Acute Eyes for ED. Enis Kocak. The Alfred Ophthalmology
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1 Acute Eyes for ED Enis Kocak The Alfred Ophthalmology
2 The problem with eyes
3 Things to cover Ocular anatomy Basic assessment Common presentations Eye first aid and procedures Ophthalmic emergencies What the Eye Reg will want to know Red flags to look out for
4 Surface anatomy
5 Anterior to posterior
6 History Blurred vision, pain, redness, irritation, tearing, flashes, floaters One or both eyes? Onset sudden or gradual Pain scratchy at the front or deep pain at the back Injury? Mechanism? Headaches, scalp tenderness Contact lens wear? Intraocular operations?
7 Triage Emergency Triage Education Kit. Australian Government Department of Health and Ageing
8 3 vital signs pupils vision pressure
9 Visual acuity with pinhole
10 Pupils Size Shape Reactivity Swinging light test (test for a relative afferent pupillary defect)
11 Pressure
12 Visual fields
13 Extraocular movements
14 Is this thing any good?
15 This thing is a lot better
16 Unilateral red eye Causes Conjunctivitis Infectious keratitis Corneal foreign body / abrasion Uveitis (epi)scleritis Angle closure glaucoma Trauma Post-operative When to refer Decreased vision Pain Hazy cornea Photophobia Newborn
17 Viral conjunctivitis Watery discharge Conjunctival injection, follicles?recent URTI Can be bilateral Usually normal vision Treatment Hand hygiene Isolate / clean room Decreased vision
18 Allergic conjunctivitis Itchy Stringy discharge?atopy vs acute allergy Papillae, mild injection Usually normal vision Treatment Avoid allergen Topical mast cell inhibitor Lubricant eye drops Decreased vision
19 Bacterial conjunctivitis Usually bilateral Sticky, gritty eyes Pus-like discharge Usually normal vision Treatment Topical antibiotics (Chlorsig 0.5%) Isolate / clean room Decreased vision Contact lens wear
20 Bacterial keratitis Pain, foreign body sensation Decreased vision Photophobia Epithelial defect/ulcer Treatment Refer urgently Hypopyon Contact lens wear Immunosuppression
21 Herpes simplex keratitis Pain, foreign body sensation Decreased vision Photophobia Dendritic ulcer Treatment Refer urgently Aciclovir ointment Hypopyon Immunosuppression
22 Corneal foreign body / abrasion Pain, foreign body sensation Red eye, photophobia Blurring if central Epithelial defect Treatment Removal of foreign body Topical antibiotics Decreased vision Aqueous leak Iris/pupil distortion
23 Removal with 25g needle
24 Always evert the eyelid!
25 Don t be afraid!
26 Subconjunctival haemorrhage Diffuse area of blood Normal vision No pain?anticoagulation, strain Treatment?investigation Trauma Circumferential haemorrhagic chemosis Cannot visualise posterior margin
27 Anterior uveitis Usually unilateral Irritation (pain), photophobia Decreased vision?autoimmune Hx Ciliary injection Treatment Refer urgently Topical steroids + cycloplegics Hypopyon Anterior chamber haze
28 Episcleritis Usually unilateral Irritation, photophobia Decreased vision?autoimmune Hx Ciliary injection (blanches with phenylephrine 10%) Treatment NSAIDs Topical steroids Pain Deep red
29 Scleritis Deep boring pain felt behind eye Wakes at night Tender globe?autoimmune/vasculiitic Hx Diffuse deep injection Treatment Refer urgently NSAIDs +/- systemic steroids Scleral thinning Decreased vision
30 Angle closure glaucoma Sudden-onset severe pain Nausea + vomiting Blurred vision +/- haloes Injection, cloudy cornea Mid-dilated pupil Very HIGH intraocular pressure Treatment Refer urgently Acetazolamide + laser iridotomy Unrelieved for several hours Renal impairment (Diamox)
31 Ocular trauma Key presentations Lid laceration Blunt trauma Penetrating eye injury Burns Things to consider Decreased vision Double vision High-speed mechanism Penetrating injury Low or high intraocular pressure Associated CNS injury Domestic violence
32 Lid lacerations Assess extent Treatment Tetanus Direct closure Prolapsed orbital fat Globe involvement Full thickness or lid margin Medial laceration (lacrimal involvement)
33 Blunt trauma Blurred vision Photophobia Need slit lamp exam with dilated fundus exam Exclude other injuries Treatment Refer urgently Head elevation Strict bed rest Raised intraocular pressure (or low!) 8 ball hyphaema Proptosis
34 Orbital fractures Periorbital ecchymosis/haemorrhage Periorbital oedema +/- crepitus Should have slit lamp exam Exclude other injuries Treatment Refer CT imaging?repair Raised intraocular pressure Double vision Proptosis
35 Penetrating eye injuries Do not check pressure Decreased vision Iris distortion Visible lac / wound / hyphaema Pain, photophobia, nausea Refer urgently Cover eye with shield or cup (not pad!) Antibiotics + antiemetics + analgesia Fast RAPD
36 Globe rupture Do not check pressure Decreased vision, pain Circumferential haemorrhagic chemosis Hyphaema, pupil distortion Risk: previous intraocular surgery Treatment Refer urgently Cover eye with shield or cup (not pad!) Antibiotics + antiemetics + analgesia Fast RAPD 8 ball hyphaema Prolapsed uveal contents
37 Chemical burns IRRIGATE first, question later Irrigate both eyes Substance: alkali worse than acid Treatment Topical amethocaine Irrigate with CSL via Morgan lens for at least 30 minutes Refer urgently Topical antibiotics + cycloplegics Contact lens No first aid / late presentation
38 Morgan lens
39 Flash burns Arc welding or UV burns Delayed onset of symptoms Blurred vision, foreign body sensation, pain, tearing Pinpoint epithelial defects Treatment analgesia Topical antibiotics + cycloplegics Diffuse areas of defect
40 Ophthalmic emergencies (Call!) Problem with their only good eye Something wrong with: Vision Pupils Pressure Trauma (esp penetrating eye injuries) Burns
41 Reading the Ophthalmology Note
42 Equipment for the ED eye room Pen torch Snellen chart Long cotton buds Fluorescein Amethocaine drops Tropicamide drops Direct ophthalmoscope with cobalt blue Slit lamp Morgan lenses 25g needles
43 Excellent resources Ophtho Book ( Tim Root s Atlas (
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