Emergency Ophthalmology

Question 1

Principles of therapy

Answer 1

• Acute ocular disease may lead to blindness
• Minimal handling of ocular tissues
• Minimize self trauma: E. collar
• 3rd eyelid flap: not prevent
corneal rupture
• Diagnostic tests: as many as possible
• Post-op. care : sooner rather than later
– All patients leave with E. collar

Question 2

Porcupine quill in eye - initial treatment

Answer 2

Porcupine quill:
Don’t give oral
Give IV Buprenorphine, hydromorphone
Don’t give acepromazine - will cause 3rd eyelid to prolapse
Don’t do a third eyelid flap or a temporary tarsoraphy (won’t prevent corneal rupture)
An elizabethan collar will give enough protection - prevent self-trauma
Recheck the dog in 24 hours

Question 3

Protocol for Emergencies

Answer 3

• Accurate history
• Carefully examine patient 
        – Beware of pain
        – Start with “good” eye
• Diagnosis
• Therapy: start what you can finish 
        – Consider referral

Question 4

Preop steps

Answer 4

– Physical exam – Blood tests
– Ancillary tests
• Control inflammation and infection 
   – Topical or systemic medications 
   – Corticosteroids or NSAIDs

Question 5

Preparation of pat

Answer 5

• Surgical prep:
– Clip area: minimal
– Scrub: if necessary
• Be careful of detergents coming into contact with cornea
– Solution: povidone-iodine 1:25 or 1:50
– Avoid:
• Chlorhexidine deacetate
• Alcohol
• Hydrogen peroxide

Question 6

Intro-op steps

Answer 6

• Intra-op:
– Position of patient
• Sternal for eyelid procedures • Lateral for orbital procedures
– Draping:
• 4 towels
• 1 impermeable drape
• Intravenous antibiotics
– Cephazolin 22 mg/kg i.v.
• Necessary for geriatric, diabetic, Cushing’s

Question 7

Intra-op surgical considerations

Answer 7

• Manipulation of tissues 
– Gentle
– Make only one incision
       • Be careful, no second chance
– Be aware of margins
– Careful placement of sutures
• Surgical material
– Magnification is needed
• Visualize 5-0 to 9-0 suture material • Ensure proper apposition of tissues
– Comfort = better surgery
• Concentration not hampered by fatigue

Question 8

Post-op treatment

Answer 8

– Slow wake-up
– Analgesia
• Opioids, NSAIDs
– Elizabethan collar: a must!
– Suture removal: 14 days
– Activity:
• Leash walks with harness for minimum 7 days --> only be on a harness, not on a collar & esp not a choke collar

Question 9

Orbital Abscess: presentation, diagnosis

Answer 9

• Acute presentation
• Exophthalmia, prolapse of 3rd eyelid
• Retropulsion of globe
• Painful on opening mouth
• PLR,F.stain
• Oral cavity exam
• Ocular ultrasound

Question 10

Orbital Abscess: treatment

Answer 10

Antibiotics - clavamox
Systemic NSAIDs -
Surgical drainage (if it is a cellulitis there is no abscess to drain) look back. If you see a budge or a fistula then investigate with a haemostat - go in behind the last molar. Close and push, then open, then repeat. Avoid clamping the optic nerve. Can be +/- discharge.

Question 11

Proptosis

Answer 11

PLR - indirect response
Fluorescein stain uptake
Cornea moist

Question 12

Proptosis - treatment

Answer 12

• TREATMENT: 
• Tarsorrhaphy
– Suture through meibomian gland 
• Antibiotics
– Oral, triple topical antibiotic
– oral NSAIDS
• Recheck 
– 24 to 48 hrs

Question 13

Lid Laceration

Answer 13

• Fluorescein stain
• Betadine prep
• Minimal debridment
• +/- conjunctival repair • Lid margin – apposition
• Antibiotics/ NSAIDS

Question 14

Corneal Foreign body

Answer 14

• Blephrospasms, tearing
• Topical anesthesia
• +/- heavy sedation/ GA
• Incision over FB
• Fluorescein stain
• Topical antibiotic QID

Question 15

Corneal Ulcer

Answer 15

• Simple ulcer:
• Check under 3rd eyelid • Triple antibiotic QID
• Atropine BID
• Recheck: 3-5 days!!!

Question 16

Complicated Ulcer

Answer 16

• TREATMENT:
• Aggressivemedicaltx
– q 1-2 hours antibiotic
• Atropine:BID
• Autologousserum:melting • NSAIDS–systemic
• Recheck:24hrs
• Surgery:
– Conjunctival graft


Question 17

Corneal Laceration

Answer 17

• Minimal handling
• Surgery
– Small defect (<5mm)
• Repair: 7-0, 8-0 Vicryl – Large defect
• Suspect lens extrusion • Enucleation

Question 18

Chemical Keratitis

Answer 18

• Corneal ulcer
• May progress if alkaline
substance involved
• Flush eye with saline
• Treat for ulcer & uveitis
Antibiotic to minimize chance of infection.
Treat with systemic NSAIDs (no topical steroids)
• Recheck: 3 days
Acidic - burns & reaction stops. Alkaline - slow going, keeps on causing problems.
Sooner they can flush then better.

Question 19

Hyphema

Answer 19

• Blood in anterior chamber
– Can also be found in vitreous
(could be warfarin, trauma, etc)
If trauma - not good news, especially if in the vitreous if the sclera near the optic nerve has a rent in it.
• Verify PLR, IOP, fluorescein stain 
• Ocular ultrasound (can sometimes help)
• Corticosteroids
– Topical and systemic
(keep the dog quiet)

Question 20

Lens luxation

Answer 20

Glaucoma can be caused
Endothelial damage
Terriers
Cats: chronic uveitis 
Referral (better odds if IOP is normal)
True ocular emergency IOP > 30 mmHg
Find the underlying cause & reduce the pressures right away

Question 21

Acute Blindness - causes

Answer 21

– Glaucoma: IOP
– Retinal detachment: visualize, IOP
– Sudden Acquired Retinal degeneration: normal – Optic neuritis: PLR, optic disc abnormalities
– Cortical blindness: cranial nerve deficits

Question 22

Retinal Detachment

Answer 22

• Acutevisionloss
• Dilatedpupils
• Retinal vessels
– +/- retinal hemorrhages – Grey veil
• Physicalexam – BP

Question 23

SARDS

Answer 23

• Acute vision loss
• Weak PLR
• Dilated pupils
• NORMALFUNDUS • ERG diagnosis
• No treatment

Question 24

Optic Neuritis

Answer 24

• NOT COMMON
• “Fuzzy”, hemorrhagic
optic nerve head • Complete workup
– MRI
• Corticosteroids