Bleeding in the anterior chamber, obstructing vision Caused by surgery, injury, coagulopathy, sickle cell or idiopathic Needs urgent care to prevent

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Anthony Burns
6 years ago
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care to prevent long-term vision loss TX by elevating head of bed,

1 Bleeding in the anterior chamber, obstructing vision Caused by surgery, injury, coagulopathy, sickle cell or idiopathic Needs urgent care to prevent long-term vision loss TX by elevating head of bed, reducing intraocular pressure, treating coag issues, and if necessary - surgery

2 Posterior Chamber & Retina Macular Degeneration Papilledema Retinal Detachment Retinal Vascular Occlusion Retinopathy

Irreversible central vision loss wet & dry types #1 cause of

lead to loss of nutritional supply and eventually vision loss

Metamorphosia: distortion of vision observed on an Amsler grid No

5 Irreversible central vision loss wet & dry types #1 cause of permanent vision loss after age 50 Drusen deposits in the retina lead to loss of nutritional supply and eventually vision loss Exam reveals mottling and hemorrhaging of the retina Metamorphosia: distortion of vision observed on an Amsler grid No truly effective TX known. Laser treatments, vitamins, antioxidants are often prescribed.

6 Swelling of the optic disc/nerve secondary to increased intracranial pressure Associated SX: Headache, N/V If you see papilledema, consider: CNS tumor Intracranial hypertension Ventricular system obstruction

Usually occurs in the superior temporal quadrant SX:

7 The retina detaches from the underlying epithelial layer causing it to flap into the vitreous humor Usually occurs in the superior temporal quadrant SX: acute, painless vision changes curtain coming down, flashes, floaters

8 PE w/ relative afferent pupillary defect (RAPD) Visualization of the detachment may be visible on fundoscopic exam TX includes: Laser or cryo surgery Patient lies supine with head to affected side 80% recover 15% need treatment 5% never recover

9 Thrombosis or embolus Sudden onset of painless unilateral vision loss Fundoscopy reveals pallor of the retina with a cherry red spot, narrowed arteries This is an EMERGENCY Refer to ED/Ophtho - however, prognosis is poor Breathe into bag - CO 2 for vasodilation

10 Thrombotic event; usually seen with diabetes, glaucoma, hyperlipidemia Sudden onset of painless unilateral vision loss Fundoscopic exam shows hemorrhage, dilated veins, optic disc edema aka blood & thunder Has the potential to recover with time (not always)

leads to: hard exudates, edema, hemorrhages, microaneurysms, venous dilation

11 Hypertensive Chronic elevated BP leads to AV nicking, cotton wool spots, copper or silver wiring, arteriole narrowing, papilledema Diabetic Chronic hyperglycemia leads to: hard exudates, edema, hemorrhages, microaneurysms, venous dilation Treat underlying disease as vision loss can be permanent. Laser treatment is often used.

12 Orbit Blowout Fracture Foreign Body Penetrating Trauma Orbital Cellulitis

$downward gaze Observation indicated for nondisplaced fracture with normal EOM Surgery (ORIF) indicated: Trapdoor entrapment of inferior rectus 40%-50% loss of orbit floor 20% globe volume loss$

14 Fracture often occurs at the weakest point in the floor, the infraorbital groove Diplopia and enophthalmos can be present Entrapment of the inferior rectus muscle can lead to diminished EOM in downward gaze Observation indicated for nondisplaced fracture with normal EOM Surgery (ORIF) indicated: Trapdoor entrapment of inferior rectus 40%-50% loss of orbit floor 20% globe volume loss Retrobulbar hematoma or optic nerve injury

with moist cotton swab If object embedded,

15 Symptoms: Pain, redness, irritation, FB sensation Always flip eyelid to look for FB underneath Fluorescein stain and Wood s lamp to eval Gently remove loose objects with moist cotton swab If object embedded, it may have to be removed with 18G needle or scoop

17 Do not attempt to remove or manipulate object Do not apply pressure (tonometry = no-no!) Positive Seidel s sign (leaking fluorescein) is pathognomonic for open globe Shield the eye Immediate ER visit with Ophtho consult

SX: ptosis, eye pain, exophthalmos, periorbital edema

19 Infection of the orbit, usually an extension from adjacent sinusitis Signs: fever, decreased/painful EOM SX: ptosis, eye pain, exophthalmos, periorbital edema CT orbits +/- sinuses/brain TX: broad spectrum IV ABX vs surgery

20 Neurologic & Musculoskeletal Nystagmus Optic Neuritis Strabismus

21 Involuntary eye movements due to abnormality in the vestibulo-ocular reflex pathway Horizontal nystagmus indicates peripheral vestibular disorder (BPPV, Meniere s, labyrinthitis) Vertical nystagmus indicates central pathology (CNS tumor, MS, congenital)

Unilateral vision loss Color vision alteration Flashing lights Papillitis MRI with

22 Inflammation of the optic nerve Associated with: Multiple Sclerosis Infections (viral, bacterial) Drugs (ethambutol for TB) SX: Pain with eye movements Unilateral vision loss Color vision alteration Flashing lights Papillitis MRI with contrast is highly sensitive Oral steroids are not effective High-dose IV steroids speed recovery

23 Misalignment of the eyes resulting in absence of binocular fixation May be observed with corneal light reflex test May be hidden (latent) and revealed with the cover-uncover test TX includes exercises and/or surgery

$Loss of vision in one eye which is not correctable with refraction caused by ocular pathology interfering w/ normal cortical visual development In childhood, if an eye isn t functional, the visual$

24 Loss of vision in one eye which is not correctable with refraction caused by ocular pathology interfering w/ normal cortical visual development In childhood, if an eye isn t functional, the visual center in the brain for that eye won t develop and will never learn to see with that eye Can be caused by: Strabismus (most common) Deprivation (like a cataract) Severe unequal refractive error on one side TX early with corrective lenses, patching the good eye, and resolution of the visual inequity If left untreated, vision loss is permanent

25 Practice Questions

26 An 80 year old female presents w/ R eye pain and injection she states began after a rash came up on my forehead. Exam w/ fluorescein and Wood s lamp reveals a dendritic-appearing corneal lesion. What class of medications would be contraindicated in TX ing this condition? A. Antivirals B. Beta blockers C. Steroids D. Carbonic anhydrase inhibitors E. NSAIDs

27 A 24 year old sexually-active male presents w/ rapidly worsening injection and discharge to both eyes failing outpatient conjunctivitis TX. Exam is notable for copious, thick purulent discharge. A gram stain of the discharge might reveal what finding to help confirm the expected pathogen? A. Gram-negative diploccoci B. Gram-positive cocci in clusters C. Gram-negative rods D. Nothing - this is likely chlamydia E. Nothing - this is likely adenovirus

28 A 57-year-old male complains of severe L eye pain after going into a movie theater. Visual acuity is 20/35 OD & 20/100 OS. Associated symptoms include headache, N/V. The L eye is injected, the cornea is steamy and the pupil is fixed & dilated. What finding would you anticipate on exam? A. Homonymous hemianopsia B. Papilledema C. Tonometry reading of 50 mmhg D. Restricted downward gaze E. Retinal pallor with a cherry red spot

29 A 10-year-old female presents with acute right eye pain after playing outside. Visual acuity is 20/25 OU. Fluorescein staining reveals a zigzag pattern of increased uptake on the cornea. Eye exam is otherwise normal. What is the most likely diagnosis? A. Viral conjunctivitis B. Bacterial conjunctivitis C. HSV conjunctivitis D. Corneal abrasion E. Corneal ulcer

30 What component of the physical exam should you skip/defer in patients with a suspected open globe injury? A. Pupillary response B. Visual acuity C. Extraocular movements D. Fluorescein stain E. Tonometry

32 Markedly decreased visual acuity/loss Severe pain/photophobia, HA, N/V Limbic flush instead of peripheral Abnormally shaped/reactive pupils Severe pain/limitation w/ EOMs All alkali and most acid burns

33 High force or penetrating trauma Large corneal lac or any ulcer Zoster rash w/ dendritic lesion Hypopion & hyphema Increased IOP w/ tonometry Severe conjunctivitis failing O/P TX

34 EM: THANK YOU! Evals appreciated!!!

Ocular Urgencies and Emergencies

Ocular Urgencies and Emergencies Pam Boyce, O.D., F.A.A.O. Boyce Family Eye Care, Ltd. 528 Devon Ave. Park Ridge, IL 60068 847-518-0303 Somebody s going to lose an eye Epidemiology 2.4 million ocular and