eye emergencies Flashcards
equipment you will need in an eye emergency
VA chart proparacaine drops (topical anesthesia) morgan lens Nitrazine paper (pH) Lid retractor woods lamp eye spud floresceine paper eye shield
Looks like a contact lens and attached to tubing and used for thorough eye irrigation
morgan lens
Tiny rotating abrasive that helps remove a metallic foreign body
eye spud
UV black lights; allows us to put fluroesceine stain in the eye
Woods Lamp
red eye ddx
i. Conjunctivitis
ii. Iritis
iii. Corneal abrasions/ulcerations
iv. Acute Angle Closure Glaucoma
v. Herpes infections
painless loss of vision
i. Central retinal artery occlusion
ii. Retinal detachment
trauma associated with the eye
i. Burns
ii. Blunt trauma
iii. Penetrating trauma
iv. Hyphema
hx and ROS from pt
onset: sudden or gradual pain VA photophobia trauma associated sxs: headache, vertigo, neuro
general PE for eye complaint
general VA- pupils-symmetry, reactivity to light, pupillary reflex fluorescein stain intraocular pressure testing slit lamp exam signs of trauma
VA testing should be done how
when would you not do a VA test first
with glasses, one eye at a time
Should be done first on all patients except those with chemical exposures or suspected globe rupture
Signs of major trauma
Obvious laceration
Distorted pupil
Proptosis
Differential for decreased visual acuity
- Refractive error (pin hole)
- Penetrating foreign body
- Iritis
- Acute Angle Closure glaucoma
- Central retinal artery occlusion
- Blunt or penetrating trauma
- Dislocated lens
- Retinal detachment
- Optic neuritis
Iritis
assoc w/ photophobia)
When is an eye problem not really an eye problem (3 scenarios)
subarachnoid hemorrhage (thunder clap)
stroke
GCA
eye issues associated with SAH
pain/photophobia))
eye issues associated with stroke
i. Diplopia
ii. Loss of vision
eye issues associated with GCA
late
MC identifiable source of optic neuritis
and what are the different presentations
MS
Clinical presentation depends on whether inflammation involves the optic disc (papillitis) or the part of the optic nerve behind the eyeball (retrobulbar neuritis).
what part of the eye has
Cones and rods transform light into visual signals, which are projected to the brain via the optic nerve.
(NIL)
reitna
what is glaucoma (NIL)
A group of eye diseases characterized by progressive optic neuropathy that results in a specific pattern of irreversible optic disc changes and visual field defects.
In the US, glaucoma is the second leading cause of blindness in adults (second to macular degeneration)
open and vs closed angle
open angle: generally bilateral, progressive loss of optic nerve fibers with open chamber angles (often with increased IOP), not caused by another systemic or local condition
closed angle: sudden and sharp increase in intraocular pressure caused by an obstruction of aqueous outflow (most commonly as a result of an occlusion of the chamber angle)
red flags
Sudden onset of pain or vision change Decreased visual acuity Photophobia Limbic/ciliary flush (keratitis) Abnormal pupil size, shape or response Visible opacity on cornea
who do you want to bring to the treatment area emergently
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
red painful eye think
Conjunctivitis/keratitis
Foreign Body/Abrasion
Corneal ulcer
Iritis/uveitis
Acute narrow angle glaucoma
conjunctivitis pertenant negatives
no change in vision
no photophobia
injection spares the edges of the iris
no limbic or ciliary flush that you see wiht more serious eye pathologies
pain culprits of conjunctivitis
adenovirus
conjunctivitis
Warm compresses, topical antibiotic if indicated
blepharitis is commonly associated with
Seborrheic dermatitis Psoriasis Acne rosacea Bacterial foliculitis
blepharitis tx
Warm compresses
Topical antibact ointment
a hordeolum is an infection of the
meibomian glands
hordeolum tx
warm compress topical antibiotic ointment
might need to call optho to I&D
inflammation of the cornea
keratitis
usually these
viral epidemic keratitis
Viral epidemic keratoconjunctivitis (EKC), adenovirus
how to deferentiate
Viral epidemic keratoconjunctivitis (EKC), adenovirus
keratitis tx
acute optho consult, steriod tx
keratitis presentation
foreign body sensation and multiple corneal infiltrates seen best with punctate floresceine uptake
typically causes severe pain, irritation, redness, watery or purulent secretion, and impaired vision.
HSV keratitis
slit lamp exam will cause fluorescine staining
differentiating conjunctivitis from keratitis
unilateral
acutely painful
photophobic and intensely injected eye
VA often reduced
profuse tearing
thick and mucopurulent d/c
may have a corneal defect/ulceration
edematous cornea
in severe cases: hypopyon
hypopyon
(pus in anterior chamber seen with ekratitis
common organisms associated with bacterial keratitis (5)
Staphylococcus aureus,
Pseudomonas aeruginosa,
coagulase-negative Staphylococcus, diphtheroids
Streptococcus pneumoniae
excessive growth of the conjunctiva
pterygium
May require elective excision if advances over the visual field
hsv keratitis presentation
when does it occur
Unilateral injection, irritation, mucoid discharge, pain, mild photophobia
Unilateral injection, irritation, mucoid discharge, pain, mild photophobia
tx of herpes keratitis
Tx: topical or systemic antivirals
Immediate optho consult
herpes zoster
what is the prodrome
the distribution
does it cross the midline?
when is it the most painful?
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
anyone with lesions around the eye are at risk for keratitis and need a consult immedeatly
typical sxs with foreign body
discharge?
VA changes?
i. Sensation of FB
1. Pain is relieved by topical anesthetic
ii. No discharge (except tearing)
iii. Vision may be decreased if lens affected
iv. Pupils normal
v. Redness spares edge of the iris
exam for foreign body
Always flip their lids to look for foreign body (pull out on the eyelid and flip it under with a cotton swab)
use fluroescein staining to look for abrasion
always flip the lid to look for FB
treatment for foreign body
- Topical antibiotic ointment +/- cycloplegic
- Patching no longer routine – don’t heal as well
- Never patch contact-lens wearers – abrasion may have happened under the contact film and that can cause pseudomonas to grow (Tx with ciprofloxacin drops)
eye spud to get out foreign body and rust ring
what do you need to be worried about with a foreign body
think about extra imaging needed
Obtain xrays if suspicious (objects can go into the globe as well
Can Ultrasound as well – will see hyperechoic
beware of ulcer and interocular foreign body
pt with increasing sensation of foreign body in the eye
ALWAY CHECK UNDER THE LID
Result from any defect in the cornea
corneal ulcer
corneal ulcer
cloudy white or gray appearing cornea
Visible without fluorescein
May have hypopion
at risk for corneal penetration
corneal ulcer treatment
vi. Requires optho consult
1. Can extend and cause permanent visual loss
was hit in face with a baseball during a little league practice
seen with injection and limbic flush
acute traumatic iritis
limbis -what is this area
transition between the cornea and the sclera
redness surrounding the cornea mostly; helps differentiate from conjunctivitis or keratitis
sxs of acute traumatic iritis
i. Aching pain, gradual onset
ii. Photophobia
iii. No discharge
tx of acute traumatic iritis
Tx steroid gtts; Optho consult
what is a corneal burns
liquifaction of the cornea
neet transplant
which chemical splash is the worse
alkali worse than acid
this is because acid, when it makes contact, does all damage immediately followed by necrotic tissue forming a barrier
alkali continues to penetrate and leads to progressively worsening destruction of the eye
how to treat chemical splashes immedeatly
test pH
then under the eyes was for 20 to 30 minutes straight
Can use Morgan lens if cannot tolerate the eye wash
before the lamp exam
look under the lids for debris
treat every exposure as caustic
what should pH be of the eye
7.4-7.6
acute angle closure glaucoma presentation
usually have a hx of glaucoma
complaints of severe photophobia
persistent eye pain
seen with limbic flush
cloudy cornea
HA, vomiting, abd pain
pupil midrange and nonreactive
what is the initial assessment involve with regards to IOP
what is normal
get a eye pressure wth a tono pen
eye pressure should always be under 20
what is disc cupping
seen with IOP
Increased intraocular pressure crowds ganglion cell axons exiting the eye at the optic disc.
tx of angle closure glaucoma
what are the three goals
Decrease size of pupil
Decrease aqueous humor production
Decrease intraocular pressure
Anti-emetics
Pain management
how can you decrease IOP
Decrease intraocular pressure with
oral diamox (Acetazolamide)
or IV mannitol
what else do we use diamox for?
also used to treat psuedo tumor cerebri
can be used as a HTN med but is rare?
Decrease production of aqueous humor with
with topical α-agonist or β-blocker (Timoptic)
Constrict pupil with
topical pilocarpine
Vitreous Hemorrhage occurs in the setting of
Occurs in the setting of trauma, spontaneous retinal tear, spontaneous vitreous detachment
pts can see floaters after virtuous breaks off
Vitreous Hemorrhage are associated
Associated with retinal neovascularization
Poorly controlled diabetes
what does the progression of virtuous hemorrhage look like
Floaters or “cobwebs”; usually unilateral but can be bilateral
Progresses over hours to visual loss
Decreased red reflex
\
what PE finding would suggest retinal detachment
Pupillary defect suggests retinal detachment
how should a vitrious hemorrhage be handled
vii. *Immediate Opthalmology consult
retinal detachment occurs in the setting of
May occur spontaneously or in the setting of trauma
complain of floaters and black spots like vitrious hemorrhage
how to differentiate retinal detachment from vitreous hemorrhage
how do you treat
curtain like film
flashing lights
visual field cut
urgent ophthalmology consult
sudden severe loss of vision
blurred vision
optic neuritis
OTHER THAN BLURRED VISION WHAT OTHER SXS DO YOU SEE ASSOCIATED WITH OPTIC NEURITIS
ii. +/- Pain on eye movement, reduced visual acuity and washed out color vision.
iii. Sluggish pupil
most cases of optic neuritis are unilateral or bilateral?
70% of cases unilateral.
tx of optic neuritis
: corticosteroid therapy improves short-term vision recovery but not shown to alter long-term vision outcome
optho consult
i. Slow painless loss of vision
central retinal vein occlusion
Occlusion/thrombosis of the central retinal vein
central retinal vein occlusion is associated with
what are the RF
Associated with chronic glaucoma
atherosclerotic
risk factors age diabetes hypertension, hyperviscosity and coagulopathy
episodes of visual loss with central retinal vein occlusion look like
seconds to–several hours.
what is the differentiating factor with central retinal vein occlusion
description of “cloudy vision” rather than visual loss.
central retinal artery occlusion looks like
Painless catastrophic visual loss over a period of seconds
what causes central retinal artery occlusion
ii. Caused by embolism of the retinal artery
amaurosis fugax
transient monocular blindness cause by a loss in blood flow
Hx of transient visual loss may be reported (amaurosis fugax)
blood and thunder fundus think
central retinal vein occlusion
cherry red spot think
central retinal artery occlusion
tx of central retinal artery occlusion
early intervention may improve chances of recovery (20-30%)
2. Immediate optho consult
hyperventilation with paper bag
inhalation of carbogen
Digital massage of affected eye Lower intraocular pressure Beta-blockers Mannitol ? rTPA
carbogen
what does it do for a pt with central retinal artery occlusion
5% carbon dioxide and 95% oxygen)
a. To induce vasodilation and improve oxygenation
what’s on the differential of foreign body
i. Conjunctival lacerations
ii. Corneal lacerations
iii. Intraocular foreign body
Tear-drop shaped pupil think
corneal laceration
other than a tear drop shaped pupil what might you find with a corneal laceration
May see aqueous humor leaking
must important management of suspected globe rupture
any suspicion of globe rupture need to shield the eye
try not to manipulate
you can be in danger of self nucliation
blunt trauma, possible presentations
Swollen lids - (use lid retractors) Traumatic mydriasis (dilation) Lens dislocation Subconjunctival hemorrhage Hyphema:
Subconjunctival hemorrhage suspect
might have an underlying injury
extraocular muscle entrapment might be associated with a
orbital floow fracture
ruptured globe presentation
i. Eye pain, decreased acuity
ii. Distorted pupil
iii. Bloody chemosis
seidel’s sign
what is seidel’s sign
– fluorescein strip turns pale
treatment of suspected globe rupture
No further exam!!
- Immediate optho consult
- Metal eye shield over affected eye
- NPO, OR ASAP
- Tetanus
- IV antibiotics
- Anti-emetics prn
Retro-orbital Hematoma
tx
pushes the eye outward
proptosis
Requires emergency lateral canthotomy (opening up the lateral canthus
or else the pressure will enucleate the eye
why does acute traumatic iritis present with photophobia
Photophobia because contraction of pupil requires contraction of inflamed iris
when does acute traumatic iritis usually present
12 hours after trauma
what usually triggers acute angle glaucoma
Prolonged dilation of pupil in susceptible person
movies
what must you rule out in a eyelid laceration
do you suture it?
Rule out penetrating injury
Rule out damage to lacrimal apparatus: assess by canulation
Don’t suture it, b/c the ducts might not be patent
