Download Episode 9 – Non-traumatic Eye Emergencies Prepared by Dr. Lucas

Episode9–Non‐traumaticEyeEmergencies
PreparedbyDr.LucasChartier
GeneralApproach:
Characterizationofapatient’seyepainhelpsdeterminethelocationofthepathology:
(a)up‐front,scratchy,‘sand‐in‐the‐eye’painrelatestoanteriorstructuressuchasthelids,conjunctivae,
cornea,andforeignbodies;
(b)deep,boring,‘behind‐the‐eye’toothachepressure‐typepainrelatestoposteriorstructures;
(c)photophobiarelatestouvealtractpathologysuchasiris,ciliarybodyandchoroid
Systematiceyeexamforeverypatientwithaneyecomplaint:6parts‐visualacuity(the'6thvitalsign'),visual
fieldsbyconfrontation,sizeandreactivityofpupil,extraocularmovements(forcranialnervepalsies),
anteriorsegment(slit‐lampexam)andposteriorsegment(fundoscopy)
Thepainfulredeye
Acuteangle‐closureglaucoma:
Characterizedbyatleast2ofthefollowingsymptoms–acuteonsetocularpainwithnauseavomiting,
intermittentblurringofvisionwithhalosseenaroundlights(duetocornealedema),photophobia,andvisual
loss–alongWITHatleast3ofthefollowingsigns–intraocularpressure(IOP)>21mmHg(often40‐80
mmHg),conjunctivalinjection,cornealepithelialedemacausinghaziness,fixedandmid‐dilatedpupil,and
shallowanteriorchamber(onobliqueflashlighttestwithshadowmedialtopupilcausedbythebulging
anteriorchamberwhenthelightisflashedfromthepatient’stemporalside)
Riskfactorsincludeelderlypatientswhoarefar‐sighted(hyperopic),andtriggersincludetransitionfrom
lighttodarkenvironment(causingmydriasis)aswellasmanymedications–anticholinergic,antimuscarinic,
antidepressant,antipsychotic,antihistaminic,andsympathomimetics(mostofthemthroughmydriasis)
EDmanagement(re‐assessIOPq15minintheearlyphasesoftreatment):
Topicalbeta‐blocker(e.g.1dropofTimolol0.25‐0.5%)todecreaseaqueoushumourproductionifno
contraindicationspresent(COPD,asthma,bradycardia)
Topicalcholinergic(1‐2dropsofPilocarpineq15minx2doses)tocausemyosis,decreaseangleofthe
anteriorchamberatthetrabecularmeshworklevel,andincreasedrainage
Parenteralagents:Acetazolaminde500mgIV(orPO)todecreaseaqueoushumourproduction,andadd
Mannitol1.25‐2g/kgIVof20%solutiontoexertanosmoticdiuresisifaresponsewithotherdrugsdoesnot
occur
Whenisacuteangle‐closureglaucomamissed?(a)Elderly,disabilities,dementia,psychiatricptswherea
thoroughhistoryandphysicalmaybechallenging(b)ptswhopresentprimarilywithheadacheorabdopain
andvomiting
Consideracuteangle‐closureglaucomainanyptwhohashadrecenteyesurgery
Anterioruveitisoriritis:
Symptoms–deep,achingpainradiatingtoperiorbitalortemporalarea,worsewitheyemovementsand
accommodation,andwithPHOTOPHOBIA(veryimportant)
Signs–ciliaryflush(erythemathatisworseclosertotheiris,andnotintheperipheryasinconjunctivitis),
painreliefwithcyclolegicsbutnotwithtopicalanesthetics,andconsensualphotophobia(lightinthe
unaffectedeye,becauseitcausesbilateralmyosis,causespain),andabnormalslitlampexamwithkeratitic
precipitatesorhypopyon,andcellsandflareintheanteriorchamber,whichscintillateformillisecondsata
timelike‘snowflakesinthecar’sheadlights’whendrivingatnightunderanobliqueslitlamplight
Importantdiagnosistomakeinordertopreventlong‐termvisionlossconsequencesduetoscarring,
malfunctionintheshapeoftheiris,andtheincreasedlikelihoodofretinaldetachment,andalsotoscreenfor
the50%ofcasesthathaveunderlyinginfectiousorautoimmunediseasessuchasherpes,tuberculosis,
syphilis,toxoplasmosis,aswellastheseronegativespondyloarthropathies–inflammatoryboweldisease,
ankylosingspondylitis,reactivearthritis,psoriaticarthritis;alsoBehçet,rheumatoidarthritis,SLE,
sarcoidosis,andscleroderma
EDmanagement:
Cycloplegicdropstopreventmyosis,whichactsasbothpaincontrolandbreakingupofthesynechiaecaused
aroundtheiris–Homatropine(1dropTIDof2‐5%solution)lastsafewdaysandisprobablybest,or
Cyclopentolate(1dropTIDof0.5‐2%solution),whichlasts1day;Mydriacyl,whichlastsonly2‐3hrs,isgood
fordiagnosisbutnotfortreatment
Steroidsshouldonlybeusedinconjunctionwithophthalmologistconsultationduetotheconcernfor
worseningofunderlyinginfectionordevelopmentofcornealulcer,bothofwhichmayleadtolossofvision
Ophthalmologicalfollow‐upwithin24hrs
Thepainlessredeye
Kawasakidisease:
Acutesystemicvasculitisofmucosalvesselsofunknownetiologyinchildren<5yoleadingtocoronaryartery
aneurysmifnottreatedacutely–thecriteriaisrememberedwiththemnemonicWarmC‐R‐E‐A‐M
Warm‐Fever>39°Cfor5days,PLUS4ofthe5followingsigns(orlessin‘atypical’formofthedisease):
C‐Conjunctivitis,bilateralnon‐exudative
R–Rash,polymorphic(e.g.urticarial,maculopapular)andonthebody(notvesicularnorbullous)
E–Edemaorerythemaofthehands,eventuallyleadingtodesquamation
A‐Adenopathywithatleastoneanteriorcervicallymphnode>1.5cm(notgeneralizedoverthewholebody)
M–Mucosalinvolvement:fissuredredlips,strawberrytongue
IncompleteKawasaki:AmericanGuidelines‐“IfthetypicalclinicalfindingsofKawasakidiseasearepresentin
achildwithfeverforlessthanfivedays,orifthreeclassicfeaturespluscoronoaryarteryfindingson
echocardiographyarefound,thediagnosisstillcanbemadeandtreatmentinitiated”
FeaturesthatgoagainstthediagnosisofKawasaki:exudativeconjunctivitisorpharyngitis,discreteintra‐oral
lesions,bullousorvesicularrashandgeneralizedlymphadenopathy
Pearls:almostalwayslookunwell/veryirritable,feverisminimallyresponsivetoanitpyretics,oftenhave
peri‐analerythema,andthereisoftenasharpdemarcationatthewristandanklesfromtherednessinthe
extremities
Abnormaltests–Highplatelets,WBC,ESRandCRP,LFTs(especiallyAST/ALT),sterilepyuriainurine(WBC
presentbutnobacteria),aswellasnormochromic,normocyticanemiaandhyponatremia
Treatment–HighdoseASAandIVIG,bestiftreatwithin10dofonsetofsymptoms(lowercomplicationrate)
Painlesslossofvision
Ddxofpainlessacutevisuallossnotrelatedtotraumaincludesvascularocclusion,retinal
detachment,vitreoushemorrhage,maculardisorders,neuro‐ophthalmologicdisease,hysteria,and
secondarytomethanolorviagra
Pearls–lossofvisionoversecondsisusuallyduetoavascularetiology,suchasischemiaoftheretina;
posteriorvitreousdetachmentwilloftencausedebristoobstructthelightbutthepatientcanseethroughit,
vs.retinaldetachmentwherebythereisafrankfielddeficit
Temporalarteritis:
Vasculitisofautoimmuneetiologyaffectingthearterialbranchesoftheinternalcarotidartery(ophthalmic
andtemporalarteries)thatisoftenprecededbyfeaturesofpolymyalgiarheumatica(PMR)
DefinitionfromtheAmericanCollegeofRheumatologists:ageover50,newheadache,abnormalityofthe
temporalartery(tendernessorpulselessness),ESR>50,andpositivetemporalarterybiopsy;3outof5
positivecriteriaresultinasensitivityof93%forthediagnosis,andaspecificityof91%
Symptoms–jawclaudicationanddiplopiaaremostpredictive,butalsotemporalareapainandsubacute
peripheralvisionloss,lowgradefever,constitutionalsymptomslastingweekstomonths(anorexia,fatigue,
myalgias,nightsweats,weightloss),ataxia,decreasedhearing
Signs–beading,prominenceortendernessofthetemporalarteryisthemostpredictive,butalsotemporal
scalpareatenderness,hyperesthesiaandhypersensitivity,andvestibularorhearingimpairmentattimeof
presentation
Thinkoftemporalarteritisinelderlypatientswhopresent'Weak&Dizzy'becauseoftensymptomsarevague
ESRandCRP–NormalESRvaluesincreasewithage(age÷2formen,and[age+10]÷2inwomen),and
biopsy‐positivetemporalarterycaseswithnormalESRvaulesarenotuncommon,butthecombinationof
normalESRandCRPhasasensitivityof99%inrulingoutthediagnosis
DonotrelyononanormalESRalonetoruleouttemporalarteritis
Treatment–Steroids,withPOformulationifnoocularsymptomsarepresentandIViftheyare;donotdelay
treatmentevenifbiopsycannotbeperformedforafewdaysasearliertreatmenthasbeenshowntoleadto
betterimprovement(60%iftreatedwithin24hrsofsymptoms,vs.only5%iftreatedafter24hrs)
CentralRetinalArteryOcclusion(CRAO)–firstimage:
Suddenabruptpainlessvisionloss(i.e.strokeoftheretina,withthe
samecar‐diovascularriskfactors),eithercomplete(withlight‐dark
perceptiononlyoverthewholevisualfield),orwithcentralvision
retained(duetothedifferentvas‐culardistributionofthefovea)
Signs–PositiveRAPD(rapidafferentpupillarydefect)withablanched,
non‐perfusedretinawiththepathognomoniccherry‐redspot,i.e.the
redfoveaunderlyingthealmosttransparentretina,lateraltoopticdisk
Management–Time‐sensitivegoaltorestorebloodflowandremove
obstructionthroughvigorousmassageofeyeballtobreaktheclotdown
andsenditdownstreamtoconvertittoabranchocclusion,antiplatelet
therapy(ASA),anddecreaseIOP(timolol,acetazolamide,and
mannitol),possiblythrombolyticsonacase‐by‐casebasis,andbreathingintoapaperbag10mineachhourto
increasetheCO2withresultantarterialvasodilation
CentralRetinalVenousOcclusion(CRVO)–secondimage:
“DVToftheeye”,vascularengorgement(gradualchanges);tell‐tale–
bigangrystormyeyeonfundcoscopicexam;hyperaemic,‘bloodand
thunder’exam
Painfullossofvision
Opticneuritis:
Inflammationoftheopticnerve(duetodemyelination),usuallyinwomen15‐45,causingtheclassictriadof
unilaterallossofvision,eyepain(especiallywitheyemovement)anddyschromatopsia(washedoutcolors,
especiallyred,asiflookingthroughfrostedglass)
Signs–Markedlydecreasedvisualacuity(oftentolightperceptiononly),withanormaleyeandfunduscopic
exam–“thepatientseesnothing,andyouseenothingonexam”(maysometimesseeblurreddiskmargins
andswollenveins),withpositiveRAPD(thepupilsparadoxicallydilatewhentheflashlightisswungfromthe
unaffectedtotheaffectedeyeduetothedecreasedlightperception;alsoseeninvitreoushemorrhage,retinal
detachmentorischemia,andretrobulbarhemorrhage);IfplaquesareseenonMRI,morelikelytodevelop
multiplesclerosis
Treatment–TheOpticNeuritisTreatmentTrialshowedthatIVmethylprednisolone250mgqidx3dfollowed
byanoralprednisonetaperover1wkrestoresvisionmorequickly,anddelaysthedevelopmentofmultiple
sclerosisby2yrs
Pearlsfromtheexperts
Infectiousconjunctivitis:Themostimportantpartofmanagementisirrigationandwashingoutoftheeye
Contactlenswearersshouldbeprescribedanti‐pseudomonalssuchasTobramycin(aminoglycoside),or
Ciprofloxacin
Suspectgonococcalinfectionwithrecentunprotectedsexualintercourse,especiallyifthereissubstantial
purulentdischargethatre‐accumulatesrapidlyafterwiping,orininfants3‐6daysoflifewithredeyesafter
vaginalbirth,whichrequireadmissionandIVantibiotics
4non‐traumaticeyeemergenciesthatrequirepromptophthalmologicalconsultation:
Acuteangle‐closureglaucoma,severeuveitis,acutelossofvision(fromCRAO,temporalarteritis,retinal
detachmentoropticneuritis),andsignificantcornealulcerationof>1mminlength
Tersonsyndrome–thirdimage:Insubarachnoidhemorrhage
(SAH),thesuddenriseinintracranialpressuremayleadto
retinalveinsrupture,resultinginasubhyloidhemorrhage
withboatshapefromcentraldiskonfundoscopy
(pathognomonicforSAH)