1. Eyes in the E.D Aaron Graham LAT1 Emergency Medicine

2. The history is all the same.. Ophthamology like a normal history plus… Past ocular history - I.e Surgery/contacts Examination - Visual Acuity !! Fluroscein staining Say what you see 2

3. Part 1: Red eye Part 2: Sudden visual loss 3

4. Part 1: The Red Eye Conjunctivitis (Viral and bacterial) Corneal abrasion Bacterial keratitis Orbital celulitis Anterior uevitis Episcleritis Sceleritis 4

5. RED EYE CORNEAL ABRASION –FB sensation, pain, photophobia, ↓VA –Try LA to see if pain settles –Injected conjunctiva, ↓VA (visual axis) –Fluroscein staining - Epithelial defect with –Chloramphenicol QDS 1 week, eye protection, lubricating eye drops

6. RED EYE Corneal FB –Very common in minors. Hx of FB, then shortly after pain, FB sensation, red eye –LA allows examination –Try & remove with cotton bud/needle –Rust Ring Iron containing FB – Key point - Is this a penetrating eye injury?

7. Seidels positive - penetrating! ophthalmology! 7

8. RED EYE CONJUNCTIVITIS –Viral more common than bacterial Red, irritated, streamy, purulent sticky eyes VA and pupils normal No staining of cornea with Fluoroscein Chloramphenicol QDS for 1 week Hygiene. Likely spread and can take weeks to go away!

9. First not to miss: Bacterial keratitis Ophthamology! Almost certainly contact lens wearer Ophthamology!

10. Second not to miss: Orbital / Peri-orbital cellulitis Red eye, proptosis, pain on eye movement = orbital cellulitis 10 Ophthamology!

11. HSV Dendritic Ulcer Ophthamology!

12. RED EYE Ocular Burns –Acid or Alkali may blind. Urgent Rx req. –Irrigate +++++ to dilute chemical ASAP. Aim for pH 8 –Alkali Penetrates eye & destroys internal structures –Acid Coagulates collagen to form barrier which prevents penetration into eye.

13. Episcleritis/ Scleritis –Red, sore ++++ (Compared with conjunctivitis) –Localised area of inflammation. –Mostly idiopathic but can be assoc. with RA / Auto-immune.

14. Episcleritis Ophthamology!

15. Scleritis Ophthamology!

16. Retinal detachment Vitreous haemorrhage Stroke! Central retinal vein / artery occlusion 16 Part 2: Sudden visual loss

17. Retinal detachment The one not to miss! F - lashing lights F - loaters F - ield loss Short sighted / trauma / diabetic at greater risk Decrease in visual acuity (If macula) Often had it before 17

18. Retinal Detachment

19. SUDDEN VISUAL LOSS Vitreous Haemorrhage –Sudden onset of “floaters” or “blobs” –VA may be normal or ↓ if haemorrhage dense. –Flashing lights indicate retinal traction which may lead to a retinal hole or detachment. –Haemorrhage from spontaneous rupture of vessels, avulsion of vessels during retinal traction, or bleeding from abnormal new vessels (diabetics)

20. Part 2: SUDDEN VISUAL LOSS Vitreous Haemorrhage –VA depends on the extent of the haemorrhage. –Red reflex reduced. –May see clots of blood that move with the vitreous. –Retina may be difficult to visualise. REFER URGENTLY

21. Vitreous Haemorrhage

22. Part 2: Sudden visual loss Central Retinal Artery Occlusion –End artery. Occlusion usually embolic. –Sudden painless ↓↓ VA (counting fingers or no light perception) –Direct pupil reaction sluggish/absent in affected eye but reacts to consensual stimulation(afferent pupillary defect)

23. SUDDEN VISUAL LOSS

24. Central Retinal Artery Occlusion

25. Part 2: Sudden visual loss Central Retinal Artery Occlusion –Digitally massage globe to ↓ IOP & try to dislodge embolus –URGENT Ophthalmology referral –Consider S/L GTN, IV acetazolamide 500mg –CO 2 rebreathing to dilate arteries. –? Giant Cell Arteritis – may lose sight in other if not treated promptly. Full Hx & Ex important.

26. SUDDEN VISUAL LOSS Central Retinal Vein Occlusion –More common than CRA occlusion. –Predisposing factors: Old age, chronic glaucoma, arteriosclerosis, ↑BP, polycythaemia. –↓↓VA with afferent pupillary defect.

27. SUDDEN VISUAL LOSS Central Retinal Vein Occlusion –Fundoscopy – “ stormy sunset ”: hyperaemia with engorged veins & adjacent flame shaped haemorrhages. Disc may be obscured by haemorrhages & oedema. Cotton wool spots may be seen(bad Px sign). –Outcome variable. No specific Rx. –Refer urgently as underlying cause may be treatable therefore protecting the other eye.

28. Central Retinal Vein Occlusion

29. PAINFUL EYE Acute Closed Angle Glaucoma –At risk: Long sighted middle aged, elderly with shallow anterior chambers. –Cause: sudden blockage of drainage of aqueous humour into Canal of Schlemm (anticholinergic drugs, pupil dilating at night) – ♀ > ♂

30. PAINFUL EYE Acute Closed Angle Glaucoma –Acute onset painful red eye 2 0 to rapid ↑ IOP – Vision blurred, haloes around lights. – Pupil semi-dilated & fixed. – Eye feels harder to palpation. – If seen shortly after attack has resolved NONE of these signs may be present, therefore Hx is paramount.

31. Acute Closed Angle Glaucoma

32. PAINFUL EYE Emergency treatment if sight to be preserved. Aim of Rx: ↓ IOP – 4% Pilocarpine (both eyes) IV/PO Acetazolamide. Laser/Surgical Rx to Iris NB Condition is bilateral. Felloe eye is at 50% risk of developing an attack within 5 years. Fellow eye should have prophylactic iridectomy or laser iridotomy.