Ophthalmologic and ENT Emergencies

1. Ophthalmologic and ENT Emergencies William Beaumont Hospital Department of Emergency Medicine

2. Sudden Loss of Vision • Central retinal artery occlusion • Central retinal vein occlusion • Retrobulbar neuritis • Amaurosis fugax • Retinal detachment

3. Central Retinal Artery Occlusion • Sudden monocular painless, complete loss of vision • Fundoscopic exam: pale retina with macular red spot

4. Central Retinal Artery Occlusion Treatment • STAT opthy consult • Digital massage of the globe • Increase CO2 (arteriolar dilatation) – carbonic anhydrase inhibitor (i.e. acetazolamide) • Definitive treatment – paracentesis of the anterior chamber

6. Central Retinal Vein Occlusion • Sudden monocular painless, and near complete loss of vision • Fundoscopic exam: chaotic, blood-streaked retina • Stat ophthalmology consult

7. Optic Neuritis • Progressive loss of central vision • May be painful, scotoma, flashing lights • Peripheral vision preserved • Associated with multiple sclerosis in 25% of cases

8. Amaurosis Fugax • Fleeting painless loss of monocular vision • Due to minute emboli of the central retinal artery • Consult neurology for TIA workup

9. Retinal Detachment • Painless • Prodromal floaters or flashing lights, followed by “lowering curtain” • Opthy consult

10. Red Eye • Acute angle closure glaucoma • Acute iritis • Conjunctivitis • Herpes simplex keratitis • Corneal ulceration • Chemical conjunctivitis • Corneal abrasions

11. Acute Angle Glaucoma • Sudden severe unilateral ocular pain • Decreased visual acuity • Precipitous increased IOP  blindness if untreated • Symptoms: HA, nausea, blurred vision or rainbow halos • Pupil dilatation is often precipitant event from sympathomimetics, parasympatholytics, stress, fatigue, darkness.

12. Acute Angle Glaucoma • Red eye • Nonreactive mid-dilated pupil • Corneal edema • Shallow anterior chamber • High intraocular pressure (60-90)** • Hazy cornea **Normal IOP <20

13. Glaucoma Treatment • Stat opthy consult for definitive treatment – iridectomy • Timolol – beta blocker • Pilocarpine – parasympathomimetic • Acetazolamide – carbonic anhydrase inhibitor • Mannitol • 50% glycerol – oral hyperosmotic – if patient can tolerate PO – give in place of mannitol

14. Timolol Solution • Beta blocker • Decreases aqueous humor formation • 0.5% solution – 1-2 drops at 10-15 min intervals x 3, then 1 drop every 12 hours

15. Pilocarpine • Parasympathomimetic • Produces miosis • 2% solution – 1 drop every 30 minutes until the pupil constricts, then 1 drop every 6 hours • Side effects: bradycardia, hypotension, sweating, tremors

16. Acetazolamide • Carbonic anhydrase inhibitor • Inhibits aqueous humor formation • 500 mg IV every 12 hours or 500 mg PO every 6 hours • Side effects: respiratory depression, metabolic acidosis

17. Mannitol • Increases blood osmolality, creating a gradient that draws water from the vitreous cavity • 20% 1-2 grams/kg IV over 30-60 minutes • Side effects: headache, confusion, CHF, dehydration

18. Acute Iritis • Blurred vision, photophobia, ocular pain • Exam: • Ciliary flush • Anterior chamber cells and flare • Constricted pupil • Decreased visual acuity • Lower IOP • Consensual photophobia

19. Acute Iritis: Treatment • Cycloplegics • i.e. Homatropine – dilates the eyes • Topical steroids • Close opthy follow up

20. Acute Iritis

21. Conjunctivitis • Nonpainful red eye • Bacterial, viral, or allergic

22. Herpes Simplex Keratitis • Red eye with foreign body sensation • Dendritic fluorescein uptake • Treatment: acyclovir drops, cycloplegics • Steroids contraindicated • Opthy consult

23. Corneal Ulceration • Red, painful eye • Slit lamp • White flocculent infiltrate of the cornea • Hypopyon • Anterior chamber exudate • May lead to corneal destruction and perforation • ?Admit, IV antibiotics

24. Corneal Ulceration

25. Chemical Conjunctivitis • Alkali burn – absolute ocular emergency • Liquefactive necrosis • Immediate irrigation (pH 7-7.5) • Opthy consult • Only opthy emergency in which visual acuity is not checked until after therapy has begun

26. Alkali Burns

27. Chemical Conjunctivitis • Acid burn • Coagulative necrosis • Immediate irrigation as above • Opthy consult

28. Corneal Abrasions • Foreign body sensation and photophobia • Diagnose: fluorescein uptake with slit lamp exam • rule out foreign body with lid eversion • Suspect foreign body if “ice rink sign” – fine linear abrasions in upper 1/3 cornea • Rule out corneal ulceration • Do not use steroid drops –may be difficult to rule out early HS keratitis • Treatment: antibiotic ointment/drops, analgesics • Prognosis is very good

29. Corneal Abrasion

30. Traumatic Eye Injuries • Corneal laceration • Perforated globe • Intraocular foreign body • Hyphema • Blow-out orbital fracture • Traumatic iritis or retinal detachment

31. Corneal Laceration • Tear shaped pupil – prolapse of the iris • Small black fragments representing iris pigment may be seen and initially mistaken for a foreign body • May not see the laceration itself • Treatment: metal shield, STAT opthy consult for surgical repair

32. Corneal Laceration

33. Perforated Globe • Suspect if penetrating wound to the eyelid • Decreased visual acuity, soft globe (do not palpate) • Fundoscopic exam may reveal vitreous hemorrhage • Treatment: Metal shield, STAT opthy consult for surgical repair

34. Intraocular Foreign Body • Patient often gives a history of striking metal on metal • May be initially painless, but then patient develops monocular pain and decreased visual acuity • May not see the wound • Diagnosis: CT scan, ultrasound or x-ray of the globe • Treatment: Opthy consult for surgical removal

35. Orbital Foreign Body

36. Hyphema • Hemorrhage in the anterior chamber • See blood/vitreous line in inferior iris • Treatment • Bed rest • Head of bed elevation • Opthy consult • Steroids • Miotics

37. Blow-out Orbital Fracture • Blunt globe trauma (i.e. fist to eye) transmits forces that lead to orbital floor fracture • Inferior rectus muscle may prolapse through the fracture • Pain and diplopia or loss of upward gaze, enophthalmos (sunken eye), infraorbital anesthesia • Treatment: OR if entrapment, opthy consult

38. Blow-out Fracture

39. Moving on to ENT Emergencies…

40. Ear Disorders • Auricular hematoma • Otitis externa • Malignant otitis externa • Ramsey Hunt • Foreign body • Tympanic membrane rupture • Otits media

41. Auricular Hematoma • Blunt trauma • Untreated, can result in cartilage necrosis (“cauliflower ear”) • Treatment: • Needle aspiration • Compression dressing

42. Auricular Hematoma

43. Otitis Externa • Swelling of the external canal • Pain with movement of the auricula • Treatment: • Abx/steroid ear drops • Ear wick

44. Malignant Otitis Externa • Deep pain with movement of TMJ, granulation tissue on the floor of the auditory canal at bony-cartilage junction • Immunocompromised patient • Pseudomonas aeruginosa • Facial nerve paralysis  multiple CN involvement  meningitis • Treatment: STAT ENT consult, surgical debridement, IV abx

45. Malignant Otitis Externa

46. Ramsay Hunt Syndrome • Herpes Zoster • Vesicular rash of ext auditory canal & auricle • Usually with sensorineural hearing loss and facial nerve paralysis • Treatment: • Admit • IV acyclovir • Steroids

47. Ramsay Hunt Syndrome

48. Ear Foreign Body • Tools for removal: • Irrigation (not vegetable matter) • Alligator forceps • Suction • Hook • Cerumen loop • Live insects should be stupefied with lidocaine or mineral oil prior to removal

49. Ear Disorders • Tympanic membrane rupture – ENT referral • Otitis media – hopefully you all know what this is

50. Nasal Disorders • Epistaxis • Foreign body • Acute sinusitis • Cavernous sinus thrombosis