Jamie Syrett, MD - NYSVARAMarcus Gunn Pupil • Afferent Pupillary Defect • Light into affected eye - no constriction and no consensual constriction • Light into normal eye - constriction

Pulsecheck - EyesJamie Syrett, MD

Opthalmology for EMSJamie Syrett

Blepharitis

Chronic Scaly Staph Infection of the Eyelid Margins

Seen chronically in old people

Associated with seborrheic dermatitis

Treatment is topical antibiotic and shampoo

Can lead to cellulitis

Dacryocystitis

• Infection of the lacrimal sac

• Anterior and medial swelling below the inner canthus

• Topical or Systemic Abx

DacryoadenitisInfection of the Lacrimal Gland

Warm Soaks and Abx, sometime needs I and D

Some systemic diseases also cause this

ChalazionSterile/Granuloma reaction of Meibomium Gland (oil that prevents evaporation of tear film)

Non-tender, non-inflammed

Usually mid-portion of upper lid

Warm Soaks/I and D

Hordeolum/Stye

Abscess of the lid margin

Pain, Redness, Swelling

Warm Compresses and Topical Antibiotics

Cellulitis

• Based on anatomy - Septum makes a closed space

• Peri-orbital (Pre-septal) Cellulitis - Minimal Pain, fever, erythema, lid edema

• Orbital (Post-septal) Cellulitis - Serious. Painful to move eye, proptosis

Orbital Cellulitis

• Meningitis - The most common complication

Eye Movements Eye Movements

Eye Movements• Cranial Nerve 3

• Upper division - Superior Rectus/Lev Palp Sup

• Lower division - Inferior, medial rectus, inferior oblique

• Cranial Nerve 4 - Superior Oblique

• Cranial Nerve 6 - Lateral Rectus

Eye Movements

• If CN3 is affected - the eye goes “down and out”

• If CN6 is affected - they can’t look laterally

• CN6 - Has a long path and when affected think raised ICP - it is the first nerve to be compressed

Eye Lid Movements

• CN7 innervates the eyelid to close the eyelid

• CN3 and sympathetic chain both innervate the eyelid to open the eye

• CN3 - Lev Palp Sup

• Sympathetic Chain - Mueller Muscle

Pupil Control

• Parasympathetics run in CN3 - Constrict

• Sympathetic Chain also innervates - Dilate

Pupillary Light Reflex

• What nerves does it check?

Pupillary Light Reflex

• Afferent leg (a before e) - CN2

• Efferent leg (constricts) - parasymp = CN3

Marcus Gunn Pupil• Afferent Pupillary Defect

• Light into affected eye - no constriction and no consensual constriction

• Light into normal eye - constriction of both eyes

• May be primary presentation of MS

• Swinging torch test

• May also get unresponsive pupil in iritis/trauma

CN3 Palsy• Eye is “Down and Out”

• Ptosis

• No parasympathetics - Pupil dilates

• Interesting - parasympathetics on outside, muscles on inside of nerve

• Compression - more dilation

• Strokes/MS - more paralysis

Sympathetic Chain

• Function - Lifts eyelid, dilates eye, stimulates face sweat glands.

• Chain leaves the chest at the lung apex

• Dysfuction - Horner’s Syndrome

• Ptosis, constricted pupil, dry face

Bell’s Palsy

• Lower VII palsy

• Facial droop

• Needs artificial tears and eye taping

• What about the forehead?

Yesterday’s ER Case• Patient presented to the ER with weakness,

smoker, normal focal neuro exam

• On exam the patient was noted to have a Horners on left and also have dilated veins over the left shoulder and arm

• She then had a seizure

• What is the appropriate treatment (benzos didn’t work)

Blown Pupil

• Head injury

• Blown pupil on right (unopposed sympathetics)

• Uncus herniates, pressing on the CN3 (can also be pressed on by aneurysm)

• Which side gets the dremmel?

Vision Loss• Monocular vision loss

• Problem with globe, retina, optic nerve, temporal arteritis

• Bitemporal hemianopsia

• Problem at optic chiasm

• Homonymous hemianopsia

• Problem in the optic tract

• Most common field deficit in CVA

Central Retinal Artery Occlusion

• Sudden, painless visual loss (usually embolic)

• Afferent Pupillary Defect

• Pale retina, fixed dilated pupil

EMS treatment

• Several treatments aimed at moving the emboli to a more peripheral position

EMS treatment

• Massage eye

• Bed at 45 degrees

• Hyperventilate in a bag………why?

• 90 minutes to restore vision

Hyperventilation

• Hyperventilation for elevated ICP works because…………

• Rebreathing hyperventilation works for Central Retinal Artery because………….

This morning

• 42 yo F presented to the ER with a “migraine” all night and then sudden loss of vision

• Marcus Gunn Pupil

• Pale retina

Differential Dx• Migraine - not typically vision loss

• Optic neuritis - not typically sudden

• Central retinal artery occlusion - not typically this age group

• Temporal Arteritis - no artery pain

• Retinal detachment - normally not blindness

• Psychiatric - hard to fake a lack of pupil response

Progression

• Placement, rubbed eye

• Suddenly had vision restore

• Admitted for embolic workup

Optic Neuritis

• Inflammation of the optic nerve

• Decreased vision over hours

• Painful to move eye

• Marcus Gunn Pupil

• “Loss of color vision”

Optic Neuritis

• Ask about other neurological symptoms since this is highly suggestive of MS

Retinal Detachment

• Tear in the retina that allows vitreous to separate retina from choroid

• Risk factors - DM, SCD, near sighted, age

• Symptoms - flashes of light in the periphery, decreased peripheral vision, new floaters, lowering a curtain

Retinal Detachment

• Why do I care?

• Place the location of the flashes inferiorly - allows the retina to lay back down

• Flashing lights and new floaters = retinal detachment

Temporal Arteritis• Age >50

• New onset headache

• Temporal artery tenderness

• Decreased pulsation in TA

• Elevated sed rate

• Impaired vision in 50% (posterior ciliary artery involved)

• Progresses to bilateral

EMS things

• Look away from a seizure but towards a stroke

• In the left MCA stroke you get speech problems in the right MCA stroke you see profound neglect

• Total paralysis - ACA and MCA

• MCA only - foot sparing

Conjunctivitis

• Viral or Bacterial

• Viral - nodes in front of ear (preauricular)

• Consider shingles

• Conjuctivitis in child <28d old - treat as sepsis

Corneal Lacerations

• Clinically you see a tear shaped pupil

• Constant tearing from eye

• Flat anterior chamber

• Avoid eye movements - may push out vitreous

Blow out fractures

• Medial wall of the orbit is very thin - orbital emphysema

• Herniation of orbital contents thru floor - limits upward gaze - diplopia looking up

• Decreased sensation of the cheek and upper lip - infraorbital nerve involved

“We are going to turn this

team around 360 degrees”

Jason Kidd