Emergency Ophthalmology justin chatten-Brown, MD CCRMC Emegency Department justin chatten-Brown, MD CCRMC Emegency Department

Objectives Learn examination of the eye, and slit- lamp basics Diagnose and be able to rule out eye emergencies Know how to treat basic conditions Know when to refer, and on what timescale

Etiologies of the Red or Painful Eye Infection Orbital Cellulitis Severe Iritis/Uveitis Hypopyon Herpetic keratitis Preseptal cellulitis Bacterial conjunctivitis Viral conjunctivitis

Etiologies of the Red or Painful Eye Primary Ophthalmologic Disease Acute Glaucoma Optic Neuritis Allergy Blepharitis Allergic Conjunctivitis

Etiologies of the Red or Painful Eye Trauma Corneal abrasions Corneal foreign bodies Subconj Hemorrhage/Hyphema Penetrating Orbital Trauma Acute Retinal Detachment Chemical Burns Alkali worse than acid

Basic anatomy

History is Key Symptom ThinkSymptom Think ItchingAllergy ItchingAllergy Scratchiness/ burninglid, conjunctival, corneal disorders, including foreign body, trichiasis, dry eye Scratchiness/ burninglid, conjunctival, corneal disorders, including foreign body, trichiasis, dry eye Localized lid tenderness Hordeolum, Chalazion Localized lid tenderness Hordeolum, Chalazion Foreign Body Sensation Foreign body, rule out trauma Foreign Body Sensation Foreign body, rule out trauma

History is Key Symptom ThinkSymptom Think Intense deep painIritis, scleritis, sinusitis, acute glaucoma Intense deep painIritis, scleritis, sinusitis, acute glaucoma Photophobia Corneal abrasion, iritis, acute glaucoma Photophobia Corneal abrasion, iritis, acute glaucoma Halo Vision Acute glaucoma, corneal edema Halo Vision Acute glaucoma, corneal edema Floaters, halos, lines Retinal Detachment or “veil” visual loss Floaters, halos, lines Retinal Detachment or “veil” visual loss

Exam Visual acuities Gross Examination Proptosis, EOM, lid malfunction Lids/Lashes (evert) irregularities in pupil size or speed of reaction (APD, anisocoria)

Exam Examine Anterior to Posterior on Slitlamp Conjunctiva (palpebral & bulbar) for injection, discharge (scant/profuse; purulent/serous) Corneal irregularities, opacities, foreign bodies Iris and lens, noting depth of anterior chamber, pupillary anomalies Measure intraocular pressures with Tono-pen if indicated

Exam Fluorescein stain and Examine with Cobalt Blue Light “streaming” on Seidel test- Penetrating trauma corneal abrasion or ulcer Dendrites- herpetic keratitis

Eye Disorders Anatomical Approach Lid Disorders Conjunctivitis/Corneal Disorders Uveitis/Iritis and Glaucoma Retinal Disorders Systemic Disorders

Lid Disorders Hordeolumstaph infection glands of Zeis warm compresses and topical abx ChalazionMeibomian gland infectionsame Blepharitis Staph or seborrhea of the lid margin same + lid scrubs with baby shampoo/H2O

Lid Disorders Chalazion Blepharitis

Corneal Lesions Conjunctivitis Localized Opacities Generalized Haziness (corneal edema) Keratitic precipitates

Patterns of Redness Diffuse Conjunctival Hyperemia (nonspecific)

Patterns of Redness Ciliary Flush- Episcleral Vessels Seen in Iritis and Acute Glaucoma

Conjunctivitis ChemicalAllergicViralBacterial Historyexposure hay fever, asthma ill contacts Distributiondependsbilateralmore often bilateral often unilateral DischargeClearMucousClearPurulent TreatmentFLUSH!!! anti- histamines, systemic + gtt symptomatic (except with Herpetic Keratitis -> can result in vision loss) Abx (Ocuflox, Polytrim)

Neonatal Conjunctivitis TypeGonococcalChlamydia Onset48 hours post-partum4-7 days post-partum Signs/SxsSevere purulent dc, chemosis pseudomembranes, less purulent, eyelid edema DxGram stainGiemsa, ab stain Treatment Systemic CTX, PCN G, Top Erythromycin Topical and oral erythromycin; Treat parents too!!

Chemical Injury Strong bases more dangerous than strong acids, as is progressive Treatment is copious irrigation with NS, towards temple away from unaffected eye, and under lids Check pH with litmus, and irrigate until pH neutralized If obvious damage, emergent ophtho referral

Corneal Ulcer Always urgent referral Often have trauma history, contact lens users Suspect fungal infection if trauma with organic matter Culture and gram stain Antibiotics +/- antifungals

Herpes Keratitis Herpetic Dendrites may have ulcers/vesicles can result in visual loss urgent Ophtho referral Treatment: topical and systemic antivirals

Uveitis/Iritis Keratitic precipitates Cellular deposits on cornea found in iritis (anterior chamber inflammation), along with “cell and flare” Idiopathic, traumatic, or associated with systemic disease Urgent referral Treatment differs on type of iritis/uveitis- steroids and cycloplegics

Chamber Anatomy Aqeous humor from ciliary process (post chamber) through pupil to ant chamber Drains through trambecular network into Canal of Schlemm, and to scleral plexus

Esimate Anterior Chamber Depth Narrow anterior chamber suggests angle closure glaucoma

Acute Angle Closure Glaucoma Etiology: Contact between the iris and trabecular meshwork, obstructs outflow of aqueous humor Symptoms: Intense eye pain, blurred vision, halos, HA, vomiting, photophobia Findings: Pupils mid- dilated and unresponsive Scleral injection Corneal edema EMERGENT REFERRAL!!!

Pupillary Abnormalities Unaffected in conjunctivitis Constricted, possibly irregular in iritis due to spasm Fixed and mid-dilated in acute angle closure Can be irregular in penetrating trauma

Proptosis Must rule out tumor or acute infection

Preseptal Cellulitis Soft tissue infection ANTERIOR to orbital septum Possibly secondary to sinus infection, trauma or simple cellulitis Consider CT scan orbit to assess for orbital cellulitis, subperiosteal or orbital abscess

Preseptal Cellulitis Treat with IV antibiotics (Unasyn) Admit moderate to severe for observation and to ensure no progression 12 Hour recheck for mild disease

Orbital Cellulitis Differentiate from preorbital cellulitis: proptosis impaired motility (pain) decreased vision optic disc edema afferent pupillary defect Complications Meningitis in ~ 2% Cavernous sinus thrombus Optic nerve damage

Orbital Cellulitis EMERGENCY! Call Ophtho STAT Admit IV abx CT orbits

Eye Trauma With any history of eye trauma, must rule out penetrating globe injury Seidel’s test is positive if streaming fluoroscein Do not put pressure on globe...stat ophtho consult if positive test

Eye Trauma “Bloody Eye” Subconjunctival Hemorrhage Resolve Spontaneously No treatment needed Hyphema Blood in anterior chamber Emergent/Urgent referral

Retinal Detachment Separation of neurosensory retina from retinal pigment epithelium Multiple Etiologies Rhegmatogenous Tractional (including trauma) Exudative

Retinal Detachment Symptoms Flashes (photopsia), floaters, loss of peripheral vision Signs Afferent pupillary defect Lower IOP Vitreous opacities Convex corrugated/undulating surface

Retinal Detachment If <24 hours Ophthalmologic Emergency If >24 hours, somewhat less urgent Ophtho consult to determine course of action