management of eye injuries: managing the red or injured eye€¦ · management of eye injuries: ......

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Management of Eye Injuries: Managing the Red or Injured Eye

Robert Baldor, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Robert Baldor, MD, FAAFPProfessor and Vice Chair, Department of Family Medicine and Community Health/Director, Community-Based Education, Office of Undergraduate Medical Education/Director of Health Policy Education, Meyers Primary Care Institute/Medical Director, Center for Developmental Disabilities Evaluation and Research at the Eunice Kennedy Shriver Center, University of Massachusetts (UMass) Medical School, Worcester

Dr. Baldor has been teaching for 30 years and practices family medicine at the UMass Memorial Medical Center, Worcester. A member of the Massachusetts Governor’s Commission on Intellectual Disability, he has been recognized in The Best Doctors in America: Northeast Region and is a past-president of the Massachusetts Academy of Family Physicians. He publishes and presents regularly on a variety of family medicine topics and is an associate editor for The 5-Minute Clinical Consult. Dr. Baldor practices family medicine with a special interest in developmental and intellectual disabilities. Throughout the years, he has spoken on a variety of primary care topics at the AAFP's annual meeting.

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Learning Objectives1. Perform timely physical examinations to determine the nature

of an eye emergency and refer patients to an ophthalmologist as necessary.

2. Evaluate eye emergencies, particularly central retinal artery occlusion and intraocular foreign bodies, to determine when further testing or surgery might be necessary.

3. Coordinate with sub-specialists, to receive necessary care to prevent vision damage, for patients identified with symptoms of iritis.

Audience Engagement SystemStep 1 Step 2 Step 3

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An Approach..

Performing a timely physical exam to determine the involved anatomical element will assist with your diagnosis and treatment methods.

The Eye….

• Lids/lashes

• Lacrimal system

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The Anterior Segment….

• Conjunctiva– Sclera

• Cornea– Iris

– Lens

J marchn/Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=34828874

Conjunctiva• Sclera

CorneaAnterior Chamber

• Iris• Pupil• Lens

Posterior Segment• Vitreous• Optic Nerve• Macula

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The Posterior Segment….

Vitreous

• Retina

• Optic Nerve

• Macula

Red Flags…

HISTORY• Trauma

• Recent ocular surgery

• Contact lens use

SYMPTOMS• Severe pain

• Severe photophobia

• Nausea/vomiting

https://commons.wikimedia.org/wiki/File:Red_flag_II.svg

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Acuity…

• The most worrisome history is a report of a recent decline in visual acuity!!

Always check visual acuity on exam…

A TC A N D Y

Modified: commons.wikimedia.org/wiki/File:1606_Snellen_Chart-02.jpg

The Ophthalmologic exam…

• Conjunctiva– Blood vessels injected? (focal or diffuse)

• Global tenderness to palpation? – Sclera involved?

• Cornea involved?– Fluorescein staining

• Size, shape and reactivity of the pupils– Iris details

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Red Flags…

ORBITAL SIGNS…

• Severe tenderness of globe or eyelids

• Significant periorbital erythema

• Decreased ocular motility

• Proptosis


Periorbital cellulitis

SYMPTOMS/SIGNS • Periocular pain

• Periorbital swelling

• Normal vision

TREATMENT

Broad Spectrum PO Antibiotic

• Gram positive coverage

Cephalexin or cloxacillin

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Orbital cellulitis

SYMPTOMS/SIGNS • Periocular pain

• Decreased eye movement

• Periorbital swelling

• Proptosis

TREATMENT

IV antibiotics

• 2nd

Generation cephalosporin Cefuroxime

• Referral

https://aneskey.com/preseptal-and-orbital-cellulitis/

Dacryocystitis

SYMPTOMS/SIGNS

• Periocular pain

• Infero-nasal swelling

• Purulent material refluxed from punctum w/pressure on distended lacrimal sac

• Normal vision

TREATMENT

• Broad Spectrum Antibiotic

• Referral

Dr. Dorothy L. Hitchmoth, PLLC

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Blepharitis

SYMPTOMS/SIGNS

• Morning stickiness

• Burning/itchy

• Lid margin debris/erythema

• Normal vision

TREATMENT

• Baby shampoo to clean lids

• Topical antibiotic qhs to eyelid margins


Dry Eyes

SYMPTOMS/SIGNS

• Itchy/burning

• Worse as day goes on

• Decreased tear film

• Vision usually normal

TREATMENT

• Artificial tears

https://creativecommons.org

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` Red Flags: The Ophthalmologic exam…

• Abnormal pupil shape, reactivity

• Circum-corneal injection (“ciliary flush”)

• Corneal signs– Fluorescein staining?

– White spots?

– Poor view of anterior chamber/iris?


AES Question #1

Chemosis is most often seen with which one of the following conditions?

1. Allergic conjunctivitis

2. Bacterial conjunctivitis

3. Chemical conjunctivitis

4. Viral conjunctivitis

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Conjunctivitis (Allergic)

SYMPTOMS/SIGNS

• Itching

• Injected conjunctiva/ chemosis

• Lid erythema/inflammation


TREATMENT• Topical antihistamines

– Ketotifen

• Topical mast cell stabilizers – Cromolyn


Conjunctivitis (Bacterial)

SYMPTOMS/SIGNS

• Constant red eye with purulent discharge

• Injected conjunctiva with discharge


TREATMENT

• Topical antibiotics– Bacitracin/neomycin/polymyxin

– Erythromycin

– Sulfacetamide


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Infectious Keratitis (bacterial)

SYMPTOMS/SIGNS

• Severe pain

• White pus on cornea

• Blurry vision

• Decreased vision

TREATMENT

• Topical antibiotics– Cefazolin and tobramycin

• Referral

Conjunctivitis (Viral)

SYMPTOMS/SIGNS • Constant red irritated eye

• Watery discharge

• Small follicles on lower bulbar conjunctiva


TREATMENT

• Reassurance

https://commons.wikimedia.org/wiki/File:Hemorragicconjunctivitis2.jpg

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Pinguecula & Pterygia

SYMPTOMS/SIGNS

• Elevated conjunctival thickening of inter-palpebral region

TREATMENT• Artificial tears

• Topical NSAIDs– Ketorolac,

diclofenac

https://commons.wikimedia.org/wiki/File:Pterygium.png

Episcleritis

SYMPTOMS/SIGNS

• Mild Eye achiness

• Focal/diffuse injection of sclera deep to the conjunctiva

• Vision normal

TREATMENT

Topical NSAIDs

• Ketorolac, diclofenac

https://commons.wikimedia.org/wiki/File:Scleritis.png

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Scleritis

SYMPTOMS/SIGNS

• Severe eye pain with radiating headache

• Diffuse bluish/purple hue to sclera

• Tender to palpation

• Vision maybe decreased

TREATMENT

• Systemic steroids

• Refer

Iritis (Uveitis)

SYMPTOMS/SIGNS

• Pain/Blurry vision

• Photophobia

• Small pupil/Perilimbal erythema

• WBCs in anterior chamber


TREATMENT• Refer

• Topical steroid hourly

• Topical dilator BID– Phenylephdrine

https://upload.wikimedia.org/wikipedia/commons/e/ec/Iritis

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Acute angle-closure glaucoma

• Risk factors: hyperopia, myopia, narrow angle, shallow anterior chamber

• An attack can occur as a result of dim lighting• Medication side effect:

– Dilating drops– Anticholinergics (e.g. antidepressants)– Sulfa & topiramate can cause ciliary body

swelling w/ secondary angle closure

https://upload.wikimedia.org/wikipedia/commons/1/13/Acute_Angle_Closure-glaucoma.jpg


SYMPTOMS/SIGNS

Blurred vision, frontal headache, colored halos around lights, pain, discomfort, nausea/vomiting

• Increased intraocular pressure (> 30 mmHg) o Globe firm to palpation

• Sluggish pupillary light reaction

• Shallow anterior chamber

• Corneal haziness, injected conjunctiva.

https://www.flickr.com/photos/communityeyehealth/5686392027

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APPROACH/TREATMENT

Lower the increased intra-ocular pressure• 1gtt 0.5% timolol, 1% apraclonidine & 2% pilocarpine

– 1 minute apart, along with 500-mg acetazolamide PO

– IOP should be measured & treated hourly

• Definitive treatment is laser iridotomy

Corneal abrasion

SYMPTOMS/SIGNS

Pain, tearing, photosensitivity

• Blepharospasm, foreign body sensation, or blurry vision.

• Minimal trauma (eye rubbing, contacts)– High-velocity injury - penetrating eye injury?

• Fluorescein staining

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Fluorescein staining

• A drop of topical anesthetic o Proparacaine 0.5%

• Touch strip onto conjunctiva

• Abrasion may stain yellow; cobalt blue light shows a green defect

• Multiple vertical lines suggest a foreign body under upper eyelido Evert eyelid to look for foreign body

https://commons.wikimedia.org/wiki/File:Human_cornea_with_abrasion_highlighted_by_fluorescein_staining.jpg

Dendritic Staining: Infectious Keratitis (HSV)

• Topical antiviral

– Trifluridine

• Topical steroid

• Referral


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AES Question #2

Corneal abrasions are best treated with which one of the following methods?

1. PO analgesics, antibiotic drops, patching x 24hrs

2. PO analgesics, antibiotic drops, patching until symptom-free

3. PO analgesics, antibiotic drops, no patching

4. PO analgesics only

Corneal Abrasion: Treatment goals….

Relieve pain, prevent infection, speed healing

• Oral analgesics

• Topical agents– Antibiotics (Erythromycin, Sulfacetamide)

– NSAIDs (Ketorolac, diclofenac)

– Cycloplegics (Cyclopentolate, Homatropine)

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Corneal foreign body

APPROACH/TREATMENT

Remove with saline irrigation or sweep with a cotton swab • If necessary use a 25-gauge needle • Foreign bodies may leave a rust ring

– Remove within a few days

Mechanical Globe Injury

Workplace, recreational events• Full-thickness rupture or laceration through

cornea/sclera • Blunt injury

o Thrown ball, MVA, physical attack• Laceration

o Knife, high-velocity projectile

pixabay.com/en/earth-globe-explosion-collapse-1773943/

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AES Question #3

The best test for mechanical globe disruption is which one of the following?

1. Retinal exam for ‘box-caring’

2. Litmus paper test

3. Seidel test

4. Tonometry

Mechanical Globe Injury

SYMPTOMS/SIGNS

• Eye pain, redness, tearing


• Irregular pupil or iris prolapse

• Dilution of fluorescein dye by aqueous flow o Positive Seidel test

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Mechanical Globe InjuryAPPROACH/TREATMENT

• Orbital CT for foreign bodies or fractures

• Superficial laceration (<1cm) w/no other findings o Topical antibiotics

• Avoid eye pressure, limit coughing or straining, antiemetics

• Prophylactic systemic fluoroquinolones

• Visible protruding foreign body should not be removedo Surgery w/in 24 hours

Chemical Injuries…

Acid or alkali exposure (liquid, powder, gas)• Alkali burns more common/more severe than acid

• Severity depends on pH and the duration of contact

• Place litmus paper in conjunctival fornix for pH

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Chemical Injuries…APPROACH/TREATMENT

• Topical anesthetics & 2 L lactated Ringer’s, NS or water irrigation

• Wipe upper & lower fornices w/swab to remove chemical crystals

• Check pH q5 minutes; irrigate until neutralized (pH 7.0 - 7.5).

• Immediate Referralo Topical ABX, artificial tears, steroids…

Central Retinal Artery Occlusion

Risk factors: Age > 70, atherosclerosis, diabetes, glaucoma, HTN, hyperlipidemia, migraine• Associated with giant cell arteritis (5-10%)

• Systemic disease: collagen vascular diseases, hypercoagulopathies, cardiac valvular disease, syphilis, sickle cell

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SYMPTOMS/SIGNS

• Painless, sudden unilateral vision loss– May report amaurosis fugax

• Pupil may be dilated with sluggish reaction to light

• ‘Box-carring’ of blood within retinal vesselso Embolus may be seen

• Retinal pallor/cherry-red spot at fovea, retinal artery attenuation



APPROACH/TREATMENT - Immediate Referral!

• Attempt to restore blood flow by lowering IOPo IV mannitol 0.25 to 2.0 g per kg once

o PO/IV acetazolamide(Diamox) 500 mg once

o Oral nitrates

o Lay patient flat on their back

• Ocular-digital massage to move embolus?

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Retinal Detachment

Annual incidence 12 in 100,000

Risk factors:– Age

– Ocular trauma

– Cataract surgery

– + FH

– Myopia (near sighted)


Retinal Detachment

SYMPTOMS/SIGNS

• Unilateral flashing lights

• Increase in floaters

• Vision may be unaffected or slightly cloudy

• Peripheral vision defect expands over a few days

TREATMENT

• Immediate referral

• Laser photocoagulation

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Practice Recommendations…

• Perform a thorough ophthalmologic exam & always include a test of visual acuity

• Keep an eye emergency reference handy

• Partner with a local eye care specialist with clear information on how to reach urgently

Topical Treatments…Antibiotics

• Erythromycin 0.5% ointment QID X 3days

• Polymyxin B/trimethoprim (Polytrim) solution, 1 drop, QID X 3days

• Sulfacetamide 10% (Bleph-10) solution 1 to 2 drops, QID X 3days

Antipseudomonal antibiotics• Ciprofloxacin 0.3% (Ciloxan) ointment; QID X 3days• Ciprofloxacin 0.3% (Ciloxan) solution; 1 to 2 drops, QID X 3days• Gentamicin 0.3% ointment TID X 3days• Gentamicin 0.3% solution; QID X 3days• Ofloxacin 0.3% (Ocuflox) solution; 1 to 2 drops, QID X 3days

Topical cycloplegics

• Cyclopentolate 1% (Cyclogyl) 1 drop, may repeat in five minutes if needed

• Homatropine 5% 1 drop, may repeat in five minutes if needed

Topical NSAIDs

• Diclofenac 0.1% (Voltaren) 1 drop, QID X 3days

• Ketorolac 0.4% (Acular LS) 1 drop, QID X 3days

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Questions

Contact Information

[email protected]

management of eye injuries: managing the red or injured eye€¦ · management of eye injuries: ......

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