Eye Emergencies

Question 1

Eye history/ROS

Answer 1

Onset: sudden vs. gradual
Pain: severity? 
 Photophobia?
Change in vision?
Trauma: when, how?
Associated symptoms: headache, vomiting, neuro sx.

Question 2

Physical Exam for the eye.

Answer 2

General inspection - noting erythema, tearing, light sensitivity, pattern of redness
Visual acuity - to be tested with glasses, one eye at the time
Evaluation of extraocular movement
Confrontation visual fields
Pupils - symmetry, reactivity to light, pupillary reflex
Fluoresceinapplication
Intraocular pressure testing (by tonometry or palpation)
Pen light or slit lamp exam (with examination for red-reflex symmetry)
Ophthalmoscopic examination.
Signs of major trauma
Obvious laceration
Distorted pupil
proptosis

Question 3

When evaluating the eyes and you see pain/photophobia, and papilledema. Think?

Answer 3

Subarachnoid hemorrhage

Question 4

When there is diplopia or loss of vision?

Answer 4

Stroke

Question 5

What would be needed to treat immediatly?

Answer 5

Bring immediately to treatment area:
Chemical burns – Irrigate
Sudden, painless vision loss: Notify MD
Sudden onset severe pain,decreased vision
Consider risk of CVA, SAH
May use 1-2 gtts of proparacaine for FB sensation.
Globe rupture – metal eye shield

Question 6

Conjunctivitis sx’s, etiology, and red flags?

Answer 6

Irritated or itchy
Discharge
No photophobia, no change in vision
Redness spares the edge of the iris 
Etiology: primarily adenovirus 
Beware: herpes keratitis, gonococcal conjunctivitis
Look for previous URI sx's...........
Slit lamp every simple pink eye case Jason......

Question 7

Conjucntivisis tx?

Answer 7

Tx: Warm compresses, topical antibiotic

Question 8

Blepharitis sx’s and tx?

Answer 8

Eyelid inflammation
Seborrheic dermatitis
Psoriasis
Acne rosacea
Bacterial 

Treatment
Warm compresses
Topical antibact ointment

Question 9

Hordeolum sx’s, etiology and tx (also called a stye)

Answer 9

Acute infection of the meibomian glands of the eyelid,
Staph aureus 95%
Warm compresses, I&D, topical antibiotic

Question 10

Keratitis (inflammation of the cornea)
what does it include?
Caused by?
What does it feel like?

Answer 10

wide variety of corneal infections, irritations, and inflammations
One form of viral conjunctivitis, epidemic keratoconjunctivitis (EKC), is particularly fulminant
typically caused by adenovirus
foreign body sensation and multiple corneal infiltrates barely visible with a penlight to the skilled observer
Vision affected; acute optho consult, steriod tx

Question 11

Bacterial Keratitis sx’s?

In severe cases?

Answer 11

Unilateral, acutely painful
Photophobic and intensely injected eye
Visual acuity often reduced
Profuse tearing
Thick mucopurulent d/c
May have a corneal defect/ulceration
Edematous cornea
In severe cases:  hypopyon

Question 12

What is a Pterygium?

Answer 12

Excessive growth of conjunctiva
easily irritated
May require elective excision

Question 13

Herpes Keratitis sx’s, tx?

Answer 13

Unilateral injection, irritation, mucoid discharge, pain, mild photophobia
Occurs during primary infection with HSV or during recurrent episodes of ocular herpes.
Discrete epithelial lesions that coalesce to form single or multiple branching (dendritic) epithelial ulcers
Tx: topical or systemic antivirals
Immediate optho consult

Question 14

Herpes Zoster sx’s, nerve affected, doesnt cross?

Answer 14

nonspecific facial pain
Fever and general malaise
4 days after onset, vesicular rash appears
5th cranial nerve distribution
Does not cross midline
Severe pain during inflammatory stage

Question 15

Foreign Body/Corneal Abrasion sx’s, discharge? what does the red spare? need what to see it?

Answer 15

Sensation of FB
Pain is relieved by topical anesthetic
No discharge (except tearing)
Vision may be decreased if lens affected
Pupils normal
Redness spares edge of the iris
Abrasion usually not visible without fluoresceine

Question 16

Treatment of Foreign Body or Abrasion?

Answer 16

Topical antibiotic ointment +/- cycloplegic
Patching no longer routine
Never patch contact-lens wearers
Beware: ulcer, intraocular foreign body
Obtain xrays if suspicious
Dont be afraid to flick it out with a needle if the object is imbeded….
Always look for the ulceration?
Always check with ocular CT to make sure there is no other peices of metal.

Question 17

Corneal Ulcer etiology?

visible w/o?

Answer 17

Result from any defect in the cornea
Visible without fluorescein
Defect surrounded by cloudy white or gray appearing cornea
May have hypopion

*Risk: corneal penetration; requires optho consult

Question 18

Acute traumatic iritis
sx’s?
cornea clear?

Answer 18

Aching pain, gradual onset
Photophobia
No discharge
constricted pupil
Slight decrease in visual acuity
Limbic flush=corneal involved

Red eye with limbic flush
Midrange or slightly small pupil
Cornea clear
Cell and flare seen in anterior chamber on slit lamp exam(not often)this is cells floating in the anterior chamber

Question 19

Treatment of Iritis?

Answer 19

Pain control
Cycloplegic medication (homatropine)
\+/- topical steroid drops
Consider workup for collagen vascular diseases 
Refer to ophthalmologist for follow up

paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation.

Question 20

Chemical Splashes.
Alkali or acid?
tx?

Answer 20

Alkali worse than acid(acid does its damage then its done, alkali keeps going)
Treatment is immediate, copious irrigation until pH normal
Test with nitrazine paper
(nml 7.4 – 7.6)
Flip lid to remove all debris
Treat all splashes initially as caustic
(Severe alkali burn causing opacification of the cornea)

Question 21

Whats the mechanism for chemical burns?
Alkali?
Acid?
Tx

Answer 21

Alkali rapidly penetrates ocular tissue and continues to cause damage long after the injury; increased intraocular pressure
Acid forms a barrier of precipitated necrotic tissue limiting further penetration and damage
Requires prolonged lavage (at least 2 liters of NS by morgan lens irrigation)
repeat pH checks until = 7.3-7.7
Tx: topical anesthetic, cycloplegic agents, topical steroids. Optho consult

Question 22

Acute Angle Closure Glaucoma sx’s

Pt’s dont wait, see them immediatly

Answer 22

Sudden onset
Severe deep pain
Photophobia
Poor visual acuity,  halos
Pupil dilated, poorly reactive
Cloudy cornea
Headache,vomiting, 
	abdominal pain
Red eye with limbic flush
Pupil midrange, nonreactive
Shallow anterior chamber
Elevated intraocular pressure

Question 23

Anatomic abnormalities that predispose individuals to AACG

Answer 23

Shallow  anterior chambers
thin ciliary bodies
thin iris
anteriorly situated, thick lens
IOP may increase suddenly to as much as 80 mmHg.

Question 24

AACG Presentation

Answer 24

aqueous humor in the posterior chamber is trapped and causes the iris to bulge forward, thus closing off the irido-corneal angle.
produces sudden pain and edema of the cornea ( patient describes eye and brow ache)
reduced vision; sensation of seeing halos around lights.
Acute increase of IOP : nausea and vomiting

Question 25

Treatment of angle closure glaucoma?

Answer 25

Call opthalmologist stat!
Goals: 
Decrease size of pupil
Decrease aqueous humor production
Decrease intraocular pressure
Decrease intraocular pressure with oral diamox or IV mannitol
Decrease production of aqueous humor with topical α-agonist or β-blocker (Timoptic) 
Constrict pupil with topical pilocarpine
Anti-emetics
Pain management

Question 26

Vitreous hemorrhage (painless loss of vision) sx’s?

Answer 26

Occurs in the setting of trauma, spontaneous retinal tear, spontaneous vitreous detachment
associated with retinal neovascularization
poorly controlled diabetes
Floaters or “cobwebs”
progresses over hours to visual loss
decreased red reflex
Pupillary defect suggests retinal detachment
*Immediate Opthalmology consult

Question 27

Retinal detachment sx’s?

Tx?

Answer 27

may occur spontaneously or in the setting of trauma
sudden onset of new floaters or black dots, often accompanied by flashes of light
Vision: cloudy, filmy or curtain-like
Visual field cut, afferent pupillary defect may be present
Once the macula has become involved, visual acuity will be severely compromised.
*Immediate Opthalmology consult
Tx of choice is surgery

Question 28

Optic neuritis (painless loss of vision) sx's?
Tx?

Answer 28

Sudden, severe loss of vision
\+/- pain on eye movement, reduced visual acuity and washed out color vision. 
afferent pupillary defect 
Sluggish pupil
high association with multiple sclerosis
70% of cases unilateral. 
Tx: corticosteroid therapy improves short-term vision recovery but has not been shown to alter long-term vision outcome or progression to multiple                           sclerosis.
Opthalmology Consult

Question 29

Central retinal vein occlusion (painless loss of vision) sx’s
Whats the difference with this and Optic Neuritis?

Answer 29

Slow painless loss of vision
Occlusion /thrombosis of the central retinal vein
associated with chronic glaucoma, atherosclerotic risk factors , age, diabetes, hypertension, hyperviscosity, and coagulopathy
Episodes of visual loss variable in length: seconds to–several hours.
distinguishing feature: description of “cloudy vision” rather than visual loss.

Question 30

Central Retinal Artery Occlusion (painless loss of vision)
Onset?
Special test?

Answer 30

Painless catastrophic visual loss over a period of seconds
caused by embolism of the retinal artery
Hx of transient visual loss may be reported (amaurosis fugax)
Exam:
Marcus-Gunn pupil
Visual acuity:
counting fingers to light perception
Retina: pale optic disk with narrowed arteries
“cherry red spot” where fovea (fed by choroid vessels) is spared

Question 31

Treatment of Central Retinal Artery Occlusion?

Prognosis?

Answer 31

Prognosis is poor; early intervention may improve chances of recovery (20-30%)
immediate optho consult
Hyperventilation with paper bag
Inhalation of Carbogen (5% carbon dioxide and 95% oxygen)
to induce vasodilation and improve oxygenation
Digital massage of affected eye
Lower intraocular pressure
Beta-blockers
Mannitol
? rTPA

Question 32

Which pts are eye emergencies?

Answer 32

Red eye

Painless Loss of Vision

Trauma

Question 33

Name some signs of Blunt Trauma?

Answer 33

Swollen lids - (use lid retractors)
Subconjunctival hemorrhage
Traumatic mydriasis
Lens dislocation
Hyphema: Blood in anterior chamber
Pain, photophobia, decreased acuity
Apply protective shield

Question 34

Subconjunctival Hemorrhage.

What do you do if the hemorrhage is all the way around the eye?

Answer 34

measure the introcular pressure of the eye.

Question 35

Ruptured Globe signs and sx’s?

Tx?

Answer 35

Eye pain, decreased acuity
Distorted pupil
Bloody chemosis
Treatment
 No further exam
Immediate optho consult
Metal eye shield over affected eye
NPO
Tetanus
IV antibiotics
Anti-emetics prn

Question 36

Retro-orbital Hematoma sx’s?

Answer 36

Decreased Vision
Proptosis
Requires emergency lateral canthotomy
(behind the orbit of the eye)