Red Eye & Ocular Emergencies. Zafar Shamoon Director of Emergency Services Dearborn Beaumont Hospital

Transcription

1 Red Eye & Ocular Emergencies Zafar Shamoon Director of Emergency Services Dearborn Beaumont Hospital

2 I have no relevant financial relationship with any manufacturers of any commerical products and or providers of commercial services discussed in this CME activity.

3 Goals of Lecture: 1.) Identify common red eye presentations in the E.R. setting 2.)Know when/how to treat and when to refer 3.) Know what to with an ocular emergency

4 A Little Eye Anatomy

5 The anterior chamber is the area bounded in front by the cornea and in back by the lens, and filled with aqueous. The aqueous is a clear, watery solution in the anterior and posterior chambers. The Canal of Schlemm is the passageway for the aqueous fluid to leave the eye. The choroid, which carries blood vessels, is the inner coat between the sclera and the retina.

6 The conjunctiva is a clear membrane covering the white of the eye (sclera). The cornea is a clear, transparent portion of the outer coat of the eyeball through which light passes to the lens. The iris gives our eyes color and it functions like the aperture on a camera, enlarging in dim light and contracting in bright light. The aperture itself is known as the pupil. The lens helps to focus light on the retina. The macula is a small area in the retina that provides our most central, acute vision.

7 The optic nerve conducts visual impulses to the brain from the retina. The ora serrata and the ciliary body form the uveal tract, an unseen part of the iris. The posterior chamber is the area behind the iris, but in front of the lens, that is filled with aqueous. The pupil is the opening, or aperture, of the iris. The retina is the innermost coat of the back of the eye, formed of light-sensitive nerve endings that carry the visual impulse to the optic nerve. The retina may be compared to the film of a camera.

8 The sclera is the white of the eye. The vitreous is a transparent, colorless mass of soft, gelatinous material filling the eyeball behind the lens.

9 Nerves of the Eye CN II (Optic): Vision CN III(Oculomotor) : Superior, Inferior, Medial Recti, Inferior Oblique, and Levator Palpebrae CN IV (Trochlear): Superior Oblique CN VI: (Abducens): Lateral Rectus SO4LR6AR3

10 RED EYE Red Eye is a cardinal sign of ocular inflammation Most cases are benign, with Conjunctivitis being the most common (allergic or viral) KEY IS TO KNOW WHEN TO REFER!!!

11 Patient Evaluation The successful evaluation of Red Eye depends on appropriate: HISTORY TAKING & VISUAL ACUITY

12 Important Questions to Ask: Onset? Past Ocular History (SX, Trauma? ) Past Medical History (DM, HTN, CA..) Is vision affected? (Blurry, Diminished, or Lost? Bilateral or one-side? Diplopia? Flashes or Floaters?) Foreign body sensation (scratchy,gritty, sharp?) Photophobia?

13 Important Questions to Ask: Trauma (finger poke, tools, punched?) Contact lens (clean properly, how long have they been in?) Discharge (color, how often, crusting?)

14

15 Subconjunctival Hemorrhage

16 Subconjunctival Hemorrhage Fragile Blood vessel ruptures Can be caused by Sneezing Coughing Straining Rubbing eyes Trauma Infection

17 Subconjunctival Hemorrhage Asymptomatic Subconjunctival Hemorrhage TX: Check BP & Artificial Tears

18 Blepharitis

19 Blepharitis Inflammation of lids that can take two forms: 1.) anterior, mainly caused by Staph aureus or 2.) posterior mainly infection of sebaceous glands.

20 Blepharitis Vision is normal Patient may have itching, burning, redness Gluing or Flaking of eye-lashes most common symptom TX: Baby shampoo to eye-lashes, warm compresses 4x/day for minutes. Erythromycin is more severe. Stop eye make up until infection resolves

21 Stye (external hordeolum)

22 Stye (external hordeolum) Inflammation of accessory glands on anterior lid margin. May be associated with Staph aureus (90%). May be caused by chronic blepharitis Patients complains of eyelid pain, burning at site, and general discomfort. Lasts 2-3days. TX: hot compress to area 4-6x/day. May add Erythromycin

23 Chalazion (internal hordeolum) Inflammation of meibomian glands. This is deeper than a stye!

24 Chalazion (internal hordeolum) TX: same as stye. May also be caused by chronic blepharitis, as shown here:

25 Pingueculum

26 Pingueculum Epithelial hyperplasia (usually yellow) on nasal bulbar conjunctiva. May be caused by excessive wind or sun exposure. Vision not usually affected. Symptoms include: Foreign body sensation, and focal redness. TX: Acular or Voltaren (Artificial tears)

27 Dacryocystitis

28 Inflammation of lacrimal sac Dacryocystitis Generally bacterial infection (Staph aureus and H. Influenza) obstructing nasolacrimal passage. Can be acute, chronic, or congenital. Congenital may result in orbital cellulitis, brain abscess, meningitis, sepsis and death. Location is usually in medial lower lid.

29 Dacryocystitis Symptoms include facial swelling/tenderness, mucopurulent discharge, & excessive tearing (which may alter vision.) TX: Oral and Topical Ab to cover suspected organism (usually Staph aureus and H. Influenza)

30 Viral Conjunctivitis

31 Viral Conjunctivitis Virus adhering to conjunctiva, producing symptoms of redness, watery discharge, irritation, itching, foreign body sensation, and possibly photophobia.no vision loss. Preauricular adenopathy usually present! 30% of all ocular complaints, increase in late fall months and early spring Adenovirus most common virus Longer course than bacterial (1-2weeks) Ask about possible exposure from school/home/work

32 Viral Conjunctivitis Highly contagious, must stay home from work/school. Throw away contacts & case. TX: Self resolving.cold compress and artificial tears for comfort, antihistamine for itching.

33 Bacterial Conjunctivitis

34 Bacterial Conjunctivitis Bacteria adhering to conjunctiva, producing symptoms of red eye, green/yellow purulent discharge, itchy. Woke up with one eye stuck shut! No vision changes. Preauricular adenopathy rarely present!(except in N. gonorrhoeae) Staph aureus, Strep pneumoniae, and Haemophilus influenzae most common organsims. TX: Topical sulfacetamide & quinolones work well.

35 Chlamydial Conjunctivitis

36 Chlamydial Conjunctivitis Chlamydial conjunctivitis typically affects sexually active teens and young adults (Subgroups D-K) Most frequent cause of neonatal conjuntivitis in U.S. (trachoma, subgroups A, B, Ba, & C). Leading cause of blindness in newborns!!!! Usually persistent infection (lasting over 3 weeks) TX: Adults: Doxyclycline, 100m.g. bid for two weeks or Zithromax 1 time 1 gram dose. Neonatal: Erythromycin

37 Allergic Conjunctivitis

38 Allergic Conjunctivitis Allergen produces marked pruritus and bilateral watery eyes (always!). Preauricular nodes never present. No pain or change in vision. TX:,artificial tears, cold compress, and possibly antihistamines.

39 Orbital Cellulitis

40 Orbital Cellulitis Infection of the soft tissues of the orbit Rare in adults, more common in kids (usually from infection originating in ethmoid sinus) Symptoms include fever, URI, swelling of upper and lower lids, reduced eye movement, and possible vision lost/diplopia Staph aureus, Strep pneumoniae, and Haemophilus influenzae most common organsims. CT to view orbit/sinus

41 Orbital Cellulitis Must refer quickly because potential of spreading to cavernous sinus leading to possible thrombosis or meningitis! TX: IV vanco, plus unasyn/clinda/rocephin/

42 Anterior Uveitis AKA = Iritis (Inflammation of iris) Can be granulomatous (systemic) and nongranulomatous Unknown mechanism (perhaps autoimmune?) Patient may present with pain, photophobia, red eye, and miosis.

43 Anterior Uveitis Flare & Inflammatory nodules seen in aqueous humor on slit lamp TX: Work up for underlying disease (sarcoid, seronegative spondyloarthpathy)

44 Keratitis Inflammation of cornea, which may be caused by UV exposure, excessive contact wear, & dry eyes. Symptoms include: Blurred vision, photophobia, foreign body sensation, possible corneal opacification. Strep, Pseudomonas, Enterobacteriaceae (Klebsiella, Proteus) HSV may cause denditic ulcer Identify quickly because may lead to vision loss (24-48hrs)!!

45 TX: Call and REFER! Keratitis

46 Ocular Emergencies

47 Chemical Burns

48 Chemical Burns 10% of all ocular related visits to E.R. 60% from work-related. Strong acid and alkaline compounds most devastating, altering ph and destroying proteins! Common acid exposure :Hydrofluoric Acid (glass polish), Sufurous Acid, Sulfuric acid (battery), Acetic Acid (vinegar) Common alkali exposure: fertilizers, cleaning products (ammonia), over and drain cleaners, fireworks, HCL.

49 Chemical Burns Patient may present with : Severe pain, photophobia, excessive tearing, blurred vision, foreign body sensation, extreme red eye! TX: Don t waste time getting a detailed history!! TREAT RIGHT AWAY!! Step 1--->: IRRIGATE, IRRIGATE, IRRIGATE with water!!!!!(ideally normal saline, lactate ringer)

50 Chemical Burns Step 2-->: Instill tetracaine or proparacaine for anesthetic Step 3 --->: Use cotton swab and sweep fornices, check both lids Step 4 --->: Check ph of eye Step 5 --->: Pain Control Step 6 --->:Check ph and send referral

51 Chemical Burns

52 Chemical Burns

53 Foreign Body

54 Foreign Body/Corneal Abrasion -Mostly airborne particles Patient presents with Red Eye, Foreign body sensation, photophobia, tearing TX: Step 1 --->: Get HX, Instill anesthetic,check acuity, look in eye, pulling lid down, and evert upper lid!! If there is any suspicion of a penetrating intraocular foreign body, then get special orbital x rays or CT scans to locate it or rule it out. Step 2 -->:A barely embedded foreign body might be touched out with a moistened swab as shown in the section on the conjunctival foreign body, but if firmly embedded, it will have to be scraped off (under magnification) with an ophthalmic spud or an 18 gauge needle.

55 Foreign Body/Corneal Abrasion Removal of the foreign body leaves a defect which is treated as a corneal abrasion. Step 3- If unclear, perform a fluorescein exam to document the extent of the corneal defect. (Document clock position ) Step 4 Abx and referal

56 Blow out Fracture and Hyphema

57 Blow out Fracture & Hyphema Trauma to the eye can cause bleeding in the front (or anterior chamber) of the eye between the cornea and the iris. This bleeding into the anterior chamber of the eye is called Hyphema. Patient may present with Red Eye, foreign body sensation, photophobia, tearing, blurry vision, double vision, decreased sensation to lower lid area 15-20% may experience further bleeding 3-5 days later

58 Blow out Fracture & Hyphema 7 bones make up the orbit of eye (Lacrimal, frontal, sphenoid, temporal, ethmoid, maxillary, nasal) Inferior orbital nerve and inferior rectus muscle runs through inferior oribit. Injury may result in decreased sensation to area & eye movement (upward and diplopia!)

59 Blow out fractures and Hyphema

60 Blow out fractures and Hyphema TX: Step 1--->: Detailed History Step 2 --->: Check acuity Step 3---->: Pain control Step 4---->: Image studies Step 5--->Shield, not patch!! Step 6---->: CALL OPTHO! *Instruct patient not to blow nose!

61 Sudden Vision Loss Acute angle-closure glaucoma Retinal Detachment Central Retinal Artery & Vein Occlusion

62 Acute Angle-Closure Glaucoma

63 Acute Angle-Closure Glaucoma Sudden elevation in IOP, arising from blocking aqueous outflow Rare, mostly in older patients, Patient present with acute loss of vision, blurred vision, associated nausea and vomit, corneal clouding, pupil not reactive to light, acute photophobia

64

65 Retinal Detachment Retina Peels Away from back of eye (vitreous from retina) Curtain coming down!!! Caused by old age, inflammation, or trauma Early signs include seeing brief flashes of light 1 in 15,000, 15% of population will get in other eye Patient may present with loss of vision, seeing spider webs, floaters, increased flashes. NO PAIN!!Dx depends on opthalmoscopic exam!

66 Retinal Detachment Tx ---->: Not much to do other then get HX and do fundoscopic exam. Requires surgery.

67 Retinal Detachment on US

68 Central Retinal Artery & Vein Occlusion Blood supply to retina is from retinal artery ( internal carotid- ---->ophthalmic artery >central retinal artery) Occlusion can result from thrombosis or embolism Usually a sign of arteriosclerosis, hypercoaguable states, or vasculitis Patient presents with sudden, painless loss of vision!! Hx reveals previous stroke, and/or HTN

69 Central Retinal Artery & Vein Occlusion Window is 4-6 hours to treat only 25% chance of retaining vision TX: Step 1--->Massage eye to increase pressure, rebreath own air with paper bag (causes increase in CO2). Step 2--> Detailed History, fundoscopic exam (cherry red macula with RAO, cotton wool spots, blotchy flame hemorrhages on RVO) Step 3-->Administer Carbonic anhydrase inhibitor (Acetazolamide) or Mannitol to decrease IOP. Step 4---> REFER!!

70 Central Retinal Artery Occlusion

71 Central Retinal Vein Occlusion

72 Systemic Diseases Diabetic Retinopathy Hypertension

73 Normal Eye 2:3 relationship of arteries to veins cup is.3 or less the of the optic nerve head Notice color, size, and margins Notice for any exudates, A-Vnickings, hemorrhages, or edema Inform patient not a true eye-exam!!

74 Normal Eye

75 Diabetic Retinopathy Estimated 16 million American with disease As many as 5,000 people a year lose their sight as result of retinal damage secondary to disease! After 15 years, 2/3 of diabetic patients may have eye complications secondary to disease. After 30 years ---->90%

76 What to look for in Diabetic Retinopathy Dilated and full retinal veins Blot and dot retinal hemorrhages Yellowish exudates in macula area Cotton-wool spots F/U with Optho every year, depending on family HX and risk factors!

77 Normal Diabetes

78 Diabetic Retinopathy

79 Hypertensive Retinopathy Estimated that well over 50% of population over the age of 50 has HTN! What to look for :cotton-wool spots, hard exudates, optic disc edema, retinal hemorrhages, copper-wire appearance of arterioles, A-V nicking

80 Hypertensive Retinopathy

81 Normal Hypertensive Retinopathy

82 Summary Know what to treat and when to refer!!! GET ACCURATE MEDICAL HX (most important!!) Know what to do for emergent situations (burns, fractures, acute loss of vision). Identify important retinal changes from common systemic diseases.

83 References Trobe, Jonathan M.D. The Physicians Guide to Eye Care, American Academy of Opthamlmology, Fauci, et al, Harrisons Principles of Internal Medicine, 14th edition, s/icp2/fundi-icp2.htm es/exam.html phthal/index.html