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Opthalmologic Emergencies

Opthalmologic Emergencies. Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02. Objectives:. Briefly review ocular anatomy and exam Recognize pathology (yeah – pictures!) Discuss treatment options Discuss areas of controversy Slit lamp review. Ocular Anatomy:. Eye Exam:. Visual acuity

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Opthalmologic Emergencies

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  1. Opthalmologic Emergencies Dave Dyck R3 Preceptor: Dr. Bryan Young Sept. 26/02

  2. Objectives: • Briefly review ocular anatomy and exam • Recognize pathology (yeah – pictures!) • Discuss treatment options • Discuss areas of controversy • Slit lamp review

  3. Ocular Anatomy:

  4. Eye Exam: • Visual acuity • Pupils • Motility • Confrontation visual fields • Anterior segment • Posterior segment • Intraocular pressure

  5. Visual Acuity: • Perform at 20 feet (6 meters) • Range from 20/15 to 20/400 then counting fingers, hand movements, light perception, and no light perception • Near vision uses a reading card at 14 inches • OD= right eye; OS= left eye; OU= both eyes • If vision< 20/20 use pinhole to check for correctable refractive errors

  6. Pupils: • Size and reaction to light • Swinging flashlight test • Afferent pupillary defect • Differential= retinal detachment, central retinal artery or vein occlusion, optic neuritis, optic neuropathy • Cataract, hyphema, vitreous hemmorhage, corneal ulcer, and iritis are associated with decreased vision but not an afferent pupillary defect

  7. Pupils cont. • Dilated • Third nerve palsy • Trauma • Adie’s pupil • Drug induced (dilating drops) • Acute glaucoma

  8. Pupils cont. • Constricted • Drug induced • Iritis • Horner’s syndrome * Anisocoria >4mm seen in 19% of normals

  9. Motility:

  10. Confrontation Visual Fields: To help localize lesions to the retina, optic nerve, optic chiasm, or visual cortex

  11. Anterior Segment: • Lids, puncta, conjunctiva, sclera, cornea, anterior chamber, and lens • Fluorescein • Remove contact lenses

  12. Posterior Segment: • Vitreous, disc, vessels, macula, and peripheral retina • Through dilated pupil UNLESS  shallow anterior chamber (or hx of angle closure glaucoma), iris supported intraocular lens (rare), head injury, ruptured globe

  13. Optic Disc: • Normally slightly oval in the vertical meridian, central depression (cup), various pigmentation • Cup-to-disc ratio <0.5 • Distinct disc margins

  14. Intraocular Pressure: • Normal < 23 mmHg. • Acute angle glaucoma often > 40 mmHg. • Tonopen- easy • Schiotz tonometry (Roberts) • Applanation tonometry • Air-puff tonometry

  15. Case 1: 66y lady watching TV tonight in a dark room. Took 50mg Benadryl for itch  increased eye pain with dec. vision

  16. Glaucoma: • Imbalance of aqueous humor production and drainage leading to increased intraocular pressure  optic neuropathy

  17. Types: • Primary angle closure glaucoma • Secondary angle closure glaucoma • Primary open angle glaucoma • Secondary open angle glaucoma

  18. Acute Angle Closure Glaucoma: • Symptoms: Redness, severe pain, headache, photophobia, decreased vision, halos, +/- N/V • Signs: Increased IOP, acute anterior angle, corneal edema, conjunctival injection, non-reactive or sluggish mid-dilated pupil • More common if history of far-sightedness (Hyperopia), Asian/Eskimo descent

  19. Treatment: • Pilocarpine 2% - 1 drop q15 min until pupillary constriction. (+ 1 drop q6h in unaffected eye for prophylaxix) • Timolol 0.5% - 1 drop (works within 30-60min) • Apraclonidine HCl 1% - 1 drop • Diamox – 250-500mg po q6h or 500mg IV • If not < 35mmHg in 30-60 minutes give Mannitol 20% - 2-7ml/Kg IV or isosorbide 1-1.5g/Kg po

  20. Treatment cont. • Opthamology : for peripheral iridectomy or laser iridotomy • When to refer urgently for surgery? • When to expect a pressure drop with medications? • What is a satisfactory pressure drop?

  21. Primary Open-Angle Glaucoma: • Most common cause of blindness in NA • Due to increased aqueous humor outflow through the trabecular meshwork • Insidious, slowly progressive, bilateral, painless vision loss (peripheral) ie. NOT AN EMERGENCY • Increased cup-to-disc ratio

  22. Fundoscopic lesions:

  23. Case 2: • 58 y male presents with acute vision loss in L eye x 90 minutes.

  24. Central Retinal Artery Occlusion: • Painless, ages 50-70, vasculopathic hx • R/O glaucoma • Signs= Decreased visual acuity, afferent pupillary defect, pale fundus with cherry-red fovea • Experimentally, 100min until irreversible ischemia

  25. Treatment: • Digital global massage (5sec on –5sec off) • Increase PCO2 by breathing into paper bag for 10min every hour vs Carbogen • IV acetozolamide + ASA • R/O and Treat glaucoma • Emergent Opthamology referral and outpatient Cardiology • R/O neuritis 2% (ESR, hx, etc)

  26. Case 3: 60 y male with painless blurry vision r eye

  27. Branch Retinal Artery Occlusion: • Same treatment as for CRAO

  28. Case 4: • 60 y female with vision loss L eye

  29. Central/Branch Retinal Vein Occlusion: • Symptoms: variable vision loss, usually painless • Signs: ischemic (neovascular glaucoma) or non-ischemic (macular edema with leaking capillaries) Dilated tortuous veins, retinal hemmorhages and disc edema

  30. Treatment: • Expectant • Referral to Opthomology within 24 hrs to R/O neovascular glaucoma

  31. Case 5: • 55 y myopic male with light flashes and complete vision loss acutely 2hrs ago in L eye. No pain

  32. Retinal Detachment: • Separation of the inner neuronal retina layer from the outer retinal pigment epithelial layer • 3 types: • i. rhegmatogenous • ii. Exudative • iii. Tractional

  33. Rhegmatogenous: • Due to tear/hole in the neuronal layer causing vitreous fluid to enter and separate the 2 retinal layers • Often due to vitreous gel pulling on retina as one ages or related to trauma • Men, myopia, age>45

  34. Exudative: • From blood/fluid leakage from vessels within the retina • HT, eclampsia, CRVO, papilledema, vasculitis, choroid tumor

  35. Tractional: • Due to fibrous band formation in the vitreous and the contraction of these bands

  36. Retinal Detachment: • Symptoms: light flashes, floaters, variable vision loss depending on macular involvement (cloudy or curtainlike), painless • Signs: area out of focus on fundoscopy • Cannot be ruled out by direct fundoscopy

  37. Treatment: • Emergent opthamologic consultation • When?

  38. Case 6: • 72 y IDDM female with 2hr hx of “cobwebs” L eye leading to marked decrease in vision now

  39. Vitreous Hemmorhage: • Bleeding into the preretinal space or vitreous cavity • Usually due to diabetic retinopathy or retinal vessel tears secondary to vitreous collapse but various other causes • Symptoms: initially floaters or cobwebs with subsequent vision loss • Fundoscopy findings are widely variable (reddish haze to black reflex)

  40. Vitreous hemmorhage: • If afferent pupillary defect present  retinal detachment likely behind hemmorhage • Treatment: bedrest, elevate HOB, avoid ASA and refer to opthomology

  41. Case 7: • 75y male with progressive vision loss x years with acute worsening central vision today. No pain.

  42. Macular Hemmorhage: • Refer to opthomology

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