Transcript Opthalmologic emergencies - Beaumont Emergency Medicine

Ophthalmologic Emergencies
William Beaumont Hospital
Department of Emergency
Medicine
Ophthalmologic emergencies
Sudden loss of vision
– Central retinal artery occlusion
– Central retinal vein occlusion
– Retrobulbar neuritis
– Amaurosis fugax
– Retinal detachment
– Acute iritis
Central retinal artery occlusion
Sudden monocular painless, complete loss of
vision
Fundoscopic exam: pale retina with macular red
spot
Treatment
– stat opthy consult
– Intermittent digital massage of the globe
– Increase CO2 (arteriolar dilatation) – carbonic
anhydrase inhibitor (ie acetazolamide)
– Definitive tx – paracentesis of the anterior chamber
Central retinal vein occlusion
Sudden monocular
painless, and near
complete loss of
vision
Fundoscopic exam:
chaotic, bloodstreaked retina
Stat ophthalmology
consult
Optic neuritis
Progressive loss of
central vision
May be painful,
scotoma, flashing
lights
Peripheral vision
preserved
Associated with
multiple sclerosis in
25% of cases
Amaurosis fugax
Fleeting painless loss of monocular vision
Due to minute emboli of the central retinal
artery
Consult neurology for TIA
Retinal detachment
Painless
Prodromal floaters or
flashing lights,
followed by “lowering
curtain”
Opthy consult
Acute iritis
Painful blurred vision
Will cover in more detail under Red Eye
in a few slides
Red eye
Acute angle closure glaucoma
Acute iritis
Conjunctivitis
Herpes simplex keratitis
Corneal ulceration
Chemical conjunctivitis
Corneal abrasions
Acute angle closure glaucoma
Sudden severe unilateral ocular pain and
decreased visual acuity
Patients may present with headache or nausea,
blurred vision or rainbow halos
Precipitous increase in IOP leads to blindness
within a few days if left untreated
In patients predisposed (ie far sighted,
cataracts), pupil dilatation is often precipitant
event (sympathomimetics, parasympatholytics,
stress, fatigue, darkness)
Acute angle glaucoma
Red eye
Nonreactive middilated pupil
Corneal edema
Shallow anterior
chamber
High intraocular
pressure (60-90)*
Hazy cornea
Normal IOP = < 20
Treatment glaucoma
Stat opthy consult for definitive tx – iridectomy
Timolol – beta blocker
Pilocarpine – parasympathomimetic
Acetazolamide (diamox) – carbonic anhydrase
inhibitor
Mannitol
50% glycerol – oral hyperosmotic – if patient can
tolerate po – give in place of mannitol
Timolol
Timoptic solution – beta blocker
Decreases aqueous humor formation
0.5% solution – 1-2 drops at 10-15 min
intervals x 3, then 1 drop every 12 hours
Pilocarpine
Parasympathomimetic
Produces miosis
2% solution – 1 drop every 30 minutes
until the pupil constricts, then 1 drop every
6 hours
Side effects: bradycardia, hypotension,
sweating, tremors
Acetazolamide
Diamox
Carbonic anhydrase inhibitor
Inhibits aqueous humor formation
Cross reactive allergen with sulfa
500 mg IV every 12 hours or 500 mg po
every 6 hours
Side effects: respiratory depression,
metabolic acidosis
Mannitol
20% 1-2 grams/kg IV over 30-60 minutes
Increases blood osmolality, creating a
gradient that draws water from the vitreous
cavity
Side effects: headache, confusion, CHF,
dehydration
Acute iritis
Blurred vision, photophobia, ocular pain
Exam: ciliary flush, anterior chamber cells
and flare, constricted pupil, decreased
visual acuity, lower IOP
Treatment:
– Cycloplegics – ie Homatropine – dilates the
eyes
– Topical steroids
– Close opthy follow up
Acute iritis
conjunctivitis
Nonpainful red eye
Bacterial, viral,
allergic
Herpes simplex keratitis
Red eye with foreign
body sensation
Dendritic fluorescein
uptake
Treat: acyclovir drops,
cycloplegics
Steroids
contraindicated
Opthy consult
Corneal ulceration
Red, painful eye
White flocculent infiltrate of the cornea on
slit lamp exam
Slit lamp may reveal a hypopyon
– anterior chamber exudate
May lead to corneal destruction and
perforation
Admit, IV antibiotics
Corneal ulceration
Chemical conjunctivitis
Alkali burn – absolute ocular emergency
– Liquefactive necrosis – worse
– Immediate irrigation to continue until pH returns to 7.0
– 7.5 and opthy consult
– Only opthy emergency in which visual acuity is not
indicated until after therapy has begun
Acid burns
– Coagulative necrosis
– Immediate irrigation as above and opthy consult
Alkali burns
Corneal abrasions
Foreign body sensation and photophobia
Diagnose: fluorescein uptake with slit lamp
exam, rule out foreign body with double upper lid
eversion
Suspect foreign body if “ice rink sign” – fine
linear abrasions in upper 1/3 cornea
Rule out corneal ulceration
Do not use steroid drops – as it may be difficult
to rule out early HS keratitis
Treat: antibiotic ointment/drops, analgesics
Prognosis is very good
Corneal abrasion
Traumatic eye injuries
Corneal laceration
Perforated globe
Intraocular foreign body
Hyphema
Blow-out orbital fracture
Traumatic lens dislocation
Traumatic mydriasis
Traumatic iritis or retinal detachment
Corneal laceration
Tear shaped pupil – from prolapse of the
iris
Small black fragments representing iris
pigment may be seen and initially
mistaken for a foreign body
May not see the laceration itself
Treat: metal shield, stat opthy consult for
surgical repair
Corneal laceration
Perforated globe
Suspect if penetrating wound to the eyelid
Decreased visual acuity, soft globe (do not
palpate however)
Fundoscopic exam may reveal vitreous
hemorrhage
Treatment: Metal shield, stat opthy consult
for surgical repair
Intraocular foreign body
Patient often gives a history of striking
metal on metal
May be initially painless, but then patient
develops monocular pain and decreased
visual acuity
May not see the wound
Diagnosis: CT scan, ultrasound or plain xray of the globe
Tx: Opthy consult for surgical removal
Orbital foreign body
Hyphema
Hemorrhage in the
anterior chamber
See blood/vitreous
line in inferior iris
directly or on slit lamp
exam
Treatment: bed rest,
head of bed elevation,
ophthy admit,
steroids, miotics
Blow-out orbital fracture
Blunt globe trauma (ie fist to eye)
transmits forces that may lead to orbital
floor fracture
Inferior rectus muscle may prolapse
through the fracture
Pain and diplopia or loss of upward gaze,
enophthalmos (sunken eye), infraorbital
anesthesia
Opthy consult
Blow out fracture
ENT emergencies
Emergent Ear Disorders
– Auricular Hematoma – blunt trauma
Untreated, can result in cartilage necrosis
(“cauliflower ear”)
Tx – needle aspiration, compression dressing, +/- Abs
– Perichondritis – admit for IV abs
– Otitis externa – swelling of the external canal,
pain with movement of the auricula
Tx: Abs/steroid combination ear drops after placing
an ear wick
Auricular hematoma
Ear
Malignant Otitis Externa – immunocompromised pt
Pseudomonas aeruginosa
Deep pain with movement of TMJ, granulation tissue on
the floor of the auditory canal at bony-cartilage junction
Facial nerve paralysis  multiple CN involvement 
meningitis
Tx: stat ENT consult for surgical debridement and IV
antibiotics
Malignant otitis externa
Ear
Ramsay-Hunt syndrome
– Vesicular (Herpes zoster) rash of ext auditory canal and
auricle
– Usually with sensorineural hearing loss and facial nerve
paralysis
– Treatment: admit for IV acyclovir and steroids
Foreign body
– Tools for removal – irrigation (not vegetable matter),
alligator forceps, suction, hook, cerumen loop
– Live insects should be stupefied with lidocaine or mineral
oil prior to removal
Tympanic membrane rupture – ENT referral
Otitis media – hopefully you all know what this is
Ramsay hunt syndrome
Nose
Epistaxis
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Anterior most common – Kiesselbach’s plexus
Posterior often due to uncontrolled HTN
Rule out coagulopathy
Silver nitrate or cautery
Oral antibiotics if nasal pack
Foreign bodies – suction, ear curette, forceps
Acute sinusitis – nasal and oral decongestant,
antibiotics (augmentin, macrolide, 2nd or 3rd
cephalosporin) if sxs > 1 week
Complications of sinusitis
Pott’s puffy tumor –
osteitis of anterior frontal
sinus wall  frontal lobe
abscess
Meningitis
Acute periorbital cellulitis
– around the orbit
– Tx: admit for IV Abs
– CT scan to rule out
orbital cellulitis
(surgical emergency)
Cavernous sinus thrombosis
High fever
Toxic appearing
Chemosis, CN 3 & 6
palsies, papilledema
Lethargy, coma or
seizures
DX: CT, MRI
Mucormycosis
Fungal sinusitis in
immunocompromised
patient
Nasopharyngeal
necrosis
CN palsies
IV antifungal Abs
High mortality rate
Throat
Pharyngitis – Grp A strep
– treat to prevent complications and acute
rheumatic fever and ARHD
– glomerulonephritis not prevented by Abs
Mononucleosis – EBV
– Pharyngitis, fever, cervical lymphadenopathy
– Splenomegaly in 50%
– Dx: monospot,  atypical lymphocytes
– Tx: fluid, rest, steroids, avoid ampicillin (rash),
contact sports/trauma (splenic rupture)
Ludwig’s angina
Bilateral cellulitis of the floor of the mouth
True emergency (airway obstruction)
Elderly, debilitated men (alcohol abuse)
Dx: CLINICAL: brawny edema of
submandibular area, febrile, protruding
elevated tongue, respiratory distress
Tx: IV antibiotics (clindamycin or Unasyn
or Pcn + metronidazole) + airway
protection
Ludwig’s angina
Peritonsillar abscess
Fever, trismus, dysphagia
Adolescents, young adults
Enlarged inflamed tonsil extending medially
Displaces uvula to opposite side
ENT consult for I & D, IV Abs (Pcn or
Clindamycin or Unasyn with Metronidazole),
IV fluids, IV steroids
Peritonsillar abscess
Retropharyngeal abscess
Children aged 6 mos – 3 yrs
Staph aureus, grp A strep, anaerobes
Fever, neck pain, muffled voice, dysphagia
Child prefers to lie supine (do not force to sit up)
Diagnosis: prevertebral edema on lateral soft tissue
neck X-ray
Tx: ICU admit for IV Abs and ENT surgical drainage
PCN or Clindamycin or Unasyn with Metronidazole
Epiglottis
Abrupt high fever, sore throat, stridor, dysphagia
Picture: child is drooling, stridorous, sitting up with
chin forward and neck extended
Any age – children more worrisome
H influenza, grp A strep, Branhamella catarrhalis
Dx: thumb print sign on ST lateral neck x-ray
Tx: cricothyrotomy set up at bedside, intubation by
ENT in OR if possible, ICU admit for IV antibiotics,
humidified oxygen, IV fluids
Ceftriaxone with Clindamycin or Vancomycin; or
Unasyn
Croup
Inflammation of the larynx and subglottic airway
Parainfluenza most common (RSV, adenovirus)
2-3 days of URI sxs, worsening to a barking cough,
hoarse voice, and stridorous
Rare after age 6
Diagnosis: steeple or pencil sign on AP soft tissue
neck x-ray
Tx: steroids (0.6 mg/kg dexamethasone PO x 1),
humidifed oxygen (cool), racemic epinephrine
Pencil sign
What is it?
THE END
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