10 EYE EMERGENCIES. Who goes, who you better not send! Brant Slomovic, MD, FRCPC University Health Network
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1 10 EYE EMERGENCIES Who goes, who you better not send! Brant Slomovic, MD, FRCPC University Health Network
2 DISCLOSURES I have none
3 PVD CASE 1
4 WHAT IS A PVD? a process of aging (45-55) liquefaction of vitreous vitreous separates from retina benign, mild, self-limiting present with floaters divided into PVD with tear and PVD without tear
5 MORE ABOUT FLOATERS PVD - small, single, cob web, crescent shaped/ring shaped retinal tear - hundreds of tiny black specks vitreous hemorrhage - large, thick, opaque, smudge
6 RD CASE 2
7 RETINAL DETACHMENT Retinal detachment occurs when the neurosensory retina layer separates from the underlying retinal pigment epithelium and choroid
8 RD rhegmatogenous (break/tear) non-rhegmatogenous (leak/pull) posterior vitreous detachment retinal flap/tear dissection - retina/pigment epithelium exudative serous/hemorrhagic hydrostatic - severe HTN inflammation - sarcoid neoplastic traction mechanical forces fibrotic tissue previous bleed/injury
9 RHEGMATOGENOUS RD tear bleeding into vitreous fluids enters and dissects between layers separation, from periphery towards macula vision threatened
10 MACULA ON vs OFF ON fovea is attached - good initial vision 20/30-2/50 better prognosis OFF retina is detached centrally worse vision, worse prognosis 20/100-20/400
11 the goal is to manage the macula on RD!
12 for patients who present with floaters or flashes, decrease in vision is the most important symptom suggesting a retinal detachment
13 There is no general consensus on how soon patients presenting with a symptomatic posterior vitreous detachment and no other visual symptoms should be referred for a definitive examination. BMJ May 31; 336(7655):
14 FOLLOW UP URGENT (days) EMERGENT (same day) new flashers or floaters WITHOUT any significant change in visual acuity or field deficit new flashers and floaters with associated changes in visual acuity field deficit and/or abnormal exam
15 CASE 3 Herpes Simplex Virus
16 HERPES SIMPLEX primary infection at any age unilateral vesicular lesion at presentation cornea - dendrite
17
18
19 HSV Tx topical antivirals (Viroptic) oral acyclovir topical erythromycin NO STEROIDS urgent follow up
20 CASE 4 Herpes Zoster Ophthalmicus/ VZV
21 ZOSTER (HZO) usually in adults unilateral DOES NOT CROSS MIDLINE V1 dermatome distribution Keratitis/Uveitis
22
23
24 HZO Tx immediate Ophtho consultation steroids cycloplegics? iv Acyclovir Erythromycin ointment narcotic analgesia
25 CASE 5 pre-septal (peri-orbital) cellulitis
26
27 PRE-SEPTAL (orbital) CELLULITIS usually in younger children lid edema, erythema and warmth tenderness sinusitis as most common cause ABSENCE of findings associated with orbital!
28 CASE 6 septal (orbital) cellulitis
29
30 ORBITAL CELLULITIS usually an extension of peri-orbital infection ethmoid sinus in 90% most commonly strep species but also MRSA fever, malaise, headache decreased vision, increased IOP, painful EOMI s
31
32 ORBITAL CELLULITIS CT MRI admit for broad-spectrum iv antibiotics some require surgical drainage
33 CASE 7 Corneal Abrasion
34 CORNEAL ABRASION an epithelial defect that stains with fluorescein absence of underlying opacification contact lens wearer - must treat with anti pseudomonal abrasions from fingernails or vegetable matter should be covered with fluoroquinolone
35
36
37 SEIDEL SIGN
38 CASE 8 Corneal ulcer (bacterial keratitis)
39 CORNEAL ULCER an ophthalmologic emergency usually follows traumatic break in epithelium increase in soft contact lens wear - increased incidence THINK WHITE
40 CORNEAL ULCER visual acuity variable erythema, ciliary injection infiltration of stroma - opaque appearance round/oval bacterial, viral (Herpes), fungal, protozoal
41
42
43
44 CASE 9 Acute Angle Closure Glaucoma by definition, increased IOP and decreased vision!
45
46 AACG symptoms (at least 2 of): ocular pain nausea/vomiting blurry vision with halo
47 AACG signs (at least 3 of): IOP > 21 conjunctival injection corneal edema non-reactive, mid dilated pupil
48
49
50 TREATMENT of AACG ophtho consult Acetazolamide 500 mg iv, then po topical beta blocker (Timolol) anti-emetics, analgesia Pilocarpine, after 1 hour. q 15 min
51 CASE 10 (Gian Cell) temporal arteritis
52 TEMPORAL ARTERITIS a chronic vasculitis of large/medium vessels mean age 72 feared complication of visual loss new headache tenderness at temple visual symptoms
53 TEMPORAL ARTERITIS systemic: fever (1/2), fatigue, weight loss headache (2/3) jaw claudication (1/2) visual symptoms: amaurosis (TIA, CRAO), vision loss PMR (1/2)
54 Giant cell arteritis: laboratory predictors of a positive temporal artery biopsy CRP has highest predictive value of biopsyproven temporal arteritis (OR = 5.3) thrombocytosis (OR = 4.2) ESR (OR = 1.5) Ophthalmology Jun;118(6):1201-4
55 TREATMENT OF GCA steroids are the mainstay treatment initiated if high suspicion, prior to definitive diagnosis initial dose mg prednisone if visual loss - pulse methylprednisolone
56 KEY POINTS you should be able to clinically differentiate RD from PVD - progression, abnormal VA, field defect. Herpes simplex is rather benign, out pt follow up, zoster is a same day referral pre-septal cellulitis NO vision changes, fever, proptosis, rarely conjunctival findings. ulcer has a grey/white base, round, look for hypopyon, examine before staining AACG usually P > 40, eye findings with headache, nausea, fever. Pilocarpine after 1 hour CRP is most sensitive marker for GCA
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