Ophthalmology

Ocular Emergencies

  • Caustic eye exposure – acid vs base
  • CRAO
  • Retrobulbar hemorrhage/Orbital compartment
  • Acute angle closure glaucoma
  • Endophthalmitis

Exam

  • VA
  • Visual fields
  • Inspection including lids, EOMI
  • Swinging flashlight
  • EOM
  • Direct ophthalmoscopy
  • Slit lamp
  • Tonometry
  • US
  • Anisocoria
    • Increases in light – 3rd nerve palsy, pharmcologic
    • Increases in dark – physiologic vs 3rd nerve palsy

Trauma

Penetrating injury

  • Think about penetrating globe or brain injury with any laceration in eye area
  • Need to ask about high speed injuries to determine if high risk for open globe
  • Eyelids don’t have fat – if fat protruding from wound, high risk for globe injury

Painful Red Eye

  • Conjunctivitis
    • Mostly viral – pre-auricular adenopathy
    • EKC – virulent and highly contagious adenovirus
    • Tx – topical abx for 7 days + local care
    • Allergic conjunctivitis – pale chemosis
    • Gonococcal conjunctivis
      • Very purulent discharge
      • Needs admission for IV Abx
    • Ophthalmia neonatorum
      • Neisirrieia – 2-5 days post birth – ceftri _ topical poluymyxin B baci
      • Chlamydia – 5-15 days – topical ineffective
  • Corneal disease
    • FB
      • Need to consider high velocity mechanism risk for globe injury
      • Organic = high risk for infection
      • Metal Rust ring removal in 48 hrs
      • Glass might be able to stay in if not easy to remove
    • Dry eye
    • Super glue
      • warm ophthalmic ointment 3-4/day for 4-5 days
      • If eyelashes inverted needs urgent ophtho f/u
  • Glaucoma
  • Episcleritis/scleritis
    • Think of if recurrent “conjunctivitis”
  • Uveitis/Iritis
    • Needs dilation for pain and to avoid posterior synechiae (adhesion of iris to cornea)

 Vision Loss

  • CRAO
    • Painless, sudden
    • APD on exam
    • Cherry red spot and possible emboli on direct
    • Doppler US measurement
    • Needs full stroke w/u and ESR/CRP
    • Tx – possibly TPA and HBO
  • CRVO
    • Painless, sudden
    • APD on exam
    • “Blood and Thunder” on direct – compare eyes
    • Often complicated by glaucoma – need to measure IOP
    • Complex treatment including lowering intraocular pressure if elevated
  • Vitreous hemorrhage
    • US to look for associated retinal detachment
    • Tx: Bedrest w/ HOB elevated
    • Refer to ophtho
  • Retinal detachment
    • Flashers and floaters
    • Vision loss – painless
    • APD usually present
    • Immediate referral to ophthalmologist – probably needs operative management in 2-3 days but not emergent surgery
  • Posterior vitreal detachment (PVD)
    • Drying vitreous pulls away from retina – presents floaters and flashes
    • Can cause a a retinal detachment as it pulls away
  • Optic neuritis
    • Vision loss over hours to days
    • Eye pain w/ movement
    • 15-45 yo usually
    • 66% women
    • Hyperemic swelling on direct in only 1/3 of pts
    • APD present
    • MRI confirms dx
    • Spontaneous recovery over wks/months in 90%; 30% will have MS w/in 5 years
    • Tx – complicated and involves high dose methylprednisolone, decreases recurrence risk and lengthens time to onset of MS
  • Temporal arteritis
    • Most pts are >60
    • HA, vision changes, jaw claudication, associated PMR
    • Temporal tenderness
    • ESR usually very high ~90-100
    • Start steroids empirically based on presentation
    • Tx – IV methylpred esp if vision loss, admission
    • Biopsy high false negative rate

Trauma

  • Hyphema
    • If SS at high risk for acute glaucoma
    • Goal is to prevent re-bleed – likely needs optho consult
  • Bloody chemosis concerning for ruptured globe
  • Lid lacs – anything other than superficial horizontal lacs need referral for repair, anything that could involve nasal lacrimal system needs referral
  • Conjunctival laceration
    • < 1 cm abx ointment only
    • > 1 cm likely sutured by ophthalmologist
    • Any darkness involved is choroid and indicates penetrating injury
  • Any fat coming out of lac around eye is from the orbit – high risk for globe injury
  • Can’t rule out penetrating globe injury just by looking at eye

Caustic injury

  • Start irrigation w/ NS (2L)
  • Use procaine q 15 min
  • Use Buffered Eye Wash if available (buffered)
  • pH needs to be normal on 3 consecutive checks

Meds

Contraindications to dilating the eye

  • Lens implant
  • Narrow angle
  • Globe penetration

Mydriatics

  • Phenylephrine

Cycloplegics

  • Atropine/homatropine – Homatropine lasts 1-2 days, atropine lasts too long, don’t use
  • Cyclopentolate
  • Tropicamide

Anesthetics

  • Proparacaine – needs refrigerating, doesn’t hurt
  • Tetracaine – room temp okay, stings

Steroids

  • Probably should talk to ophthalmologist every team

Topical NSAIDs

  • Risk for ulcers – esp. w/ diclofenac

Ocular Decongestants

Artificial tears

  • Want non-preserved if going to use frequently