Transcript Red Eyes and Ocular Emergencies

Ocular Urgencies and
Emergencies
Mindy J. Dickinson, OD
Midwest Eye Care, PC
Omaha/Council Bluffs
Objectives
Triage Procedure
Emergent vs Urgent
Using symptoms to help decide urgency
Overview of acute eye problems
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3)
4)
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What symptoms cue you in to problem
What history is important
How soon should patient be seen
What does the problem look like
Triage
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Screening process
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Assess patient’s problem to determine if and
how soon patient needs seen
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Done over phone or if patient walks into clinic
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Need to decide if problem is emergent, urgent,
or routine
Triage
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Questions should ask:
1) Chief complaint or symptoms ?
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got something in eye, matted shut, red, tearing, pain, blurred
vision, loss of vision, double vision, floaters/flashes
2) When did it happen ? How long how long has
problem been going on ?
3) Severity ? Worsening ?
4) Have they tried any treatments already ?
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Irrigated the eye, old antibiotic they had at home, artificial
tears
5) Did someone tell them to come in ?
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Dr in ER, their PCP, etc
Triage
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Must get patient’s information
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Name
Date and time of call
Telephone number patient can be reached at
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May want to get idea how long they can be reached at
that number so we get back to them in time
Be professional, calm
Exhibit care and concern
Triage
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Urgency usually greater when problem is
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Severe
Worsening
Recent onset
Affecting vision
Referred by another doctor
Patient is very concerned
Triage
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Emergent Situation
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Urgent Situation
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Requires immediate action
Come to clinic or go to ER same day
Requires patient be seen within 24-36 hours
Routine Situation
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Requires patient to be seen within few days to a
week
Using Symptoms to help you…
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Redness
Discharge
Foreign Body Sensation
Itching
Burning
Eye Lid Swelling “edema”
Light Sensitivity “photophobia”
Pain
Changes in Vision or something blocking Vision
Causes of Redness
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Blepharitis
Conjunctivitis
Episcleritis/Scleritis
Dryness/Exposure
Trichiasis/Entropion
Uveitis
Subconjunctival Hemorrhage
Contact Lens related problems
Corneal Ulcer
Corneal Abrasion/Recurrent Corneal Erosion
Foreign Body
Chemical Burns/Welding Burns
Acute Glaucoma
Discharge
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Tearing, thick mucus, stringy
Green or yellow
Lots or just a little
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Causes of Discharge
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Conjunctivitis (bacterial, viral, allergic)
Blepharitis
Hordeolum (stye)
Corneal trauma – scratch, foreign body, ulcer, chemical burn
contact lens related problem
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Dry Eye Disease
Foreign Body Sensation
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Scratchy
“gravel in eye”, “eyelash in eye”
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Causes of FBS
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Foreign body in cornea or conjunctiva
Trichiasis (eye lash rubbing on eye)
Corneal or Conjunctival Abrasion
Dry Eye Disease
Conjunctivitis
Contact Lens Intolerance
Itching/Burning
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Usually less urgent
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Causes
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Blepharitis *
Allergy *
Conjunctivitis *
Dry Eye Disease *
Contact Lens intolerance
Keratitis (corneal inflammation)
Inflamed pinguecula or pterygium
Swelling “edema”
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Eyelid swelling
Conjunctival swelling “chemosis”
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Causes of lid edema
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Conjunctivitis
Corneal disease (foreign body, abrasion, ulcer)
Hordeolum (stye)
Preseptal Cellulitis/Cellulitis
Blunt Trauma
Contact Dermatitis
Chemical exposure/burn
Herpes Zoster (shingles)
Light Sensitivity “Photophobia”
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Indicates eye inflamed
Corneal and/or Anterior Chamber involvement
More urgent !!
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Causes of Photophobia
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Corneal trauma – abrasion, ulcer, foreign body, CL overwear
Keratitis
Herpes Simplex Keratitis
Uveitis
Dry Eye Disease
PAIN
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Grading scale 1 to 10 (10 is worst ever)
Superficial, sharp pain
Deep, achy, throbbing pain
On eye movement?
Constant vs intermittent?
History of trauma?
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More severe the pain = more urgent !!!
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Vision
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Affected or Unaffected
If affected = more urgent!!
Hazy, blurred, missing half of vision, black spot in middle
Floaters, flashes of light, “curtain”
Double vision
Constantly reduced vs comes and goes
May be associated with pain or be painless
Even if not affected now…
is vision threatened ?
Vision-Threatening vs.
Not Vision-Threatening
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Not Vision-Threatening
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Conjunctivitis
Episcleritis
Blepharitis
Trichiasis
Dry Eye Syndrome
Subconjunctival Hemorrhage
Hordeolum/Chalazion
Potentially Vision Threatening
Emergencies that HURT
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Corneal Ulcer
Corneal Abrasion
Chemical Burn
Foreign body
Herpes Simplex
Herpes Zoster
Uveitis
Cellulitis
Trauma
Hyphema
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Orbital Fracture
Ruptured Globe
Acute Glaucoma
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These are all
associated with pain,
redness, &/or
photophobia
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All are EMERGENCIES!!
PAINLESS
Loss or Threats to Vision
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No pain or redness, but
may have…
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New Floaters
Flashes of Light
Curtain in Vision
Significant reduction in overall
vision
“Smudge” in central vision
Half of vision missing
Vision dimmed out, went
black, now its back
Double vision (diplopia)
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All are EMERGENCIES !!
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Posterior Vitreous Detachment
Retinal Tear
Vitreous Hemorrhage
Retinal Detachment
Retinal Vascular Occlusion
Amaurosis Fugax
Wet Macular Degeneration
Macular Edema
Optic Nerve Swelling
Cranial Nerve Palsy
Impending Stroke
Other Helpful Information…
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Do they Wear Contacts ?
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Trauma ?
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Sleep in lenses? Are lenses old?
More urgent !!
Tell patient to take lenses out !!
More urgent !!
Previous Treatments tried ?
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If not working or problem worsening = more urgent
If haven’t tried anything, may be able to make some
suggestions (artificial tears, cold or warm compresses)
Other Helpful Information…
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Ocular history – if any of these, likely more urgent
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Corneal abrasion - risk of recurrent corneal erosion
Corneal ulcer
Herpes simplex
Uveitis
Trichiasis
Recent Posterior Vitreous Detachment
High Myopia
Lattice Degeneration
s/p Ocular Surgery or Laser
Macular Degeneration
Other Helpful Information
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Ocular History
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History of a chronic problem like Blepharitis or Dry Eye
disease may reduce urgency
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Ask patient what they have been trying to do for relief
and what is and isn’t working
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May be able to make suggestions over the phone or at
least to get patient by until exam time in a few days
Other Helpful Information
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Referral from another doctor
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Schedule based on need requested by other doctor
If urgent request, need to get worked in regardless
of schedule
Get Dr’s name, phone number, address, fax
Patient’s level of anxiety or concern
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Even though may be less urgent problem, good
care may mean seeing patient to ease concern
When in doubt … Ask your doctor!!
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Would rather error on side of caution and see
sooner
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Dr may know more about patient’s history to
recommend sooner or later appointment
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Even if less urgent (ie. broken glasses), Dr’s
schedule may allow for sooner appointment
and therefore better customer service
Overview of Acute Eye Problems
Objectives:
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Familiar with name of problem
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Familiar with what problem might look like
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Symptoms associated with problem
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Urgency of examination
Subconjunctival Hemorrhage
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Broken blood vessel
causing blood to
collect under
conjunctiva
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Symptoms
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Confluent Redness
No discharge, pain
No change in vision
Confluent Redness in
Subconjunctival hemorrhage
Subconjunctival Hemorrhage
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History of trauma ?
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Use of blood thinners ?
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Coumadin, Plavix, Aspirin
High dose of ibuprofen,
naproxen, vitamin E
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Recurrent ?
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NOT URGENT
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may be able to triage over
phone
Patient may need Dr for
reassurance
Conjunctivitis
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Inflammation
of conjunctiva
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Injection of
bulbar and
palpebral
conjunctiva
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DISCHARGE !
Types of Conjunctivitis
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Bacterial *
Viral *
Allergic *
Blepharoconjunctivitis (associated with Blepharitis)
Keratoconjunctivis Sicca (Dry Eye Syndrome)
Contact Lens Related
Chlamydial
Gonococcal
Vernal/Atopic
Symptoms of Conjunctivitis
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Mild to moderate redness
Scratchy, Burning, Stinging, Sticky, Itchy
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DISCHARGE
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Little to no affect on vision
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Tearing, Watery, Stringy, Mucoid, Purulent (LOTS)
“eyelids matted shut upon awakening”
If affected, usually “hazy”, intermittent
Little to no pain
Perhaps hx of exposure to someone else with
“pink eye” or recent cold symptoms
Mucopurulent Conjunctivitis
Viral Conjunctivitis
Conjunctivitis associated with
Contact Lenses
Sub-Epithelial Infiltrates
in Viral Conjunctivitis
Conjunctivitis
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Usually Self-Limiting !!!
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Going to get better no matter what
Even without treatment, most will resolve in 10-14
days
More are viral than bacterial
If vision affected, more pain, or more severe symptoms
--- should see same day
Also if not getting better, could be misdiagnosed
--- see urgently
Conjunctivitis – Treatment
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Antibiotic drops (if bacterial)
Anti-allergy drops (if allergic)
Preservative-Free Artificial tears
(chilled tears good for inflammation and very soothing)
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Cold compresses
Oral NSAID (ibuprofen)
Good hand washing
Discontinue contact lens use (at least temporarily)
Keratoconjunctivitis Sicca “Dry Eye Syndrome”
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Poor tear film covering eye
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Due to not enough production or evaporating too quickly
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Leads to exposure, mucus build up, and inflammation of
cornea and conjunctiva
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Symptoms
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Burning, stinging, tearing, fluctuations in vision,
foreign body sensation, stringy mucus
Dry Eye Syndrome
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CHRONIC problem
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symptoms can vary
from mild to severe
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Mild urgency –
see same day or
next day if not
already diagnosed
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If already diagnosed
but worsening, then
a few days okay
Tear Break Up in Dry Eye Syndrome
Eye Lid Disease - Blepharitis
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Inflammation of lid margin
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Crusting along lashes
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Clogging of Oil Glands
(meibomian glands)
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“Red-rimmed” eyes
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Chronic recurrent issue
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Symptoms:
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Burning, itchy, mattering,
crusty, foreign body
sensation, red
Blepharitis
Anterior blepharitis
Posterior blepharitis
Blepharitis
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Chronic Disease with good days and bad days
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Patient’s history may help you know how soon
patient needs soon
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What treatment are they already on
Mild to Moderate Urgency – 24 to 72 hours
Trichiasis
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Misdirected
eyelashes rubbing
on eye
Recurrent
Scratchy, foreign
body sensation,
tearing, mild
discomfort
See within 24 hrs
Entropion
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Eye lid turned inward
Lashes rub on eye
Scratchy, foreign body
sensation, tearing, mild
discomfort
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See in 24-36 hours
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Tx with surgery
may tape lid out or use
ung to get by until surgery
Hordeolum “stye”
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Blocked eyelid gland
Localized
infection/inflammation
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Eyelid is very tender and red
with localized swelling
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See in 24-36 hours if vision
not affected and eye still
open
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If vision affected or cannot
open eye = emergent
Chalazion
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Old blockage of gland in eyelid
No longer inflamed
Non-tender, non-red bump in eyelid that “been
there for a while”
Not Urgent, may be seen in few days to week
Ask if did hot packs
Warn likely won’t be removed that day of first
office visit
Preseptal Cellulits vs Cellulitis
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Spreading of infection / inflammation into surrounding
eyelid tissue or into orbital socket and into brain
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May start as stye or with trauma
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Symptoms:
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SIGNIFICANT eyelid swelling
Red, hot skin
Pain, Fever
In orbital cases, causes decreased vision, pain on eye
movement, afferent pupil defect, proptosis (bulging of eye)
EMERGENCY!!
Preseptal Cellulitis second to Trauma
Orbital Cellulitis
Allergic Reaction of Eyelids
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Lid edema
Scaling of eyelid skin
Red, warm skin
Painless!!
Itchy
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Mild urgency
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24 to 36 hours
Epicleritis vs Scleritis
- inflammation of episcleral or scleral layers of eye
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EPISCLERITIS
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SCLERITIS
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not serious
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very serious
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Eye is mildly pink
No discharge
Vision not affected
None to minimal pain
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Very Red but no discharge
Photophobic
Very Painful – can wake pt
from sleep, cause
decreased appetite, pain
may radiate into temple or
brow
Vision may be decreased
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URGENT – 24 hours
EMERGENT – right away
More Superficial Injection in
EPISCLERTIS
Episcleritis
Scleritis
Corneal Foreign Body
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Metal embedded in
cornea
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Often get Rust Ring and
surrounding edema
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Tearing, pain, light
sensitivity, redness
Hx of grinding metal
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See right away!
Corneal Abrasion
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History of trauma
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Significant pain and
tearing
Photophobia
Blurred vision
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EMERGENCY
– see right away !
Recurrent Corneal Erosion
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Corneal epithelium sloughs off without any new
history of scratching it
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Usually happens upon awakening in morning
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Have history of either
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2)
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corneal abrasion
anterior basement membrane dystrophy
Very painful
Tearing, red, swollen lid ** see that day
Corneal Ulcer
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Epithelial defect with infiltration by immune
cells – may be inflammatory or infectious
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Non-light passing opaque lesion
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Symptoms are severe
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PAIN, redness, tearing, photophobia
Important history – CL wearer?
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Sleep in CL? Swim in CL? How old are CL?
Corneal Ulcers
Corneal Ulcers
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Hypopyon may be
present (pus in anterior
chamber)
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If suspect ulcer,
see ASAP!!
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Patient may need
cultures, seen daily
until showing
improvement
Corneal
Ulcers
Herpes Simplex Dendritic Keratitis
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Cold sore virus causing
ulceration of cornea
Very classic pattern of
staining – dendritic “treebranching” lesions
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VISION THREATENING!
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Severe Pain, Redness,
Photophobia
Unilateral
Can be recurrent
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Herpes Simplex EPITHELIAL Keratitis
Herpetic Keratitis
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Often misdiagnosed as pink eye or corneal ulcer
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If pink eye that not getting better – could be suspicious
Likely to recur
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If have this history, bring patient in same day
Herpes Simplex STROMAL Keratitis
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Due to immune system
reactivating in response to
virus, not the virus itself in
the cornea
Cornea edema, anterior
chamber reaction, but no
ulcer
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++ Pain, Photophobia,
Reduced vision
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See ASAP, especially if
hx of HSV
Herpes Zoster = “Shingles”
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Related to chicken pox
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Sores on skin on 1/2 of body, torso or face –
usually forehead and eyelids
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Usually preceded by pain or tingling while
combing hair or along eyebrow
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Can cause eyelid sores, conjunctivitis,
corneal plaques, or uveitis
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If immunocomprimised, can also cause
retinitis or neuritis
Shingles
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Patient usually comes as a consult from
family practice doctor
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If reduced vision or red eye, need to see
ASAP
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If just confirming no ocular involvement, likely
okay to see within 24 hours
Uveitis
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Inflammatory reaction in
anterior chamber of eye
Also called “iritis” or
“iridocyclitis”
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May be idiopathic or due to
underlying systemic disorder
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Often initially misdiagnosed as
“pink eye” by PCP
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Symptoms:
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Redness, Photophobia, Deep
Throbbing/Aching pain
“headache behind eye”
Uveitis
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Potentially threatening to vision
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Can cause cataract or glaucoma
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May involve retina, optic nerve, macula
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Often recurrent and patients can tell when it
comes back – so if history of uveitis – see
same day
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Based on symptoms alone, but also history,
see same day
Hyphema
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Blood in anterior
chamber due to blunt
trauma
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Immediate risk of
pressure spike,
rebleed, retinal
detachment,
traumatic optic nerve
damage
Hyphema
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Need to see these
patients right away
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Put on bed rest
until blood clears
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Long term risk of
traumatic cataract
and glaucoma
Penetrating Injury
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History of Trauma
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Excess tearing
Extreme Pain
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True EMERGENCY!!
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When use fluorescein
dye, see a stream of
aqueous seeping out
and washing it away
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“seidel postive”
Penetrating injury
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Manipulate globe as
little as possible!!
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Do not check IOP
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Place shield over eye
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Requires immediate
Surgical Referral
Sutured corneal laceration
Chemical Burn – Acidic or Alkali
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POTENTIALLY VISION THREATENING!
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1st thing to tell them to do over the phone is
IRRIGATE, IRRIGATE, IRRIGATE !
( before ever coming in to the office)
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At least 20-30 minutes
if wearing contact lens, irrigate for 5 minutes or so, then
remove lens and continue to irrigate for another 25 minutes
Then come to office or go to ER right away !
Chemical Burns
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Mild = Red eye (good prognosis)
Severe = White eye (poor prognosis)
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Expect to see
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eyelid edema
burns of periocular skin
conjunctival chemosis & hyperemia
conjunctival abrasion
corneal staining – mild irritation to complete loss of skin
If severe – get blanching of conjunctiva – no blood/oxygen
getting to eye or cornea – BAD !!
ACUTE Glaucoma
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Sudden Significant Increase in IOP
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Due to blockage of drainage system
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High IOP (usually 50 or greater)
Angle closure, inflammatory, neovascular
Hx of high hyperopia, narrow angles, proliferative
diabetic retinopathy, central retinal vein occlusion
Symptoms (SEVERE)
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Pain, Headache (brow ache), Nausea, Vomiting,
Red Eye, Blurred Vision
Acute Glaucoma
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See ASAP
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Work in ahead of all other patients
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Need to get pressure down right away to
prevent permanent vision loss (from central
retinal artery occlusion – not from glaucoma
damage to nerve)
Acute Glaucoma
Acute Glaucoma
Shallow anterior chamber, red eye, hazy cornea, middilated pupil
Posterior Vitreous Detachment
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Vitreous gel liquifies
with age
Eventually pulls away
from retina
May or may not tear a
blood vessel or the retina
when pulls away
~10% of retinal tear
FLASHES OF LIGHT
NEW FLOATERS
Posterior Vitreous Detachment
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If patient denies decreased vision or curtain/veil
in vision, may wait until next day
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If decreased vision, lots of “little dots in vision” or
“curtain/veil” in vision, or following history :
1)
2)
3)
4)
Highly myopic (near-sighted)
Lattice Degeneration
s/p cataract surgery
Recent posterior vitreous detachment (PVD)
*** then see same day, ASAP
Retinal Tear
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May or may not be
associated with
retinal detachment
Painless
May or may not
have a decrease
in VA
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If blood in eye
going to be blurry
Retinal Detachment
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“Rhegamotogenous”
means due to tear(s)
in retina
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Fluid in eye seeps out
and breaks down seal to
hold retina on
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May be partial or total
Retinal Detachment
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Sudden painless loss
of vision
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May start as
flashes/new floaters
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“Curtain” or “Veil” in
vision or portion of
side vision missing
Retinal Detachment
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If Macula still on
= good VA
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Emergency surgery
If Macula already off
= bad VA
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Surgery within few
days to week
Flashes of Light – Retina or Migraine
Retina
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One eye
Pinpoint or lightning bolts
that come from same
direction
Last a split second, but
may repeat many times
over hours to days
No associated headache
EMERGENCY
Ocular Migraine
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Both eyes
Usually swirling lights,
perhaps colored, altered
side vision
Last 5-30 minutes and
then over
May or may not be
followed by headache
Not Emergent (other than to
ease patients and dr’s minds)
Vein Occlusion
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Painless loss of vision
Often associated with long-standing diabetes
and hypertension
Hard-walled arteries push down and
compress squishy-walled veins
Risk of neovascularization and glaucoma
May be central vein or a branch vein
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If blood is not spilt into macula then patient may
have no symptoms
Central Retinal Vein Occlusion
(CRVO)
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Blockage along main
vein draining eye
Blood backs up and
spills out into retina
Swelling of optic nerve
Vision very poor
(20/200 or worse)
See same day
Branch Retinal Vein Occlusion
Arterial Occlusion

Sudden painless loss of vision

“Vision kept getting dimmer and dimmer”

Clot or thick blood blocks flow of blood into eye

If temporary blockage and then passes, only
get intermittent loss or dimming of vision


“Amaurosis fugax”
Need to consider underlying cause to prevent
other problems like a stroke!
Central Retinal Artery Occlusion

Blockage of main artery
into eye

No blood getting in = no
oxygen

Very limited time to get
blood to eye or tissue
suffocates and dies

EMERGENCY!
Central Retinal Artery Occlusion
Branch Retinal Artery Occlusion

Plaque breaks off from
either carotid artery or
heart valve and travels to
eye

Gets trapped in small
arteriole of eye

Usually leaves a longterm blind spot in area
where there was no blood
flow
Vitreous Hemorrhage

Blood leaking into vitreous due to:



Trauma
Retinal tear
Leakage from new blood vessels growing in the
retina that are not supposed to be there




Proliferative diabetic retinopathy
Neovascularization after central or branch vein occlusion
Wet macular degeneration where blood breaks
out of retina and into vitreous
Tumor in retina
Vitreous Hemorrhage
Vitreous Hemorrhage





Usually painless, sudden loss of vision
Emergent - See same day
May look like “lots of dots” in vision or may be
“hand motion” vision if blood is more dense
Sometimes so much blood we cannot even
see in to tell where it is coming from
B-scan ultrasound to see retina
Exudative “Wet” Macular Degeneration

Blood or fluid
leaking into
macula from
abnormal
vessels

1 in 10 “dry”
become “wet”
Wet Macular Degeneration

Symptoms:

Rapid onset of visual loss
Central blind spot
Distortion of straight lines (Amsler Grid)
No pain

+/- History of Dry AMD

See same day!



Macular Degeneration
Amsler Grid
Central scotoma
Exudative Macular Degeneration

Lots of new therapies exist, but more
effective when done right away


Injections (Avastin, Lucentis, Eyelea)
Need to get these consults into retinal clinic
schedules as soon as possible

Often need fluorescein angiography and/or
macular OCT
Optic Neuritis

Swelling of optic nerve
Unilateral or bilateral

Symptoms




See same day
Slow deterioration of
vision over hours to days
Orbital pain, especially
on eye movements
Loss of color vision or
light intensity
Optic Nerve Edema

Vision loss may be mild
“smudge” to severe
(20/400)

+/- headache
+/- neck pain
+/- fatigue while chewing
+/- scalp tenderness
+/- malaise “sick feeling”




Optic Nerve Edema

May be due to:





Infection
Multiple scleroris
Inflammatory disease
Severe “malignant” hypertension
Lack of oxygen “ischemic”




NAION
AION – “Giant cell arteritis” – “temporal arteritis”
Tumor along optic nerve or in brain
Pseudotumor (intracranial hypertension)
Chief Complaint of “Diplopia”

When gathering history on this patient, ask:
1) Happening with one eye or with both eyes open ?
2) Constant or intermittent ?
3) How long has it been going on ?
4) Do the images appear side by side, up and down, or diagonal
from one another?
5) Recent trauma, headache, stroke, long term vascular disease
(hypertension, diabetes)?
6) Any other muscle weakness?
7) Have they already had prism in their glasses?
** if not previously established cause for diplopia, then see same
day!!
Causes of Diplopia

Palsy of Extraocular Muscle





Trauma that restricts an extraocular muscle




Blow-out fracture of orbit
Sudden onset
Usually have surgery to fix
Decompensating Phoria



Cranial Nerve 3, 4, 6
Sudden onset
May resolve over 3 month period, may last forever
May due to vascular disease, trauma, aneurysm, tumor, increased pressure in brain
Have had eye misalignment since young, but muscles no longer can compensate
Gradual cause with sudden observation
Orbital Disease


Thyroid Eye Disease “Grave’s Disease”
Orbital Mass
Questions?
Thank you!