Emergency Ophthalmology Flashcards
Principles of therapy
• 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
Porcupine quill in eye - initial treatment
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
Protocol for Emergencies
• Accurate history
• Carefully examine patient
– Beware of pain
– Start with “good” eye
• Diagnosis
• Therapy: start what you can finish
– Consider referralPreop steps
– Physical exam – Blood tests – Ancillary tests • Control inflammation and infection – Topical or systemic medications – Corticosteroids or NSAIDs
Preparation of pat
• 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
Intro-op steps
• 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
Intra-op surgical considerations
• 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 fatiguePost-op treatment
– 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
Orbital Abscess: presentation, diagnosis
- Acute presentation
- Exophthalmia, prolapse of 3rd eyelid
- Retropulsion of globe
- Painful on opening mouth
- PLR,F.stain
- Oral cavity exam
- Ocular ultrasound
Orbital Abscess: treatment
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.
Proptosis
PLR - indirect response
Fluorescein stain uptake
Cornea moist
Proptosis - treatment
• TREATMENT: • Tarsorrhaphy – Suture through meibomian gland • Antibiotics – Oral, triple topical antibiotic – oral NSAIDS • Recheck – 24 to 48 hrs
Lid Laceration
- Fluorescein stain
- Betadine prep
- Minimal debridment
- +/- conjunctival repair • Lid margin – apposition
- Antibiotics/ NSAIDS
Corneal Foreign body
- Blephrospasms, tearing
- Topical anesthesia
- +/- heavy sedation/ GA
- Incision over FB
- Fluorescein stain
- Topical antibiotic QID
Corneal Ulcer
- Simple ulcer:
- Check under 3rd eyelid • Triple antibiotic QID
- Atropine BID
- Recheck: 3-5 days!!!
Complicated Ulcer
• TREATMENT: • Aggressivemedicaltx – q 1-2 hours antibiotic • Atropine:BID • Autologousserum:melting • NSAIDS–systemic • Recheck:24hrs • Surgery: – Conjunctival graft 
Corneal Laceration
• Minimal handling • Surgery – Small defect (<5mm) • Repair: 7-0, 8-0 Vicryl – Large defect • Suspect lens extrusion • Enucleation
Chemical Keratitis
• 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.
Hyphema
• 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)
Lens luxation
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
Acute Blindness - causes
– Glaucoma: IOP
– Retinal detachment: visualize, IOP
– Sudden Acquired Retinal degeneration: normal – Optic neuritis: PLR, optic disc abnormalities
– Cortical blindness: cranial nerve deficits
Retinal Detachment
• Acutevisionloss • Dilatedpupils • Retinal vessels – +/- retinal hemorrhages – Grey veil • Physicalexam – BP
SARDS
- Acute vision loss
- Weak PLR
- Dilated pupils
- NORMALFUNDUS • ERG diagnosis
- No treatment
Optic Neuritis
• NOT COMMON • “Fuzzy”, hemorrhagic optic nerve head • Complete workup – MRI • Corticosteroids
