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Ocular Urgencies & Emergencies: Anterior Segment -- Julie A. Tyler, OD Mechanical Trauma - Acute o Lid laceration o Conjunctival abrasions & lacerations o Corneal abrasion o Corneal laceration/perforation o Corneal foreign body o Uveitis o Hyphema o Orbital “Blow-out” Fracture o Angle recession = Anterior CB tear o Crystalline lens complications Subluxation/Dislocation Cataract Non “treating” conditions: o Iris sphincter tears o Iridodialysis o Cyclodialysis/TM tears Chemical Trauma o Overview of chemical injuries o Acidic solutions, pH<7 o Alkaline solutions, pH>7 Triage: Now, what happened? o Did something get into the eye? o A chemical? Start Lavage IMMEDIATELY o A foreign body? o Was it Metal-on-Metal? DILATION required o Was it vegetative material? Keep secondary fungal infection risk in mind o Is this associated with an event? o Medico-legal: Name, Place (including address), Date, Time, and details Lid Laceration o Signs/symptoms o Goal o Betadine scrub o Irrigate the wound sterile saline o Topical antibiotic ointment o Cover with sterile dressing if NOT surgical Case One: Wilma Woes….. o A patient contacted the emergency service while the clinic was closed following Hurricane Wilma…. o 55 year old WM o History of trauma to the eye x 12 hours Conjunctival Abrasions/Lacerations o Symptoms: Less painful than a corneal abrasion o Signs o Management Lavage with sterile saline Small abrasions Larger abrasions (or lacerations) Substantially large lacerations “Bandage” considerations….. o Historical o FDA approved lenses Corneal Abrasion o Symptoms o Signs o Secondary reactions – signs & symptoms Anterior chamber (AC) reaction Secondary corneal edema o Responds wonderfully to topical anesthetics o Management Least “invasive” tool Cycloplege & prophylactic antibiotic Size considerations FDA Approved” Bandage Contact Lens options Other considerations Corneal Foreign Body o Symptoms o Signs o Secondary anterior chamber reaction likely o Look for signs of PENETRATING eye injury IF metal on metal, MUST dilate pupils to ensure no penetration into the posterior segment o Management - Step-by-step Least invasive means possible Follow directions for corneal abrasion Based on size and location of FB Consider referrals The “Rust Ring” Case Two: It’s been two weeks… o 30 YO male presents during normal hours o Complaints of mild blur & light sensitivity o Sudden onset associated with trauma, occurred once Corneal Laceration/Perforation o TRUE OCULAR EMERGENCY o Symptoms o Signs o (+) Seidel’s test = see percolation of aqueous as blue stream in NaFl field o Additional signs may be seen: HYPHEMA Anterior chamber reaction Relatively flattened anterior chamber Intraocular contents (iris) may extrude through wound IOP expected low DO NOT perform tonometry to risk further loss of AC fluid or prolapse o Management o Additional concerns Traumatic Anterior Uveitis o Common in patients with blunt trauma o Common secondary concern o Symptoms o Signs o Complications of traumatic uveitis o IOP considerations o Management Cycloplegia Corticosteroids Re-evaluate 12-24 hrs & taper depending on outcome “Differences” in opinion Prevent Negative Sequalae o Upon resolution, follow-up with gonioscopy to rule-out ANGLE RECESSION… Hyphema o Symptoms o Signs o Often accompanied by other trauma signs o Grade by level of blood o Risks Longstanding decreased VA due to corneal blood staining Secondary glaucoma due to trabecular blockade o Management Cycloplege Possible topical corticosteroids if uveitis Avoid: Blood-thinning analgesics REST and IMMOBILIZATION Consider “shielding” involved eye Re-evaluate daily for first 5-7 days Monitor IOP “Traditional” consideration: Aminocaproic acid (Amicar) Follow up with gonioscopy to rule-out ANGLE RECESSION Angle Recession o Defined A traumatic cleft in the CB that occurs between the circular and longitudinal muscle fiber bands o Gonioscopy is necessary to identify and ascertain degree of angle recession o Signs o Symptoms o Risks Theories Degree of recession directly proportional Iris atrophy o Management: Gonioscopy on all pts with hx of blunt trauma AFTER at least 1-month post-incident Perform IOP once a month for 3 months, then q 3 months for 6 months Long-term Case Report: “Picking Fruit” o 49 year-old Hispanic male o Complaints of a “white” pupil OD noticed ~ 1 year ago o Was struck in the eye with tree branch Dislocation/Subluxation of the Crystalline Lens o Etiology: Zonular support of the lens is damaged or lost o Symptoms o Signs o Definitions: Lens position abnormalities (ectopia lentis) Subluxation Partial change in position Dislocation Zonules become completely detached o Management for subluxation Monitor vision and lens position if stable Chronic, low-concentration Pilocarpine Clear lens extraction/exchange cataract surgery ACIOL o Management of dislocation Depends on “new” location of lens Crystalline Lens: Cataracts o Any ocular trauma can result in a cataract o Rosette pattern most common Orbital Blow-out Fracture o Trauma compromising the inferior floor of the orbit o Generally accompanied by other signs of trauma o Signs o Symptoms o Management Careful evaluation including close evaluation on EOM testing Risk of infection secondary to direct sinus penetration Management of inflammation Chemical Trauma o TRUE OCULAR EMERGENCY o Review of Chemical Injuries o Intact epithelium protection o Key element is HISTORY What was the patient exposed to? What amount & over what length of time was the exposure? Was anything done for the patient? (eg, lavage) o Chemical review Acidic solutions pH < 7 Bind with tissue proteins; create their own barrier More immediate damage but not as persistent RED eye Common sources Sulfuric acid (H2SO4) = battery acid Hydrochloric acid (HCl) Hydrofluoric acid (HF) Acetic acid (CH2COOH) = vinegar o Chemical review Alkaline (base) solutions pH > 7 Saponify fatty aspects of tissue; “melt” tissue and penetrate deeper Long lasting, persistent damage done WHITE EYE Common sources Ammonia (NH3) = found in household cleaners Lye (NaOH) = found in commercial cleaning Lime (CaOH2) = found in cement Magnesium hydroxide (MgOH2) = found in fireworks o Signs Mild, Moderate, Severe Late complications o Symptoms o Diagnosis & Mx of chemical trauma ONLY presentation when VA not first - Lavage and then VA Topical anesthetic q15-20 minutes Litmus evaluation If not neutral continue irrigation Flush, check & sweep fornices dry materials or dead tissue Debridement of necrotic tissue Topical Medications Cycloplegia – 0.25% Scopolomine or 1% Atropine Broad spectrum antibiotic Frequent use of non-preserved lubricants Questions regarding corticosteroids Possible bandage CL or pressure patch Follow up and continued care Other “chemical” complications o Superglue o Nail glue o Ear drops o Anything that looks like an eye dropper… Anterior Segment “True” Ocular emergencies o Definition: Conditions that could lead to severe vision loss, including loss of light perception, and/or death, without immediate management - based on the associated ocular findings o Already covered: Corneal laceration, Chemical burns o To cover: Acute angle closure, Orbital cellulitis Acute Angle Closure o Signs o Symptoms o Associations: Various etiologies Pupil block Plateau iris syndrome Neovascular Mechanical o Differential diagnosis Glaucomatocyclitic crisis Inflammatory open-angle glaucoma Traumatic glaucoma Pigmentary glaucoma o Management In-office: gonio and IOP evaluation Topical pressure lowering meds Oral CAI Osmotic agents (mannitol or isosorbide) Identify underlying etiology & manage that condition (eg, lens, DR) Orbital Cellulitis o Signs o Symptoms o Associations Generally direct “expansion” Sinus infection Orbital fracture Focal infection around the eye May be secondary to complications of orbital surgery or FB o Management In-office Look for APD Careful evaluation of EOM Extensive history o Recent infection or surgery? o Trauma? o Stiff neck or change in mental status? o Diabetes or immunosuppressive disease? Refer Blood work including CBC with differential CT scan of the orbits and sinuses Possible Lumbar puncture & neuro consult Treatment Admit patient for IV antibiotics Prophylactic antibiotic for corneal coverage if exposure May take 24-36 hrs for improvement