Ocular Trauma and Emergencies - Exam 3 Flashcards
_____ is very common when there is history of trauma to the eye due to fingernail, piece of paper or contact lens
corneal abrasion
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
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
How is the visualization of a corneal abrasion enhanced?
use of cobalt blue filter or Wood’s lamp
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
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
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
______ commonly causes UV keratitis due to excess UV exposure. What is the highlighted symptom?
Welder’s flash
**severe pain 6-12 hours after exposure
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
When dx a corneal foreign body you always need to do _____
**always evert the eyelid to make sure there is no penetrating globe injury
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
_____ 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
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
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
Orbital blowout fracture is MC in what pt population? What are some common causes?
young adult and adolescent males
assaults, MVC, struck by ball
**______ is the MC bone associated with an orbital blowout fracture. **What is the most concerning clinical finding?
maxillary bone
enophthalmos: eye looks pushed in
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
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
What does orbital emphysema with palpable crepitus indicate?
Abnormal collection of air within orbital soft tissues
Usually d/t orbital fractures communicating with sinuses
**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)
**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
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.
