Eye Emergencies. Dr Carmel Crock FACEM Director, Emergency Department, RVEEH November 24 th ACEM ASM, Sydney
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1 Eye Emergencies Dr Carmel Crock FACEM Director, Emergency Department, RVEEH November 24 th ACEM ASM, Sydney 1
2 OUTLINE Intro history/examination Slit lamp Red eye Trauma 2
3 History Mechanism of injury?hammering *Photophobia *Pain/painful eye movements *Vision loss Haloes/vomiting GCA symptoms Flashes/floaters Contact lens wear 3
4 Difficult to assess?? Elderly Poor historian/language barriers Child 4
5 Ocular history Contact lens wearer High myope Previous surgery eg. laser (disrupt flap), cataract (endophthalmitis) PHx Uveitis PHx Herpes simplex PHx injury (RES) FHx glaucoma 5
6 Examination Record visual acuity With glasses Pinhole Count finger, hand movement, light perception, no light perception
7
8 Pupils Equal/round/reactive Test for Relative Afferent Pupillary Defect (RAPD) and record 8
9 RAPD - significance Optic nerve Chiasm Retina 9
10 RAPD -technique Darkened room Focus in distance Swinging flashlight Both pupils constrict one less brisk One dilates when light shone in it = RAPD 10
11 11
12 Examination Test visual fields to confrontation Test eye movements pain/limited Fundus/red reflex
13 Anatomy of eye 13
14 14
15 15
16 Cornea 5 layers Depth mm 16
17 17
18 Normal Cup/Disc ratio
19 Normal retina 19
20 20
21 21
22 22
23 Optic disc swelling 23
24 Malignant hypertensive retinopathy. Grosso A et al. Br J Ophthalmol 2005;89: by BMJ Publishing Group Ltd.
25 Anatomy of a Slit Lamp 25
26 Features Illumination system Magnification via binocular microscope 26
27 Basic Components: illumination Bulb Filters Slit height control Slit rotator Mirror Slit width control 27
28 Height Filters & Cobalt blue Filters 1.Unfiltered 2. Heat absorbing % Grey 4. Red free 5. Cobalt blue 28
29 Width 29
30 Basic Components: magnification Eye pieces Magnification changer Joy stick Lock Base carriage 30
31 Magnification Most slit lamps have: 2 objective settings (1 and 1.6) 2 eye piece options (10x and 16x) Total magnification ranges thus from 10x-25x 31
32 32
33 Step by step guide how to use 1. clean 2. practice turn on and using 3. bring in patient adjust chin rest, lat. canthus at line, forehead against band 4.prepare microscope - interpupillary distance, oculars set at 0, low mag 5.prepare light - low volt, 10% grey, wide beam 33
34 Microscope Interpupillary distance Oculars set at 0 Low mag Vs high mag How to move up/down, in/out 34
35 Light Brightness Width Height Cobalt blue 35
36 36
37 Use of the Slit Lamp Seat patient comfortably Adjust table, chair Position patient s head 37
38 38
39 Focus the Microscope by 1. Adjusting inter-puplillary distance Adjusting the eye pieces (set at 0 or dial in your refraction) 3. Checking magnification is on 1x setting 39
40 3 40
41 Focus Patient s Eye Microscope straight Light column degrees from side Microscope moves via joystick Move laterally Move in and out Bimanual 41
42 Adjust the Illumination Brightness: filters Width: slit vs broad beam Height: long vs pinpoint Cobalt blue 42
43 Trouble Shooting: unable to turn it on Check all connections 43
44 Trouble Shooting: power on - but no light Slit width closed Slit height too small Bulb burned out Bulb not positioned correctly 44
45 Trouble Shooting: difficulty moving instrument Unlock Check patient position 45
46 Trouble Shooting: difficulty focusing Check eye-pieces on correct setting Make sure patient s head in correct position Adjust joy stick in and out 46
47 Trouble Shooting: misalignment of slit and view Check magnification changer 47
48 Anterior Segment Examination Systematic examination of the eye from front to back 48
49 no FB no FB Lashes/ Lids Conjunctiva Cornea Sclera Anterior chamber -deep and quiet Iris Lens 49
50 50
51 51
52 52
53 53
54 54
55 Assessment of Depth 55
56 Abrasion versus Laceration 56
57 Do not remove deep CFB 57
58 Assessment of Depth Corneal Lesion Thin beam of light Illumination column degrees 58
59 Stain Cornea Use fluorescein (+/- do Seidel s test) Corneal abrasions 59
60 Fluorescein Absorbs light in blue wavelength Emits green fluorescence 60
61 Tips - fluorescein Don t forget to use it eg. HSV Measure size abrasion Total vs nil staining - chemical injury Fluorescein under lid upper lid abrasion Seidel s + or ve -document Self sealing wounds Apply fluorescein then wait for bit to see more subtle staining 61
62 Measuring Size of Lesion 62
63 Anterior Chamber Setting up to look at anterior chamber -darkened room 1mm beam height Bright intensity illumination High magnification Is the anterior chamber deep and quiet? 63
64 Grading of AC Cells (counted with 1x1 mm slit) Activity Cells SUN 2005 Am J Opthalmol 2005: 140:
65 65
66 Removing a Foreign Body 66
67 Removal of corneal foreign body with needle and with burr
68 Video cells in AC 68
69 Step by step guide how to use slit lamp - summary 1. clean 2. practice turn on and using 3. bring in patient - adjust chin rest, lat. canthus at line, forehead against band 4. prepare microscope - interpupillary distance, oculars set at 0, low mag 5. prepare light - low volt, 10% grey, wide beam 69
70 Step by step guide how to use slit lamp - summary 6. Examine lids, lashes, conj, sclera, cornea, iris, lens 7. Use narrow beam to examine corneal lesion measure depth 8. Set up to look at anterior chamber - depth, cells, flare - bright/1mm beam/high mag 9. Use fluorescein measure size lesion 10.Turn off and clean 70
71 Chemical Injury
72 How long to irrigate? How to measure ph? How bad is it? Underestimations of severity 72
73 Management of chemical injuries Immediate irrigation N. saline/hartmanns At least 30 mins (up to 8-10 Litres) Evert upper lid Remove particulate matter/debride necrotic tissue Sweep fornices cotton bud Measure ph wait until 5-10mins after irrigation irrigate until ph neutral (7.0)
74 Limbal ischaemia Test in 4 quadrants 3/6/9/12 o clock Local anaesthetic Cotton bud Watch vessels empty/ refill May be difficult to diagnose reliably 74
75 75
76 76
77 77
78 Grading of Chemical eye injuries Cornea Conjunctiva I epithelial loss no ischaemia II some stromal haze iris visible III widespread stromal haze, iris details obscure IV opaque no view iris or pupil ischaemia < 1/3 limbus ischaemia 1/3-1/2 limbus ischaemia > ½ limbus
79 Alkali Burns Protocol RVEEH (grade III/IV) G.Citrate 10% 2/24 G.Ascorbate 10% 2/24 G.Atropine 1% tds G.Flarex 2/24 G.Chlorsig qid Tablet Ascorbate 500mg qid Ural sachets Analgesia
80 80
81
82 The Red Eye
83 83
84 84
85 85
86 Ciliary flush 86
87 Amelanotic melanoma 87
88 88
89 Subconjunctival Haemorrhage
90 Adenoviral conjunctivitis
91
92 92
93 In the case of adenoviral infection removal of the inflammatory membrane and application of topical steroids may prevent the formation of symblepharon. 93
94
95 Adenoviral conjunctivitis Recent URTI or contact Eyes stuck down in am Preauricular lymph node Inferior palpebral follicles Subconjunctival haemorrhages Pseudomembranes Subepithelial infiltrates at 1-2 weeks Worse for first week Treat with lubricants
96 Chlamydia conjunctivitis
97 Allergic 97
98 98
99 HSV 99
100 Herpes simplex Conjunctivitis Corneal epithelial disease Corneal stromal disease Uveitis PCR and debride with swab (in adult) Needs referral acyclovir eye ointment 5/day for corneal epithelial disease
101 Recurrent erosion syndrome 101
102 Herpes Zoster Ophthalmicus
103 Herpes zoster ophthalmicus Conjunctivitis,corneal involvement (SPK,pseudodendrites, stromal keratitis), uveitis,scleritis,retinitis,cranial nerve palsy,glaucoma Oral antiviral if rash <72 hours Needs referral for topical steroid eye drops
104 Microbial Keratitis
105 Acanthamoeba
106 Marginal keratitis 106
107 Marginal keratitis Staph hypersensitivity 107
108 Acute angle closure glaucoma
109 Acute angle closure glaucoma 1.Diamox 500mg IV (if present acutely with symptoms otherwise give orally) 2.Pilocarpine 2% (4% in dark irides) stat Combigan stat (Use Alphagan 0.2% stat if has medical contraindication to Beta blocker) Pred Forte 1% stat Lie patient supine Analgesics and antiemetics as indicated Urgent U&Es 109
110 Measurement of IOP in general EDs Tonopen Applanation tonometry Icare (?) 110
111 Applanation tonometry 111
112 Tonopen Icare 112
113 Uveitis
114 Uveitis Pred forte hourly Opthalmology review 114
115 Endophthalmitis 115
116 Scleritis 116
117 Orbital Cellulitis
118 Matching CT shows proptosis, ethmoiditis
119 Orbital cellulitis Painful eye movements RAPD Proptosis IV ceftiaxone ENT and ophthalmology review 119
120 Children Measuring VA Remember fluorescein (HSV) High suspicion for possible penetrating injury Consider senior eye review 120
121 Trauma
122 Corneal abrasion Measure size Assess depth Corneal infiltrate AC activity Review eg. central/plant material Recurrent erosion syndrome 122
123 Blunt trauma cornea
124 Hyphaema
125 Iridodialysis-stone from lawnmower
126 Traumatic cataract
127 Blunt trauma-lens dislocation
128 Commotio retinae
129 Commotio retinae 129
130 Traumatic retinal detachment
131 Choroidal and retinal injury (netball)
132 Retrobulbar haemorrhage 132
133 Retrobulbar haemorrhage Decreased vision Painful/limited eye movements Proptosis RAPD Loss of color vision High IOP 133
134 Lateral canthotomy/ inferior cantholysis Timely, aggressive decompression Clinical diagnosis do not wait for imaging Blunt tipped scissors + heavy teeth forceps Canthotomy Inferior cantholysis strum, then cut Eyelid should come away from globe 134
135 Lateral canthotomy/ inferior cantholysis It would not be considered a standard of care for most emergency physicians to possess the skills for this procedure, but under the proper scenario, it may be a prudent intervention. Robert and Hedges 5 th Ed
136 136
137 Penetrating injury (misdiagnosed)
138 138
139 Penetrating trauma
140 Penetrating injury Shield Antiemetic Oral ciprofloxacin Tetanus 140
141 Diagnostic error HSV HZO AAC GCA AAU PEI 141
142 DEER Taxonomy
143 What went wrong: DEER Taxonomy Localization
144 What Not To Miss Subtarsal FB - always evert upper lid Microbial keratitis (especially in contact lens wearer) Herpes simplex and zoster Penetrating Injury/Intraocular FB Ruptured globe Retrobulbar haemorrhage Temporal arteritis (GCA) Amaurosis fugax Retinal detachment flashes/floaters Acute glaucoma Acute uveitis Orbital cellulitis Endophthalmitis Chemical injury
145 Should your patient be driving? 145
146
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