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The Eye

The Eye. Ocular Pursuit “Eye wanna win” but “There is no eye in team”. History. 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

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The Eye

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  1. The Eye

  2. Ocular Pursuit“Eye wanna win”but“There is no eye in team”

  3. History • 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

  4. Eye exam(the basics. From a non-ophthalmologistwho isn’t particularlygood at examining eyes.)if you can read this last line I’ll eat my shoe right here and now.

  5. Eye exam • 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

  6. Visual Acuity • Snellen Chart • Use corrective lenses (or pinhole) • Examine each eye separately • If can’t read largest letter, go to finger counting • If can’t count fingers, check motion perception • If no motion perception, go to light perception

  7. Abbreviations which will impress your chart reader • OS – Left eye • OD – Right eye • OU – Both eyes • VA – Visual acuity

  8. Ocular Pursuit Question #2 • What does the latin abbreviation OS stand for?

  9. More Abbreviations • L/L/L – Lids, lashes, lacrimal • C/S – Conjunctiva and Sclera • K – Cornea • AC – Anterior Chamber • I – Iris • L – Lense • AV – Anterior Vitreous • CF – Count Fingers • HM – Hand motion • LP – Light perception

  10. Extraocular Muscle Superior Oblique Superior Rectus Lateral Rectus Medial Rectus Inferior rectus Inferior oblique Cranial Nerve VI III IV Match the nerve with the extraocular muscle!

  11. Pupillary Reactions • Patient looks in the distance • Hold light in front of eye #1 for 3-5 seconds, then swing to the other eye • Should get initial constriction, then dilation

  12. Anterior – posterior • Lids, lashes • Conjunctiva, sclera, cornea • Evert eyelids • Anterior chamber • Retina

  13. Intraocular Pressure Measurement • Tonopen – need to calibrate first • Normal measurements 10 – 21 mmHg

  14. Approach to Ophthalmic Emergencies • Diagnostic Category – trauma, vascular, infectious, inflammatory, chemical exposure • Location - extraocular and periorbital, conjunctiva, sclera, cornea, anterior chamber, lens, posterior chamber, retina, vascular • Symptom

  15. Symptom approach • 1. Vision loss • Painless • Painful • 2. Eye pain • 3. Red eye and discharge • 4. Double vision

  16. Painless Vision Loss • Retinal Detachment • Central Retinal Artery Occlusion • Central Retinal Vein Occlusion • Vitreous hemorrhage • Occipital lobe TIA/CVA • Toxins (Methanol)

  17. Central Retinal Artery Occlusion • Anatomy • Internal Carotid Artery – • Ophthalmic Artery • Central Retinal Artery

  18. CRAO

  19. History • Sudden, painless, monocular blindness • Most of the visual field - worse in the central visual field

  20. Causes • Emboli – most common • Vasculitidies (temporal arteritis) • Trauma

  21. EMERGENCY!!!

  22. Yes. True. But… • Loss of vision may be irreversible within 90 minutes. Needs emergent ophthalmology referral. • Unfortunately… not much evidence for any therapeutic interventions. Studies tend to be small, not one center, without significant change in long term vision.

  23. Therapies (you can try) • Hemodilution – bolus 1-2 liters of normal saline • Ocular massage – closed lids – 10 -15 seconds – sudden release of pressure • Rebreathing CO2 – paper bag strategy • Intra-arterial thrombolysis • Anterior Chamber paracentesis – tetracaine – 30 guage needle – aspirate 0.1 ml.

  24. Bottom line… • Call the opthalmologist immediately if you suspect this diagnosis. • Post CRAO immediate window – treat like TIA – need to look at risk factors (HTN, dyslipidemia, diabetes, smoking), carotid doppler U/S, look for Atrial fibrillation.

  25. Central Retinal Vein Occlusion • Again, sudden, painless, monocular vision loss • More common than CRAO (CRVO prevalence ~ 1%, compared to ~ 1/10000 for CRAO) • Ischemic and non-ischemic variants

  26. Central Retinal Vein Occlusion

  27. Branch Retinal Vein Occlusion

  28. More treatments that may (or may not) be helpful • Aspirin • Intravitreal t-PA • Surgical options • Treat underlying disease

  29. Which of the following ocular problems is most commonly associatedwith a patient report of “curtain-like” vision loss? • A. Vitreous hemorrhage • B. Retinal detachment • C. Optic neuritis • D. Central retinal artery occlusion

  30. Retinal Detachment

  31. Retinal Detachment • Acute or subacute monocular vision loss • Floaters • Peripheral vision loss • Patients might describe “curtain like” visual loss

  32. Retinal Detachment • Occurs in 1/300 over the course of a lifetime • Risk factors: • Age • Previous cataract surgery • Focal retinal atrophy • Myopia • Trauma • Diabetic retinopathy, • Family history of retinal detachment • Uveitis • Prematurity

  33. If you suspect it… • Immediate ophthalmology consultation • Surgical options • Laser treatment of tears –

  34. Vitreous Hemorrhage • History – painless, monocular vision loss • Patients may describe “haze”, “smoke”, “streaks”

  35. Vitreous Hemorrhage • Causes: • Diabetic retinopathy • Posterior vitreous detachment • Trauma (shaken baby)

  36. Vitreous Hemorrhage • Consult ophthalmology: • Will look for any retinal tears which could be mended • Coag studies • Avoid exertional activities which could increase IOP

  37. Doctor… • My eye hurts! • And I can’t see out of it!

  38. Optic Neuritis

  39. Physical exam • Pain with eye movements • Afferent pupillary defect • May see optic disc swelling on fundoscopy

  40. Optic Neuritis • Inflammatory demyelination of the optic nerve • Most common in 20-40 year old women • Association with multiple sclerosis

  41. Imaging • MRI: • Optic nerve inflammation • Periventricular white matter lesions somewhat predictive of MS

  42. Treatment • Generally improves spontaneously over days – weeks • ?Steroids – may decrease progression to MS – talk to Neurology

  43. Which of the following is one of the diagnostic criteria for temporalarteritis? • A. Bounding temporal artery pulse • B. Erythrocyte sedimentation rate of > 20 • C. New headache • D. Age > 70

  44. Temporal Arteritis • Medium/large vessel vasculitis • Carotid artery branches • Disease of the elderly

  45. Physical Exam • Palpate – firm, tender temporal artery • Joint pain with movement • Visual acuity

  46. Diagnosis • Age > 50 • New Headache • Abnormalities of the temporal artery (tender, pulseless) • ESR > 50 • Positive biopsy • 3/5 positive findings give sensitivity of 93% and specificity of 91%

  47. Treatment • Consult Ophtho and/or Rheumatology • High dose steroids

  48. Amaurosis Fugax • Transient monocular vision loss (minutes) • TIA of the eye • Neurology consult

  49. Name the phenomenon demonstrated in this picture

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