9/27/2019 1 Ocular Emergencies Maria Pribis, OD, FAAO OcularPrime.com . Course Objectives: ❖ Review ocular emergencies ❖ Review how to triage true emergencies from routine eye problems ❖ When to refer ❖ Review life threatening emergencies that present with eye findings –Thomas Edison “The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.” What is an Ocular Emergency? ❖ Any condition that can cause permanent loss of vision ❖ Emergency = Right now ❖ Urgent = Today ❖ Routine = Next week 1 2 3 4 5 6
18
Embed
OD, FAAO Emergencies Emergencies.pdf · 9/27/2019 1 Ocular Emergencies Maria Pribis, OD, FAAO OcularPrime.com. Course Objectives: Review ocular emergencies Review how to triage true
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
9/27/2019
1
Ocular Emergencies
Maria Pribis, OD, FAAOOcularPrime.com
.
Course Objectives:
❖ Review ocular emergencies
❖ Review how to triage true emergencies from routine eye problems
❖ When to refer
❖ Review life threatening emergencies that present with eye findings
–Thomas Edison
“The doctor of the future will give no medicine, but will interest her or his patients in the care of
the human frame, in a proper diet, and in the cause and prevention of disease.”
What is an Ocular Emergency?
❖ Any condition that can cause permanent loss of vision
❖ Emergency = Right now
❖ Urgent = Today
❖ Routine = Next week
1 2
3 4
5 6
9/27/2019
2
Case 1:
❖ 58 year old Asian female
❖ CC: severe right eye pain, halos around lights, headache and nausea
❖ BCVA: OD: 20/200 OS: 20/25
❖ IOP: OD: 38mmHg OS: 17mmHg
Primary Angle Closure
❖ Pupillary block
❖ Risk Factors: age, female, Asian ethnicity, hyperopia
Secondary Angle Closure
❖ PAS
❖ Neovascularization of the Angle
❖ Lens induced
❖ Topiramate and sulfonamides ‐within 2 weeks of starting
❖ Posterior segment tumor
7 8
9 10
11 12
9/27/2019
3
Differential Diagnosis of Acute IOP increase
❖ Posner‐Schlossman syndrome: mild cell and flare with recurrent IOP spikes
❖ Inflammatory open angle glaucoma
❖ Traumatic glaucoma ‐ RBC’s in the anterior chamber
❖ CC: blurry vision and pain after inserting toilet bowl cleaning drops into the right eye
❖ BCVA: OD: 20/400 OS: 20/30
❖ IOP: OD: 20 OS: 15mmHg
13 14
15 16
17 18
9/27/2019
4
❖ Follow up: s/p prokera slim x 1 day
❖ CC: less pain in the right eye
❖ BCVA: OD: 20/400 OS: 20/30
❖ IOP: OD: 18 OS: 16mmHg
❖ Final follow up: s/p prokera x 3
❖ CC: vision seems back to normal
❖ BCVA: OD: 20/40 OS: 20/30
❖ IOP: OD: 15mmHg OS: 16mmHg
Examination for Chemical Burns
❖ Detailed history ‐ type of chemical, time between exposure and irrigation
❖ Visual acuity
❖ Check pH if not at 7.45 irrigate
❖ Slit lamp exam with IOP assessment if able
Treatment
❖ Cycloplegic
❖ Antibiotic ointment or drops q2h while awake
❖ If IOP elevated give oral CAI ‐monitor electrolytes especially potassium
❖ Preservative free artificial tears q2h
❖ Pressure patch vs amniotic membrane
❖ Topical steroid if significant inflammation 4‐9 times per day as soon as 1 day follow up (consider combination antibiotic ‐ steroid)
19 20
21 22
23 24
9/27/2019
5
Case 3:
❖ 66 year old male
❖ CC: blurry vision in the left eye, no pain
❖ BCVA: OD: 20/150 OS: 20/25
❖ IOP: OD: 20 OS: 17mmHg
❖ H/O poorly controlled hypertension and high cholesterol
Differential Diagnosis
❖ Ocular ischemic syndrome/carotid occlusive disease (veins dilated but not tortuous)
❖ Diabetic retinopathy ‐ typically bilateral
❖ Papilledema ‐ bilateral
❖ Radiation retinopathy ‐ history of radiation
Etiology
❖ Atherosclerosis of the adjacent CRA ‐> compresses vein inducing thrombosis in the lumen of the vein
❖ Hypertension
❖ Optic disc edema
❖ Glaucoma
❖ Optic disc drusen
❖ Hypercoagulable state
❖ Vasulitis ‐ sarcoidosis, syphilis, SLE
❖ Oral contraceptives
Ischemic vs Non ‐ Ischemic
❖ Ischemic ‐ VA 20/400 or worse, RAPD, nonperfusion on IVFA
❖ Nonischemic ‐ no RAPD, VA better than 20/400
25 26
27 28
29 30
9/27/2019
6
Treatment
❖ If macular edema anti ‐ VEGF or intravitreal triamcinolone
❖ Discontinue oral contraceptives if applicable
❖ Glaucoma management if elevated in EITHER eye
❖ Refer to PCP for systemic management (Blood pressure)
❖ Refer to retina if neovascularization
SCORE Study
❖ Steroids vs sham for CRVO macular edema
❖ 4mg vs 1mg
❖ After 1 year 27% of 1mg group had 3 line improvement in VA compared to 7%?of sham
❖ 35% given 4mg needed IOP lowering compared to 20% given 1mg
CRUISE Study
❖ Lucentis vs sham for CRVO induced macular edema
❖ Lucentis improved VA by 3 lines in 47% of patients given .3mg lucentis 50% given .5mg lucentis and 33% given sham
HORIZON Study
❖ Continued CRUISE Study through 2 years
❖ 0.5mg Lucentis was given PRN to each of the original three groups
❖ 0.5mg Lucentis was superior through the entire study (45% gained 3 or more lines of VA) and is the currently recommended dose
Epstein Study
❖ Avastin vs sham
❖ 60% gained 3 lines given avastin vs 20% given sham
❖ Delayed treatment resulted in poorer outcome
COPERNICUS Study
❖ Does Eyelea (Trap‐eye) improve VA in macular edema secondary to CRVO?
❖ Improvement when given Eyelea
❖ Best when given within 2 months of onset of CRVO
❖ Equal response for perfused (<10 DD of non‐perfusion) or non‐perfused eyes
❖ May be able to use quarterly for some patients but some still require monthly treatment and should be monitored at least quarterly for 2 years from onset of CRVO
31 32
33 34
35 36
9/27/2019
7
Ding, et al Study
❖ Avastin vs intravitreal triamcinolone
❖ Only 32 patients in Study
❖ Equal VA but avastin group required more treatments
Clinical Pearls
❖ Prompt referral is necessary but if delayed should still receive treatment
❖ Monitor for POAG in fellow eye
❖ If no macular edema or neovascularization monitor every 2 weeks for 1 month then monthly for 6 months
Follow Up
❖ If vision is 20/40 or better monitor every 1‐2 months for 6 months
❖ If vision is worse than 20/200 every month ‐monitor for NVA, NVD or NVE
❖ 10% risk of BRVO or CRVO in fellow eye
Case 4:
❖ 26 year old male
❖ CC: recent fight after leaving a bar, struck in eye with beer bottle, right eye is in pain, blurry, seems smaller than the left eye
❖ BCVA: OD: CF at 3’ OS: 20/20
❖ IOP: OD: 3 OS: 17mmHg
❖ Anterior segment exam: OD: 360 SCH, +Seidel, full thickness scleral laceration OS: normal
Treatment
❖ Once confirm ruptured globe defer further examination until surgical repair takes place in the OR
❖ Protect eye with a shield at all times until surgery
❖ Obtain CT to confirm or rule out IOFB
❖ Admit patient to hospital with no food or drink
❖ Bed rest no bending over or valsalva maneuvers
❖ Systemic antibiotics within 6 hours of injury (IV vancomycin, IV/PO ciprofloxacin
37 38
39 40
41 42
9/27/2019
8
Treatment
❖ Tetanus toxoid
❖ Antiemetic (compazine) to prevent vomiting
❖ Plan surgical repair ASAP
❖ If no chance of repair enucleation within 7‐14 days to prevent sympathetic ophthalmia
Sympathetic Ophthalmia
❖ Decreased vision at near prior to distance
❖ Suspect any inflammation in the uninvolved eye following trauma (4‐8 weeks prior but can range from 5 days to 66 years, 90% within 1 year)
❖ Bilateral severe AC reaction with large mutton fat KP’s
❖ Depigmented changes at the RPE level (Dalen ‐ Fuchs nodules)
Additional Testing
❖ CBC, RPR, FTA‐ABS, ACE
❖ Chest XRay
❖ IVFA or BSCAN to confirm diagnosis
Treatment
❖ Prevention: enucleation of blind traumatized eye
❖ Topica steroids
❖ Intravitreal steroids
❖ Systemic steroids with an antacid or H2 blocker
❖ Cycloplegic
❖ Systemic immunosuppressant like methotrexate
❖ Continue steroids 3‐6 months after resolution of inflammation
Case 5:
❖ 54 year old female
❖ CC: Since yesterday seeing new floaters, significant flashes of light in the left eye
❖ BCVA: OD: 20/20 OS: 20/20
❖ IOP: OD: 15mmHg OS: 15mmHg
43 44
45 46
47 48
9/27/2019
9
Rhegmatogenous Retinal Detachment
❖ Previous ocular surgery
❖ Acute PVD (10‐15% will have a break)
❖ Trauma
❖ Family Hx or previous RD (both eyes 10% of the time)
❖ Myopia (40% of all RD’s)
❖ Lattice Degeneration (30%)
Anatomy
❖ Vitreous ‐ gel filled with collagen, cells, protein
❖ Strongest attachment is the vitreous base weakest is at the retinal vessels
❖ Retina is 10 layers including RPE
Pathophysiology
❖ RRD result from retinal breaks allowing vitreous into subretinal space —> separates sensory retina from RPE
❖ Atrophic holes
❖ Vitreous‐retinal traction
Symptoms
❖ Floaters
❖ Photopsia
❖ Curtain over the vision ‐ helpful in predicting location of RD —> superior temporal quadrant most likely (60%)
❖ Blurry vision
49 50
51 52
53 54
9/27/2019
10
Treatment
❖ Stat referral to retinal specialist for surgical repair
❖ Macular on vs macular off RD ‐ bed rest until surgery
❖ Vitrectomy and scleral buckle vs laser photocoagulation vs cryotherapy vs pneumatic retinopexy
Scleral Buckle
Cryotherapy Pneumatic Retinopexy
Case 6:
❖ 73 year old male
❖ CC: for the last few days I’ve had headaches, difficulty eating due to pain in my temple, tired and in general not feeling well, want to know if my eyes are causing the headaches
❖ BCVA: OD: 20/25 OS: 20/25
❖ IOP: OD: 15mmHg OS: 16mmHG
❖ S/P PCIOL OU
❖ H/O dry macular degeneration ‐ on AREDS
❖ Hypertension ‐ well controlled with lisinopril also takes aspirin 81mg daily
55 56
57 58
59 60
9/27/2019
11
Work Up
❖ Complete ocular exam to test for AION
❖ Stat ESR, CRP, CBC with platelets
❖ Temporal artery biopsy ( within 1 week of starting steroids)
Treatment
❖ Systemic steroids: IV methylprednisolone for 3 days then oral prednisone with antacid (ranitidine 150mg bid)
❖ If positive TAB remain on prednisone 1mg/kg initially then slowly lower to smallest dose to keep ESR low and symptom free —> 6‐12 months typically
❖ Forced duction testing if EOM restriction longer than 1 week
❖ CT orbit scans
79 80
81 82
83 84
9/27/2019
15
Treatment
❖ Broad spectrum antibiotics (Keflex 500mg pro bid for 1 week)
❖ Do not blow nose (recommend Afrin bid for 3 days)
❖ Ice for 24‐48 hours
❖ Medrol dose pack
Surgical Repair
❖ Within 24‐72 hours if CT shows severe muscle herniation plus diplopia
❖ Repair in 1‐2 weeks if symptomatic diplopia, large orbital floor fractures >50% or large medial wall and floor fractures
❖ Old fractures that resulted in enophthalmos
Follow Up
❖ At 1 and 2 weeks to evaluate for persist diplopia
❖ At 1 month for gonioscopy and dilated fundus exam
❖ Long term for Angle recession
Case 9:
❖ 28 year old female
❖ CC: I was diagnosed with a sinus infection about 1 week ago, now my entire eye is swollen shut, painful, blurry vision
❖ BCVA: OD: 20/20 OS: 20/40
❖ IOP: OD: 10mmHg OS: 13mmHg
❖ Pain on eye movement
❖ +proptosis
❖ +fever
Pathophysiology
❖ An infection posterior to the orbital septum
❖ Typically from sinus infection, orbital infection, orbital fracture, dental infection
❖ Staphylococcus aureus in adults
❖ Haemophilus influenzae in children
85 86
87 88
89 90
9/27/2019
16
Symptoms
❖ Red eye
❖ Pain
❖ Blurry vision
❖ Fever
❖ Decreased color vision
❖ +APD
❖ Proptosis
❖ Diplopia with pain due to EOM restrictions
Prognosis
❖ Serious infection that untreated can lead to cavernous sinus thrombosis, brain abscess and or meningitis
❖ Diabetics and immune compromised can develop fungal infection (mucormycosis)
Work Up
❖ Complete ophthalmic exam
❖ CT scan of orbits and sinuses with and without contrast
❖ CBC with differential
❖ Lumbar puncture if suspect meningitis
Treatment
❖ Admit patient to hospital
❖ Broad spectrum IV antibiotics for at least 72 hours than PO for 1 week
❖ Nasal decongestant (Afrin bid for 3 days) if needed
❖ Erythromycin ung if severe proptosis with corneal exposure
❖ If optic neuropathy present, severely elevated IOP stat canthotomy performed
91 92
93 94
95 96
9/27/2019
17
Follow Up
❖ Once released from hospital monitor every few days to ensure condition resolves
❖ Medication non‐compliance is reason for condition to worsen or not resolve
Case 10:
❖ 53 year old male
❖ CC: I noticed my right pupil is much smaller than my left pupil, saw it about 2 days ago
❖ BCVA: OD: 20/20 OS: 20/20
❖ IOP: OD: 12mmHg OS: 13mmHg
Horner Syndrome
❖ First order neuron disorder ‐ stroke, tumor, MS
❖ Second order neuron disorder ‐ tumor (Pancoast tumor, ask about pain in the arm or scapular area)
❖ Third order neuron disorder ‐ headache syndrome, internal carotid dissection, HZV, Tolosa‐Hunt syndrome
❖ Congenital Horner ‐ trauma during delivery
Work Up
❖ Diagnosis with positive cocaine or apraclonidine testing (Horner pupil dilates less with cocaine and more with apraclonidine compared to normal pupil)
❖ Hydroxyamphetamine for pre‐ganglionic (first and second order neuron) vs post‐ganglionic (third order neuron) —> no dilation is post ganglionic lesion
97 98
99 100
101 102
9/27/2019
18
Work Up
❖ CBC with differential
❖ CT of chest to look for Pancoast tumor (apex of lung)
❖ MRI of brain and neck
❖ MRA to evaluate for carotid dissection
Treatment
❖ Carotid dissection requires urgent anti‐coagulation to prevent thrombosis
❖ Surgical intervention if ischemic symptoms in the distribution of the dissection
Follow Up
❖ Once life threatening carotid dissection ruled out ‐ same day as presentation other tests should be obtained within 1‐2 days
❖ Chronic Horner syndrome requires less urgency ‐nothing to necessitate close follow up