The eye in ED. Dr Steve Costa Emergency Medicine Training Hub Ballarat & Grampians Region 18 th July 2013

Transcription

1 The eye in ED Dr Steve Costa Emergency Medicine Training Hub Ballarat & Grampians Region 18 th July 2013

2 Learning objectives Diagnostic reasoning Describe the common injuries and diagnostic dilemmas seen in ED Case discussion to highlight and explore diagnostic issues, treatment, follow up Practical interaction in-session eye examination Pre-reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, Most images obtained from : EYE EMERGENCY MANUAL - An Illustrated Guide. Second Edition NSW Agency for Clinical Innovation (ACI) Refer to ED lecture series and self directed workbooks

3 Introduction Emotive topic - risk to sight Often banal and ordinary... Infrequently serious and emergent May represent other systemic illness No local specialists on call

4 Referral to an ophthalmologist Conditions requiring urgent referral to, or consultation with, an ophthalmologist (Box 14.22)

5 Sight-threatening conditions presenting with painful red eye Table 14.26a

6 Table 14.26b

7 Table 14.26c

8 Therefore Ask yourself: Is there any reason not to ask a senior or refer directly to an ophthalmologist

9 Diagnostic reasoning History Symptoms Anatomy Signs

10 History Contacts Infective conjunctivitis Traumatic injury / environmental factors I was hit in the face by a tractor-driven grass mower blade that came off when the bolt broke Welding equipment Associated past medical history Predisposing factors or illness e.g. HLA-B27, long sightedness

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13 65yo with acute severe pain

14 65yo with acute severe pain Vomiting History of longsightedness Reduced vision Describes halos Fixed pupil Hazy cornea

15 Treatment (see ED guidelines) Reduce vitreous production Acetazolomide β-blockers (Betaxolol, Timoptol) Increase flow Pilocarpine muscarinic agonist Prostoglandin inhibitors latanoprost α-agonists Brimonidine Morphine Stemitil/Ondansetron

16 Symptoms Lumps and bumps Itching Discharge Redness Pain Photophobia Loss of vision

17 Anatomy

18 Examination Also perform AMSLER CHART

19 Look at the patient Listen to your patient, he is telling you the diagnosis

20 Look at the patient Listen to your patient, he is telling you the diagnosis - William Osler c.1880

21 Look at the patient Listen to your patient, he is telling you the diagnosis - William Osler c.1880 Look at him [the patient] and you will see it for yourself

22 Look at the patient Listen to your patient, he is telling you the diagnosis - William Osler c.1880 Look at him [the patient] and you will see it for yourself - Steve Costa c.0830

23 Lid lacerations Require specialist suturing if margin or medial canthus affected full thickness Risk of underlying penetrating injury to globe or other structures

24 Significant lid trauma

25 Lid laceration

26 Associated injury

27 Severe eye injury

28 Severe trauma Penetrating Blunt Combination Consider associated injury Brain Other major trauma Facial injury including orbital and facial fractures

29 Penetrating injury Usually obvious traumatic event Hammering metal on metal Other well defined event Pain Visual disturbance often severe Globe deformed/boggy Humour extruded or hyphaema / haemorrhage Reduced ocular pressure

30 Obvious when you look for it...

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33 Retrobulbar haemorrage

34 Treatment Analgesia Prevent vomiting Antibiotics Tetanus Fast for theatre Eye shield REFER TO OPHTHALMOLOGIST

35 Indirect indication of trauma

36 Blunt trauma consult with ophthalmologist early maintain bed rest during assessment and consultation, elevate head of bed exclude injury to other parts of the globe and orbit apply a protective eye shield (do not increase intraocular pressure by padding) analgesia (avoid aspirin and other NSAIDs) discharge - advise patient to rest

37 Chemical Injury Patient usually knows the chemical Symptoms include pain conjunctival injection and/or corneal opacification visual impairment coexisting chemical burn to surrounding skin Irrigation is the mainstay of treatment Copious litres Use litmus paper to ensure effective Topical anaethesia may assist

38 Irrigation Morgan lens

39 Irrigation

40 Chemical Injury Patient usually knows the chemical Symptoms include pain conjunctival injection and/or corneal opacification visual impairment coexisting chemical burn to surrounding skin Irrigation is the mainstay of treatment Copious litres Use litmus paper to ensure effective (5mins after) Topical anaethesia 10 min intervals

41 Examination Also perform AMSLER CHART

42 Testing acuity Essential component of eye assessment Take into account patients normal state Ensure compensative kit (pinhole, glasses) Snellen Chart Set up appropriately

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44 6 distance from chart 36 size of font read

45 Pinhole to correct refractive error

46 Amsler Grid 1. Hold the grid about 36 centimeters (14 inches) away. 2. Wear your normal reading glasses if you normally use them. 3. Cover one eye at a time. 4. Focus on the dot at the center of the grid. 5. While looking at the center dot, note whether the grid lines appear straight or wavy, blurry, or if there are missing lines or any blind spots.

47 Eye movements Which muscles move the eye where? Which nerves supply them? Which animals do not have a VI cranial nerve?

48 Even my 3yo knows that...

49 Eye movements

50 CT shows inferior rectus in the maxillary sinus

51 Examination Also perform AMSLER CHART

52 Pupil examination Reaction of each pupil Glaucoma Iritis/Anterior uveitis Trauma Aneurysms Prosthetic eyes! Integrity of consensual reflex (Swing test) Afferent pathway i.e. optic nerve integrity CRVO, CRAO

53 Anisocoria

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55 Visual fields Scotoma Quadrantopia Hemianopia Horizontal Central arterial or vein branch occlusion, Amaurosis Fugax, glaucoma (can affect regions of the optic nerve) Vertical/homonymous hemianopia stroke

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57 Visual fields Scotoma Quadrantopia Hemianopia Horizontal Central arterial or vein branch occlusion, Amaurosis Fugax, glaucoma (can affect regions of the optic nerve) Vertical/homonymous hemianopia stroke

58 Examining the eylid Lumps and bumps Chalazion Stye Inflammation Blepharitis Abnormal Structure Ectropion Entropion Trichiasis

59 Lid abnormalities

60 Lid lumps

61 Everting the eyelid

62 Examining the globe Use well lit room to view the cornea and conjunctiva Look for Inflammation Tearing Pus FBs Scratches Uneven surface ulceration, cobblestoning Flouroscein enhances irregularities

63 Foreign bodies

64 Cobblestoning

65 Slit lamp examination Set up the slit lamp height comfortable for you and the patient Black line at the lateral canthus Chin in cup Head on band Centralise the light source before turning on Start with low power

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68 Adjust for filters, central position, both on

69 General techniques Viewing the eye Look straight on (beware of pupil on strong light discomfort) 45 degree view Broad beam for sclera Narrow beam for anterior eye Long thin slit for the corneal surfaces (view from front or tangentially) Short 3mm narrow beam for anterior chamber Squat beam for corneal pathology

70 Oblique views from slit lamp

71 Uveitis

72 Fluorescein Highlights surface defects One or two drops only Use with blue light Repeat surface examination

73 Dendritic ulcers

74 Fluoroscein enhanced corneal abraisions

75 Topical Anaesthesia Oxybupivicaine drops 0.5% One or two drops given every 1-2 mins until no stinging when applied Allows painful eye to be opened Allows an otherwise painful procedure to be undertaken

76 Ocular burr

77 Measuring intraocular pressure Topical anaesthetic to eye Attach cover to tonometer Set to ready Tap on eye until constant tone

78 Mydriatics/Cycloplegics tropicamide 0.5% and 1% eye drops, 1 to 2 drops For optimal view of the retina Use only if confident there is no increased intraocular pressure Takes 20-40mins to work Lasts up to 6-8 hours Must give driving advice and ensure verbal consent

79 Fundoscopy Can be performed with slit lamp In ED usually with opthalmascope We have panoptic opthalmascope also!

80 Image:

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82 Unilateral loss of vision Sudden CRVO central retinal vein occlusion Ischaemic and non-ischamic CRAO central retinal artery occlusion Giant cell arteritis Treat as TIA Progressive Optic neuritis Loss of acuity, colour vision, contrast

83 Fundal findings in acute unilateral loss of vision

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85 Unilateral loss of vision Sudden CRVO central retinal vein occlusion Ischaemic and non-ischamic CRAO central retinal artery occlusion Giant cell arteritis Treat as TIA Progressive Optic neuritis Loss of acuity, colour vision, contrast

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87 Unilateral loss of vision Sudden CRVO central retinal vein occlusion Ischaemic and non-ischamic CRAO central retinal artery occlusion Giant cell arteritis Treat as TIA Progressive Optic neuritis Loss of acuity, colour vision, contrast

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89 Any Questions?

90 Summary Careful examination If you have seen it you can describe it Refer early to seniors and ophthalmologists

91 References and resources Emergency Department, Ballarat Base Hospital - Eye and Dental Guidelines The Golden Eye Rules - Royal Victorian Eye and Ear Hospital %20V pdf EYE EMERGENCY MANUAL - An Illustrated Guide. Second Edition NSW Agency for Clinical Innovation (ACI) data/assets/pdf_file/0013/155011/eye_manual.pdf#zoom=100

92 Common problems Foreign body Purulent eye and/or itchy and/or slightly red

93 Less common problems Trauma Retrobulbar haemorrhage The red eye Sudden visual loss Venous and Arterial occlusion TIA/Amaurosis Fugax Retinal detachment

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102 Cases 43y.o. male at work Felt something go in eye as bumped into colleague carrying nail gun magazine Loss of vision immediately with severe pain

103 66y.o. female Rapidly increasing left eye pain Wears reading glasses but severe change in vision Family history of eye problems Funny lights

104 26y.o. male Increasing eye pain yesterday evening Eyes very red, sore No history of trauma/dust Apprentice welder

105 34y.o. female Discomfort Left eye Thinks she could go blind White of eye growing over her iris