eye emergencies unc department of emergency medicine nikki waller 2009-2010

Eye EmergenciesEye Emergencies

UNC Department of Emergency UNC Department of Emergency MedicineMedicine

Nikki WallerNikki Waller

2009-20102009-2010

InfectionsInfections

Stye (External Hordeolum)Stye (External Hordeolum)– Infected oil gland at the lid marginInfected oil gland at the lid margin– Treatment: Treatment:

Warm compressesWarm compresses

Erythromycin ointment for 7-10 daysErythromycin ointment for 7-10 days

StyeStye

Chalazion (Internal Hordeolum)Chalazion (Internal Hordeolum)– Infected meibomian gland (acute or chronic)Infected meibomian gland (acute or chronic)– Treatment: same as styeTreatment: same as stye

Warm CompressesWarm Compresses

Erythromycin ointment for 7-10 daysErythromycin ointment for 7-10 days

PLUS: Doxycycline for 14-21 days in refractory PLUS: Doxycycline for 14-21 days in refractory casescases

Refer to ophthalmology for persistent casesRefer to ophthalmology for persistent cases

ChalazionChalazion

ConjunctivitisConjunctivitisBacterialBacterial– Eyelash matting, mucopurulent discharge, conjunctival Eyelash matting, mucopurulent discharge, conjunctival

inflammation (without corneal lesions)inflammation (without corneal lesions)– Treatment: topical antibioticsTreatment: topical antibiotics

Adults: Trimethoprim-polymixin B or erythromycin dropsAdults: Trimethoprim-polymixin B or erythromycin drops

Infants: Sulfacetamide 10%Infants: Sulfacetamide 10%

– Contact lens wearers: need to cover Contact lens wearers: need to cover PseudomonasPseudomonasCipro, ofloxacin, or tobramycin topical coverageCipro, ofloxacin, or tobramycin topical coverage

Bacterial ConjunctivitisBacterial Conjunctivitis

ConjunctivitisConjunctivitisBacterialBacterial– If severe purulent discharge and hyperacute onset If severe purulent discharge and hyperacute onset

(12-24 hours), need prompt ophtho eval for work-up (12-24 hours), need prompt ophtho eval for work-up of of Gonococcal conjunctivitisGonococcal conjunctivitis

Gonococcal ConjunctivitisGonococcal Conjunctivitis

ConjunctivitisConjunctivitisViralViral

Monocular/Binocular watery discharge, chemosis, Monocular/Binocular watery discharge, chemosis, conjunctival inflammationconjunctival inflammation

Associated with Associated with – Viral respiratory symptomsViral respiratory symptoms

– Palpable preauricular nodePalpable preauricular node

Fluorescein stain may reveal superficial keratitisFluorescein stain may reveal superficial keratitis

Treatment: Treatment: – Cool compressesCool compresses

– Naphazoline/pheniramineNaphazoline/pheniramine for conjunctival congestion for conjunctival congestion

– Ophthalmology follow up in 7-14 daysOphthalmology follow up in 7-14 days

ConjunctivitisConjunctivitisViralViral

Monocular/Binocular watery discharge, chemosis, Monocular/Binocular watery discharge, chemosis, conjunctival inflammationconjunctival inflammation

Associated with Associated with – Viral respiratory symptomsViral respiratory symptoms

– Palpable preauricular nodePalpable preauricular node

Fluorescein stain may reveal superficial keratitisFluorescein stain may reveal superficial keratitis

Treatment: Treatment: – Cool compressesCool compresses

– Naphazoline/pheniramineNaphazoline/pheniramine for conjunctival congestion for conjunctival congestion

– Ophthalmology follow up in 7-14 daysOphthalmology follow up in 7-14 days

ConjunctivitisConjunctivitisAllergicAllergic– Monocular/binocular pruritis, watery discharge, Monocular/binocular pruritis, watery discharge, chemosischemosis– History of allergiesHistory of allergies– No lesions seen with fluorescein staining, no preauricular nodes, No lesions seen with fluorescein staining, no preauricular nodes,

Conjunctival papillaeConjunctival papillae– Treatment: Treatment:

Eliminate inciting agentEliminate inciting agent

Cool compressesCool compresses

Artificial tearsArtificial tears

Naphazoline/pheniramineNaphazoline/pheniramine

Herpes Simplex VirusHerpes Simplex Virus– Classic: Classic: Dendritic epithelialDendritic epithelial defect defect– ED care depends on the site of infectionED care depends on the site of infection

Eyelid and conjunctivaEyelid and conjunctiva– Topical antivirals (trifluorothymidine drops/vidarabine ointment) Topical antivirals (trifluorothymidine drops/vidarabine ointment)

5 times/day5 times/day– Topical erythromycin ointmentTopical erythromycin ointment– Warm soaksWarm soaks

CorneaCornea– Topical antivirals Topical antivirals 9 times/day9 times/day

Anterior chamberAnterior chamber– CycloplegicCycloplegic agent may be used agent may be used

– First 3 days of infection: Acyclovir/famcyclovirFirst 3 days of infection: Acyclovir/famcyclovir

Herpes Zoster OphthalmicusHerpes Zoster Ophthalmicus– Shingles with trigeminal distribution, ocular Shingles with trigeminal distribution, ocular

involvement, concurrent iritisinvolvement, concurrent iritis– ““PseudodentritePseudodentrite””

Mucous corneal plaque with epithelial erosionMucous corneal plaque with epithelial erosion

– Treatment: Treatment: AcyclovirAcyclovir

Topical antiviralsTopical antivirals

Oral analgesics or cycloplegics for pain reliefOral analgesics or cycloplegics for pain relief

– Ophthalmology consult mandatoryOphthalmology consult mandatory

Herpes Zoster OphthalmicusHerpes Zoster Ophthalmicus– Shingles with trigeminal Shingles with trigeminal

distribution, ocular involvement, distribution, ocular involvement, concurrent iritisconcurrent iritis

– ““PseudodentritePseudodentrite””Mucous corneal plaque with Mucous corneal plaque with epithelial erosionepithelial erosion

Oral analgesics or cycloplegics Oral analgesics or cycloplegics for pain relieffor pain relief

– Ophthalmology consult Ophthalmology consult mandatorymandatory

Periorbital Cellulitis (Preseptal Cellulitis)Periorbital Cellulitis (Preseptal Cellulitis)– Warm, indurated, erythematous eyelids onlyWarm, indurated, erythematous eyelids only– Treatment:Treatment:

Augmentin Augmentin (if older than 5 years)(if older than 5 years) if non-toxic if non-toxic

Toxic appearing, comorbidities, younger than 5Toxic appearing, comorbidities, younger than 5– Hospital admission for IV Ceftriaxone/VancomycinHospital admission for IV Ceftriaxone/Vancomycin– < 5 years old: Septic workup (bacteremia/meningitis may < 5 years old: Septic workup (bacteremia/meningitis may

be present)be present)

Periorbital Cellulitis (Preseptal Cellulitis)]Periorbital Cellulitis (Preseptal Cellulitis)]– Warm, indurated, erythematous eyelids onlyWarm, indurated, erythematous eyelids only– Treatment:Treatment:

Orbital Cellulitis (Postseptal Cellulitis)Orbital Cellulitis (Postseptal Cellulitis)– Warm, indurated, erythematous eyelids onlyWarm, indurated, erythematous eyelids only– Fever, toxicity, proptosis, painful ocular motility, Fever, toxicity, proptosis, painful ocular motility,

limited limited ocular excursionocular excursion– Diagnosis: Diagnosis:

emergent orbital and sinus thin-slice CT w/o contrast, if emergent orbital and sinus thin-slice CT w/o contrast, if negativenegative::

– CT with contrast - may reveal subperiosteal abscessCT with contrast - may reveal subperiosteal abscess

– Treatment:Treatment:Ophtho consultOphtho consult

Hospital admission for IV CefuroximeHospital admission for IV Cefuroxime

Orbital Cellulitis (Postseptal Cellulitis)Orbital Cellulitis (Postseptal Cellulitis)– Warm, indurated, erythematous eyelids onlyWarm, indurated, erythematous eyelids only– Fever, toxicity, proptosis, painful ocular motility, Fever, toxicity, proptosis, painful ocular motility,

limited limited ocular excursionocular excursion– Diagnosis: Diagnosis:

emergent orbital and sinus thin-slice CT w/o contrast, if emergent orbital and sinus thin-slice CT w/o contrast, if negativenegative::

– CT with contrast - may reveal subperiosteal abscessCT with contrast - may reveal subperiosteal abscess

– Treatment:Treatment:Ophtho consultOphtho consult

Hospital admission for IV CefuroximeHospital admission for IV Cefuroxime

Corneal UlcerCorneal Ulcer– Pain,redness, photophobiaPain,redness, photophobia– Etiology: desiccation, trauma, direct invasion, contact Etiology: desiccation, trauma, direct invasion, contact

lens uselens use– Slitlamp exam:Slitlamp exam:

Staining corneal defect with hazy infiltrate,Staining corneal defect with hazy infiltrate,

HypoponHypopon

– Treatment:Treatment:Topical ofloxacin or cipro drops every hourTopical ofloxacin or cipro drops every hour

Topical cycloplegiaTopical cycloplegia

Optho eval within 24 hoursOptho eval within 24 hours

HypoponHypopon

Traumatic Eye InjuriesTraumatic Eye Injuries

Subconjunctival HemorrhageSubconjunctival Hemorrhage– Disruption of conjunctival blood vesselDisruption of conjunctival blood vessel– EtiologyEtiology

TraumaTraumaSneezingSneezingGaggingGaggingValsalvaValsalva

– Will resolve spontaneously within 2 weeksWill resolve spontaneously within 2 weeks*If dense, circumferential *If dense, circumferential bloody chemosisbloody chemosis is is

present, must rule out globe rupturepresent, must rule out globe rupture

Conjunctival AbrasionConjunctival Abrasion– Superficial abrasionsSuperficial abrasions

Treatment: 2-3 days of erythromycin ointmentTreatment: 2-3 days of erythromycin ointment

– Ocular foreign body should be excludedOcular foreign body should be excluded

Corneal AbrasionCorneal Abrasion– Tearing, photophobia, blepharospasm, severe painTearing, photophobia, blepharospasm, severe pain– Fluorescein: dye uptake at defect siteFluorescein: dye uptake at defect site– Rule out foreign bodyRule out foreign body– Treatment:Treatment:

CycloplegicCycloplegic

Topical Tobramycin, Erythromycin, or Bacitracin/polymyxin Topical Tobramycin, Erythromycin, or Bacitracin/polymyxin dropsdrops

Contact lens wearers: Cipro, Ofloxacin, or Tobramycin dropsContact lens wearers: Cipro, Ofloxacin, or Tobramycin drops

Tetanus shotTetanus shot

Ophthalmology consult within 24 hoursOphthalmology consult within 24 hours

Corneal AbrasionCorneal Abrasion– Tearing, photophobia, blepharospasm, severe painTearing, photophobia, blepharospasm, severe pain– Fluorescein: dye uptake at defect siteFluorescein: dye uptake at defect site– Rule out foreign bodyRule out foreign body– Treatment:Treatment:

Topical Tobramycin, Erythromycin, or Bacitracin/polymyxin Topical Tobramycin, Erythromycin, or Bacitracin/polymyxin dropsdrops

Contact lens wearers: Cipro, Ofloxacin, or Tobramycin dropsContact lens wearers: Cipro, Ofloxacin, or Tobramycin drops

Tetanus shotTetanus shot

Ophthalmology consult within 24 hoursOphthalmology consult within 24 hours

Conjunctival Foreign BodiesConjunctival Foreign Bodies– Lid eversionLid eversion– Remove with a moistened sterile swabRemove with a moistened sterile swab

Corneal Foreign BodiesCorneal Foreign Bodies– May be removed with fine needle tip, May be removed with fine needle tip, eye spudeye spud, or , or eye eye

burrburr after topical anesthetic applied after topical anesthetic applied– Then treat as a corneal abrasionThen treat as a corneal abrasion– Deep corneal stoma FB or those in central visual axis Deep corneal stoma FB or those in central visual axis

require ophtho consult for removalrequire ophtho consult for removal– Rust ringsRust rings can be removed with eye burr, but not can be removed with eye burr, but not

urgenturgent– Optho follow up in 24 hours for residual rust or deep Optho follow up in 24 hours for residual rust or deep

stromal involvementstromal involvement

Lid LacerationsLid Lacerations– Must exclude damage to eye and Must exclude damage to eye and

nasolacrimal systemnasolacrimal system– Fluorescein staining in the tear layer that Fluorescein staining in the tear layer that

appear in the adjacent lac confirm appear in the adjacent lac confirm nasolacrimal involvementnasolacrimal involvement

– Most require ophtho consultMost require ophtho consult

Blunt TraumaBlunt Trauma– Immediately assess integrity of globe and Immediately assess integrity of globe and

visual acuityvisual acuity– Eval depth of anterior chamber, pupil size, Eval depth of anterior chamber, pupil size,

monocular blindness monocular blindness ruptured globe ruptured globe

HyphemaHyphema

HyphemaHyphema– Blood in the anterior chamberBlood in the anterior chamber– Spontaneous or post-traumaSpontaneous or post-trauma– Treatment: Treatment:

Place the pt upright to allow inferior settling of bloodPlace the pt upright to allow inferior settling of bloodExclude ruptured globeExclude ruptured globeDilate the pupil with atropineDilate the pupil with atropineMeasure intraocular pressure – if > 30 mmHg apply topical Measure intraocular pressure – if > 30 mmHg apply topical TimololTimololEmergent Optho evalEmergent Optho eval

HyphemaHyphema– Risk for worse rebleed in the next 2-5 days is Risk for worse rebleed in the next 2-5 days is

very highvery high

Blowout FracturesBlowout Fractures– Inferior and medial wall most at riskInferior and medial wall most at risk– Evaluate for Evaluate for

inferior rectus entrapment (diplopia on upward gaze)inferior rectus entrapment (diplopia on upward gaze)

infraorbital nerve paresthesiainfraorbital nerve paresthesia

subcutaneous emphysema (when blowing the nose)subcutaneous emphysema (when blowing the nose)

– Orbital cut CT scanOrbital cut CT scan– Treatment: rule out ocular trauma and give oral KeflexTreatment: rule out ocular trauma and give oral Keflex– Isolated blowout fracture – ophtho eval in 3 – 10 daysIsolated blowout fracture – ophtho eval in 3 – 10 days

Blowout FracturesBlowout Fractures

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe– Severe subconjunctival hemorrhageSevere subconjunctival hemorrhage– Shallow or deep anterior chamber in one eyeShallow or deep anterior chamber in one eye– HyphemaHyphema– Tear-drop shaped pupilTear-drop shaped pupil

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe– Severe subconjunctival hemorrhageSevere subconjunctival hemorrhage– Shallow or deep anterior chamber in one eyeShallow or deep anterior chamber in one eye– HyphemaHyphema– Tear-drop shaped pupilTear-drop shaped pupil– Limited extraocular motilityLimited extraocular motility– Extrusion of globe contentsExtrusion of globe contents– Significant reduction in visual acuitySignificant reduction in visual acuity

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe– Seidel’s testSeidel’s test

Fluourescein Fluourescein streamingstreaming

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe– If a globe injury is suspected: If a globe injury is suspected:

Don’t manipulate the eye any moreDon’t manipulate the eye any more

……Step away from the eyeStep away from the eye

Place the pt uprightPlace the pt upright

NPONPO

Protective eye shieldProtective eye shield

Administer IV cephazolin and antiemeticAdminister IV cephazolin and antiemetic

TetanusTetanus

Penetrating Trauma/Ruptured GlobePenetrating Trauma/Ruptured Globe– Orbital CT Orbital CT

If intraocular foreign body suspectedIf intraocular foreign body suspected

– Call Ophtho right awayCall Ophtho right away

Chemical Ocular InjuryChemical Ocular Injury– Acid or alkali – treat the sameAcid or alkali – treat the same– Immediately flush (at the scene)Immediately flush (at the scene)– Continue to flush until pH is normal (7.0)Continue to flush until pH is normal (7.0)

Check with urine dipstickCheck with urine dipstick

– Recheck pH after sweeping the fornices for Recheck pH after sweeping the fornices for retained particlesretained particles

– Measure IOPMeasure IOP

Chemical Ocular InjuryChemical Ocular Injury– Treatment:Treatment:

Erythromycin ointmentErythromycin ointment

Narcotic pain medsNarcotic pain meds

TetanusTetanus

– Immediate ophtho eval if not completely Immediate ophtho eval if not completely normal after initial measuresnormal after initial measures

Crazy Glue!Crazy Glue!

Crazy Glue!Crazy Glue!– Injury occurs only as a result of hard particles Injury occurs only as a result of hard particles

that form after dryingthat form after drying– Ophtho uses crazy glue as treatment in clinicOphtho uses crazy glue as treatment in clinic– Treatment:Treatment:

Erythromycin ointmentErythromycin ointment

Remove pieces that are easy to removeRemove pieces that are easy to remove

Optho can remove residual glue within 48 hoursOptho can remove residual glue within 48 hours

Crazy Glue!Crazy Glue!– Mineral oil may help separate the lidsMineral oil may help separate the lids– Never use acetone or other substance that Never use acetone or other substance that

breaks up gluebreaks up glue

Acute Vision LossAcute Vision Loss

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma– Eye pain, headache, cloudy vision, colored Eye pain, headache, cloudy vision, colored

halos around lights, conjunctival injectionhalos around lights, conjunctival injection– Fixed, mid-dilated pupilFixed, mid-dilated pupil– Increased IOP (40-70 mm Hg)Increased IOP (40-70 mm Hg)

Normal range is 10 – 20 mm HgNormal range is 10 – 20 mm Hg

– Nausea, vomitingNausea, vomiting

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma– Immediate treatment:Immediate treatment:

TimololTimololApraclonidineApraclonidinePrednisolone acetatePrednisolone acetate

– If IOP > 50 mm Hg or severe vision loss:If IOP > 50 mm Hg or severe vision loss:Acetazolamide 500mg IVAcetazolamide 500mg IV

– If no decrease in IOP or vision improvement:If no decrease in IOP or vision improvement:IV MannitolIV Mannitol

– Pilocarpine 1-2% in affected eye, pilocarpine 0.5% in Pilocarpine 1-2% in affected eye, pilocarpine 0.5% in contralateral eye (after IOP < 40 mm Hg)contralateral eye (after IOP < 40 mm Hg)

– Immediate Ophtho consultImmediate Ophtho consult

Optic NeuritisOptic Neuritis– Inflammation of the optic nerveInflammation of the optic nerve

Infection, demyelination, autoimmune dxInfection, demyelination, autoimmune dx

– Presentation:Presentation:Vision reduction (poor color perception)Vision reduction (poor color perception)

Pain with extraocular movementPain with extraocular movement

Afferent pupillary defectAfferent pupillary defect

– Swelling of the optic disc may be seenSwelling of the optic disc may be seen

Optic NeuritisOptic Neuritis

Optic NeuritisOptic Neuritis– DiagnosisDiagnosis

Red Desaturation TestRed Desaturation Test– Stare at bright red object with normal eye onlyStare at bright red object with normal eye only– Object will appear pink or light red in affected eyeObject will appear pink or light red in affected eye

– TreatmentTreatmentDiscuss with OphthoDiscuss with Ophtho

Central Retinal Artery OcclusionCentral Retinal Artery Occlusion– CausesCauses

Thrombosis, embolus, giant cell arteritis, vasculitis, sickle cell Thrombosis, embolus, giant cell arteritis, vasculitis, sickle cell disease, traumadisease, trauma

– Preceded by amaurosis fugaxPreceded by amaurosis fugax– Painless vision lossPainless vision loss

May be complete or partialMay be complete or partial

– Afferent pupillary defectAfferent pupillary defect– Pale fundus with narrowed arterioles and segmented Pale fundus with narrowed arterioles and segmented

flows (boxcars) and bright red macula (cherry red flows (boxcars) and bright red macula (cherry red spot)spot)

Central Retinal Artery OcclusionCentral Retinal Artery Occlusion

Central Retinal Artery OcclusionCentral Retinal Artery Occlusion– Treatment:Treatment:

Ocular massage!Ocular massage!– 15 seconds of direct pressure with sudden release15 seconds of direct pressure with sudden release

Topical timolol or IV acetazolamideTopical timolol or IV acetazolamide

Emergent Optho evalEmergent Optho eval

Central Retinal Vein OcclusionCentral Retinal Vein Occlusion– Thrombosis – diuretics and oral Thrombosis – diuretics and oral

contraceptives predisposecontraceptives predispose– Painless, rapid monocular vision lossPainless, rapid monocular vision loss– Fundoscopy:Fundoscopy:

Diffuse retinal hemorrhageDiffuse retinal hemorrhage

Cotton wool spotsCotton wool spots

Optic disc edemaOptic disc edema

““Blood and thunder”Blood and thunder”

Central Retinal Vein OcclusionCentral Retinal Vein Occlusion

Central Retinal Vein OcclusionCentral Retinal Vein Occlusion– Treatment:Treatment:

ASA 325ASA 325

Ophtho referralOphtho referral

Temporal Arteritis (Giant Cell Arteritis)Temporal Arteritis (Giant Cell Arteritis)

Temporal Arteritis (Giant Cell Arteritis)Temporal Arteritis (Giant Cell Arteritis)– Systemic vasculitis that can cause ischemic Systemic vasculitis that can cause ischemic

optic neuropathyoptic neuropathy– UsuallyUsually

> 50 years old> 50 years old

FemaleFemale

Polymyalgia rheumaticaPolymyalgia rheumatica

Temporal Arteritis (Giant Cell Arteritis)Temporal Arteritis (Giant Cell Arteritis)– Presentation:Presentation:

HeadacheHeadache

Jaw claudicationJaw claudication

Myalgias, fatigueMyalgias, fatigue

Fever, anorexiaFever, anorexia

Temporal artery tendernessTemporal artery tenderness

TIA or stroke?TIA or stroke?

Afferent pupillary defectAfferent pupillary defect

Temporal Arteritis (Giant Cell Arteritis)Temporal Arteritis (Giant Cell Arteritis)– DiagnosisDiagnosis

Don’t waste your time if you suspect diagnosisDon’t waste your time if you suspect diagnosis

ESR, CRPESR, CRP

Temporal artery biopsy (gold standard)Temporal artery biopsy (gold standard)

– TreatmentTreatmentIV steroids and Ophtho consultIV steroids and Ophtho consult

Temporal Arteritis (Giant Cell Arteritis)Temporal Arteritis (Giant Cell Arteritis)

Subluxed GlobeSubluxed Globe

QUESTIONSQUESTIONS

eye emergencies unc department of emergency medicine nikki waller 2009-2010

Documents

days slide

chalazion slide

stye slide

acyclovirfamcyclovir

bacterial conjunctivitis

conjunctival inflammation

chronic treatment

corneal lesions treatment