Eye Emergencies Dr Dane Horsfall Emergency Physician Cabrini Emergency Department
Eye Emergencies
Dr Dane Horsfall
Emergency Physician
Cabrini Emergency Department
Overview
Eye Anatomy/Terminology History/Examination Red Eye Acute visual loss Eye Trauma
Anatomy
Anatomy
Terminology Keratitis = inflammation of
cornea Blepharitis = inflammation of the
eyelid Iritis = inflammation of Iris Uveitis = inflam of uvea, (middle
layer-iris, ciliary body and choroid) Anterior uveitis (most
common) – inflam. iris and ciliary body aka “Iritis”
Intermediate uveitis – inflam. ciliary body
Posterior uveitis – inflam. choroid
Diffuse uveitis - all
History/Examination Glasses? Contact Lenses? Previous eye
conditions/trauma/surgery/meds Visual Acuity
Snellen chart x/y X is distance from chart (ie 6
metres) Y is smallest font size read Eg Normal 6/6, just top line
6/60 Vision less than 6/60 count no.
of fingers/hand movements/light perception
Pin hole corrects refractory error to 6/9 or better
Examination Visual Fields Evert eyelids-local
anaesthetic (Amethocaine) aids thorough eye exam
Eye movements “H” CN III, IV, VI palsies, fatigability (myasthenia)
Examination Ophthalmoscopy: dark, dioptric to zero, pt focus on
corner of room Pupils
Reflex Symmetry
Cornea Lens Humour Retina-Fundoscopy-dilate pupil-Tropicamide Can use cobalt blue light with fluorescein
Examination Slit Lamp-where is it?
Lateral canthus at black line on frame Pt to look at examiners R ear when examining R eye Joystick to focus Cobalt blue light for fluorescein-NOT green light filter.
But Fluorescein dye appears green under blue light
Painful Red Eye
Case: 65yo F, 1/52 increasing
R unilateral eye pain assoc n/v, Dx as migraine
o/e visual acuity reduced hazy cornea fixed mid-dilated pupil hard eyeball
Acute Angle Closure Glaucoma Females in 60-70s, esp. Asians/Eskimos, +ve FHx defined as
> 2 of ocular pain, nausea/vomiting, intermittent blurred vision with halos
and at least 3 of: conjunctiva injection corneal epithelial oedema = hazy mid-dilated non-reactive pupil IOP >21 mmHg can be >60 mmHg shallower chamber in the presence of occlusion.
Acute Angle Closure Glaucoma Aqueous humor
produced by ciliary body (posterior chamber)
passes thu pupil into ant chamber drained via trabecular meshwork and canal of Schlemm in the angle.
Contact between the lens and the iris blocks flow, pressure in posterior chamber - iris bows forward closing angle – reduce drainage
Precipitated by dilated pupil- darkness, stress, medications (anticholinergic, sympathomimetic)
Chronic open angle- no pain no attacks-slow progressive vision loss
Acute Angle Closure Glaucoma Intra-ocular pressure
measurement: Normal 10-20mmHg Goldman applanation
tonometer: attached to the slit lamp
Storz/Schiotz Tonometer Tono-Pen handheld electronic
contact tonometer ($3000)
Acute Angle Closure Glaucoma
Mx Ophthal. referral Acetazolamide 500mg IV Topical beta-blocker Topical steroid Analgesics/Anti-emetics/Supine Once pressure-induced ischemic paralysis of the iris
resolves around 1 hour post initial Rx then: Pilocarpine: a miotic (constricts pupil) – opens angle,
should be administered every 5 mins for 30 mins Laser peripheral iridotomy performed 24-48 hours after
IOP is controlled is definitive treatment
Famous Eyes
Who’s eyes are they?
Painful Red Eye
Case: 45yo F with unilateral
red, painful eye PHx Crohn’s Disease o/e blurred vision,
perilimbal injection, Slit lamp
“floaters/debris in anterior chamber”
Acute Anterior Uveitis (Iritis) Unilateral, painful red eye, blurred vision,
photophobia, and tearing Peri-limbal injection, worse closer to
limbus: (conjunctivitis= worse further from limbus)
Visual acuity may be decreased Examine anterior chamber with Slit lamp
Increase in protein content of aqueous causes an effect known as “flare”, looks “smokey”
White or red blood cells may be observed in the anterior chamber
Severe cases - inflam. cells accumulate as sediment in ant. chamber = Hypopyon
Iritis
Causes 50% idiopathic Assoc
CTD (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome, psoriatic arthritis, sarcoidosis)
Infections: Herpes, syphilis, TB, toxoplasmosis, histoplasmosis, CMV, Candida
Trauma Mx Referral: steroids and cycloplegics,
antimicrobials.
Painful Red Eye
Herpes simples – dendritic ulcers Rx topical Acyclovir
Bacterial Ulcer or Acanthamoebal ulcer: amoeba assoc contact lens Mx urgent Ophthal ref. ?admit/antimicrobials
Painful Red Eye - Eyelid Chalazion - eyelid cyst inflam. of
blocked meibomian gland -usually painless and larger. Rx warm compresses/antis/usually resolve can inject steroids/surgically remove
Stye – infection (staph) of the sebaceous glands at base of the eyelashes. Rx warm compress, pull out eyelash, antis
Blepharitis – inflam. eyelid can be infective. Rx warm wet compress/antis
Herpes Zoster – vesicular rash, can cause infection of all parts of eye. Nasociliary branch involvement predicts serious complications: ocular inflam. and corneal denervation. Mx Opthal ref, Acyclovir
Painful Red Eye
Conjunctivitis Viral - recent URTI,
clear, watery discharge Allergic –pruritus,
clear, watery discharge Bacterial – pus, swab,
staph/strep/ gonococcal/chlamydia, Rx Chlorsig
Red Eye Scleritis:
Inflam sclera- localized, nodular, or diffuse
Vision may be impaired Sclera thick, discoloured Severe pain Assoc with CTD (esp RA) and
Vasculitis Mx Analgesia, Ophthal ref
steroids/immunosuppressant Pterygium :
raised yellow, fleshy lesion at limbus, may be inflamed
Asymptomatic or redness, swelling, itching, irritation, blurred vision
r/f UV, FHx, Male Mx lubricant, sunglasses, refer -
surgery
Famous Eyes
Who’s eyes are they?
Case 60yo M Sudden, painless
loss of vision L eye, previous partial/intermittent loss of vision over a few days
PHx IHD, HT, DM L eye light perception
only, relative afferent pupillary defect
Fundus: pale, arteries/veins narrowed
Central Retinal Artery Occlusion Embolism
Most commonly cholesterol, cardiac (assoc HT,DM) can be calcific, bacterial, Giant cell arteritis
Amaurosis Fugax : transient loss of vision lasting seconds to minutes, can precede
Mx Urgent ophthal referral Decrease intra-ocular pressure
Acetazolamide/Anterior chamber paracentesis
Move clot Pulsed ocular compression Anticoagulate Intra-arterial fibrinolysis
Central Retinal Vein Occlusion Sudden painless loss of vision R/F: age, HT, DM,
prothrombotic disorders Types: Non-ischaemic and
Ischaemic Signs: Decreased visual
acuity, Relative Afferent pupillary Defect, abnormal red reflex
Fundus haemorrhage (“Stormy sunset”)
Mx Ophthal referral Anticoag, aspirin Surgery incl. Laser
photocoagulation
Optic Neuritis
Vision loss (esp. colour) over hours-days, pain with eye movements, central scotoma
Usually unilateral, F 18-45yo may be 1st presentation of demyelinating disease-MS
Swollen optic disc May have other neurology Mx Ophthal referral, IV
IV steroids
Giant Cell Arteritis AKA Arteritic Ischaemic Optic
Neuropathy Females, 60’s Profound unilateral visual loss Check for
Jaw claudication Headache Scalp tenderness Polymyalgia Rheumatica in 50%
Fundus: disc oedema ESR >60mm/hr Rx Ophthal referral,
Prednisolone
Retinal Detachment Result of retinal hole with
seepage of fluid between retina and choroid
R/F age, trauma Signs
flashing lights, floaters Vision loss may be filmy,
cloudy, irregular, or curtainlike Visual field defects
Mx Ophthal ref., Repair Laser therapy Cryotherapy Intraocular gas (ie, pneumatic
retinopexy) tamponades retina Intraocular repair
Famous Eyes
Who’s eyes are they?
Eye Trauma
Corneal injuries
Corneal Abrasion Sensation of foreign body, light
sensitivity, tearing Local drops (Amethocaine 0.5%) Fluorescein with blue light Rx Chlorsig (drops/ointment)
Corneal Flash burns Arc welding/UV lamp Red, painful, tearing LA, Fluorescein Rx Chlorsig
Corneal foreign body
Dirt/glass/metal (rust ring) Velocity of impact Signs of penetration Removal
Local 25G needle, lateral
approach using slit lamp Dental burr for rust ring
(adherent rust ring may loosen with Chlorsig/patch for 24hrs as the cornea heals, may recall pt)
Chemical burns Acids: toilet/pool cleaner,
battery fluid Alkalis (more harmful): lime,
mortar/plaster, drain cleaner, oven cleaner, ammonia
Immediate Mx: LA copious irrigation with fluid-bag of N/Saline + Morgan Lens until pH 7.5, test aquity
Degree of vascular blanching (esp at limbus) proportional to severity of burn
Chlorsig, Ophthal. referral
Blunt Trauma - Haemorrhage Subconjunctival Hemorrhage
usually benign, if spont. Check BP/Coags
If cant see post border ?Orbital # Hyphaema: blood in anterior chamber
If >1/3 = damage to drainage angle, risk glaucoma
Mx shield/patch/semi-recumbent/rest +/- sedation/admission no NSAIDs, Ophthal. Ref.
Recurrent bleeding in 10% esp with early mobilization
Hemorrhage vitreous or retina, can be accompanied by a retinal detachment.
Iris damage can result in poor pupil reactivity = Traumatic mydriasis. Misleading Neuro signs
Lens can be damaged or dislocated and a cataract may develop
Blunt trauma - Orbital blowout fracture
Usually inferior wall since weakest Signs:
Diplopia/Ophthalmoplegia from muscle entrapment. Tethering of inferior rectus prohibits the upward movement of the globe.
Proptosis from swelling or retrobulbar hemorrhage and later Enophthalmos from loss of volume
Infraorbital nerve entrapment- numb cheek/upper teeth
Epistaxis 30% incidence of a ruptured globe in
conjunction with orbital fractures. (Wilkins RB, Havins WE. Current treatment of blow-out fractures. Ophthalmology. May 1982;89(5):464-6)
Blowout Fracture Mx
Repair: Indicated if significant diplopia or cosmetically unacceptable enophthalmos. Most surgeons will wait 10 to 14 days following the trauma to allow for resolution of the associated edema and hemorrhage
Medical : if no diplopia/enophthalmos o antis/no nose blowing/?
steroids
Ruptured Globe May be from blunt or
penetrating trauma Occurs at thinnest part:
Limbus (Visible with slit lamp) Insertions of the extra-ocular
muscles (reduced eye movements, loss red reflex from vitreous haemorrhage)
Around the optic nerve Signs:
Pupil : peaked, teardrop-shaped, or otherwise irregular
Seidel’s Sign Enophthalmos (recession of
the globe within the orbit) Exophthalmos from retrobulbar
hemorrhage
Ruptured Globe Ix: CT most sensitive Mx : Anti-emetics/analgesics/prophylactic
antibiotics/tetanus/fast Urgent Ophthal. referral always requires surgical
intervention. ? Suxamethonium in open globe injury
controversial, weigh up risk to airway Mx and theoretical risk of ocular extrusion and ask opthal.
Penetrating Eye Trauma Easily missed since may seal over and abnormal signs may
be subtle High risk with high velocity eg metal striking metal and glass Leave bodies insitu until surgery Signs:
Distorted pupil Cataract Prolapsed black uveal tissue on the ocular surface Vitreous hemorrhage. Seidel’s Sign Shallow/flat anterior chamber or bubbles in anterior chamber
Mx as for ruptured globe
Lid Lacerations
Require Ophthal. ref. if: Torn lid margins - must
be closed accurately Lacrimal ducts damage Any suspicion of a
foreign body or penetrating eyelid injury
Mx refer/Tetanus/iv antis/antiemetics/shield eye
Famous Eyes
Who’s eye’s are they?
Golden Rules
Always check visual acuity Always attempt to open eye early and
examine pupil/acuity etc in trauma Beware Dx unilateral conjunctivitis until more
serious disease is excluded Don’t D/C pt with LA drops - impedes
healing, further injury may occur to anaesthetized eye.
Don’t start Steroid drops without ophthalmology r/v
References Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com Handbook of ocular disease, 2000 - 2001 Jobson Publishing,
www.revoptom.com/handbook/hbhome.htm P T Khaw et al, Clinical review “ABC of Eyes- Injury to the eye” BMJ 2004;328:36-
38 (3 January) Cameron et al, Textbook of Adult Emergency Medicine, Second Ed, Churchill
Livingston, 2004 Eye Emergency Manual, NSW Ophthalmology Service, 2007 Retinal Detachment, G Larkin , Apr 7, 2008 www.emedicine.com Acanthamoeba, N Crum-Cianflone, Jun 30 2008, www.emedicine.com Facial Trauma, Orbital Floor Fractures (Blowout), A Cohen, Dec 18 2006,
www.emedicine.com Glaucoma, Acute Angle-Closure, A Darkeh, Oct 3 2007, www.emedicine.com Scleritis, T Gaeta, Apr 14 2008 www.emedicine.com Wilkins RB, Havins WE. Current treatment of blow-out
fractures. Ophthalmology. May 1982;89(5):464-6