EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident.

EM RoundsColleen Carey, BA, MD, CCFP (EM)

July 31, 2008Thanks to Dr. Jean Chuo, UBC

Ophthalmology Resident

Hx Exam Most common etiologies

Traumatic versus atraumatic Diagnosis Treatment When to get help

Trauma Consider unrecognized trauma- awoke with

symptoms Pain? Itch? FB sensation? Visual acuity changes, halos Contact lenses- ? Overwear Sick contacts/Viral symptoms Prior surgery or eye disorders Systemic disease

Visual acuity Visual fields Pupil shape and reactivity Lid closure Foreign bodies Ciliary flare Foggy cornea (edema) Corneal infiltrate Fluorescein- corneal defects, Sidel’s sign Anterior chamber cells Intraocular pressure

Projectile metallic FB Get orbital Xray

Rust ring Visual axis involved?- refer if unable to

completely remove Burr

Tetanus status Antibiotic prophylaxis?

Get help if not healing corneal ulcer large surface area infringing on visual axis

Usually due to blunt trauma and immediate Gross: layers out Microscopic: cells in anterior chamber Always refer Tx: cycloplegics, steroids, serial IOP monitoring,

sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertion

Complications: Iritis Synechiae, glaucoma Rebleeding

Penetrating FB Blunt trauma by an object smaller than a

fist Blunt trauma with an orbital fracture Prior open globe surgery All must be repaired to prevent

sympathetic ophthalmia Need a hard shield. Emergency referral, poor prognosis

Red, painful, decreased vision Anterior chamber cells+/- hypopion Almost exclusively post-surgical

complication Rare: 1:100,000 cataract surgeries Urgent referral

Very common problem Mild itch, dry, gritty sandpaper sensation Many causes:

Contact lens overwear Dry Calgary air Preservatives, antibiotic eye drops Incomplete lid closure

Rule out other problems Discontinue cause, moisturize, follow up in

ER

Allergic Viral Bacterial Irritative Treat bacterial conjunctivitis with

flouroquinolone or erythromycin drops. Treat allergic with antihistamines, nasal

steroid spray, allergen avoidance, cromolyn drops

Refer any keratitis

Short fat branches with bulbs

HSV keratitis Dendritic fluoroscein enhancing lesion Hypoesthetic cornea +/- periocular HSV vesicles• Tx is acyclovir +/- viroptic drops • HSV can affect any part of the eye• Next day referral as long as Tx started

Long thin tapered branches

HHV 3 (VZV) V1 (opthalmic branch of CN V)

Macular rash =>vesicular lesions Conjunctivitis Keratitis Uveitis/iritis +/- retinal necrosis Cranial nerve palsies 3,4,6 Cxns: Chronic ocular inflammation, vision

loss, neuralgia, late corneal sequelae

Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, age

Hx: Sudden eye pain, photophobia, halos PE: Shallow anterior chamber, iris bombe,

middilated pupil, hazy cornea, elevated IOP

Tx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitol

Ensure pressure drops within an hour

Complete occlusion of the anterior chamber angle by iris tissue

Causes: Infections, eye disorders, systemic

disorders Trauma, autoimmune disorders, VZV,

lyme disease, leukemia/lymphoma, idiopathic

Photophobia and dull ache Urgent referral to ophtho Get baseline IOP and start Predforte

drops and cycloplegics

Intense injection at limbus

Causes Valsalva Coagulopathy

Presentation Visual acuity Absence of pain Absence of photophobia Absence of discharge

Should resorb in 1-2 weeks

And that is the problem. Alkali chemical burn- large corneal

epithelial defect and scleral ischemia.

Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosis

You have only minutes to diagnose and irrigate

Morgan lens, many litres Afterward:confirm pH, slit lamp exam for

corneal defect, r/o deposits in conjunctival recesses.

Insidious onset Consider retro-orbital causes: mass,

aneurysm.

Chronic recurrent eyelid inflammation Staph aureus or seborrhea

(pityrosporum) Warm lid compresses Topical antibiotic eyedrops+/- ointment Dandruff shampoos to scalp to eradicate

pityrosporum Slow response

Hordeolum- acute, painful Chalzion- chronic, non painful Hot compresses, milking Refer if not resolving for I+C Chronic lesions- ? Biopsy to r/o CA

Note irregular corneal light reflex