chapter 4 icd-9-cm coding guidelines
TRANSCRIPT
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High risk
OphthalmologyDavid Duong, MD MS
University of California, San Francisco
Department of Emergency medicine
conflicts of interest
• no personal financial relationships for
products or services in this talk
objectives
• Pointers and pitfalls in:
• Eye trauma
• The red eye
• Visual loss
Diagnosis CORNEAL FOREIGN BODY
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foreign body removal
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Pearls for
Rust Rings
• Rust Rings do not have to be removed
immediately
• Removal is often easier 1-2 days after
the injury and with a corneal drill
• Homatropine can help with ciliary
spasm
• Arrange follow-up in 1-2 days after
removalCan J Rural Med 2013
everting the lid
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subtarsal foreign body
corneal Foreign Body pitfalls
• Not everting the lid
• Not considering an intraocular FB
• Not considering corneal laceration
high risk lacerations? ALL OF THEM anatomy
ophtho or plastics need to be involved for
lacerations involving the:
tarsal plate
lid margin
nasolacrimal system
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canalicular laceration
eyelid laceration pitfalls
• Not assuming there are other ocular
injuries
• Not obtaining visual acuity
so get Va, assess EOM,
RAPD, etc.
Va helps to risk stratify for
eye emergencies
EM Clin NA. 2008
globe rupture
• decreased Va
• RAPD
• eccentric pupil
• bullous subconjunctival hemorrhage
• extrusion of vitreous
• hyphema
• Seidel test
Globe rupture
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seidel test
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key actions
globe rupture
• Consult ophthalmology and order CT
• Protect the eye (eye shield, avoid eye
manipulation)
• Avoid ocular extrusion (antiemetics,
pain meds, sedation)
• Antibiotic prophylaxis
• Tetanus prophylaxis
Diagnosis HYPHEMA
HYPHEMA TREATMENT
<33% (Grade 1)
microhyphemagood prognosis
eye shield
HOB >30 deg
cycloplegia
ophtho referral
no NSAIDS
90% visual acuity prognosis 20/50 or better.
HOB >30 deg to prevent synechiae
cycloplegia only if no incr IOP
referral to monitor for incr IOP and rebleeding
within 5 days.
33-50% (Grade 2)
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HYPHEMA TREATMENT
>50% (Grade 3 & 4)
↑ IOP (>24)
sickle cell
ophtho consult
eye shield
HOB >30 deg
no NSAIDS
topical B-blocker if increased
IOP.
c/s may also recommend
steroid drops
HYPHEMA
PITFALLS
• Not obtaining an IOP or asking about
sickle cell disease or trait
• Discharging with NSAIDs
• Neglecting close ophthalmology follow-
up
• Not considering globe rupture or IOFB
The Red Eye
case of red eye
• 52-yo F with 1 day of severe right eye
pain, and decreased vision. On exam,
you see corneal cloudiness and diffuse
conjunctival injection with ciliary flush.
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medical treatment of acute
angle glaucoma
• How do you use the drops?
• How many times can you repeat the
drops?
• What about acetazolamide and
mannitol?
medical treatment of acute
angle glaucoma
• Give separate eye drops 1 minute apart
(timolol, apraclonidine, prednisolone,
pilocarpine are acceptable)
• Give acetazolamide PO early
• Repeat drops once in 15 minutes
medical treatment of acute
angle glaucoma
• Goal IOP is 35 mmHg or >25%
presenting IOP
• Consider mannitol IV if IOP is still high
• Call ophthalmology again
Choong et al. Eye. 1999
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vision loss
floaters
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Hollands et al. JAMA 2009
approach to floaters and
flashes
• Bottom line is to determine when to
refer a vision threatening condition to
prevent further vision loss or restore
vision
Hollands et al. JAMA 2009
PVD can lead to retinal tears
14% prevalence
33-46% of retinal tears lead
to retinal detachment
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JAMA meta-analysis
• floaters vs flashes vs both is not
diagnostically helpful for retinal tear
• older age (>60) is not associated with
increased risk of retinal tear; younger
age is not less likely to have retinal tear
discuss evidence behind
recommendations from the
JAMA paper subjective visual acuity
baseline 14%
prevalence of
retinal tear in
those with
PVD
worse vision
no change
45% probability
of retinal tear
9% probability of
retinal tearHollands et al. JAMA 2009
vitreous hemorrhage or
pigment
baseline 14%
prevalence of
retinal tear in
those with
PVD
vitreous hemorrhage
LR = 10
vitreous pigment
LR = 44
62% probability
of retinal tear
88% probability
of retinal tear
besides allergy and glaucoma -
there is no absolute contraindication for pupillary
dilation for a good exam.
1 gtt tropicamde + 1 gtt
phenylephrine and wait 20
minutes
Key actions
• Assess subjective visual acuity
• Assess visual acuity and peripheral
vision
• Fundiscopic exam +/- slit lamp
need pictures or videos or vitreous hemorrhage and
pigment - assess via slit lamp or direct ophthalmoscopy (Shafer’s or Shaffer’s sign)
root atlas has a video of retinal detachment
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pitfalls in the case of floaters
and flashes
• Not referring to ophthalmology with only
subjective visual acuity loss
• Not giving return precautions with a
PVD diagnosis (more floaters or vision
reduction)
Case of vision loss
• 72-yo F with sudden painless,
decreased left eye vision 2 hours. Va
OS = cannot read the eye chart or
count fingers, but can see hand motion.
Diagnosis CENTRAL RETINAL
ARTERY OCCLUSION
key actions
CRAO
• Rule-out temporal arteritis (including
ESR & CRP)
• Consider ocular massage (within 24
hrs)
• Ophtho consult (to consider AC
paracentesis or thrombolytics)
Fraser et al. Cochrane review. 2009
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pitfalls
CRAO
• Failing to consider embolic source of
CRAO
• ECG for AFib
• carotid imaging
• cardiac evaluation
Case of vision loss
• 38-yo F with decreased left eye vision
for 2d with mild eye pain. She has
decreased Va, a + RAPD on the left,
and swollen optic disc. nl slit lamp
exam.
relative afferent
pupillary defect
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key actions
optic neuritis
• Neurology consult for MS and NMO
work-up
• Consider MRI with gadolinium
• Consider IV steroids
ONTT - 457 patients with optic neuritis
IV methylprednisolone was associated
with faster recovery in visual fxn and a
lower 2-year risk of development of
multiple sclerosis. but did not affect
long term outcome
Oral prednisone was associated with
an increased incidence of recurrent
optic neuritis and did not improve visual
outcomes compared to placebo
Beck et al. NEJM. 1993
Cochrane. 2012
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summary
• Key Actions and Pitfalls in:
• Eye trauma
• The red eye
• Vision loss
www.rootatlas.com
podcasts@ucsf
particular thanks to those
who gave consent to be
photographed for
educational purposes
thank you for your
attention
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pediatrics
• CORNEAL ABRASIONS
• antibiotic ointments lubricate
• consider 1 drop of cycloplegia
• consider codeine elixir
Video of a baby crying before
this slide?
CORNEAL ABRASION
PITFALL
• Return precautions
• RED FLAG: persistent pain or
unwillingness or open the eye after
1 day of treatment
pediatric Eye trauma
PITFALL
• Consider sedation to fully evaluate the
eye
• Ketamine: total dose <3mg/kg does not
raise IOP
Nagdeve. J Ped Ophth Strab. 2006
pediatric vision testing
• Pediatric Eye Chart
• Fix and Follow (F/F)
• Blink to Light (BTL)
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fixation target
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Fix and follow
Can start to fix and follow at
2 months
References
• 1. Magauran. Emerg Med Clin N Am. 2008; 26; 23.
• 2. Carley. Emerg Med J. 2001; 18: 273.
• 3. Guess S et al. Ocul Surf. 2007; 5(3): 240.
• 4. Choong YF et al. Eye. 1999; 13: 613
• 5. Hollands et al. JAMA. 2009; 302(20): 2243.
• 6. Germann et al. AJEM. 2007; 25: 834.
• 7. Fraser et al. Cochrane Database of systematic reviews. 2009.
• 8. Mohamed et al. Ophthalmology. 2007; 114(3):507.
• 9. Nagdeve et al. J Ped Ophth Strab. 2006; 43(4):219.
• 10. Brock G et al. Can J Rural Med. 2013; 18(4)
• 11. Gharaibeh A et al. Cochrane Database of systematic reviews. 2013.
• 12. Halstead SM et al. Acad EM. 2012; 19:1145-1150
• 13. Gal RL et al. Cochrane Database of systematic reviews. 2012. cells and flare
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