Transcript Opthalmologic Emergencies - Calgary Emergency Medicine

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
• Pupils
• Motility
• Confrontation visual fields
• Anterior segment
• Posterior segment
• Intraocular pressure
Visual Acuity:
• Perform at 20 feet (6 meters)
• Range from 20/15 to 20/400 then counting
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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:
• 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.
• Dilated
– Third nerve palsy
– Trauma
– Adie’s pupil
– Drug induced (dilating drops)
– Acute glaucoma
Pupils cont.
• Constricted
– Drug induced
– Iritis
– Horner’s syndrome
* Anisocoria >4mm seen in 19% of normals
Motility:
Confrontation Visual Fields:
To help localize lesions to the retina, optic
nerve, optic chiasm, or visual cortex
Anterior Segment:
• Lids, puncta, conjunctiva, sclera, cornea,
anterior chamber, and lens
• Fluorescein
– Remove contact lenses
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:
• Normally slightly oval in the vertical
meridian, central depression (cup), various
pigmentation
• Cup-to-disc ratio <0.5
• Distinct disc margins
Intraocular Pressure:
• Normal < 23 mmHg.
• Acute angle glaucoma often > 40 mmHg.
• Tonopen- easy
• Schiotz tonometry (Roberts)
• Applanation tonometry
• Air-puff tonometry
Case 1: 66y lady watching TV tonight in a dark
room. Took 50mg Benadryl for itch  increased
eye pain with dec. vision
Glaucoma:
• Imbalance of aqueous humor production
and drainage leading to increased
intraocular pressure  optic neuropathy
Types:
• Primary angle closure glaucoma
• Secondary angle closure glaucoma
• Primary open angle glaucoma
• Secondary open angle glaucoma
Acute Angle Closure Glaucoma:
• Symptoms: Redness, severe pain, headache,
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photophobia, decreased vision, halos, +/- N/V
Signs: Increased IOP, acute anterior angle,
corneal edema, conjunctival injection, nonreactive or sluggish mid-dilated pupil
More common if history of far-sightedness
(Hyperopia), Asian/Eskimo descent
Treatment:
• Pilocarpine 2% - 1 drop q15 min until pupillary
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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 11.5g/Kg po
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:
• 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
Fundoscopic lesions:
Case 2:
• 58 y male presents
with acute vision loss
in L eye x 90 minutes.
Central Retinal Artery Occlusion:
• Painless, ages 50-70, vasculopathic hx
• R/O glaucoma
• Signs= Decreased visual acuity, afferent
pupillary defect, pale fundus with cherryred fovea
• Experimentally, 100min until irreversible
ischemia
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)
Case 3: 60 y male with painless
blurry vision r eye
Branch Retinal Artery Occlusion:
• Same treatment as for CRAO
Case 4:
• 60 y female with
vision loss L eye
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
Treatment:
• Expectant
• Referral to Opthomology within 24 hrs to
R/O neovascular glaucoma
Case 5:
• 55 y myopic male
with light flashes and
complete vision loss
acutely 2hrs ago in L
eye. No pain
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:
• 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:
• From blood/fluid leakage from vessels
within the retina
• HT, eclampsia, CRVO, papilledema,
vasculitis, choroid tumor
Tractional:
• Due to fibrous band formation in the
vitreous and the contraction of these
bands
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
Treatment:
• Emergent opthamologic consultation
• When?
Case 6:
• 72 y IDDM female
with 2hr hx of
“cobwebs” L eye
leading to marked
decrease in vision
now
Vitreous Hemmorhage:
• Bleeding into the preretinal space or vitreous
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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 hemmorhage:
• If afferent pupillary defect present 
retinal detachment likely behind
hemmorhage
• Treatment: bedrest, elevate HOB, avoid
ASA and refer to opthomology
Case 7:
• 75y male with
progressive vision loss
x years with acute
worsening central
vision today. No pain.
Macular Hemmorhage:
• Refer to opthomology
Macular Disorders:
• Loss of central vision with preservation of
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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
Drusen:
Macular Star:
ER role:
• Recognition primarily and referral to
opthamology for fluorescein angiogram
within 24-48 hrs
Non-Penetrating Ocular Trauma:
• Orbit and globe
• Cornea and conjunctiva
• Anterior chamber and iris
• Lens
• Posterior Segment
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 floor is weakest point and orbital tissues
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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
Treatment:
• Consultation with plastic surgery for
possible surgical repair
• Abx unnecessary unless involved sinus
previously infected
• Avoid nose blowing (dec emphysema)
Retrobulbar Hemmorhage:
• Hemmorhage in potential space surrounding
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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:
• Infection, hemmorhage, injury to globe
• Rare
• Canthotomy wounds heal well without
suturing or significant scarring
Case 9: 22y male in MVA
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:
• Hx/Px +/- CT or U/S
• Fluorescein
• Avoid tonometry
Treatment:
• Protective shield, avoid manipulation,
NPO, tetanus, IV Abx, urgent
opthalmology
• Avoid succ or use defasciculator if must
use it
Case 10: 32 y male with drain
cleaner in eye
Alkali burns:
• Liquefaction necrosis
• Severe injury= (severity judged by degree
of corneal whitening)
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.
Complications:
• Perforation, scarring and corneal
neovascularization. Lid adhesions,
glaucoma, cataracts, and retinal damage
Neovascularization:
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:
• 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:
• Eyelid usually worse than globe
• If superficial treat with irrigation and Abx
ointment. If deeper as above + involve
optho
Case 11: 16y male scratched in eye
Corneal Abrasion:
• Symptoms: pain, photophobia, foreign
body sensation, dec vision.
• Signs: injected conjunctiva, fluorescein
defect
Treatment:
• R/O foreign body and herpes keratitis (evert lids,
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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:
-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:
• Bring back in 24 hrs or not?
• Optho follow-up?
Case 12: 38 y male feels something
got in his eye while chopping wood
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
Case 12: 42y male with acute
redenning of eye after rubbing it.
No other sx
Subconjunctival Hemmorhage:
• Treatment= reassurance, cool compresses
• Resolves in 2-3 weeks
Case 13: 22y male struck in eye by
squash ball
Hyphema:
• Blood in anterior chamber
• Due to disruption of blood vessels in the iris or
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ciliary body (trauma or spontaneous)
Typically lasts 4-6 days if uncomplicated
Classification:
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Grade
Grade
Grade
Grade
1
2
3
4
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less than 1/3 of ant chamber filled (72%)
1/3 to ½ (20%)
greater than ½ (5%)
complete filling of ant chamber (3%)
“eight ball hyphema”
Complications
• Glaucoma 1/3 (esp if Sickle Cell Anemia)
• Rebleeding 4-38% usually at 2-5 days
• Corneal staining 2-5%
Management:
• Document VA, pupils, IOP, aff pupillary
defect (eight ball)
• Slit lamp and complete eye exam to r/o
other injuries
Treatment:
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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
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:
• Uncontrolled increased IOP
• Persistent total/near total hyphema x days
• Prolonged clot duration
• Corneal blood staining
• Surgery required in 5%
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
Case 14: 12y boy 2 wk f/u post
hyphema
Iridodialysis:
• Tearing of the iris root from the ciliary
body
• ED tx- only if hyphema present
• May require non-urgent surgical correction
Case 16: Tall thin 32y male
presents with diplopic vision L eye
after minor eye trauma
Lens subluxation/dislocation:
• Due to trauma, Marfan’s, homocystinuria,
and tertiary syphilis
• Tx.= optho referral
Anterior chamber lens dislocation:
Penetrating Trauma:
Case 17:18y male hit in eye by TV
remote
Lid lacerations:
• What can ED do?
– Simple horizontal and oblique partial thickness
lacerations
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 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
Case 17:
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
Case 18: 70y male 3days post L
cataract surgery. Increased pain
and dec. vision.
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.
Non-traumatic red eye (other than
glaucoma)
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:
• Allergic: cool compresses, remove allergens,
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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 cont.
• No evidence comparing one abx to
another, but good evidence that abx
ameliorate symptoms faster than placebo.
(Sheikh & Hurwitz, 2001)
Case 19:
Herpetic keratoconjunctivitis:
• Tx.= trifluridine 1% 8x/day, acyclovir
400mg 5x/day (no clinically significant
evidence), new topical acyclovir ointment
5x/day
Case 20:
Herpes Zoster Opthalmica:
• PO acyclovir 600-800mg 5x/day or
famcyclovir 500mg po tid.
• Start within 72 hrs
• +/- po prednisone under guidance of
opthamology
Disorders of Lids and Ocular Soft
Tissues:
Case 21:
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
Case 22:
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
Case 23:
Dacrocystitis:
• Acute infection of lacrimal sac from
Nasolacrimal obstruction
• Staph aur.
• May express pus from puncta
• Tx. Po abx and hot compresses, massage
Case 24:
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
Case 25:
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:
• 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
Case 26:
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
Case 27:
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.
Case 28:
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
Case 29:
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
Dry Eyes:
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
END