Ocular Emergencies Flashcards
About __% of the population have unequal pupils as a normal baseline.
25
Assessing the external features of the eye consists of examining the ____ and ____
eyelids and conjunctiva
Evaluate the extraocular muscles by assessing the __ cardinal fields by asking the patient to follow an object.
6
Fluorescein staining - what is it?
yellow orange staining used to evaluate the integrity of the corneal epithelium.
Fluorescein staining - what are the 5 steps in its use?
- Remove any contact lenses - Moisten the strip with NSS, pull down the patients lower lid and touch the strip to the conjunctive - Ask the patient to blink several times to completely cover the cornea - Examine the eye with a fluorescent lamp, the dye will cause epithelial defects to appear as highlighted yellow areas. - Instruct the patient not to wear soft contacts for at least 4 hours so not to stain the lens
Electric indentation devices that are handheld instruments that are to be placed directly on the cornea to measure intraocular pressure are called what?
Tonometry Tonometer
What are three steps to follow when using a Tonometer?
-Darken the room to minimize the amount of pupillary action -Anesthetize the cornea -Ask the patient to focus on a fixed object
When using a tonometer, Expect the normal intraocular pressure to be 10 to 20 mmHg. Consult an ophthalmologist if the pressure exceeds __ mmHg The most common cause of elevated intraocular pressure is ____
10 to 20 20 Glaucoma
An ____ (____) examination is performed to visualize the posterior chamber of the eye, using a light beam directed through the pupil.
ophthalmoscopic (fundoscopic)
Follow these three steps when performing a ophthalmoscopic (fundoscopic) procedure
-Darken the room -Instill mydriatic eye drops to dilate the patient’s pupils. -Using an opthalmoscope, visualize the posterior chamber of the eye, including the optic disc, retina, retinal artery, and macula.
In a patient with a ruptured globe, expect to find a ____-shaped pupil in the injured eye when performing a ophthalmoscopic (fundoscopic)
teardrop
When recording a visual acuity, the numerator represents what?
the distance on the chart
Remind the patient not to rub the eyes after topical anesthetic because why?
it can cause corneal abrasion
Because tears and drops drain into the tear duct, beta blocker eye drops such as Timolol can exacerbate what?
asthma in asthmatics.
When using beta blocker eye drops such as Timolol, Have the patient occlude the puncta to decrease systemic absorption and prolong eye exposure to the medication. How is this done? (3)
-This is done by pressing firmly on the bridge of the nose -If additional drops are prescribed, wait 5 to 10 minutes before administering them. -Always instill drops before ointments
A green top on an ophthalmic medication container indicates that the medication is a ____. What does that mean?
Miotic Miosis, or myosis, is excessive constriction of the pupil. The term is from Ancient Greek μύειν mūein, “to close the eyes”. The opposite condition, mydriasis, is the dilation of the pupil. These medications reduce eye pressure by increasing the drainage of intraocular fluid through the trabecular meshwork.
A red top indicates that the medication is a ____. What does that mean?
Mydriatic A mydriatic is an agent that induces dilation of the pupil. Drugs such as tropicamide are used in medicine to permit examination of the retina and other deep structures of the eye, and also to reduce painful ciliary muscle spasm
Periorbital contusion is also called a what?
Black Eye
Three types of orbital Blunt trauma include Orbital fractures Hyphemas Subconjunctival Hemorrhage
Orbital fractures Hyphemas Subconjunctival Hemorrhage
What is a Hyphema?
A hyphema is a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris). The blood may cover most or all of the iris and the pupil, blocking vision partially or completely. A hyphema is usually painful.
what are blowout fractures?
Fractures of the orbital floor and the medial orbital wall
Orbital Fracture (Blowout) Commonly involve the orbital floor or orbital rim. A fracture to the orbital floor or ____ bone usually result from a direct blow. This fracture may be an isolated injury, however, when an orbital floor fracture results in increased intraocular pressure, the orbital contents may herniate into the ____ or ____ sinuses. This is known as a blowout fracture. An orbital fracture is not considered an ocular emergency unless what?
Zygomatic maxillary ethmoid visual impairment or globe injury is present.
What is Enophthalmos?
sunken eye
What is diplopia?
Diplopia is the perception of 2 images of a single object.
Diplopia, limited upward gaze, and enophthalmos result from the ____ of the inferior rectus and oblique muscles
entrapment
When is Sx needed for the repair of a blowout fracture?
Sx repair is indicated if the patient has entrapment of the inferior rectus muscle or infraorbital nerve or significant enophthalmos
Patients who have sustained a blowout Fx may be discharged home with instructions to avoid things that may increase pressure such as
sneezing, nose blowing, and bearing down
Hyphema - or blood in the anterior chamber of the eye usually results in ____ ____. How does this result happen?
blunt trauma
The trauma usually tears the small blood vessels of the iris, and blood leaks into the normally clear aqueous fluid of the anterior chamber.
What is the size range for a hyphema?
Hyphemas can range from microscopic to total involvement of the anterior chamber.
What is an eight-ball hyphema?
Name 3 things this can lead to.
Any patient with a hyphema requires evaluation by an ____.
An “eight-ball” hyphema is a total hyphema that has begun to clot.
This serious injury can obstruct the aqueous outflow, increase intraocular pressure, and lead to secondary glaucoma.
ophthalmologist.
S/S of hyphema include ____, ____, and ____ ____. As red blood cells settle in the lower portion of the iris, a fluid level or ____ forms. A hyphema usually is easy to see, especially in patients with light-colored eyes. For example, a layer of blood collected in a blue iris is more visible than the same layer of blood collected in a brown iris.
include pain, photophobia, and blurred vision
limbus
The most common complication of hyphema is ____, which occurs in __% of all patients, usually __ to __ days after the initial injury. Can cause what three other complications?
rebleeding
33%
2 to 5 days
corneal staining, secondary glaucoma, and permanent vision loss
Patients with these comorbidities or take this type of medications are at increased risk of complications with hyphema.
Patients who take anticoagulants or have a bleeding disorder, kidney or liver disease, or sickle cell disease are at increased risk for complications and require close monitoring
Most uncomplicated Hyphemas resolve within __ to __days. The mainstay of management is head elevation, with the bed at __ to __ degrees. To improve comfort and to protect the eye, have the patient wear an ____ ____ at all times until the hyphema resolves. If the patient is nauseated, prevent ____. Before discharge, warn the patient to avoid (these medications) to avoid bleeding and refer to an ophthalmologist for follow up.
5 to 6
30 to 45
eye shield
vomiting
aspirin and NSAIDS
What is this image depicting?
Subconjunctival Hemorrhage
What is Subconjunctival Hemorrhage a result of?
How is it treated?
How long does it take to resolve?
Can result from vomiting, coughing, or sneezing, and concerns patients because of its appearance.
A painless, bright red flat patch on the sclera
Mild discomfort
Provide reassurance that no medical treatment is needed and that the blood should be reabsorbed in 2 to 3 weeks.
If lacerations are present, prepare the patient for early wound closure, why?
before swelling distorts the tissues and and makes wound approximation more challenging.
S/S of globe rupture include
Pain
Loss of or blurry vision
Diplopia (double vision)
Misshapen eye
When treating a patient with a globe rupture, do these two things.
Avoid administering eye drops and defer the detailed examination.
Arrange for an emergent ophthalmologic consultation.
These among the most common ocular injuries in the emergency department or urgent care setting, what are they?
Corneal Abrasions
Corneal damage occurs when an object such as a contact lens, finger, dirt, or debris, scratches or abrades the epithelial layer.
Typical signs include (5)
Foreign body sensation
Photophobia
Acute pain
Excessive tearing
Eyelid spasms
Treatment for corneal abrasion includes (5)
Anesthetic eye drops for purpose of assessment
Dx requires fluorescein staining and a Cobalt Light (Woods Lamp)
May also require slit lamp microscopic evaluation.
Patching is no longer recommended.
Provide discharge instructions that include self-administration of antibiotic eye drops to prevent secondary infection and the need to follow up in 24 hours.
Corneal Lacerations
Produce S/S that resemble ____ ____, but ____ staining shows a waterfall of dye from the lacerated area
Treat small lacerations like ____ ____.
What should you do for a Large laceration?
corneal abrasions
fluorescein
corneal abrasions
Conjunctival and Corneal Foreign Bodies
The most common foreign body in the eye is what? The patient will complain of these 4 S/S.
a small particle of dust
A foreign body sensation
Photophobia
Tearing
Pain that increases when the eyelids open and close which causes the FB to move
Conjunctival and Corneal Foreign Bodies
To remove, first try this.
If that doesn’t work, then what?
Assist with removal by saline irrigation, moist swab, or the use of an eye spoon or small gauged needle.
Ocular burr drills are used to remove rust rings and may be used to free foreign bodies stuck to the cornea.
What do you call it when a forgien body adheres to the eye? If the forgien body is metal and has been in there for a while, what can you expect to see? What do you do when this happens?
retaining FB
rust ring
arrange for an ophthalmologic evaluation within 24 hours.
Administer topical antibiotic therapy as prescribed.
Intraocular foreign Bodies
What can happen when something small penetrates the eye?
Small and easy to overlook. An object may enter the eye, and the mucosal lining may seal itself.
In the case of an intraocular foreign body, The pupils may assume the shape of a cats eye, which may indicate what?
a ruptured globe
Intra Ocular FB is an ocular emergency and ____ intervention is essential to preserving vision.
The amount of eye damage depends on the size, shape, and composition of the FB. Metal objects are more likely to penetrate the ____ chamber.
early
posterior
Intraocular foreign Bodies
Organic objects such as ____ ____ are more likely to cause infection.
Consider all FB to be ____
Administer prof ABx and determine ____ ____ status.
___ is the best way to locate an IOFB
Expect to prepare the patient for ____.
wood splinters
contaminated
tetanus immunization
CT
surgery
Acid burns immediately damage the cornea by breaking down the tissue proteins so that the cornea appears ____ and ____. After initial exposure, they cause no further damage, why?
white and opaque
because the acid is neutralized on contact
Hydrofluoric acid and all alkalis (such as concrete, lye, and drain cleaners) cause corneal ____. How do alkalis and acids differ in the burns they can cause to the eyes?
opacification
alkalis continue to penetrate and damage the cornea until they are removed.
Acids, After initial exposure, cause no further damage because the acid is neutralized on contact.
A motor vehicle accident can cause what type of chemical burn to the eye?
Motor vehicle collisions that cause airbag deployment increase the risk of chemical burns from the alkali powder that is released.
Treatment of chemical eye burns Begin with copious irrigation and anesthetics using a ____ lens.
Decontaminate the eye using pH as your guide, measuring with ____ paper
The normal pH ranges from __ to __
For any chemical burn, the goal is to rapidly move the pH back to __ or __
Periodically measure the pH during initial irrigation.
Morgan
litmus
- 0 to 7.3
- 3 or 7.4
If litmus paper is not available, irrigate with at least __ L of solution over __ minutes. For a severe chemical burn, irrigate for __ to __ hours.
2 L of solution over 60 minutes
2 to 4 hours
Chemical eye burns
Be aware that the suspected globe disruption contraindicates the use of a ____ ____ and requires manual irrigation with irrigation with IV tubing held at the ____ ____.
Morgan lens
inner canthus
Thermal Burns to the eye
Most commonly affect the eyelid but rarely the globe because of the what?
Describe treatment.
lid reflex closure
Treatment is similar to other parts of the body
Anticipate consultation with an Ophthalmologist, or a burn center, or both.
Ultraviolet burns
Commonly affect who?
snow skiers, welders, and those who read on the beach or use sun lamps
how does Ultraviolet burns affect the eyes?
radiation is absorbed by the cornea and produces keratitis, conjunctivitis, or both.
Ultraviolet burns of the eye
What are the S/S?
Pain, tearing, photophobia, and a FB sensation usually begin 8 to 12 hours after exposure.
Ultraviolet burns are the most ____ of all ocular burns and usually decrease visual ____.
painful
acuity
What would you expect to see in an ultraviolet ocular burn using Fluorescein staining and slit lamp examination?
Fluorescein staining and slit lamp examination of the cornea reveal superficial punctate keratitis that looks like small microdots on the corneal surface.
How are ultraviolet ocular burns treated? (4)
How long does it take to resolve?
Treatments include topical ABX, cycloplegics, systemic analgesics, and light avoidance.
The cornea usually heals itself in 24 hours without scarring.
Infrared Burns are (more/less) serious than ultraviolet burns but are (more/less) common because of the use of protective eyewear.
more
less
The usual source of infrared exposure with infrared ocular burns is ____, which are used in surgery, cutting, and drilling.
lasers
Infrared ocular injuries do not produce ____ but can result in what?
pain
permanent vision loss
A ____, or external stye, is an infection of the eyelash oil gland that causes a small external abscess with pain, redness, and swelling.
Treatment includes what?
Hordeolum
Treatment includes the application of warm compresses four times a day. Once the abscess comes to a point, it may rupture spontaneously.
Hordeolum Lesions that do not respond to several weeks of conservative therapy require what?
a referral to an ophthalmologist for possible incision and drainage
Unlike a Hordeolum, a ____ does not produce acute inflammation and usually is nontender and painless. What is it?
Chalazion
Treatment of a Chalazion includes what?
the application of a topical antibiotic ointment and incision and drainage if vision is affected.
Blepharitis, what is it? - an acute infection or chronic inflammation of the lid margin.
S/S include (4).
Describe the appearance.
How is it treated?
an acute infection or chronic inflammation of the lid margin.
S/S include eyelid burning, stinging, and itching, as well as conjunctival irritation. The eye appears red-rimmed (from eyelid inflammation), and crusts and cleaning the lid margins twice daily with a mild shampoo, applying warm compresses, and using artificial tears.
Bacterial Conjunctivitis
describe its presentation and S/S
Usually presents with a significant amount of purulent discharge that causes the eyelids to feel glued together in the mornings. Infection may be one or both eyes, and recent exposure to others with the same condition is common.
S/S include purulent discharge, reddened eye, and swollen, tender eyelid.
Bacterial Conjunctivitis treatment
For a contact lens wearer, anticipate using an agent that is effective against ____ species, such as ____ or ____.
Pseudomonas
aminoglycoside or fluoroquinolone
Bacterial Conjunctivitis
Cases caused by ____ ____ causes a “waterfall of pus”, effects who? To treat this infection, administer IV or IM ____ and arrange for immediate consult with an ophthalmologist. If untreated, can lead to permanent vision impairment.
Neisseria gonorrhea
sexually active patients and newborns of infected mothers
Rocephin
Viral Conjunctivitis
Usually results from an ____ and causes itchy, watery eyes, although a ____ discharge may be present.
Highly contagious and may accompany an ____ ____ infection.
Describe the onset.
Treatment is with ____ ____.
adenovirus
mucopurulent
upper respiratory
Crusted or matted eyelashes when waking is common. The onset is abrupt and progresses to both eyes.
cold compresses
____ ____ usually results from an allergen that causes the eyes to tear and may cause intense itching. To treat, apply cold compresses or administer antihistamine eye drops or systemic antihistamines as prescribed.
Allergic Conjunctivitis
____ is a generic term for inflammation of the cornea, which can threaten the patient’s vision. It might be cause by a corneal ulcer, bacteria, virus, or fungus. Factors that increase the risk of ____ include ultraviolet light, exposure and corneal injury from contact lens use.
Keratitis
S/S may of Keratitis include what?
(6)
conjuntivitis, pain, photophobia, Mucopurulent discharge, decreased vision, Hypopyon (a collection of pus due to white blood cells in the anterior chamber of the eye)
Keratitis treatment includes
How do you determine the offending organism?
Interventions include (3)
What should you NOT do, due to risk of infection of this organism.
Obtain a specimen of discharge for C+S to determine the specific cause of the infection. To intervene, apply warm compresses, administer braod spectrum ABx, and instill antifungal eye drops.
Do not patch the eye because of the risk of pseudomonas infection, which is a particular concern to contact lens wearers. Arrange for a consultation with an ophthalmologist.
Occurs when the retina tears and allows vitreous humor to seep between the retina and the choroid, reducing the blood and O2 supply, and the retina can no longer perceive light.
what is it?
Retinal Detachment
What are the S/S of Retinal Detachment?
Classic patient complaints include light flashes, floaters, or a curtain coming down over the visual field.
What are some of the causes of Retinal Detachment?
May result from a medical problem, such as HTN, or a traumatic event, especially a direct blow to the eye or head
Describe the prognosis and treatment of Retinal Detachment.
Is a time sensitive ocular emergency, with early treatment, prognosis is excellent.
Prepare for ophthalmic US which is the current recommended test
Consult ophthalmologist for definitive treatment, which may include laser repair or scleral buckling
Common cause of blindness in the US that results from inadequate drainage of the aqueous humor from the anterior chamber, dangerously elevating pressure.
What is it?
Glaucoma
Glaucoma is classified in two ways.
What are they and what is the difference?
Primary or secondary - Primary has no underlying cause. Secondary results from underlying trauma or systemic condition.
Open or closed angle
Open - the anterior angle is normal
Closed - the angle is narrowed.
Primary open is the most common, however, primary angle-closure is the most emergent form.
What are the S/S of Acute Angle closure Glaucoma?
(6)
Typically causes severe eye pain or HA
A fixed and slightly dilated pupil
Foggy appearance of the cornea
Reports of halos around lights
Nausea and vomiting
Many patients report being in a darkened environment such as a movie theater when the symptoms begin. Darkness dilates the pupil, which can block the aqueous flow and increase the intraocular pressure.
Describe the pressures involed in the Dx of Acute Angle closure Glaucoma
An intraocular pressure above 20 mmHg is elevated.
An intraocular pressure above 60 to 70 mmHg damages the corneal epithelium, lens, iris, optical nerve, and retina
Dx is based on intraocular pressure
What are the treatments involved with Acute Angle closure Glaucoma?
(3)
Decrease the aqueous humor production with beta-blocker eye drops such as timolol, alpha-agonists such as brimonidine, and carbonic anhydrases inhibitors such as Dorzolamide
Increase outflow with Pilocarpine eye drops to increase the rate of fluid movement from the eye and are a mainstay of this disorder
Relieve nausea and pain with antiemetics and narcotics if indicated
