Ocular Trauma and Emergencies - Exam 3 Flashcards by Johannah Crumpton

_____ is very common when there is history of trauma to the eye due to fingernail, piece of paper or contact lens

corneal abrasion

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Significant Eye discomfort
Tearing
Often foreign body sensation
+/- ciliary flush
+/- change in visual acuity due to large abrasion or those in central visual axis
Photophobia or headache due to ciliary muscle spasm

What am I?
What are some common complications?

corneal abrasion
bacterial keratitis
corneal ulcers
traumatic iritis
hypopyon

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How do you dx a corneal abrasion?

Evert lid to rule out foreign body
if possible, check visual acuity
sterile fluorescein staining: eye will appear yellow to the naked eye

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How is the visualization of a corneal abrasion enhanced?

use of cobalt blue filter or Wood’s lamp

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What is the tx for a corneal abrasion? When would you need to follow up with ophthalmology?

topical anesthetic prior to staining (Proparacaine or tetracaine)

Topical antibiotics: bacitracin-polymyxin ointment/drops 1st line

Short acting cycloplegic if needed - pain relief due to ciliary spasm for patients with headache and photophobia (Cyclopentolate 1% or Homatropine 5%)

NSAID eye drops: Diclofenac or Ketorolac

if still having s/s after 24-48 hours

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For a chemical karatitis, the severity of the ocular injury depends on what 4 factors? Is alkaline or acidic chemicals worse for the eye?

The toxicity of the chemical,
How long the chemical is in contact with the eye,
The depth of penetration, and
The area of involvement.

alkaline chemicals are worse for the eye

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What is the tx for chemical keratitis?

-determine if it alkaline or acidic
-Topical anesthetics
-Copious amounts of irrigation ASAP (use Morgan lense and irrigate until pH 7 (pH should be checked prior to and 5 min after)
-Thorough slit lamp exam with lid eversion
-Measure IOP with significant burns
Cycloplegic-decrease pain iris-ciliary spasm and dilate using Cyclopentolate 1% drops
-Topical antibiotic
-Steroids if severe
-Narcotic analgesic
-Refer to ophthalmologist

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______ commonly causes UV keratitis due to excess UV exposure. What is the highlighted symptom?

Welder’s flash

**severe pain 6-12 hours after exposure

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Death of a small group of cells on cornea. Speckles that stain with fluorescein are both characteristic of _____. What is the tx?

UV keratitis

Binocular patching
1-2 drops Cyclopentolate (cycloplegic) to dilate pupil and relieves discomfort of ciliary spasm

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When dx a corneal foreign body you always need to do _____

**always evert the eyelid to make sure there is no penetrating globe injury

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What is the tx for a corneal foreign body?

-check visual acuity
-topical anesthetic drops
-if superficial, saline flush to remove or sterile moistened cotton swab
-topical abx drops
-evert upper lid
-tetanus prophylaxis

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_____ can form from a foreign body containing iron. When do you need to refer out?

Rust ring

refer if no improvement after removal for 2-3 days

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What is hyphema? What are s/s?

injury to anterior chamber that causes a hemorrhage into the anterior chamber

blood in anterior chamber, Pain, photophobia, possible blurred vision
N/V may signal a rise in IOP

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What is the tx of hyphema? When do re-bleeding occurs?

-to prevent further hemorrhage!
-keep patient in supine position with head slightly elevated
**NO NSAIDS or ASA!!!
-hard eye shield
-antiemetics prn
-consult ophthalmology

most re-bleeding occurs within the first 72 hours

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Orbital blowout fracture is MC in what pt population? What are some common causes?

young adult and adolescent males

assaults, MVC, struck by ball

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**______ is the MC bone associated with an orbital blowout fracture. **What is the most concerning clinical finding?

maxillary bone

enophthalmos: eye looks pushed in

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pain and periorbital ecchymosis
Diplopia or restriction on upward gaze d/t restriction of _______
Decreased eye movement

What am I?
What is the decreased eye movement sometimes due to?

orbital blowout fracture

restriction of the inferior rectus muscle and anesthesia along the trigeminal V2 due to infraorbtial nerve entrapment

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How do you dx an orbital blowout fracture? What is the imaging of choice?

Obtain mechanism of injury
Examine eye and contents; Check visual acuity
**CT of the orbit imaging of choice

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What does orbital emphysema with palpable crepitus indicate?

Abnormal collection of air within orbital soft tissues
Usually d/t orbital fractures communicating with sinuses

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**What is the MC orbital walls to be fractures and which sinus do they lead into?

M/C inferior wall (into maxillary sinus)

medial wall (into ethmoid sinus)

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**Soft tissue mass extending into the maxillary sinus related to entrapment of ______. What may happen as a result?

inferior rectus muscle

Ischemia and subsequent loss of muscle function may occur

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What is the tx for an orbital blowout fracture? What is an important pt education point?

-Refer / Consult ophthalmology
-Tetanus prophylaxis/pain management
-consider Augmentin or Doxy to cover for sinus pathogens
- consider systemic steroids to decrease swelling and double vision
-may need sx depending on the severity

Avoid valsalva maneuvers, give antiemetics, instruct patient to not sneeze/blow nose aka anything that would increase pressure

______entrapment may occur in patients with orbital floor blow-out fractures.

Inferior rectus muscle

**What is the highlighted symptom that is classic for ruptured globe? What is the tx?

teardrop shaped pupil

Protective eye shield
Elevate head of bed 45 degrees
**Vancomycin PLUS Ceftazidime (or Fluoroquinolone) IV
Tetanus updated
Sedation, anesthesia
Antiemetic
CT of orbit
Make patient NPO in preparation for surgery
Consult ophthalmology immediately without further manipulation

What is the medical term for sudden vision loss? Is it usually unilateral or bilateral? How long does it last? What are some causes?

Amaurosis Fugax unilateral a few minutes retinal emboli or giant cell arteritis

_____ is described as a curtain descending over the visual field with complete monocular visual loss lasting a few minutes

amaurosis fugax

_____ is sudden, painless, monocular loss of vision, loss of visual fields. Has cherry-red spot on fovea, RAPD, boxcar segmentation. This is considered a form of a _____. What other eye condition do you need to rule out?

Central retinal artery occlusion form of stroke because the central retinal artery provides blood to the inner layer of retina giant cell arteritis

Why do you see boxcar segmentation with central retinal artery occlusion?

because. the vascular blood flow is stasis/sluggish due to occlusion

In young pts are some common causes of central retinal artery occlusion? in older pts?

younger: thrombophilia and OCPs, older: Carotid artery atherosclerosis

**What is the tx for central retinal artery occlusion?

consult ASAP!! **Laying patient flat, ocular massage, high concentrations of oxygen, IV acetazolamide or mannitol, vasodilators (nitro)

What is the tx for giant cell arteritis?

High dose corticosteroids

Sudden, acute, painless, monocular vision loss "Blood and thunder fundus" often first noticed upon awakening Can see macular edema and neovascularization What am I? What is it caused by?

Central Retinal Vein Occlusion (CRVO) Blockage of this vein causes vein to leak blood and excess fluid

What is the tx for central retinal VEIN occlusion?

1st line: Anti VEGF 2nd: Intravitreal Corticosteroids laser photocoagulation: aka seal the leaky vessels and prevent formation of VEGF that will cause neovascularization

What are the differences between CRAO and CRVO?

Retinal detachment is most commonly caused by ______. What is the common pt population? Risk factors?

spontaneous retinal tear: posterior vitreous detachment pts older than 50 risk factors: Nearsightedness (longer eyeballs, thinner retinas), Cataract extraction, penetrating or blunt trauma

Once there is a tear in the retina, what happens next?

Once a defect in the retina, vitreous fluid passes under retina, gravity and increasing fluid filling results in progressive detachment

Photopsia (flashing lights) Floaters Eye pain Monocular, decreased vision A description of a “curtain or veil” moving across vision field. What am I? How long does the central vision last?

retinal detachment Central vision remains intact until the macula becomes detached

What is the tx for a retinal detachment?

consult!!! sx: close all retinal holes/tears by forming a permanent adhesion between retina, retinal epithelium, and choroid with laser photocoagulation (pneumatic retinopexy)

_____ is Inflammation at any point along the optic nerve. **What disease is it strongly associated with?

Optic Neuritis multiple sclerosis

Name some additional diseases that you may also find optic neutitis.

**multiple sclerosis: MAJOR one Sarcoidosis Varicella zoster Autoimmune disorder, SLE Meningitis, paranasal sinusitis

Subacute Unilateral vision loss Pain behind the eye, particularly with EOM Field loss - central Loss of color vision/perception RAPD may have a normal optic nerve may have a swollen optic disc What am I? What are the 2 highlighted s/s?

optic neuritis **pain behind the eye, especially with EOM **loss of color vision/perception

What is the tx for optic neuritis?

consult!!! IV Methylprednisolone for 3 days, then tapering oral course of prednisone aka: high dose IV steroids then sent home with a tapering dose

____ optic disc swelling due to elevated intracranial pressure. Is it usually unilateral or bilateral? What is the highlighted s/s?

Papilledema usually bilateral **Flame-shaped hemorrhages

What is the imaging needed for papilledema? What procedure do you NOT want to perform?

MRI CONSULT!! Do not perform an LP on a patient with papilledema---can worsen ICP

______ Inadequate perfusion of the posterior ciliary arteries that supply the anterior portion of the optic nerve (infarction of the optic disc).How does it present? What is it the cause? What is the treatment?

Ischemic Optic Neuropathy **Sudden, painless, monocular visual loss: altitudinal field defect: Defect in superior or inferior portion of the visual field caused by optic disc swelling in older pts often due to giant cell arteritis **Systemic high dose corticosteroids and REFER high dose steroids are needed to decrease inflammation

What eye abnormality shows a “cherry red” fovea upon fundoscopic examination? What are the presenting s/s?

central retina artery oclusion sudden, painless, monocular

When is Central Retinal Vein Occlusion usually first noticed?

first thing in the morning, upon waking

If a patient complains of eye pain, flashing lights, and floaters, what should be at the top of your differential diagnosis?

retinal detachment

What eye disorder is d/t increased Intracranial pressure? What eye disorder is d/t demyelination?

papilladema optic neuritis

Tear shaped pupil, as well as a hyphema. The patient states he is having trouble seeing out of his eye. What is your diagnosis? What testing should you do next?

ruptured globe CT

36 y/o women presents to ER complaining that one of her eyes does not appear normal. On first appearance, you note that her right pupil is small and irregular. While continuing to exam her, you note that the pupil does not respond to direct or consensual light stimuli. It does, however, become smaller during accommodation testing. What is her most likely diagnosis?

tertiary syphilis

In acute angle closure glaucoma, aqueous humor is prevented from reaching what structure?

Trabecular meshwork

Where is aqueous humor produced?

In the posterior chamber, the ciliary body makes aqueous humor.