2-Trauma and ocular emergencies

Question 1

What are symptoms of chemical conjunctivitis

Answer 1

acute pain, burning, blurry/impaired vision
may present with corneal abrasion
sclera can be red, pink, or white

Question 2

How do you treat chemical conjunctivitis

Answer 2

IRRIGATE!!!!! Irrigate more (2L) if alkaline substance

then, topical lubricants. refer to ophthalmology

Question 3

What causes a subconjunctival hemorrhage

Answer 3

Trauma, or trivial events like sneezing, coughing, valsalva

Question 4

What are signs of subconjunctival hemorrhage

Answer 4

usually acute and asymptomatic
vision is not affected
Redness stops at the LIMBUS

Question 5

Does subconjunctival hemorrhage require treatment

Answer 5

No, just reassurance

Should resolve in 2-4 weeks

Question 6

What is a hyphema

Answer 6

injury to anterior chamber disrupting vasculature to ciliary body, causes blood to pool

Question 7

What are symptoms of hyphema

Answer 7

acute onset pain
photophobia
tearing
N/V due to IOP

Question 8

What will you see on hyphema PE

Answer 8

+/- visual acuity

layered heme in anterior chamber

Question 9

How do you treat Hyphema

Answer 9

Ophth referral THAT DAY
bed rest, supine wit head slightly ELEVATED
Need to control IOP and ease discomfort

Question 10

What meds are used in Hyphema treatment

Answer 10

Oral diuretic (acetazolamide [carbonic anhydrase inhibitor])
topical diuretic (dorzolamide)
topical cycloplegic
+/- topical steroid

Question 11

What are symptoms of conjunctival/corneal FB

Answer 11

\+/- Hx of something in eye
pain
inability to open eye
May have attempted irrigation 
tearing, conjunctival injection, FB presence
Vision usually NOT affected

Question 12

How do you preform a FB exam

Answer 12

topical anesthetic (tetracaine) 
Check visual acuity pre and post 
every eyelid (look for FB) 
fluorescein if suspected abrasion
Pupil exam if suspected intraocular FB (REFER)

Question 13

How do you treat FB

Answer 13

FB removal (irrigation/cotton swab)
Lubricant/abx drops
Refer to ophtho if you can’t remove FB, or large abrasion

Question 14

What causes a perforated globe

Answer 14

penetrating trauma (hammering/shaving metal)
EMERGENCY surgical referral

Question 15

What will you see on PE if with perforated globe

Answer 15

loss of anterior chamber depth
misshapen pupil
vitreous leakage (jelly)

Question 16

How do corneal abrasion patients present

Answer 16

acute onset pain
FB sensation
Tearing
Light sensitivity 
Cant open eyes

Question 17

What do you see on corneal abrasion PE

Answer 17

+/- affected vision
visible epithelial defect
abrasions with fluorescein and black light

Question 18

What is a corneal abrasion

Answer 18

abrasion in corneal epithelial tissue often due to trauma by paper, nail, or contact

Question 19

How do you treat corneal abrasion

Answer 19

topical Abx/lubricant

Heals quickly, F/u 1-2 days

Question 20

Why shouldn’t you send a patient home with anesthetics

Answer 20

they inhibit healing
Patient can’t protect eyes due to lack of sensation
Anesthetic keratitis occurs with overuse, needs corneal transplant

Question 21

What is Keratitis

Answer 21

corneal ulcer most commonly due to infection (bacteria, virus, fungi, or amoebic)
Often associated with contacts

Question 22

What are symptoms of keratitis

Answer 22

eye pain, photophobia, tearing, decreased vision

Question 23

What will you see on keratitis PE

Answer 23

injected conjunctiva (esp. by limbus)
cloudy, hazy opacity overlying cornea
+/- hypopyon (pus in ant. chamber)
Dendritic pattern on fluorescein (HSV)

Question 24

How do you treat keratitis

Answer 24

Opto referral promptly
Moxifloxacin (bacterial)
topical acyclovir 9x day (HSV)

Question 25

What is Uveitis/iritis

Answer 25

inflammation of uvea (includes iris, ciliary body, choroid) | commonly immunologic, can be caused by trauma

Question 26

What are symptoms of uveitis

Answer 26

Eye pain, redness, photophobia, HA, tearing

Question 27

What will you see on uveitis PE

Answer 27

``` decreased vision Ciliary flush (circumlimbal) constricted pupils cells (dust thru flashlight) and flare (headlights in fog) (slit lamp) low/norm IOP ```

Question 28

Why are cells and flare present on exam

Answer 28

inflammation of uveal tract allows proteins and WBC into aqueous humor

Question 29

What are possible causes of uveitis

Answer 29

HSV, herpes zoster | Ankylosing spondylitis, arthritis, IBS

Question 30

How do you manage uveitis

Answer 30

Prompts Ophtho referral topical steroids topical cycloplegics

Question 31

How does a blowout fracture occur

Answer 31

Direct compressive force to globe (baseball to eye)

Question 32

What are symptoms of a blow out fracture

Answer 32

Diplopia Restricted EOM (trapped IR muscle) Decreased sensation to inferior orbital rim Palpable step off at inferior orbital rim exophthalmos

Question 33

What is first line diagnostic test for blow out fracture

Answer 33

CT orbit | can also use XR, but not 1st choice

Question 34

How do you treat blow out fracture

Answer 34

``` emergency referral empiric abx (amoxicillin/clavulanate) during transport ```

Question 35

What are the types of glaucoma

Answer 35

Both types cause changes in optic disc due to IOP (canal of scheme blocked), and progressive loss of visual field acute angle closure (emergency but rare) chronic open angle (most common)

Question 36

What is acute angle closure glaucoma

Answer 36

outflow is obstructed secondary to pupil dilation, pressure builds due to continuous aqueous production Occurs in pt with pre-existing narrow anterior chamber angle

Question 37

What are symptoms are acute angle closure glaucoma

Answer 37

extreme eye pain, HA, photophobia, blurry vision (halo's around lights), N/V

Question 38

What disease should AACG be a part of

Answer 38

acute abdomen | it causes N/V

Question 39

What will you see on AACG PE

Answer 39

``` ill appearing patient decreased vision red eye steamy cornea fixed, mid-dilated cornea, crescent shadow increased IOP (>50 mmHg) ```

Question 40

How do you treat AACG

Answer 40

control IOP! check every hour until ophtho consult IV acetazolamide, then oral dose QID topical timolol (BB) +/- biotic drop definitive Tx: laser peripheral iridotomy

Question 41

What is chronic open angle glaucoma

Answer 41

(usually bilateral) loss of vision by constriction in visual fields due to progressive nerve damage Over months-years (asymptomatic in beginning)

Question 42

What will you see on COAG PE

Answer 42

optic disc cupping | vessels over optic disc

Question 43

What does diagnosis of COAG require

Answer 43

consistent, reproducible abnormalities in 2 of the following: Optic disc, visual field, IOP

Question 44

Who should you screen for COAG

Answer 44

every person 40+, every 2-5 years | Diabetics: yearly

Question 45

What is the treatment for COAG

Answer 45

lower IOP! Topical anti-HTN (timolol, dorzolamide) Laser trabeculoplasty Surgical trabeculotomy