Eye Workshop

Eye WorkshopRegions Hospital Emergency MedicineEye Anatomy

Basic ExaminationVisual AcuityTonometryPupillary ReactionOcular MotilityVisual Field TestingExternal ExaminationOphthalmoscopy

Ocular Emergencies

48 yo F who was doing some cleaning at home and splashed some kind of cleaning solution in her eye. Her eye is now extremely painful with blurred vision.What do you suspect with A? with B?Which is more dangerous?ABChemical BurnsAlkali BurnsAcid BurnsLiquefactive necrosisContinue to penetrate cornea long after exposureEg. Ammonia, lye, limeCoagulative necrosisTypically confined to superficial tissueEg. Exploding car batteries (sulfuric acid), lab chemicals

Treatment?COPIOUS IRRIGATION!!!

36 yo M who was carrying a pencil at work when he fell, landing with his face on the pencil. Comes to the ED complaining of eye pain, lacrimation, and blurred vision. Pupil is irregularly shaped and non-reactive. What if it looked like A? like B?

ABWhat test do you want to do?Seidels test

Corneal LacerationIntense pain, lacrimation, and photophobiaReduced visual acuityBubbles in the anterior chamberTreatment?No unnecessary manipulationEye shieldEmergent ophtho consult

Globe RuptureSimilar presentation to corneal laceration but full-thicknessEye often rotates upwards as it closes as a protective reflexTreatment?Avoid intraocular pressure measurements!!!No unnecessary manipulationEye shield to protect the eyeEmergent ophtho consult

26 yo mechanic who was welding and felt something shoot into his eye. Now complaining of severe eye pain, redness, and tearing.

Ocular Foreign BodyTreatment?Apply proparacaine eye dropsRemoval:Cotton swabs18-gauge needleElectric drill for rust ring removal

86 yo F with sudden onset painful vision loss. She has diffuse corneal edema, marked conjunctival injection, and corneal hazing. Pupil is mid-range and fixed.

Acute Angle-Closure GlaucomaPresentationSudden painful vision lossConjunctival injection, corneal edema, corneal hazingMarkedly elevated intraocular pressures >50 mm HgPathophysiologyAngle between the cornea and iris is reduced due to shallow anterior chamber resulting in relative block of flow of aqueous humor

Treatment?Elevate head of bed >30 degrees to improve drainage5 MedicationsTimolol (Beta blockade)Alphagan (decreases aqueous humor)Acetazolamide (decreases aqueous humor)Pilocarpine (increase aqueous humor drainage)Oral mannitol (dehydrates aqueous humor)Must be given 5 minutes apart

Acute Angle-Closure Glaucoma63 yo F with HTN, DM, and ischemic heart disease presents with sudden, painless vision loss in the left eye.

Retinal Artery OcclusionFundoscopic exam :Retinal swellingCherry red spotTreatment?Relief of vasospasm by increasing PCO2Rebreathing techniquesBreathing 95% O2, 5% CO2

75 yo M with gradual onset painless vision loss over the course of the day.

Central Retinal Vein OcclusionDeterioration more gradualOften secondary to diabetes or hyperviscosity syndromeFundoscopic examBlood and thunderTreatment?Aimed at treating underlying medical condition and relieving ouflow obstruction (eg. laser)1/3 completely resolve, 1/3 stay the same, 1/3 worsen29 yo F presents with darkening vision in her right eye. Symptoms were sudden in onset and preceded by flashers/floaters.

Retinal DetachmentPresentationOften present initially with floaters and flashing lightsProgress to dark area encroaching on the central visionUS highly accurate for detecting retinal detachmentTreatment?Ophtho consult for surgical repair

Normal Ocular USRetinal DetachmentOcular Urgencies

ConjunctivitisSymptoms typically include redness, discharge, and painCould be viral vs bacterialViral more likely to be bilateral with URI symptomsBacterial more likely to be unilateral with dischargeTreatment?Antibiotic eye drops to both eyes

Corneal AbrasionMost common corneal pathology in the EDPresent with pain, redness, and tearingPain relieved with proparicaine eye dropsTreatmentAntibiotic dropsOphtho f/u

Corneal UlcerPresent with severe eye pain, redness, tearing, foreign body sensation, sensitivity to light, blurred visionMore common in contact usersMost likely offending agent: PseudomonasTreatment:Urgent ophtho referralAntibiotic eye dropsDiscontinue use of contacts

Herpes Keratitis (HSV)Present with localized pain and foreign body sensationCaused by herpes simplex virusFluorescein staining reveals classic branching or dendritic patternTreatmentEye dropsOphtho referralDo NOT give steroids unless toldto do so by ophtho

How do you tell this difference between A &BABExtraocular Movements!Periorbital CellulitisOrbital CellulitisInfection of soft tissue superficial to orbital septumSecondary to focal infection, trauma, sinusitis, or bacteriaTreatment?PO antibioticsOften arise from adjacent sinuses or skin/eyelid infectionSymptoms:Pain with EOM, eyelid swelling, redness, discharge, blurred vision, protrusionTreatment?IV antibiotics

Hordeolum or StyeInfection of the glans caused by Staph AureusTreatment?Warm compresses

ChalazionChronic granulomatous infectionNo acute inflammatory signsTreatmentNoneCan refer to optho if bothersum

Now lets slit lamp!!!