Ophthalmic Emergencies

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Ophthalmic Emergencies

• Swati J. S. Parekh, M.D. F.A.A.O.
• Director, Ambulatory Eye Clinic
• St. Josephs Regional Medical Center

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• By definition, an ophthalmic emergency requires
  immediate medical attention to avert permanent
  visual impairment.
• Recognize the signs and symptoms of these
  emergencies, obtain an ophthalmic consult, and
  manage the patient until the patient is seen by
  an ophthalmologist.

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Top 10

• 1. Trauma blunt
• 2. Trauma penetrating
• 3. Trauma burn
• 4. Infection contact lens
• 5. Infection viral, HSV/HZV, bacterial
• 6. Neurovascular CRAO, CRVO
• 7. Neurovascular Diabetes
• 8. Neurovascular AACG
• 9. Neurovascular TA
• 10. Neurovascular - RD

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Trauma

• If chemical exposure, to what chemicals?
• If blunt or penetrating trauma, what was the
  object and where did it strike?
• Loss of consciousness
• Use of power tools

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Inflammatory conditions

• Recent illness, surgery, trauma, or infection
• Contact lens wearer/Agriculture worker
• Autoimmune diseases (rheumatoid arthritis,
  sarcoidosis, ankylosing spondylitis, or Reiter's
  syndrome)
• Infection (herpes simplex, herpes zoster, Lyme
  disease, or tuberculosis)
• Malignancy

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Neurovascular conditions Sudden onset of vision
changes

• Central retinal artery occlusion
• Hypertension, diabetes, coagulation
  abnormalities, trauma, hemoglobinopathies, or
  cardiac disorders
• Arteritic ischemic optic neuropathy
• Severe vision loss (no light perception),
  headache, scalp tenderness, jaw claudication,
  fever, and proximal joint stiffness
• Acute angle-closure glaucoma
• Pain, diaphoresis, nausea, and vomiting
  ascertain patient's activity at the time
• Retinal detachment
• Floaters or flashes of light followed by
  decreases in visual field or acuity

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Ophthalmic Terms

• Amaurosis fugax Transient blindness.
• Boxcarring The segmented appearance of the
  arteries or veins with a severe embolus.
• Cells and flare WBCs (cells) in the anterior
  chamber and the reflection of light (flare) on
  protein shed from the inflamed iris or ciliary
  body.
• Chemosis Edema of the bulbar conjunctiva, causing
  swelling around the cornea.
• Ciliary flush Circumcorneal conjunctival
  injection.
• Hollenhorst plaques Cholesterol emboli that
  appear as glistening yellow deposits occluding
  the retinal vasculature.
• Hyphema Blood in the anterior chamber of the eye.
  
• Hypopyon The layering of WBCs inferiorly in the
  anterior chamber of the eye.
• Metamorphopsia Distortion of the visual image
  resulting in cloudy, foggy, or wavy vision.
• Oblique flashlight test The shining of a
  flashlight tangentially from the lateral canthus
  toward the medial canthus so as to reveal a
  shadow on the medial aspect of the iris. Assesses
  anterior chamber depth.
• Relative afferent pupillary defect The absence of
  direct pupillary response to light but intact
  consensual response to light. Assesses optic
  nerve function.

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Facts to elicit from the history

• General
• Are both eyes affected or only one?
• Time of onset
• Recurrence
• Events preceding the current state
• Recent history of ocular disease or surgery
• Other diseases, specifically cardiac, vascular,
  or autoimmune
• Family history for ocular problems
• Current medications or recent changes to
  medications
• Changes in vision (lost, blurred, or decreased
  vision diplopia, sudden or gradual)
• Visual acuity before the current event
• Other symptoms (pain, nausea, vomiting)

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History, physical exam, and laboratory studies

• Focused H P
• In case of chemical burn, irrigate first
  talk/look later
• Visual acuity the vital sign of the eyes
• External anatomy
• trauma, neuromuscular compromise, skin
  rash/vesicles, foreign bodies, or deviations from
  normal anatomy
• both eyes
• Pupillary response
• damage to the optic nerve may not be seen for
  weeks
• relative afferent pupillary defect - early sign
  often develops within seconds of ischemia or
  optic nerve damage
• Extraocular eye movements, and Visual Fields

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• Tonometry
• Tonopen or digital
• Slit Lamp
• L/L, SC, K, AC, I, L
• Fundus
• CT image of choice
• Labs
• ESR, CRP, CBC/diff
• Path
• Corneal scraping, TA Bx

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Traumatic injuries EPIDEMIOLOGY AND
PATHOPHYSIOLOGY

• 2,500,000 traumatic eye injuries /yr USA
• 40,000-60,000 lead to visual loss
• 40 of all new cases of monocular blindness
• 80 occur in men
• average age 30

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Chemical Trauma

• alkaline exposure
• lye, ammonia found in household cleaners,
  fertilizers, and pesticides
• destroys cell structure
• more dangerous than an acid exposure because
  penetrate and have a prolonged effect
• Acid exposure
• car battery, bleach, and some refrigerants
• Only penetrate through epithelium
• Corneal Scarring

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Copious Irrigation
Immediate, copious 30 minutes Morgan
Lens lactated Ringer's solution Normal
pHbetween 7.3 to 7.6
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Blunt trauma

• Superficial FB flourescein stain
• fractures, hemorrhage, or damage to the globe or
  adnexa
• Fx sharp edges that can cause entrapment or
  damage to the muscle or globe
• Retrobulbar hemorrhage - analogous to compartment
  syndrome
• elevated intraocular and extraocular pressures,
  causing permanent damage
• Hyphema
• warrants suspicion for penetrating trauma,
  orbital fracture, acute glaucoma, or retinal
  detachment

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• CT for fracture, retrobulbar hemorrhage,
  laceration, or intraocular foreign body
• control swelling and pressure
• Cold compresses
• Nasal decongestants
• Lateral canthotomy
• tetanus prophylaxis

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Rx Corneal Abrasion

• Cycloplegia
• Topical antibiotic
• 4th generation cephalosporin (Vigamox,Zymar)
• Ointment (Ciloxan)
• No aminoglycoside (Tobrex, Gent)
• Topical NSAID
• anesthesia
• NO patch unless 90 involvement
• Dont need strong pain control

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• Preseptal Cellulitis
• Warm compress
• Oral Abx
• Orbital Cellulitis
• IV Abx
• CT
• ENT consult for surgical eval
• Beware mucormycosis in diabetic/immunocompromised
  pts

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Hyphema

• r/o rupture
• Fox shield all times
• Restrict activity (BRP only)
• Cycloplegia, corticosteroids
• Control intraocular pressure
• r/o sickle/sickle trait
• 10-20 rebleed rate cx
• corneal staining, glaucoma

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Penetrating Injury

• r/o rupture
• If rupture no further exam - EUA
• eye protected fox shield
• CT
• systemic antibiotics initiated- NOT topical
• NPO, time of last meal
• tetanus prophylaxis

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Lid repair

• Avoid retraction of lid margin
• Gray line to gray line
• Check canilicular system
• Remove FB
• Tetanus prophylaxis

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penetrating/lacerating trauma

• damage or destroy anatomic structures
• compromise protective outer layers, increasing
  the risk of infection
• Sympathetic ophthalmia
• lt2

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Inflammatory conditions

• Endophthalmitis
• inflammation in the vitreous chamber
• staphylococci, streptococci, Bacillus cereus,
  Haemophilus influenzae, and Candida
• IVDA and pts with indwelling catheters,
  penetrating trauma
• Anterior uveitis or iritis
• inflammation in anterior eye structures
• potential for elevated pressures
• Causes trauma, autoimmune diseases, infection,
  or malignancy
• Keratitis
• Inflammation of the cornea
• Causes bacterial, viral, or fungal infection
• Can rapidly cause blindness or perforation
• immune complexes inflammatory cpd.
• corneal scar

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Common Corneal Pathogens

• Bacteria
• Staphylococcus aureus, Pseudomonas aeruginosa,
  acanthamoeba
• CL Extended-wear, wearing while swimming,
  homemade saline solution, and inadequate
  disinfection
• Herpes Virus
• simplex (HSV)- most frequent cause of corneal
  blindness in the United States
• zoster (HZV)- not necessarily an emergent problem
  
• Fungus
• Fusarium, Candida
• trauma to the eye involving plants or soil
• Agricultural workers, persons in warm climates
  more at risk
• gray-white opacity w/ feathery border, /-
  satellite lesions

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• HSV Emergency
• usually unilateral clear vesicles on an
  erythematous base that progress to crusting (can
  be bilateral), does have to follow dermatome
• Prior hx of sores
• Dendrite has true terminal bulbs that stain well
  (HZV terminal bulbs adhere to the epithelium and
  do not stain well)

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• HSV Rx
• Self limiting leaves scar
• Systemic acyclovir
• trifluorothymidine 1 drops (Viroptic) 9/day or
  vidarabine 3 ointment (Vira-A), 5/day x 14 days
• Very corneal toxic reserve for confirmed cases
• HZV Rx (not always emergency)
• Supportive
• Acyclovir
• Artificial tears, erythro oint (Ilotycin)
• NO Steroids

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Inflammatory Conditions

• Symptoms
• pain, photophobia, or decreased visual acuity,
  esp. with consensual stimulus
• Signs
• SLE - "cell and flare, adhesions irregularly
  shaped pupils
• Lower or Higher IOP
• Bilateral or Recurrent
• Warrents search for systemic cause

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Uveitis
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• Endophthalmitis
• worsening pain, redness, and decreased vision esp
  in setting of recent sx
• floaters, purulent discharge, or fever
• eyelid edema, decreased red reflex, hypopyon, or
  corneal abscess
• Leukocytosis, diagnostic vitrectomy with cultures
  and smear
• culture contact lenses or case
• Keratitis
• red eye, photophobia, decreased vision, or
  discharge
• Foreign body sensation and inability to open the
  eye
• Fluorescein- dendrites or ulcerations
• SLE corneal opacification, ciliary flush

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• Do Not Patch Possible Infections
• Endophthalmitis Rx
• intravitreal Abx
• vitrectomy
• Keratitis Rx
• Cycloplegia
• Corneal scraping
• c s, stain (gram/geimsa)
• Bacterial
• 4th gen cephalosporin/ topical azithromycin
  (Vigamox/ Azasite, Ciloxan/ Erythro)
• Fungal
• Natamycin
• Tectonic PKP
• Uveitis/Iritis
• Cycloplegia pain relief, prevent miotic
  scarring
• Corticosteroids
• IOP control

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Neurovascular conditions

• central retinal artery occlusion (CRAO),
  nonarteritic
• arteritic anterior ischemic optic neuropathy
  (AION)
• acute angle closure glaucoma (ACG)
• retinal detachment (RD)

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CRAO

• thrombus, embolus, or vasculitis blocks blood
  flow to the central retinal artery, resulting in
  ischemia and infarction of the retina

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CRAO

• Hypertension 2/3 patients
• structural cardiac pathology and carotid
  atherosclerosis ½ pts
• diabetes mellitus ¼ pts
• coag abnl, hemoglobinopathies
• esp in younger pts
• trauma
• 30 to 50 have giant cell or temporal arteritis

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AION

• advanced age, white race, female gender, family
  history
• Mean age 70
• Incidence in patients older than 80 is approx 1

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• Symptoms
• Unilateral severe vision loss
• Scalp/forehead tenderness
• Jaw claudication
• /- polymyalgia rheumatica
• Signs
• APD
• ON edema
• Elevated ESR, CRP
• men, ESR gt age/2 women, ESR gt (age 10)/2

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ACG

• anterolateral portion of the iris occludes the
  canal of Schlemm
• retinal ganglion cell death and irreversible
  vision loss
• Stimulates strong vasovagal response
• Nausea/vomitting can lead to met acidosis
• Etiology - pupillary block 90
• aqueous flow from the posterior chamber is
  occluded where the lens meets the iris
• posterior chamber pressure builds, bowing the
  iris and narrowing the angle until the outflow
  pathway is obstructed

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• age gt 30 yrs
• Peak age 55-70
• Eskimo or Asian ethnicity
• Eskimo 40x incidence of whites
• hyperopia
• female gender
• 3-4x gtrisk than males
• first-degree relative with ACG

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RD

• vitreous separates from the retinal pigment
  epithelium
• Flashes
• Separation fibrous aggregates on the vitreal
  posterior surface
• prevents light rays from reaching retina
• Separation at retinal vessel may leak blood into
  the vitreous body
• Floaters, blurred vision
• Macular involvement can lead to severe, permanent
  vision loss

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• 1 in 15,000 persons each year
• 50 yrs age
• Risk factors retinal hole, inflammation, trauma,
  previous eye surgery, myopia, and family hx

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Treatments

• CRAO
• break up the embolus or move it downstream to
  minimize retinal damage
• More likely if begun within 8 hours of onset of
  symptoms
• digital pressure applied to the globe several
  times for a few seconds, repeated every few
  minutes
• decrease intraocular pressure
• IV acetazolamide, 500 mg, topical ß-blocker
• rebreathe CO2 from paper bag (carbogen)

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• AION
• high-dose corticosteroid if vision loss
• IV methylprednisolone, 250 mg Q 4hr x 3 d
  initially, then 60 mg Q 6hr
• TA bx within 2 weeks

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• ACG
• Reduce IOP with medication followed by surgery
• topical pilocarpine 2 Q 5 min x 3, timolol 0.5
  x 1, acetazolamide 500 mg orally or IV
• laser iridectomy
• Control Pain and vomiting
• Prophylactic iridectomy of fellow eye

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• RD
• immediate surgical intervention
• diathermy, cryotherapy, or laser
• patient supine with head turned to the same side
  as the detachment
• PX worsens with macular involvement duration

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Conclusion

• History and physical exam can help make a prompt
  and accurate diagnosis of ophthalmic emergencies
• Important to administer appropriate therapies
  until the ophthalmologist can assess the patient