg po q6h or 500mg IV
  • If not < 35mmHg in 30-60 minutes give Mannitol 20% - 2-7ml/Kg IV or isosorbide 1-1.5g/Kg po
treatment cont
Treatment cont.
  • Opthamology : for peripheral iridectomy or laser iridotomy
  • When to refer urgently for surgery?
  • When to expect a pressure drop with medications?
  • What is a satisfactory pressure drop?
primary open angle glaucoma
Primary Open-Angle Glaucoma:
  • Most common cause of blindness in NA
  • Due to increased aqueous humor outflow through the trabecular meshwork
  • Insidious, slowly progressive, bilateral, painless vision loss (peripheral) ie. NOT AN EMERGENCY
  • Increased cup-to-disc ratio
case 2
Case 2:
  • 58 y male presents with acute vision loss in L eye x 90 minutes.
central retinal artery occlusion
Central Retinal Artery Occlusion:
  • Painless, ages 50-70, vasculopathic hx
  • R/O glaucoma
  • Signs= Decreased visual acuity, afferent pupillary defect, pale fundus with cherry-red fovea
  • Experimentally, 100min until irreversible ischemia
treatment32
Treatment:
  • Digital global massage (5sec on –5sec off)
  • Increase PCO2 by breathing into paper bag for 10min every hour vs Carbogen
  • IV acetozolamide + ASA
  • R/O and Treat glaucoma
  • Emergent Opthamology referral and outpatient Cardiology
  • R/O neuritis 2% (ESR, hx, etc)
branch retinal artery occlusion
Branch Retinal Artery Occlusion:
  • Same treatment as for CRAO
case 4
Case 4:
  • 60 y female with vision loss L eye
central branch retinal vein occlusion
Central/Branch Retinal Vein Occlusion:
  • Symptoms: variable vision loss, usually painless
  • Signs: ischemic (neovascular glaucoma) or non-ischemic (macular edema with leaking capillaries) Dilated tortuous veins, retinal hemmorhages and disc edema
treatment37
Treatment:
  • Expectant
  • Referral to Opthomology within 24 hrs to R/O neovascular glaucoma
case 5
Case 5:
  • 55 y myopic male with light flashes and complete vision loss acutely 2hrs ago in L eye. No pain
retinal detachment
Retinal Detachment:
  • Separation of the inner neuronal retina layer from the outer retinal pigment epithelial layer
  • 3 types:
    • i. rhegmatogenous
    • ii. Exudative
    • iii. Tractional
rhegmatogenous
Rhegmatogenous:
  • Due to tear/hole in the neuronal layer causing vitreous fluid to enter and separate the 2 retinal layers
  • Often due to vitreous gel pulling on retina as one ages or related to trauma
  • Men, myopia, age>45
exudative
Exudative:
  • From blood/fluid leakage from vessels within the retina
  • HT, eclampsia, CRVO, papilledema, vasculitis, choroid tumor
tractional
Tractional:
  • Due to fibrous band formation in the vitreous and the contraction of these bands
retinal detachment44
Retinal Detachment:
  • Symptoms: light flashes, floaters, variable vision loss depending on macular involvement (cloudy or curtainlike), painless
  • Signs: area out of focus on fundoscopy
  • Cannot be ruled out by direct fundoscopy
treatment45
Treatment:
  • Emergent opthamologic consultation
  • When?
case 6
Case 6:
  • 72 y IDDM female with 2hr hx of “cobwebs” L eye leading to marked decrease in vision now
vitreous hemmorhage
Vitreous Hemmorhage:
  • Bleeding into the preretinal space or vitreous cavity
  • Usually due to diabetic retinopathy or retinal vessel tears secondary to vitreous collapse but various other causes
  • Symptoms: initially floaters or cobwebs with subsequent vision loss
  • Fundoscopy findings are widely variable (reddish haze to black reflex)
vitreous hemmorhage48
Vitreous hemmorhage:
  • If afferent pupillary defect present  retinal detachment likely behind hemmorhage
  • Treatment: bedrest, elevate HOB, avoid ASA and refer to opthomology
case 7
Case 7:
  • 75y male with progressive vision loss x years with acute worsening central vision today. No pain.
macular hemmorhage
Macular Hemmorhage:
  • Refer to opthomology
macular disorders
Macular Disorders:
  • Loss of central vision with preservation of peripheral vision, central vision distortion, abnormal retinal changes at macula
  • Due to trauma, radiation, inflammation, vascular disease, toxins, genetics, idiopathic
  • Drusen
  • Neovascularization
  • *no afferent defect and optic nerve normal
er role
ER role:
  • Recognition primarily and referral to opthamology for fluorescein angiogram within 24-48 hrs
non penetrating ocular trauma
Non-Penetrating Ocular Trauma:
  • Orbit and globe
  • Cornea and conjunctiva
  • Anterior chamber and iris
  • Lens
  • Posterior Segment
case 8
Case 8:
  • 22y male hit in L eye with puck. Vision slightly blurry (20/60) and decreased up gaze. Tender inferior orbit.
orbital wall fractures
Orbital Wall Fractures:
  • Orbital floor is weakest point and orbital tissues may prolapse inferiorly  enopthalmos, ptosis, diplopia, aneasthesia of ipsilateral cheek/upper lip, and decreased up gaze
  • Medial orbital wall # into ethmoid sinus (look for orbital emphysema)
  • Globe injuries in 10-25%
  • Facial x-rays (imperfect)
    • Teardrop sign
    • AF level
treatment59
Treatment:
  • Consultation with plastic surgery for possible surgical repair
  • Abx unnecessary unless involved sinus previously infected
  • Avoid nose blowing (dec emphysema)
retrobulbar hemmorhage
Retrobulbar Hemmorhage:
  • Hemmorhage in potential space surrounding globe may increase intraorbital pressure and cause CRAO.
  • Symptoms=proptosis, visual loss, increased IOP
  • Signs= CRAO
  • Dx= above + orbital CT scan
  • Tx=immediate optho consult, IV mannitol +/-lateral canthotomy or anterior chamber paracentesis
complications
Complications:
  • Infection, hemmorhage, injury to globe
  • Rare
  • Canthotomy wounds heal well without suturing or significant scarring
globe rupture
Globe Rupture:
  • Most common at EOM insertions into sclera or at limbus
  • Pain and decreased vision
  • Examination: various = teardrop pupil (iris plugging limbal hole), distortion of anterior chamber, others
diagnosis
Diagnosis:
  • Hx/Px +/- CT or U/S
  • Fluorescein
  • Avoid tonometry
treatment73
Treatment:
  • Protective shield, avoid manipulation, NPO, tetanus, IV Abx, urgent opthalmology
  • Avoid succ or use defasciculator if must use it
alkali burns
Alkali burns:
  • Liquefaction necrosis
  • Severe injury= (severity judged by degree of corneal whitening)
treatment76
Treatment:
  • Prehospital- copious irrigation with clean water x 15 min prior to transport. Bring in chemical
  • Hospital- topical anaesthesia, lid retraction and 2L continuous irrigation NS. Continue until pH=7.4-7.6. Remove foreign bodies. Urgent optho consult.
complications77
Complications:
  • Perforation, scarring and corneal neovascularization. Lid adhesions, glaucoma, cataracts, and retinal damage
acid burns
Acid burns:
  • Less devastating
  • Coagulation necrosis  precipitates tissue proteins to limit depth of injury
  • If pH>2  usually min damage unless very high concentration or long duration of exposure
  • Treatment as for alkali burns
miscellaneous exposures
Miscellaneous exposures:
  • Treat as if acid/alkali
  • Superglue= If eyelids sealed shut in normal position  leave alone. If eyelids in abnormal position  may require surgery. Optho should see both in consultation
thermal burns
Thermal Burns:
  • Eyelid usually worse than globe
  • If superficial treat with irrigation and Abx ointment. If deeper as above + involve optho
corneal abrasion
Corneal Abrasion:
  • Symptoms: pain, photophobia, foreign body sensation, dec vision.
  • Signs: injected conjunctiva, fluorescein defect
treatment84
Treatment:
  • R/O foreign body and herpes keratitis (evert lids, use slit lamp)
  • Refer immed if pain not relieved with top anaesthetics or if large abrasion esp if in central field of vision
  • Cycloplegics (cyclogyl 1%)
  • Abx drops (sulfacetamide 10%, polytrim, ocuflox, etc)
  • Patch vs no patch (Kaiser 1995; Hart 1997; Patterson 1996)
  • If no patch give topical NSAID for pain control eg ketorolac 0.5% QIDx3d
contact lens related abrasions
Contact lens related abrasions:

-remove contact lens

-gram neg coverage (gentamycin, ocuflox)

-cycloplegic

-don’t patch

-may require opth follow-up so that a corneal ulcer doesn’t develop

follow up
Follow-up:
  • Bring back in 24 hrs or not?
  • Optho follow-up?
corneal foreign body
Corneal foreign body:
  • Dx.=topical aneasthetic and slit lamp exam
  • r/o intraocular foreign body
  • Treatment= irrigation or needle removal (25 guage) and then as for abrasion
  • Rust ring removal
subconjunctival hemmorhage
Subconjunctival Hemmorhage:
  • Treatment= reassurance, cool compresses
  • Resolves in 2-3 weeks
hyphema
Hyphema:
  • Blood in anterior chamber
  • Due to disruption of blood vessels in the iris or ciliary body (trauma or spontaneous)
  • Typically lasts 4-6 days if uncomplicated
  • Classification:
    • Grade 1 = less than 1/3 of ant chamber filled (72%)
    • Grade 2 = 1/3 to ½ (20%)
    • Grade 3 = greater than ½ (5%)
    • Grade 4 = complete filling of ant chamber (3%)
          • “eight ball hyphema”
complications93
Complications
  • Glaucoma 1/3 (esp if Sickle Cell Anemia)
  • Rebleeding 4-38% usually at 2-5 days
  • Corneal staining 2-5%
management
Management:
  • Document VA, pupils, IOP, aff pupillary defect (eight ball)
  • Slit lamp and complete eye exam to r/o other injuries
treatment95
Treatment:
  • Shield
  • Rest, elevate HOB, no straining/bending/valsalva
  • No near viewing activities eg reading
  • Control IOP (avoid acetazolamide in Sickle Cell Anemia)
  • Stop anticoagulation and avoid ASA/NSAIDs
  • Steroids controversial – leave up to optho
  • Systemic antifibrinolytics (aminocaproic acid) – controversial (dec rebleeding but inc N/V)
  • Cycloplegics ok and tx corneal abrasions w abx
treatment96
Treatment:
  • To admit or not?
    • No answer in literature
    • Growing opinion to allow grade 1-11 hyphemas with controlled IOP to be treated at home with close optho follow-up daily
indications for surgery
Indications for Surgery:
  • Uncontrolled increased IOP
  • Persistent total/near total hyphema x days
  • Prolonged clot duration
  • Corneal blood staining
  • Surgery required in 5%
traumatic iridocyclitis
Traumatic Iridocyclitis:
  • Contusion to iris/ciliary body  ciliary spasm
  • Photophobia and deep eye pain
  • Exam= ciliary flush, anterior chamber cells (WBCs and protein)
  • Tx=long acting cycloplegics x7-10 days
  • Steroids may be given by optho
iridodialysis
Iridodialysis:
  • Tearing of the iris root from the ciliary body
  • ED tx- only if hyphema present
  • May require non-urgent surgical correction
lens subluxation dislocation
Lens subluxation/dislocation:
  • Due to trauma, Marfan’s, homocystinuria, and tertiary syphilis
  • Tx.= optho referral
lid lacerations
Lid lacerations:
  • What can ED do?
    • Simple horizontal and oblique partial thickness lacerations
complex lid lacerations needing referral 24 hrs
Complex lid lacerations needing referral (24 hrs):
  • Lid margins
  • Canalicular system involvement (medial lower eyelid)
  • Levator or canthal tendon involvement
  • Lacs with tissue loss
conjunctival corneal scleral lacerations and punctures
Conjunctival, Corneal, Scleral lacerations and punctures:
  • Conjunctival lac: small,superficial no suturing, topical abx. O/W optho
  • Corneal lac: Dx.= fluorescein flow. Tx as for globe rupture.
  • Scleral lac: Dx and Tx as for globe rupture
orbital and intraocular foreign body
Orbital and Intraocular Foreign Body:
  • May have normal physical exam. Therefore high index of suspicion is crucial.
  • Low threshold for plain orbital plain films or orbital CT scan if non radioopaque substance
  • Tx=optho
endophthalmitis
Endophthalmitis:
  • Infection involving the deep structures of the eye
  • Tx=early diagnosis, IV abx (Vanco + 3rd gen antipseudomonal ceph. +/- clinda), prompt optho referral for intravitreal abx, vitreous tap/vitrectomy, and possible steroids.
conjuncitivitis key points
Conjuncitivitis key points:
  • Bilateral findings less likely bacterial
  • Gonococcus only bacterial conjunctivitis with a preauricular node
  • Always fluorescein eyes to r/o herpes lesions
  • Never prescribe steroids from ER
treatments
Treatments:
  • Allergic: cool compresses, remove allergens, meds
  • Viral (non-herpetic): cool compresses, reassurance, some advocate for prophylactic abx (adenovirus may take 3 weeks to resolve)
  • Bacterial: warm compresses, Na Sulamyd, tobramycin, polymyxin, or erythro (chloramphenical); if o/w healthy avoid topical fluoroquinolones. Culture if non responders. (gonococcus systemic tx, ocular lavage, topical erythro, notification).
treatment cont116
Treatment cont.
  • No evidence comparing one abx to another, but good evidence that abx ameliorate symptoms faster than placebo.

(Sheikh & Hurwitz, 2001)

herpetic keratoconjunctivitis
Herpetic keratoconjunctivitis:
  • Tx.= trifluridine 1% 8x/day, acyclovir 400mg 5x/day (no clinically significant evidence), new topical acyclovir ointment 5x/day
herpes zoster opthalmica
Herpes Zoster Opthalmica:
  • PO acyclovir 600-800mg 5x/day or famcyclovir 500mg po tid.
  • Start within 72 hrs
  • +/- po prednisone under guidance of opthamology
hordeolum
Hordeolum:
  • Localized, nodular acute infection of an eyelid (staph aureus most common)
  • Can point to either skin or conjunctival side
  • Tx=warm compresses 4-6x/day, topical abx. I&D if large
chalazion
Chalazion:
  • Chronic inflammatory process develops after incomplete resolution of a meibomian gland
  • Conjunctival or skin side
  • Non-tender
  • Tx as for hordeolum (most resolve on own) Sx if still present x3-4 wks
dacrocystitis
Dacrocystitis:
  • Acute infection of lacrimal sac from Nasolacrimal obstruction
  • Staph aur.
  • May express pus from puncta
  • Tx. Po abx and hot compresses, massage
preseptal cellulitis
Preseptal Cellulitis:
  • Hx URTI, eyelid trauma, external eye infection
  • Normal vision, no proptosis, normal ocular motility, no pain with eye movements
  • Staph, strep, heamophilus
  • PO/IV Abx and optho referral to r/o orbital involvment
orbital cellulitis
Orbital Cellulitis:
  • Pain, decreased vision, +/- diplopia
  • Proptosis, limited EOM, Dec visual acuity, +/- afferent pupillary defect
  • w/u=CT scan, blood/eye c&s
  • Tx= admit, broad spectrum Abx. Consider mucormycosis
blepharitis
Blepharitis:
  • Chronic condition
  • Due to staph infection or seborrheic gland inflammation
  • Tx=warm compresses, eyelid scrubs (diluted baby shampoo) erythro ointment & chronic eyelid hygeine. PO doxycycline added in severe cases
phlyctenule
Phlyctenule:
  • R/O foreign body
  • Due to hypersensitivity rxn to antigen such as staph or TB
  • CXR/mantoux as outpt -refer to optho for ? Topical steroids
  • Tx coexistant blepharitis
episcleritis
Episcleritis:
  • “Salmon pink” hue of the superficial layer of the eye between conjunctiva/sclera
  • Usually idiopathic
  • 1/3 tender, 2/3 sectoral
  • Tx. Outpatient referral to optho for topical steroids only if severe.
scleritis
Scleritis:
  • More painful, often bilateral
  • 50 % have systemic dx (Crohns, UC, collagen vasc dx, sarcoid, etc)
  • Simple vs nodular (immobile nodules with q tip) vs necrotizing
  • Tx: NSAIDs, Optho referral for steroids and systemic w/u
iritis
Iritis:
  • Redness, photophobia, tearing and decreased vision
  • Ciliary flush and pupillary constriction
  • Slit lamp= anterior chamber rxn with WBCs, flare (protein leakage), and keratic precipitates
  • Always fluorescein to r/o abrasion/herpes
  • Tx=cycloplegics & Topical NSAIDs and referral to optho for steroids
summary
Summary:
  • Always do a complete eye exam with documentation of acuity and fluorescein
  • Never prescribe steroids from ER
  • Very low threshold to x-ray orbits
  • When in doubt consult your opthomologist