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Ophthalmic emergencies

Ophthalmic emergencies. Rahul Chakrabarti Ophthalmology HMO. Case 1: Sudden visual loss.

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Ophthalmic emergencies

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  1. Ophthalmic emergencies RahulChakrabarti Ophthalmology HMO

  2. Case 1: Sudden visual loss • 70 yo female brought to emergency by neighbour. She reports that half an hour previously her vision in right eye has suddenly been lost. There has been no improvement since. The eye is not painful or red. • Past ophthalmic history: early cataracts in both eyes. • Past history: angina, hypertension. Both well controlled with medication.

  3. Further history • Moderate to severe headaches for previous 3 months • Chewing food produced ache in her jaw • Scalp tenderness when brushing hair • Felt generally unwell during this period of time

  4. Examination • Acuity : hand movements right eye, 6/9 left eye • Profound relative afferent pupillary defect • Ophthalmoscopy of left eye normal • Right optic disc abnormal • Remainder of right retina normal

  5. Giant cell arteritis • 5-10% of all anterior ischaemic optic neuropathies • 90% are “non-arteritic” ION • Occlusive granulomatousvasculitis • Untreated eventual loss of vision in both eyes • Age 50 or older • Clinical features • Loss of vision • Headache, scalp tenderness • Jaw claudication • Neck pain • Weight loss/malaise/ night sweats • Myalgia – association with polymyalgiarheumatica • Double vision

  6. Signs • Reduced VA (<6/60) • Relative afferent pupil defect • Field deficit • Altitudinal loss • Swollen, pale disc +- disc haemorrhages, cotton wool spots • Superior + inferior optic disc swelling • Tender, thickened, nodular temporal vessels/absent pulses • CN 3/4/6 palsies • Ix • Elevated ESR (mean 70)/CRP • Temporal artery biopsy • Within 10 days of steroids

  7. Treatment • Immediate • Methylprednisolone 1g IV daily for 1-3 days • Oral prednisolone 1-2mg/kg daily • High dose steroid for 12-24 months • Side effect prophylaxis • Prognosis • Risk of second eye – 10% if treated, 95% if untreated • Complications: TIA, CVA, neuropathies, thoracic artery aneurysms • Bottom line • Arrange urgent inflammatory markers • Seek advice • Safer to start treatment if any delay

  8. Non-arteritic AION • Insufficient circulation to crowded optic nerve  local oedema, compromised circulation • Associations • Diabetes, hypertension, disc morphology (small cup, crowded disc) • Smoking, hyperlipidaemia, anaemia, OSA • Mean age 60yo • Acuity usually better than 6/60, altitudinal field loss common • No associated symptoms • ESR, CRP, platelets – normal • Lower risk to other eye – 20% at 5 yrs • Treatment • No proven benefit anything in particular • Aspirin 75mg / day • Optimising risk factors

  9. Case 2 : Sudden vision loss (2) • 45 yo female referred from oncology unit with sudden, painless vision loss in her right eye. • Progressive loss of upper vision in right eye • Past history of metastatic lung carcinoma • Past ophthalmic history – nil signifcant, but noticed blurred vision over past 8 weeks

  10. Examination • Acuity 6/6 right, light perception only left • Pupils equal and round • RAPD present right eye • Full range of extraocular motility

  11. Retinal detachment • Retina has 2 layers • Separation of neural retina from pigment epithelium • due to fluid entering this potential space (sub-retinal space) • Most cases are rhegmatogenous (tear/ hole in neural retina) • Non rhegmatogenous • Much less common • Tractional: pulled off by membranes (eg proliferative DR) • Exudative: breakdown of blood-retinal barrier (egchoroidaltumours, uveitis) • Usually less extensive detachment • Pathogenesis • Vitreous is more firmly attached to retina in certain places • Periphery • Optic disc • Bloood vessels

  12. Rhegmatogenous retinal detachment • Commonest form of RD • Due to vitreous liquefaction + break in retina • Clinical features • Flashes, floaters • Peripheral field loss (early) • Curtain-type field defect • Loss of central vision (macula) • Loss of red reflex • Vitreous – PVD, vitreal pigment +/- blood • Retinal breaks • U-shaped, round holes • Upper temporal quadrant in 60% • Detached retina • Looks grey, balloons forward • Retinal blood vessels on the surface • Unilateral convex, corrugated dome

  13. Vitreous detachment • Vitreous liquefies due to aging • Collapse inwards • Floaters • Traction on retina at points of firmer attachment • Flashes • Floaters – vitreous opacities • 2 possible outcomes • Posterior vitreous detachment (PVD) • Retinal tear • Fluid can then can access to sub-retinal space • Retinal detachment • Loss of visual field in this area • Extension to macular = loss of central vision

  14. Principles of management • Position patient so dependent fluid moves away from macula • Urgent referral for surgery • Relief of vitreoretinal traction • Vitrectomy or indenting eye wall from outside (suture explant : scleral buckling) • Augmented by injection of silicone oil or gas • Closure of retinal break • Drainage of subretinal fluid • Needle puncture through sclera + choroid • Adhesion of detached retina to RPE • External cryotherapy or internal laser •  inflammation of choroid + retina  adhesion of layers

  15. Key points • Flashes and floaters common • Most will be PVD • Should have a dilated exam to exclude tears • Check confrontation visual fields • If loss more suspicious for detachment • Urgent referral

  16. Case 3: Acute red eye • 64 year old male presents to emergency with red swollen, watery right eye for the past 2 days, but now sudden deterioration of vision. • No significant medical history • No past ophthalmic history • Saw LMO yesterday • Impression of viral conjunctivitis, • Commenced chloramphenicol drops • Minimal relief. • Vision now much worse.

  17. Further history • Severe pain in the right eye since for last 3 hours • Associated frontal headache, malaise

  18. Examination • Visual acuity- counting fingers only in right eye, 6/6 in the left eye • Right afferent pupillary defect • Oval shaped pupil, fails to react to direct or consensual

  19. Acute angle closure glaucoma • Differentials • Iritis • Conjunctivitis • Acute corneal problems • Fluorescein stain

  20. Acute angle closure glaucoma (AACG) • Glaucoma – progressive optic neuropathy • 1% over 40 yo, 3% over 70 yo • Primary open angle glaucoma (POAG) – 1/3 • Secondary glaucoma – 1/3 • AACG • Usually primary • Risk factors • Epidem: Age >40, female, Chinese, SE Asians • Anatomical: Pupil block, crowding of AC angle  prevents access to trabecular meshwork

  21. Clinical features of AACG • Pain (periocular, headache, abdominal) • Blurred vision • Haloes • Nausea / vomit • Ipsilateral • Red eye • Raised IOP (usually 50-80mmHg) • Corneal oedema (hazy cornea) • Diminished red reflex • Fixed semi-dilated pupil • Due to iris ischaemia • Contralateral angle is narrow • Bilateral shallow AC

  22. Acute congestive angle-closure glaucoma Signs • Ciliary injection • Complete angle closure • Severe corneal oedema • Shallow anterior • chamber • Dilated, unreactive, • vertically oval pupil Treatment • Topical anti-glaucoma drops • Diamox • Laser peripheral iridotomy

  23. Approach to treatment of AACG • Immediate • Systemic – acetazolamide 500mg IV stat (then 250mg oral, qid), analgesia, anti-emetic • Carbonic anhydrase inhibitor – decreased aqueous production • Ipsilateral eye • B-blocker (egtimolol 0.5% stat, then bd) • Decreased aqueous production • Pilocarpine 2% (reverse the pupil block) • Parasympathomimetics – ciliary contraction  opens trabecular meshwork • Sympathomimetic (egapraclonidine a2 agonist 1% stat)  decreased aqueous production + increased outflow • Hourly IOP check • Definitive management – Bilateral Nd-YAG Peripheral iridotomy

  24. Case 4: The swollen, painful eye • 21 year old female presents to emergency with increasing swelling and pain of the right eye region for past 10 days. • Associated diplopia in up and left gaze • Systemic symptoms: productive cough, fevers over this time • No significant past medical or ophthalmic history

  25. Examination • Acuity – Right 6/18, left 6/6 • Proptosis – 5mm on the right • No RAPD • Pain on all movements of right eye • Limitation of elevation, adduction right eye, with accompanying diplopia • Anterior segment • Dilated conjunctival vessels in right eye • Normal left eye examination

  26. Orbital vsPeriorbitalcellulitis • Orbital cellulitis = ophthalmic emergency • S.pneumoniae, S.aureus, H influenzae • Risk Fx: sinus disease, local infection, trauma (septal perforation), ENT/ ophthal surgery • Hx: FEVER, MALAISE, PAINFUL, SWOLLEN orbit • O/E: Swollen lids +- chemosis, Proptosis, Painful eye movements, Optic nerve function (VA, colour, RAPD) • Complications: • Local- keratopathy, raised IOP, CRVO, CRAO • Systemic- orbital abscess, cavernous sinus thrombosis, meningitis, cerebral abscess!

  27. Treatment of orbital cellulitis • Admit • Vital signs • FBE, Blood cultures • CT- orbit and sinuses • IV Fluclox 1g qid or Cefuroxime 1g tds PLUS Metronidazole 500mg tds • Majority need drainage of collection – diagnostic and therapeutic

  28. Periorbital cellulitis • Not an emergency, it’s not in the orbit! • Similar organisms • Much less severe • Risk FX: local infection, URTIs • Fx: fever, malaise, swollen lids, but no proptosis, pain on eye movement or optic nerve deficits • INV: not necessary usually • RX: oral fluclox 500mg qid for a week + metronidazole 400mg tds for a week

  29. Case 5: Trauma • A 26 year old male is brought to emergency late at night with sudden blurred vision and pain in the right eye after being assaulted. • He states he was struck with a glass bottle to the right side of his face in an assault. • Past medical and ophthalmic history are unremarkable.

  30. Globe rupture • Clinical Features • Anterior rupture • Herniating iris, oozing aqueous, vitreous, lens • Severe subconjunctival haemorrhage • hyphaema • Posterior rupture • Suspect if deep AC but low IOP compared to other eye

  31. Treatment of Penetrating FB, Globe rupture • Prepare patient for urgent surgery • Imaging • Plain XR • Ocular ultrasound • Orbital + facial bone CT • High risk of endophthalmitis • Clear plastic shield • Systemic ABx: Ciprofloxacin, po, 750mg bd • Tetanus is required • Take to theatre for primary repair

  32. Potential problems • Corneal abrasion • Acute and chronic glaucoma • Traumatic cataract • Vitreous haemorrhage • Retinal damage • Commotioretinae • Choroidal rupture • Orbital blow-out fracture

  33. Orbital compartment syndrome • Globe and retrobulbar contents encased within a fascial cone, bound by 7 rigid bony walls • Anteriorly – medial and lateral canthal tendons attach eyelids to orbital rim • Small increases in orbital volume  forward movement of globe  rapid rise in orbital tissue pressure • If intraorbital pressure > central retinal artery pressure  ischaemia • Classically in retrobulbar haematoma (post op, trauma)

  34. Symptoms of acute orbital compartment syndrome • Eye pain • Diplopia • Loss of visual acuity • Reduced ocular motility • Proptosis

  35. Examination • Proptosis • Ecchymosis of eyelids • Chemosis • Ophthalmoplegia • Afferent pupillary defect • Decreased fields • Papilloedema • Increased IOP • Reduced acuity

  36. Lateral canthotomy

  37. Orbital blow-out fractures • Floor (maxilla) > medial wall (ethmoid) • Clinical features • Soft tissue bruising/ oedema, surgical emphysema • Enophthalmos • Altered infra-orbital sensation • Reduced ocular motility – vertical diplopia • Investigation • Facial XR • CT (2mm coronal slices): prolapsed extraocular muscles, haemorrhage

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