Emergency Ophthalmology justin chatten-Brown, MD CCRMC Emegency Department justin chatten-Brown, MD CCRMC Emegency Department.

EmergencyOphthalmology

EmergencyOphthalmology

justin chatten-Brown, MDCCRMC Emegency Departmentjustin chatten-Brown, MDCCRMC Emegency Department

Objectives

• Learn examination of the eye, and slit- lamp basics

• Diagnose and be able to rule out eye emergencies

• Know how to treat basic conditions

• Know when to refer, and on what timescale

Etiologies of the Red or Painful Eye

• Infection• Orbital Cellulitis

• Severe Iritis/Uveitis

• Hypopyon

• Herpetic keratitis

• Preseptal cellulitis

• Bacterial conjunctivitis

• Viral conjunctivitis

Etiologies of the Red or Painful Eye

• Primary Ophthalmologic Disease• Acute Glaucoma

• Optic Neuritis

• Allergy• Blepharitis

• Allergic Conjunctivitis

Etiologies of the Red or Painful Eye

• Trauma• Corneal abrasions

• Corneal foreign bodies

• Subconj Hemorrhage/Hyphema

• Penetrating Orbital Trauma

• Acute Retinal Detachment

• Chemical Burns• Alkali worse than acid

Basic anatomy

History is Key

• SymptomSymptom ThinkThink

• ItchingItching AllergyAllergy

• Scratchiness/ burningScratchiness/ burning lid, conjunctival, lid, conjunctival, corneal disorders, corneal disorders, including foreign body, trichiasis, dry eye including foreign body, trichiasis, dry eye

• Localized lid tendernessLocalized lid tenderness Hordeolum, Hordeolum, ChalazionChalazion

• Foreign Body Sensation Foreign body, Foreign Body Sensation Foreign body, rule out traumarule out trauma

History is Key

• SymptomSymptom ThinkThink

• Intense deep painIntense deep pain Iritis, scleritis, Iritis, scleritis, sinusitis, acute glaucomasinusitis, acute glaucoma

• PhotophobiaPhotophobia Corneal abrasion, Corneal abrasion, iritis, acute glaucoma iritis, acute glaucoma

• Halo VisionHalo Vision Acute glaucoma, Acute glaucoma, corneal edemacorneal edema

• Floaters, halos, lines Retinal Floaters, halos, lines Retinal Detachment Detachment or “veil” visual loss or “veil” visual loss

Exam

• Visual acuities

• Gross Examination

• Proptosis, EOM, lid malfunction

• Lids/Lashes (evert)

• irregularities in pupil size or speed of reaction (APD, anisocoria)

Exam• Examine Anterior to Posterior on Slitlamp

• Conjunctiva (palpebral & bulbar) for injection, discharge (scant/profuse; purulent/serous)

• Corneal irregularities, opacities, foreign bodies

• Iris and lens, noting depth of anterior chamber, pupillary anomalies

• Measure intraocular pressures with Tono-pen if indicated

Exam

• Fluorescein stain and Examine with Cobalt Blue Light

• “streaming” on Seidel test- Penetrating trauma

• corneal abrasion or ulcer

• Dendrites- herpetic keratitis

Eye Disorders Anatomical Approach

• Lid Disorders

• Conjunctivitis/Corneal Disorders

• Uveitis/Iritis and Glaucoma

• Retinal Disorders

• Systemic Disorders

Lid Disorders

Hordeolumstaph infection glands of

Zeiswarm compresses and topical abx

Chalazion Meibomian gland infection same

BlepharitisStaph or seborrhea of the lid margin

same + lid scrubs with baby shampoo/H2O

Lid Disorders

Chalazion

Blepharitis

Corneal Lesions

• Conjunctivitis

• Localized Opacities

• Generalized Haziness (corneal edema)

• Keratitic precipitates

Patterns of Redness

• Diffuse Conjunctival Hyperemia (nonspecific)

Patterns of Redness

• Ciliary Flush- Episcleral Vessels

• Seen in Iritis and Acute Glaucoma

Conjunctivitis

Chemical Allergic ViralBacteria

l

History exposurehay

fever, asthma

ill contacts

Distribution

depends bilateralmore often bilateral

often unilater

al

Discharge Clear Mucous Clear Purulent

Treatment FLUSH!!!

anti-histamine

s, systemic + gtt

symptomatic (except with Herpetic Keratitis

-> can result in vision loss)

Abx (Ocuflox

, Polytrim

)

Neonatal Conjunctivitis

Type Gonococcal Chlamydia

Onset 48 hours post-partum4-7 days post-

partum

Signs/SxsSevere purulent dc,

chemosis

pseudomembranes, less purulent, eyelid edema

Dx Gram stain Giemsa, ab stain

TreatmentSystemic CTX, PCN G, Top Erythromycin

Topical and oral erythromycin; Treat parents

too!!

Chemical Injury

• Strong bases more dangerous than strong acids, as is progressive

• Treatment is copious irrigation with NS, towards temple away from unaffected eye, and under lids

• Check pH with litmus, and irrigate until pH neutralized

• If obvious damage, emergent ophtho referral

Corneal Ulcer•Always urgent referral•Often have trauma history, contact lens users•Suspect fungal infection if trauma with organic matter•Culture and gram stain•Antibiotics +/- antifungals

Herpes Keratitis

Herpetic Dendrites•may have ulcers/vesicles•can result in visual loss•urgent Ophtho referral•Treatment: topical and systemic antivirals

Uveitis/Iritis• Keratitic precipitates

• Cellular deposits on cornea found in iritis (anterior chamber inflammation), along with “cell and flare”

• Idiopathic, traumatic, or associated with systemic disease

• Urgent referral

• Treatment differs on type of iritis/uveitis- steroids and cycloplegics

Chamber Anatomy• Aqeous humor from ciliary process (post chamber) through pupil to ant chamber

• Drains through trambecular network into Canal of Schlemm, and to scleral plexus

Esimate Anterior Chamber Depth

Narrow anterior chamber suggests angle closure glaucoma

Acute Angle Closure Glaucoma

•Etiology: Contact between the iris and trabecular meshwork, obstructs outflow of aqueous humor

•Symptoms: Intense eye pain, blurred vision, halos, HA, vomiting, photophobia• Findings:

• Pupils mid- dilated and unresponsive• Scleral injection• Corneal edema•EMERGENT REFERRAL!!!

Pupillary Abnormalities

• Unaffected in conjunctivitis

• Constricted, possibly irregular in iritis due to spasm

• Fixed and mid-dilated in acute angle closure

• Can be irregular in penetrating trauma

Proptosis

• Must rule out tumor or acute infection

Preseptal Cellulitis

• Soft tissue infection ANTERIOR to orbital septum

• Possibly secondary to sinus infection, trauma or simple cellulitis

• Consider CT scan orbit to assess for orbital cellulitis, subperiosteal or orbital abscess

Preseptal Cellulitis

• Treat with IV antibiotics (Unasyn)

• Admit moderate to severe for observation and to ensure no progression

• 12 Hour recheck for mild disease

Orbital Cellulitis• Differentiate from preorbital cellulitis: • proptosis• impaired motility (pain)• decreased vision• optic disc edema• afferent pupillary defect

• Complications• Meningitis in ~ 2%• Cavernous sinus thrombus• Optic nerve damage

Orbital Cellulitis

• EMERGENCY!

• Call Ophtho STAT

• Admit

• IV abx

• CT orbits

Eye Trauma

• With any history of eye trauma, must rule out penetrating globe injury

• Seidel’s test is positive if streaming fluoroscein

• Do not put pressure on globe...stat ophtho consult if positive test

Eye Trauma “Bloody Eye”

Subconjunctival Hemorrhage

•Resolve Spontaneously•No treatment needed

Hyphema•Blood in anterior chamber•Emergent/Urgent referral

Retinal Detachment

• Separation of neurosensory retina from retinal pigment epithelium

• Multiple Etiologies• Rhegmatogenous • Tractional (including trauma)

• Exudative

Retinal Detachment• Symptoms

• Flashes (photopsia), floaters, loss of peripheral vision

• Signs

• Afferent pupillary defect

• Lower IOP

• Vitreous opacities

• Convex corrugated/undulating surface

Retinal Detachment

• If <24 hours Ophthalmologic Emergency

• If >24 hours, somewhat less urgent

• Ophtho consult to determine course of action