Ocular Emergencies Flashcards
Describe the etiology/risk factors for a corneal ulcer
Epithelial defect on cornea
- bacterial/fungal
- contact lenses at risk for pseudomonas
Describe the clinical presentation of a corneal ulcer
- pain, blurred vision
Describe the PE/diagnostic testing for a corneal ulcer
- May see white spot/infiltrate on cornea
- associated iritis
- culture
Describe the treatment for a corneal ulcer
Broad spectrum abx drops (coverage for pseudomonas)
- cipro or ofloxacin 2gtts q30 mins on day 1
- 2gtts/hr on day 2 until fully healed
Avoid contact lenses
Urgent ophtho referral
Describe the complications of a corneal ulcer
possible permanent visual loss
Describe the types of ocular foreign bodies
- conjunctival
- corneal
- intraocular
Describe the clinical presentation of ocular foreign bodies
Sensation, pain, redness, tearing, discomfort relieved with anesthetic drops
Intraocular FB can be obvious or enter glove and leave little evidence (suspect when periorbital wounds present)
Describe the diagnostic testing/PE for ocular foreign bodies
Conjunctival:
- Careful inspection including lid eversion after topical anesthesia
- “Ice rink sign” = multiple linear corneal abrasions from FB beneath the lid
Corneal:
- topical anesthetic, small corneal abrasion results after removal
Intraocular:
- ophthalmoscope, slit lamp, x-ray, CT
Describe the treatment for conjunctival ocular foreign bodies
Remove with moistened cotton-tip applicator/eye spud, +/- abx
Describe the treatment for corneal ocular foreign bodies
remove under slit lamp with moistened cotton-tip applicator/eye spud, abx drops and pain meds, +/- removal of rust ring (soften after 24hrs)
Describe the treatment for intraocular foreign bodies
prevent endophthalmitis, broad spectrum IV abx
What is this sign called
Ice rink sign
- seen in conjunctival foreign bodies
What is this sign called
corneal rust ring - seen after removal of a corneal foreign body
Describe the etiology of an orbital blowout fracture
Fracture through orbital wall (MC floor or medial wall of orbit) d/t blunt force
Describe the clinical presentation of an orbital blowout fracture
Pain, diplopia, swelling, ecchymosis, limitation of upward gaze
Infraorbital nerve anesthesia
Describe the diagnostic testing for orbital blowout fractures
CT of orbits, x-ray: water’s view
Describe the treatment for orbital blowout fractures
Ice, elevate head of bed to reduce swelling, prophylactic abx, avoid blowing your nose
Ophtho consult, surgery for persistent entrapment or enophthalmos
Describe the complications of orbital blowout fractures
May lead to entrapment of orbital contents leading to gaze restriction
Medial wall fx into ethmoid sinus may lead to orbital emphysema
Describe the etiology of hyphema
Blood in the anterior chamber usually d/t trauma
Microscopic or obvious
25% rebleed 2-5 days after injury, often worse than initial bleed
Describe the treatment of a hyphema
Rest, elevate head of bed to 45°, protective eye shield, avoid ASA & NSAIDs
- Dexamethasone gtts: decrease inflammation
- Myadriatic gtts (cyclopentolate, atropine): dilate & temporarily paralyze pupil
- Aminocaproic acid gtt/PO: prevent clot lysis & rebleed
Describe the complications of a hyphema
reduced vision, secondary glaucoma, corneal staining
Describe the etiology of a ruptured globe
penetrating trauma leading to disruption of the cornea/sclera and extravasation of intraocular contents
Describe the clinical presentation of a ruptured globe
- pain
- decreased vision
- hyphema
- leaking aqueous humor
- prolapsed iris - loss of anterior chamber depth
- eccentric “tear drop” pupil
- subconjunctival hemorrhage encircling cornea
Describe the diagnostic testing for a ruptured globe
CT to eval for facial/orbital injury
*do not perform tonometry
Describe the treatment for a ruptured globe
Immediate ophtho consult
Metal eye shield, broad spectrum IV abx to prevent endophthalmitis, tetanus update
Describe the complications of a ruptured globe
- vision loss
- endophthalmitis
Describe the etiology of orbital cellulitis
Cellulitis of the orbital & periorbital tissues usually due to staph aureus, strep pneum, or H flu
Hematogenous spread or direct extension from sinuses
Describe the clinical presentation of orbital cellulitis
periorbital redness/swelling, possible fever
Describe the diagnostic testing/PE for orbital cellulitis
CT to determine orbital involvement or inflammatory mass
Look for proptosis, limitations of EOMs
Describe the treatment for orbital cellulitis
Broad spectrum IV abx
Surgical emergency
Describe the complications of orbital cellulitis
May progress to meningitis or an abscess
Describe the etiology of acute angle-closure glaucoma
Sudden increase in intraocular pressure d/t narrowing of the angle between the corena & iris
Impaired drainage of aqueous humor thru trabeculae & canal of Schlemm = increased IOP damaging CN2
Describe the clinical presentation and PE findings of acute angle-closure glaucoma
Periorbital pain w/wo headache, n/v, intermittent blurred vision
Conjunctival injection/corneal edema, mid-dilated non-reactive pupil, globe firm to palpation, shallow anterior chamber, decreased visual acuity
Describe the diagnostic testing for acute angle-closure glaucoma
Tonometry: IOP >21 mmHg (normal 10-20 mmHg)
Describe the treatment of acute angle-closure glaucoma
Ocular emergency needing immediate treatment - definitive tx: laser peripheral iridotomy to open the angle
- Decrease aqueous production & enhance angle opening: Acetazolamide, beta-blocker gtts (Timolol), pilocarpine gtts (causes miosis)
- osmotic diuretics: mannitol IV, glycerol PO
- reduce inflammation: steroid gtts
Treat pain & n/v to decrease IOP
Describe the etiology of papilledema
optic disc swelling d/t increased ICP resulting in pressure on CN2 (can lead to visual loss)
Usually bilateral
Describe the clinical presentation & PE of papilledema
headache, blurred vision, blind spots
Fundoscopic exam shows blurred optic disc margins, elevated optic disc, venous engorgement
contraindication to lumbar puncture
Describe the treatment for papilledema
Treat underlying cause (tumor, hemorrhage, injury) and reduce ICP (mannitol)
Describe the etiology & risk factors for retinal detachment
Separation of inner layers of retina from choroid
Separates from source of O2 & nutrients
RF: age, myopia, prior cataract surgery, diabetic retinopathy, trauma
Describe the clinical presentation of retinal detachment
Sudden increase in floaters, flashing lights, dark cloud/black curtain over part of visual field
Describe the PE for retinal detachment
Fundoscopic: wrinkling of retina, difficult to see peripheral retina with ophthalmoscope
Refer to ophtho for dilated fundus exam using indirect ophthalmoscope
Describe the treatment for retinal detachment
Surgery to reattach retina
Laser photocoagulation: wall off small tears
Sclera buckling: band placed around sclera to pinch it toward retinal tear
Describe the etiology of a central retinal artery occlusion
Obstructed retinal artery causing loss of blood to the retina
Secondary to: emboli, vasculitis, coagulopathy, sickle cell
Describe the clinical presentation of a central retinal artery occlusion
Sudden painless onset of near/total vision loss
Describe the diagnostic testing/PE of a central retinal artery occlusion
Fundoscopy shows:
- afferent pupillary defect
- narrowing of retinal arterioles
- infarcted retina with grayish appearance in late stages
- cherry red spot on macula d/t retinal thinning
- pale retina & optic disc
describe the treatment of a retinal artery occlusion
Immediate ophtho consult (+/- decompressive surgery)
Digital massage of globe to dislodge clot to smaller artery branch
Reduce IOP: mannitol, acetazolamide, anterior chamber paracentesis
IV thrombolytics
Describe the timeframe for retinal artery occlusion treatment
Flow needs to be re-established within 90 mins to preserve vision
Describe the etiology/risk factors for central retinal vein occlusion
Obstructed retinal vein causing lack of blood drainage from retina
RF: HTN, diabetes, glaucoma, hyperviscosity syndromes
Describe the clinical presentation of central retinal vein occlusion
painless vision loss varying in severity depending on obstruction
Describe the PE for retinal vein occlusion
Fundoscopy: retinal hemorrhages “blood and thunder”, “cotton-wool spots”, macular edema
Describe the treatment for central retinal vein obstruction
Laser coagulation to prevent neovascularization
