Emergencies Flashcards
What is AACG
Risks / examination
Acute angle closure glaucoma
Iris adheres to cornea obliterating angle, obstructing outflow of aqueous - raised IOP
Red severely painful red eye with nausea, seeing halos around lights, occasionally asymptomatic. Brow ache / ache above eye, blurred vision
Previous episodes of similar nature during evening, darkness dilates pupil - thicker iris - closes angle
Risk factors:
- positive family history
- Asian ethnicity
- age >40 years
- cataracts (get bigger and thicker with age, push iris fowards)
- hypermetropia
Exam: hard on palpation with lids shut, unreactive semi-dilated pupil (fixed mid dilated), redness around a hazy cornea
Management of AACG?
Emergency referral, do NOT use pupil dilating drops
lie supine, constrict pupil (pilocarpine drops) - better once pressure is down, topicals can’t really penetrate under high pressure
IV acetazolamide - reduce aqueous production
Prednisolone drops - educe inflammation
Laser iridotomy (burn new hole in iris)
Replace lens to prevent problem happening
IV mannitol?
What are the two different types of CN III palsy
Pupil involvement - nerve compression due to aneurysm, most commonly of the pCom
Double vision, thunderclap headache.
History: HTN. Exam: unreactive dilated ‘blown’ pupil, ptosis, down and out, paralytic strabismus
Emergency neuroimaging and referral to neurosurgery
Pupil sparing - usually due to ischaemic changes secondary to diabetic neuropathy. Double vision. History: CV disease risk factors including diabetes. Exam: responsive pupil, ptosis, down and out, paralytic squint.
Ix: screen for CV risk factors, HbA1c
Mgmt: treat risk factors
What is orbital cellulitis?
Include mgmt
Potentially lifethreatening infection of orbit, typically Staph or Strep
Painful swollen eyelid, fever.
History: sinus infection, recent facial trauma e.g. insect bite, surgery. Exam: proptosis, reduced eye movements.
Ix: temperature, blood cultures, CT to look for abscesses
Management: IV broad-spectrum Abx, admission to hospital with emergency referral to ENT and ophthalmology
If eye movements not restricted by pain, peri-orbital (pre-septal) cellulitis more likely. In children peri-orbital cellulitis warrants emergency Ophthalmology referral as high risk of developing orbital cellulitis
What is temporal arteritis?
Include Ix/Tx
Giant cell arteritis (GCA).
Inflammation of arteries supplying optic nerve, causes necrosis and visual loss
Sudden blurred vision (unilaterally), headache, tender scalp, jaw claudication, malaise, weight loss, night sweats
History: polmyalgia rheumatica, age >50
Exam: tender and thickened temporal arteries, reduced visual acuity in affected eye, RAPD, pale and swollen optic disc
Ix: RAISED ESR / platelets, CRP - gold standard is temporal artery biopsy
Management: IV steroids, emergency referral to opthalmology, long-term oral steroids with bone protection
What causes absent red reflex in child?
Retinoblastoma - commonest malignant ocular tumour of childhood, white pupil, red eye, positive family history, reduced visual acuity, strabismus, white lesion on fundus
Ix: USS, mutation testing
Tx; emergency oph referral, combination Tx coordinated with oncologists, if heritable form of tumour found screen relatives
Congenital cataract - can cause long-term visual impairment if not treated promptly
Symptoms: parent concern, white pupil, History: positive family history, intra-uterine exposures (TORCH infections, corticosteroids). Exam: reduced acuity, strabismus, nystagmus, features of associated syndromes e.g. Down’s
Ix: paediatrician assessment. Management: surgical extraction
What is endophthalmitis?
Post-operative sight-threatening infection
Red painful eye, blurred vision, swollen lids
Onset of minutes-hours, recent eye surgery, diabetes
Exam: RAPD, hypopyon, worsening inflammatory changes, purulent discharge
Ix: aqueous and vitreous taps
Mgmt: emergency oph referral, rapid intravitreal Abx and systemic steroids to prevent blindness
What are the types of retinal detachment?
Rhegmatogenous (with break)
Non-Rhegmatogenous (without break)
- exudative
- traditional
What is a rhegmatogenous retinal detachment?
Ix / Tx?
Break in the retina allows fluid entry, which lifts the retina.
Symptoms: flashes, floaters, curtain being drawn across vision, distorted vision if macula involved
History: myopia, diabetes
Exam: reduced visual acuity, retinal break with lifted retina
Ix: USS. Mgmt: emergency surgical repair
What is an exudative non-rhegmatogenous retinal detachment?
Ix / Tx?
Fluid leaks from damaged blood vessels under retina, lifts the retina
Visual field defect, distorted vision if macular involved
History: systemic inflammation / infection
Exam: smooth dome in retina
Ix: USS. Management: rarely requires surgery
What is a traditional non-rhegmatogenous retinal detachment?
Ix / Tx?
Traction from fibrovascular membranes e.g. those in proliferative diabetic retinopathy and CRVO
Progressive field loss, history: diabetes / CRVO. Exam: proliferation of retinal vessels
Management: retinal surgery depending on risk to macular and risk of progression to rhegmatogenous retinal detachment
What is a CRAO?
Ix / Tx?
Central retinal artery occlusion - thromboembolic blockage causing retinal infarction
Painless sudden visual loss unilaterally often described as shutter coming down, transient in amaurosis fugax (‘TIA of retina).
CV disease risk factors, episodes of curtain dropping down over vision. Exam: pale retina with ‘cherry red spot’ over macula, carotid bruits, heart mumurs
Ix: rule out temporal arteritis, screen for CV disease risk factors, fluorescein angiography
Mgmt: emergency referral to ophth, reduce IOP to encourage blood flow into eye, - acetazolamide or by removing aqueous
What is BRVO / CRVO?
Ix / Tx?
Branch / central retinal vein occlusion - thrombosis of retinal veins, BRVO:CRVO 3:1
Painless visual loss (unilaterally), occasionally asymptomatic.
Risk factors: age, GLAUCOMA, DIABETES, CV disease risk factors, polycythaemia, autoimmune disease, clotting disorders
Exam: reduced acuity / fields, distorted vision, tortuous dilated retinal vessels, SEVERE retinal HAEMORRHAGES, cotton wool spots, swollen optic disc
Ix: screen for CV disease risk factors / autoimmune disease / clotting disorders / glaucoma
Mgmt: regular monitoring, low dose aspirin, treat risk factors, consider laser surgery to prevent new vessels formation
Chemical trauma emergency?
Acid or alkali - alkali more common and more destructive, treat first, questions later
Pain - painless if more severe as nerves are destroyed
Detailed mechanism of injury, name of agent or ask for bottle. Exam: red eye, white eye if more severe as blood vessels are destryoed, corneal haze
Management: test tear pH, topical anaesthetic drops, irrigate copiously with neutral fluid until pH normalises, emergency referral to Oph
Ocular trauma - penetrating?
High velocity or sharp object entering eyeball
Painful eye, watering, blurred vision, photophobia
Detailed mechanism e.g. hammering, grinding metal, likely material of penetrating object
exam: avoid pressure on eye, look for signs of trauma e.g. haemorrhage, irregular pupil, iris prolapse, occasionally no obvious lesion
Ix: emergency XR / CT, avoid MRI if any suspicion of metal foreign body
Management: any suspicion of a penetrating injury to eye or intraocular foreign body needs emergency referral to Opthlamology meanwhile pad both eyes and apply prophylactic Abx
