jamie syrett, md - nysvaramarcus gunn pupil • afferent pupillary defect • light into affected...
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Pulsecheck - EyesJamie Syrett, MD
Opthalmology for EMSJamie Syrett
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Blepharitis
Chronic Scaly Staph Infection of the Eyelid Margins
Seen chronically in old people
Associated with seborrheic dermatitis
Treatment is topical antibiotic and shampoo
Can lead to cellulitis
Dacryocystitis
• Infection of the lacrimal sac
• Anterior and medial swelling below the inner canthus
• Topical or Systemic Abx
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DacryoadenitisInfection of the Lacrimal Gland
Warm Soaks and Abx, sometime needs I and D
Some systemic diseases also cause this
ChalazionSterile/Granuloma reaction of Meibomium Gland (oil that prevents evaporation of tear film)
Non-tender, non-inflammed
Usually mid-portion of upper lid
Warm Soaks/I and D
Hordeolum/Stye
Abscess of the lid margin
Pain, Redness, Swelling
Warm Compresses and Topical Antibiotics
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Cellulitis
• Based on anatomy - Septum makes a closed space
• Peri-orbital (Pre-septal) Cellulitis - Minimal Pain, fever, erythema, lid edema
• Orbital (Post-septal) Cellulitis - Serious. Painful to move eye, proptosis
Orbital Cellulitis
• Meningitis - The most common complication
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Eye Movements Eye Movements
Eye Movements• Cranial Nerve 3
• Upper division - Superior Rectus/Lev Palp Sup
• Lower division - Inferior, medial rectus, inferior oblique
• Cranial Nerve 4 - Superior Oblique
• Cranial Nerve 6 - Lateral Rectus
Eye Movements
• If CN3 is affected - the eye goes “down and out”
• If CN6 is affected - they can’t look laterally
• CN6 - Has a long path and when affected think raised ICP - it is the first nerve to be compressed
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Eye Lid Movements
• CN7 innervates the eyelid to close the eyelid
• CN3 and sympathetic chain both innervate the eyelid to open the eye
• CN3 - Lev Palp Sup
• Sympathetic Chain - Mueller Muscle
Pupil Control
• Parasympathetics run in CN3 - Constrict
• Sympathetic Chain also innervates - Dilate
Pupillary Light Reflex
• What nerves does it check?
Pupillary Light Reflex
• Afferent leg (a before e) - CN2
• Efferent leg (constricts) - parasymp = CN3
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Marcus Gunn Pupil• Afferent Pupillary Defect
• Light into affected eye - no constriction and no consensual constriction
• Light into normal eye - constriction of both eyes
• May be primary presentation of MS
• Swinging torch test
• May also get unresponsive pupil in iritis/trauma
CN3 Palsy• Eye is “Down and Out”
• Ptosis
• No parasympathetics - Pupil dilates
• Interesting - parasympathetics on outside, muscles on inside of nerve
• Compression - more dilation
• Strokes/MS - more paralysis
Sympathetic Chain
• Function - Lifts eyelid, dilates eye, stimulates face sweat glands.
• Chain leaves the chest at the lung apex
• Dysfuction - Horner’s Syndrome
• Ptosis, constricted pupil, dry face
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Bell’s Palsy
• Lower VII palsy
• Facial droop
• Needs artificial tears and eye taping
• What about the forehead?
Yesterday’s ER Case• Patient presented to the ER with weakness,
smoker, normal focal neuro exam
• On exam the patient was noted to have a Horners on left and also have dilated veins over the left shoulder and arm
• She then had a seizure
• What is the appropriate treatment (benzos didn’t work)
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Blown Pupil
• Head injury
• Blown pupil on right (unopposed sympathetics)
• Uncus herniates, pressing on the CN3 (can also be pressed on by aneurysm)
• Which side gets the dremmel?
Vision Loss• Monocular vision loss
• Problem with globe, retina, optic nerve, temporal arteritis
• Bitemporal hemianopsia
• Problem at optic chiasm
• Homonymous hemianopsia
• Problem in the optic tract
• Most common field deficit in CVA
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Central Retinal Artery Occlusion
• Sudden, painless visual loss (usually embolic)
• Afferent Pupillary Defect
• Pale retina, fixed dilated pupil
EMS treatment
• Several treatments aimed at moving the emboli to a more peripheral position
EMS treatment
• Massage eye
• Bed at 45 degrees
• Hyperventilate in a bag………why?
• 90 minutes to restore vision
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Hyperventilation
• Hyperventilation for elevated ICP works because…………
• Rebreathing hyperventilation works for Central Retinal Artery because………….
This morning
• 42 yo F presented to the ER with a “migraine” all night and then sudden loss of vision
• Marcus Gunn Pupil
• Pale retina
Differential Dx• Migraine - not typically vision loss
• Optic neuritis - not typically sudden
• Central retinal artery occlusion - not typically this age group
• Temporal Arteritis - no artery pain
• Retinal detachment - normally not blindness
• Psychiatric - hard to fake a lack of pupil response
Progression
• Placement, rubbed eye
• Suddenly had vision restore
• Admitted for embolic workup
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Optic Neuritis
• Inflammation of the optic nerve
• Decreased vision over hours
• Painful to move eye
• Marcus Gunn Pupil
• “Loss of color vision”
Optic Neuritis
• Ask about other neurological symptoms since this is highly suggestive of MS
Retinal Detachment
• Tear in the retina that allows vitreous to separate retina from choroid
• Risk factors - DM, SCD, near sighted, age
• Symptoms - flashes of light in the periphery, decreased peripheral vision, new floaters, lowering a curtain
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Retinal Detachment
• Why do I care?
• Place the location of the flashes inferiorly - allows the retina to lay back down
• Flashing lights and new floaters = retinal detachment
Temporal Arteritis• Age >50
• New onset headache
• Temporal artery tenderness
• Decreased pulsation in TA
• Elevated sed rate
• Impaired vision in 50% (posterior ciliary artery involved)
• Progresses to bilateral
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EMS things
• Look away from a seizure but towards a stroke
• In the left MCA stroke you get speech problems in the right MCA stroke you see profound neglect
• Total paralysis - ACA and MCA
• MCA only - foot sparing
Conjunctivitis
• Viral or Bacterial
• Viral - nodes in front of ear (preauricular)
• Consider shingles
• Conjuctivitis in child <28d old - treat as sepsis
Corneal Lacerations
• Clinically you see a tear shaped pupil
• Constant tearing from eye
• Flat anterior chamber
• Avoid eye movements - may push out vitreous
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Blow out fractures
• Medial wall of the orbit is very thin - orbital emphysema
• Herniation of orbital contents thru floor - limits upward gaze - diplopia looking up
• Decreased sensation of the cheek and upper lip - infraorbital nerve involved
“We are going to turn this
team around 360 degrees”
Jason Kidd