Transcript
What conditions to expect
How to get help
History
Examination
Common (less serious) conditions
Rarer but more serious conditions
Helpful websites
The Eye in Casualty: a seminar
What conditions to expect: working in pairs, (2 minutes) think of:
• Common (less serious) conditions, e.g.
• Rarer but more serious conditions
If time, work out how you would refer, treat
Feedback…………what conditions to expect
• Common (less serious) conditions, e.g.– Conjunctivitis– Corneal abrasion– Foreign body– Blunt eye injury
• Rarer but more serious conditions– Acute glaucoma, acute uveitis– Central retinal artery occlusion– CVA– Giant Cell arteritis– Papilloedema– Retinal bleeding: maculopathy or diabetes– Severe trauma
• Common less serious– Conjunctivitis---------------– Corneal abrasion-----------– Foreign body---------------– Blunt eye injury------------
• Rarer serious conditions– Acute glaucoma,
acute uveitis– Central retinal artery occln– CVA-------------------------– Giant Cell arteritis---------– Papilloedema---------------– Retinal bleeding:
maculopathy or diabetes– Severe trauma--------------– Orbital cellulitis-----------
again in pairs, (2 minutes) think of best method of referral/treatment
• Common less serious– Conjunctivitis---------------– Corneal abrasion-----------– Foreign body---------------– Blunt eye injury------------
• Rarer serious conditions– Acute glaucoma,
acute uveitis– Central retinal artery occln– CVA-------------------------– Giant Cell arteritis---------– Papilloedema---------------– Retinal bleeding:
maculopathy or diabetes– Severe trauma--------------– Orbital cellulitis-----------
– diagnose/treat– diagnose/treat– diagnose/treat– diagnose/treat/refer
– diagnose, refer urgently
– diagnose, refer urgently– diagnose, refer urgently to RMO– diagnose, refer with diagnosis– refer to neurosurgeon (?via RMO)– diagnose, semi-urgent referral
– diagnose, start treatment, refer urgently
– urgent RMO/paediatrician
Feedback answers
Referral: severe problems/out of hours, Eye Casualty, City Hospital
Immediate
Chemical burn, plaster under upper lid
Irrigation+++
refer
Refer asap (even at night)
Severe trauma
GCA
CRAO
Acute glaucoma
Orbital cellulitis (to paediatrician for IV Rx?)
Trauma: examine gently/carefully
ESR
Hours (if present after 11pm, best to seek advice, some seennext morning)
Retinal detachment
Hypopyon uveitis
Corneal abscess
Most milder uveitis present in evening can be treated next day
Refer to eye clinic or to GP
(optometrist should check?)
Retinal vein occlusion
Macular haemorrhage
(Cataract
Dry eyes)
Treat in
A & E
•Conjunctivitis
•Corneal abrasion
•Foreign body
•Sub-tarsal
•Lid infections that may need flucloxacillin
Referral: severe problems/out of hours, Eye Casualty, City Hospital
Immediate Refer asap (even at night)
Hours (if present after 11pm, best to seek advice, some seennext morning)
Refer to eye clinic or to GP
(optometrist should check?)
Treat in
A & E
Chemical burn, plaster under upper lid
Severe trauma
GCA
CRAO
Acute glaucoma
Orbital cellulitis (to paediatrician for IV Rx?)
Retinal detachment
Hypopyon uveitis
Corneal abscess
Retinal vein occlusion
Macular haemorrhage
(Cataract
Dry eyes)
•Conjunctivitis
•Corneal abrasion
•Foreign body
•Sub-tarsal
•Lid infections that may need flucloxacillin
Irrigation++++
refer
Trauma: examine gently/carefully
ESR
Most milder uveitis present in evening can be treated next day
Will be many conditions you’re unsure of. Exclude more urgent problems; ring for advice.
History
Later………., as we go along
Examination
• Lids• Everting upper lid• Visual acuity • Visual fields• Pupils• Conjunctiva• Anterior chamber…later• Red reflex• Discs• Eye movements…later if time
Lids
• Pain & redness = inflammation
• Severe swelling = ? Orbital cellulitis
Lids: evert upper lid
Evert lid with cotton bud
Visual acuity
TNCEN
OTNC
LOXEWTYURNG
TYURNG
TYURNG
6/606/36
6/24
6/18
6/12
6/9
6/6
6/5
Visual fields
paper
paper
Pupils
Red reflex
Check red reflex from 10 cm, focusing on iris
Check discs & retina
• Dim light• pupils, eyelids, red reflex • Patients look in distance, 15o up• Try not to obstruct sight in other eye,
otherwise examined eye will move.• Look 15o medially, to see the optic nerve first.• Going close increases field of view• Optic nerve first• Move along vessels• Find macula last (this will make pupils small)• Dilating pupil makes examination easier,
quicker and more complete. But it is time consuming, and is rarely needed to exclude papilloedema .
Examination……….in pairs, 5 minutes
• Eye movements
• Fields
• Pupils
• Red reflex
• discs
Slides, with a few questions
Lids
Conjunctivitis
Foreign body & cornea
Anterior segment (uveitis/glaucoma)
Retina
Optic nerve
Major trauma
Previous eye surgery
Give out quiz for later, in pairs, 2 minutes, what is the treatment/plan
Corneal abrasion Diagnose how…………
treat…………………
Foreign body Diagnose how…………
treat…………………
iritis findings……………………….
Refer? …comments……………
Acute glaucoma findings……………………….
Refer? …comments……………
Chemical burn Treat…………………………….
Which is worst chemical…………..
Lids
A chalazion
some ‘point’ with pus needing draining: some lid infections need systemic antibiotics
Severe infections like this orbital cellulitis need admission (often under paediatricians) and IV antibiotics
Corneal abrasion
Staining with fluorescein drops shows any active corneal lesion
Foreign body
Foreign body/rust
entropian
Foreign body
Foreign body & fluorescein drops
•Fluorescein drops do not sting and are comfortable for children (all other drops sting).
•Arc eye: wake up with pain at night, due to an ultraviolet (welding) flash earlier in the day.
Conjunctiva & anterior chamber
Conjunctivitis
No pain
Watery eye
Gritty, something in eye
Iritis/acute glaucoma
Achy eye
Tender
% fixed/sluggish pupil
Glaucoma..eye hard
Conjunctivitis
Conjunctivitis: no pain, red eyes, irritable, watery/ thin discharge (viral), itchy (possible allergic).
Conjunctivitis
Thick discharge = bacterial conjunctivitis
Treatment foreign body/conjunctivitis
Remove foreign body
Fluorescein excludes corneal ulcers
Chloramphenical drops qid (ointment tid), mild cases
Severer cases 2 hourly drops
Conjunctivitis is very infectious
Refer severe cases
Examples of nastier corneal problems
•Dendritic ulcer (acyclovir x5 day x 10d)
•Corneal abscess
•Giant papillary conjunctivitis
•pterygium
Pain & irritation
Ache Inflammation
(acute glaucoma, iritis, episcleritis etc)
Gritty scratchy eye, as though there is something there
Foreign body/abrasion/ulcer (=uneven surface)
Watery red eye
No pain
conjunctivitis
Severe knife like pain trigeminal neuralgia, spasms: history important
Iritis
• Achy eye, misty vision,
• Previous attacks lasting weeks, HLA B27 symptoms= iritis
Ciliary injection
Iritis cont.
‘dust’ particles = cells
‘smoke’= protein
Hypoyon in severe uveitis
Iritis cont.
Iritis cont.
Dilating pupil reveals adhesions: = posterior synechiae
Acute glaucoma
• Achy eye, misty vision
• Previous mild episodes with haloes
• Pupil fixed (sluggish), semi-dilated
• Eye feels hard
Press eye with 2 fingers..Try this on your own eye
normal shallow anteriorchamber
Acute glaucoma cont
Acute glaucoma cont (2)
Complete quiz now, in pairs,
Corneal abrasion Diagnose how…………
treat…………………
Foreign body Diagnose how…………
treat…………………
iritis findings……………………….
Refer? …comments……………
Acute glaucoma findings……………………….
Refer? …comments……………
Chemical burn Treat…………………………….
Which is worst chemical…………..
feedback answers
Corneal abrasion Diagnose how…………
treat…………………
Foreign body Diagnose how…………
treat…………………
iritis findings……………………….
Refer? …comments……………
Acute glaucoma findings……………………….
Refer? …comments……………
Chemical burn Treat…………………………….
Which is worst chemical…………..
History, pain, scratchy: examn chloramphenicol drops qid
History, pain, scratchy: examn chloramphenicol drops qid
Medical history, ache, misty vision, examn, : ciliary injection
Ocular history, ache, nausea, abdo pain, headache misty vision, examn, : semidilated, hard eye
Irrigate, fluoresceinammonia>alkalli>acid
Posterior segment: vision affected
Symptoms
Central vision
Central visual changes suggest macular disease: refer to Eye casualty same week
Sudden, most of sight, or part
TIA: retinal emboli, central/branch retinal artery occlusion
retinal artery occlusion
If within 3 hours of onset, can dislodge clot
(massage, IV diamox, AC paracentesis)
Refer ASAP, aspirin
ESR (10% are GCA)
Loss of sight over weeks/days/hours
• Retinal detachment, with flashes/floaters
• Ischaemic optic neuropathy (older patients)(%GCA with GCA symptoms)
• With pain on movement: optic neuritis (younger patients)
• Retinal vein occlusion
• Eye conditions: may lose top/bottom half of sight
Retinal detachment
1. Vitreous gel liquifies (floaters)
2. May pull retina if attached (flashes)
3. Causes a hole
4. Fluid enters hole
5. Retina peels off (more floaters, vision affected)
6. Dilate pupil, with careful look usually obvious, refer same day
Loss of sight over months
• Cataract
• Many other problems, dilate pupil…………
• red reflex
• Retina
• discs
Visual symptoms: quiz, in pairs, 2 minutes, what are the causes……….
Misty vision Aches…………
No ache…………………
Sudden onset visual loss ………………….
Specific symptoms Give examples……………………….
Loss of sight on one side What may be going on?………….…………………………………….
Episodes of visual loss ………………………………….Clues…………………………..
Blurred vision with flashes and floaters
……………………………….
Visual symptoms
Misty vision
If eye aches, acute glaucoma/uveitis
No ache, cataract/retinal disease etc
Sudden onset visual loss
Vascular
Specific symptoms
E.g. GCA, optic neuritis, HZO
Loss of sight on one side Differentiate eg right side of BOTH eyes (CVA), or ONE eye alone (eye disease)
Episodes of visual loss
TIAs: occur suddenly, resolves over minutes
Blurred vision with flashes and floaters
retinal detachment/vitreous haemorrhage
Eye general health: 1
• What is the history?– Vomiting
– Nausea
– Stomach not tender
– Headache?
– Sight GOOD
– Papilloedema
– Refer to RMO/neurosurgeon
healthy
• Loss of sight 2 days ago, one eye• Headaches 1 week• Shoulder pains months• Weight loss months• Jaw aches eating• unwell months• Test needed:• ESR high• Giant cell arteritis• (if eye OK, refer to RMO)
Eye general health: 2
• Episcleritis• Scleritis• No steroid drops from casualty• Herpes zoster:
– IV antiviral if immunosuppressed
Eye general health: 3
Eye & major trauma
Birmingham and Tamworth are increasingly violent. A careful eye exam will exclude problems. Sometimes the eye is impossible to examine (as lids are shut). Refer/ask on-call eye SPR to assess. Causes: fist, glass bottle, car windscreen.
Eye & major trauma: perforating
glass bottle, car windscreen, dart
Tetanus, antibiotic, refer (ring first), starve for operating
theatre
Eye & major trauma: blunt
Fist, foot, squash ball: blunt eye injury, refer many
Hyphaema:
% retinal detachment also
Eye & major trauma: blunt cont.
Fist, foot, squash ball: orbit injury
Double vision:
Globe itself fine, but floor of orbit fractured, and inferior rectus muscle tethered = blow out fracture
Eye & previous eye surgery
There are many possible problems after ocular surgery: refer, sometimes urgently
Visual fields
• Common conditions less serious, need to treat (includes antibiotics, chloramphenicol)
• Serious conditions: history provides a clue, but a careful examination through a dilated pupil and ophthalmoscope excludes most major pathology
• Generally provide an escape plan “see your doctor if it does not get better” etc
• Serious conditions always need expert advice
• Only really ‘immediate’ action is for chemical burn such as plaster under the lids…irrigate profusely.
• ASAP retinal artery occlusion, GCA
• Within hours..acute glaucoma
• Retinal detachment same day, operation next day often
• Many ‘none’ urgent conditions present; local optometrists help with less urgent
• RMO or nursing colleague can provide useful advice, as can on-call time in Eye Casualty
Summary
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