Ocular emergencies

1
Ocular emergencies

• Prepared by Mick Svoboda
• Presented by Dr. Cardinal

2
Lid Infections

• Stye
• Acute staph. infection of an oil gland
  assoc. w/ an eyelash.
• Small pustule at the lash line.
• Tx.warm compresses, erythromycin ophthalmic
  ointment Bid x 7-10 days.
• Chalazion
• Acute or chronic inflammation of eyelid 2
  to blockage of the meibomian oil gland.
• Red, tender, lump in lid/lid margin
• Initial tx. Warm compresses, erythromycin
  ophthalmic ointment Qid, /- 100mg doxy PO if
  chronic or reoccurring, ophtho. f/u.

3
conjunctivitis

• Bacterial
• mucopurulent d/c, inflamed conjunctiva.
• Pt reports eye crusted shut upon wakening.
• Tx.
• Stain eyes of infants/toddlers to avoid missing
  corneal abrasions.
• Abx. Non-contact wearer- topical Polytrim or
  erythromycin, 1 gtt Qid x 5-7 days.
• Abx. Contact wearer- Tobrex, Ocuflux, or Ciloxin
  for pseudomonas coverage. 1 gtt Qid x 5-7 days.
• Viral
• Watery d/c, conjunctiva red and swollen
  (chemosis)
• Often preceded by URI.
• Monocular w/ eventual spread to other eye.
• Tx. is supportive- artificial tears, Naphcon-A,
  cool compresses.
• Stain the eye to avoid missing herpes dendrite
• Allergic
• D/c, redness, and itching.
• Tx. is similar to that of viral conjunctivitis.

4
Ocular HSV
NO STERIODS

• HSV can infect the eyelids, conjunctiva,
  and cornea.
• Surrounding skin may have typical
  vesicular eruptions.
• Fluorescein staining may reveal the
  dendrites assoc. w/ herpes keratitis.
• Tx.
• Initial outbreak lt 3-4 days can treat w/
  PO acyclovir.
• w/out corneal involvement- Viroptic 1 gtt 5/day.
• w/ corneal involvement- Viroptic 1 gtt 9/day.
• Can add erythromycin ophthalmic ointment to avoid
  2º bacterial infection.
• Ophtho. f/u.

5
Herpes Zoster Opthalmicus

• Shingles in the distribution of
  the trigeminal nerve w/ocular involvement.
• Hutchinson sign, pain, photophobia
• Tx.
• Narcotics, cycloplegic agents for pain
• Erythromycin ophthalmic ointment to
  prevent 2º bacterial inf.
• Prednisolone acetate 1gtt 5/day if iritis and no
  corneal defects.
• Consider for admission and IV acyclovir.

6
Periorbital cellulitis

• Periocular superficial cellulitis.
• Full ocular mobility w/out pain and pupillary
  reaction maintained.
• Most often d/t inoculation by skin infection or
  trauma S. areus.
• Tx.
• Children above 5- clindamycin, Augmentin
• Adults- same options
• Children under 5 or severe cases- admission for
  full work-up and IV abx. (ceftriaxone plus vanc.)

7
Orbital cellulitis

• Orbital infection most
  commonly by S. areus.
• EOM entrapment, pain w/ EOM movement, fever,
  proptosis.
• Often a result of extension form a paranasal
  sinus infection.
• CT of orbit and sinuses aids in diagnosis
• If neg. enhanced CT looking for subperiosteal
  abscess.
• Tx.
• Admission w/ IV abx.

8
Corneal ulcer

• D/t breaks in the epithelial
  barrier allowing access to infectious
  agents.
• Risk factors- trauma, soft contact use and
  extended wear of contacts.
• Painful, red, tearing, photophobia, white hazy
  infiltrate underlying the defect.
• Tx.
• Topical Ciloxin or Ocuflux
• NO patching- risk of pseudomonas inf.
• Ophtho. f/u.

9
Trauma (superficial)

• Subconjunctival hemorrhage
• Disruption of fragile vessels 2º to trauma or
  valsalva spikes (coughing, sneezing, straining)
• Conjunctival abrasion
• If isolated can be treated w/ topical
  erythromycin for 2-3 days.

10
Trauma (superficial)

• Corneal abrasion
• Pain, tearing, photophobia
• Exam can be aided w/ topical anesthetic.
• Fluorescein staining
• Eversion of lids and FB inspection
• Assess ant. chamber w/ slit lamp for assoc.
  injury.
• Tx.
• Identify source of abrasion
• Cycloplegic agents- reduce ciliary spasm reducing
  pain.
• Not related to contact lens wear- topical
  erythromycin, /- patch
• Related to contact lens wear- topical Tobramycin,
  NO patch.
• Organic source- topical erythromycin, NO patch.
• Ophtho. f/u.

11
Trauma (superficial)

• Corneal FB
• Remove carefully under best magnification (slit
  lamp).
• Topical anesthetic- may use in unaffected eye to
  reduce blink reflex.
• Evert lid
• Burr , 25 or 30 gage needle recommended.
• Rust rings- do not need to remove all rust in the
  ED, but secure ophtho. f/u.
• Full thickness FB or rust should not be removed
  in the ED.
• Treat abrasion

12
Lid laceration

• Full thickness
• Should be closed by an ophthalmologist in order
  to obtain best alignment.
• If not available can be closed w/
• One 6-0 silk vertical mattress using meibomian
  glands as landmarks to repair lid margin.
• Tarsus repaired w/ 5-0 vicryl.
• Skin closure w/ 6-0 monofilament or silk.
• Partial thickness
• Can be repaired in the ED w/ ophtho. f/u.

13
Blunt/penetrating trauma

• Indications of globe rupture
• Flat ant. chamber
• Full thickness laceration
• Irregular pupil- will peak towards injury
• Blind eye
• Itraocular FB
• If globe rupture not suspected examine and treat
  appropriately (hyphema, blowout fx, abrasions,
  etc.).
• If globe rupture suspected
• do not attempt IOP measurements
• Shield the eye
• Check tetanus status
• IV abx, NPO
• Ophtho. consult

14
Hyphema

• Blood in the ant. chamber.
• Traumatic vs. spontaneous
• Blunt/penetrating trauma usually to
  the iris root
  vessels.
• Spontaneous cases frequently assoc. w/sickle cell
  ds.
• Tx.
• All cases should be evaluated by an
  ophthalmologist.
• ED management focuses on IOP control.
• Elevate head- promotes settling of RBCs
• Dilate pupil- keeps pupil at rest, avoids vessel
  stretch and inc. bleeding.
• IOP gt30- topical ß blocker, PO or IV Diamox, or
  IV mannitol
• IOP gt24 and suspicion of sickle cell trait/ds-
  avoid Diamox
• Ophtho. f/u.

15
Blowout fx.

• Most frequently occur at inferior
  and medial walls.
• Often involve the sinuses ? sub-Q emphysema.
• Entrapment of the inferior rectus can cause an
  upgaze restriction and diplopia.
• Isolated blowout fx do not require immediate tx.
  Appropriate f/u and repair w/in 3-10 days.
• PO abx (Keflex) esp. if sinus wall
  fx present on CT.
• Ophtho. f/u.

16
Chemical ocular injury

• Acid burns- proteins coagulated ? superficial
  injury.
• Alkali burns- rapidly penetrate ? deep injury.
• Tx.
• 1st copious irrigation (1-2L NS) w/ a Morgan lens
  until tear pH (7.5-8). Use topical anesthetic.
• thorough exam and assess visual acuity after
  irrigation.
• W/out corneal defect- topical erythromycin
• W/ corneal defect- topical erythromycin,
  cycloplegic agent, /- patching
• Ophtho. f/u.

17
Cyanoacrylate (super/crazy glue)

• Can cause lids to adhere or adhesive clumps on
  the corneal surface.
• Main concern is mechanical abrasive effect to
  corneal surface.
• Tx.
• Moisten eye w/ erythromycin ointment and remove
  as much as can be removed easily.
• Ophtho. f/u.

18
Acute angle-closure glaucoma

• Pt symptoms- foggy vision,
  halos around lights, eye pain, HA,
  n/v.
• Pt signs- mid fixed dilated nonreactive pupil,
  inc. IOP ( often gt50), hazy cornea.
• Tx.
• Reduce IOP, check q 1º
• topical ß-blocker, alpha-agonist, mannitol
• After pressure reduced can give pilocarpine to
  make pupil miotic ? prevents reoccurrence until
  f/u.
• Ophtho. f/u.

19
Optic neuritis

• FgtM, often B/L in children.
• Rapid onset, painful vision reduction/loss.
• Check visual acuity, Red desaturation test.
• On exam
• Affected eye w/ papilledema- anterior optic
  neuritis.
• Affected eye w/out papilledema- retrobulbar optic
  neuritis.
• Tx.
• Consult ophtho. or neuro. regarding tx w/ IV
  steroids or d/c w/out tx.
• No difference at 1 year between IV steroid tx
  grp. vs. placebo. (ONTT)
• Oral steroids contraindicated as initial tx.

20
Central retinal artery/vein occlusion

• CRAO
• Sudden, profound, painless, monocular vision
  loss.
• My be preceded by amaurosis fugax.
• Causes- embolus, thrombosis, giant cell
  arthritis, vasculitis.
• On exam- infarcted retina will appear pale, w/
  sparing of the macula (cherry red spot).
• Tx. Consult ophtho.
• Attempts to dislodge embolus to distal branches
  to reduce size of infract.
• Ocular message
• Dec. IOP- topical ß-blocker, Diamox

• CRVO
• Sudden, profound, painless, monocular vision
  loss.
• Risk factors- uncontrolled Htn,
  hypercoagulopathies, vasculitis, glaucoma.
• On exam- optic disc edema and diffuse retinal
  hemorrhages.
• Tx.
• Can consider ASA therapy
• Ophtho. f/u.

21
Flashing lights and floaters

• Binocular- intracranial etiology
• Monocular- intraocular etiology
• W/ age vitreous gel separates from the posterior
  wall of the eye. Traction stimulates the retina
  and is perceived as light.
• Complete separation results in floaters.
• If traction is great enough ? retinal detachment.
• Consult ophtho.

22
Temporal arteritis

• FgtM
• Age usually gt 50
• Sxs- headache, temporal tenderness, fever, jaw
  claudication. May be assoc. with polymyalgia
  rheumatica.
• Can result in visual disturbances/loss.
• Sed rate and biopsy of temporal artery aid diag.
• Tx.
• If vision loss suspected- admit for IV
  Solu-Medrol
• No vision loss suspected- d/c w/ PO prednisone.
  Secure f/u.

23
Neuro-ophthamology

• Bells palsy- CN VII palsy
• Rx lacriube to prevent corneal drying and
  scarring.
• R/o genu VII Bells palsy by testing for EOM
  abduction.
• DM/Htn CN palsies
• Above result in vascular compromise to EOM.
• Pt present w/ new onset diplopia and an isolated
  CN III or VI palsy.
• Pupil spared.
• Post.communicating artery aneurysm
• Acute CN III palsy w/ dilated pupil

24
Neuro-ophthamology

• Internuclear opthalmoplegia
• CVA or demyelinating ds. of the MLF.
• Pt presents w/ diplopia when looking to the side
  opposite the lesion, d/t ipsilateral medial
  rectus weakness.
• Horner syn.
• Ipsilateral ptosis, miosis, anhidrosis.
• Causes- trauma, CVA, ICA dissection.
• Papilledema
• B/L disc edema
• Causes- intracranial tumors, psuedotumor cerebri,
  malignant Htn, hydrocephalus.
• psuedotumor cerebri
• Inc ICP, papilledema, normal CSF, normal head CT.
  
• Age- 20-30, obese women.
• Often c/o morning HA, transient visual
  disturbances.