ocular emergencies

Question 1

proptosis

Answer 1

sudden, anterior displacement of the globe

eyelids are entrapped behind globe

secondary to trauma-HBC, dog fight, restraint, play

Question 2

first step when seeing patient with proptosis

Answer 2

evaluate entire body with PE

keep eye lubricated

stablize patient

Question 3

treatment choices for proptosis

Answer 3

replacement of globe combined with a temp tarsorrhaphy

enucleation

Question 4

favorable prognostic factors for proptosis

Answer 4

brachycephalic dogs

evidence of vision at presentation

shorter duration of proptosis

shorter distance of proptosis

normal findings on posterior segment examination

positive PLR

Question 5

negative prognostic factors

Answer 5

nonbrachycephalic dog

cat

hyphema

pupil not visible on exam

globe laceration

globe rupture

facial fractures

optic nerve damage

avulsion of >3 extraocular muscles

Question 6

Which extraocular muscle are likely to rupture when eye is proptosed

Answer 6

medial rectus

ventral rectus

ventral oblique

Question 7

globe replacement and tarsorrhaphy

Answer 7

goal: bring eyelids anterior to globe

return to original position impossible-extensive swelling and hemorrhage within orbit

globe held in place by tarsorrhaphy until swelling is reduced and fibrosis secures globe in more normal position

Question 8

steps for replacing globe

Answer 8

induce gen anes

flush conjunctival sac with dilute betadine solution

lubricate eye

stay sutures in upper and lower eyelids

place lubricated, gloved finger on globe

gentle posterior pressure on globe while sutures pulled anteriorly

temporary tarsorrhaphy-stents to decrease tension-horizontal mattress

leave medial 1/3 open to allow for drainage of d/c and application of eye meds

Question 9

post op care for globe replacement and tarsorrhaphy

Answer 9

abx drops q6h

corneal lubrication

therapy for uveitis

broad spectrum PO abx 10-14 d

oral anti-infl meds

tarsorrhaphy-min of 2-3 weeks, as swelling reduces over time, sutures may require tightening, sutures removed all at once or singly over time

Question 10

Sequelae to proptosis

Answer 10

blindness

strabismus-lateral

KCS

lagophthalmos

exposure keratitis

corneal ulceration

repeated proptosis

squelae to uveitis

Question 11

eyelid laceration-consideration

Answer 11

patient stabilization needed prior to addressing eyes

time from injury to presentation-bacterial contamination, tissue viability

extent of eyelid injury-involvement of puncta, canaliculi, margins

injury to globe

rich vascular supply-tissue necrosis uncommon, relatively resistant to infection, edema & hemorrhage, minimal tissue debridement necessary

preservation of eyelid margins and length

Question 12

sequence for evaluation of eyelid laceration

Answer 12

PE and patient stabilization

determine time from injury to presentation: <4 hr-repair immediately; >4 hr-repair can be delayed

thorough ophtho exam-extent of laceration, r/o damage to globe, entrapped foreign material, cannulate nasolacrimal puncta

Question 13

steps for repair of eyelid laceration

Answer 13

injectable abx and anti-infl

tetanus prop-eq

sedate/induce gen anes

thorough irrigation and sx prep-dilute betadine solution

repair-if extensive damage, protect wound and refer

minimal debridement

Question 14

eyelid margin closure

Answer 14

closure of tarso-conjunctival layer-horizontal mattress suture, first suture placed at eyelid margin for best apposition

avoid penetrating conjunctiva with suture

Question 15

figure of 8

Answer 15

allows suture placement at margin with increased distance between margin and knot

avoid excessive wound tension

must close in 2 layers to avoid wound gaping

Question 16

postop care of eyelid lacerations

Answer 16

systemic abx and anti-infl

eye protection

treat injury to globe

suture removal -14 d

px-good

Question 17

blunt trauma

Answer 17

acute compression and deformation of globe

eye is shortened axially but stretches in other directions

rebound trauma

Question 18

common signs of blunt trauma

Answer 18

skull fx

eyelid laceration

subconjunctival hemorrhage

corneal ulceration

anterior uveitis

hyphema

iris dialysis

lens (sub)luxation

lens rupture

choroidal rupture

retinal detachment

Question 19

penetrating trauma

Answer 19

globe perforation by sharp object

may penetrate uvea, lens

pinpoint injury or laceration

may have retained foreign material

Question 20

common signs of penetrating trauma

Answer 20

eyelid laceration

corneal defect

anterior uveitis

hyphema

iris prolapse

lens capsule perforation

cataract

lens rupture

retinal hemorrhage

Question 21

initial management of globe trauma

Answer 21

prevent further trauma-sedation, topical anesthetic

handle gently

gentle cleansing of eye if exudates preclude exam-warm, sterile saline

Question 22

initial dx and tx for globe trauma

Answer 22

skull rads, ocular u/s

tx as for anterior uveitis-Steroids or NSAIDs, atropine

tx for corneal ulceration

systemic abx if globe ruptured

analgesia

e-collar

Question 23

when to refer for surgical repair

Answer 23

lacerations or perforations

corneal and intraocular foreign material

Question 24

complicated corneal ulcers

Answer 24

likely infected, collagenolysis, uveitis, pain, risk of globe rupture

C&S, begin broad spectrum abx drops, serum for melting ulcers

Oral NSAIDS

atropine

e-collar

temporary tarsorrhaphy

referral for conjunctival graft

Question 25

acute glaucoma

Answer 25

usually primary

Dogs

PGE analogues, mannitol, carbonic anhydrase inhibitors

referral for gonioscopy

Question 26

anterior lens luxation

Answer 26

uveitis and pain- topical or sysemic steroid or NSAID,NO atropine

+/- elevated IOP-topical or systemic CAI

displaced lens-referral for surgical lens extraction, enucleation