Trauma/Ocular Emergencies Flashcards
What are the sxs of chemical conjunctivitis? PE signs?
Sxs: -Acute pain/burning -Blurry/impaired vision Signs: -decreased visual acuity -corneal abrasion -red, pink, or white sclera
How do you treat chemical conjunctivitis
-Irrigate! -Topical lubricants -Abx -Refer to optho
What causes a subconjunctival hemorrhage
-Trauma -Trivial events (sneezing, coughing, valsalva)
Sxs: -Acute or asymptomatic -Loud bark, no bite Signs: -Vision unaffected -Diffuse, flat red patch which stops at limbus
Subconjunctival hemorrhage (blood under conjunctiva due to vessel rupture)
Does subconjunctival hemorrhage require treatment
No, just reassure pt it will resolve in 2 - 4 weeks
-Injury (blunt trauma) to anterior chamber disrupting vasculature to iris or ciliary body, causes blood to pool
Hyphema
-acute onset pain -photophobia -tearing -N/V due to IOP
Hyphema sxs
+/- visual decrease -layered heme in anterior chamber
Signs of hyphema
How do you treat Hyphema
-Refer to optho that day! -Bed rest (supine w/ head slightly elevated) **goal is to control IOP, ease discomfort, prevent complications**
What meds are used in Hyphema treatment
-Oral diuretic (acetazolamide [carbonic anhydrase inhibitor]) -Topical diuretic (dorzolamide) -Topical cycloplegic +/- topical steroid
What are symptoms of conjunctival/corneal FB
- +/- Hx of something in eye
- Pain
- Inability to open eye
- May have attempted irrigation
- Vision usually unaffected
- Tearing
- Conjunctival injection
- FB present
- Staining w/ fluorescein if abrasion
Signs of Conjunctival/Corneal FB
5 steps of exam for FB
- Topical anesthetic (tetracaine drops)
- Check visual acuity (pre/post tx)
- Evert eyelid (look for FB)
- Fluorescein dye/lamp to look for FB
- Check pupils (if you suspect intraocular FB, then refer to optho)
How do you treat FB
- FB removal (w/ irrigation or cotton swab)
- Lubricant or abx drops
- Refer to ophtho if you can’t remove FB or large abrasion
What causes a perforated globe?
What do you do if you suspect perf globe?
- Penetrating trauma (hammering/shaving metal)
- Emergency referral for surgical repair
- Avoid manipulation until pt seen by specialist and put an eye patch on
What 3 things will you see on PE w/ perforated globe
- Loss of anterior chamber depth
- Mis-shapen pupil
- Vitreous leakage (jelly)
Presentation of corneal abrasion
-Pt reports trauma to eye
Sxs include:
- acute onset pain
- FB sensation
- Tearing
- Light sensitivity
- Inability to open eyelids
Sign of corneal abrasion on PE
- +/- affected vision
- visible epithelial defect
- abrasions seen w/ fluorescein and black light
What is a corneal abrasion?
Abrasion in corneal epithelial tissue often due to trauma by paper, nail, or contact lens
How do you treat corneal abrasions?
How long do they take to heal?
- Topical Abx
- Lubricant
- Heals quickly. Have pt f/u 1-2 days
Why shouldn’t you send a patient home with anesthetics
- They inhibit healing. Patient can’t protect eyes due to lack of sensation.
- Anesthetic keratitis occurs with overuse, needs corneal transplant
What is Keratitis?
What is it often associated with?
- Corneal ulcer, most commonly due to infection (bacteria, virus, fungi, or amoebic)
- Often associated with contact lens abuse
Sxs of keratitis
- eye pain
- photophobia
- tearing
- decreased vision
- Conjunctival injection (esp. by limbus)
- Cloudy, hazy opacity overlying cornea
- +/- hypopyon (pus in ant. chamber)
- Dendritic pattern on fluorescein staining (HSV)
Signs of Corneal Ulcer (Keratitis)
3 possible steps of tx for Keratitis depending if viral or bacterial
- Prompt ophtho referral
- Bacterial - Moxifloxacin
- HSV - Topical Acyclovir 9X/day
What is Uveitis/iritis
inflammation of uvea (includes iris, ciliary body, choroid) commonly immunologic, can be caused by trauma
What are symptoms of uveitis
- Eye pain
- redness
- photophobia
- HA
- tearing
- Decreased vision
- Ciliary flush/circumlimbal injection
- Constricted pupils
- Cells and Flare on slit lamp exam
- IOP low or normal
PE findings for Uveitis/Iritis
“Headlights in fog”
Flare (seen on uveitis/iritis as proteins and WBC escape into aq humor)
“Dust through flashlight”
Cells (seen on uveitis/iritis as proteins and WBC escape into aq humor)
Why are cells and flare present on exam
inflammation of uveal tract allows proteins and WBC to escape into aq humor
What are possible causes of uveitis/iritis (infectious and systemic inflammatory causes)
Infectious:
- HSV
- Herpes Zoster
Systemic Inflammatory:
- Ankylosing spondylitis
- arthritis (JIA)
- IBS
How do you manage uveitis
- Prompts Ophtho referral
- topical steroids
- topical cycloplegics
How does a blowout fracture occur
Direct compressive force to globe (baseball to eye)
- Pain
- Diplopia
- Restricted EOM (entrapment of inf rectus)
- Decreased sensation to inferior orbital rim
- Palpable step off at inferior orbital rim
- Enophthalmos (posterior displacement of globe)
Presentation of Blow Out Fx
What is first line diagnostic test for blow out fracture
CT orbit (can also use XR, but not 1st choice)
How do you treat blow out fracture
- emergency referral
- empiric abx (amoxicillin/clavulanate) during transport
How is glaucoma characterized?
- Changes in optic disc, results in increased IOP
- Progressive loss of visual fields, due to compression of optic disc
- Occurs in pt w/ pre-existing narrow ant chamber angle (secondary to pupil dilation)
- Outflow obstructed, pressure builds bc/ aq humor still being produced at ciliary body
- Optho emergency
- Rare, but common question on boards
Acut Angle-Closure Glaucoma (AACG)
Sxs of Acute Angle-Closure Glaucoma
- extreme eye pain
- HA
- photophobia
- blurry vision (halo’s around lights)
- N/V
AACG should be included on Diff Dx for which condition?
acute abdomen (it causes N/V)
- Ill appearing patient
- decreased vision
- red eye (circumlimbal injection)
- steamy cornea
- fixed, mid-dilated pupil
- crescent shadow
- increased IOP (>50 mmHg)
PE findings of AACG
- Control IOP!
- IV Diamox, then oral QID
- Topical Timoptic (beta blocker, reduce aq humor)
- Miotic drops
- Check IOP hourly
- Iridotomy
Tx for AACG
- Gradual nerve damage (cupping/pallor)
- Result: loss of vision
- Increased IOP (from reduced drg thru meshwork) or (obstructed flow into ant. chamber)
- Months to years
Chronic Glaucoma
What will you see on COAG PE
- optic disc cupping
- vessels over optic disc
- Asymptomatic in early stages
- Usually bilateral
What does diagnosis of COAG require
consistent, reproducible abnormalities (2 of 3):
- Optic disc
- Visual field
- IOP
Who should you screen for COAG/Chronic Glaucoma
- 40+ y/o, every 2-5 years
Diabetics or +FH: yearly
Tx for COAG
Goal is to lower IOP!
- Topical anti-HTN (timolol, dorzolamide)
- Laser trabeculoplasty
- Surgical trabeculotomy
