Justin Bowra Ulster Hospital 2003 Eyes in the E.D. Justin Bowra Ulster Hospital 2003

Summary The eye history The eye examination Documentation Drugs & the eye Conditions Pitfalls Referral

The eye history (1) Presenting complaint: High velocity metal? Events, trauma Pain Haloes Flashers Floaters Systemic syx High velocity metal? FB sensation? Decreased acuity? Pain… on blinking? … on moving the eye? Sudden floaters? Headache, nausea?

The eye history (2) Past medical Hx Meds Allergies Immunisations (tetanus) ..etc Plus: past ophthalmic Hx Spectacles Lens implants Laser corneal surgery Laser retinal surgery …etc

The eye exam (1) As for all ED patients: Where? Equipment? How? ABCDE first Then the eyes Where? Equipment? How?

The eye exam (2) Where: the eye room Equipment: Eye chart (how far away do you stand?) Slit lamp, ophthalmoscope, eye lamp Pinhole correction Cotton bud (why?) Amethocaine, fluorescein Switch off lamp after use!

What if you can’t open the eyelids? (eg swollen++ after trauma)                     The eye exam (3) What if you can’t open the eyelids? (eg swollen++ after trauma)

Use vertical strips of strong tape & amethocaine Answer: yes, you can! Use vertical strips of strong tape & amethocaine

Why is it important?

If you don’t look, you won’t find! (Globe rupture from fist)

The eye exam (4) I Actually Fear Funny Purple Moo Cows

The eye exam (4) I Actually Fear Funny Purple Moo Cows Inspection Acuity (do this 1st, PTO) Fields Fundi Pupillary reflex EOM (Corneal reflex)

Acuity corrected Snellen’s chart at 6m (ideally!) Count fingers Detect hand movement Light perception

Documentation is crucial (esp VA) Most medicolegal issues are due to poor documentation

Documentation History (relevant) Exam: Your Dx VA LE RE 6/60 6/5-1 Lids, cornea, conjunctiva, anterior chamber, lens: always Post chamber, retina, fields, EOM: sometimes Your Dx Any other doctors consulted (eg ED consultant) Your Rx plan Followup

Drugs & the eye Amethocaine (does it last 4 hours?) Fluorescein (always? Before or after amethocaine?) Dilators & Cycloplaegics (which?) Antibiotic drops? Steroid drops? NSAID drops?

Answers (1-2 drops/eye) Amethocaine’s FX last <1 hour Fluorescein (just 1 drop): always use (after amethocaine) Cyclopentolate: esp after flashburns Antibiotic: unnecessary after simple abrasion. Chloramphenicol ointment is better than drops *Consider Antifungals if diabetic ulcer *Steroids: never prescribe without seeking advice! *NSAIDs: ‘1 drop only!’ * = only to be prescribed by ophthalmology registrar

Padding the eye Probably not needed after amethocaine, but traditional Pre-shaped pads Fold 1st in half over closed eye Place 2nd over it Tape it down If you pad the eye, legally the patient cannot drive

Common eye problems Sudden blindness Trauma Chemical burns FB sensation Two red eyes One red eye

Sudden blindness Is it one or both eyes? All need urgent referral!

Sudden blindness/decreased vision: one or both eyes? Optic nerve: optic neuritis Retinal detachment, vitreous haemorrhage Blood supply: giant cell arteritis, CRAO, CRVO TIA/CVA Both Metabolic eg methanol, quinine, ethambutol Cortical eg CVA

Optic neuritis Younger patients 20-40y Often MS Pain behind eyes on looking L/R etc Afferent pupillary defect Red ‘washout’ Swollen optic disc (later pale) Urgent referral to ophthalmologist/neurologist Most recover; IV steroids help; oral may make it worse!

Retinal detachment Diabetics & high myopes & trauma Flashes, floaters, ‘curtain’ Affected retina is dark on fundoscopy Elevate head of bed (decreases IOP) Urgent referral

Vitreous haemorrhage If large, may cause absent red reflex Elevate head of bed (decreases IOP and allows blood to collect inferiorly) Urgent referral

Giant cell arteritis Older patents >60 Rapid visual loss Clues: headache, jaw claudication, malaise, aching muscles Tender temporal arteries Give 100mg IV hydrocortisone/50mg pred then check ESR (typically >40) then urgent referral

What’s this? …and how will you treat it?                    

Central retinal artery occlusion Embolus Pale retina, cherry red macula Digital massage globe 5 sec on, 5 sec off Carbogen (or brown paper bag rebreathe!) Urgent referral

What’s this?                    

Central retinal vein occlusion ‘Blood & thunder’ ‘Stormy sunset’ No specific ED treatment Urgent referral (rationale: protect the other eye)

Blunt trauma Life & limb-threatening conditions 1st ‘Can’t open lids’- open them anyway! Mimimum eye examination: Acuity, diplopia (eg blowout #), hyphaema, retinal detachment, orbital margins, NEO (naso-ethmoidal-orbital complex) Consider facial XR/CT (eg if suspicion & already planning brain CT)

Penetrating trauma to globe Clues? Management?

Answers: Clues: acuity, misshapen iris, Seidel’s sign Management: Do not remove the penetrating fragment! Check other injuries, sit the patient up (if c-spine allows) Eye shield/cone (not eye pad) Topical anaesthetic & IV morphine & antiemetic & IVAB & tetanus NBM & urgent transfer

What’s this?                    

Chemical burns Alkali worse than acid (NB- cement is alkali!) Treat 1st: irrigate+++ Until normal pH tears (how will you check?) Then do the rest of the exam Refer same day to ophthalmologist Hydrofluoric acid burn: give Ca-gluconate gel & inform senior ED staff immediately

FB sensation Differential Dx?

FB sensation DDx Foreign body Corneal abrasion Allergy Ulcer (eg dendritic)

Corneal FB Rx: Remove with the side of big needle on end of 2ml syringe: see practical demo 1st!) Always evert the eyelid Always use fluorescein & slit lamp Always remove the FB! If you can’t, get help!

Metal FB Xrays? Followup?

Metal FB: answers Xrays: eyes up & eyes down…if high velocity Followup: all patients need r/v in 48-72h for rust ring removal by middle grade/senior ED doctor

What’s this?                    

Bacterial corneal ulcer …with hypopyon Get help!

Two red eyes Orbital/periorbital cellulitis conjunctivitis Allergy eye Arc eye/flashburn

Differential Diagnosis? One red eye Differential Diagnosis?

One red eye Differential Diagnosis: Acute angle closure glaucoma (PTO) Anterior uveitis Burn-thermal, electrical FB, abrasion, conjunctivitis… Subconjunctival haemorrhage

Acute angle closure glaucoma Presentation (history, eye findings) Diagnosis Treatment

Acute angle closure glaucoma: features acuity Severe pain, headache, nausea Hazy cornea Pupil fixed, oval, mid-dilated Anterior chamber shallow Eyeball tender & hard

Clues in assessing the red eye Acute glaucoma Anterior uveitis Conjunctivitis Visual acuity Pupil Other features

Clues in assessing the red eye Acute glaucoma Anterior uveitis Conjunctivitis Visual acuity Normal Pupil Fixed, mid- dilated, unreactive Constricted/normal, lacrimation limbic injection Reactive Other features ocular disc cupping++, Headache & nausea Ant. chamber flare; often associated IBD, sarcoid etc

Acute angle closure glaucoma: diagnosis

Acute angle closure glaucoma: diagnosis IOP (intraocular pressure) elevated >25mm (ref 10-20)

Acute angle closure glaucoma: treatment

Acute angle closure glaucoma: treatment Get help! (ED reg, eye reg) Pilocarpine 4% drops (meiosis) every 10 minutes for 1st hr (& QID to other eye) Timoptol 1 drop into the affected eye Acetazolamide 1g po or 500mg IV qid ( aqueous) (Mannitol IV may be used if no response to acetazolamide) IV morphine & antiemetic & NBM Urgent transfer for laser iridotomy/peripheral iridectomy

Subconjunctival haemorrhage If spontaneous & painless, reassure Except… On warfarin/other bleeding disease- check INR! Trauma & can’t see posterior margin- Look for basal skull #

Other causes of acute red eye Anterior uveitis: usually idiopathic; refer Orbital cellulitis: consider CT (in case collection), IVAB, admit to ophthalmology Conjunctivitis: bacterial, viral or allergic? Bacterial: abx, don’t share towels etc adenoV: stay home until recovered

3 markers for urgent referral Decreased acuity Pain Red eye Unless: simple FB/conjunctivitis/abrasion, arc eye

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Eye room practical demo Snellen chart Slit lamp Eyelid eversion Cormeal FB removal

Summary Thorough eye history Thorough eye examination Thorough documentation Drugs & the eye (no steroids or NSAID drops) Referral: urgent if decreased acuity, pain, or red eye (& no simple explanation) If in doubt, get help