Eye emergencies

Question 1

Extra-ocular foreign body symptoms:

Answer 1

FB sensation
Watering
Pain

Question 2

Signs of an extra-ocular foreign body:

Answer 2

Red eye
Visible FB if on cornea
Fluorescein staining around FB or cornea (if CFB) or on the linear corneal scratches from a sub tarsal FB

Question 3

Examination and removal of an extra-ocular FB:

Answer 3

1 drop proxymetacaine 0.5% with fluorescein 0.25%
Observe for corneal staining with blue light
Use CTA with NaCl 0.9%/needle with slit lamp

Question 4

Treatment for an extra-ocular FB:

Answer 4

Chloramphenicol ointment QDS 5 days

Padding and analgesia for corneal abrasion

Question 5

Symptoms of corneal abrasion:

Answer 5

Immediate pain
Watering
FB sensation
Light sensitivity

Question 6

Signs of corneal laceration?

Answer 6

Shallow AC

Distorted pupil

Question 7

Treatment for corneal abrasion:

Answer 7

Chloramphenicol 1% stat
Double eyepad for 12-24 hours
Chloramphenicol QDS for 5 days after pad removed

Question 8

Protocol for if corneal abrasion is >50% of the corneal surface?

Answer 8

Use mydriatic (tropicamide) which dilates the pupil and prevents painful spasm (similar to migraine)

Question 9

Symptoms of conjunctivitis:

Answer 9

Uni/bilateral mucopurulent discharge
Gritty/burning discomfort not pain
Blurring of the vision that clears with blinking

Question 10

Signs of conjunctivitis:

Answer 10

Redness affects all of the conjunctiva whereas in uveitis/scleritis redness is only in the globe

Question 11

Exam for conjunctivitis:

Answer 11

1 drop proxymetacaine 0.5% w/ fluorescein 0.25% to look for major corneal staining/clouding which may suggest another diagnosis e.g. corneal ulcer

Question 12

Treatment for conjunctivitis:

Answer 12

Bacterial = chloramphenicol QDS
Viral = topical lubricants/topical steroids for infiltrates
Allergy = anti-histamine/anti-mast cell drops (e.g. cromoglycate, nedocromil, opatanol)

Question 13

How do you differentiate between bacterial and viral conjunctivitis?

Answer 13

Bacterial has persistent daytime discharge whereas viral has daytime water
Viral associated with URTI, sore throat and periauricular lymph nodes
Bacterial starts in one eye then goes to other whereas viral is usually bilateral
Bacterial is purulent whereas viral may have small white corneal infiltrates

Question 14

Eye emergencies:

Answer 14

Acute angle-closure glaucoma
Orbital cellulitis
Dendritic corneal ulcer

Question 15

Anterior uveitis and orbital floor fractures are…

Answer 15

Not eye emergencies

Question 16

Causes of RAPD?

Answer 16

Large retinal detachment
Central retinal artery occlusion/ischaemic central retinal vein occlusion
Optic nerve ischaemia
Optic neuritis
Compression
Asymmetric glaucoma
(has to be to do with the afferent pathway)

Question 17

Symptoms of an intra-ocular FB:

Answer 17

Pain (sudden following explosion/metal-on-metal)

FB sensation

Question 18

Signs of intra-ocular FB:

Answer 18

Distorted light reflex over cornea/decreased VA
Peaked pupil (e.g. oval)
Aqueous leak on fluorescein staining (via tears)
Rent (tear) in iris
Prolapsed iris

Question 19

Exam for intra-ocular FB:

Answer 19

X-ray if history suggests metal FB

organic FB may lead to infection

Question 20

Which type of chemical injury is more dangerous?

Answer 20

Alkali as there is more a buffering capacity for acid

Question 21

Treatment for chemical ocular injury?

Answer 21

Must repeatedly irrigate and check pH with a urine dipstick/pH paper until pH is 6.5-8.5/same as other eye
Then sweep fornices and evert eyelids to remove particulates
Severe burns require at least 30 mins irrigation
Then cyclopegic if recommended, chloramphenicol ointment, consider opioid analgesia and tetanus

Question 22

Features of dendritic ulcer?

Answer 22

Emergency
Caused by HSV deposits down V1
There is a refractal pattern of branching on the iris
Need acyclovir and steroid eye drops (specialist)

Question 23

If a contact-lens wearer has a painful red-eye…

Answer 23

It is keratitis until proven otherwise

Question 24

Symptoms of keratitis:

Answer 24

FB sensation
Very painful
Photophobia
Blurred vision

Question 25

Signs of keratitis:

Answer 25

May have ring infiltrate | May have hypopyon (white clouding)

Question 26

Signs specific to bacterial keratitis:

Answer 26

``` Cornea can be destroyed in 24-48 hours Corneal ulceration Stromal abscess formation Corneal oedema Iritis ```

Question 27

How can infection spread from the cornea?

Answer 27

The infected cornea can stick to the iris and allow spread to the iris

Question 28

Common microorganisms causing bacterial keratitis?

Answer 28

Streptococcus, pseudomonas, enterobacteriaceae, staphylococcus

Question 29

Complications of keratitis:

Answer 29

``` Corneal leukoma (scar tissue with corneal vascularisation) Irregular astigmatism (uneven stromal healing) Corneal perforation ```

Question 30

Treatment for bacterial keratitis?

Answer 30

Antibiotic eyedrops every 2 hours/4 times a day

Question 31

Differentials between abrasion and an ulcer:

Answer 31

Abrasion is transparent as it only affects the epithelium, whereas an ulcer is opaque as it affects the entire depth of the cornea down to the stroma Abrasion will have a normal corneal contour whereas ulcer will have an uneven contour

Question 32

Symptoms of anterior uveitis:

Answer 32

Decrease in visual acuity Pain Photophobia Conjunctival infection - red

Question 33

Signs of anterior uveitis:

Answer 33

History of AI Cells in anterior chamber - hypo-yon Synechiae (iris adheres to cornea/lens)

Question 34

Management of anterior uveitis:

Answer 34

Refer +/- mydriatics

Question 35

Symptoms of AACG:

Answer 35

Sudden onset redness Decreased VA Intense peri-orbital pain with ipsilateral pain N+V Blurry vision and seeing halos around lights

Question 36

Res for AACG:

Answer 36

``` 55-70 years old Female Hypermetropia (long-sighted) FH Asian ```

Question 37

Signs of AACG:

Answer 37

Marked ocular injection especially at limbus Hazy/oedematous cornea Pupil may be mid-dilated and unresponsive Tense eyeball on palpation Shallow anterior chamber (oblique flashlight test)

Question 38

What is 'Arc eyes'?

Answer 38

UV keratitis | Intense UV radiation causing burns on the eyes

Question 39

Symptoms of arc eyes (UV keratitis):

Answer 39

Pain Tearing Photophobia

Question 40

Signs of arc eyes:

Answer 40

Microscopic punctate burns on the cornea (requires morphine for pain) - staining won't reveal much 6-12 hours after UV exposure

Question 41

Treatment for arc eyes:

Answer 41

Cyclopentolate drops Topical Abx Diclfenac eye drops/systemic NSAIDs/analgesia

Question 42

How do you diagnose optic neuritis?

Answer 42

Red desaturation test (red object looks pink in bad eye)

Question 43

Symptoms of central retinal artery occlusion:

Answer 43

Painless vision loss

Question 44

Signs of central retinal artery occlusion:

Answer 44

Pale fundus with narrowed arterioles and segmented flows and cherry-red macula

Question 45

Causes of central retinal artery occlusion:

Answer 45

``` Thrombosis Embolus GCA Sickle cell disease Trauma ```

Question 46

Treatment for central retinal artery occlusion:

Answer 46

Ocular massage Topical timolol or IV acetazolamide Emergency referral

Question 47

Causes of central retinal vein occlusion:

Answer 47

Thrombosis Diuretics Oral contraceptives

Question 48

Signs of central retinal vein occlusion:

Answer 48

Fundoscopy - diffuse retinal haemorrhage, cotton wool spots, optic disc oedema ('blood and thunder')

Question 49

Treatment for central retinal vein occlusion:

Answer 49

ASA 300mg

Question 50

Risk factors for GCA (temporal arteritis):

Answer 50

Women >50 Polyneuralgia

Question 51

Presentation of GCA:

Answer 51

Headaches Jaw claudication Afferent pupillary defect Strokes/TIA

Question 52

Diagnosis of GCA:

Answer 52

ESR, CRP | Temporal artery biopsy

Question 53

Treatment for GCA:

Answer 53

IV steroids