em rounds colleen carey, ba, md, ccfp (em) july 31, 2008 thanks to dr. jean chuo, ubc ophthalmology...
TRANSCRIPT
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EM RoundsColleen Carey, BA, MD, CCFP (EM)
July 31, 2008Thanks to Dr. Jean Chuo, UBC
Ophthalmology Resident
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Hx Exam Most common etiologies
Traumatic versus atraumatic Diagnosis Treatment When to get help
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Trauma Consider unrecognized trauma- awoke with
symptoms Pain? Itch? FB sensation? Visual acuity changes, halos Contact lenses- ? Overwear Sick contacts/Viral symptoms Prior surgery or eye disorders Systemic disease
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Visual acuity Visual fields Pupil shape and reactivity Lid closure Foreign bodies Ciliary flare Foggy cornea (edema) Corneal infiltrate Fluorescein- corneal defects, Sidel’s sign Anterior chamber cells Intraocular pressure
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Projectile metallic FB Get orbital Xray
Rust ring Visual axis involved?- refer if unable to
completely remove Burr
Tetanus status Antibiotic prophylaxis?
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Get help if not healing corneal ulcer large surface area infringing on visual axis
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Usually due to blunt trauma and immediate Gross: layers out Microscopic: cells in anterior chamber Always refer Tx: cycloplegics, steroids, serial IOP monitoring,
sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertion
Complications: Iritis Synechiae, glaucoma Rebleeding
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Penetrating FB Blunt trauma by an object smaller than a
fist Blunt trauma with an orbital fracture Prior open globe surgery All must be repaired to prevent
sympathetic ophthalmia Need a hard shield. Emergency referral, poor prognosis
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Red, painful, decreased vision Anterior chamber cells+/- hypopion Almost exclusively post-surgical
complication Rare: 1:100,000 cataract surgeries Urgent referral
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Very common problem Mild itch, dry, gritty sandpaper sensation Many causes:
Contact lens overwear Dry Calgary air Preservatives, antibiotic eye drops Incomplete lid closure
Rule out other problems Discontinue cause, moisturize, follow up in
ER
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Allergic Viral Bacterial Irritative Treat bacterial conjunctivitis with
flouroquinolone or erythromycin drops. Treat allergic with antihistamines, nasal
steroid spray, allergen avoidance, cromolyn drops
Refer any keratitis
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Short fat branches with bulbs
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HSV keratitis Dendritic fluoroscein enhancing lesion Hypoesthetic cornea +/- periocular HSV vesicles• Tx is acyclovir +/- viroptic drops • HSV can affect any part of the eye• Next day referral as long as Tx started
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Long thin tapered branches
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HHV 3 (VZV) V1 (opthalmic branch of CN V)
Macular rash =>vesicular lesions Conjunctivitis Keratitis Uveitis/iritis +/- retinal necrosis Cranial nerve palsies 3,4,6 Cxns: Chronic ocular inflammation, vision
loss, neuralgia, late corneal sequelae
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Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, age
Hx: Sudden eye pain, photophobia, halos PE: Shallow anterior chamber, iris bombe,
middilated pupil, hazy cornea, elevated IOP
Tx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitol
Ensure pressure drops within an hour
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Complete occlusion of the anterior chamber angle by iris tissue
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Causes: Infections, eye disorders, systemic
disorders Trauma, autoimmune disorders, VZV,
lyme disease, leukemia/lymphoma, idiopathic
Photophobia and dull ache Urgent referral to ophtho Get baseline IOP and start Predforte
drops and cycloplegics
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Intense injection at limbus
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Causes Valsalva Coagulopathy
Presentation Visual acuity Absence of pain Absence of photophobia Absence of discharge
Should resorb in 1-2 weeks
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And that is the problem. Alkali chemical burn- large corneal
epithelial defect and scleral ischemia.
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Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosis
You have only minutes to diagnose and irrigate
Morgan lens, many litres Afterward:confirm pH, slit lamp exam for
corneal defect, r/o deposits in conjunctival recesses.
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Insidious onset Consider retro-orbital causes: mass,
aneurysm.
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Chronic recurrent eyelid inflammation Staph aureus or seborrhea
(pityrosporum) Warm lid compresses Topical antibiotic eyedrops+/- ointment Dandruff shampoos to scalp to eradicate
pityrosporum Slow response
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Hordeolum- acute, painful Chalzion- chronic, non painful Hot compresses, milking Refer if not resolving for I+C Chronic lesions- ? Biopsy to r/o CA
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Note irregular corneal light reflex