Ocular Emergencies Flashcards
What are the symptoms of Acute Angle Closure Glaucoma (AACG)?
- Red eye
- Dilated unreactive pupil
- Pain (globe, headache, abdominal)
- Blurred vision»_space; vision loss
- Haloes around lights
- N+V
What are the risk factors for AACG?
- Long sighted: smaller eyes (reduced axial length) and shallow anterior chambers are more likely to occlude as pupil dilates (prevents draining of aqueous fluid out of eye)
- Female: live longer and have shallower anterior chambers
- Progressive headache: patients commonly complain of headache, usually affected eye side. Intermittent headaches, in evening (sometimes misdiagnosis of migraine)
- Blurred vision: progressively reduced vision, as IOP increases cornea gets progressively oedematous and leads to corneal clouding (set ophthalmoscope to +10 to see hazy cornea)
What is the normal IOP?
10-20mmHg
Can rise to >60mmHg in AACG, aqueous drains from canal of Schelmm, if this becomes blocked can cause IOP to rise.
What is the management of AACG?
- Refer to ophthalmology immediately - if untreated can cause permanent optic nerve damage
- Do slit lamp test to check for shallow anterior chamber and see cornea oedema
- Tonometry to measure IOP
- Gonioscopy - checks iridocorneal angle which are shut in AACG. Can check anterior chamber is not significantly shallow by shining light across front of eye from limbus.
What is the treatment for AACG?
To decrease IOP:
- Timolol (beta blocker)
- Apraclonidine (sympathomimetic)
- Prednisolone
- Pilocarpine
- Then IV meds acetazolamide (carbonic anhydrase inhibitors), with mannitol (if not responding)
What do you do after treatment of AACG?
- Perform peripheral iridotomy (makes hole in cornea for fluid to escape) to restore aqueous flow. Can do this as prophylaxis in other eye.
- Patient should be followed up in glaucoma clinic with visual field testing.
- Should take care in prescribing phenylephrine and tropicamide as can cause narrowing of drainage angle.
How does central retinal artery occlusion present?
- Sudden onset painless vision loss (in one eye), can be reduced to perception of light only
- On fundoscopy can see cherry red spot (choroidal circulation), retina becomes ischaemic and very pale
What should be asked in the history for central retinal artery occlusion?
- PMH: DM, HTN, hypercholesterolaemia, associated vascular problems e.g. angina, TIA
- SH: smoking
- FH: vascular problems
- Full CV exam and bloods
What is the management for retinal artery occlusion?
Referred urgently to ophthalmologist to restore vision
What are symptoms of retinal detachment?
- Flashes of light
- Floaters
- Peripheral vision loss (peripheral scotoma) - may describe curtain closing in on them
What are risk factors for retinal detachment?
- Trauma: causes high velocity vitreous movement, therefore traction on retina and can cause retinal tear
- Myopia: larger eyeballs so retina is thinner at peripheries, leads to increased chance of retinal tears and detachments
What is orbital cellulitis?
- Painful swelling of eyelids and possibly eyebrow and cheek (peri-orbital oedema)
- Limitation of upgaze
- Bulging eyes
- Decreased vision
- Pain on moving eye (due to inflammation)
- Fever
- General malaise
- Shiny red or purple eyelid
What is the management for orbital cellulitis?
- Sight threatening and life threatening - urgent referral to oculoplastic team and sometimes ENT (sinus involvement)
- Broad spectrum antibiotics IV
- Surgery if infection does not respond to antibiotics or spreads to other parts of the head - draining fluid, removing foreign object, obtaining culture samples
What pathogens can cause orbital cellulitis?
- Staphylococcus aureus
- Streptococci pneumoniae
- Haemophilius influenzae
- Betahaemolytic streptococcus
- Fungal e.g. aspergillus
What are the investigations for orbital cellulitis?
- FBC
- Blood cultures
- Orbital scan (MRI or CT)
- Conjunctivae swab
- A to E assesmenet
- Hourly temp, HR, BP, visual acuity
