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
Marginal keratitis: differential diagnosis
Differential diagnosis
- Consider other causes of peripheral ulceration
CLPU, rosacea keratitis, HSK, peripheral keratitis secondary to meumatoid arthritis
Marginal keratitis: Management
• Pharmacological
• Ocular lubricants (drops - daytime, un-medicated ointment - at night)
• Lid hygiene for associated blepharitis
• Chloramphenicol and concurrent topical steroid
• Oral analgesia
Herpes simplex keratitis
Things to keep in mind
• Multiple presentation types
• 4 distinct types of keratitis
• 50 - 80% of presentations are epithelial keratitis
Management
• Epithelial Keratitis can be managed by optometrists in some circumstances
Zoster Opthalmicus Key features and Presentations
Key features
• Unilateral painful vesicular rash
• Periorbital oedema (often boggy appearance)
• Lymphadenopathy
• Hutchinson’s sign
Presentations
• Mucopurulent conunctivits
• Scleritis
• Keratitis
• Anterior uveitis
Herpes Simplex Keratitis vs Varcella Zoster Keratitis
• HSK
- often central ulceration
- Brightly stains
- Has end bulbs
• VZV (technically pseudodendrites)
- no central staining
- minimal staining
- appears more raised “stuck on” than HSK
- no end bulbs
- often peripheral
Zoster opthalmicus: Keratitis progression
Keratitis types
•punctate epithelial - early sign, within 2 days (50% of cases)
•pseudodendrites - fine, multiple stellate lesions (around 4-6 days)
•nummular - tine granular deposits under bowman’s layer
•discitorm - 3 weeks after the rash (occurs in 5% of cases)
•reduced corneal sensation (neurotrophic keratitis)
•endothelial changes and keratic precipitates
Zoster opthalmicus: presentation and management
Presentations
• Retinitis
• Cranial nerve palsies
• Encephalitis
Management
• Co manage with GP if keratitis is only epithelial
- Urgent referral to GP and
- Review after one week to check for the development of uveitis
• Urgent referral to ophthalmologist if signs of uveitis, scleritis, keratitis, retinitis
Cellulitis: Predisposing factors
Pre-septal cellulitis:
• upper respiratory tract infection
• dacryocystitis
• hordeolum
• impetigo (skin infection)
• trauma, sharp or blunt, around eye
• recent surgery around eye
Orbital cellulitis:
• acute sinusitis (especially ethmoid sinusitis)
• trauma including orbital fracture
• dacrvocystitis
• preseptal cellulitis
• dental abscess
Features of cellulitis: Preseptal Vs Orbital
• Proptosis: Absent vs present
• Ocular motility: normal vs painful, constricted
• Visual acuity: Normal vs reduced in severe cases
• Colour vision: Normal vs reduced in severe cases
• RAPD: Normal vs present in severe cases
Cellulitis: Management
Emergency referral to ophthalmology
• Managed by multidisciplinary team
• Systemic antibiotics for both presetal and orbital cellulitis
• CT investigation
• Blood investigation
• Drainage of orbital abscess in orbital cellulitis
Differentiation between symptoms of IAG and AAC glaucoma
• ACAG - sudden onset symptoms of severe pain of the eye and surround, associated marked HA and nausea, marked redness and rapid onset decrease vision, haloes around lights
• Intermittent Angle closure - onset of symptoms of pain in and around the eye with frontal HA and nausea, redness and haloes without noticing reduced vision (rise in IOP slow and little to no ONH damage occurs during attack) and Sx overall less severe. WORSENED/ONSET IN LOW LIGHT LEVELS due to mydriasis brining iris in closer contact with trabecular meshwork
Differentiation between signs of IAG and AAC glaucoma
• Intermittent:
Increased on normal IOP
Narrow angle
Possible abnormal optic disc cupping
Possible abnormal visual fields
Shallow anterior chamber
ITC on gonioscopy
Hypermetropia
• Acute:
Red eye
Fixed mid-dilated upil
Hazy blue/green cornea
IOP > 40mmHg
Shallow anterior chamber
Differentiation between management of IAG and AAC glaucoma
• ACAG - first aid i.e - ocular massage to try and force some drainage, pilocarpine to miose the pupil and open drainage pathway, systemic analgesia or anti nausea medications.
- EMERGENCY REFERRAL HES - YAG iridotomy likely action to allow drainage through to anterior chamber
• intermittent - if px presents with previous Hx of these attacks but no signs at appt and IOP doesnt meet referral from NICE guidelines
i.e - is less than 25mmHg - REVIEW IN COMMUNITY IN 12/12
- If px presents with Hx of intermittent and has angle with risk of closure i.e - VH grade 2 or below and has risk factor of DM, high hypermetropia, FH of CAG, only one remaining good eye, lives in a rural area without easy access to HES then routine referral HES
