Ocular Urgencies and Emergencies
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1 Ocular Urgencies and Emergencies Pam Boyce, O.D., F.A.A.O. Boyce Family Eye Care, Ltd. 528 Devon Ave. Park Ridge, IL
2 Somebody s going to lose an eye
3 Epidemiology 2.4 million ocular and orbital injuries in the US per year 20,000 to 68,000 are vision-threatening
4 Exam Ocular and medical history Visual acuity Pupil responses EOM s External exam Tonometry Visual field Fundus exam
5 Emergency Supplies Ph paper Eyepads/shield Surgical tape Forceps Sterile swabs Sterile irrigation solution Lid speculum medications
6 True Emergencies Chemical burn (alkali) Central retinal artery occlusion Sudden loss of vision Transient vision loss Penetrating injury
7 Urgent Situations Acute (angle closure) glaucoma Acute uveitis Hyperacute conjunctivitis Corneal abrasion Corneal foreign body Corneal ulcer Hyphema Retinal detachment Orbital cellulitis Trauma
8 Orbital Fractures Fracture of the orbital floor or nasal wall may force air from the sinuses into the orbit Signs include proptosis, subconjunctival air, crepitus, orbital emphysema, epistaxis, enophthalmos, and depressed nose bridge Avoid coughing and do not blow nose Treat with ice packs, nasal decongestants, and broad-spectrum antibiotics
9 Blow-out Fracture Due to blunt trauma to inferior rim, compressing the globe within the orbit Most common sign is restriction of vertical motility Requires x-ray or CT scan Surgical repair if diplopia persists or cosmetically unacceptable enophthalmos
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13 LeFort Fracture Severe blunt trauma separating facial structures Usually hospitalized patients CT scan needed
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15 Follow Up Check at one and two weeks post-trauma for diplopia and enophthalmos Education patient on signs and symptoms of orbital cellulitis and retinal detachment
16 Chemical Burn Time and action are critical Outcome depends on Rapidity of treatment Duration of exposure ph and concentration of solution
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18 Acid Burn Sulfuric (battery acid), hydrofluoric, hydrochloric Usually a self-limiting burn Less damaging to cornea than alkali
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21 Alkali Burn Lime (plaster, cement), lye (drain cleaner), ammonia (cleaning solutions) Very damaging Penetrates cell membranes
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24 Chemical Burns Treat first Irrigate for at least 30 minutes Neutral solutions: sterile saline, H2O Take ph Continue until neutral
25 Penetrating Injury
26 Penetrating Trauma
27 Penetrating Trauma Plastic shield with tape until can get to emergency room. Requires surgery Antiobiotics
28 Anterior Uveitis Vast majority of cases are idiopathic Differentially diagnose trauma, connective tissue disorders, Sarcoid Workup several bilateral or recurrent cases
29 Hyperacute Conjunctivitis
30 Bacterial Conjunctivitis Main causes are staph, strep, neisseria, hemophilus Mucopurulent discharge No preauricular node Most are self-limiting (except neisseria) Treat with culture and broad spectrum antibiotic
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33 Corneal Abrasion Trauma is the leading cause Males
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36 Topical Therapy May be sufficient for small abrasions with minimal discomfort Cycloplegic Antibiotic drop or ung qid Lubrication NSAID optional Follow up 1-2 days
37 Corneal Laceration Small full or partial thickness lacerations may generally be treated as abrasions with patching therapy Larger wounds often require surgery
38 Corneal Foreign Body Get consent from patient for removal, inform of risk of scarring Evert lid to look for remaining particles Foreign body tracking Anterior chamber evaluation Seidel s sign Dilate
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41 Irrigation Removal
42 Intraocular Foreign Body Take possibility into consideration with high-velocity injuries Look for: corneal laceration, iris tear, lens opacity, collapsed anterior chamber, low IOP, FB Rule out with dilation, b-scan, CT scan High risk of endophthalmitis Treatment is surgical removal
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44 Hyphema Tear of anterior ciliary body Child vs. adult Traumatic vs. spontaneous
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48 Hyphema Treatment Hospitalization for children and elderly Bed rest vs. limited activity Limited ocular motility Patch Cycloplege Steroids antifibrinolytic
49 Rebleed Usually occurs day 2-5 after initial injury Frequently worse than original hyphema
50 Retinal Detachment Rhegmatogenous due to a hole or break, symptoms of flashes/floaters/veil, see convex elevation of retinal next to break Exudative due to tumors, inflammatory lesions, congenital anomalies, see clear fluid elevation which shifts upon head movement
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55 Choroidal Damage Choroid is weaker than the sclera or retina and more likely to suffer damage secondary to blunt trauma Choroidal rupture is usually from a contrecoup (indirect) injury Concentric to the disc SRNVM may be a late complication
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58 Macula Macular holes can follow commotio retinae, choroidal ruptures, or subretinal hemorrhages Can also occur with whiplash injury May present years after trauma BIO and FANG differentiate full from partial thickness holes
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62 Orbital Cellulitis Usually results from the spread of infection from the paranasal sinuses Additional causes are deep puncture wounds, surgical (dental), trauma, acute dacryocystitis, hordeolum, and dog or insect bites
63 Orbital Cellulitis Symptoms including decreased VA, pain on eye movement with decreased ocular motility, fever, and double vision differentiates orbital from preseptal cellulitis, which does not penetrate the orbital septum but involves only the eyelid and brow
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67 Treatment Hospitalization is typically required Prognosis for full recovery is excellent when treated
68 Questions?
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