Week 14 - Ocular emergencies anterior eye Flashcards
College or optom definition of emergency:
• red eye
• recent loss of vision
• recent onset of ocular pain
• symptoms which strongly suggest a recent retinal tear or detachment, or
• giant cell (temporal) arteritis (GCA).”
What to do when emergency presents
If you conduct an emergency examination of a patient who presents with an acute condition, you should make it clear to the patient that it is not a statutory sight test or full eye examination and that you are only addressing the presenting symptoms. You should:
• record all findings and any advice you give the patient
• make it clear that the patient should return to their usual optometrist for a routine eye examination when it is due, and
• refer the patient to an appropriate healthcare professional if applicable.
• If you decide not to conduct an emergency examination of a patient who presents with an acute condition you should: direct the patient to an appropriate healthcare professional, and indicate the degree of urgency!”
Describe chemical injury and alkali’s
• Presentation - Most commonly following household cleaning/DIY or industrial/manual work
• More damaging than acids due to both being hydrophilic and lipophilic, penetrating cell membranes easier
Common causative agents
Alkalis, such as:
• ammonia compounds (household cleaners, fertiliser)
• sodium hydroxide (drain and oven cleaners)
• calcium hydroxide -lime (cement, plaster)
Describe chemical injury and acids
• Presentation - Most commonly following household cleaning/DIY or industrial/manual work
• Less famage than alkali’s and corneal proteins bind and act as chemical buffer
Common causative agents: Acids, such as:
• sulphuric (car batteries)
• hydrofluoric (glass etching)
• hydrochloric (>25% is corrosive)
• glacial acetic (wart, verruca treatment - rarely)
• citric (limescale removal)
Chemical injury: Treatment
Treatment
• Evert lids to remove any particulate matter
• Irrigate, irrigate, irrigate
• ASAP and for at least 15-30min
• Sterile saline, if not tap water
Refer
• So eye can be irrigated until reaches pH 7
• And to repair any damage
Signs of chemical injury
• Burns to eyelids and surrounding skin
• Particulate matter under lid (evert to examine)
• Conjunctival chemosis and hyperaemia
• Limbal and conjunctival blanching (cessation of blood flow in superficial vessels; may indicate poor prognosis)
• Corneal epithelial defects ranging from superficial punctate keratitis through focal epithelial loss to sloughing of the entire epithelium
• Corneal oedema and pacification in severe cases (may prevent view of anterior chamber, iris, lens or beyond)
• Raised IOP
• Various chemical trauma classification systems exist, e.g. those of Roper-Hall and Dua and the ILSI classification.
• Each of these establishes limbal ischaemia as dividing mild from more severe trauma
Indicators of poor prognosis related to chemical injury
Indicators of poor prognosis ( using a classification of ocular burns)
• Limbal blanching of more than 270 degrees
• loss of corneal, limbal and conjunctival epithelium
Blunt trauma - Red flags
• Blow to the eye - deliberate/accidental
- in children there may be little bruising
Signs indicating urgent referral needed
• infraorbital nerve anaesthesia (lower lid, cheek, side of nose, upper lip, teeth), enophthalmos (sunken eye), diplopia in up or downgaze may indicate orbital fracture
• nasal bleeding (direct trauma, or could indicate skull fracture)
• relative afferent pupillary defect (indicates traumatic optic neuropathy)
• corneal oedema or laceration
• AC: hyphaema, uveitis, flare and cells
• traumatic mydriasis, Iridodialysis
• lens: evidence of subluxation, cataract, capsule damage
• IOP increase or decrease
• vitreous haemorrhage
• commotio retinae, retinal detachment or dialysis
• traumatic macular hole
Blunt trauma - Management
Appropriate and thorough history and investigations to rule out anterior and posterior complications including pupils, motility, cover test, dilation
Management dependent on severity
• Mild cases:
- alleviation or palliation; referral unnecessary
• Severe cases:
- First aid measures and emergency (same day) referral to A&E
Photo Keratitis:
Key Features
• Exposure to UVB or UVC
• Delayed onset of symptoms
• Pain/photophobia/blepharospasm/lacrimation/blurred vision
• Punctate staining of epithelium
• Associated skin burns from UV exposure
Photo keratitis symptoms
Delay of 6-12 hours between exposure and onset of symptoms is usual; however, latency varies inversely with exposure dose and can be as short as 1 hour
• Mild cases:
- irritation and foreign body sensation
• Severe cases:
- pain
- redness
- photophobia
- blepharospasm
- Lacrimation
- Blurring of vision
Photo keratitis signs
• Bilateral (if unilateral, suspect corneal or subtarsal foreign body)
• Lid chemosis and redness
• Conjunctival hyperaemia
• Epiphora
• Punctate staining of corneal epithelium with fluorescein (may be coalescent)
• Mild transitory visual loss
• Associated skin burns from UV exposure
Blunt trauma symptoms:
• Pain varies from mild to severe
• Epiphora
• Visual loss (variable)
• Photophobia
• Possible diplopia
Blunt trauma signs:
• Mild cases
- usually with good corrected vision, bruising, swelling, corneal abrasion
• Severe
- usually loss of some visual function
- infraorbital anaesthesia indicating floor fracture
- Nasal bleeding
- Corneal oedema
• Other signs:
- AC chamber involvement
- Increased IOP, glaucoma
- vitreous haemorrhaging
- retinal detachment + dialysis
- Traumatic macular hole
- Globe rupture
- RAPD
Photokeratitis management
Non-pharmacological
• Patient counselling - rest with eyes closed as much as possible until resolution, sunglasses, cold compresses, future eye protection
Pharamcological
• Local anaesthetic only to aid examination, tear supplements (preferably unpreserved), un-medicated so ointment, oral analgesic for pain relief
Photokeratitis : severe cases
• If infection risk high may consider prophylactic antibiotic
• If significant corneal epithelial defect may consider cyclople alleviate ciliary spasm
Corneal foreign body - History
• Onset (acute / gradual), Duration, Nature of symptoms.
• (What happened in Pxs own words.)
• Nature of foreign body if known; metallic, mascara, organic.
• Pain; severity, nature (dull or sharp) worsening or improving, worse on blinking, constant, deep, throbbing etc. (use 10 point scale).
• Photophobia.
• Blepharospasm
• Lacrimation.
• Discharge/stickiness: (Nature watery, purulent, colour etc).
Corneal foreign body - Red flags
• High velocity object strong suspicion of penetration of the globe
• Note any signs such as lid laceration or anterior segment damage
• Any signs of penetrating injury then dilate and check for cells/flare
• Siderosis - from intraocular steel foreign body
• Vegetative foreign body more likely to lead to fungal infection
Corneal foreign body - Clinical pearl
• Superficial or penetrating?
• Use Seidel’s Test
• Consider double lid eversion to rule out secondary foreign bodies in the fornix
Removing a foreign body
• Needle tangential to cornea
• Needle sharp edge slid under the edge of foreign body and scrape out and away from central cornea
• Alger burr to remove any residual rust
Superficial Corneal Foreign Body - Non Pharmacological Management
Non pharmacological
• Rule out multiple particles - cornea, conjunctiva (bulbar, fornix, palpebral):
double evert lids
• Loose foreign body can be irrigated away with normal saline
• Foreign body on conjunctiva can be removed with a sterile cotton bud
• Corneal foreign body may require removal with a hypodermic needle or other disposable instrument. To reduce the risk of corneal penetration, ensure that the needle approaches the cornea tangentially
• After removal, assess size of remaining epithelial defect so that healing can be monitored
Superficial Corneal Foreign Body - Pharmacological Management
• Remove foreign body under topical anaesthesia
Consider use of ointment (unmedicated or medicated) following removal (as ocular lubrication)
• If there is a likelihood of infection, consider topical antibiotic prophylaxis (e.g. gutt. chloramphenicol 0.5% qds for 5 days)
• For large epithelial defects, cycloplegia to prevent pupil spasm (e.g. gutt cyclopentolate 1% twice daily until healed)
Corneal abrasion clinical pearls
• Ensure you evert lids to check for retained subtarsal FB
• Pay attention to edges of the lesion
• Ocular lubricants to improve comfort
• Large abrasions or abrasions with associated iritis consider cycloplegia
Corneal abrasion management
For large abrasions
- Ocular lubricants
- Consider bandage contact lens
- Do not patch the eye
- Systemic analgesia for 24 hours
- Cycloplegia 1% bds until healed
- IP optoms may prescribe topical NSAIDS
Features of Marginal keratitis
Key Features
• History of recent upper respiratory tract infection or blepharitis
• Starts as discomfort gradually changes to pain
• Stromal infiltrate with epithelial loss in the periphery but separated from the limbus by clear cornea
• Hyperaemia of adjacent bulbar conjunctiva
