Lecture 4: Ocular Emergencies COPY Flashcards
What historical findings suggest corneal abrasions?
- Fingernail
- Piece of paper
- Contact lens
What clinical findings would suggest corneal abrasion?
- Significant eye discomfort
- Tearing
- Foreign body sensation
- +/- ciliary flush
- +/- change in visual acuity
- Photophobia or HA due to ciliary muscle spasms
What complications are we worried about in corneal abrasions?
- Bacterial keratitis
- Corneal ulcers
- Traumatic iritis
- Hypopyon
What are the initial steps in checking for a corneal abrasion?
- Check VA
- EVERT lid to r/o foreign body
- Fluorescein stain if suspected but not seen.
How does a fluorescein stained corneal abrasion appear?
- Yellow if viewed with naked eye
- Ideally, use a cobalt blue filter or Wood’s lamp
What is the first-line treatment for corneal abrasions?
- Topical ABX: Bacitracin-polymixin ointment/drops.
What are the secondary treatment options for corneal abrasions?
- Short-acting cycloplegic (dilating eye drops)
- NSAID drops
- Oral opioid analgesics
- Tetanus prophylaxis, don’t smoke
What four factors about a chemical influence the severity of chemical keratitis?
- The toxicity of the chemical
- Duration chemical was in the eye
- Depth of penetration
- Area of involvement
What 5 history questions should be asked regarding ocular trauma with a chemical?
- When did the injury occur?
- Whether they rinsed their eye and for how long
- Mechanism of injury (high pressure?)
- Type of chemical
- Eye protection
What are the initial treatments for chemical keratitis?
- Topical anesthetics
- Morgan lens irrigation ASAP (pH of 7 ideal)
- View eye EVERTED with slit lamp
- Check IOP
What is Welder’s flash? Risk factors?
- Excess UV exposure
- Welding flashes
- Tanning booths
- Prolonged sun exposure
How does welder’s flash typically present?
- Severe pain and photophobia 6-12 hrs post exposure.
- Conjunctival hyperemia and superficial punctate keratitis
- Dead corneals or speckles with fluorescein stain.
How is Welder’s flash treated?
- Binocular patching
- Cyclopentolate (cyclopegic) to dilate pupils and relieve spasms.
How do you check for a corneal foreign body?
- Use cotton swab and tip upward.
- EVERT eyelid while patient looks downward.
What do I need to remove a superficial foreign body?
- Saline flush
- Sterile, moist cotton swab
- Sterile eye spud
- 25-G needle
What does a rust ring in the eye suggest?
Foreign body contained iron. Refer for removal of the iron if it does not improve after 2-3 days.
Treat them as a corneal abrasion patient.
What is a hyphema?
Injury to anterior chamber vasculature, resulting in hemorrhage.
What symptoms suggest a hyphema?
- Past Hx of trauma (historical)
- Pain
- Photophobia
- Blurred vision
- N/V (if IOP is elevated)
What is the initial treatment for a hyphema?
- Lay supine with head elevated at 45deg
- Hard eye shield
- NO NSAIDS OR ASA
- Pain meds, antiemetics if N/V
What are the MCC of orbital blowout fractures?
- Assault
- MVC
- Getting hit by a ball
What is the most common bone injured in an orbital blowout fracture? What does it make up?
- Maxillary bone
- Makes up the floor of the orbit.
How does an orbital blowout fracture typically present?
- Pain and periorbital ecchymosis
- Diplopia/restriction of UPWARD gaze.
- Decreased eye movement
- Concerning finding: enopthalmos (indicates significant displacement of contents into the orbital floor)
What are the initial treatment steps for a suspected orbital blowout fracture?
- Find out MOI
- Check VA and eye
- CT of the orbit
What does orbital emphysema with palpable crepitus suggest?
Abnormal collection of air in sinuses.
Orbital fracture near sinuses.
If I have a fracture of the medial or floor of the orbit, what sinus is affected?
Medial: Ethmoid sinus
Inferior: Maxillary sinus
If I have soft tissue mass trapping the inferior rectus muscle, what is the main concern?
Ischemia and subsequent loss of muscle function.
What is enopthalmos?
Posterior displacement of the eye.
AKA a sunken eyeball. Opposite of the Graves’ eyes.
What specifically should someone with an orbital blowout fracture not do?
Valsalva or blowing out through their nose.
What are the initial treatments for an orbital blowout fracture?
- Tetanus prophylaxis
- Pain management
- CT scan
What could I give to help with swelling and diplopia in orbital blowout fractures?
Systemic steroids
What key finding suggests penetrating trauma or ruptured globe?
Teardrop shaped pupil
What is the primary pharmacotherapy for penetrating trauma or ruptured globe?
IV Vanco + Ceftazidime/Fluoroquinolone
What is amaurosis fugax more commonly known as?
Transient monocular vision loss (TMVL) or ocular transient ischemic attack.
It is a SYMPTOM
What are the MCC of amaurosis fugax?
- Migraine
- Retinal emboli
- Giant cell arteritis
How would a patient usually describe amaurosis fugax?
Curtain descending over visual field and causing temporary blindness
What is the treatment for amaurosis fugax?
Consult to figure out case
What is the hallmark symptom of central retinal artery occlusion? (CRAO)
Sudden, painless, monocular vision loss
AKA amaurosis fugax, since it is a type of stroke.
What is the hallmark sign of CRAO?
Cherry-red spot on fovea.
Why is the retina highly susceptible to ischemia?
Extremely high O2 consumption.
If a patient is over 50 and has a suspected CRAO, what additional lab should I order?
- ESR and CRP to r/o giant cell arteritis
What other findings might I see in CRAO?
- RAPD
- Pale retina
- Boxcar segmentation
What is the MCC of CRAO in older patients?
Carotid artery atherosclerosis
What is the initial treatment for a suspected CRAO?
- Lay pt supine
- Ocular massage
- O2 therapy
- IV acetazolamide or mannitol
- Nitro/vasodilators
- Thrombolysis
- CONSULT OPHTHALMOLOGY
What is the treatment for giant cell arteritis induced CRAO?
High dose corticosteroids
What is the hallmark symptom of central retinal vein occlusion? (CRVO)
Sudden, acute, painless monocular vision loss, usually first noticed upon awakening.
Same as CRAO.
What is the hallmark sign of CRVO?
Blood and thunder fundus
What can CRVO progress to if left untreated?
- Neovascularization
- Neovascular macular degeneration (aka wet)
What are the risk factors for CRVO?
- Diabetic retinopathy
- HTN
- Hypercoagulable disorders
- Smoking
- Obesity
- Glaucoma
What is the first line treatment for CRVO?
- Anti-VEGF drops
What is the second-line treatment for CRVO?
- Intravitreal corticosteroids
If a patient is having significant hemorrhages and neovascularization even with medications for their CRVO, what should I recommend?
Laser photocoagulation (seals vessels)
What is the MCC of retinal detachment?
A retinal tear due to posterior vitreous detachment.
What are the risk factors for retinal detachment?
- > 50 y/o
- Nearsightedness
- Cataract extraction
- Penetrating/blunt trauma
What are the main clinical findings that suggest retinal detachment?
- Monocular, decreased vision
- Central vision intact until macula is detached (often described as a curtain or veil over their visual field)
- Photopsia (flashing lights)
- Floaters
- Eye pain
On examination, what might suggest retinal detachment?
- Irregular surface on retina.
- Retinal tears or holes
What is the treatment for retinal detachment?
- Consult.
- Surgery to fix holes (pneumatic retinopexy)
- Worse prognosis with macular detachment or long duration
What condition is most associated with optic neuritis?
MS
What other conditions can cause optic neuritis?
- Sarcoidosis
- Varicella Zoster
- Autoimmune disorders/SLE
- Meningitis
- Paranasal sinusitis
What are the clinical findings for optic neuritis?
- Subacute, unilateral vision loss
- Pain behind the eye, particularly with EOM
- Central field loss
- LOSS OF COLOR VISION/PERCEPTION
- RAPD
Is the optic nerve typically inflamed during optic neuritis?
- 2/3 are normal during acute phase.
- 1/3 have swollen optic discs (papillitis)
How do we treat acute demyelinating optic neuritis?
IV methylprednisolone 3 days followed by oral prednisone.
How do we treat other causes of optic neuritis?
Prolonged corticosteroid therapy
What is papilledema?
Optic disc swelling due to elevated ICP, almost always bilateral. It is different from papillitis.
What signs suggest papilledema?
- Disc margins blurred
- Flame-shaped hemorrhages
- Engorged retinal veins
What kind of symptoms does papilledema usually present with?
Rare visual changes.
What is the treatment for papilledema?
- MRI
- Refer to ophthalmology and treat underlying cause
What specific treatment should you not perform for papilledema?
DO NOT DO A LP
What is ischemic optic neuropathy?
Inadequate perfusion of the posterior ciliary arteries that supply the anterior portion of the optic nerve (infarction of the optic disc)
How does ischemic optic neuropathy typically present?
- Sudden, painless, monocular visual loss
- Altitudinal field defect
- Optic disc swelling
What is the MCC of Ischemic Optic Neuropathy?
Giant Cell Arteritis
What is the treatment for ischemic optic neuropathy?
Systemic high dose corticosteroids and REFER
