Ocular emergencies

1. Ocular emergencies Tintinalli Chapter 236

2. Anatomy

3. Anatomy

4. Lid Infections • External hordeolum (Stye) • Acute staph. infection • Blockage sebaceous glands • Zeiss • Moll • Small pustule at the lash • Purulent material exudes from the eyelash line • Treatment • warm compresses • Erythromycin ophthalmic ointment Bid x 7-10 days.

5. Lid Infections • External hordeolum (Stye) • Acute staph. infection • Blockage sebaceous glands • Zeiss • Moll • Small pustule at the lash • Purulent material exudes from the eyelash line • Treatment • warm compresses • Erythromycin ophthalmic ointment Bid x 7-10 days.

6. Lid Infections • Internal hordeolum (Stye) • Acute staph. infection • Meibomian glands • Suppurate on the conjunctival surface of eyelid • Treatment • warm compresses • Erythromycin ophthalmic ointment Bid x 7-10 days.

7. Lid Infections • Internal hordeolum (Stye) • Acute staph. infection • Meibomian glands • Suppurate on the conjunctival surface of eyelid • Treatment • warm compresses • Erythromycin ophthalmic ointment Bid x 7-10 days.

8. Lid Infections • Chalazion • Blocked meibomian gland. • Subacute, nontender, and usually painless nodule. • Initial treatment • Warm compresses, erythromycin ophthalmic ointment Qid, +/- 100mg doxy PO if chronic or reoccurring, ophtho. f/u.

9. Conjunctivitis • Bacterial • Symptoms • mucopurulent d/c • Inflamed conjunctiva • Crusted eye upon awakening • Treatment • Stain eyes of infants/toddlers • Antibiotics • Non-contact wearer • topical Polytrim or erythromycin, 1 gtt Qid x 5-7 days. • Contact wearer • Tobrex, Ocuflux, or Ciloxin for pseudomonas coverage. 1 gtt Qid x 5-7 days.

10. Conjunctivitis • Viral • Symptoms • Watery d/c • Inflamed conjunctiva • Often preceded by URI • Monocular and spreads binocular • Treatment • Supportive • Naphcon-A, cool compress • Stain eye to R/O HSV

11. Conjunctivitis • Allergic • Symptoms • Watery d/c • Inflamed conjunctiva • Itching • Often binocular • Treatment • Supportive • Patanol, Alcon BID • Contacts OK

12. Ocular HSV • Symptoms • HSV can infect the eyelids, conjunctiva, and cornea • Surrounding skin may have typical vesicular eruptions • Diagnosis • Fluorescein staining may reveal the dendrites assoc. w/ herpes keratitis • Treatment • Initial outbreak < 3-4 days • PO acyclovir • w/out corneal involvement • Viroptic 1 gtt 5/day • w/ corneal involvement • Viroptic 1 gtt 9/day • Can add erythromycin ophthalmic ointment to avoid 2º bacterial infection • Ophthalmologist follow up

13. Herpes Zoster Opthalmicus • Shingles in the distribution of the trigeminal nerve w/ocular involvement. • Hutchinson sign, pain, photophobia • Tx. • Narcotics, cycloplegic agents for pain • Erythromycin ophthalmic ointment to prevent 2º bacterial inf. • Prednisolone acetate 1gtt 5/day if iritis and no corneal defects. • Consider for admission and IV acyclovir.

14. Periorbitalcellulitis • Periocular superficial cellulitis. • Full ocular mobility w/out pain and pupillary reaction maintained. • Most often d/t inoculation by skin infection or trauma S. areus. • Tx. • Children above 5- clindamycin, Augmentin • Adults- same options • Children under 5 or severe cases- admission for full work-up and IV abx. (ceftriaxone plus vanc.)

15. Orbital cellulitis • Orbital infection most commonly by S. areus. • EOM entrapment, pain w/ EOM movement, fever, proptosis. • Often a result of extension form a paranasal sinus infection. • CT of orbit and sinuses aids in diagnosis • If neg. enhanced CT looking for subperiosteal abscess. • Tx. • Admission w/ IV abx.

16. Orbital cellulitis • Orbital infection most commonly by S. areus. • EOM entrapment, pain w/ EOM movement, fever, proptosis. • Often a result of extension form a paranasal sinus infection. • CT of orbit and sinuses aids in diagnosis • If neg. enhanced CT looking for subperiosteal abscess. • Tx. • Admission w/ IV abx.

17. Corneal ulcer • D/t breaks in the epithelial barrier allowing access to infectious agents. • Risk factors- trauma, soft contact use and extended wear of contacts. • Painful, red, tearing, photophobia, white hazy infiltrate underlying the defect. • Tx. • Topical Ciloxin or Ocuflux • NO patching- risk of pseudomonas inf. • Ophtho. f/u.

18. Trauma (superficial) • Subconjunctival hemorrhage • Disruption of fragile vessels 2º to trauma or valsalva spikes (coughing, sneezing, straining) • Conjunctival abrasion • If isolated can be treated w/ topical erythromycin for 2-3 days.

19. Trauma (superficial) • Corneal abrasion • Pain, tearing, photophobia • Exam can be aided w/ topical anesthetic. • Fluorescein staining • Eversion of lids and FB inspection • Assess ant. chamber w/ slit lamp for assoc. injury. • Tx. • Identify source of abrasion • Cycloplegic agents- reduce ciliary spasm reducing pain. • Not related to contact lens wear- topical erythromycin, +/- patch • Related to contact lens wear- topical Tobramycin, NO patch. • Organic source- topical erythromycin, NO patch. • Ophtho. f/u.

20. Trauma (superficial) • Corneal FB • Remove carefully under best magnification (slit lamp). • Topical anesthetic- may use in unaffected eye to reduce blink reflex. • Evert lid • Burr , 25 or 30 gage needle recommended. • Rust rings- do not need to remove all rust in the ED, but secure ophtho. f/u. • Full thickness FB or rust should not be removed in the ED. • Treat abrasion

21. Lid laceration • Full thickness • Should be closed by an ophthalmologist in order to obtain best alignment. • If not available can be closed w/… • One 6-0 silk vertical mattress using meibomian glands as landmarks to repair lid margin. • Tarsus repaired w/ 5-0 vicryl. • Skin closure w/ 6-0 monofilament or silk. • Partial thickness • Can be repaired in the ED w/ ophtho. f/u.

22. Blunt/penetrating trauma • Indications of globe rupture • Flat ant. chamber • Full thickness laceration • Irregular pupil- will peak towards injury • Blind eye • Itraocular FB • If globe rupture not suspected examine and treat appropriately (hyphema, blowout fx, abrasions, etc.). • If globe rupture suspected • do not attempt IOP measurements • Shield the eye • Check tetanus status • IV abx, NPO • Ophtho. consult

23. Hyphema • Blood in the ant. chamber. • Traumatic vs. spontaneous • Blunt/penetrating trauma usually to the iris root vessels. • Spontaneous cases frequently assoc. w/sickle cell ds. • Tx. • All cases should be evaluated by an ophthalmologist. • ED management focuses on IOP control. • Elevate head- promotes settling of RBCs • Dilate pupil- keeps pupil at rest, avoids vessel stretch and inc. bleeding. • IOP >30- topical ß blocker, PO or IV Diamox, or IV mannitol • IOP >24 and suspicion of sickle cell trait/ds- avoid Diamox • Ophtho. f/u.

24. Blowout fx. Most frequently occur at inferior and medial walls. Often involve the sinuses  sub-Q emphysema. Entrapment of the inferior rectus can cause an upgaze restriction and diplopia. Isolated blowout fx do not require immediate tx. Appropriate f/u and repair w/in 3-10 days. PO abx (Keflex) esp. if sinus wall fx present on CT. Ophtho. f/u.

25. Chemical ocular injury • Acid burns- proteins coagulated  superficial injury. • Alkali burns- rapidly penetrate  deep injury. • Tx. • 1st copious irrigation (1-2L NS) w/ a Morgan lens until tear pH (7.5-8). Use topical anesthetic. • thorough exam and assess visual acuity after irrigation. • W/out corneal defect- topical erythromycin • W/ corneal defect- topical erythromycin, cycloplegic agent, +/- patching • Ophtho. f/u.

26. Cyanoacrylate (super/crazy glue) • Can cause lids to adhere or adhesive clumps on the corneal surface. • Main concern is mechanical abrasive effect to corneal surface. • Tx. • Moisten eye w/ erythromycin ointment and remove as much as can be removed easily. • Ophtho. f/u.

27. Acute angle-closure glaucoma • Pt symptoms- foggy vision, halos around lights, eye pain, HA, n/v. • Pt signs- mid fixed dilated nonreactive pupil, inc. IOP ( often >50), hazy cornea. • Tx. • Reduce IOP, check q 1º • topical ß-blocker, alpha-agonist, mannitol • After pressure reduced can give pilocarpine to make pupil miotic  prevents reoccurrence until f/u. • Ophtho. f/u.

28. Optic neuritis • F>M, often B/L in children. • Rapid onset, painful vision reduction/loss. • Check visual acuity, Red desaturation test. • On exam • Affected eye w/ papilledema- anterior optic neuritis. • Affected eye w/out papilledema- retrobulbar optic neuritis. • Tx. • Consult ophtho. or neuro. regarding tx w/ IV steroids or d/c w/out tx. • No difference at 1 year between IV steroid tx grp. vs. placebo. (ONTT) • Oral steroids contraindicated as initial tx.

29. Central retinal artery/vein occlusion • CRAO • Sudden, profound, painless, monocular vision loss. • My be preceded by amaurosis fugax. • Causes- embolus, thrombosis, giant cell arthritis, vasculitis. • On exam- infarcted retina will appear pale, w/ sparing of the macula (cherry red spot). • Tx. Consult ophtho. • Attempts to dislodge embolus to distal branches to reduce size of infract. • Ocular message • Dec. IOP- topical ß-blocker, Diamox • CRVO • Sudden, profound, painless, monocular vision loss. • Risk factors- uncontrolled Htn, hypercoagulopathies, vasculitis, glaucoma. • On exam- optic disc edema and diffuse retinal hemorrhages. • Tx. • Can consider ASA therapy • Ophtho. f/u.

30. Flashing lights and floaters Binocular- intracranial etiology Monocular- intraocular etiology W/ age vitreous gel separates from the posterior wall of the eye. Traction stimulates the retina and is perceived as light. Complete separation results in floaters. If traction is great enough  retinal detachment. Consult ophtho.

31. Temporal arteritis • F>M • Age usually > 50 • Sxs- headache, temporal tenderness, fever, jaw claudication. May be assoc. with polymyalgia rheumatica. • Can result in visual disturbances/loss. • Sed rate and biopsy of temporal artery aid diag. • Tx. • If vision loss suspected- admit for IV Solu-Medrol • No vision loss suspected- d/c w/ PO prednisone. Secure f/u.

32. Neuro-ophthamology • Bells palsy- CN VII palsy • Rx lacriube to prevent corneal drying and scarring. • R/o genu VII Bells palsy by testing for EOM abduction. • DM/Htn CN palsies • Above result in vascular compromise to EOM. • Pt present w/ new onset diplopia and an isolated CN III or VI palsy. • Pupil spared. • Post.communicating artery aneurysm • Acute CN III palsy w/ dilated pupil

33. Neuro-ophthamology • Internuclear opthalmoplegia • CVA or demyelinating ds. of the MLF. • Pt presents w/ diplopia when looking to the side opposite the lesion, d/t ipsilateral medial rectus weakness. • Horner syn. • Ipsilateral ptosis, miosis, anhidrosis. • Causes- trauma, CVA, ICA dissection. • Papilledema • B/L disc edema • Causes- intracranial tumors, psuedotumor cerebri, malignant Htn, hydrocephalus. • psuedotumor cerebri • Inc ICP, papilledema, normal CSF, normal head CT. • Age- 20-30, obese women. • Often c/o morning HA, transient visual disturbances.