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Acute Ophthalmology
F Dean
Consultant Ophthalmologist
Aims of the session
• Anatomy of the eye and orbit
• Ophthalmic history, examination and
assessment
• Ophthalmic triage
• Conditions –true emergencies
• Using an ophthalmoscope
Anatomy of the eye
Frontal View Of Orbital Muscles
Anatomy of the Visual Pathway
Taking the history
What symptoms may be specific to the
eye?
• Red/sore/watering/itchy/burning/hot
• Aching
• Can’t see
– Intermittent
– Complete or partial
• Double vision
• Funny vision- flashes/floaters/distortion
Ophthalmic History
Loss of Vision
• rate of loss
• near or distance
• total blurr or part blurr
– general loss = loss of acuity
– part loss = loss of visual field
• associated features e.g distortion, floaters,
flashing lights, pain etc
Ophthalmic Symptoms from different
structures
• Eyelid-itchy, burning,dry
• Conjunctiva- watery,sticky, burn, sore
• Eye ball- aching, visual disturbance,
floaters
• Orbit- watery, ache
• Brain- headache, visual disturbance,
photopsia, diplopia
Pain
Pain
• Type of pain
– Gritty sandy feeling = ocular surface
– Ache within the eye = deeper tissue involvement
e.g. uveal tissues
• duration
• precipitating or relieving factors
• Location/radiation
History
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Past medical history
Social history
Drug history
Family history
General History
• Diseases with known ocular associations
– Diabetes, atherosclerosis, collagen vascular
disease,
– Hypertension
– Meningitis
– Raised intracranial pressure
Eye Examination
• Visual acuity.
• Examination of the
– Lids
– Cornea and conjunctiva
– Pupils
– Red reflex/lens
– Fundus
• Examination of the eye movements
• Examination of the fields
Visual Acuity
• Logmar acuity
Newspaper for near
vision
• With spectacle
correction as required
• With and without a
pinhole
Acuity Chart testing
• 6/6 = line 7
– Person can see at 6 m
what a normal person
can see at 6 m
• 6/60 = top line
– Person can see at 6 m
what a normal person
can see at 60 m
6/60
6/36
6/24
6/18
6/12
6/9
6/6
Using an occluder with a pinhole
Ophthalmic examination
• Visual acuity.
– With and without
glasses
• Examination of the
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Lids
Cornea and conjunctiva
Pupils
Red reflex/lens
Fundus
• eye movements
• Visual fields
Topical Medication for Examination
• To check for break in epithelium
– Fluorescein
• Local anaesthetic
– Benoxinate 0.4%
• For pupil dilation
– Tropicamide 0.5%
– Phenylephrine 2.5%
External Eye
• Use good general illumination e.g angle poised lamp
• Pen torch pencil beam for tangent illumination +
fluorescein stain
• Use topical anaesthetic when required for patient
comfort
• Start with eyelids, then conjunctiva, cornea and pupil
Pupils
• Direct and consensual
reflex
• Afferent defect
– problem with message
reaching the brain
• Efferent defect
– problem responding to
light stimulus
Assessment of the extraocular movements
Visual Fields
Assessment of Squint
• Monocular vision
– may have amblyopia (lazy eye)
• Eye movements
– is there any restriction of movement
– is there any double vision
• Cover Test
– check for ocular deviation
Extra ocular movements
• Visual axes are not in
parallel
Ophthalmoscopy
• Don’t be afraid to
DILATE the pupil
• Correct for refractive
errors
• Use the optic disc as a
landmark and follow
the arcades
Ophthalmoscopy
To see with an ophthalmoscope you have to be
very close to the patient
What is Triage?
A process by which a patient is
assessed upon arrival to determine
the urgency of the problem and to
designate the appropriate healthcare
resources to care for the identified
problem
Aim of Triage System
• Realistic priorities of care are determined
which result in appropriate, efficient and
effective service delivery
Discriminators
• General
• Specific
General Discriminators
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Life Threat
Pain
Haemorrhage
Conscious level
Temperature
Acuteness
General Discriminator
• Ophthalmic patients with pain in
conjunction with specific discriminators.
Specific Discriminators
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Chemical eye injury
Penetrating eye trauma
Sudden loss of vision
Reduced visual acuity
Inappropriate history
Red eye with abnormal pupil reaction
Specific discriminators
• Chemical eye injury
– Acid
– Alkali
– molten metal
– CS gas
Specific discriminators
• Penetrating eye trauma
– Traumatic event causing perforation of the globe
– May contain foreign body
Specific discriminators
• Sudden complete loss of vision
– loss of vision in one or both eyes within the
preceding 24 hours
– Normally vascular
Specific discriminators
• Reduced Visual acuity
– corrected visual acuity loss.
Specific discriminators
• Inappropriate history
– alleged mechanism of injury does not fit the injury
Specific discriminators
• Red eye
– with or without pain
– complete or partially red
Discriminators
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In addition to specific discriminators add
Pupil reaction
Shape
Size
Specific discriminators
• Pupil reaction
– fixed dilated pupil
– distorted pupil
– festooned pupil
Red Flags
• Ocular pain- particularly deep ache
• Visual loss
• Bleeding
• Always refer when pain and visual loss are
present simultaneously.
MANCHESTER TRIAGE
DISCRIMINATORS
(OPHTHALMIC)
Categories
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Red
Orange
Yellow
Green
Blue
RED CATEGORY
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Alkali
most commonly Lime
Sodium hydroxide
Cleaning solutions
Bleach
Chemical Injury
• Alakali injury
• Other chemical injury.
RED CATEGORY
– Acid eg battery
– molten metal
– CS gas
ORANGE CATEGORY
• Urgent -see within 5
minutes a delay in
treatment could be
sight threatening
Intra-orbital foreign body
ORANGE CATEGORY
• Perforating injurieswith a suspicion of
intraocular foreign
bodies
Air bag injury
ORANGE CATEGORY
• Acute Glaucoma
• Non- accidental
causes loss of vision
within hours
• Post operative
patients before the
fifth day
ORANGE CATEGORY
• Acute orbital cellulitis
• Accidents causing gross
visual disturbance
• Obvious bleeding/
lacerations/ Hyphaema
ORANGE CATEGORY
• Corneal ulcers with
hypopion
• Endophthalmitis
• Sudden onset diplopia
Penetrating Injury
Corneal
laceration
Perforating injury
Shot Gun Injury
Blunt Injury, Contusion
• Bruising to eye lids
Blunt Injury
Blunt injury
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Irido dialysis
Pain
Risk of Pressure
Likely other injury
– Eg.retinal trauma
• Distortion of globe
• Tearing of internal structures
Blunt Injury
• Hyphaema- blood in anterior chamber
• Microscopic or Macroscopic
– Blood in the anterior chamber
– Pressure problems, esp. re-bleed
• Must ask if FH of sickle cell in relevant ethnic gp
– Other injury
– Children require admission
– Must ask if FH of sickle cell in relevant ethnic
group
Blow-out Fracture
• Usually caused by impact from object larger than
bony margins of the orbit
• high pressure in orbit causes fracture of floor
• Inferior orbital contents prolapsed into the
maxillary sinus
Blow-out fracture-symptoms
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Black Eye
Double Vision
Blurred Vision
Small eye (enopthalmos)
Pulling sensation on up gaze
Blow-out Fracture- signs
• Chemosis and
echimosis around eye
• Limitation of up and
down gaze.
• Loss of sensation below
lower lid
• Order X-ray
Facial Bone Fractures
• In a facial injury involving a fracture there is a
30% chance of maxillary involvement
• Chance of ocular injury
– 10-23% in Le Fort II and III
– 2-10% blinded
– 89% frontal sinus and supra orbital
Le Fort 3
All red and orange conditions need
referral to an ophthalmologist
• All conditions
classified as
Blue/green can wait
What Ophthalmic conditions require
fundoscopy?
• Anything with Visual loss
• What systemic conditions require
ophthalmoscopy?
Systemic diseases requiring
ophthalmoscopy
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Head injury?
Suspicious of raised ICP
Meningitis
Neurological- MS
Vascular presentations- CVA, Hypertension
What does the fundus tell you?
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Papilloedema- raised ICP
Pale disc- previous optic neuritis
Haemorrhagic disc
Hypertensive changes
Diabetic retinopathy- control/ renal function