Trauma and Ocular Emergencies

Question 1

What could some inflammatory etiologies be for red eye?

Answer 1

blepharitis, chalazion/hordoleum, cellulitis, conjunctivitis, dacyroadenitis/-cystitis, corneal ulcer (keratitis), uveitis

Question 2

What could some traumatic etiologies be for red eye?

Answer 2

subconjunctival hemorrhage, corneal abrasion, foreign body, hyphema

Also, could be caused by glaucoma or tumor!

Question 3

symptoms of chemical conjuncitivits (caustic chemical exposure)

Answer 3

acute pain and burning

blurry/impaired vision

Question 4

What are three signs of chemical conjunctivitis?

Answer 4

decreased visual acuity
corneal abrasion
red, pink, or white

Question 5

How is chemical conjunctivitis treated?

Answer 5

irrigate, irrigate, irrigate!
topical antibiotics and lubricants
refer to ophthalmology

Question 6

Which requires more extensive irrigation: acidic, alkaline, or saline exposure?

Answer 6

alkaline

Question 7

What is a subconjunctival hemorrhage?

Answer 7

blood in the conjunctiva due to vessel rupture

Question 8

What can cause a subconjunctival hemorrhage?

Answer 8

trauma, trivial events like cough, sneeze, or valsalva

Question 9

Symptoms of a subconjunctival hemorrhage – are they acute or asymptomatic?

Answer 9

could be either; patient may only notice in mirror or when informed

Question 10

Is vision affected in a subconjunctival hemorrhage?

Answer 10

vision unaffected

Question 11

A subconjunctival hemorrhage is a diffuse, red patch that stops at the ___.

Answer 11

limbus

Question 12

What is the treatment for a subconjunctival hemorrhage?

Answer 12

Nothing! Reassure the patient that it will resolve on its own after two to four weeks.

Question 13

A hyphema results from an injury to the ___ that disrupts the vasculature of the __ or __.

Answer 13

injury to anterior chamber

disrupts vasculature supporting the iris or ciliary body

Question 14

A hyphema is often due to __ trauma.

Answer 14

blunt

Question 15

symptoms of hyphema (4)

Answer 15

acute onset pain, photophobia, tearing, N/V may indicate a rise in IOP

Question 16

signs of hyphema (2)

Answer 16

+/- vision decrease

layered heme in anterior chamber

Question 17

Should hyphema cases be referred to ophthalmology?

Answer 17

Yes – that day!

Question 18

What should you recommend for patients with hyphema?

Answer 18

bed rest, supine position with head slightly elevated

Question 19

What medications are prescribed for a hyphema?

Answer 19

oral diuretic (acetazolamine), topical diuretic (dorzolamide), topical cycloplegic (atropine), and +/- topical steroid

Question 20

What are three goals of treatment with hyphema?

Answer 20

1. control IOP
2. ease discomfort
3. prevent complications

Question 21

How does a foreign body on the cornea or under the upper lid present?

Answer 21

patient complains of something in their eye or a foreign body sensation (and a consistent history)

Question 22

symptoms of foreign body

Answer 22

+/- history of something entering eye
pain
inability to open eye
may have attempted irrigation

Question 23

signs of foreign body in eye

Answer 23

tearing, injection, presence of foreign body

Question 24

Is vision affected or unaffected in a foreign body case?

Answer 24

usually unaffected

Question 25

How do you check for an abrasion in a foreign body case?

Answer 25

stain with fluorescin

Question 26

When examining for a foreign body, what topical anesthetic should be used?

Answer 26

tetracaine drops

Question 27

How do we check for visual acuity in a foreign body case?

Answer 27

Test it before and after!

Question 28

How do we search for a foreign body in the eye, and how do we remove it?

Answer 28

evert eyelid, stain with fluorescin, examine pupils if you suspect it is intraocular...remove it with irrigation or cotton swab -- refer to ophthalmology if unable to remove the foreign body or if you suspect a big abrasion

Question 29

How would we treat a patient with a foreign body in the eye?

Answer 29

remove it with irrigation or cotton swab, prescribe lubrication or antibiotic drops,

Question 30

When would you suspect that a patient has a perforating globe?

Answer 30

penetrating trauma like hammering or shaving metal

Question 31

three signs of perforated globe

Answer 31

loss of anterior chamber depth, misshapen pupil, vitreous jelly leakage

Question 32

How would you address a perforated globe?

Answer 32

emergency referral to ophthalmology; avoid manipulation

Question 33

Corneal abrasions are defects in the __ caused by ___.

Answer 33

corneal epithelial tissue; trauma to the eye like fingernail, paperclip, or contact lens

Question 34

five symptoms of corneal abrasion

Answer 34

acute onset of pain, foreign body sensation, tearing, light sensitivity, inability to open eyelids

Question 35

2 signs of corneal abrasion

Answer 35

+/- vision affected | visible epithelial defect

Question 36

How do we view corneal abrasions?

Answer 36

fluorescin and black light

Question 37

How is a corneal abrasion treated?

Answer 37

topical antibiotic drops like azithromycin or moxifloxacin; topical lubricants...heals quickly; follow up within 1-2 days

Question 38

Why don't we ever send the patient home with anesthetics?

Answer 38

inhibit healing and decrease patient's ability to protect the eye due to lack of sensation; anesthetic keratitis could occur and require corneal transplant!

Question 39

Corneal ulcers (keratitis) are caused by what?

Answer 39

infection (viral, bacterial, fungal, amebic)

Question 40

Corneal ulcers (keratitis) are associated with what?

Answer 40

contact lens abuse

Question 41

4 symptoms of corneal ulcers

Answer 41

eye pain, photophobia, tearing, decreased vision

Question 42

3 signs of corneal ulcers

Answer 42

conjunctival injection, especially over limbus cloudy and hazy opacity over cornea +/- hypopyon

Question 43

What would HSV look like in a corneal ulcer with fluorescin staining?

Answer 43

dendritic pattern

Question 44

treatment of corneal ulcer

Answer 44

prompt referral! bacterial = moxifloxacin HSV = topical aciclovir 9x daily

Question 45

A patient presents with blurred vision and acute pain/burning. Her visual acuity is decreased and she has a corneal abrasion. What could be happening?

Answer 45

chemical conjunctivitis

Question 46

A patient presents with acute onset of pain, photophobia, and tearing. There is layered heme in the anterior chamber. What is going on?

Answer 46

hyphema

Question 47

What is uveitis/iritis?

Answer 47

inflammation of the uvea

Question 48

What is the uvea?

Answer 48

iris, ciliary body, choroid

Question 49

What is the cause of uveitis?

Answer 49

mostly immunologic, sometimes trauma

Question 50

symptoms of uveitis

Answer 50

eye pain, redness, photophobia, headache, tearing

Question 51

signs of uveitis/iritis

Answer 51

decreased vision ciliary flush/circumlimbal injection (around iris) constricted pupils cells and flare on SLE

Question 52

What do cells and flare look like?

Answer 52

``` cells = like dust through flashlight flare = like headlights in fog ```

Question 53

Inflammation of the uveal tract allows proteins and WBCs to escape into the...

Answer 53

aqueous humor

Question 54

What could be two infectious causes of uveitis?

Answer 54

HSV and herpes zoster

Question 55

What could be three systemic inflammatory causes of uveitis/iritis?

Answer 55

anklyosing spondylitis arthritis (JIA) inflammatory bowel diease

Question 56

How is uveitis/iritis managed?

Answer 56

prompt referral; topical steroids like prednisolone and topical cycloplegics like cyclopentolate

Question 57

How does a blow out fracture occur?

Answer 57

direct compressive force to globe, like baseball to eye

Question 58

Does a blow out fracture present with diploplia?

Answer 58

Yes

Question 59

Why are there restricted EOMs in a blow out fracture?

Answer 59

2 degrees because of entrapment of inferior rectus muscles

Question 60

With a blow out fracture there is decreased sensation along the...

Answer 60

inferior orbital rim

Question 61

Why is there exopthalmos in a blow out fracture?

Answer 61

posterior displacement of globe

Question 62

T/F. There is a palpable step off at the rim in uveitis.

Answer 62

FALSE -- in blow out fracture

Question 63

How are blow out fractures diagnosed?

Answer 63

X-rays work but CTs are preferable

Question 64

How do we treat a blow out fracture?

Answer 64

emergency referral; empiric antibiotics started during transport (amoxicillin clauvanate)

Question 65

Glaucoma is a group of ocular diseases characterized by...

Answer 65

changes in optic disk and progressive loss of visual field

Question 66

Why does the optic disk change in glaucoma patients?

Answer 66

increased IOP

Question 67

What are the two types of glaucomas and which is more common?

Answer 67

acute angle closure | chronic open angle (more common)

Question 68

Which type of glaucoma is rare but important to know because it is an emergency?

Answer 68

acute angle closure

Question 69

Acute angle closure glaucoma occurs in what kind of patients, and what happens?

Answer 69

in patients with existing narrow anterior chamber angle; occurs secondary to pupil dilation like in a theater

Question 70

What is pupillary block?

Answer 70

occurs in acute angle closure glaucoma; outflow is obstructed and pressure builds due to continuous aqueous production at the ciliary body

Question 71

How does a patient with acute angle closure glaucoma present?

Answer 71

extreme eye pain, headache, photophobia, blurred vision with halos around lights, nausea and vomiting

Question 72

PE for a patient with acute angle closure glaucoma

Answer 72

patient appears sick, decreased vision, red eye due to circumlimbal injection, steamy cornea, fixed mid-dilated pupil, crescent shadow, increased IOP

Question 73

How can we tell there is increased IOP in acute angle closure glaucoma?

Answer 73

firm globe, pressure more than 50 mmHg (normal is 10-21)

Question 74

What is the treatment goal in patients with acute angle closure glaucoma?

Answer 74

control IOP with IV acetazolamide followed by oral doses QID, topical timolol (Timoptic), sometimes add miotic drop or systemic diuretic; check IOP hourly until emergency opthalmology referral

Question 75

What is the definitive treatment for acute angle closure glaucoma?

Answer 75

laser peripheral iridotomy

Question 76

Chronic glaucoma is characterized by gradually progressive ___ ___ resulting in...

Answer 76

nerve damage; constriction of visual fields to complete blindness

Question 77

Chronic glaucoma is characterized by "cupping," or ___.

Answer 77

pallor

Question 78

Why is there IOP in chronic glaucoma (closed vs. open angle)?

Answer 78

from reduced drainage through trabecular meshwork (in chronic open angle) or obstruction of flow into anterior chamber (chronic closed angle)

Question 79

How long does the IOP in chronic glaucoma take to progress?

Answer 79

months to years

Question 80

What are the recommendations for monitoring all patient's IOP?

Answer 80

all people over 40 should have dilated fundus exam and measurement of IOP every two to five years; if positive FH or diabetic, yearly

Question 81

Is chronic glaucoma unilateral or bilateral?

Answer 81

usually bilateral

Question 82

Diagnosis for chronic glaucoma requires consistent and reproducible abnormalities in two of three parameters, which are...

Answer 82

optic disk, visual field, IOP

Question 83

T/F. In the beginning, chronic glaucoma has a lot of symptoms.

Answer 83

F -- asymptomatic

Question 84

How is chronic glaucoma treated?

Answer 84

need to lower IOP, ophthalmology referral, topical anti ocular hypertensives like timolol (Timoptic) or dorzolamide; laser trabeculoplasty, surgical trabeculectomy