Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Idiopathic intracranial hypertension wikipedia , lookup
Eyeglass prescription wikipedia , lookup
Cataract surgery wikipedia , lookup
Retinitis pigmentosa wikipedia , lookup
Keratoconus wikipedia , lookup
Dry eye syndrome wikipedia , lookup
Diabetic retinopathy wikipedia , lookup
Visual impairment wikipedia , lookup
Vision therapy wikipedia , lookup
Immediate threats to the visual system that can lead to permanent loss of visual function or threat to life if left untreated Often detected by primary care physicians, treatment and referral to an ophthalmologist if necessary Basic knowledge of the ocular anatomy and conditions Discussion: ER presentation, H&P, Dx and Treatment Careful HPI Important symptoms: reduced visual acuity, visual field changes, floaters, photopsia, head, orbital or ocular pain, changed appearance of the ocular adnexae, ptosis, diplopia, alteration in pupil size If symptoms are severe or rapidly progressive urgent referral to an ophthalmologist is appropriate Old vs Chronic Possible complications, e.g. recent surgery Recurrent ophthalmic condition ? Common systemic conditions with ophthalmic manifestation: diabetes, thyroid disease, HTN, autoimmune and inflammatory, infectious disease (HIV), malignant disease Asymmetry between the two eyes Visual Acuity (hand held card or Maxwell) Visual Field by confrontational; may reveal retinal or neurological diseases Color Vision: asymmetry may be sign of optic nerve pathology Eye Movement: adduction, abduction, upand down-gaze Diplopia: monocular vs binocular Pupils: relative afferent pupillary defect (RAPD/Marcus-Gunn pupils) Intraocular pressure (IOP): can cause visual field defect Anterior segment: examining the lid, conjunctiva, anterior chamber, cornea, iris, and pupils with handheld penlight, flash light, or slit-lamp › Traumatic Iritis - Inflammation of the front part of the eye is referred to as anterior uveitis or iritis, whereas inflammation behind this is known as posterior uveitis › Hyphema Posterior segment: direct ophthalmoscope (optic nerve) Traumatic Iritis – › Inflammation of the front part of the eye is referred to as anterior uveitis or iritis › inflammation behind this is known as posterior uveitis Hyphema › bleeding in the front (or anterior chamber) of the eye between the cornea and the iris › anterior chamber of the eye contains a clear liquid fluid called aqueous humor secreted by the ciliary processes in the posterior chamber of the eye passes through the pupil into the anterior chamber -provides important nutrition to the inner structures of the eye Determine: › Type of injury › Velocity/vector of trauma › Were glasses worn at the time Vision prior to injury Pt with multiple facial lacerations should be considered high risk for globe perforation until proven otherwise Examination of anterior segment Extraocular movements Ophthalmoscope Lids: laceration Lids: laceration › To be repaired within 72 hrs of injury › Best to wait for closure in OR › Examine eye/orbit for injury › HIGH INDEX of clinical Suspicion for FBs › Admin of Antitetanus › Wound Debridement Lids: laceration › Surgical Repair CORNEAL SHIELD and Ophth drops to affected eye with LA In layers – with non-resorbable approximating gray line Resorbable sutures – for approximation of the tarsal plate Repair to upper eyelid – requires care – to prevent ptosis Wound explored to ensure integrity of the Levator and superior rectus Levator complex isolated and lacerations sutured Failure to recognize dmg to the levator may result in unsightly Ptosis Acute conjunctivitis › Viral – sick contact, URI, BL, follicles, LAD, corneal infiltrate, contact isolation › Bacterial – common in children, tx w erythromycin, suspect gonorrhea with purulent discharge › Allergic – sudden chemosis, epiphora, allergen, usually resolves in 24 hrs Optic nerve: visual acuity, pupillary light reflex, color plate, IOP Vascular supply: vein or artery occlusion Extraocular muscles: movement Displacement of the globe: CT scan Orbital infection: vitals and CT scan Presentation: erythema, tenderness, blurry vision, HA, diplopia On exam: conjunctival chemosis, purulent discharge, fever, proptosis, restricted ocular motility, pain upon movement, decreased skin sensation Common organisms: staph, strep, H flu, bacteroides, gram- bacillirods Direct extension from sinus or dental infection, complication from trauma, surgery Mucormycosis in diabetic Labs: CBC w Diff, blood cx, gram stain and culture of discharge Treatment: broad spectrum IV Abx (unasyn, or ceftriaxone + vancomycin) for 72 h, then orally 1 week Ophtho and ENT consults Presentation: pain, tight eyelid, subconjunctival hemorrhage, proptosis resisting retropulsion, decreased vision, lid ecchymosis, limited ocular motility, incresed IOP Vision threatened/IOP dangerously high lateral canthotomy +/- cantholysis to prevent permanent visual loss Tx: Emergent Lateral Canthotomy Management › In 5 min intervals: - Visual Acuity, Pupillary reaction, and IOP measured - in some cases spontaneous decompression takes place - Within 20 mins IOP – loss of vision may progress – IOP increases (30 – 40 mm Hg) – normal?, pupil reaction becomes sluggish Management › Tx: Lateral Canthotomy Allows the globe to move forward and facility blood to escape from the orbit › MC – pt note immediate return to visual acuity and normal pupillary reaction › If bleeding source not IDed – then – may require slow IVP of Acetazolamide up to 500 mg – reduces the IOP Management › If pt deteriorate further – may require division of orbital septum superiorly and inferiorly with placement of drains Presentation: painful, red eye, mucopurulent discharge Corneal epithelial defect, inflammatory infiltrate of corneal stroma, possible hypopyon Staph, Strep, Pseudomonas (in CL users, needs flouroquinolone) Bacterial, fungal, acanthamoebal, viral cultures Fortified abx (vanco, tobramycin, cefazolin) q1h for vision threatening cases No eye patch Herpetic keratitis: dendritic ulcer viral swab Pain, FBS, decreased vision Need to rule out corneal laceration Can be removed with a 27G needle by an ophthalmologist or skilled physician Ppx for microbial keratitis with erythromycin or bacitracin ointment Pain control with patch, non-narcotic analgesics, cold comlpresses CC: “a scratch on my eye” Dx at slit lamp with fluoroscein dye to reveal abraded epithelium Evert lids to detect hidden FB Topical abx for ppx of infection Degree of severity: superficial punctate keratitis to corneal opacification with limbal ischemia Alkali worse than Acidic burn Treatment: Don’t wait! Copious irrigation with tap water/saline/LR 30 min of irrigation for alkali burn, lid eversion, remove FB Treat with top abx, prednisolone acetate 1%, cycloplegic agents Presentation: ocular pain, decreased vision, frontal HA, nausea, halos around lights, hazy cornea, mid dilated pupil, increased IOP Common causes of IOP increase: narrow anterior chamber angles, increased lens thickness, neovascular glaucoma, uveitic glaucoma Immediate ophthalmic referral; tx: PI Presentation: decreased vision, subconjunctival hemorrhage, hyphema, irregularly shaped pupil CT scan: orbit and brain Surgical emergency = immediate referral Prior to surgery: eye shield, systemic abx ASAP (cefazolin with moxifloxacin for adults and cefazolin with gentamicin for children under 12 yrs), tetanus shot, anti-emetic Ocular complaint following striking metal upon metal should justifies referral even if exam appears normal Exam: VA, FB entry site, damage to the globe, prolapse of intraocular tissue Warning signs: iris transillumination defect, pupil irregularity, hyphema, vitreous hemorrhage Imaging: CT with 1mm or finer cuts, B scan ultrasound Requires removal by ophthalmologists; same management as ruptured globe plus cycloplegic Common cause of sudden painless loss of vision, but can also be gradual Central vs branch Extent of visual field corresponds to affected area No emergency management is required ophthalmology consultation for management Internist should work up risk factors (DM, HTN, hematologic and inflammatory causes of venous thrombosis in persons under 60 CBC, ESR, homocysteine, ANA, anti phospholipid Unilateral, acute, painless loss of vision Hx of amaurosis fugax Causes: embolus from heart, aorta, carotid arteries, giant cell arteritis, collagen vascular diseases, hypercoagulability White retinal edema, cherry red spot No proven treatment: ocular masaage, anterior chamber paracentesis Labs: CBC, hypercoagulability w/u, ESR, CRP, carotid artery Doppler, cardiac eval to eval for treatable embolic source VS Present with photopsia or multiple floaters Semi-urgent evaluation and treatment by an ophthalmologist Requires ophthalmic referral within 24 hours Commonly presents with loss of vision or visual field defect, “veil” or “fog” Acute traction on the retina gives appearance of flashing lights or photopsia; viterous hemorrhage Dx on ophthalmoscopy or B scan Infection of the contents of the eye Sources: surgery, trauma, hematogenously, infection of the trabeculectomy bleb, cornea, or sclera Presentation: rapidly deteriorating vision, pain, decreased visual acuity, hypopyon, vitritis Most treated with intravitreal antibiotic injection Presentation: BL chemosis, eyelid edema, eye movement abnormality, proptosis, fever, nausea, altered consciousness Causes: extension of an infection or aseptically from trauma, surgery CT or MRI, blood culture and wound cx Co-management with internist: IV fluid, abx (nafcillin or vanco plus ceftazidime, systemic anticoagulation or aspirin Classic triad: unilateral ptosis, miosis (anisocoria in dim light), facial anhidrosis Causes: internal carotid dissection (need emergent exclusion), trauma, cluster HA, herpes zoster, Pancoast tumor, stroke Imaging: CT angiogrphy, MRI/MRA Presentation: diplopia , ptosis, periocular pain (aneurysmal compression), impaired ocular motility (turned down and out; nerve compression) +/- pupil Causes: micro-vascular infarcts in diabetics, HTN, atherosclerosis, berry aneurysm (PCAP, tumor, uncal herniation, pituitary apoplexy w/u: complete hx (GCA, cancer, mass, HTN, DM, infection), BP, ocular exam MRI/MRA w contrast to r/o mass or aneurysm when pupil-involving; neuro eval in absence of aneurysm PCA aneurysm emergent referral to neurosurgery Bilateral vision loss on one side of visual field, normal pupillary responses Causes: unilateral lesion of the optic tract posterior to optic chiasm, e.g. stroke, tumor, hemorrhage, demyelinating dz, infection (PML) Quandrantanopia – more likely optic radiation lesion Complete ocular and neurologic exam, MRI brain, stroke risk factors, EKG to r/o MI, A-fib, CT/MRI to r/o CVA Pain increases with vertical eye movement, binocular diplopia, crepitus after nose blowing, epistaxis, ecchymosis CT scan Ruptured globe should be ruled out Nasal decongestant spray, Abx to cover respiratory flora – e.g. Amox/Ampicillin, ice packs Clinical Signs › Enophthalmous – may be masked by tissue › › › › › › edema Entrapment Diplopia Pseudoptosis and deepening of the supratarsal fold acompanying enophthalmous Ortibal Emphysema Infraorbital nerve parasthesias Serious injury to the eye in 40% of cases Accompanying orbital floor fracture › Medial Orbital Wall fracture Found with orbital floor Fx in 21-70 % of cases › Supraorbital rim/wall fracture › ZMC Fractures Fractures of the Supraorbital rim › Incidence of 5% of facial bone injury › Penetrating injuries › Careful neurologic assessment › 38% incidence of ocular injuries › Orbital roof is weak in the posterior aspect › Comprehensive CT & Radiographic assessment necessary Fractures of the Supraorbital rim › Must consider and R/O: Epidural Hematoma Depressed Fx of the superior orbital rim Persistent Pneumocephalus with CSF Rhinorrhea › Check orbital movements with Forced Duction test Treatment Goals › Restoration of Binocular vision › Relief of Diplopia › Restoration of pre-traumatic anatomy Results of a majority of studies – conclude – orbital floor fracture repair should be carried out when symptomatic diplopia or cosmetically unsatisfactory enophthalmous is present 14 days after initial injury Notable enophthalmous with an extensive orbital floor injury will not resolve spontaneously and requires surgical reconstruction – most successfully with a titanium mesh Dx CT Evaluation Classification Treatment