Download - SCHHS Emergency Department

2003.1 VAQ 6 Quiz Clinical 021 CJJ06
Scenario
A 19 year old female presents with a painful right eye and decreased vision after
being out for most of the night previously at clubs. She is normally myopic. Her
visual acuity is 6/24 in her right eye and 6/12 in her left eye.
1. List 3 possible causes for the above lesion
a. Trauma
i. Blunt/Penetrating
ii. Chemicals
iii. Contact lens
b. Infections- bacterial , viral, fungal , contaminated
medications
2. Outline steps in further management.
a. Analgesia –oral & local
b. Corneal sensation testing
c. Slit lamp examination with Fluorescing testing Defects,
Seidel’s sign
i. Slit lamp exam –epithelial layer, Stroma, Endothelial
layer , corneal oedema, infiltrates in AC etc.
d. Corneal scrapes
e. Intraocular pressure
f. Refer to ophthalmologist
i. Pachmetry
ii. Specular microscopy
iii. Cornea topography
g. Antibiotics / Antiviral +-Cycloplegics
3. Pseudomonas cover with Fluoro quinolones if contact lens wearer
i. Viral
… -keratitis
HSV, V2V….corneal
…. - …epithelium
……
Most bacteria
can cause
only if…the
is
breached except – N gonorrhoea & H influenza . Viral Keratitis is caused
by HSV, VZV( Herpes zoster ophthalmicus)
A 50 YO woman presents with a monocular visual loss.
1: List your differential diagnosis.
2: For each differential give 2 features of history and 2 features of examination that would
be supportive
3: What are your treatment priorities for central retinal arterial occlusion?
1: Central Retinal Artery Occlusion
(Hx: sudden painless profound visual loss, recent amaurosis fugax episodes, vascular risk
factors.
Ex: Severly reduced VA effected eye, RAPD, fundoscopy: pale retina, cherry red spot)
2: Ischaemic optic neuropathy (eg Giant cell arteritis)
Hx: Polymyalgia rheumatic, Jaw claudication, headaches, scalp tenderness, Profound visual
loss.
Ex: Temporal artery tenderness, RAPD, oedematous optic disk on fundoscopy
3: Retinal Detachment
Hx- Flashes and floaters, Shade / curtain. Associated trauma sometimes
Ex- Variable VA / RAPD depending on size, Visual field defect.
4: Vitreous Haemorrhage.
Hx: Proliferative diabetic retinopathy, trauma, blurred vision of variable severity
Ex: Variable VA, Loss of red reflex. No RAPD unless associated retinal detatchment
5: Optic Neuritis: Eg: MS
young women, Subacute visual loss, (over days) pain on eye movement
Ex: Disk oedema, RAPD,
6: Central Retinal Vein occlusion.
Subacute variable visual loss,
variable RAPD, VA, blood and thunder retina.
CRAO – Rx
Urgent ophthalmology advice and referral
Poor evidence for intervention but try
-Pulsed ocular massage
-Acetazolamide 500mg PO / IV.
-Consider anterior chamber paracentesis in conjunction with ophthalmology.
A 30 YO male presents to ED after an assault with a broomstick. He is GCS 15 with no other
apparent injury.
1: List 6 important features of this photo
2: What important diagnoses must be considered. Give 2.
3: Outline 5 important features of your examination.
4: Outline your further investigation
5: His VA is light perception only in the effected eye. Outline your management
1:
- Dilated pupil.
-Proptosis
-Marked subconjunctival haemorrhage / bloody chemosis
-Periorbital ecchymosis
-Small Hyphema
-Corneal opacity (?abrasion / laceration)
2:
Retro-orbital haemorrhage / orbital compartment syndrome
Ruptured globe / Penetrating eye injury
3: VA – marked reduction in VA implies possible optic nerve ischemia and mandates early
management
Pupillary reaction / RAPD Consistent with optic nerve ischemia
Eye movements (? Entrapment )
Tonometry High IOP (>40)consistent with retroorbital haemorrhage, low/ normal with
penetrating eye injury
Fundoscopy (may see papiloedema)
Fleuroscine stain (?corneal abrasion / ? evidence of penetrating injury/ rupture)
4: CT orbit – may confirm diagnosis / delinate associated injury eg Fracture / entrapment.
Should not delay treatment if significant reduction in VA.
5: Needs urgent reduction of orbital pressure. Lateral canthotomy is indicated
Urgent opthal involvement (ideally they perform procedure)
Analgesia
Consider procedural sedation in ED to expediate lateral canthotomy.
Note: Ruptured globe is a contraindication and needs exclusion first.
Ref http://lifeinthefastlane.com/ophthalmology-befuddler-033-2/
Also dunn and exam feedback
SAQ 6
a. Compare and contrast the clinical features of pre-septal and orbital cellulitis (6
marks)
Pre-septal
Orbital cellulitis
Infection
More superficial (usually
skin source)
Deep (sinus, dental source)
Sight threatening
Unlikely
Possible
Life threatening
Unlikely
Possible
Visual acuity
Normal
Usually reduced
Eye movements
Normal
Painful/reduced
Proptosis
No
Possible
Neurological signs
No
Possible
Organisms
Skin (staph) more prevalent
Gram negs more prevalent
Generally unwell/URTI
Possible
Possible
Toxic, severe headache
Unlikely
Possible
b. List three features essential for managing orbital cellulitis (3 marks)
 Broad spectrum IV Abs
i. Staph cover (eg flucloxacillin, vancomycin alternative)
ii. Gram neg cover (3rd generation ceph)
 Urgent ophthalmology review and admission, consideration of surgical
intervention
 CT to confirm Dx and identify surgically amenable lesions
VAQ 2
An 18 year old man presents with right eye pain. There is no history of trauma.
His vital signs are:
Temp 38oC
Pulse 110/min
BP 120/80 mmHg
SaO2 98% RA
A contrast enhanced CT scan is performed – 2 slices are shown.
a) Describe 4 features seen on the CT scan (4 marks)
Proptosis of right eye and/or retrobulbar oedema
Periorbital oedema of right eye
Right intra-orbital gas or air/fluid level
Right orbital abscess or right orbital (post septal) cellulitus with gas formation
b) Outline the important features of the eye examination in this patient (2 marks)
Range of movement of eye +/or pain on movement
Visual acuity
a. List 3 differentials with 3 key symptoms / signs and management in the table below:
Differential
Symptoms
Management
5.
a.
Differential
Acute angle closure
glaucoma
Symptoms
1. severe pain
2. systemically unwell
3. fixed, semi-dilated pupil
Management
Acetazolamide 500mg IV stat
then 250mg PO q8hr or
mannitol
Pilocarpine 2% 1drop q5min
x 6 then QID
Timolol 0.5% 1drop BD +/prednisone 0.5%
Analgesia
Urgent referral for surgery
Acute anterior uveitis
1. photophobia
(Iritis)
2. hypopyon
3. small or irregular pupils
Urgent referral if hypopyon
+/- steroids if no corneal
infection
Scleritis
1. gradual onset pain
2. thickened sclera with blue
nodules
3. associated systemic disease
(RA, gout, syphilis, TB,
sarcoid, HT, drugs)
Analgesia, topic steroids if no
infection
Cycloplegics
Urgent referral
2011-2 New Format VAQs
Question 1
A 4 year old boy is brought into your emergency department following an injury sustained to
his right eye from a small rubber ball thrown by his brother earlier that day.
a) Please describe the photograph (4 marks)
b) What is the diagnosis (1 mark)
c) What are the potential complications of this injury (4 marks)
Question 1 Answers
a) Please describe the photograph (4 marks)
Blood in anterior chamber: approximately 30 - 40% of chamber height
Mild conjunctival injection of right eye
Equal pupillary size
No other obvious trauma to orbit or peri-orbital area
Child not in distress
b) What is the diagnosis (1 mark)
Small to moderate hyphaema secondary to blunt trauma.
c) What are the potential complications of this injury (4 marks)
Short to Medium Term
- Rebleeding
-
Decreased visual acuity
Pain due to increase IOP
Retinal damage (ie retinal detachment)
Long term
- Glaucoma
- Iron pigmentation staining to the cornea
References:
Dunn’s page 1108 – Ocular Trauma
Cameron’s page 610 – Ocular Emergencies
VAQ 6
While waiting for the Ct need in the last patient the triage nurse tells you of a 30 year old
male waiting to be seen whose child threw a toy soldier at his eye.
Question 1
List 2 salient positives and 2 salient negatives in the picture supplied
Question 2
What are 3 complications of this injury
VAQ 6 Answers
Question 1
List 2 salient positives and 2 salient negatives in the picture supplied.


Sub conjunctiva haemorrhage
Hyphema in the anterior chamber almost obscuring the inferior half of the pupil

Pupil looks to be normal shape – but abnormal according to marking scheme. 30%
pass rate for this question may have been because the abnormalities were not
obvious apart from the hyphema

No other surrounding traumatic injury – lid or face laceration, ecchymosis or
swelling
Question 2
List 3 complications of this injury.




Raised intra ocular pressure
Glaucoma
Optic atrophy , Field loss
Corneal opacification
References – Cameron, 4th ed page 610, Exam report.
VAQ 2
A 25 year old male presents with photophobia, increasing left eye pain and decreased vision
Question 1
List 2 important positive and 2 important negatives in this photograph
Question 2
As pert of your initial assessment what are 3 salient historical features that you must explore
Question 3
What are 3 important examination finding that you will attempt to illicit
VAQ 2 Answers
Question 1
List 2 important positive and 2 important negatives in this photograph




Conjunctival injection
Hypophyon – inflammatory cells in the anterior chamber of the eye.
Opacified cornea
Discharge and the nature of the discharge
Question 2
As pert of your initial assessment what are 3 salient historical features that you must
explore?





Contact lens wearer
Previous eye issues, surgery or keratitis
Trauma
Foreign body
Systemic symptoms
Question 3
What are 3 important examination finding that you will attempt to illicit?



Visual acuity
Pupils reaction to light
Slit lamp exam and fluorocene staining
References – Exam report.