6/21/2018. Ophthalmic Emergencies: Ten Diagnoses You Can t Afford to Miss. Center for Excellence in Eye Care Baptist Hospital of Miami.
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1 Ophthalmic Emergencies: Ten Diagnoses You Can t Afford to Miss Carlos Buznego, M.D. Center for Excellence in Eye Care Miami, Florida Clinical Associate Professor Florida International University Herbert Wertheim College of Medicine Center for Excellence in Eye Care Baptist Hospital of Miami Carlos Buznego, M.D. Cristobal Cruz, M.D. Eugene Eisner, M.D. Morvarid Fallahzadeh, O.D. Jack Gabay, M.D. Charles Kaiser, M.D. Louis Kasner, M.D. Lourdes Casuso, M.D. Gaston Lacayo, M.D Junhee Lee, M.D. Pedro Lopez, M.D. Carolina Pedroletti, O.D. Andrew Schimel, M.D. Richard Simon, M.D. Frank Spektor, M.D. Henry Trattler, M.D. William Trattler, M.D. Marilyn Zuniga, O.D. Disclosures Allergan Bausch and Lomb CXL Glaukos New World Medical Sun 1
2 Educational Objectives Identify patients with sight threatening conditions. Distinguish between benign and dangerous ocular conditions. Refer patients to appropriate providers in efficient manner. Eye Examination Eye Examination Visual Acuity Pupils Pressure Visual Fields Motility External Exam Slit lamp exam Fundus exam Use Glasses Cover Other Eye 2
3 Eye Examination Visual Acuity Pupils Pressure Visual Fields Motility External Exam Slit lamp exam Fundus exam Swinging flashlight test Marcus Gunn Pupil Afferent Pupil Defect Irregular Pupil--Trauma Eye Examination Visual Acuity Pupils Pressure Visual Fields Motility External Exam Slit lamp exam Fundus exam One Eye at a time Use yourself as control Eye Examination Visual Acuity Pupils Pressure Visual Fields Motility External Exam Slit lamp exam Fundus exam Direct Ophthalmoscope Use as loupe 3-5X Look for Red reflex 3
4 Patient photograph reproduced with consent. 65yo Eye Pain/Swelling 2 days Fever, Headache, Stuffy OTC Nasal Steroids no better Exam: Vision: Pupils: EOM: External: Patient photograph reproduced with consent 65yo Eye Pain/Swelling 2 days Fever, Headache, Stuffy OTC Nasal Steroids no better Exam: Vision: Count Fingers Pupils: APD Left EOM: Restricted all gazes External: Proptosis Orbital Cellulitis Bacterial Infection IV abx Imaging Sinuses Brain Abscess 4
5 Orbital Cellulitis in ICU Patient Patient photograph reproduced with consent Septic ICU Patient Orbital Cellulits Eschar in palate Mucormycosis Pulmonary Fungus Orbital Cerebral Extension Orbital Cellulitis Bacterial Infection IV abx Surgical Drainage Abscess Imaging Sinuses Brain Abscess Mucormycosis Rare Chronically Ill/ICU Eschar face/nares/palate Surgical Debridement Exenteration High Mortality ER Consult 75yo Recent eye surgery cataract 24 hours of pain, redness Decreased vision 5
6 Endophthalmitis Uncommon condition: 1:2000 cataract surgery Potentially devastating Intraocular culture Intraocular abx ER Consult 32yo Landscaper Working near partner with Weedeater Sudden pain Loss of vision Small FB/Rapid Velocity Metal on Metal R/O Inra-Ocular Foreign Body Xrays CT Scan Ophthalmic Consultation Patch, IV abx R/O IOFB, Surg Repair 6
7 70yo Man With Painful Facial Rash Exam: Va External: What nerves responsible to facial sensation Patient photograph reproduced with consent 70yo Man With Painful Facial Rash Exam: Va External: What nerves responsible to facial sensation Treatment? Contagious? Patient photograph reproduced with consent ER: 53yo Latin Woman Painful red eye: 48 hours Blurred vision Rainbow haloes H/A, nausea, vomiting EXAM: Va: Penlight: Pressure: Pupils: 7
8 ER: 53yo Latin Woman Painful red eye: 48 hours Blurred vision Rainbow haloes H/A, nausea, vomiting EXAM: Va: Count fingers Penlight: Steamy K, red Pressure: elevated Pupils: non-reactive Glaucoma Acute Glaucoma Rare Painful lasting hours, not seconds Red Severe Blurred Vision Rainbow Haloes Chronic Glaucoma Common Asymptomatic Not emergent Treatment Acute Glaucoma Lower IOP Drops: BetaBlockers, CAI, Alpha Agonist Pills: CAI (or IV) Laser: Peripheral Iridotomy Fellow eye: LPI 8
9 ER: 17yo Red Painful Eye History: Pertinent positives/negatives: Contact lens use Recent URTI/Allergies Exam: Red eyes DDX: Conjunctivitis Corneal abrasion Corneal ulcer ER: 17yo Red Painful Eye History: Pertinent positives/negatives: Contact lens use Recent URTI/Allergies Exam: Red eyes DDX: Conjunctivitis Corneal abrasion Corneal ulcer Corneal Abrasion vs. Ulcer 9
10 Corneal Ulcers Bacterial most common: Contact Lenses Pseudomonas/Gram Negative Trauma/Garden Fungus Staph Colonization Viral: Herpes Simplex I, Herpes Zoster Acanthamoeba: Fresh Water Lakes, Homemade CL Solution Fungus: Agricultural Workers/Vegetable Trauma Conjunctivitis Allergic Itching, Tearing, Mucus, Associated Nasal Allergies Stop Rubbing, Cold compresses, Antihistamine Steroids short course for severe cases Viral Bacterial Toxic Conjunctivitis Viral most common: Exposure history URTI Adenopathy Uni- or Bi-Lateral Very contagious Treat symptoms no specific antiviral rx 10
11 Conjunctivitis Bacterial Blepharitis Itchy Burnies Severe Conjunctivitis Hospital acquired Debilitated Hyper-purulent Gonorrhea Well Baby Exam: Funny Reflex Well Baby exam Direct ophthalmoscope Dial to Green +5 great magnifier! Arms length to baby confirm bilateral red reflex! White Pupil Leukocoria Causes: Cataract Cong Anomalies Tumors: Retinal/Choroidal Retinoblastoma: 20,000 cases annually in US. Frequent extension into brain, Metastasis. Rx: Chemo, Radiation, Enucleation 11
12 30yo Man With Decreased Vision Right Eye Ocular history: LASIK for Myopia New Onset floaters for a few weeks Few days of flashes then curtain over vision EXAM: VISION: may be good or bad VISUAL FIELD: Obstructed PUPILS: RIGHT APD FUNDUS EXAM: RD Retinal Detachment COURTESY AMERICAN ACADEMY OF OPHTHALMOLOGY 30yo Woman With Decreased Vision Right Eye No prior ocular history Prior episodes of numbness, lasted weeks VA: Right 20/200; left 20/20 Pupils: Right APD VF Describes Central Blind spot Fundus: Swollen Optic Disk 12
13 30yo Woman With Decreased Vision Right Eye? PHOTOS COURTESY OF MEDSCAPE AND SLIDEPLAYER.COM Papilledema or Papillitis? IMAGE COURTESY OF SLIDESHARE.NET Optic Neuritis Decreased vision over days Unilateral Pain on eye movements Decreased color vision (red cap test) + RAPD Visual field defects vary Swollen disc or retrobulbar MRI of brain and orbits with flair sequencing 13
14 85yo With Right Optic Neuritis Etiologies? Vascular Inflammatory Optic Neuritis Arteritis Giant Cell Arteritis/Temporal Arteritis Giant Cell Arteritis Temporal Arteritis Temporal Arteritis Age >50 years Headache, neck pain, jaw claudication, scalp tenderness, facial pain, visual loss Thickened, nodular, pulseless superficial temporal artery Headache is mild to severe, and of acute or gradual onset; the patient is typically without a history of HA or deviation from his or her chronic HA patter (New) Associated with polymyalgia rheumatic, especially in elderly patients Image courtesy of Pinterest Ophthalmic Emergencies: Ten Diagnoses You Can t Afford to Miss Orbital Cellulitis/Mucormycosis Endophthalmitis Acute Glaucoma Temporal Arteritis Retinal Detachment Open Globe Corneal Ulcer Retinoblastoma Optic Neuritis Herpes Zoster Ophth 14
15 Thank You! 15
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