common ocular emergencies
TRANSCRIPT
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COMMON OCULAR EMERGENCIES
Mahmoud Tawfik ,MD AFHSR
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WHAT IS MOST IMPORTANT ORGAN IN BODY ?
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So ocular emergencies for all medical staff is very important that if u safe ptn eye as u safe his life
So all of us must know 1st Aid in ophtha cases as we know CPR
My lecture looks like BLS
You will be never blamed if you cann’t treat cardiac arrest case but will be very impressed if you fail to maintain life tell code blue team arrive
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OBJECTIVES
How non ophthalmologist triaging and give 1st aid of ocular emergencies
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IOP
INTRODUCTION
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EYE EXAMINATION
visual acuityPupillary light reflex
ocular motility
external eye
Orbit : proptosisPeriorbital skin Lid, conj
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indirect ophthalmoscopy
Direct ophthalmoscopy
Slit lamp
Ant segment examination Fundus examination
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USEFUL TOOLS
Near vision cardPenlight with blue filterTopical anestheticFluorescein stripsTopical mydriatic
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ESTIMATING ANTERIOR CHAMBER DEPTH
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ALGORITHM FOR DIAGNOSING
Key worrisome clinical findings (ophtho referral needed):
Pain: Pain in eye often indicates more serious intraocular pathology (iritis, glaucoma).
Visual acuity: if decreased, usually more serious cause.
Pupil: if sluggish
Pattern of redness: CILIARY FLUSH (Redness worse near cornea, usually
serious intraocular cause
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RED EYE: KEY HISTORICAL QUESTIONS
DO YOU HAVE PAIN ?Biggest distinguishing factor between emergent and non-emergentDo you wear contacts? (increased risk of keratitis-corneal infection)Do you have any associated symptoms ?
Decreased visionphotophobia/diplopiaflashes/floatersHalos/N/V/Abd painAny above require referral
Main differential of red eye:
Conjunctivitis (infectious/noninfectious)Trauma, Foreign bodySubconjunctival hemorrhageAngle closure glaucomaIritis/uveitisKerititisScleritis, episcleritis
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Ocular Emergencies
Trauma Non-Trauma
Blunt Penetrating Eye Neuro-
ophthalmology
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Chemical burns
CRAO
Orbital Hemorrhage
IMMEDIATEWithin minutes
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Endophthalmitis
Orbital Cellulitis
Rupture Globe
IOFB
Macula-on RDAcute Glaucoma
Microbial Keratitis
Very URGENTWithin hours
cavernous sinus thrombosis
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Urgent Within 1 day
orbital fractures
lid laceration
Hyphema
corneal abrasioncorneal FB
Sudden or recent loss of vision
acute ocular motility problems
diplopia,nystagmus,limited movement
macula off RD
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SUDDEN OR RECENT LOSS OF VISION
Painless
Hydrops
Abnormal cornea
viterous hge
RD
Abnormal fundus
CRAOCRVO
AION
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PainfullAbnormal cornea
Bullous keratopathyKeratitis
Abnormal fundus
Optic neuritis
anterior uveitis
AACG
Pain on eye movement
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MOST COMMON EMERGENCIES CASES
DIAGNOSIS,MANGEMENT
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CHEMICAL BURN
Tap water
Emergency Treatment:Saline Copious irrigation (until neutral pH):, may range from a few liters to many liters (more than 8 to 10 L
Treatment should be instituted IMMEDIATELY,
even before talking history
Lids should be retracted and fornices swabbed for particulate matter
Once pH is stabilized
Cycloplegic agent Broad-spectrum
antibiotic
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RUPTURED GLOBETrauma leads to corneal or scleral disruption and extravasation of intraocular contents .Can lead to:Irreversible visual lossEndophthalmitis
Hypotony
pain, decreased vision
Hyphema
Loss of AC depth
“tear-drop” pupil which points toward laceration subconjunctival hemorrhage
Stop the examination
Cover with eye shield , DO NOT PATCH.
CT head and orbit to evaluate for concomitant facial/orbital injury.
NPO
Tetanus
Systemic AntibioticsRepair.
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Central Retinal Artery Occlusion
Sudden severe monocular vision loss over seconds
90% VA CF or less
Etiology:Emboli – cardiac, atherosclerotic
Narrow arteriolesOptic disc and retinal pallorCherry red spot at fovea
Must have VERY high index of suspicion, especially in patients with appropriate risk factors.
Immediate referral. Retina irreversibly damaged (100 min)
Mannitol or acetazolamide to reduce IOP .
Carbogen inhalation
Oral nitrates
Lay the patient flat on his/her back
Globe Massage.
Paracentesis.
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Signs and symptoms
“black coming down over visual field ”
Bright flashes of light (photopsia)
Increasing floaters
Decreased visual acuity (macula off)
Retinal detachment
separation of neurosensory layer of retina from underlying choroid and retinal pigment epithelium
KEY MANAGEMENT POINT- know “classic” presentation so you can refer to an ophthalmologist quickly.
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Acute Angle Closure Glaucoma (AACG)- Pain (sever brusting )
Halos (around lights)
Nausea/vomiting
Conjunctival injection (ciliary flush)
Corneal edema
Mid-dilated, fixed pupil
IOP ( stony hard)
Medical TxReduce production of aqueous humorTopical -blocker (timolol 0.5% - 1- 2 gtt)Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)Or increase outflowTopical -agonist (phenylephrine 1 gtt)Miotics (pilocarpine 1-2%)Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H
Definitive TxLaser peripheral iridectomy
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RETROBULBAR HEMATOMA
Acute orbital compartment syndrome 2° to blunt or penetrating trauma
Hemorrhage into closed space of orbit
IOP leading to vision loss from optic nerve damage / retinal ischemia
Immediate lateral canthotomy and cantholysis indicated if IOP > 40mmHg or vision loss
APD ,
Proptosis
Ophthalmoplegia
Diminished vision
IOP
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ORBITAL BLOWOUT FRACTUREEnophthalmosDiplopiaImpairment of eye movementOrbital emphysema
CT should include axial and coronal cuts
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Periorbital Cellulitis (Preseptal Cellulitis)Warm, indurated, erythematous eyelids only
Orbital Cellulitis (Postseptal Cellulitis)Warm, indurated, erythematous eyelids only
Treatment:Hospital admission for IV Cefuroxime
Fever, toxicity, proptosis, painful ocular motility, limited ocular excursion
emergent orbital and sinus CT
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foreign body sensation, tearing, red, or painful eye .
Linear epithelial defects suggestive of
foreign body under the eye lid
Often metallic foreign body following work injury
Remove foreign body
Topical AB
Corneal FB
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5 .CORNEAL INJURIES(ABRASIONS, LACERATIONS, ULCERS)
Symptoms :extreme eye pain, relieved with lidocaine drops.Visual acuity usually decreased, depending on location of injury in relation to visual axis .
Diagnosis :fluorescein staining to see epithelial defect .
Seidel’s test
Topical antibiotics and follow up with ophthalmologist
Avoid contact lenses
Avoid patching.
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CORNEAL INJURIES
Seidel’s test: Concentrated fluorescein is dark orange but turns bright green under blue light after dilution .
This indicates aqueous leakage which is diluting the green dye.
+ve >>>> laceration
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HYPOPON (AC PUS )
Endoopthalmitis Microbial keratitis
Iritis
Very urgent refferal
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LID LACERATION
Eyelids don’t have fat
Orbital fat usually protrudes through septal lacerationsFat in the lid laceration confirms the diagnosisHigh incidence of globe penetration and intraocular foreign bodiesHigh risk for orbital cellulitis
Take care check lid margin
Medial injuries may affect lacrimal passages
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Hopefully I convey my message to my
colleges today together we will safe ptns eyes
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