ophthalmology board review- emergency medicine 2014

OPTHO REVIEWAmy Begnoche DO

Anatomy

Hoarders

Hordeolum (Sty)Acute painful nodule external lid

Zeis gland

Abcess of eyelid

Usually S. aureus

Tx: warm compress, abx ointment, I&D refractory cases

Chalazion Chronic stye

Chronic internal granulomatous (sterile) rxn of Meibomian glands

Tx: warm compress, refer to Optho for excision

Blepharitis

Inflammation of the eyelid

Dandruff of the eyelid

Chronic staph or strep

Tx: gentle scrub with baby shampoo, topical abx

ConjunctivitisBacterial:-pus drainage-strep or staph-pseudomonal (contact lens, treat with aminoglyc/quinolone)

Tx: topical abx

ghonorrhea: 1st 3 days of life, ocular emergency, pouring pus out of the eye, systemic abx (rocephin, topical erythromycin, cover for chlamydia)

Chlamydia: first 5-14 days of life, systemic and topical abx

Contagious for 2 weeks

Viral Conjunctivitis

adenovirus

Tx: cool compress, no school

Consider allergic or chemical

Corneal Abrasion Minor trauma

Painful

Tx: abx ointment, pain meds

***metal on metalsuspect intraocular FB

Corneal Ulcer Focal white opacity

Pain, redness, photophobia, visual defect

Caused by bacteria, fungal, HSV

Urgent Ophtho referral

No patch (corneal melting from pseudomonas)

Dacrocystitis

Clogged lacrimal duct

tears don’t drainPurulent discharge

s. aureus

Tx: warm compress, abx (augmentin)

Foreign Body

Remove with moistened cotton swab, needle

Evert eyelids, stain with flourescein

Rust ring: needs to be removed, burr device, refer ophtho

Keratitis

Inflammation of the cornea

Punctate: UV exposure (welder, snow blindness)

Supportive care, artificial tears, topical abx

HerpesSimplex

Keratitis causing foreign body sensation

Dendritic corneal lesion

Tx: urgent ophtho consult, topical/po antiviral, no topical steroids

Zoster

Ophthalmic branch of the trigeminal N. (V1)

Hutchinson sign

Tx: systemic/topical antiviral, emergent ophtho consult, +/- steroids, pain control

Preseptal v. Orbital Cellulitis

Preseptal/PeriorbitalPain, swollen lid

OrbitalSick, pain with eye movement, proptosis

Tx: CBC, Bld cx, CT obrits, IV abx

Complications: meningitis, sepsis, abscess, cavernous sinus thrombosis (CN 3, 4, 6) vision loss from high IOP

Glaucoma

Increased intraocular pressure

Problem with flow of aqueous humor through trabecular meshwork and Canal of Schlemm

Leads to damage of optic nerve

Chronic (Open angle glaucoma)

Gradual peripheral vision loss

age >40, African American, family hx

Tx: topical/systemic meds to decrease aqueous humor production and increase flow

Acute angle glaucomaPrecipitated by dim light (dilated pupil)

“walking out of a movie theater”

Painful loss of vision, headache, nausea, halos

Eye injected, steamy cornea, elevated IOP 40-70

Tx: emergency ophtho referral, topical/systemic meds to decrease aqueous humor production and increase flow

IV carbonic anhydrase inhibitor, BB gtt, mannitol, pilocarpine gtt

Iritis Acute painful red eye, blurry vision

Can be traumatic

Ciliary flush – reddening of sclera at the limbus

Cells and flare

No relief with topical anesthetic

Tx: topical cycloplegic

Hypopyon

Pus in the anterior chamber of the eye

White cells layering out

Endophthalmitis

Infection of deep eye structures

Pain + vision impairment

Tx: intraocullar and systemic abx

Optic Neuritis Acute painful (central) vision loss

Pain with eye movement

Inflammation of optic nerve

“Marcus gun pupil” (APD)

Associated with MS

Can be caused by toxins, meds, autoimmune dz

Tx: IV steroids

Retinal DetachmentTraumatic or atraumatic

Retinal tear allows vitreous fluid to separate retina from choroid

Risk factors: old, degenerative myopia, previous detachment

Painless flashes of light, floaters, curtain over eye

Tx: emergent ophtho consult

Central Retinal Artery OcclusionOcular emergency

Sudden painless unilateral vision loss

Emboli, thrombotic plaque, vascultitis

Cherry red spot (perifoveal atrophy), box cars (arteriolar narrowing)

Tx: emergency ophtho referral, poor prognosis, atherosclerotic wkup

Central Retinal Vein Occlusion

Thrombosis

Sudden, painless, unilateral vision loss

“blood and thunder retina”

Tx: thrombosis wkup

Eye Trauma

BurnsAlkali: liquefication necrosis (worse)

Acidic: coagulation necrosis

Irrigate the eye until pH is normal (7.4)

Globe Rupture

Scleral rupture from high IOP

Teardrop pupil, seidel’s sign

NO TONOPEN

Tx: hard shield, analgesia, tetanus, IV abx, ophtho consult

Hyphema Blood in the anterior chamber

Can lead to increased IOP, eye staining

Trauma, anticoagulation, spontaneous (sickle cell)

Secondary bleeding as clot retracts

Increased risk of glaucoma, adhesions, vision loss

Tx: bedrest, analgesics, no anticoag, ophtho consult

Orbital Fracture

Orbital walls made of thin bones

Weakest = floor -infraorbital nerve involvement, inhibited upward gaze, numbness of cheek or upper lip, diplopia

Tx: if nml exam, urgent ophtho referral

Retrobulbar Hematomahematoma causes

increased IOP

pressure on retinal A.

eye ischemia (compartment syndrome)

Vision loss

Tx: lateral canthotomy, meds to lower IOP

Lid Lacerations

Ophtho repair:

involve lid margin

6-8mm from medial canthus

involving lacrimal duct

involving inner surface of the lid

associated ptosis

<1mm heal spontaneously

References

Peer VIII

HippoEM

Intensive Review for Emergency Medicine Qualifying Exam

Rivers Emergency Medicine Review