Opthalmological emergencies Flashcards
Why are why marks on the cornea a concern
Corneal infiltrate
Corneal ulcer
Scar->herpetic
Severe allergy
Concern about metal on metal
Sharp object, metal penetrate through the eye
What are the concerns with a painful photophobic eye
Iritis
Keratitis
Acute angle glaucoma
Should topical steroids be used
Not if unsure of diagnosis especially if herpes not ruled out
Components of functional eye examination
Pupils->afferent/efferent, direct/consensual
Optic nerve->snellen, pinhole, confrontation, VF/red colour
Motility 3, 4, 6->posture, ptosis, cover/uncover, movement
Anatomical eye examination
General Lids, lacrimal, position, movement Conjunctiva, sclrea Cornea->clairty, fluroscein stain Subtarsal lid Anterior chamber Iris Pupil Opthalmoscope->red reflex, disc, vessels, periphery, red/white spots, masses
What are sight threatening conditions which require urgent consultation to an opthalmologist
Lid/globe lacerations Chemical burns Corneal ulcer Gonoccocal conjunctivities Acute iritis Acute angle-closure glaucoma CRAO Intraocular foreign body Retinal detachment Endophthalmitis
What is CRAO
Central retinal artery occlusion
What are life threatening ocular emergencies
Proptosis CN3 palsy w/ dilated palsy Papilloedema Orbital cellulitis Temporal arteritis Leukocoria
When there is proptosis, what are they at risk of
Cavernous sinus fistula or thrombosis
What does a CN3 palsy with dilated pupils suggest
IC aneurysm
Herniation
Neoplastic lesion
Which is worse, acid or alkali burns, and why
Alkali worse--> lime, cement, dishwashing, caustic soda--> Even with clear cornea, can burn for weeks Acids coagulate tissue and stop further corneal penetration
Management of chemical burn
\+++Irrigate w/ Saline water-->continuous drip Swab upper and lower lids to remove possible particulate matter Do not neutralise--> heat produced= further damage Refer urgently! \+/- dilate Antibiotics, patch
What is a dendritic ulcer
Herpes simplex keratitis
What is hutchinson’s sign
If tip of nose if involved with herpes, 75% will have globe involved
Xnose involved, 1/3 eye involved
Management of dendritic ulcer
Refer
Aciclovir 5X daily
+/- minimal wipe debridement
Complications of herpes zoster occular involvement
Corneal keratitis Ulceration Perforation Scarring Secondary- iritis, glaucoma, cataracts Muscle palsies Severe post herpetic neuralgia
Signs requiring referral
Decreased VA Shallow anterior chamber Hyphema Abnormal pupil Ocular misalignment Retinal damage
What does penetrating trauma inclue
Ruptured globe, prolapsed iris, IO foreign body
Initial management of penetrating trauma
REFER ABCs Do not press on eye globe Dont check IOP Check vision, diplopia Apply rigid eye sheild Keep head elevated Keep NPO Tetanus status Give IV antibiotics CT orbits
Management of suspected globe rupture
CT orbits Cefazolin + aminoglycoside NPO Tetanus Pethidine Metoclopramide
Management of central retinal artery occlusion
Massage globe to dislodge thrombus
Decrease IOP->B blocker, IV mannitol, IV acetazolamide, rebreathing CO2, CCB, ant chamber paracentesis
Treat underlying cause
Causes of CRAO
Emboli->arrythmia, endocarditis, valvular disease
Thrombus
Temporal arteritis
Presentation of CRAO
Sudden, painless, severe monocular LOV RAPD May have had episodes of amaurosis fugax Fundoscopy-> Cherry red spot Retinal pallor Narrowed arterioles Cotton wool spots->infarct After 6 weeks cherry red spot recedes and optic disc pallor becomes evident
What is the timeframe to initiate treatment for CRAO before vision loss
2 hours
What is the hallmark for central venous occlusion
Dilated arteries and veins
What are the associated conditions with CRVO
Hypertension
Diabetes
Hyperviscosity syndromes
Glaucoma
How does CRVO present
Rapid monocular vision loss
RAPD
Fundoscopy->blood and thunder
Distinct groups of CRVO
- venous stasis/non-ischemic retinopathy
no RAPD, VA approximately 20/80
mild hemorrhage, few cotton wool spots
resolves spontaneously over weeks to months
may regain normal vision if macula intact - hemorrhagic/ischemic retinopathy
usually older patient with deficient arterial supply
RAPD, VA approximately 20/200, reduced peripheral vision
more hemorrhages, cotton wool spots, congestion
poor visual prognosis
Etiology of painless sudden LOV
CRVO CRAO IO hemorrhage Retinal detachment Optic neuropathy Optic neuritis Migraines
If suspect temporal arteritis/GCA- investigations and management
Refer ESR->elevated C-reactive protein (CRP)->elevated FBC->normochromic, normocytic anemia LFTs->mild elevation temporal artery biopsy temporal artery ultrasound
no visual or neurological symptoms or signs
1st line: prednisolone
visual or neurological symptoms or signs
1st line: methylprednisolone pulse therapy
confirmed GCA
1st line: prednisolone adjunct: aspirin adjunct: osteoporosis prevention recurrent or relapsing disease or severe corticosteroid adverse effects plus: methotrexate
Purpose of acetazolamide in acute glaucoma
Diamox= carbonic anhydrase inhibitor=
reduction in aqueous humor->reduction in IOP
Purpose of pilocarpine 4% in acute glaucoma
Cholinergic= iris sphincter miosis->ciliary muscle +outflow through trabecular
Presentation of acute glaucoma
presence of risk factors halos around lights aching eye or brow pain headache nausea, vomiting reduced visual acuity eye redness elevated intraocular pressure (IOP) corneal oedema fixed dilated pupil
Investigations in acute glaucoma
Refer
gonioscopy, examination of anterior chamber angle
slit-lamp examination
automatic static perimetry
Initial management acute glaucoma
initial presentation: acute angle-closure glaucoma
1st line: carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist
adjunct: topical ophthalmic cholinergic agonists
adjunct: hyperosmotic agents->glycerol
plus: laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)
Ongoing management of acute glaucoma
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
1st line: topical prostaglandin analogues and/or topical beta-blocker and/or topical alpha-2 agonist->latanaprost + timolol + brimonidine
adjunct: carbonic anhydrase inhibitors
adjunct: argon laser peripheral iridoplasty (when there is a component of plateau iris)
adjunct: lens extraction surgery ± goniosynechialysis
adjunct: topical cholinergic agonists
adjunct: trabeculectomy or tube shunt implantation
Red eye differential
Lids/orbit Conjunctival/sclera Cornea Anterior chamber Other
Lids/orbit/lacrimal causes of red eye
Chalazion Blephritis Entropion/ectropion Foreign body Laceration Dacryocystitis
Conjunctival/scleral causes of red eye
SC hemorrhage Conjunctivitis Dry eye Pterygium Epi/scleritis Orbital cellulitis
Corneal causes of red eye
Foreign body
Keratitis
Abrasion/laceration
Ulcer
Anterior chamber causes of red eye
Anterior uveitis
AA glaucoma
Hyphema
Hypopyon
Other causes of red eye
Trauma
Post op
Endophthalmitis
What is arc eye/snow blindness and how to manage
Arc eye/snow blindness--> Radiation keratitis, welding, skiing without eye protection, treat as for abrasion--> Topical antibiotic, topical NSAID, patch, dilate
