Ophthalmology Flashcards Preview

Emergency Medicine Module 3 > Ophthalmology > Flashcards

Flashcards in Ophthalmology Deck (38):
1

Equipment

  • —Vision Acuity Chart
  • —Proparacaine drops
  • —Morgan Lens
  • —Nitrazine paper (pH)
  • —Lid retractor
  • —Eye Spud
  • —Woods Lamp
  • —Floresceine paper
  • —Eye Shield

2

eye emergencies

  • —Red eye:
    • —conjunctivitis
    • —Iritis
    • —Corneal abrasions/ulcerations
    • —Acute Angle Closure Glaucoma
    • —Herpes infections
  • —Painless Loss of Vision
    • —Central retinal artery occlusion
    • —Retinal detachment
  • —Trauma
    • —Burns
    • —Blunt trauma
    • —Penetrating trauma  
    • —Hyphema

3

History/ROS

  • —Onset: sudden vs. gradual
  • —Pain: severity?
  • — Photophobia?
  • —Change in vision?
  • —Trauma: when, how?
  • —Associated symptoms: headache, vomiting, neuro sx.

4

Physical Exam

  • —General inspection - noting erythema, tearing, light sensitivity, pattern of redness
  • —Visual acuity - to be tested with glasses, one eye at the time
  • —Pupils - symmetry, reactivity to light, pupillary reflex
  • —Fluorescein 
  • —Intraocular pressure testing (by tonometry or palpation)
  • —slit lamp exam
  • —Signs of major trauma
    • —Obvious laceration
    • —Distorted pupil
    • —proptosis

5

visual acuity

  • —Should be done first on all patients except those with chemical exposures or suspected globe rupture
  • —If pt wears reading glasses, use pinhole correction
  • —Abnormal visual acuity always worrisome

6

Differential for decreased visual acuity

  • —Refractive error (pin hole)
  • —Penetrating foreign body
  • —Iritis (assoc w/ photophobia)
  • —Acute Angle Closure glaucoma
  • —Central retinal artery occlusion 
  • —Blunt or penetrating trauma
  • —Dislocated lens
  • —Retinal detachment
  • —Optic neuritis

7

when is an eye problem not really an eye problem?

  • —Subarachnoid hemorrhage (pain/photophobia))
  • —Stroke
    • —Diplopia
    • —Loss of vision
  • —Giant cell (temporal) arteritis

8

worrisome signs in eye emergencies

  • —Sudden onset of pain or vision change
  • —Decreased visual acuity
  • —Photophobia
  • —Limbic/ciliary flush
  • —Abnormal pupil size, shape or response
  • —Visible opacity on cornea

9

triage issues

  • —Bring immediately to treatment area:
    • —Chemical burns – Irrigate
    • —Sudden, painless vision loss: Notify MD
    • —Sudden onset severe pain,decreased vision
    • —Consider risk of CVA, SAH
    • —May use 1-2 gtts of proparacaine for FB sensation.
    • —Globe rupture – metal eye shield

10

red, painful eye

  • —Conjunctivitis/keratitis
  • —Foreign Body/Abrasion
  • —Corneal ulcer
  • —Iritis/uveitis
  • —Acute narrow angle glaucoma

11

conjunctivitis

  • —Irritated or itchy
  • —Discharge
  • —No photophobia, no change in vision
  • —Redness spares the edge of the iris
  • —Etiology: primarily adenovirus
  • —Beware: herpes keratitis, gonococcal conjunctivitis
  • —ConjunctivitisTx: Warm compresses, topical antibiotic if indicated

  • The conjunctiva is the mucous membrane that lines the inside surface of the lids and covers the surface of the globe up to the limbus (the junction of the sclera and the cornea). The portion covering the globe is the "bulbar conjunctiva," and the portion lining the lids is the "tarsal conjunctiva."

12

Blepharitis

  • —Eyelid inflammation
    • —Seborrheic dermatitis
    • —Psoriasis
    • —Acne rosacea
    • —Bacterial
  • Treatment
    • Warm compresses
    • Topical antibact ointment

13

Hordeolum

  • —Acute infection of the meibomian glands of the eyelid,
  • —Staph aureus   95%
  • —Warm compresses, I&D, topical antibiotic

14

Keratitis (inflammation of the cornea)

  • —wide variety of corneal infections, irritations, and inflammations;
  • —Incr risk = contact lens wear
  • —Viral epidemic keratoconjunctivitis (EKC), adenovirus
  • —HSV = severe sx, branching lesions on slit lamp
  • —foreign body sensation and multiple corneal infiltrates  seen best with punctate floresceine uptake
  • —acute optho consult, steriod tx

15

bacterial keratitis

  • Unilateral, acutely painful
  • Photophobic and intensely injected eye
  • Visual acuity often reduced
  • Profuse tearing
  • Thick mucopurulent d/c
  • May have a corneal defect/ulceration
  • Edematous cornea
  • In severe cases:  hypopyon
  • Common organisms: Staphylococcus aureus, Pseudomonas aeruginosa, coagulase-negative Staphylococcus, diphtheroids, Streptococcus pneumoniae,

16

pterygium

  • —Excessive growth of conjunctiva 
  • —easily irritated
  • —May require elective excision

17

Herpes keratitis

  • —Unilateral injection, irritation, mucoid discharge, pain, mild photophobia
  • —Occurs during primary infection with HSV or during recurrent episodes of ocular herpes. 
  • —Discrete epithelial lesions that coalesce to form single or multiple branching (dendritic)  epithelial ulcers
  • —Tx: topical or systemic antivirals
  • —Immediate optho consult

18

Herpes zoster

  • —nonspecific facial pain
  • —Fever and general malaise
  • —4 days after onset, vesicular rash appears
  • —5th cranial nerve distribution
  • —Does not cross midline
  • —Severe pain during inflammatory stage

19

Foreign body/corneal abrasion

  • —Sensation of FB
    • —Pain is relieved by topical anesthetic
  • —No discharge (except tearing)
  • —Vision may be decreased if lens affected
  • —Pupils normal
  • —Redness spares edge of the iris
  • —Abrasion usually not visible without fluorescein
  • Tx:
    • —Topical antibiotic ointment +/- cycloplegic
    • —Patching no longer routine
    • —Never patch contact-lens wearers
    • —Beware: ulcer, intraocular foreign body
    • —Obtain xrays if suspicious

20

corneal ulcer

  • —Result from any defect in the cornea
  • —Visible without fluorescein
  • —Defect surrounded by cloudy white or gray appearing cornea
  • —May have hypopion
  • —*Risk: corneal penetration;
  • — requires immediate optho consult

21

Acute traumatic iritis clinical presentation

  • —Aching pain, gradual onset
  • —Photophobia
  • —No discharge
  • —constricted pupil
  • —Slight decrease in visual acuity
  • —Limbic flush
  • — tx steroid gtts; Optho consult

22

Chemical splashes

  • —Alkali worse than acid
  • —Alkali rapidly penetrates ocular tissue and continues to cause damage long after the injury; increased intraocular pressure
  • —Acid forms a barrier of precipitated necrotic tissue limiting further penetration and damage
  • —Treatment is immediate, copious irrigation until pH normal
    • —Test with nitrazine paper
      • —(nml 7.4 – 7.6)
    • —Flip lid to remove all debris
  • —Treat all splashes initially as caustic

23

Acute angle closure glaucoma

  • TRUE EMERGENCY—
  • Sudden onset
  • —Severe deep pain
  • —Photophobia
  • —Poor visual acuity,  halos
  • —Pupil dilated, poorly reactive
  • —Cloudy cornea
  • —Headache, vomiting, abd pain
  • —Red eye with limbic flush
  • —Pupil midrange, nonreactive
  • Tx:
    • —Call opthalmologist stat!
    • —Goals:
      • —Decrease size of pupil
      • —Decrease aqueous humor production
      • —Decrease intraocular pressure
    • —Decrease intraocular pressure with oral diamox or IV mannitol
    • —Decrease production of aqueous humor with topical α-agonist or β-blocker (Timoptic)
    • —Constrict pupil with topical pilocarpine
    • —Anti-emetics
    • —Pain management

24

Vitreous hemorrhage

  • —Occurs in the setting of trauma, spontaneous retinal tear, spontaneous vitreous detachment
  • —associated with retinal neovascularization
    • —poorly controlled diabetes
  • —Floaters or “cobwebs”
  • —progresses over hours to visual loss
  • —decreased red reflex
  • —Pupillary defect suggests retinal detachment
  • —*Immediate Opthalmology consult

 

  • Sudden onset
  • Severe deep pain
  • Photophobia
  • Poor visual acuity, patients see halos
  • Pupil dilated, poorly reactive
  • Cloudy cornea
  • Headache,vomiting, abdominal pain
  • Red eye with limbal flush
  • Pupil midrange, nonreactive
  • Shallow anterior chamber
  • Elevated intraocular pressure
  • A Marcus Gunn pupil is said to occur when there is a unilateral lesion in the afferent visual pathway anterior to the chiasm.
  • The integrity of the afferent pathway may be ascertained by rapidly stimulating each eye in succession with a torch and observing the direct and consensual light response in each. The normal light response is pupillary constriction. In a Marcus Gunn pupil, there is reduced afferent input and the pupils fail to constrict fully. Stimulation of the normal eye produces full constriction in both pupils. Immediate subsequent stimulus of the affected eye produces an apparent dilation in both pupils since the stimulus carried through that optic nerve is weaker

25

Retinal detachment

  • —may occur spontaneously or in the setting of trauma
  • —sudden onset of new floaters or black dots,  accompanied by flashes of light
  • —Vision: cloudy, filmy or curtain-like
  • —Visual field cut
  • —*Immediate Opthalmology consult
  • —Tx of choice is surgery
  • Scleral buckle surgery, peumatic retinoplexy, vitrectomy + lasar

26

Optic neuritis

  • —Sudden, severe loss of vision (blurred)
  • —+/- pain on eye movement, reduced visual acuity and washed out color vision.
  • —Sluggish pupil
  • —common association with multiple sclerosis
  • —70% of cases unilateral.
  • —Tx: corticosteroid therapy improves short-term vision recovery but not shown to alter long-term vision outcome
  • —Opthalmology Consult.

27

central retinal vein occlusion

  • —Slow painless loss of vision
  • —Occlusion /thrombosis of the central retinal vein
    • —associated with chronic glaucoma, atherosclerotic risk factors , age, diabetes, hypertension, hyperviscosity, and coagulopathy
  • —Episodes of visual loss variable in length: seconds to–several hours.
  • —distinguishing feature: description of "cloudy vision" rather than visual loss.
  • cotton wool spots that create a dramatic appearance, often called "the blood and thunder” fundus

28

central retinal artery occlusion

  • —Painless catastrophic visual loss over a period of seconds
  • —caused by embolism of the retinal artery
  • —Hx of transient visual loss may be reported (amaurosis fugax)
  • —Exam:
    • —Visual acuity:
      • —counting fingers to light perception
    • —Retina: pale optic disk with narrowed arteries
      • —“cherry red spot” where fovea (fed by choroid vessels) is spared
  • The Marcus Gunn phenomenon is a relative afferent pupillary defect indicating a decreased pupillary response to light in the affected eye.
  • In the swinging flashlight test, a light source is alternately shone into the left and right eyes. A normal response would be equal constriction of both pupils, regardless of which eye the light is directed at. This indicates an intact direct and consensual pupillary light reflex. When the test is performed in an eye with an afferent pupillary defect, light directed in the affected eye will cause only mild constriction of both pupils (due to decreased response to light from the afferent defect), while light in the unaffected eye will cause a normal constriction of both pupils (due to an intact afferent path, and an intact consensual pupillary reflex). Thus, light shone in the affected eye will produce less pupillary constriction than light shone in the unaffected eye.
  • A Marcus Gunn Pupil is distinguished from a total CN II lesion, in which the affected eye perceives no light. In that case, shining the light in the affected eye produces no effect.

29

treatment of central retinal artery occlusion

  • —Prognosis poor; early intervention may improve chances of recovery (20-30%)
  • —immediate optho consult
  • —Hyperventilation with paper bag
  • —Inhalation of Carbogen (5% carbon dioxide and 95% oxygen)
    • —to induce vasodilation and improve oxygenation
  • —Digital massage of affected eye
  • —Lower intraocular pressure
  • —Beta-blockers
  • —Mannitol
  • —? rTPA
  • Topical medications are used to lower intraocular pressure.
  • Further treatments Carbogen therapy (5% CO2, 95% O2): CO2 dilates retinal arterioles, and O2 increases oxygen delivery to ischemic tissues. Perform for 10 minutes every 2 hours for 48 hours.
  • Hyperbaric oxygen therapy (HBOT) may be beneficial if begun within 2-12 hours of symptom onset. Institute treatment with other interventions first, as transport to a chamber may usurp precious time.
  • Rtpa: recombinant tissue plasminogen activator

30

penetrating trauma

  • —Conjunctival lacerations
  • —Corneal lacerations
    • —Tear-drop shaped pupil
    • —May see aqueous humor leaking
    • —Rx: shield
  • —Intraocular foreign body
    • —History is everything!
      • —Grinding, sanding, drilling, hammering

31

blunt trauma

  • —Swollen lids - (use lid retractors)
  • —Subconjunctival hemorrhage
  • —Traumatic mydriasis
  • —Lens dislocation
  • —Hyphema: Blood in anterior chamber
    • —Pain, photophobia, decreased acuity
    • —Apply protective shield

32

ruptured globe

  • —Eye pain, decreased acuity
  • —Distorted pupil
  • —Bloody chemosis
  • —Treatment
    • —No further exam
    • —Immediate optho consult
    • —Metal eye shield over affected eye
    • —NPO
    • —Tetanus
    • —IV antibiotics
    • —Anti-emetics prn

33

Retro-orbital hematoma

  • —Decreased Vision
  • —Proptosis
  • —Requires emergency lateral canthotomy

34

acute traumatic iritis

  • —Reactive inflammation in anterior chamber due to blunt trauma
  • —Usually develops >12 hours after injury
  • —Photophobia because contraction of pupil requires contraction of inflamed iris

35

acute angle closure glaucoma

  • —Acutely increased intraocular pressure
  • —Blocked drainage of aqueous humor from anterior chamber
  • — Prolonged dilation of pupil in susceptible person
  • —Ophthalmologic emergency

36

hyphema

  • —Collection of blood in anterior chamber
  • —Meniscus layering
  • —Opthalmalogic emergency

37

ruptured globe

  • ——Fixed, teardrop-shaped pupil
  • —Prolapsed iris may be seen
  • —Fluorescein may show streaming aqueous humor
  • —Treatment
    • — No further exam
    • —Metal eye shield over affected eye
    • —NPO
    • —Tetanus
    • —IV antibiotics
    • —Anti-emetics prn
  • —Surgical emergency

38

eyelid laceration

  • —Rule out penetrating injury
  • —Rule out damage to lacrimal apparatus:  assess by canulation
  • —Eyelid tarsal plate must be repaired
  • —Refer to ophthalmic plastic surgeon