Download OPTHALMOLOGY

OPTHALMOLOGY
Complete examination and good documentation is essential.
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Assessment of visual acuity in each eye separately. If VA is reduced, try correction with pinhole.
Testing visual fields by confrontation.
External exam of periorbital structures.
Examination of external ocular movements.
Examination of the pupillary light reflex- direct, consensual, swinging flashlight.
Eversion of the eyelids to look for foreign body under the upper lid.
Ophthalmoscopy
Examination under the slit lamp.
Fluoroscein staining to check for corneal ulcers or abrasions. Use blue light.
Tonometry - which we are not equipped to do in the department.
Further investigations that may need to be done include
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Xray orbit for penetrating foreign body or orbital blowout fracture
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CT Scan
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Swabs for discharge.
MANAGEMENT OF TRAUMATIC CONDITIONS
Conjunctival foreign body
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Can be picked off with a moistened cotton tip applicator
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Irrigate the eye with normal saline if a lot of foreign particulate material is present.
Corneal foreign body
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1% Amethocaine drops to anaesthetise the eye.
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Remove using a 21 gauge needle on 2 ml syringe.
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Use the beveled edge of the needle to pick off the foreign body gently.
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Chloramphenicol ointment QID
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Review by GP or eye clinic the next morning.
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If rust ring refer to eye clinic in 2 days.
Corneal abrasion
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1% Amethocaine drops to facilitate examination. Prolonged application causes corneal damage
therefore do not prescribe ongoing amethocaine.
Cycloplegic / Mydriatic - 1% Cyclopentolate or 2% homatropine drops - 1 dose in the department
only if there is a lot of pain.
Chloromycetin ointment qid for 2 days
Eye patching in corneal abrasion has been shown recently to be not useful, and perhaps even to
cause delayed healing of the cornea.
Arc eyes/welder's flash/ultraviolet keratitis
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Cycloplegic: 1% cyclopentolate one drop in each eye repeat 6 hourly prn
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Chloramphenicol eye ointment qid
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Pressure patching 24 hours for comfort, required bilaterally but patient may choose not to have
both eyes patched. Use 2 patches, the first one double folded to fit into the orbital contour.
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Oral analgesia - codeine, voltaren, paracetamol.
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Refer to eye clinic for follow up within 2 days.
Hyphaema
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Range is from 0% (suspended RBCs only, called a microhyphaema) to 100%.
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Management is controversial.
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Previous recommendation was hospitalization and forced bed rest with head elevation for 3 days.
Recent trends have been toward outpatient management.
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Discuss with ophthalmology registrar on call.
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Treatment is initiated only by the ophthalmologist and includes atropine drops, prednisilone drops,
and measurement of IOP and appropriate treatment if it is raised.
Eyelid lacerations : Refer to Ophthalmology Registrar if:
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Lid margin is involved / full thickness .
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Deep lacerations medial to the punctum for assessment of integrity of the nasolacrimal duct.
Blowout fractures
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Rule out ocular trauma with examination as above.
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Oral antibiotics Keflex or amoxicillin for 10 days
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Refer to faciomaxillary clinic at MMH unless there is an eye complication, in which case refer to
ophthalmology first.
Penetrating globe injury
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Suspect with high velocity injury, as hammer on chisel,
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Pupil maybe misshapen
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Globe may feel soft
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Obtain xray +/- CT scan and refer to ophthalmology
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Treat nausea promptly with IV metaclopramide or cyclizine
Chemical burns
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Alkali burns are worse than acid burns.
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Irrigate the eye with 1 to 3 litres of normal saline for 20 minutes or until pH of the tears is 6 to 8,
measured by pH paper (urine dipstick paper can be used).
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If there is no defect and the anterior segment is normal, administer chloramphenicol ointment.
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If there is a corneal defect or if there is clouding, administer chloramphenicol ointment,
cyclopentolate 1% drop, and an eye patch and refer to ophthalmology clinic within 1 day.
NON-TRAUMATIC CONDITIONS
Conjunctivitis
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Bacterial
Rule out corneal involvement
Chloromycetin oint qid for 7 days
If wearing contact lenses, discus with ophthalmology registrar. May need to use a fluoroquinolone
or aminoglycoside drop.
Viral
Fluorescein stain to rule out dendritic ulcer.
Cool compression qid
Albalon A 1 drop 4 hourly prn for itch
Topical antibiotic if bacterial infection likely
GP follow up.
Allergic
Eyedrops: Albalon A 4 hourly or Livostin BD
Cool compresses
Herpetic dendritic ulcer
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Discus with ophthalmology reg
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Acyclovin 3% ointment 5 times a day
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Eye clinic follow up
Herpes Zoster Ophthalmicus
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Refer to eye registrar
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May need admission for intravenous acyclovir.
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Will also need local antibiotic ointment, prednisone forte for iritis without corneal involvement,
and cycloplegics.
Periorbital (preseptal) cellulitis
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Ascertain that the eye is not involved.
If mild infection, afebrile patient, oral amoxicillin clavulanic acid.
If significant infection, admit for iv antibiotics. Discus with ophthalmology registrar. Patient may
need to go to MMH plastics or ENT.
Orbital (postseptal) cellulitis
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Serious ocular infection that “can be life threatening”.
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The most frequent cause is orbital extension of a paranasal sinus infection.
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Recognition: swelling and redness around the eye with discharge may be present as in periorbital
cellulitis, but additionally there is proptosis, fever, pain on extraocular movements. The patient
may be toxic with a fever. Decreased visual acuity, loss of sensation over the ophthalmic and
maxillary branches of the trigeminal nerve, and raised IOP are uncommon but may be present.
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Administer iv antibiotics, cefuroxime 750mg 8 hourly or amoxicillin clavulanic acid 1 g 8 hourly.
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Obtain CT scan to rule out subperiosteal abscess.
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Admit patient – may require surgical drainage.
Acute angle closure glaucoma
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Typical presentation is acute onset of deep eye pain after a prolonged exposure to a low light
environment.
Other features: headache, photophobia, decreased vision, nausea and vomiting, abdominal pain
may be present, halos around lights.
Examination findings: poorly reactive midposition pupil, cloudy cornea, increased IOP, usually
over 50 (normal 10 to 20 mm Hg)
Refer immediately to ophthalmology registrar on call.
Therapeutic modalities include
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Acetazolamide 500 mg iv and 0.5 % timolol eye drops will reduce aqueous production
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Mannitol 1 to 2 g iv will cause osmotic diuresis.
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Pilocarpine 2% one drop every 15 minutes until pupillary constriction.
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Topical timolol 0.5 % will drop the IOP in 20 to 30 minutes.
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Topical steroid drops
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Definitive therapy is surgical.
Acute Nontraumatic Loss of Vision
Differential Diagnosis
1. Central artery occlusion
2. Central vein occlusion
3. Retinal detachment
4. Vitreous haemorrhage
5. Macular disorders
6. Neurophthalmic disease
7. Hysteria
Central retinal artery occlusion
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Age 50 to 70
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45 % of patients have carotid artery disease. Is usually embolic and a complete neurologic and
cardiovascular evaluation is necessary.
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Risk factors : HT, cardiac disease, diabetes, collagen vascular disease, vasculitis, cardiac valvular
abnormality, and sickle cell disease. Raised IOP and endocrine exophthalmos are also predisposing
factors.
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Diagnosis : Painless, markedly reduced visual activity, afferent pupillary defect, retina oedematous
with a pale gray white appearance, and the fovea appears as a cherry red spot.
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Refer to ophthalmology registrar . Therapeutic interventions include digital global massage,
rebreathing into a paper bag for 10 minutes every hour, topical timolol drops and intravenous
acetazolamide.
Central Vein Oclusion
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Painless loss of vision ranging from minimal to recognition of hand motion only.
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Retinal appearance varies depending on aetiology. Non-ischemic: macular oedema with dilated,
leaking capillaries. Ischaemic : classically dilated and tortuous veins , retinal haemorrhages, and
disk oedema.
Retinal Detachment
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Symptoms : flashes of light, floaters, visual loss. Visual loss is described as a filmy, cloudy or
curtain like appearance. Pain is absent. Visual acuity is preserved unless the macula is involved.
Visual field cuts are present.
Vitreous Haemorrhage
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Most common causes are diabetic retinopathy and retinal tears.
References:
Emergency Medicine , A Comprehensive Guide, 5th edition, Tintinalli et al.
Critical Decisions in Emergency Medicine Vol 12 and Volume 13 No 7 March
1998 and No 4 December 1998
Emergency Medicine. Concepts and clinical practice. Edited by Rosen. 3 rd edition.