Ocular Emergencies Lecture Powerpoint

Question 1

VVEEPP

Answer 1

Way to remember components of H&P in ocular exam

• Visual acuity (ALWAYS put corrected or not)
• visual fields (always do by confrontation)
• External exam (characteristics visible to naked eye)
• Extraocular movements (important to know if can move normally without twitching or pain)
• pupillary eval
• pressure determination

Question 2

What exam should be done every encounter? What assessment should be done in any ocular complaint?

Answer 2

• fundoscopic

- visual acuity test

Question 3

Slit lamp exam

Answer 3

Low power binocular microscope with high intensity light that has different illuminating options and light filters to see different things, can only allow for fundus observation with additional lens and can only see angle between cornea and iris with additional goniolens

Question 4

A transient visual loss (TVL) is equivalent to…

Answer 4

…a TIA - may signify impending CVA or retinal vessel obstruction

Question 5

Amaurosis fugax presents with ____ and begins in the ___ progressing ____

Answer 5

painless monocular vision loss, upper fields, downwards

Question 6

If binocular vision loss lasting for hours occurs, consider…

Answer 6

…vertebrobasilar insufficiency

Question 7

Labs useful for amaurosis fugax (5)

Answer 7

• ESR (erythrocyte sed rate)
• CBC
• lipid panel
• A1c
• CRP

Question 8

Ischemic optic neuropathy

Answer 8

Infarction of the optic disc that is either arteritic (involving an artery) or non, typically presents with painless unilateral vision loss, may present with giant cell arteritis (along with jaw claudication), optic disc appears pale in arteritic or hyperemic in nonarteritic

Question 9

If concern for giant cell arteritis need to undergo…

Answer 9

….temporal artery biopsy within 1-2 weeks

Question 10

Ischemic optic neuropathy treatment (1 for each type)

Answer 10

Corticosteroids for arteritic, risk factor modification (no effective treatment for nonarteritic)

Question 11

Ischemic optic neuropathy prognosis

Answer 11

Worse for arteritic causing more severe visual loss

Question 12

Central retina artery occlusion

Answer 12

Typically seen in adults with cardiovascular dz, presents as acute, unilateral, persistent, painless vision loss, may have preceding amaurosis fugax episodes, requires ruling out of temporal arteritis first, will see cherry red spot on fundoscopic,

Question 13

Central retina artery occlusion prognosis

Answer 13

• loss of vision severely

- decrease in life expectancy by 15 years

Question 14

Central retinal artery occlusion treatment (3)

Answer 14

• referral
• systemic steroids
• laser embolectomy

Question 15

Acute angle closure glaucoma

Answer 15

Emergent occlusion of anterior chamber angle resulting in inadequate drainage of aqueous humor, elevates IOP causing damage to optic nerve, increased risk from certain medications, causes decreased vision and severe pain, nausea/vomiting, intermittent blurry vision with halos

Question 16

Medications that increase risk of acute angle closure glaucoma (5)

Answer 16

• anticholinergics
• TCA’s
• Tetracyclic antidepressants
• sulfa drugs
• Adrenergic agents

Question 17

Physical exam findings of acute angle closure glaucoma (4)

Answer 17

• pain with eye movement
• firm globe
• corneal edema and cloudiness
• mid dilated pupil that does not react to light

Question 18

As soon as acute angle closure glaucoma is suspected, need to get….

Answer 18

….intraocular pressure measurement (>20mmHg is bad), confirm with gonioscopy

Question 19

Acute angle closure glaucoma treatment (4)

Answer 19

• corneal indentation
• acetazolamide
• pilocarpine
• topical prednisone

Question 20

Retinal detachment

Answer 20

1 of 4 types of neurosensory retinal detachment from underlying retinal pigment epithelium

• Rhegmatogenous RD: most common type caused by tear in retina allows vitreous fluid to flow into sensory retina
• Tractional RD
• Exudative RD
• Non RRD: subacute chronic vision loss progression

All present with acute onset of floaters

Question 21

Once the ___ is involved in retinal detachment, it becomes ____ to preserve vision

Answer 21

macula, much harder

Question 22

Conjunctivitis

Answer 22

Any inflammatory process that involves the conjunctiva (bulbar surface of eye or palpebral inner surface of eyelid), one of most common nontraumatic ocular ED complains, usually benign and self limited, etiology can be bacterial, viral, allergic, fungal, parasitic, or chemical, presents with redness, itching, gritty sensation, normal visual acuity preserved

Question 23

Different types of conjunctivitis and a brief description (4)

Answer 23

• Bacterial: staph and strep most common
• Chlamydial: waxes and wanes
• Viral: acute or subacute onset
• Allergic: very pruritic

Question 24

Caustic keratoconjuntivitis

Answer 24

Ocular emergency due to chemical eye injury most often from occupation, eye penetration continues until removal of offending agent, pH at 11.5 is irreversible damage and can penetrate anterior chamber in 15 minutes, often brought on by NaOH

Question 25

After motor vehicle accident where airbags were deployed….

Answer 25

….get an eye wash for patient because airbags release aersolized sodium hydroxide

Question 26

Eye wash procedure for caustic keratoconjunctivitis

Answer 26

Use of lactated ringers at least 1-2 liters to treat eye burn (followed by pH check then an additional 8-10 L), can use topical anasthetic procaine or tetracaine as well

Question 27

Morgan lens

Answer 27

A tube inserted up against the eye in the eyelid to allow for intense flushing very quickly of the eye

Question 28

Keratitis

Answer 28

Inflammation of cornea with or without disruption of epithelium, most often caused by bacterial or viral infection, causes painful red eye with increased tearing, foreign body sensation, severe photophobia

Question 29

Dendritic lesion upon corneal staining from ____ indicates….

Answer 29

viral keratitis, …immediate ophthalmology referral

Question 30

Ocular involvement due to reactivation of zoster

Answer 30

Occurs when herpes zoster outbreak occurs anywhere in the orbital area, requires ophthalmology referral

Question 31

Bacterial keratitis

Answer 31

Ophthalmogic keratitis that is an emergency can result in blindness, often streptococcus species and often pseudomonas in contact lens wearers, treated with dropper broad spectrum antibiotics every 5 min for an hour then 15 for another hour, require admission and ophthalmomlogy consult

Question 32

Uveitis

Answer 32

Inflammation of uveal tract either anterior (iris and ciliary body) or posterior (choroid), often idiopathic but can be traumatic, presents in pain and redness of eye, treatment is with corticosteroids

Question 33

Corneal abrasion

Answer 33

Traumatic, infectious, or contact lens injury to the eye that causes pain, photophobia, tearing, can make it difficult to perform exam and require topical anesthetic to complete exam, diagnosed with fluorescein stain

Question 34

Corneal ulcer

Answer 34

Defect in epithelial layer in cornea with deeper involvement, can be bacterial or viral (HSV most common), present with eye pain, foreign body sensation, erythema, blurry vision***, need eye exam and fluorescin staining, treated with topical antibiotics

Question 35

Hyphema

Answer 35

Blood in anterior chamber of eye, typically due to trauma but can be spontaneous from neovascularization (DM), can result in outlfow obstruction of aqueous humor, can be managed conservatively if less than 1/3 anterior chamber occupied, remind patient to avoid NSAIDS for risk of bleed

Question 36

Open globe injury

Answer 36

Most common in males age 10-30, usually from violence or occupational injury, can be subtle without obvious external injury, presents with decreased visual acuity, teardrop pupil, need PE and fluorescin stain and CT, consult ophthalmology and prescribe bed rest and pain meds

Question 37

Orbital blowout fracture

Answer 37

2nd most common midfacial fracture (2nd to nasal bone), often occurs with blow to orbit that can entrap muscle such as inferior rectus (upward gaze dysfunction) and medial rectus (lateral gaze dysfunction), diagnosed with CT, treated withsurgical decompression for entrapment, avoiding of sneezing, antibiotics, follow up with ophthalmology

Question 38

Weakest point of the orbit

Answer 38

The floor

Question 39

7 bones of the orbit

Answer 39

• zygomatic
• frontal
• maxilla
• lacrimal
• ethmoid
• sphenoid
• palatine

Question 40

Medial wall fractures may develop alongside….

Answer 40

….subcutaneous emphysema

Question 41

Corneal foreign body

Answer 41

Can be organic or inorganic, frequent ophthalmogic emergency, present with pain, sensation, tearing, red eye, may be asymptomatic, physical exam and CT needed, treated with topical anesthesia and removed using irrigation or needle, antibiotic

Question 42

Intraocular foreign body

Answer 42

Most often associated with powertool use and hammering, causes internal damage resting in posterior segment with resultant injury to cornea, lens, and retina, slit lamp to evaluate anterior segment can help visualization as well as CT of orbits, treatment is wound closure in 24 hrs and topical antibiotics and steroids

Question 43

Periorbital vs orbital cellulitis

Answer 43

• Periorbital (preseptal) is infection of eyelid and surrounding skin that does not involve orbital tissue and is anterior to that, can extend to orbital cellulits
• Orbital cellulitis involves orbital tissue (posterior to orbital septum) may be caused by extension of sinus infection or direct infection, begins in eyelid and surrounding tissue and causes pain with extraocular motions

Question 44

Pain with Extra ocular movements indicates need to rule out these 2 things

Answer 44

• orbital cellulitis

- acute angle closure glaucoma