Optho Flashcards
crepitus felt around the eye is indicative of
sub q emphysema from an orbital medial or inferior wall fx
infraorbital paresthesia is indicative of
an orbital rim fx
not being able to move the eye up is indicative of
inferior rectus immobility- entrapment
when do you not do a slit lamp exam in an ocular trauma?
pt is not mobile
type of burn that is especially disastrous for the eyes
alkali chemical burns
copious irrigation is indicated when?
for chemical burn. Should be initiated before arrival and at the ED.
initial management of chemical eye burn
immediate triage at bedside, defer vision testing, instill topical anesthetic, check for and remove FB, start copious irrigation
irrigation protocol
NS or LR >10 minutes.
> 1 L for acid burns and > 2 L for alkali burns
treatment protocol post irrigation
full eye exam, instill additional topical anesthetic, fluorescein stain and note any uptake, instill topical cycloplegic (only if sure no glaucoma) and instill topical antibiotic. PRN tetanus vac. Patch eye. Consider referral and do not forget to r/o FB and ruptured globe
topical cycloplegics
paralyzes and dilates pupil. helps to ease pain. Examples: atropine, tropic amide, cyclopentate, homatropine
topical anesthetics
example: tetracaine
brown discoloration of the sclera could be indicative of
uveal prolapse- it is a prolapse of the iris or ciliary body. this is in and of itself indicative of an ocular laceration or rupture.
an irregularly shaped pupil could be indicative of
an ocular rupture, laceration or uveal prolapse. Irregularity points to the site of the injury.
a hyphema is
blood in the anterior chamber. detected with a penlight
a vitreous hemorrhage is
blood in the posterior chamber. will have loss of red reflex or hazy view of retina on opthalmascope exam
sudden onset/ acute lens opacification could be indicative of
globe lac or FB
lowered IOP could be indicative of
a globe lac. ACEP does not recommend testing IOP with suspected lacs because of increased risk of further damage
suspected ruptured/lac globe imaging
CT is the study of choice. Plain films used if suspect fracture or if large metallic FB present. MRI should not be performed if there is any indication of metallic FB
suspected ruptured/lac globe protocol
stop the exam immediately to reduce risk of further damage. SHIELD the eye- do not patch. Call optho. Tetanus vac PRN
Hyphema protocol
the globe may or may not be ruptured. Assume it IS ruptured. Shield the eye and call optho immediately
Major orbital hematoma protocol
assume globe rupture. Shield the eye. Immediately call optho
Mild orbital hematoma protocol
apply cold compress to orbit. PO tylenol for pain. Do not give topical and do not give NSAIDS (can increase bleeding). Have pt f/u with optho
suspected blow out fx imaging
CT scan, coronal and sagittal views are imaging study of choice.
blow out fx protocol
Get CT, call optho, be sure to document EOM exam. May need surgery if diplopia does not resolve
full thickness lid lac
involves the lid margin and needs to be repaired in layers. Improper closure can result in “notching” of lid margin
extensive lid lac
any laceration that extends into the medial third of the upper or lower lids. can involve the canalicular system
deep lid lac
can involve the levator muscle. must be properly repaired or can result in permanent ptosis
deep lid lac with fat prolapse
associated with higher incidence of globe injury/penetration, FB, and lid impairment. requires urgent optho referral
Superficial lid lac protocol
avoid retraction of the lid margin, remove any FB and r/o deeper FB. tetanus vac prn. consult optho if extends into lid margin. have f/u with optho otherwise
corneal abrasion protocol
do an initial exam. instill topical anesthetic (tetrocaine). apply moistened fluorescein strip to inferior conjunctival surface and examine eye with cobalt-blue filter, looking for areas of uptake. Give topical erythromycin ointment and cover eye. should f/u with optho in 24 hrs. do not rx topical anesthetic!
welders keratitis
corneal abrasion with epithelial irregularities d/t UV exposure- will appear hours after UV exposure. Pt will have ground glass sensation. refer to optho.
contact lens corneal abrasion protocol
remove lens, r/o infection. instill cycloplegia and abx that covers gr- Do not patch and f/u with optho in 24 hrs. avoid contacts for at least 48 hrs.
FB protocol
evert lid. remove FB with stream of irrigation fluid or gents with a cotton swab. If it is lodged on corneal surface remove with beveled edge of a sterile syringe. If it is a metallic FB, it will be removed under slip lamp by optho. apply topical anesthetic for removal procedure. Following removal instill a topical cycloplegia, apply topical abx and consider systemic tylenol/NSAID for pain. Remember tetanus prn.
viral conjunctivitis
b/l red inflammation with watery d/c. do not use abx. apply warm or cold compresses for comfort and encourage fastidious hygeine
bacterial conjunctivitis
b/l mucopurulent d/c. give topical tobramycin, oflocacin, neomycin or gentamyacin ointment or drops. Warm compresses for comfort and good hygiene.
Gonococcal conjunctivitis
consider when there is remarkable mucopurulent d/c. Consult optho, may need admit. Highly suggestive of abuse in children (except for neonates).
allergic conjunctivitis
big key here is itchiness. do cold compresses pro, topical antihistamines and po antihistamines. must r/o herpes keratitis so do not ever rx topical corticosteroids for allergic conjunctivitis. Must be evaluated by optho if persistent symptoms.
Iritis
is inflammation of the anterior chamber, pts will complain of photobia and a “deep pain”. will have circumcorneal redness and maybe a smaller pupil. Refer to optho, will need corticosteroids but it is a diagnosis of exclusion
corneal inflammation
SIGNIFICANT pain, FB sensation, decreased vision, + Fluorescein exam. this is an ocular emergency, refer to optho asap and do not give anything to eye
acute angle closure glaucoma protocol
give pilocarpine 2% q 5 min x 3 doses and timolol 0.5% x1 stat and Diamox (acetazolamide) 500 mg IV or PO x1 stat. Call optho immediately, is an ocular emergency
Preseptal cellulitis protocol
EOMs are normal- if not it is orbital cellulitis. Give warm compress, systemic abx and get CT and consult optho
Orbital cellulitis protocol
EOM impaired, proptosis, etc. get stat CT, nasopharyngeal and blood culture and optho and ID referral.
Mucormyocosis
fungal infection, requires emergent CT and endoscopic sinus/nasal exam
Herpes zoster opthalmicus
iritis, Hutchinson’s sign, vesicular lesions present on face are all indicators. will see psudodendrites on fluorescein exam. Give PO valcyclovir 1000mg TID x 7 days, cool compresses, topical lubrication +/- PO opiates for pain and refer to optho
CRAO protocol
cherry red spot on ophthalmic exam may not be present immediately, can sometimes take a few hours. Unilateral vision loss requires emergent tx. Give 500 mg PO or IV bolus of acetazolamide, instill timolol and start rebreathe CO2 therapy, for 10 minutes every 2 hrs x 2 days. Optho emergency
Temporal arteritis
pt will have unilateral vision loss, afferent pupil defect, and scalp/forehead tenderness. +/- jaw claudication. Get a ESR/CRP give high dose corticosteroids stat. Will also biopsy temporal artery
