Eyes Flashcards
Retobulbar
vs
Globe rupture
vs
IO blow out
Retrobulbar Heamorrhage
- Visual loss
- RAPD
- Reduced extraocular movements
- IOP > 40 mmHg
- Protosis
- May also see extensive subconjunctival hemorrhage and bloody chemosis, as well evidence of periorbital swelling and hematoma.
Ruptured globe
- Pupil - hyphaema, teardrop if iris prolapsed thru cornea
- VA, VF, red reflex may be abnormal
- Slit lamp - defect of anterior chamber
- Usually no proptosis or raised IOP
Infra-orbital blowout fracture
- Inferior rectus entrapment
- Dipolpia with upward gaze
- Paresis with upgaze
- Raised IOP, RAPD and decreased visual acuity are not typical unless coexistent retrobulbar hemorrhage
- Peri-orbital swelling/haematoma
Penetrating Eye Trauma
EMERGENCY
Suspect with any lid laceration
Types
- Eye lid lacerations
- Corneal lacerations
- Scleral lacerations
- Perforating trauma (+/- an exit wound) including occult foreign body penetration (e.g. when metal strikes metal)
- Assoc injury to
- Intraocular structures — e.g. lens, iris, retina
- Extraocular structures — e.g. lids, extra-ocular muscles, orbital bones, optic nerve and brain
Symptoms
- Visual disturbance or loss of vision, pain at rest or on movement, and diplopia.
- Mechanism of injury
- Eye protection use
- Type of projectile and velocity - small + high = inc risk
- Hx of previous trauma or surgery that may compromise the structural integrity of the eye
Exam
- Lids - check under for laceration
- Pupil - tear drop pupil, hyphaema
- Slit lamp - corneal or scleral defect, distortion of the anterior chamber structures (e.g. a shallow anterior chamber with a self-sealing corneal laceration)
- VA - usually decreased
- Red reflex — may be abnormal
- Fundoscopy — look for foreign bodies and retinal injury
- Siedel sign
Mx
- NBM
- Analgesia
- Anti-emetic
- Broad spec ABs
- Tetanus
- DO NOT put drops, force eye open, remove FB
- Eye referral
Chemical Burns
Eye pH 6.5-8
Alkali - liquefactive necrosis (corrosion continues until irrigation)
Acid - coagulative necrosis
Severity of Injury
- Blepharospasm inc injury
- Clearer the cornea, lesser the injury
- 6 Grades - depedent on extent of limbal and conjunctival involvement
Mx
- Analgesia, anti-emetic
- Irrigation, aim for pH 7.0
- Abs
- Mydriatics - if burn more extensive
- Discuss all with eyes
- Some may need steroids
- Surgery for extensive
Acute Angle Closure Glaucoma
Acute closure of the anterior chamber angle => blockage of the trabecular meshowrk and raised IOP
Presentation
Acute painful red eye
Headahce
N+V
Dec VA
Risk factors
Age > 50yrs, F>M
Longsighted
Race - black, asian, hispanic
FHx
ACh drugs
Moving to dark area - transient contraction of iris crowds angle
Trauma
Exam
* Conjunctival injection - red eye
* Mid-dilated pupil, poorly reactive
* Dec VA
* Shallow anterior chamber
* Raised IOP > 35mmHg
Seidel Sign
Fluorescein dilutes in the aqueous humor and causes it to fluoresce bright green and stream down the eye with gravity
INDICATIONS
1. To ID ocular leak after injury to the globe
2. Determine if a corneal or scleral laceration is of full-thickness depth
3. ID corneal perforation in the setting of infection or trauma
4. Ensure appropriate wound closure intraoperatively or postoperatively
CONTRAINDICATIONS
1. Obvious globe rupture
2. Allergy to fluoroscein
RAPD
Flashlight swumg from one eye to the other
Assess direct and consensual light reflexes
Positive if: pupil dilates direct beam of light and other eye constricts w/ consensual response
Causes
1. Vitreous / Retinal haemorrhage
2. Retinal detachment
3. Ischaemia
4. Optic neuritis
5. Prechiasmal optic nerve compression
6. Trauma
Orbital pathology
Diplopia - Monocular
- Keratoconjunctivitis sicca
- Corneal abrasions/defects
- Cataracts
- Lens dislocation
- Macular Disruption
Diplopia - Binocular
https://canadiem.org/wp-content/uploads/2020/01/CRACKCast-E209-Diplopia-PDF.pdf
Orbital vs CN vs neurological vs vascular vs neuromuscular pathology
CRITICAL
- Basilar artery thrombosis (Post Circ Stroke)
- Botilusm
- Basilar meningitis
- Aneurysm
EMERGENT
- Vertebral Dissection
- Myaesthenia gravis
- Wernicke’s Encephalopathy
- Orbital Apex Syndrome, Cavernous sinus process
URGENT
- Brainstem tumour
- Miller Fischer Syndrome
- MS
- Thyroid myopathy
- Opthalmoplegic migraine
- Ischaemic neuropathy
- Orbital myositis
- Orbital apex mass
Eye Nerve Palsies
Lacunar Strokes + Diplopia Syndromes
Acute Glaucoma Treatments
Decrease IOP and then Rx anatomical abnormality
Decrease production of aqueous humour
* Timilol 0.5% 1-2 drops q 30 mins
* Acetazolamide 500mg IV/PO
* Mannitol 1-2g/kg IV over 45 mins
Increase outflow of aqueous humour
* Pilocarpine 4% 1 drop
* q15min for 1hr then 30 minutely
* Latanoprost 0.005%
* q2hrly
* Prednisolone 1%
* q1hr
Other
Head of bed at 30 degrees
Anti-emetics
Analgesia
Definitive
* Laser peripheral iridotomy within 24-48hrs
Optic Neuritis
Acute inflammation of optic nerve
Strong association with MS
Other causes - autoimmune, infective
Hx
Monocular
Dec VA
Dec VF - esp central scotoma
Pain
Exam
Check VA, VF
RAPD in affected eye
Papilloedema
Ix MRI best choice
Mx
IV methylyprednisolone 1g daily for 3 days
then PO prednisolone 1mg/kg for 11 days
Neurology admission/referral
Peri-orbital vs orbital cellulitis
Acute Vision Loss
Acute Vision Loss w/ Exam findings
Acute Monocular Vision Loss
Painless Vision Loss 1
Painless Vision Loss 2
