Ophthalmologic Emergencies

1. Ophthalmologic Emergencies William Beaumont Hospital Department of Emergency Medicine

2. Ophthalmologic emergencies • Sudden loss of vision • Central retinal artery occlusion • Central retinal vein occlusion • Retrobulbar neuritis • Amaurosis fugax • Retinal detachment • Acute iritis

3. Central retinal artery occlusion • Sudden monocular painless, complete loss of vision • Fundoscopic exam: pale retina with macular red spot • Treatment • stat opthy consult • Intermittent digital massage of the globe • Increase CO2 (arteriolar dilatation) – carbonic anhydrase inhibitor (ie acetazolamide) • Definitive tx – paracentesis of the anterior chamber

5. Central retinal vein occlusion • Sudden monocular painless, and near complete loss of vision • Fundoscopic exam: chaotic, blood-streaked retina • Stat ophthalmology consult

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

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

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

9. Acute iritis • Painful blurred vision • Will cover in more detail under Red Eye in a few slides

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

11. Acute angle closure glaucoma • Sudden severe unilateral ocular pain and decreased visual acuity • Patients may present with headache or nausea, blurred vision or rainbow halos • Precipitous increase in IOP leads to blindness within a few days if left untreated • In patients predisposed (ie far sighted, cataracts), pupil dilatation is often precipitant event (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. Treatment glaucoma • Stat opthy consult for definitive tx – iridectomy • Timolol – beta blocker • Pilocarpine – parasympathomimetic • Acetazolamide (diamox) – carbonic anhydrase inhibitor • Mannitol • 50% glycerol – oral hyperosmotic – if patient can tolerate po – give in place of mannitol

14. Timolol • Timoptic 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 • Diamox • Carbonic anhydrase inhibitor • Inhibits aqueous humor formation • Cross reactive allergen with sulfa • 500 mg IV every 12 hours or 500 mg po every 6 hours • Side effects: respiratory depression, metabolic acidosis

17. Mannitol • 20% 1-2 grams/kg IV over 30-60 minutes • Increases blood osmolality, creating a gradient that draws water from the vitreous cavity • 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 • Treatment: • Cycloplegics – ie Homatropine – dilates the eyes • Topical steroids • Close opthy follow up

19. Acute iritis

20. conjunctivitis • Nonpainful red eye • Bacterial, viral, allergic

21. Herpes simplex keratitis • Red eye with foreign body sensation • Dendritic fluorescein uptake • Treat: acyclovir drops, cycloplegics • Steroids contraindicated • Opthy consult

22. Corneal ulceration • Red, painful eye • White flocculent infiltrate of the cornea on slit lamp exam • Slit lamp may reveal a hypopyon • anterior chamber exudate • May lead to corneal destruction and perforation • Admit, IV antibiotics

23. Corneal ulceration

24. Chemical conjunctivitis • Alkali burn – absolute ocular emergency • Liquefactive necrosis – worse • Immediate irrigation to continue until pH returns to 7.0 – 7.5 and opthy consult • Only opthy emergency in which visual acuity is not indicated until after therapy has begun • Acid burns • Coagulative necrosis • Immediate irrigation as above and opthy consult

25. Alkali burns

26. Corneal abrasions • Foreign body sensation and photophobia • Diagnose: fluorescein uptake with slit lamp exam, rule out foreign body with double upper 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 – as it may be difficult to rule out early HS keratitis • Treat: antibiotic ointment/drops, analgesics • Prognosis is very good

27. Corneal abrasion

28. Traumatic eye injuries • Corneal laceration • Perforated globe • Intraocular foreign body • Hyphema • Blow-out orbital fracture • Traumatic lens dislocation • Traumatic mydriasis • Traumatic iritis or retinal detachment

29. Corneal laceration • Tear shaped pupil – from 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 • Treat: metal shield, stat opthy consult for surgical repair

30. Corneal laceration

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

32. 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 plain x-ray of the globe • Tx: Opthy consult for surgical removal

33. Orbital foreign body

34. Hyphema • Hemorrhage in the anterior chamber • See blood/vitreous line in inferior iris directly or on slit lamp exam • Treatment: bed rest, head of bed elevation, ophthy admit, steroids, miotics

35. Blow-out orbital fracture • Blunt globe trauma (ie fist to eye) transmits forces that may 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 • Opthy consult

36. Blow out fracture

37. ENT emergencies • Emergent Ear Disorders • Auricular Hematoma – blunt trauma • Untreated, can result in cartilage necrosis (“cauliflower ear”) • Tx – needle aspiration, compression dressing, +/- Abs • Perichondritis – admit for IV abs • Otitis externa – swelling of the external canal, pain with movement of the auricula • Tx: Abs/steroid combination ear drops after placing an ear wick

38. Auricular hematoma

39. Ear Malignant Otitis Externa – immunocompromised pt Pseudomonas aeruginosa • Deep pain with movement of TMJ, granulation tissue on the floor of the auditory canal at bony-cartilage junction • Facial nerve paralysis  multiple CN involvement  meningitis • Tx: stat ENT consult for surgical debridement and IV antibiotics

40. Malignant otitis externa

41. Ear • Ramsay-Hunt syndrome • Vesicular (Herpes zoster) rash of ext auditory canal and auricle • Usually with sensorineural hearing loss and facial nerve paralysis • Treatment: admit for IV acyclovir and steroids • 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 • Tympanic membrane rupture – ENT referral • Otitis media – hopefully you all know what this is

42. Ramsay hunt syndrome

43. Nose • Epistaxis • Anterior most common – Kiesselbach’s plexus • Posterior often due to uncontrolled HTN • Rule out coagulopathy • Silver nitrate or cautery • Oral antibiotics if nasal pack • Foreign bodies – suction, ear curette, forceps • Acute sinusitis – nasal and oral decongestant, antibiotics (augmentin, macrolide, 2nd or 3rd cephalosporin) if sxs > 1 week

44. Complications of sinusitis • Pott’s puffy tumor – osteitis of anterior frontal sinus wall  frontal lobe abscess • Meningitis • Acute periorbital cellulitis – around the orbit • Tx: admit for IV Abs • CT scan to rule out orbital cellulitis (surgical emergency)

45. Cavernous sinus thrombosis • High fever • Toxic appearing • Chemosis, CN 3 & 6 palsies, papilledema • Lethargy, coma or seizures • DX: CT, MRI

46. Mucormycosis • Fungal sinusitis in immunocompromised patient • Nasopharyngeal necrosis • CN palsies • IV antifungal Abs • High mortality rate

47. Throat • Pharyngitis – Grp A strep • treat to prevent complications and acute rheumatic fever and ARHD • glomerulonephritis not prevented by Abs • Mononucleosis – EBV • Pharyngitis, fever, cervical lymphadenopathy • Splenomegaly in 50% • Dx: monospot,  atypical lymphocytes • Tx: fluid, rest, steroids, avoid ampicillin (rash), contact sports/trauma (splenic rupture)

48. Ludwig’s angina • Bilateral cellulitis of the floor of the mouth • True emergency (airway obstruction) • Elderly, debilitated men (alcohol abuse) • Dx: CLINICAL: brawny edema of submandibular area, febrile, protruding elevated tongue, respiratory distress • Tx: IV antibiotics (clindamycin or Unasyn or Pcn + metronidazole) + airway protection

49. Ludwig’s angina

50. Peritonsillar abscess • Fever, trismus, dysphagia • Adolescents, young adults • Enlarged inflamed tonsil extending medially • Displaces uvula to opposite side • ENT consult for I & D, IV Abs (Pcn or Clindamycin or Unasyn with Metronidazole), IV fluids, IV steroids