Ocular Lecture. Sue Bednar NP Ali Atwater PA-C

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1 Ocular Lecture Sue Bednar NP Ali Atwater PA-C

2 Triaging Ocular Complaints Painful Eye/Red eye +/-blurry vision +/-visual loss +/-floaters +/-fevers If any of the above findings exist, pt is likely to have a more urgent/emergent eye problem and therefore requires increased level of acuity. Visual Acuities (MUST BE PERFORMED ON ALL PTS WITH EYE COMPLAINT) Objective baseline measurement Comparison (OD vs OS) Include with or without correction

3 Triaging Ocular Complaints Periorbital swelling Surrounding eye redness i.e periorbital cellulitis Commonly seen in children Requires IV antibiotics and admission Complications: CNS infection (meningitis, epidural abscess, subdural empyemas, brain abscess), orbital involvment (cellulitis, abscess), Cavernous sinus thrombosis, Toxic shock syndrome, Eschar formation leading to scarring

4 Triaging Ocular Complaints Facial Symmetry Proptosis Facial droop Consider Bells Palsy/CVA

5 Ocular Emergencies Vision loss Closed-angle glaucoma Retinal Detachment FB Orbital Fracture Corneal Abrasion/Lacerations Chemical Burn Central Retinal Artery Occlusion Ruptured Globe Retrobulbar hematoma

6 Acute Painless Visual Loss Differential Diagnosis CVA Central Retinal Artery Occlusion Central Retinal Vein Occlusion Wet Macular Degeneration Vitreous Hemorrhage Retinal Detachment

7 Retinal Detachment True Emergency Painless vision loss Associated with Vascular disorders Congenital malformations Metabolic disarray Trauma Shrinking of the vitreous Myopia Degeneration And less commonly with diabetic retinopathy and uveitis Separation of the neurosensory layer of the retina from the underlying choroid and retinal pigment epithelium

Bright flashes of light, floaters, fine dots, cobwebs

8 Presentation Black curtain coming down over visual field Visual loss: sudden and starts peripherally. Bright flashes of light, floaters, fine dots, cobwebs Visual acuity correlates with the extent of macular involvement

9 Physical Findings Afferent pupillary defect is possible CHECK for consensual reaction The retina may appear gray or translucent or may seem out of focus

10 Treatment Early diagnosis and treatment are imperative preserve vision Consult Optho ASAP Retina needs to be replaced onto underlying nourishing layers. Laser photocoagulation or cyrotherapy Surgical repair to fix tear

11 Vitreous Hemorrhage Bleeding into preretinal space or the vitreous cavity itself. Difficult to distinguish from a retinal detachment Painless vision loss Floaters, cobwebs No afferent pupil defect This will help distinguish from a retinal detachment

12 Central Retinal Artery Occlusion Embolus from the carotid artery that lodges in the ophthalmic artery (leads to an ocular stroke) Visual complaints Caused by ischemia s/s: extremely sudden, acute unilateral PAINLESS vision loss

so the macula appears pink and healthy against the ischemic retina)

13 Central Retinal Artery Occlusion Ocular exam Cherry red spot on fundoscopic exam (cilioretinal artery will maintain perfusion of macula, so the macula appears pink and healthy against the ischemic retina) Listen for bruits over carotids, tenderness over the temporal arteries Examine for AFIB

14 Treatment Immediate! Visual loss is usually irreversible after 2 hours of ischemia Intermittent globe massage to dislodge clot Anterior chamber paracentesis and IV Acetazolamide Both decrease IOP & allow for better perfusion of the retinal artery Inhaled Carbogen (mixture of O2 and CO2) Dilates the vasculature, thereby increasing retinal PO2 Admit to the hospital if sudden vision loss To determine the underlying cause

collagen vascular disease, diabetes Two Types Ischemic (aka

15 Central Retinal Vein Occlusion Risk Factors CV disease, HTN, Glaucoma, Venous stasis, hypercoaguable conditions, collagen vascular disease, diabetes Two Types Ischemic (aka hemorrhagic retinopathy) Non-ischemic (venous stasis retinopathy)

16 Types Ischemic Acute and profound vision loss Afferent pupil defect Non-Ischemic Progressive blurry vision Worse in the morning BOTH Funduscopic exam shows Edema to optic disc and macula Dilated retinal veins Retinal hemorrhage Cotton wool spots

17 Diagnostic Tests Diagnosis of exclusion Excluding all the other processes that cause painless visual loss

18 Treatment Immediate optho consult Search for a cause In order to protect the contralateral eye No specific treatment exists Interventions (which are outside the scope of the ER) Laser photocoagulation Steroids

19 The Red Eye FB Iritis Keratoconjunctivitis Narrow-angle glaucoma Pterygium Scleritis Subconjunctival hemorrhages Differential Diagnosis Blepharitis Canaliculitis Conjunctivitis (viral, bacterial, allergic) Corneal Inflammation/Infection Dacryocystitis Episcleritis

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21 Blepharitis Inflammation of the eyelids usually involving the lid margins Often associated with conjunctivitis

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23 Canaliculitis Characterized by a mildly red eye Usually unilateral Slight discharge that can be expressed from the canaliculus

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25 Conjunctivitis Vascular dilation Inflammation of the mucous membranes that line the sclera and the inner eyelids Cellular infiltration Exudation

26 Types Viral Adenovirus-most common Extremely contagious Itchy, watery discharge Herpes simplex Usually unilateral, watery discharge Photophobia and FB sensation Look for dendritic pattern on slit lamp/fluorescein exam Look for facial vesicles Hutchinson s sign Seen with herpes zoster Lesion on the tip of the nose Involvement of the nasociliary branch of the 5 th nerve Much higher likelihood of ocular involvement

Staph, Strep and Heamophilus Gonococcal Usually unilateral Seen in infants,

27 Types Bacterial Erythema, fb sensation, purulent drainage, morning crusting of the eye. Staph, Strep and Heamophilus Gonococcal Usually unilateral Seen in infants, health care workers and sexually active young adults May also have urethritis or arthritis Usually more discharge than other bacterial infections

28 Types cont d Chlamydial Sexually active young adults and neonates May have associated GC Urethral discharge and arthritis Scant seropurulent eye dishcarge Pseudomonas Immune compromised Contact lens wearers Yellow green discharge, sticky Inspect for corneal perforation which is a major concern with this organism Allergic Typically bilat. Watery discharge Might see chemosis Fungal Actinomyces, Aspergillus, candida, coccidioides and mucor Diabetic pts immunocompromised pts and pts with eye trauma with vegetable matter May have corneal infiltration May see hypopyon Chemical

29 Treatment Supportive Warm compresses Artificial tears Alleviates photophobia and keratitis Broad spectrum antibiotic drops (prevent superinfection w/ other bugs) Erythromycin For uncomplicated cases Fluoroquinolones Cover for pseudomonas Use in contact lenses wearers Topical Corticosteroids Only if consult optho NEVER USE IN PT WITH SUSPECTED HERPES Adenovirus Decongestants Lubricants Herpes Simplex Topical antivirals Vidarabine 3% Trifluridine 1% Herpes Simplex Ophthalmicus Systemic antivirals

30 Treatment Uncomplicated Bacterial Conjunctivitis Erythromycin Sulfacetamide 10% Gentamicin 0.3% Neosporin Cipro Gonococcal Emergent optho consult Topical and parenteral antibiotic therapy IM Ceftriaxone Frequent eye irrigation Prevent corneal perforation Chlamydial Oral and topical antibiotics Fungal Natamycin 5% Allergic Supportive Diphenhydramine

31 Ocular Foreign Bodies Generally superficial Photophobia, fb sensation, tearing, conjunctival injection & lid/corneal edema +/-flare ant chamber +/- visual acuities decrease Metallic FB RUST RING

32 Corneal Abrasion One of the most common ocular injuries 10% of ED visits related to eye complaints Abrasion of the corneal epithelium More common in contact lens wearers Severe injuries can involve the deeper thicker stromal layers

33 Corneal Abrasions Presentation Fb sensation, pain, watery discharge, photophobia If over the pupil, then may have decreased VA Physical exam findings Proparacaine first to control pain Evert eyelid Don t miss FB Fluoroscein exam with slit lamp Uptake-blue light Cell/Flare-white light Hyphema-white light Treatment for both FB and Corneal abrasions Update TDAP Preventative antibiotic drops If contact lens wearer, cover for pseudomonas Cycloplegic Homatropine Relief from photophobia and blepharospasm AVOID PATCHING May lead it increased infection No contact lens use while healing.

34 Corneal Ulcers Infectious in etiology Pseudomonas in contact lens wearers S/S: Fb sensation, pain, watery or purulent discharge, photophobia If over the pupil, then may have decreased VA

35 Slit lamp exam- Corneal Abrasion vs Corneal Ulcer

36 Treatment of Corneal Ulcer Immediate optho consult Cycloplegic agent Optho adovacate discharge with follow up the next day Homatropine for comfort Frequent topical antibiotic therapy A drop every 1-2 hours until follow up the next day

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38 Corneal Infection Decreased visual acuity Photophobia Severe pain Opacification of the cornea OPHTHALMIC EMERGENCY!!

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40 Dacrocystitis Localized pain,edema, erythema over the lacrimal sac at the medial canthus Usually unilateral Often purulent drainage

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42 Episcleritis Differentiated from the injection of themore superficial conjunctival vessels and from the deeper scleral vessels. Unlike Conjunctivitis, the inflammation tends to be limited to an ISOLATED PATCH Hx of recurrent episodes is common Mild to moderate tenderness over the area of injection

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44 Iritis Peri-limbal flush due to dilation of the radial vessels Compared to conjunctivitis, in which the intensity of the vascular engorgement decreases toward the limbus +/- decreased visual acuity Usually unilateral

Traumatic Iritis Onset 1-4 days after trauma Presentation and PE Eye pain, photophobia Impaired vision Peirlimbal conjunctival injection Cells and

45 Traumatic Iritis Onset 1-4 days after trauma Presentation and PE Eye pain, photophobia Impaired vision Peirlimbal conjunctival injection Cells and flare in the anterior chamber Contricted,weakly dilated pupil Treatment Cycloplegic Homatropine 5% Topical steroid (consult optho) Oral anlagesics

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47 Subconjunctival Hemorrhage May occur spontaneously i.e. If pt is on anticoagulants Or secondary to trauma i.e. Increased pressure: singing, screaming etc May appears as a flat thin Hemorrhage or a thicker collection of blood No treatment required Absorbs on its own

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49 Hyphema Mostly due to trauma. Post-injury accumulation of blood in the anterior chamber The agent producing a hyphema is usually projectile Spontaneous hyphemas are rare. i.e secondary to neoplasms, vascular anomalies, neovascularization such as from DM, ischemia

50 Hyphemas Present with eye pain, decreased va, photophobia. Diagnosis is made by looking for blood in anterior chamber May see with your naked eye Esp if pt is upright and it has had time to layer out Slit lamp exam May see cells in anterior chamber or layered blood If large, then check IOP

Treatment stop damage to vision Elevate pt s head Dilate the pupil Avoid pupillary play Topical B Blockers (lower IOP) Topical carbonic anhydrase inhibitor

51 Treatment stop damage to vision Elevate pt s head Dilate the pupil Avoid pupillary play Topical B Blockers (lower IOP) Topical carbonic anhydrase inhibitor Systemic acetazolamide or mannitol Avoid ASA/antiplatelet meds Pain control Surgery to remove clot When other therapies do not work. Complications: rebleeding

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53 Chemosis Cornea is recessed and the conjunctiva is swollen Due to allergic reaction. Treat with antihistamines

54 Narrow (Closed) Angle Glaucoma Presentation >50 years and older Unilateral severely painful red eye and head pain Nausea, vomiting common Halos around light are common IOP elevated Reduced visual acuity Immediate referral to optho

55 Diagnostic testing Visual Acuities Slit-lamp exam Depth of anterior chamber If <¼ of the corneal thickness, then chamber is narrow. Likely done by Optho and not in the ER May have a middilated pupil and corneal haziness IOP measurement with tonometer

56 Treatment Ophthalmologic emergency- Consult Optho ASAP! Therapy is geared toward Decreasing the aqueous production Increasing aqueous outflow Reducing vitreous volume to lower IOP Topical B-blockers Timolol (decrease aqueous production) Parasympathomimetic Miotic Agent Pilocarpine (improves aqueous outflow) Carbonic Anhydrase Inhibitor Acetazolamide (limits aqueous humor formation) Osmotic Diuretic Mannitol (creates an osmotic gradient b/w the vitreous and the blood to cause vitreous volume reduction).

57 Chemical Burns Presentation Eye pain, limited visual acuity Corneal cloudiness Scleral whitening Eye may be erythematous or whitened Chemosis Vascular engorgement FB sensation Physical Findings Punctate lesions on the cornea Conjunctival injection Decreased visual acuity

58 Chemical Burn A TRUE OCULAR EMERGENCY Test ph IRRIGATE, IRRIGATE, IRRIGATE 30 minutes using IV NS or LRs with morgans lens. Morgans lens alternatives Use the tubing and tape over pt s eye. Acid vs Alkali Alkali causes necrosis. Will destroy vessels and denature collagen (Lipophilic- so it absorbs into the eye more easily, causing more damage) i.e household cleaners (bleach), fertilizers Acid also causea necrosis. Less common i.e sulfuric acid (automobile batteries), industrial cleaners

59 Ruptured Globe From penetrating trauma to cornea or sclera Extravasation of the intraocular contents May lead to irreversible vision loss or Endophthalmitis

60 Ruptured Globe S/S: pain, decreased vision, hyphema, tear drop pupil, severe subconjunctival hemorrhage Management Immediately place an eye shield to protect eye from further manipulation DO NOT PERFORM TONOMETRY

61 Orbital and Periorbital Celllulitis Orbital cellulitis without treatment causes blindness and death in 20% of patients Venous drainage of the orbital region communciates with vessint in the brain via the cavernous since, infection can progress rapidly

62 Peds! Preseptal cellulitis is more common than orbital cellulitis. 2 pediatric case series 94% and 87% of cases, respectively, were dx as pre-septal cellulitis. Remainder were dx as orbital cellulitis. accordingly, most of the data regarding these infections comes from studies in children. Pub Med references

63 Orbital Septum Orbital Cellulitis Tissues within the orbit posterior to the orbital septum Periorbital Cellulitis Confined to the tissues anterior to the septum

66 Presentation Erythema, edema, warmth of the external eye tissues Unilateral usually Infection can be bilat Fever and malaise Ocular pain, ophthalmoplegia, pain with movement of EOM SUGGESTS ORBITAL INFECTION May also have decreased VA and pupillary paralysis

67 Treatment Pre-orbital infection Oral antibiotics and close f/u outpt Lower threshold for admission in children Cover for staph, strep, enterobacteriaceae Clindamycin in children and adults or Trimethoprim-sulfamethoxazole (TMP-SMX; in children and adults plus one of the following: Amoxicillin or Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir In pts with comorbid conditions, admit!

68 Treatment Orbital celllulitis Broad spectrum IV antibotics Vancomycin in children and adults plus one of the following: Ceftriaxone in children and adults or Cefotaxime in children and adults or Ampicillin-sulbactam in children and adults or Piperacillin-tazobactam in children and adults Admit I&D if imaging reveals collection

69 References Adams Up to date rbital+cellulitis+children&selectedtitle=1~14# H bital+cellulitis+children&selectedtitle=1~25&s ectionrank=1&anchor=h24#h24

Ocular Lecture. Sue Bednar NP Ali Atwater PA-C

Ocular Lecture. Sue Bednar NP Ali Atwater PA-C Ocular Lecture Sue Bednar NP Ali Atwater PA-C Triaging Ocular Complaints Painful Eye/Red eye +/-blurry vision +/-visual loss +/-floaters +/-fevers If any of the above findings exist, pt is likely to have