Download Ophthalmic emergencies, Mr K Lett

Mr. Kim Son Lett
Consultant Ophthalmologist & Vitreo-Retinal Surgeon
Birmingham & Midland Eye Centre & BMI The Priory
Pre-Triage System
 Red
Need to be seen within a few hrs, further triaging.
 Amber Need to be seen within 72 hrs, diverted to UCC
slots.
 Green No need for urgent assessment, referred to GP,
optometrist or to OPD (via GP).
v
Red – Very Urgent
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Penetrating eye injury
Acute post-op endophthalmitis
Severe chemical injury
Orbital cellulitis
GCA with visual symptoms
Sudden loss of vision <6hrs
v
Red - Urgent
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Painful red eye with visual loss
Retinal detachment with good VA
Corneal ulcer, esp. with CL wear
Blunt trauma with hyphaema & ↑ IOP
Corneal graft rejection
Painful diplopia
v
Amber
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Flashes & floaters, no loss of vision
Red eye without pain or visual loss
Retinal vein occlusions (OPD 4-6/52)
Diabetic retinopathy with vitreous haemorrhage
Wet AMD (preferably refer to Fast Track Macular Clinic)
v
Green – GP / Optometrist Mx
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Bacterial & viral conjunctivitis
Allergic conjunctivitis
Blepharitis
Dry eyes
Lid lumps and bumps
v
Green – OPD Referral
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Cataract
Chronic / gradual visual loss (months)
Open angle glaucoma, ocular hypertension
Watery eyes
Ectropion, entropion
Lid lumps & bumps
v
Non-acute diplopia
Trauma
 Burns
 Acid, alkali, thermal, arc eye
 Abrasions & lacerations
 Lid, corneal and conjunctival, Penetrating Eye Injuries
 Foreign bodies
 Corneal, conjunctival, sub-tarsal, intra-ocular
 Blunt trauma
v
 Sub-conjunctival haemorrhage, hyphaema, choroidal rupture
 Orbital Blowout Fracture, Traumatic Optic Neuropathy
Chemical Injury
 Emergency
 Alkali or Acid
 pH check
 Immediate irrigation
v
 May result in limbal stem cell
failure
Corneal Abrasion
 History provides diagnosis &
indication of severity
 Mostly doesn’t require A & E
 Oc. Chloramphenicol qid 5/7
v
Foreign Bodies
 Can be removed if confident
 g. Chlor qid 5/7
 Refer (PEARS?) if unable to
remove or rust rings
 Always check for subtarsal FB v
as well
Sub-conjunctival Haemorrhage
 Spontaneous vs traumatic
 Self limiting
 No treatment
 No referral required
v
Blow Out Fracture
 Assess for globe damage,
Traumatic Optic Neuropathy
 Orbital surgery only if tissue
entrapment
 Normally performed within
4/52
v
Cornea
 Dry eye
 Recurrent erosion syndrome
 Ulcers
 CL related
 Acanthamoeba
 Dendritic
 Shingles
v
Dry Eyes
 Lubricants
 Look for blepharitis
 Refer OPD only if unable to
improve symptoms
v
Recurrent Corneal Erosion
 H/O Index injury
 Typically pain on waking /
opening eyes
 Oc. Simple / Lacrilube nocte
3/12
 Refer OPD if no improvement
v
Bacterial Keratitis
 Esp in CL wearers
 Excess wear, poor hygiene
 Urgent referral
 Differentiate from marginal
keratitis
v
Dendritic Ulcer
 Typically HSV 1, as with cold
sores
 Self limiting
 Treat with topical Acyclovir /
Valgancyclovir 5x/d, 7/7
 UCC referral
v
Herpes Zoster Ophthalmicus
 Oral antiviral Rx if started
within 72hrs onset of rash
 Not always eye involvement
 Hutchinson’s sign

70% chance eye involvement
 Most eye involvement doesn’t
require specialist Rx
v
Conjunctiva
 Conjunctivitis
 Bacterial, viral, allergic
 Episcleritis
 Scleritis
v
Bacterial Conjunctivitis
 Purulent / mucopurulent
discharge
 Self limiting
 OTC g. Chlor qid 1/52
 No referral required
v
Viral Conjunctivitis
 Watery discharge
 Follicular reaction
 Self limiting
 No referral required unless
corneal involvement
v
Allergic Conjunctivitis
 Identification and avoidance of
trigger allergen
 Topical Sodium cromoglycate
 Oral anti-histamines
 No referral required unless
persistent problem
v
Episcleritis
 Self limiting
 Mild – Moderate discomfort
 Oral NSAIDs, eg ibuprofen
 No referral required unless
persistence
 Steroid dependency
v
Scleritis
 Severe dull boring pain
 Brawny red appearance
 Strong association with autoimmune and connective tissue
disease
 Urgent referral
 Needs extensive management
v
Lids
 Blepharitis
 Anterior, posterior
 Chalazion, stye
 Ectropion, entropion
 Pre-septal cellulitis
v
Anterior & Posterior Blepharitis
 Lid hygiene
 Hot compresses
 Treat associated dry eye
 No referral required
v
Chalazion
 Hot compresses
 I&C if refractory
 Prescribe oral Abx if infected
 No referral to A & E
v
Senile Ectropion & Entropion
 Ensure lubrication of ocular
surface
 No acute management in
A&E
 Refer routinely
v
Pre-Septal Cellulitis
 Need to differentiate with
orbital cellulitis
 Pt not systemically unwell
 No orbital signs
 Needs oral Abx (GP)
 Refer if in doubt
v
Orbital Cellulitis
 Potentially sight / life
threatening condition
 Pt systemically unwell, pyrexial
 Orbital signs
 Emergency referral
 Need admission and IV ABx
v
Neuro-ophthalmology
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IIIrd, IVth, VIth nerve palsies
Optic neuritis
Papilloedema
Giant cell arteritis
v
3rd, 4th, 6th Palsy
 Majority will be microvascular
in elderly diabetic hypertensive
population
 Consider duration
 Beware of painful nerve palsy
esp 3rd PCA aneurysm
 Beware of assoc headache
esp 6th GCA
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Disc Swelling
 Physiological
 Hypermetropes
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Optic cup
SVP
Vessel changes
Exudates
Haemorrhages
Hyperaemia
Retinal folds
 VISUAL SYMPTOMS?
v
Optic Neuritis
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Mostly due to demyelination
Unilateral vs bilateral
Child vs adult
2/52 ↓, 2/52 ↔, 2/52 ↑
Reduced vision, colour vision,
RAPD
Uhtoff’s phenomenon
Pain esp ocular movement
Haemorrhages
Hyperaemia
Venous distension
Swelling
Or no physical signs
v
Papilloedema
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Due to raised ICP
Bilateral
Reduced vision
Obscurations
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Blind spot enlargement
Haems
Hyperaemia
Tortuous congested vessels
Exudates
Cup obliteration
Retinal folds
v
Giant Cell Arteritis
 Temporal headache and
tenderness
 Blurred vision
 Jaw claudication
 Polymyalgia
 Associated with RAOs
 Emergency referral to Eye Cas
ONLY if visual symptoms eg.
v
Amaurosis
 Otherwise refer urgently to
Rheumatology / Physicians
Glaucoma
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Open vs Closed angle
1̊ vs 2̊
Neovascular
What IOP is urgent?
 <30mmHg refer to outpatients
 >30mmHg D/W on call team
v
Acute Angle Closure Glaucoma
 Typically presents midday
onwards
 Fixed, semi-dilated pupil
 High pressure, corneal
oedema
 Closed angle – may need to
examine fellow eye
 Emergency referral
 Needs medical treatment then
laser iridotomy
 More extensive surgery may
be necessary
v
Vitreo & Medical Retina
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Posterior Vitreous Detachment
Vitreous haemorrhage
Retinal tears and holes
Retinal detachment
Wet AMD
Vascular occlusions
v
Proliferative diabetic retinopathy
Posterior Vitreous Detachment
 Only 30-50% PVD
symptomatic
 Symptomatic PVD refer to
UCC, depending on duration
 Most are not associated with
retinal detachment
v
Vitreous Haemorrhage
 Check for systemic
associations eg. DM, HT,
Sickle
 Examine fellow eye
If present, UCC referral
(duration dependent)
 In absence of systemic
disease, PVD with VH has
70% incidence of retinal tear
 Urgent referral to Eye Cas
v
Retinal Detachment
 Is the macula on or off?
 VA
 Clinical exam
 If on, emergency referral
 If off, Eye Cas, UCC or clinic
depending on duration
 Check for symptoms of
chronicity
 NOT ALL DETACHMENTS
ARE AN EMERGENCY!
v
Wet Macular Degeneration
 Sudden onset reduction of
vision, distortion
 H/O dry AMD
 Optician can diagnose
 Fast track macular service
v
Venous Occlusions
 No emergency treatment
available
 Refer via fast track system
 Need long term treatment
v
Arterial Occlusions
 Irreversible retinal damage
from 4hrs of onset
 Immediate emergency
treatment up to 8hrs from
onset
 Aspirin
 ocular massage
 rebreathing into bag
 Beyond this time no heroic
measures
 Check for GCA symptoms
 Stroke/TIA pathway
v
Proliferative Retinopathy
 Most commonly diabetics
 Also Sickle, prior RVOs and
rarely RAOs
 Refer to UCC unless also VH
v
The Future
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6-9% annual increase in demand
<30% of attenders are genuine 4hr cases
PEARS / MECS
Rapid access clinics
Allied professionals in house
 Nurses
 Optometrists
 Orthoptists
v
 GP surgeries open all hours!