Download Ophthalmology - Aberdeen Emergency Medicine

Eyes in the E.D
Aaron Graham
LAT1 Emergency Medicine
The history is all the same..
• Ophthamology like a normal history
plus…
• Past ocular history - I.e Surgery/contacts
• Examination - Visual Acuity !!
• Fluroscein staining
• Say what you see
2
Part 1: Red eye
Part 2: Sudden visual loss
3
Part 1: The Red Eye
• Conjunctivitis (Viral and bacterial)
• Corneal abrasion
• Bacterial keratitis
• Orbital celulitis
• Anterior uevitis
• Episcleritis
• Sceleritis
4
RED EYE
• CORNEAL ABRASION
– FB sensation, pain, photophobia, ↓VA
– Try LA to see if pain settles
– Injected conjunctiva, ↓VA (visual axis)
– Fluroscein staining - Epithelial defect with
– Chloramphenicol QDS 1 week, eye
protection, lubricating eye drops
RED EYE
• Corneal FB
– Very common in minors. Hx of FB, then
shortly after pain, FB sensation, red eye
– LA allows examination
– Try & remove with cotton bud/needle
– Rust Ring
• Iron containing FB
– Key point - Is this a penetrating eye
injury?
Seidels positive - penetrating!
ophthalmology!
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RED EYE
• CONJUNCTIVITIS
– Viral more common than bacterial
• Red, irritated, streamy, purulent sticky eyes
• VA and pupils normal
• No staining of cornea with Fluoroscein
• Chloramphenicol QDS for 1 week
• Hygiene. Likely spread and can take weeks to
go away!
First not to miss: Bacterial
keratitis
• Ophthamology! Almost certainly
contact lens wearer • Ophthamology!
Second not to miss: Orbital /
Peri-orbital cellulitis
• Red eye, proptosis, pain on eye
movement = orbital cellulitis
• Ophthamology! 10
HSV Dendritic Ulcer
• Ophthamology!
RED EYE
• Ocular Burns
– Acid or Alkali may blind. Urgent Rx req.
– Irrigate +++++ to dilute chemical ASAP. Aim
for pH 8
– Alkali
• Penetrates eye & destroys internal structures
– Acid
• Coagulates collagen to form barrier which
prevents penetration into eye.
• Episcleritis/ Scleritis
– Red, sore ++++ (Compared with
conjunctivitis)
– Localised area of inflammation.
– Mostly idiopathic but can be assoc. with RA /
Auto-immune.
Episcleritis
• Ophthamology!
Scleritis
• Ophthamology!
Part 2: Sudden visual loss
• Retinal detachment
• Vitreous haemorrhage
• Stroke!
• Central retinal vein / artery occlusion
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Retinal detachment
• The one not to miss!
• F - lashing lights
• F - loaters
• F - ield loss
• Short sighted / trauma / diabetic at
greater risk
• Decrease in visual acuity (If macula)
• Often had it before
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Retinal Detachment
SUDDEN VISUAL LOSS
• Vitreous Haemorrhage
– Sudden onset of “floaters” or “blobs”
– VA may be normal or ↓ if haemorrhage dense.
– Flashing lights indicate retinal traction which
may lead to a retinal hole or detachment.
– Haemorrhage from spontaneous rupture of
vessels, avulsion of vessels during retinal
traction, or bleeding from abnormal new vessels
(diabetics)
Part 2: SUDDEN VISUAL LOSS
• Vitreous Haemorrhage
– VA depends on the extent of the
haemorrhage.
– Red reflex reduced.
– May see clots of blood that move with the
vitreous.
– Retina may be difficult to visualise.
REFER URGENTLY
Vitreous Haemorrhage
Part 2: Sudden visual loss
• Central Retinal Artery Occlusion
– End artery. Occlusion usually embolic.
– Sudden painless ↓↓ VA (counting fingers or
no light perception)
– Direct pupil reaction sluggish/absent in
affected eye but reacts to consensual
stimulation(afferent pupillary defect)
SUDDEN VISUAL LOSS
Central Retinal Artery Occlusion
Part 2: Sudden visual loss
• Central Retinal Artery Occlusion
– Digitally massage globe to ↓ IOP & try to
dislodge embolus
– URGENT Ophthalmology referral
– Consider S/L GTN, IV acetazolamide 500mg
– CO2 rebreathing to dilate arteries.
– ? Giant Cell Arteritis – may lose sight in
other if not treated promptly. Full Hx & Ex
important.
SUDDEN VISUAL LOSS
• Central Retinal Vein Occlusion
– More common than CRA occlusion.
– Predisposing factors: Old age, chronic
glaucoma, arteriosclerosis, ↑BP,
polycythaemia.
– ↓↓VA with afferent pupillary defect.
SUDDEN VISUAL LOSS
• Central Retinal Vein Occlusion
– Fundoscopy – “stormy sunset”: hyperaemia
with engorged veins & adjacent flame shaped
haemorrhages. Disc may be obscured by
haemorrhages & oedema. Cotton wool spots
may be seen(bad Px sign).
– Outcome variable. No specific Rx.
– Refer urgently as underlying cause may be
treatable therefore protecting the other eye.
Central Retinal Vein Occlusion
PAINFUL EYE
• Acute Closed Angle Glaucoma
– At risk: Long sighted middle aged, elderly
with shallow anterior chambers.
– Cause: sudden blockage of drainage of
aqueous humour into Canal of Schlemm
(anticholinergic drugs, pupil dilating at
night)
–♀>♂
PAINFUL EYE
• Acute Closed Angle Glaucoma
– Acute onset painful red eye 20 to rapid ↑ IOP
– Vision blurred, haloes around lights.
– Pupil semi-dilated & fixed.
– Eye feels harder to palpation.
seen shortly after attack has resolved NONE of these
– Ifsigns
may be present, therefore Hx is paramount.
Acute Closed Angle Glaucoma
PAINFUL EYE
• Emergency treatment if sight to be preserved.
• Aim of Rx: ↓ IOP – 4% Pilocarpine (both eyes)
IV/PO Acetazolamide.
Laser/Surgical Rx to Iris
NB Condition is bilateral. Felloe eye is at 50% risk of
developing an attack within 5 years. Fellow eye should
have prophylactic iridectomy or laser iridotomy.