Ocular Emergencies. What is an emergency to the patient is not necessarily an emergency to the staff

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OCULAR EMERGENCIES Ophthalmic Photographers Society November 15, 2013 Michael A.

emergency to the patient is not necessarily an emergency to the staff the dog ate my glasses and I m

this lid droop!!! OCULAR EMERGENCIES BLURRY VISION WHAT IS THE HISTORY?

VISUAL ACUITY SNELLEN CHART NEAR CARD CONSIDER AGE AVAILABLE PRINT C.F./H.M.

color changes field of vision Patient can: read the paper count my fingers at 3 feet see my hand wave

1 OCULAR EMERGENCIES Ophthalmic Photographers Society November 15, 2013 Michael A. DellaVecchia MD PhD FACS Wills Eye Emergency Department Philadelphia PA Ocular Emergencies What is an emergency to the patient is not necessarily an emergency to the staff the dog ate my glasses and I m going on vacation tomorrow I lost total sight suddenly in my right eye two weeks ago and now I have this lid droop!!! OCULAR EMERGENCIES BLURRY VISION WHAT IS THE HISTORY? WHAT PART OF THE ANATOMY IS THE CAUSE? VISUAL ACUITY SNELLEN CHART NEAR CARD CONSIDER AGE AVAILABLE PRINT C.F./H.M. DISTANCE LIGHT PERCEPTION VISUAL FIELD ASSESS VISUAL ACUITY Try to determine the extent of the problem color changes field of vision Patient can: read the paper count my fingers at 3 feet see my hand wave can see light OCULAR EMERGENCIES Changes in appearance SUBCONJUNCTIVAL HEMORRHAGE (spontaneous) red eye subconjunctival hemorrhage inflammation with injection ptosis 3 BASIC QUESTIONS: - Over white of the eye? - Does it hurt? - Change in vision?

$IOFB PTOSIS HISTORY WAS IT THERE BEFORE DID AN EVENT CAUSE IT (trauma) ANY RELATED MEDICAL HISTORY myasthenia OCULAR EMERGENCIES REFRACTIVES CHANGES»Pin hole refraction» glasses»near card - any near$ card OCULAR EMERGENCIES REFRACTIVES CHANGES SURFACE DISEASE dry eyes, epithelial defects CORNEA dysfunction / inflammation/edema AQUEOUS LENS VITREOUS REFRACTIVE CHANGES AQUEOUS Inflammation - flare

card OCULAR EMERGENCIES REFRACTIVES CHANGES SURFACE DISEASE dry eyes, epithelial defects CORNEA dysfunction / inflammation/edema AQUEOUS LENS VITREOUS REFRACTIVE CHANGES AQUEOUS Inflammation - flare

2 SUBCONJUNCTIVAL HEMORRHAGE SPONTANEOUS - ETIOLOGY USUALLY UNDETERMINED COUGHING, SNEEZING = physical pressure HYPERTENSION ANTICOAGULANTS IF TRAUMATIC, MAKE SURE THERE IS NO OTHER INJURY; MAY MASK AN IOFB PTOSIS HISTORY WAS IT THERE BEFORE DID AN EVENT CAUSE IT (trauma) ANY RELATED MEDICAL HISTORY myasthenia OCULAR EMERGENCIES REFRACTIVES CHANGES»Pin hole refraction» glasses»near card - any near card OCULAR EMERGENCIES REFRACTIVES CHANGES SURFACE DISEASE dry eyes, epithelial defects CORNEA dysfunction / inflammation/edema AQUEOUS LENS VITREOUS REFRACTIVE CHANGES AQUEOUS Inflammation - flare and cells - hypopion Blood - hyphema REFRACTIVE CHANGES LENS Cataract Lens (IOL) dislocation REFRACTIVE CHANGES VITREOUS Vitritis Hemorrhage Intravitreal foreign body RETINA / VASCULAR - non - refractable Ocular Emergencies Circulatory emergencies arterial occlusions longstanding cause vasculopathy embolic origin? hypotensive (shock)

3 Ocular Emergencies Circulatory venous occlusions manage the systemic condition hypertension glaucoma glaucoma acute attack Ocular Emergencies rapid increase in pressure treat as soon as possible to avoid permanent optic nerve damage

Ocular Emergencies Retina detachment Diabetic hemorrhage OCULAR TRAUMA EXTERNAL & SURFACE INJURIES EYELID

RULE: OCULAR TRAUMA More intraocular damage the less orbital damage and vice versa MOMENTUM THE GREATER THE

TRAUMA OCULAR TRAUMA sinuses Orbit encircling globe EVALUATION HISTORY BEFORE THE EXAMINATION CAUSATIVE AGENT

4 Ocular Emergencies Retina detachment Diabetic hemorrhage OCULAR TRAUMA EXTERNAL & SURFACE INJURIES EYELID LACERATIONS SUBCONJUNCTIVAL HEMORRHAGE CORNEAL ABRASION FOREIGN BODIES BLUNT/SHARP TRAUMA CHEMICAL BURNS GENERAL RULE: OCULAR TRAUMA More intraocular damage the less orbital damage and vice versa MOMENTUM THE GREATER THE MOMENTUM THE GREATER THE DAMGE velocity x mass = momentum speed x size = punch SKULL = PROTECTIVE ANATOMY OCULAR TRAUMA OCULAR TRAUMA sinuses Orbit encircling globe EVALUATION HISTORY BEFORE THE EXAMINATION CAUSATIVE AGENT FORCE & DIRECTION PRIOR TO MANIPULATING EYE PEN LIGHT VISUAL EXAM OBTAIN VISUAL ACUITY BASIC ANATOMY OBSERVE STRUCTURE - GATHER THE EVIDENCE

OCULAR TRAUMA EYELID LACERATIONS CHECK FOR INVOLVEMENT OF PUNCTI, CANALICULAR DUCTS

sac lacrimal duct EYELID LACERATIONS (repairs) MINOR HORIZONTAL CUTS CAN BE SUTURED

INTEGRITY FOREIGN BODIES: CONJUNCTIVAL INSPECT THE CONJUNCTIVA TOPICAL ANESTHETIC

THE UPPER LID REMOVE WITH STERILE SWAB OR INSTRUMENT SWEEP THE UPPER CUL-DE-SAC

AGENT CORNEAL ABRASION BULBAR CONJUNCTIVAL FOREIGN BODY ETIOLOGY Object finger, claw,

5 OCULAR TRAUMA EYELID LACERATIONS CHECK FOR INVOLVEMENT OF PUNCTI, CANALICULAR DUCTS CHECK FOR UNDERLYING INVOLVEMENT OF GLOBE lacrimal gland puncti canniliculi lacrimal sac lacrimal duct EYELID LACERATIONS (repairs) MINOR HORIZONTAL CUTS CAN BE SUTURED IF EYELID MARGIN INVOLVED, NEED PLASTIC REPAIR TO PRESERVE LID FUNCTION AND TEAR INTEGRITY FOREIGN BODIES: CONJUNCTIVAL INSPECT THE CONJUNCTIVA TOPICAL ANESTHETIC FOREIGN BODY TENDS TO MIGRATE TO UPPER TARSUS (from blink mechanism) LEARN TO FLIP THE UPPER LID REMOVE WITH STERILE SWAB OR INSTRUMENT SWEEP THE UPPER CUL-DE-SAC ANTIBIOTIC COVERAGE? AGENT CORNEAL ABRASION BULBAR CONJUNCTIVAL FOREIGN BODY ETIOLOGY Object finger, claw, vegetable, inert Method force Bungee cord, weed wacker RULE OUT IOFB PALPEBRAL CONJUNTIVAL FOREIGN BODY WITH ABRASION TOPICAL ANESTHESIA usually helps in the diagnosis

CORNEAL ABRASION: TREATMENT WARN OF CONTINUED PAIN SYSTEMIC

(2 IRITIS FREQUENT) SEE THE NEXT DAY IF ABRASION LARGE OR

POTENTIAL RECURRENT EROSION FOREIGN BODIES: CORNEAL TOPICAL

OR FURTHER INFLAMMATION WILL OCCUR NON-METALIC MAY BE

NEEDLE, MECHANICAL BURR TOPICAL ANTIBIOTIC, CYCLOPLEGIC

HISTORY -- FIST, TENNIS BALL, ETC CHECK VISION INSURE GLOBE

6 CORNEAL ABRASION: TREATMENT WARN OF CONTINUED PAIN SYSTEMIC ANALGESIC TOPICAL ANTIBIOTIC SOLUTION/OINTMENT CYCLOPLEGIC (2 IRITIS FREQUENT) SEE THE NEXT DAY IF ABRASION LARGE OR CENTRAL NEVER PRESCRIBE ONGOING TOPICAL ANESTHETIC POTENTIAL RECURRENT EROSION FOREIGN BODIES: CORNEAL TOPICAL ANESTHETIC EMBEDDED RUST NEEDS TO BE REMOVED AT SLIT LAMP OR FURTHER INFLAMMATION WILL OCCUR NON-METALIC MAY BE REMOVED WITH IRRIGATION OR GENTLY WITH SWAB STERILE SMALL NEEDLE, MECHANICAL BURR TOPICAL ANTIBIOTIC, CYCLOPLEGIC PAIN RX, SEE NEXT DAY BLUNT TRAUMA: ANTERIOR SEGMENT CHECK HISTORY -- FIST, TENNIS BALL, ETC CHECK VISION INSURE GLOBE IS INTACT CHECK PUPIL, MUSCLE FUNCTION, SKIN SENSATION PALPATE ORBITAL RIM, - IMAGING

OCULAR TRAUMA INTRAORBITAL PRESSURE TRANSMITTED FORCE

Initial force EYE REACTION DECREASES IN ANTERIOR -

PRESSURE TRANSMITTED TO ORBITAL BONES AND CREATES SHOCK

BLUNT TRAUMA (resultant pathology) HYPHEMA TRAUMATIC

ORBITAL FRACTURE BLOWOUT FRACTURE DECREASED SENSATION IN

7 OCULAR TRAUMA INTRAORBITAL PRESSURE TRANSMITTED FORCE BLUNT MECHANISM: A-P DIAMETER EQUATORIAL DIAMETER Initial force EYE REACTION DECREASES IN ANTERIOR - POSTERIOR DIAMETER INCREASES IN LATERAL DIAMETER PRESSURE TRANSMITTED TO ORBITAL BONES AND CREATES SHOCK WAVE INITIAL FORCE REBOUND FORCE REBOUND FORCE EVERYTHING STARTS TO jiggle resultant deformation,forces, pressure rise TRANSMITTED FORCE BLUNT TRAUMA (resultant pathology) HYPHEMA TRAUMATIC IRITIS DISLOCATED LENS RETINOPATHY RUPTURED GLOBE ORBITAL FRACTURE BLOWOUT FRACTURE DECREASED SENSATION IN INFRA-ORBITAL NERVE DISTRIBUTION CHEEK VERTICAL DIPLOPIA IR/IO SUBCUTANEOUS AIR ETHMOID Precautions for nose blowing

8 BLOWOUT FRACTURE THIN ORBITAL FLOOR, MEDIAL WALL ORBITAL CONTENTS ENTRAPED IN FRACTURE CLOUDING OF MAXILLARY, ETHMOID SINUSES ON CT MEDIAL WALL FRACTURE FLOOR FRACTURE MEDIAL WALL FRACTURE MEDIAL RECTUS ENTRAPMENT SINUS OPACITY RETROBULBAR HEMORRHAGE

RETROBULBER HEMORRHAGE RETROBULBAR HEMORRHAGE RETROBULBAR HEMORRHAGE OPHTHALMIC EMERGENCY MUST ASSESS IF OPTIC NERVE IS IN JEOPARDY MOSTLY CLINICAL DECISION PROPTOSIS TIGHT LIDS

canthotomy & cantholysis OCULAR TRAUMA EMERGENT MANAGEMENT SAFE TO SHIELD DO NOT PATCH - PREVENT ANY PRESSURE ON WHAT MAY BE AN OPEN GLOBE!

PROTECTIVE SHIELD ORBITAL FRACTURE: EMERGENT MANAGEMENT POST TRAUMATIC IRITIS TOPICAL STEROID AFTER EPITHELIUM HEALS CYCLOPLEGIA FOR COMFORT PROTECTIVE SHIELD ENT,NEURO, DENTAL

9 RETROBULBER HEMORRHAGE RETROBULBAR HEMORRHAGE RETROBULBAR HEMORRHAGE OPHTHALMIC EMERGENCY MUST ASSESS IF OPTIC NERVE IS IN JEOPARDY MOSTLY CLINICAL DECISION PROPTOSIS TIGHT LIDS DEMINISHED/(ING) VISION LIGHT PERCEPTION IF vision is adequate & stable - monitor hemorrhage/hematoma vision eye pressure IF the optic nerve is in jeopardy emergency lateral canthotomy & cantholysis OCULAR TRAUMA EMERGENT MANAGEMENT SAFE TO SHIELD DO NOT PATCH - PREVENT ANY PRESSURE ON WHAT MAY BE AN OPEN GLOBE! ORBITAL FRACTURE: EMERGENT MANAGEMENT IMAGING TO DEFINE THE PROBLEM ULTRASOUND X-RAY CT MRI SYSTEMIC ANTIBIOTIC TOPICAL ANTIBIOTIC (ABRASIONS) TOPICAL STEROID, CYCLOPLEGIC (IRITIS) PROTECTIVE SHIELD ORBITAL FRACTURE: EMERGENT MANAGEMENT POST TRAUMATIC IRITIS TOPICAL STEROID AFTER EPITHELIUM HEALS CYCLOPLEGIA FOR COMFORT PROTECTIVE SHIELD ENT,NEURO, DENTAL EVALUATIONS HYPHEMA MAY BE FROM BLUNT OR PENETRATING TRAUMA PUPIL DISTORTION POOR VISION SHIELD THE EYE CHECK VISION HYPHEMA MAKE SURE GLOBE INTACT NOTE BLOOD LEVEL PRECISE MEASUREMENTS FOR MONITORING HEALING CHECK IOP, SICKLE CELL PREP

10 HYPHEMA EVALUATE THE POSTERIOR POLE If you can t see it it s no excuse ULTRASOUND LOOSE CLOT RADIOLOGICAL IMAGING FORMED CLOTTED LAYER HYPHEMA THERAPHY TOPICAL STEROIDS HELPS WITH THE INFLAMMTION MONITOR IOP CYCLOPLEG COMFORT AND EXAMINATION BED REST/ UPRIGHT TO HELP RBC s SETTLE PROBLEM: RE-BLEEDS, BLOOD STAINING B L U N T T R A U M A PROJECTILE TRAUMA SMALL INJURY MAY APPEAR MINOR BUT CAN CAUSE A LARGE AMOUNT OF DAMAGE

11 P E N E T R A T I N G T R A U M A TRAUMA: POSTERIOR SEGMENT RETINAL EDEMA MACULAR EDEMA (BERLIN S) CHOROIDAL RUPTURE RETINAL TEAR, DETACHMENT TRAUMATIC OPTIC NEUROPATHY AVULSION OPTIC NERVE OCULAR TRAUMA TRUE OCULAR EMERGENCIES SECONDS COUNT CHEMICAL INJURIES FLUSH, QUICK HISTORY AGENT TOPICAL ANESTHETIC IMMEDIATE IRRIGATION LITERS PHYSIOLOGIC SALINE LACTATED RINGERS IV BOTTLE IDEAL REMOVE PARTICULATE MATTER GET TO 7 ph???

12 OCULAR TRAUMA CHEMICAL INJURY IRRIGATE! FLUSH! DILUTE! MINIMUM 30 MINUTES! PROJECTILE TRAUMA THIS DOESN T LOOK GOOD! how deep? how much damage? how do I get it out? THE ANSWER provided by his co-worker

13 TRAUMA - INTRAOCULAR

14 WHAT S THE DIAGNOSIS? THAT S ALL FOLKS THANKS AGAIN FOR THE OPPORTUNITY AND HONOR Dr. D

UC SF. g h. Eye Trauma. Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California

UC SF. g h. Eye Trauma. Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California UC SF Eye Trauma sf g h Martha Neighbor, MD Emergency Services San Francisco General Hospital University of California Goals Recognize vision threatening eye emergencies Treat them when we can Know when