Acute Ophthalmology

1. Acute Ophthalmology F Dean Consultant Ophthalmologist

2. Aims of the session • Anatomy of the eye and orbit • Ophthalmic history, examination and assessment • Ophthalmic triage • Conditions –true emergencies • Using an ophthalmoscope

3. Anatomy of the eye

4. Frontal View Of Orbital Muscles

5. Anatomy of the Visual Pathway

6. Taking the history

7. What symptoms may be specific to the eye? • Red/sore/watering/itchy/burning/hot • Aching • Can’t see • Intermittent • Complete or partial • Double vision • Funny vision- flashes/floaters/distortion

8. Ophthalmic History Loss of Vision • rate of loss • near or distance • total blurr or part blurr • general loss = loss of acuity • part loss = loss of visual field • associated features e.g distortion, floaters, flashing lights, pain etc

9. Ophthalmic Symptoms from different structures • Eyelid-itchy, burning,dry • Conjunctiva- watery,sticky, burn, sore • Eye ball- aching, visual disturbance, floaters • Orbit- watery, ache • Brain- headache, visual disturbance, photopsia, diplopia

10. Pain Pain • Type of pain • Gritty sandy feeling = ocular surface • Ache within the eye = deeper tissue involvement e.g. uveal tissues • duration • precipitating or relieving factors • Location/radiation

11. History • Past medical history • Social history • Drug history • Family history

12. General History • Diseases with known ocular associations • Diabetes, atherosclerosis, collagen vascular disease, • Hypertension • Meningitis • Raised intracranial pressure

13. Eye Examination • Visual acuity. • Examination of the • Lids • Cornea and conjunctiva • Pupils • Red reflex/lens • Fundus • Examination of the eye movements • Examination of the fields

14. Visual Acuity • Logmar acuity Newspaper for near vision • With spectacle correction as required • With and without a pinhole

15. Acuity Chart testing • 6/6 = line 7 • Person can see at 6 m what a normal person can see at 6 m • 6/60 = top line • Person can see at 6 m what a normal person can see at 60 m 6/60 6/36 6/24 6/18 6/12 6/9 6/6

16. Using an occluder with a pinhole

17. Ophthalmic examination • Visual acuity. • With and without glasses • Examination of the • Lids • Cornea and conjunctiva • Pupils • Red reflex/lens • Fundus • eye movements • Visual fields

18. Topical Medication for Examination • To check for break in epithelium • Fluorescein • Local anaesthetic • Benoxinate 0.4% • For pupil dilation • Tropicamide 0.5% • Phenylephrine 2.5%

19. External Eye • Use good general illumination e.g angle poised lamp • Pen torch pencil beam for tangent illumination + fluorescein stain • Use topical anaesthetic when required for patient comfort • Start with eyelids, then conjunctiva, cornea and pupil

20. Pupils • Direct and consensual reflex • Afferent defect • problem with message reaching the brain • Efferent defect • problem responding to light stimulus

21. Assessment of the extraocular movements

23. Visual Fields

24. Assessment of Squint • Monocular vision • may have amblyopia (lazy eye) • Eye movements • is there any restriction of movement • is there any double vision • Cover Test • check for ocular deviation

25. Extra ocular movements • Visual axes are not in parallel

26. Ophthalmoscopy • Don’t be afraid to DILATE the pupil • Correct for refractive errors • Use the optic disc as a landmark and follow the arcades

27. Ophthalmoscopy

28. To see with an ophthalmoscope you have to be very close to the patient

29. What is Triage? A process by which a patient is assessed upon arrival to determine the urgency of the problem and to designate the appropriate healthcare resources to care for the identified problem

30. Aim of Triage System • Realistic priorities of care are determined which result in appropriate, efficient and effective service delivery

31. Discriminators • General • Specific

32. General Discriminators • Life Threat • Pain • Haemorrhage • Conscious level • Temperature • Acuteness

33. General Discriminator • Ophthalmic patients with pain in conjunction with specific discriminators.

34. Specific Discriminators • Chemical eye injury • Penetrating eye trauma • Sudden loss of vision • Reduced visual acuity • Inappropriate history • Red eye with abnormal pupil reaction

35. Specific discriminators • Chemical eye injury • Acid • Alkali • molten metal • CS gas

36. Specific discriminators • Penetrating eye trauma • Traumatic event causing perforation of the globe • May contain foreign body

37. Specific discriminators • Sudden complete loss of vision • loss of vision in one or both eyes within the preceding 24 hours • Normally vascular

38. Specific discriminators • Reduced Visual acuity • corrected visual acuity loss.

39. Specific discriminators • Inappropriate history • alleged mechanism of injury does not fit the injury

40. Specific discriminators • Red eye • with or without pain • complete or partially red

41. Discriminators • In addition to specific discriminators add • Pupil reaction • Shape • Size

42. Specific discriminators • Pupil reaction • fixed dilated pupil • distorted pupil • festooned pupil

43. Red Flags • Ocular pain- particularly deep ache • Visual loss • Bleeding • Always refer when pain and visual loss are present simultaneously.

44. MANCHESTER TRIAGE DISCRIMINATORS (OPHTHALMIC)

45. Categories • Red • Orange • Yellow • Green • Blue

46. RED CATEGORY • Alkali • most commonly Lime • Sodium hydroxide • Cleaning solutions • Bleach

47. Chemical Injury • Alakali injury • Other chemical injury.

48. RED CATEGORY • Acid eg battery • molten metal • CS gas

49. ORANGE CATEGORY • Urgent -see within 5 minutes a delay in treatment could be sight threatening Intra-orbital foreign body

50. ORANGE CATEGORY • Perforating injuries- with a suspicion of intraocular foreign bodies Air bag injury