Download Ocular Injection

Ocular Emergencies
Dr Mahmood Fauzi
Assist. Prof Ophthalmogy
Eye Anatomy
Illinois EMSC
2
Ocular Emergencies
• Lid Lacerations
• Foreign Bodies
• Corneal
Lacerations/Abrasions
• Penetrating Injuries and
Contusions of the Eyeball
• Globe Rupture
• Burns of the Eye
• Chemical injuries
• Orbital Fractures
• Acute congestive glaucoma
Facts to elicit from the history
• General
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Are both eyes affected or only one?
Time of onset
Recurrence
Events preceding the current state
Recent history of ocular disease or surgery
Other diseases, specifically cardiac, vascular, or autoimmune
Family history for ocular problems
Current medications or recent changes to medications
Changes in vision (lost, blurred, or decreased vision; diplopia, sudden
or gradual)
– Visual acuity before the current event
– Other symptoms (pain, nausea, vomiting)
Emergency Eye Examination
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Visual acuity
External examination
Pupils
Extraocular muscles
Injection
Discharge
Preauricular lymphadenopathy
Follicles
– (usually viral)
• Follicles
– (usually viral; chronic – r/o chlamydial)
• Papillae
– (usually allergy)
Papillae
Emergency Eye Examination,
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Cornea-fluorescein test
Evert lid
IOP
Confrontational fields
Ophthalmoscopy
Lab & radiology testing
Treat/refer/consult
Pearls
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Infection control
Chemical injuries, irrigation STAT, Morgan lens
Compare both eyes
Iritis
Corneal Abrasion
Corneal Abrasions
• History of scratching the eye
• Symptoms:
– Foreign body sensation
– Pain
– Tearing
– Photophobia
Corneal Abrasions
• Treatment:
– Topical antibiotic
– Pressure patch over the eye
– Refer to ophthalmologist
Corneal Ulcer
• Corneal ulcer occur secondary to lid and
conjunctival inflammation but is often due to
trauma or contact lens wear
• Bacterial, viral, fungal or parasitic
Corneal Ulcer
• Ocular pain, redness and discharge with
decrease vision and white lesion on the
cornea
Corneal Ulcer
• Prompt diagnosis of the etiology by doing
corneal scraping
• Treatment with appropriate antimicrobial
therapy are essential to minimize visual loss
Contact lens wearer
• Any redness occurring for patients who wear contact
lens should be managed with extreme caution
• Remove lens
• Rule out corneal infection
• Antibiotics for gram negative organisms
• Do not patch
• Follow up with ophthalmologist in 24 hours
Chemical Injuries
• A vision-threatening emergency
• The offending chemical may be in the form of
a solid, liquid, powder, mist, or vapor.
• Can occur in the home, most commonly from
detergents, disinfectants, solvents, cosmetics,
drain cleaners…..
Chemical Injuries
• Can range in severity from mild irritation to
complete destruction of the ocular surface
• Management
– Instill topical anesthetic
– Check for and remove foreign bodies
Chemical Injuries
– Immediate irrigation essential, preferably with
saline or Ringer’s lactate solution, for at least 30
minutes
Chemicals Injuries
– Irrigation should be continued until neutral pH
is reached (i.e.,7.0)
– Instill topical antibiotic
– Frequent lubrications
– Oral pain medication
– Refer promptly to
ophthalmologist
Burns
• Chemical Burns
– Call EMS
– Irrigate continuously, gently
• Heat Burns
– Apply a loose, moist dressing
• Light Burns
– Symptoms delayed - bilateral
– Cover both eyes with dark patches
Illinois EMSC
19
Alkali Burn of the Cornea
Illinois EMSC
20
Corneal and Conjunctival Foreign Bodies
• History of trauma
• Foreign body sensation-Tearing
Corneal and Conjunctival Foreign Bodies
• Management
– Instill topical anesthetic
– Removal of the foreign body
– Topical antibiotic
– Treat corneal abrasion
Fluorescein Stain
Linear epithelial defects suggestive of foreign body
under the eye lid
Blunt trauma
• Superficial FB – flourescein stain
• fractures, hemorrhage, or damage to
the globe or adnexa
– Fx sharp edges that can cause
entrapment or damage to the muscle
or globe
– Retrobulbar hemorrhage - analogous to
compartment syndrome
• elevated intraocular and extraocular
pressures, causing permanent damage
• Hyphema
– warrants suspicion for penetrating
trauma, orbital fracture, acute
glaucoma, or retinal detachment
• CT for fracture, retrobulbar hemorrhage,
laceration, or intraocular foreign body
• control swelling and pressure
– Cold compresses
– Nasal decongestants
– Lateral canthotomy
• tetanus prophylaxis
Orbital Floor or Blow-Out Fracture
• Trauma
• Orbital floor – most common
• Symptoms
– Diplopia
– Restricted eye movement
– Hyposthesia
– Air accumulation
– Sunken eye
– View globe inferior
– Crepitus – nose blowing
Orbital Floor or Blow-Out Fracture
Pearls
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Broad-spectrum po antibiotic
Cold compress – ice pack
Nasal decongestants
Nose blowing
Retinal detachment – coup, counter-coup
CAT scan of orbit
Refer always, same day
– Opthalmology, ENT
Preseptal Cellulitis
Preseptal Cellulitis
• Lid swelling and erythema
• Visual acuity ,motility, pupils, and globe are normal
Preseptal Cellulitis
• Etiology
– Puncture wound
– Laceration
– Retained foreign body from trauma
– Vascular extension, or extension from sinuses or
another infectious site ( e.g.,dacryocystitis,
chalazion)
– Organisms
• Staph aureus – Streptococci- H.influenzae
Preseptal Cellulitis
• Management:
– Warm compresses
– Systemic antibiotics
– CT sinuses and orbit if not better or +ve history of
trauma
Orbital Cellulitis
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Pain
Decreased vision
Impaired ocular motility/double vision
Afferent pupillary defect
Conjunctival chemosis and injection
Proptosis
Optic nerve swelling
Orbital Cellulitis
• Management:
– Admission
– Intravenous antibiotics
– Nasopharynx and blood cultures
– Surgery maybe necessary
Orbital Cellulitis
Penetrating/lacerating trauma
• damage or destroy anatomic structures
• compromise protective outer layers,
increasing the risk of infection
• Sympathetic ophthalmia
– <2%
Penetrating Injury
• r/o rupture
– If rupture no further exam - EUA
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eye protected – fox shield
CT
systemic antibiotics initiated- NOT topical
NPO, time of last meal
tetanus prophylaxis
Lid repair
• Avoid retraction of lid margin
– Gray line to gray line
• Check canilicular system
• Remove FB
• Tetanus prophylaxis
“Eyelids don’t have fat”
• Orbital fat usually protrudes
through septal lacerations
• Fat in the lid laceration
confirms the diagnosis
• High incidence of globe
penetration and intraocular
foreign bodies
• High risk for orbital cellulitis
Ruptured globe
• Penetrating trauma leads to
corneal or scleral disruption
and extravasation of
intraocular contents.
• Can lead to:
– Irreversible visual loss
– Endophthalmitis inflammation of the
intraocular cavities
Ruptured Globe
• Signs and symptoms:
– pain, decreased vision
– hyphema
– loss of anterior chamber
depth
– “tear-drop” pupil which
points toward laceration
– severe subconjunctival
hemorrhage completely
encircling the cornea.
• Diagnosis: positive Seidel’s
test, clinical exam.
Ruptured Globe Management
• Stop the examination
• Cover with metal eye shield or styrofoam
cup. DO NOT PATCH.
• Consult ophthalmology immediately
• Do not perform tonometry.
• CT head and orbit to evaluate for
concomitant facial/orbital injury.
• NPO, tetanus
• Antibiotics: Cefazolin + ciprofloxacin
provides good coverage.
• Antiemetics and analgesics decrease risk of
Valsalva or movement which could increase
IOP.
Acute Angle Closure Glaucoma (AACG) Diagnosis
• History: Acute onset, higher risk in farsighted
• Symptoms:
– Pain
– Halos (around lights)
– Visual loss (usually peripheral)
– Nausea/vomiting
• Signs:
– Conjunctival injection
– Corneal edema
– Mid-dilated, fixed pupil
–  IOP (normal: 10 – 20 mmHg)
www.eyemd.com
Glaucoma - Pathophysiology
• Aqueous humor produced
by ciliary body, enters ant.
chamber, drains via
trabecular meshwork at
angle to enter canal of
Schlemm
• In AACG, iris obstructs
trabecular meshwork by
closing off angle
• Optic nerve damage 2° IOP
www.eyesearch.com
Acute Angle Closure Glaucoma
• Medical Tx
– Reduce production of aqueous humor
• Topical -blocker (timolol 0.5% - 1- 2 gtt)
• Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)
• Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)
– Or increase outflow
• Topical -agonist (phenylephrine 1 gtt)
• Miotics (pilocarpine 1-2%)
– Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then
Q1H
• Definitive Tx
– Ophtho referral: Laser peripheral iridectomy
Eye Injury Prevention
• Education
• Require use of protective eyewear
• Investigate causes of
eye
injuries and
remove
hazards
• Collaborate with
school
staff to reduce
incidence
of injury
Illinois EMSC
50
“If two people agree on everything, then only one of them
is thinking.”
- Senator Sam Rayburn
• “Your job is to make discussions.”
- Pierre Rouzier, M.D.
A “Red Eye”
• Patient presents whose
right eye is red, painful and
very sensitive to light.
• When you shine the
penlight in her left eye, it
causes her pain in the right
(affected) eye.
• What diagnosis does it
suggest?
Another red eye
• A three-year old child presents
with erythema and swelling
around the left eye.
• The Pediatric resident says,
“It’s periorbital cellulitis; start
the kid on antibiotics and send
him home.”
• Are you comfortable with that?
Poked in the eye!
• A young boy presents to the
ER after having been poked in
the eye by another student.
• He is being seen by a resident
who is just about to measure
the child’s intra-ocular pressure
when you yell “STOP!!!!!!”
• Why are you so uptight?
• Now what should you do?
Drain cleaner in the eye
• A patient comes to the ER having
gotten some drain cleaner in her eye
and it's causing her a lot of pain.
• The triage nurse tells her the wait to
be seen is 1 hour and the patient
becomes irate and starts to leave.
• You happen to overhear this
conversation
• What should you do? Why?
• Treatment?
• How long?
Baseball versus eye
• A young male presents to
the ER after having been
hit in the eye with a
baseball. He says, "I keep
seeing double when I look
up".
• Diagnosis?
• Pathophysiology?
• Treatment?
FB sensation
• A young male presents to the ER with foreign body
sensation to this left eye.
• He was pounding a nail and felt something get into
his eye.
• You examine patient and find that other than some
photophobia, his exam is normal.
• You are about to discharge him when the attending
says, hold on just a minute. What could you have
possibly missed?
• How do you make the diagnosis?
Positive Seidel’s
• You carefully examine
the patient and place
fluorescein in his eye.
You see the fluorescein
streaming.
• What is this called?
• What does it signify?
• Where could be the
likely truama?
Red Eye Danger Signs
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Decreased visual acuity
Pain
Ciliary flush
Pupillary asymmetry
Irregular corneal light reflex
Corneal infiltrate
Photophobia
Trauma
Emergency Eye Examination
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Visual acuity
External examination
Pupils
Extraocular muscles
Injection
Discharge
Preauricular lymphadenopathy
Follicles
– (usually viral)
• Follicles
– (usually viral; chronic – r/o chlamydial)
• Papillae
– (usually allergy)
Papillae
Ocular Injection
Conjunctival injection
– Conjunctivitis
Ciliary (circumcorneal) injection
– Keratitis
• including corneal abrasions,
foreign bodies
– Iritis
– Glaucoma
Ocular Injection
Segmental injection
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Episcleritis
Injected pinguecula
Embedded foreign body
Marginal keratitis
Phlyctenular limbal
keratoconjunctivitis
Non- Vision Threatening Red Eye
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Conjunctivitis
Stye (hordeolum)
Chalazion
Blepharitis
Conjuctival foreign bodies
Subconjunctival Hemorrhage
Pearls
– No trauma
• normal vision, no pain,
self-limited, benign
– Trauma
• r/o intraocular injury
– Worse day 2?
– BP
– Treatment?
• ASA?
When to refer
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Concommitant trauma
Stye (hordeolum)
Infection
– Usually staph aureus
Treatment
– WC
– P.o pain medication
– Topical antibiotics
– Systemic antibiotics
• lid cellulitis or pain?
Cyst (chalazion)
Inflammation
Treatment
• WC
• Near lid margin
– steroid injection
Pearls
• R/o
– rosacea
– malignancy w/recurrence
• Systemic doxycycline
Cyst (chalazion)
When to refer
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Not resolving in 2 – 3 weeks
Cosmetic
Vision
Lid margin
Vision-Threatening Red Eye
& Emergencies
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Corneal abrasions
Conjunctival & corneal
foreign bodies
Keratitis
Iritis
Hyphema
Blow-out fracture
Retinal detachment
Papilledema
4th Generation Fluoroquinolones
Options:
– Zymar, Allergan (gatifloxacin)
– Vigamox, Alcon (moxifloxacin)
Benefits:
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lower incidence of resistance
may shorten infection
more effective for gram +
potency, concentration
active – pseudomonas aerunginosa
permeability, solubility
comfort
Thank you