ocular emergencies Flashcards
proptosis
sudden, anterior displacement of the globe
eyelids are entrapped behind globe
secondary to trauma-HBC, dog fight, restraint, play
first step when seeing patient with proptosis
evaluate entire body with PE
keep eye lubricated
stablize patient
treatment choices for proptosis
replacement of globe combined with a temp tarsorrhaphy
enucleation
favorable prognostic factors for proptosis
brachycephalic dogs
evidence of vision at presentation
shorter duration of proptosis
shorter distance of proptosis
normal findings on posterior segment examination
positive PLR
negative prognostic factors
nonbrachycephalic dog
cat
hyphema
pupil not visible on exam
globe laceration
globe rupture
facial fractures
optic nerve damage
avulsion of >3 extraocular muscles
Which extraocular muscle are likely to rupture when eye is proptosed
medial rectus
ventral rectus
ventral oblique
globe replacement and tarsorrhaphy
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
steps for replacing globe
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
post op care for globe replacement and tarsorrhaphy
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
Sequelae to proptosis
blindness
strabismus-lateral
KCS
lagophthalmos
exposure keratitis
corneal ulceration
repeated proptosis
squelae to uveitis
eyelid laceration-consideration
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
sequence for evaluation of eyelid laceration
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
steps for repair of eyelid laceration
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
eyelid margin closure
closure of tarso-conjunctival layer-horizontal mattress suture, first suture placed at eyelid margin for best apposition
avoid penetrating conjunctiva with suture
figure of 8
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
postop care of eyelid lacerations
systemic abx and anti-infl
eye protection
treat injury to globe
suture removal -14 d
px-good
blunt trauma
acute compression and deformation of globe
eye is shortened axially but stretches in other directions
rebound trauma
common signs of blunt trauma
skull fx
eyelid laceration
subconjunctival hemorrhage
corneal ulceration
anterior uveitis
hyphema
iris dialysis
lens (sub)luxation
lens rupture
choroidal rupture
retinal detachment
penetrating trauma
globe perforation by sharp object
may penetrate uvea, lens
pinpoint injury or laceration
may have retained foreign material
common signs of penetrating trauma
eyelid laceration
corneal defect
anterior uveitis
hyphema
iris prolapse
lens capsule perforation
cataract
lens rupture
retinal hemorrhage
initial management of globe trauma
prevent further trauma-sedation, topical anesthetic
handle gently
gentle cleansing of eye if exudates preclude exam-warm, sterile saline
initial dx and tx for globe trauma
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
when to refer for surgical repair
lacerations or perforations
corneal and intraocular foreign material
complicated corneal ulcers
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
acute glaucoma
usually primary
Dogs
PGE analogues, mannitol, carbonic anhydrase inhibitors
referral for gonioscopy
anterior lens luxation
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
