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

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

3. 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?

4. 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

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

6. 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!

7. 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)

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

9. Why is it important?

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

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

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

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

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

15. 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

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

17. 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

18. 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

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

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

21. 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

22. 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!

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

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

25. 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

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

27. 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

28. What’s this?
                   

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

30. 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)

31. Penetrating trauma to globe
Clues?
Management?

32. 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

33. What’s this?
                   

34. 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

35. FB sensation
Differential Dx?

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

37. 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!

38. Metal FB
Xrays?
Followup?

39. 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

40. What’s this?
                   

41. Bacterial corneal ulcer
…with hypopyon
Get help!

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

43. Differential Diagnosis?
One red eye
Differential Diagnosis?

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

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

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

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

48. 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

49. Acute angle closure glaucoma: diagnosis

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

51. Acute angle closure glaucoma: treatment

52. 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

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

54. 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

55. 3 markers for urgent referral
Decreased acuity
Pain
Red eye
Unless: simple FB/conjunctivitis/abrasion, arc eye

56. ?

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

58. 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