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EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident.

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Presentation on theme: "EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident."— Presentation transcript:

1 EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident

2 Hx Exam Most common etiologies Traumatic versus atraumatic Diagnosis Treatment When to get help

3 Trauma Consider unrecognized trauma- awoke with symptoms Pain? Itch? FB sensation? Visual acuity changes, halos Contact lenses- ? Overwear Sick contacts/Viral symptoms Prior surgery or eye disorders Systemic disease

4 Visual acuity Visual fields Pupil shape and reactivity Lid closure Foreign bodies Ciliary flare Foggy cornea (edema) Corneal infiltrate Fluorescein- corneal defects, Sidels sign Anterior chamber cells Intraocular pressure

5 Projectile metallic FB Get orbital Xray Rust ring Visual axis involved?- refer if unable to completely remove Burr Tetanus status Antibiotic prophylaxis?



8 Get help if not healing corneal ulcer large surface area infringing on visual axis


10 Usually due to blunt trauma and immediate Gross: layers out Microscopic: cells in anterior chamber Always refer Tx: cycloplegics, steroids, serial IOP monitoring, sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertion Complications: Iritis Synechiae, glaucoma Rebleeding


12 Penetrating FB Blunt trauma by an object smaller than a fist Blunt trauma with an orbital fracture Prior open globe surgery All must be repaired to prevent sympathetic ophthalmia Need a hard shield. Emergency referral, poor prognosis


14 Red, painful, decreased vision Anterior chamber cells+/- hypopion Almost exclusively post-surgical complication Rare: 1:100,000 cataract surgeries Urgent referral



17 Very common problem Mild itch, dry, gritty sandpaper sensation Many causes: Contact lens overwear Dry Calgary air Preservatives, antibiotic eye drops Incomplete lid closure Rule out other problems Discontinue cause, moisturize, follow up in ER


19 Allergic Viral Bacterial Irritative Treat bacterial conjunctivitis with flouroquinolone or erythromycin drops. Treat allergic with antihistamines, nasal steroid spray, allergen avoidance, cromolyn drops Refer any keratitis



22 Short fat branches with bulbs

23 HSV keratitis Dendritic fluoroscein enhancing lesion Hypoesthetic cornea +/- periocular HSV vesicles Tx is acyclovir +/- viroptic drops HSV can affect any part of the eye Next day referral as long as Tx started

24 Long thin tapered branches

25 HHV 3 (VZV) V1 (opthalmic branch of CN V) Macular rash =>vesicular lesions Conjunctivitis Keratitis Uveitis/iritis +/- retinal necrosis Cranial nerve palsies 3,4,6 Cxns: Chronic ocular inflammation, vision loss, neuralgia, late corneal sequelae

26 Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, age Hx: Sudden eye pain, photophobia, halos PE: Shallow anterior chamber, iris bombe, middilated pupil, hazy cornea, elevated IOP Tx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitol Ensure pressure drops within an hour

27 Complete occlusion of the anterior chamber angle by iris tissue

28 Causes: Infections, eye disorders, systemic disorders Trauma, autoimmune disorders, VZV, lyme disease, leukemia/lymphoma, idiopathic Photophobia and dull ache Urgent referral to ophtho Get baseline IOP and start Predforte drops and cycloplegics

29 Intense injection at limbus


31 Causes Valsalva Coagulopathy Presentation Visual acuity Absence of pain Absence of photophobia Absence of discharge Should resorb in 1-2 weeks

32 And that is the problem. Alkali chemical burn- large corneal epithelial defect and scleral ischemia.

33 Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosis You have only minutes to diagnose and irrigate Morgan lens, many litres Afterward:confirm pH, slit lamp exam for corneal defect, r/o deposits in conjunctival recesses.

34 Insidious onset Consider retro-orbital causes: mass, aneurysm.




38 Chronic recurrent eyelid inflammation Staph aureus or seborrhea (pityrosporum) Warm lid compresses Topical antibiotic eyedrops+/- ointment Dandruff shampoos to scalp to eradicate pityrosporum Slow response


40 Hordeolum- acute, painful Chalzion- chronic, non painful Hot compresses, milking Refer if not resolving for I+C Chronic lesions- ? Biopsy to r/o CA

41 Note irregular corneal light reflex

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