opthalmology in the ed - dr andrew white (june 2013)

Eye Emergencies

Dr Andrew White

BMedSci(hons) MBBS PhD FRANZCOClinical Senior Lecturer

Discipline of Ophthalmology and Eye Health

Glaucoma Specialist, Westmead Hospital

A Useful Resource

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0013/155011/eye_manual.pdf

Anatomy

Anatomy

The Basic Eye Exam

• You can learn a lot from pinhole acuity!

• Better with pinhole: refractive/anterior segment problem

• Not better: posterior segment problem

• Dilate (Tropicamide)! The risk of angle closure is tiny and you are in a hospital!

• Pupil exam will tell you a lot.

• Look for RAPD– Optic nerve problem

• Look for sluggish pupil– Uveitis– Angle closure glaucoma

Common Benign Things

• Pingueculum

• Pterygium

• Trabeculectomy bleb

Lids

Chalazion

• Often a child but also young adults

• Small lump on the upper or lower lid with some swelling

• Usually sent in by LMO as periorbital cellulitis but rarely is

• Treated by warm compresses and chlorsig

• Often spontaneously discharges

Periorbital and Orbital Cellulitis

• Usually in young children who are fairly well

• May start from a small scratch or chalazion

• Usually a 48hr trial of oral antibiotics before moving to IV if needed

• Don’t need to do a CT straight off

• Children with orbital cellulitis look sick.

• CT will show full sinuses and ENT need to be involved to drain it +IV antibiotics

Dacryocystitis

• Usually a young to middle aged adult with localised cellulitis over the lacrimal sac and a fever

• Needs IV antibiotics and warm compresses

• A pimple may form that will discharge spontaneously or can be incised by eye team

Lid Trauma

• We are more concerned about medial canthus injuries than lateral canthus due to location of lacrimal system

• Lid margin injuries need specialised repair

• Make sure the eye and orbit are intact

Cornea

Corneal Abrasion

• Commonly from a finger in the eye

• Very painful• Treat with chlorsig and a

double firm pad• QID chlorsig drops 7 days• Intensive chlorsig is

totally useless• Look under the lids for

tarsal foreign body!• Can lead to recurrent

erosions

Corneal Foreign Body

• Typically from angle grinding or small piece of wood

• Usually can be lifted off with a cotton bud or 25/23G needle

• Rust ring can be removed later in clinic

• Chlorsig QID 1 week

Subconjunctival Haemorrhage

• Looks worse than it is• Trivial• Idiopathic• Not related to INR.

Sometimes high BP• Will get better in 2

weeks• May need lubricants

for comfort

Conjunctiva

Bacterial Conjunctivitis

• Unilateral• Mucous discharge• ?Previous foreign

body

• Swab the discharge and give chlorsig 7 days

• Clinic f/u if no better

Viral Conjunctivitis

• Fairly common and goes in runs

• Characterised by watery discharge and itch

• 2 main forms:

• Adenoviral

• Herpes (simplex and zoster)

Adenoviral Conjunctivitis• Probably the most contagious

thing on the planet• Wash everything after contact!!!• Often an flu like prodrome• Accompanied by chemosis and lid

swelling• Characterised by conjunctival

follicles

• Typically goes from one eye to the next over a few days

• Self limiting but can persist for 2-3 weeks.

• Patient is contagious for 2 weeks• Lubricants and cool compresses

help

Herpes Conjunctivitis

• Either HSV 1, 2 or Zoster• Unilateral• Usually fairly mild

symptoms• May be accompanied by

a dendritic ulcer• Treatment is zovirax

ointment 5x a day 10 days

• Check the retina!

Herpes Zoster Ophthalmicus

• Only possible if the V1 division is involved.

• Usually only a mild conjunctivitis is involved treated with lubricants and cool compresses

• There may be some corneal ulceration

• Main concern is retinal involvement – check!

• Treatment is systemic oral antivirals (acyclovir. Valtrex etc).

• Trigeminal neuralgia may be a long term problem

Allergic Conjunctivitis

• Can be seasonal, drugs or contact

• Frequently bilateral but can be unilateral with mild lid swelling

• History is usually the giveaway• Papillae under the lids• Remove the stimulus, lubricate • Call us if contemplating

steroids• DO NOT GIVE STERIODS

INDEPENDENTLY• There are a number of over

the counter topical antihistamines (eg Lomide, Zatiden)

Inflammatory Conditions

Uveitis• Essentially an arthritis of the eye• Usually young, unilateral red eye

with photophobia• Flare and cells in the anterior

chamber +/- hypopion and irregular sluggish pupil

• May be HLAB27 +ve (ankylosing spondylitis)

• Other causes: Drugs, HSV, Syphilis, Sarcoid, TB, Bartonella, Lyme disease, LYMPHOMA – beware the elderly patient

• Treated with dilating drops and intensive topical steroids (by ophthalmology)

Scleritis and Episcleritis• Episcleritis: Young, localised

area of redness over the conjunctiva that blanches with phenylephrine 2.5%

• Self limiting. Gets better with NSIADS and weak topical steroids

• Scleritis: Old, rheumatoid patients but also seen in infections like syphilis

• Redness does not blanch• Extremely painful.• Treated with oral steroids and

NSAIDS• Risk of perforation

Blinding Conditions

Contact Lens Keratitis

• Painful, rapidly progressive

• Almost always pseudomonas

• Characterised by white corneal infiltrates

• Can progress to blindness in 24hrs

• Needs intensive ciloxan eye drops (hourly)

• Chlorsig will do nothing!

Chemical Burns

• Acid and chemical burns will damage superficial cornea then stop

• Alkali burns will continue to penetrate until neutralised

• Blindness results not only from initial damage but limbal stem cell failure

• Irrigate, irrigate, irrigate! ASAP

• Check pH of all chemical injuries at presentation and after irrigation

Endophthalmitis• Will be surgical or endogenous• Surgical typically presents day

1-7 post surgery with a rapidly progressive history of pain and redness (it is rare to present months to years later but it does happen)

• Endogenous is found in the immunosuppressed, moribund and IV drug users

• Blindness is rapid if untreated (hours)

• Needs a vitreous tap and intravitreal antibiotics/antifungals/antivirals as determined by ophthalmology

Acute Glaucoma

• Will be open or closed angle• Open angle usually has a long

history of glaucoma and a slowly progressive history

• Angle closure glaucoma is typically an elderly, dark iris patient who presents at night (when the eye dilates)

• Acute glaucoma is unilateral, painful, often accompanied by nausea

• The iris is usually stuck to the cornea and the eye will feel relatively firm

• The pupil will not react

Sudden Painless Loss of Vision

Optic Neuritis

• Typically young sudden loss of vision accompanied by pain on eye movement

• May or may not have a background of MS• Will have a RAPD• Otherwise normal exam though there may be

swelling of the optic disc• There is no role for oral steroids• IV methylprednisone shortens the duration of the

attack but not the severity or risk of recurrence• Needs MRI to look for plaques

Ischemic Optic Neuritis

• Will be arteritic or non arteritic

• May or may not have optic disc swelling

• Check ESR and CRP as GCA symptoms are vague and GCA patients tend to be poor historians

• Carotid dopplers need to be done via LMO

Central Retinal Vein Occlusion

• Typically large hypertensive 50+ year old women

• Dilated exam reveals widespread haemorrhage and swelling (chronic diabetics look the same but the vision loss is not acute)

• Can be ischemic or non ischemic

• May progress to neovascularisation and rubeosis if untreated (the 100 day glaucoma) so followup is important

Central Retinal Artery Occlusion

• Presents with a very pale retina (look at the other side) and you may or may not see an embolus

• Needs aggressive IOP lowering if presents within 6 hrs but patients rarely do

• Needs carotid dopplers via LMO

Wet ARMD

• Usually an elderly patient with known ARMD with sudden loss of central vision

• Needs f/u for intravitreal Lucentis (rooms)

Retinal Detachment

• Usually presents with a few days of flashes/floaters then a slowly progressive shadow or cobweb in 1 eye that doesn’t move or go away

• Usually sent in by optometrists who may be wrong

• Needs VR review/repair

Vitreous Haemorrhage

• Often confused with detachment as symptoms are similar

• May be a known diabetic who bleeds from neovascularisation or a traumatic vitreous detachement

• You won’t be able to see the retina on dilated exam and neither will we.

• Needs f/u for a B scan U/S to ensure no detachment

Hyphema

• Typically a history of blunt trauma to the eye and sudden loss of vision

• The AC may be cloudy before a blood level settles in the AC (microhyphema)

• IOP is usually low but can go high

• Needs dilating drops, topical steroids and strict bed rest

Orbital fractures• Usually from an assault or

sports injury• Usually medial wall or floor• Needs CT to check for globe

rupture• True entrapment of rectus

muscles is rare, usually in young teens and they will vomit/be unwell

• They need oral antibiotics and are not to blow nose

• Maxfax/plastics need to be involved.

• If acuity is OK, eye review can be within the week as an outpatient

Major Blunt Trauma

• MVAs etc• High

impact/deceleration injuries can shear the optic nerve

• The patients are usually intubated

Perforating Eye Injury

• Something flies into the eye at high speed

• Vision is down• Pupil will look irregular and will

point towards the perforation• Leave the eye alone• No pressure on the eye• Give ADT and an IV

cephalosporin• Get whatever imaging you can

for intraocular foreign body (CT is best)

• Keep NBM

Ruptured Globe

• Occurs in high speed MVAs and assaults involving bats and crowbars

• Fists are not usually enough

• Lids may be so swollen the eye can’t open – get a CT

• No pressure on the eye, ADT and an IV cephalosporin

• Keep NBM