1. Ophthalmology Emergencies
Presenter ：莊海華 醫師
Supervisor：李景行 醫師
Moderator ：陳俊宇 醫師
2006/12/13(Wed)

2. Case 1
2006/12/13(Wed)

3. General Data Vital signs: 2006/11/08 10:15 姓名：彭xx 病歷號碼：2101xxxx 性別：男
出生：85年10月16日
年齡：10歲
主訴因車禍後視線異常
Vital signs:
BT 36.2 ℃
HR 121/min
RR 20/min
BP 113/72 mmHg
GCS:E4V5M6
2006/12/13(Wed)

4. Pediatric Assessment Triangle
Appearance: fine
Breathing: smooth
Circulation: good
2006/12/13(Wed)

5. Chief Complaint
Left eye upgaze and downgaze movement limitation after traffic accident 2 days ago
2006/12/13(Wed)

6. Present Illness
Traffic accident (hit by a motorcycle) with left eye blunt injury
Left eye persistent soreness and pain since then
Left eye upgaze and downgaze limitation
2006/12/13(Wed)

7. Past and Personal History
Drug allergy：nil
Admission history：95/11/6-95/11/8 天晟 SAH and r/o orbital floor fracture
2006/12/13(Wed)

8. Physical Examination HEENT neck: no tenderness Chest
breathing sound: clear
heart sound: RHB, no cardiac murmur
Abdomen
soft and flat, no tenderness
Extremity
no edema, freely movable
2006/12/13(Wed)

9. Hemogram 951108 15:08 RBC:million/uL 5.16 WBC:1000/uL 8.2
:08
RBC:million/uL
Hemoglobin:g/dL
Hematocrit:%
MCV:fL
MCH:pg/Cell
MCHC:g/dL
RDW:%
Platelets:1000/uL 324
WBC:1000/uL
Segment:%
Lymphocyte:%
Monocyte:%
Eosinophil:%
Basophil:%
2006/12/13(Wed)

10. Biochemistry 951108 15:07 AST (GOT):U/L 16 ALT/GPT:U/L 14 Na:meq/L 140
:07
AST (GOT):U/L
ALT/GPT:U/L
Na:meq/L
K:meq/L
BUN (B):mg/dL
Creatinine(B):mg/dL 0.5
2006/12/13(Wed)

11. Ophthalmology Examination
2006/12/13(Wed)

12. CT of orbit
2006/12/13(Wed)

13. CT of orbit
2006/12/13(Wed)

14. CT of orbit
2006/11/08
Blow-out fracture of left orbital floor with herniation of inferior rectus muscle and orbital fat content
Minor fractures at left inferior orbital rim and left maxillary sinus
2006/12/13(Wed)

15. CT of brain
2006/12/13(Wed)

16. CT of brain 2006/11/08 No intracranial hemorrhage
Fracture of left orbital wall
2006/12/13(Wed)

17. Admission Course 2006/11/08 Surgery: repair of orbital floor, OS
2006/11/15 Discharge the patient
Diagnosis at discharge:
Orbital floor fracture with inferior rectus muscle incarceration, os
Ocular blunt injury, os Principle Procedure: repair of orbital floor
Out-patient-department follow-up
2006/12/13(Wed)

18. Key Points Trauma history + EOM limitation or diplopia
-> orbital wall fracture
2006/12/13(Wed)

19. Case 2
2006/12/13(Wed)

20. General Data Vital signs: Saturation: 96% BW: 20kg 2006/11/23 20:30
姓名：陳xx
病歷號碼：8986xxx
性別：女
出生：89年4月27日
年齡：6歲
病患主訴因左眼皮膚潰瘍
Vital signs:
BT 36.4 ℃
HR 126/min
RR 22/min
BP / mmHg
GCS:E4V5M6
Saturation: 96%
BW: 20kg
2006/12/13(Wed)

21. Pediatric Assessment Triangle
Appearance: fine
Breathing: smooth
Circulation: good
2006/12/13(Wed)

22. Chief Complaint Left periorbital skin erosion noted for 2-3 days
2006/12/13(Wed)

23. Present Illness Left periorbital skin erosion for 2-3 days
Left eye swelling today, itching(+), pain(-)
No fever, no couhg, no rhinorrhea, no vomiting, no diarrhea
Activity: fair, Appetite: fair
2006/12/13(Wed)

24. Past and Personal History
Admission history: AGE, asthma, hand cellulitis
Drug allergy: nil
2006/12/13(Wed)

25. Physical Examination General fair looking HEENT:
left eye periorbital swelling, and erythema
eyes: conjunctiva: not injected; sclera: not icteric
mouth: no ulcer , mucosa: wet, no erythema
throat: injected
tonsil: no edematous
2006/12/13(Wed)

26. Physical Examination Chest: breathing sound: clear
heart sound: RHB, no murmur
Abdomen:
soft and flat
active bowel sound
no tenderness
2006/12/13(Wed)

27. Hemogram 951123 22:44 RBC:million/uL 5.04 WBC:1000/uL 9.5
:44
RBC:million/uL
Hemoglobin:g/dL
Hematocrit:%
MCV:fL
MCH:pg/Cell
MCHC:g/dL
RDW:%
Platelets:1000/uL 252
WBC:1000/uL
Segment:%
Lymphocyte:%
Monocyte:%
Eosinophil:%
Basophil:%
2006/12/13(Wed)

28. Biochemistry
:00
CRP:mg/L < 0.5
2006/12/13(Wed)

29. Ophthalmology Examination
2006/12/13(Wed)

30. Ophthalmology Consultation
Impression:
Eyelid abrasion (OS)
Pre-septal cellulites (OS)
Conjunctivitis (OS)
Suggestion:
OSMD 1 GTT QID (OS) (眼內)
Tetracyclin oph oint 1 GTT BID (OS) (眼外)
Admitted to Ped and apply antibiotic
2006/12/13(Wed)

31. Admission course
2006/11/23 Admission with antibiotic use oxacillin 500mg/vial 1pc Q6H IVF sulfisomezole oph soln 4% 1GT QID tetracycline HCl % 1GT BID
2006/11/24 cefirizine and periactin
2006/11/27 Discharge the patient
Out-patient-department follow-up
2006/12/13(Wed)

32. Key Point
Differential diagnosis of preseptal cellulits and orbital cellulitis
-> EOM limitation & diplopia
2006/12/13(Wed)

33. Case 3
2006/12/13(Wed)

34. General Data Vital signs: 年齡: 54歲 BT 36.5 ℃ 性別: 男 HR 121/min 已婚
:11
年齡: 54歲
性別: 男 已婚
職業: 水電工
檢傷三級
病患主訴：左眼睛痛
Vital signs:
BT 36.5 ℃
HR 121/min
RR 20/min
BP 124/76 mmHg
GCS: E4V5M6
2006/12/13(Wed)

35. Chief Complaint
Left eye pain for 2 days
2006/12/13(Wed)

36. History and PE PI: N/V(-), no trauma (-) Left visual loss (+)
Polydipsia x 2 days
Transferred from 恩主公醫院
F/S 500
s/p RI 8U st
Plt 21K
Denied past Hx of DM
Allergy: NKA
Physical examination:
Cons: E4V5M6
Neck: supple, free
Chest:
Breath sound: bilateral clear
RHB
Abdomen:
soft and flat
Pelvic/back: NP
Extremities: free
2006/12/13(Wed)

37. Initial order 6/19 20: 43 (0hr 32 mins) F/S stat  268 mg/dl
CBC/DC, BUN, Cr, ketone body, Blood osmo, Na, K, U/A, ALT
IV with N/S run 120 ml/hr
Consult Ophthalmologist
2006/12/13(Wed)

38. Ophthalmologist ConsultationOD OS VA
0.6
Hand movement 5~10cm
Pupil
25 mm round
Mid-dilate
L/R + -
RAPD
EOM
Full and free
IOP
15 mmHg
38, 39, 40 mmHg
Lid/conj
Slight inject
Congestion
Cornea
Clear
Edema, SPK(+)
A/C
Shallow/ Clear
Shallow/ Blurred
Lens
NS+
Blurred
F’d
2006/12/13(Wed)

39. Ophthalmologist Consultation
IMP: acute angle closure glaucoma (OS)
Suggestion:
Mannitol (20%) 300 ml ivf st (check IOP 1hr later)
Acetazolamide (250 mg) 2# PO st and 1# QID
Pilocarpine 2% 1gt QID OS and st
Carteolol 2% 1gt QID OS and st
Prednisolone 1% 1gt QIH OS and st
2006/12/13(Wed)

40. 6/19 Lab data BUN 15 Cr 0.9 Osmo 282 ALT 69 Na 131 K 4.0 Ketone (-)
WBC
14200
Seg
81%
Band 9%
Lym 6%
Mono 3%
Meta-M 1%
RBC
5.11 Hb
15.9
Hct
45.7
MCV
89.4
Plt
24000
BUN 15
Cr 0.9
Osmo 282
ALT 69
Na 131
K 4.0
Ketone (-)
U/A
Yellow/clear
Sp gravity
1.010 pH
6.5
Nitrite
Negative
Protein 25
Glucose
1.0
Ketone 2+
Urobilinogen
Bilirubin
Blood 1+
Bacteria
Positive
WBC 6
RBC
Epi 3
2006/12/13(Wed)

41. Follow up and Disposition
Reduction of IOP (OS) from 45, 46 mmHg to 31, 32 mmHg
ED Imp: (1) Acute angle closure glaucoma, OS
(2) r/o DM (fresh case)
 Well explain and OPD f/u on 6/20
2006/12/13(Wed)

42. More About Past History
1996/9: Left deep neck infection, s/p incision and drainage
(Pus culture: Kleb. pneumoniae)
1997/11: Right deep neck infection, s/p incision and drainage
(Pus culture: Aerobic bacteria growth)
1999/5: Right deep neck infection, s/p incision and drainage
1999/10: Left deep neck infection, s/p incision and drainage
2006/12/13(Wed)

43. Second ED Visit 6/20 15:34 T36.8, P 112, R 20, BP 96/65 E4V5M6 檢傷三級
病患主訴：L’t eye blindness for 2 days
2006/12/13(Wed)

44. History and PE PE: C.C: Blindness for 2 days Right eye redness
Visual acuity:
Left-blind, Right-intact
Clear breath sound
RHB, no murmurs
Abdomen: Soft and flat, tenderness (-)
Extremities: freely
C.C: Blindness for 2 days
PI:
Eye pain (+)
Blurred vision (+)
Diplopia (-)
Left headache (+)
PH: DM (+), HTN (-), glaucoma(OS)
2006/12/13(Wed)

45. Consult ophthalmologist
6/20 15: 50 (0hr 16 mins)
Consult ophthalmologist
2006/12/13(Wed)

46. Ophthalmologist ConsultationOD OS VA
0.4
Hand movement 5 cm
Pupil
25 mm round
Mid-dilate
L/R -
RAPD
EOM
Full and free
IOP
14 mmHg
6, 8, 9 mmHg
Lid/conj
Quiet
Congestion
cornea
Clear
Edema , SPK, ED 4*4mm
A/C
Shallow/ Clear
Shallow/ Blurred
Lens
NS+
Blurred
F’d
No view
2006/12/13(Wed)

47. 2006/12/13(Wed)

48. Ophthalmologist Consultation
IMP: Acute glaucoma, OS
Corneal erosion, OS
Suggest:
1.Tobrex oint bid (OS)
2.pred-forte q2h (OS)
3.Carteolol bid (OS)
4.Analgesics
5.RTC on 6/21
2006/12/13(Wed)

49. Disposition 2005-06-20 17: 10 (1hr 36 mins) Medication
Indomethacin (25 mg) 1# QID
MgO (250 mg) 1# QID
Tobramycin oph oint 1 gtt BID OU
餘青光眼藥水續用
Imp: Glaucoma (OS)
Corneal abrasion (OS)
 MBD and OPD f/u (at 6/21 PM)
2006/12/13(Wed)

50. Third ED Visit 6/21 15:52 (0 hr 0 mins)
T38, P131, R 37, BP 105/69, E2V1M4
檢傷二級
病患主訴：SOB
2006/12/13(Wed)

51. History and PE CC: 在眼科OPD sudden onset SOB, then conscious drowsy
PI: 前兩天是glaucoma (OS)來ER
PH: DM (+)
PE: (T38, P131, R 37, BP 105/69 E2V1M4)
General appearance: clear?
Neck: supple  stiffness
Chest: clear BS, no wheezing
Abdomen: tender (++); no guarding
Other: NP
2006/12/13(Wed)

52. 6/21 16:24 (0hr 33mins)
CBC/DC, Cr, Na, K, ABG, Ketone, Osmo, Ck-MB, Tn-I, Amylase, Lipase, ALP, Bil(T), B/C
F/S: 516 mg/dl  RI 10U iv stat
Complete EKG, on EKG monitor, on pulse oximeter
CXR, KUB
O2 mask 35%
N/S challenge 500 ml
2006/12/13(Wed)

53. 6/21 CXR
Multiple nodules
2006/12/13(Wed)

54. 6/21 Lab data WBC 14700 Seg 88% Band 3% Lym 4% Mono At-lym 1% RBC 4.98Hb
15.4
Hct
44.5
MCV
89.4
Plt
38000 Cr
1.2
Osmo (B)
314
ALT 56
ALP
182
Bil (T)
2.5 Na
133 K
3.8
Ketone 1+
Amylase 15
Lipase 32
CK-MB
0.4
Troponin-I
<0.02
2006/12/13(Wed)

55. ABG data ABG pH 7.423 PaCO2 13.9 PaO2 97.5 HCO3 8.9 SBE -15.6 Sat%
97.8%
2006/12/13(Wed)

56. 6/21 18:03 (2hr 12 mins)
Obtain Brain CT (C-)
2006/12/13(Wed)

57. 3 5 2 1 6 4
2006/12/13(Wed)

58. 7 10 9 8 11 12
2006/12/13(Wed)

59. 13 14 16 15 17 18
2006/12/13(Wed)

60. 19 20 21 23 24
2006/12/13(Wed) 22

61. Report of brain CT
1. No definite intracranial hemorrhage or space-occupying lesion
2. Mild prominent sulci, fissures, and dilated ventricles
3. Atherosclerosis with wall calcification of the intracranial ICAs and VAs
IMP: Mild brain atrophy and intracranial arteriosclerosis
2006/12/13(Wed)

62. 6/21 19:47 (3hr 56 mins)
Abdominal CT (C+/-)
2006/12/13(Wed)

63. Multiple lung nodules ( ) with cavitations ( )
2006/12/13(Wed)

64. Hypodense hepatic lesions5
2006/12/13(Wed) 6

65. Hypodense hepatic lesions: DDX: necrotic tumor, abscess, or
Report of abdominal CT
Lung nodules: metastasis is favored DDx- septic emboli, granulomatous vasculitis
Hypodense hepatic lesions:
DDX: necrotic tumor, abscess, or
hemangiomas
2006/12/13(Wed)

66. 6/21 20:38 (4 hr 47 mins)
Arrange lumbar puncture
2006/12/13(Wed)

67. CSF data Xanthochromic (+), turbid 2+ WBC 1020 (N22/L1/M7),
Protein 2+
Cell count
WBC 1020 (N22/L1/M7),
RBC 1840 (fresh : old = 59:41)
Gram stain
GNB 1+
Acid fast stain
Negative
India ink
CSF Sugar/ blood sugar
33/516
CSF/plasma protein
413.1/4.5
Lactate ( )
171.1
Open/close pressure
20/8 cmH2O
Cryptococcal antigen
2006/12/13(Wed)

68. Ophthalmologist ConsultationOD OS VA
Can’t check
Pupil
25 mm round
Blurred and haze
L/R -
RAPD
EOM
IOP 12
9,11
Lid/conj
quiet
SCH K
clear
Haze, blurred, central > peripheral
A/C
Shallow/ clear
Shallow/ blurred
Lens
NS+
Blurred
F’d
No view
Imp: glaucoma with medication (OS)
Suggestion:
1.Hold oral medication
2.Hold brimonidine eye drop (due to CNS side effect)
3.先處理內科問題
4.OPD f/u or consult 3 days later (if admitted)
2006/12/13(Wed)

69. 6/22 00:34 (8hr 43 mins) 6/22 01:55 (10hr 04 mins)
E4V1M5 T 37.7, P134, R42, BP 139/72, CVP 6cm H2O, Sat 100%
Persistent tachycardia, tachypnea and conscious disturbance
Consult Chest (for ICU) at 01:04 (9hr 13mins)
6/22 01:55 (10hr 04 mins)
Intubation and Admission to MICU
2006/12/13(Wed)

70. ER Diagnosis Severe sepsis Bacterial meningitis
Multiple lung nodules, r/o septic emboli
Liver nodules, r/o liver abscess
R/O endophthalmitis, OS
DKA
2006/12/13(Wed)

71. Key Point
Endophthalmitis may mimic glaucoma
2006/12/13(Wed)