OCULAR EMERGENCIES M.R. SHOJA SHAHEED SADOUGHI UNIVERSITY . 02/12/2018 EYE EMERGENCIES

EYE ANATOMY 02/12/2018 EYE EMERGENCIES

SUDDEN LOSS OF VISION Usually Unilateral, Pain-less Rapid onset, if due to vascular cause More gradual if due to inflammation 02/12/2018 EYE EMERGENCIES

Causes of sudden visual loss Vascular occlusion Ischemic optic retinal vein occlusion retinal artery neuropathy Retinal detachment Vitreous hemorrhage 02/12/2018 EYE EMERGENCIES

Central retinal vein occlusion (CRVO) Systemic causes Age Hypertension Hyperviscosity Ocular causes Raised IOP 02/12/2018 EYE EMERGENCIES

BRVO 02/12/2018 EYE EMERGENCIES

Central retinal artery occlusion(CRAO ) Visual loss profound RAPD Pale retina, thread-like retinal vessels Cherry red spot (can see normal choroidal circulation at fovea where the retina is thinnest) 02/12/2018 EYE EMERGENCIES

Causes of CRAO Emboli from the heart Carotid artery disease from calcific valves vegetations thrombus Carotid artery disease fibrinoplatelet calcific Inflammatory GIANT CELL ARTERITIS 02/12/2018 EYE EMERGENCIES

Clinical Features of CRVO VA Moderate to severe loss Relative afferent pupil defect (RAPD) Retinal haemorrhages Dilated/engorged, dark, tortuous veins Retinal ischaemia/Cotton wool spots Optic disc swelling/retinal oedema Neovascularisation 02/12/2018 EYE EMERGENCIES

Retinal Detachment Sudden onset of flashes/floaters Shadow in vision Myopic patients Management usually surgical 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Posterior segment (3) Retina - retinal tear => retinal detachment - commotio retina - macular hole 02/12/2018 EYE EMERGENCIES

Ocular infections 02/12/2018 EYE EMERGENCIES

Orbital Cellulitis In 3% of acute sinusitis Pain, proptosis, chemosis Mucopurulent rhinorrhea Motility defect, globe displacement Decreased vision, pupillary signs 02/12/2018 EYE EMERGENCIES

BACTERIAL KERATITIS 02/12/2018 EYE EMERGENCIES

Predisposing factors Trauma 32 (39%) Ocular diseases 28 (34.1%) Previous ocular surgery 8 (9.8%) Contact lens 8 (9.8%) Systemic disease 6 (7.3%) Diabetes R.Arthritis 02/12/2018 EYE EMERGENCIES

Acute Red Eye Subconjunctival. H Scleritis HZO Bacterial.C Uniocular Binocular No Pain Pain Subconjunctival. H Scleritis HZO Bacterial.C Episcleritis Anterior uveitis Viral.C Pterygium A.C.glaucoma Allergic.C Conjunctivitis Bacterial Keratils VKC 02/12/2018 EYE EMERGENCIES

Red Eye Red Eye 02/12/2018 EYE EMERGENCIES

Primary Angle Closure Glaucoma (PACG) Epidemiology: 1- Age 2-Gender 3-Race 4-Heriditary 5-Refractive Error 6-Seasonal Incidence (10% of all glaucoma , 5-10% bilatesal) Primary Angle Closure Glaucoma (PACG) Eastern Asia less in black 02/12/2018 EYE EMERGENCIES

Findings Diminished vision Ciliary flush , corneal Edema Elevated Iop (40-75 mmHg ) Shallow Anterior Chamber Dilated , vertically Oval nonreactive pupil. Cell and Flare in Ac Hyperemic Swollen optic disk Findings 02/12/2018 EYE EMERGENCIES

CONGENITAL GLUCOMA 02/12/2018 EYE EMERGENCIES

Stevens-Johnson syndrom Acute bullose mucocutaneous disease Hypersensitivity reactions to drugs Pseudomembrane, fibrosis, Dry Eye 02/12/2018 EYE EMERGENCIES

Chemical Burns - basic Can be: - acid A true ocular emergency => basic Immediate irrigation essential 02/12/2018 EYE EMERGENCIES

Chemical burns Treatment in the first ten minutes has a major impact on the final outcome. In all chemical eye injuries, immediate, continuous irrigation with clean water is a priority. Chemical burns are generally the most urgent emergencies. 02/12/2018 EYE EMERGENCIES

Chemical Burns: Initial Management Instill anesthetic drop (topical) ____________________________________ Instill anesthetic drop (topical) Check and remove foreign bodies Institute copious irrigation Refer promptly to ophthalmologist Irrigation of chemical burns should be initiated before arrival to emergency room 02/12/2018 EYE EMERGENCIES

Eye Injuries: Blunt trauma Contusion Rupture Sharp:Penetrating trauma With foreign body Without foreign body 02/12/2018 EYE EMERGENCIES

Foreign Body 02/12/2018 EYE EMERGENCIES

Penetrating Trauma: IOFB-Intra-Ocular Foreign Body Metal Fe (siderosis) Cu (chalcosis) Non-metal Organic Non-organic 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Anterior segment (2) Cornea - corneal erosion - corneal foreign body Symptoms: Pain Tearing Foreign-body sensation 02/12/2018 EYE EMERGENCIES

CORNEAL ABRASION & LACERATION 02/12/2018 EYE EMERGENCIES

Corneal erosion: Symptoms Treatment: Topical antibiotic Patch over eye Topical cycloplegia 02/12/2018 EYE EMERGENCIES

EYE PROTECTION During SURGERY 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma:External(1) Eye lids - hemorrhage - laceration Conjuctiva 02/12/2018 EYE EMERGENCIES

OCULAR HEMORHAGE 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Anterior segment (3) Iris - HYPHEMA - Mydriasis - Iridodialysis - Angle recess 02/12/2018 EYE EMERGENCIES

Hyphema – physician management: Assume globe is ruptured Shield eye and refer to ophthalmologist Ophthalmologic management: Restricted activity Protective metal shield Topical cycloplegic +/- corticosteroids 02/12/2018 EYE EMERGENCIES

OCULAR TRAUMA 02/12/2018 EYE EMERGENCIES

Complete Eye Examination Visual Acuity External exam Motility exam Pupils Anterior segment Intraocular pressure Ophthalmoscopy Peripheral vision 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Anterior segment (3) Iris - hyphema - traumatic mydriasis: light, reading - angle recession, iridodialysis 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Anterior segment (3) Iris - hyphema - traumatic mydriasis: light, reading - ruptures of pupillary sphincter - angle recession, iridodialysis 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Anterior segment (2) Lens - cataract - dislocated lens 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma Posterior segment (3) Retina - retinal tear - commotio retina - macular hole 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Posterior segment (4) Choroid - choroidal break Sclera - scleral rupture Optic Nerve: - traumatic optic neuropathy - avulsed optic nerve 02/12/2018 EYE EMERGENCIES

Blunt Ocular Trauma: Posterior segment (4) Choroid - choroidal break Sclera - scleral rupture: open globe Optic Nerve: - traumatic optic neuropathy - avulsed optic nerve 02/12/2018 EYE EMERGENCIES

Penetrating Trauma: Reduced IOP is common with globe laceration or rupture. Evaluate cautiously to avoid extrusion of intra-ocular contents 02/12/2018 EYE EMERGENCIES

Penetrating Trauma: When globe rupture is suspected Stop examination Shield the eye (do not patch) Give tetanus prophylaxis Refer immediately to ophthalmologist 02/12/2018 EYE EMERGENCIES

Penetrating Trauma: Penetrating site of IOFB Cornea - 79% Sclera - 21% 02/12/2018 EYE EMERGENCIES

Penetrating Ocular Trauma : Cornea: laceration, irregular corneal reflex Iris: prolapse, irregular pupil Lens: traumatic cataract Retina: retinal detachment 02/12/2018 EYE EMERGENCIES

History - What is your current level of vision? General Ocular - Vision - Is one eye affected, or both? - What is your current level of vision? - Was vision normal prior to trauma? 02/12/2018 EYE EMERGENCIES

Primary goal: Patient care and preservation of vision Eye Trauma Primary goal: Patient care and preservation of vision Early, accurate emergency diagnosis and treatment Appropriate ophthalmologic referral 02/12/2018 EYE EMERGENCIES

THANKS FOR YOUR ATTENTION 02/12/2018 EYE EMERGENCIES