Flashcards in Opthalmological emergencies Deck (44)
1
Why are why marks on the cornea a concern
Corneal infiltrate
Corneal ulcer
Scar->herpetic
Severe allergy
2
Concern about metal on metal
Sharp object, metal penetrate through the eye
3
What are the concerns with a painful photophobic eye
Iritis
Keratitis
Acute angle glaucoma
4
Should topical steroids be used
Not if unsure of diagnosis especially if herpes not ruled out
5
Components of functional eye examination
Pupils->afferent/efferent, direct/consensual
Optic nerve->snellen, pinhole, confrontation, VF/red colour
Motility 3, 4, 6->posture, ptosis, cover/uncover, movement
6
Anatomical eye examination
General
Lids, lacrimal, position, movement
Conjunctiva, sclrea
Cornea->clairty, fluroscein stain
Subtarsal lid
Anterior chamber
Iris
Pupil
Opthalmoscope->red reflex, disc, vessels, periphery, red/white spots, masses
7
What are sight threatening conditions which require urgent consultation to an opthalmologist
Lid/globe lacerations
Chemical burns
Corneal ulcer
Gonoccocal conjunctivities
Acute iritis
Acute angle-closure glaucoma
CRAO
Intraocular foreign body
Retinal detachment
Endophthalmitis
8
What is CRAO
Central retinal artery occlusion
9
What are life threatening ocular emergencies
Proptosis
CN3 palsy w/ dilated palsy
Papilloedema
Orbital cellulitis
Temporal arteritis
Leukocoria
10
When there is proptosis, what are they at risk of
Cavernous sinus fistula or thrombosis
11
What does a CN3 palsy with dilated pupils suggest
IC aneurysm
Herniation
Neoplastic lesion
12
Which is worse, acid or alkali burns, and why
Alkali worse-->
lime, cement, dishwashing,
caustic soda-->
Even with clear cornea,
can burn for weeks
Acids coagulate tissue
and stop further corneal
penetration
13
Management of chemical burn
+++Irrigate w/
Saline water-->continuous drip
Swab upper and lower
lids to remove
possible particulate matter
Do not neutralise-->
heat produced= further
damage
Refer urgently!
+/- dilate
Antibiotics, patch
14
What is a dendritic ulcer
Herpes simplex keratitis
15
What is hutchinson's sign
If tip of nose if involved with herpes, 75% will have globe involved
Xnose involved, 1/3 eye involved
16
Management of dendritic ulcer
Refer
Aciclovir 5X daily
+/- minimal wipe debridement
17
Complications of herpes zoster occular involvement
Corneal keratitis
Ulceration
Perforation
Scarring
Secondary- iritis, glaucoma, cataracts
Muscle palsies
Severe post herpetic neuralgia
18
Signs requiring referral
Decreased VA
Shallow anterior chamber
Hyphema
Abnormal pupil
Ocular misalignment
Retinal damage
19
What does penetrating trauma inclue
Ruptured globe, prolapsed iris, IO foreign body
20
Initial management of penetrating trauma
REFER
ABCs
Do not press on eye globe
Dont check IOP
Check vision, diplopia
Apply rigid eye sheild
Keep head elevated
Keep NPO
Tetanus status
Give IV antibiotics
CT orbits
21
Management of suspected globe rupture
CT orbits
Cefazolin + aminoglycoside
NPO
Tetanus
Pethidine
Metoclopramide
22
Management of central retinal artery occlusion
Massage globe to dislodge thrombus
Decrease IOP->B blocker, IV mannitol, IV acetazolamide, rebreathing CO2, CCB, ant chamber paracentesis
Treat underlying cause
23
Causes of CRAO
Emboli->arrythmia, endocarditis, valvular disease
Thrombus
Temporal arteritis
24
Presentation of CRAO
Sudden, painless, severe monocular LOV
RAPD
May have had episodes of amaurosis fugax
Fundoscopy->
Cherry red spot
Retinal pallor
Narrowed arterioles
Cotton wool spots->infarct
After 6 weeks cherry red spot recedes and optic disc pallor becomes evident
25
What is the timeframe to initiate treatment for CRAO before vision loss
2 hours
26
What is the hallmark for central venous occlusion
Dilated arteries and veins
27
What are the associated conditions with CRVO
Hypertension
Diabetes
Hyperviscosity syndromes
Glaucoma
28
How does CRVO present
Rapid monocular vision loss
RAPD
Fundoscopy->blood and thunder
29
Distinct groups of CRVO
1. venous stasis/non-ischemic retinopathy
no RAPD, VA approximately 20/80
mild hemorrhage, few cotton wool spots
resolves spontaneously over weeks to months
may regain normal vision if macula intact
2. hemorrhagic/ischemic retinopathy
usually older patient with deficient arterial supply
RAPD, VA approximately 20/200, reduced peripheral vision
more hemorrhages, cotton wool spots, congestion
poor visual prognosis
30
Etiology of painless sudden LOV
CRVO
CRAO
IO hemorrhage
Retinal detachment
Optic neuropathy
Optic neuritis
Migraines
31
If suspect temporal arteritis/GCA- investigations and management
Refer
ESR->elevated
C-reactive protein (CRP)->elevated
FBC->normochromic, normocytic anemia
LFTs->mild elevation
temporal artery biopsy
temporal artery ultrasound
no visual or neurological symptoms or signs
1st line: prednisolone
visual or neurological symptoms or signs
1st line: methylprednisolone pulse therapy
confirmed GCA
1st line: prednisolone
adjunct: aspirin
adjunct: osteoporosis prevention
recurrent or relapsing disease or severe corticosteroid adverse effects
plus: methotrexate
32
Purpose of acetazolamide in acute glaucoma
Diamox= carbonic anhydrase inhibitor=
reduction in aqueous humor->reduction in IOP
33
Purpose of pilocarpine 4% in acute glaucoma
Cholinergic= iris sphincter miosis->ciliary muscle +outflow through trabecular
34
Presentation of acute glaucoma
presence of risk factors
halos around lights
aching eye or brow pain
headache
nausea, vomiting
reduced visual acuity
eye redness
elevated intraocular pressure (IOP)
corneal oedema
fixed dilated pupil
35
Investigations in acute glaucoma
Refer
gonioscopy, examination of anterior chamber angle
slit-lamp examination
automatic static perimetry
36
Initial management acute glaucoma
initial presentation: acute angle-closure glaucoma
1st line: carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist
adjunct: topical ophthalmic cholinergic agonists
adjunct: hyperosmotic agents->glycerol
plus: laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)
37
Ongoing management of acute glaucoma
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
1st line: topical prostaglandin analogues and/or topical beta-blocker and/or topical alpha-2 agonist->latanaprost + timolol + brimonidine
adjunct: carbonic anhydrase inhibitors
adjunct: argon laser peripheral iridoplasty (when there is a component of plateau iris)
adjunct: lens extraction surgery ± goniosynechialysis
adjunct: topical cholinergic agonists
adjunct: trabeculectomy or tube shunt implantation
38
Red eye differential
Lids/orbit
Conjunctival/sclera
Cornea
Anterior chamber
Other
39
Lids/orbit/lacrimal causes of red eye
Chalazion
Blephritis
Entropion/ectropion
Foreign body
Laceration
Dacryocystitis
40
Conjunctival/scleral causes of red eye
SC hemorrhage
Conjunctivitis
Dry eye
Pterygium
Epi/scleritis
Orbital cellulitis
41
Corneal causes of red eye
Foreign body
Keratitis
Abrasion/laceration
Ulcer
42
Anterior chamber causes of red eye
Anterior uveitis
AA glaucoma
Hyphema
Hypopyon
43
Other causes of red eye
Trauma
Post op
Endophthalmitis
44