Presentation on theme: "The Red Eye EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008"— Presentation transcript:
1The Red Eye EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008 Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident
2Goals Hx Exam Most common etiologies Traumatic versus atraumatic DiagnosisTreatmentWhen to get help
3History Trauma Pain? Itch? FB sensation? Visual acuity changes, halos Consider unrecognized trauma- awoke with symptomsPain? Itch? FB sensation?Visual acuity changes, halosContact lenses- ? OverwearSick contacts/Viral symptomsPrior surgery or eye disordersSystemic diseaseWhat are halos, what do they indicate? - corneal edemaWhat causes corneal edema?- transudation of fluid into corneal stroma by elevated intraocular pressure as in acute glaucoma, or by inflammation as in healing corneal lesion.VIPERDT vision, irritation, pain, epiphora (tearing), redness, diplopia, trauma
4Red eye exam Visual acuity Visual fields Pupil shape and reactivity Lid closureForeign bodiesCiliary flareFoggy cornea (edema)Corneal infiltrateFluorescein- corneal defects, Sidel’s signAnterior chamber cellsIntraocular pressureWhat might cause an irregularly shaped pupil?- globe rupture with retinal prolapse tugs at the edge of the pupil causign a teardrop shape. Posterior synechiae (adhesions between lens and iris) cause a mid-dilated pupil with sl irregular shape. A smaller pupil may indicate iris sphincter spasm as in iridocyclitis.
5Foreign body Projectile metallic FB Rust ring Tetanus status Get orbital XrayRust ringVisual axis involved?- refer if unable to completely removeBurrTetanus statusAntibiotic prophylaxis?Update tetanus for any ocular foreign body, ocular burn, or corneal abrasion.Topical antibiotic prophylaxis is quite controversial. It is not required for a routine FB that is completely removed. Can be considered if pt is immunocompromised, large corneal defect, corneal ulcer, or dirty/wooden foreign body.Don’t be too aggressive with rust rings, you can always bring the patinet back 2 days later to remove a bit more, or just leave part of the rust ring if it is not interfering with the visual axis. That is much better than perforating the globe or causing a corneal ulcer that does not heal.
6The small metallic BF here would be best removed by a tangential approach with an 21-25G needle. If a rust ring remains afterward, gently remove it with a burr. This patient needs follow up to ensure visual acuity returns to normal and the rust ring completely resolves, preferably with a n ophthalmologist since this does encroach on the visual axis.
7Remember to evert the lid Remember to evert the lid. Embedded FBs on upper lid will often leave vertical linear corneal abrasions as a clue.
8Corneal abrasion Get help if not healing corneal ulcer large surface areainfringing on visual axisConsider antibiotics if large area. If painful, give an antibiotic ointment- erythromycin or chloramphenicol. Update tetanus.
9What is this? Macroscopic hyphema What is a hyphema called that opacifies the entire anterior chamber?- an eight ball hyphemaWhat is the Tx for an 8 ball hyphema?- surgery! Anterior chamber paracentesis
10Hyphema Usually due to blunt trauma and immediate Gross: layers out Microscopic: cells in anterior chamberAlways referTx: cycloplegics, steroids, serial IOP monitoring, sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertionComplications:IritisSynechiae, glaucomaRebleedingRebleeds are severe, eight ball hyphema, will elevate IOP and require anterior chamber wash-out surgery. Rebleeds occur within 8 days. Elevated IOP is refractory to medical therapy and requires surgery.
12Globe rupture Penetrating FB Blunt trauma by an object smaller than a fistBlunt trauma with an orbital fracturePrior open globe surgeryAll must be repaired to prevent sympathetic ophthalmiaNeed a hard shield.Emergency referral, poor prognosisUsually get a retinal detachment at the same time. If the retina is intact prognosis is much better.Exception to poor prognosis is a corneal laceration- these have a good prognosis as retina is usually intact.Traumatic cataract- lens opacifies with any direct lens trauma. Occurs within one hour.Styrofoam cup serves as a hard shield.Avoid valsalva with open globe.
13A bad day of fishing Approach? IV access, vitals, r/o other injuries. Pain control, anxiolytics.Check finger counting, rough confrontational visual fields.Eye ointments to keep cornea moist. Cut loose strings so entire fishing rod isn’t following patient. Hard shield. Tetanus status.Call ophtho.
14Endophthalmitis Red, painful, decreased vision Anterior chamber cells+/- hypopionAlmost exclusively post-surgical complicationRare: 1:100,000 cataract surgeriesUrgent referralGlaucoma surgeries leave a foreign body or a tract, and these patients can get endophthalmitis as a delayed complication. Otherwise endophthalmitis occurs within a few days of surgery.
15What is this?Hypopion- pus in the anterior chamber. Can occur with iritis/iridocyclitis, endophthalmitis.Non painful hypopion can be lymphoma or metastatic Ca. They will have decreased vision but no other symptoms.Urgent referral.
16What is this?Superficial punctate keratitis- note fine speckled lesions across cornea, often worse inferiorly
17Superficial punctate keratitis Very common problemMild itch, dry, gritty sandpaper sensationMany causes:Contact lens overwearDry Calgary airPreservatives, antibiotic eye dropsIncomplete lid closureRule out other problemsDiscontinue cause, moisturize, follow up in ERKnowing these causes for SPK, why is it often worse on the inferior cornea?- drops pool on inferior cornea, lid closure defects expose inferior cornea to air. Better name is exposure keratopathy, contact lens keratopathy, antibiotic keratopathy because there is no keratitis.
18Is this SPK?NOT SPK! Nummular keratitis secondary to VZV. Note the larger areas of corneal defect, with more depth, and possibly infiltrate. Any time you are questioning an infiltrate it is time to refer.
19Conjunctivitis/keratoconjunctivitis AllergicViralBacterialIrritativeTreat bacterial conjunctivitis with flouroquinolone or erythromycin drops.Treat allergic with antihistamines, nasal steroid spray, allergen avoidance, cromolyn dropsRefer any keratitisBoth allergic and viral conjunctivitis can have upper respiratory symptoms. Viral has more prominent itching.All types of conjunctivitis and keratitis can have some eye discharge. Serous eye discharge overnight will causes lid crusting/glue. The key difference is that during the day, only the bacterial conjunctivitis will have continual, large volume milky or purulent discharge.Both viral and bacterial can have a tender pre-auricular lymph nodeBacterial: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Gonorrhea can cause hyperacute bacterial conjunctivitis. STD screening. Systemic Abx and urgent referral if fulminant course. If not fulminant, 95% are viral.Viral: adenovirus, many serotypes. Second eye is usually involved by hours. Tarsal conjunctivae have a bumpy appearance. Eye crusting in morning, then serous d/c thereafter. Eye feels gritty, sandy, dry.
20What is this?Bacterial conjuncitivitis- note continuous purulent d/c. You will treat many cases of viral conjunctivitis as bacterial to be on the safe side, but when your patient is filling a bucket with purulent drainage in the waiting room- get urgent ophtho and start a broad spectrum topical antibiotic (4th generation cephalosporin- Zymar). Assess for gonorrhoea and chlamydia with eye and genital swabs.
21What is this?Could be viral, allergic or irritative. Ask about amount of itching, sneezing, resp symptoms, atopic history, pre-auricular node.
22What is this?Short fat branches with bulbsHSV keratitis
23Herpes Simplex Virus HSV keratitis Dendritic fluoroscein enhancing lesionHypoesthetic cornea+/- periocular HSV vesiclesTx is acyclovir +/- viroptic dropsHSV can affect any part of the eyeNext day referral as long as Tx startedSometimes a healing corneal ulcer will have a pseudodendritic appearance. A healing ulcer should be exquisitely painful, and the branches will not be as complex. The ends of each branch of an HSV ulcer should have a bulb.Viroptic is now controversial- systemic antivirals work just as well with eye lubricants. If severe kertitis, give viroptic. Viroptic required 9 times daily. Causes keratitis.HSV can cause many other eye complications- iritis, retinal necrosis/detachment
24What is this?Long thin tapered branchesVZV epithelial keratitis
25Herpes Zoster Ophthalmicus HHV 3 (VZV)V1 (opthalmic branch of CN V)Macular rash =>vesicular lesionsConjunctivitisKeratitisUveitis/iritis +/- retinal necrosisCranial nerve palsies 3,4,6Cxns: Chronic ocular inflammation, vision loss, neuralgia, late corneal sequelaeKeratitis- punctate with infiltrate, dendritic (each branch is longer and more tapered than HSV keratitis, without the branch-terminal bulbs.Retinal necrosis can occur.All should be referred to ophtho, can be seen the next day if vision intact. Start systemic acyclovir immediately.
26Acute angle closure glaucoma Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, ageHx: Sudden eye pain, photophobia, halosPE: Shallow anterior chamber, iris bombe, middilated pupil, hazy cornea, elevated IOPTx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitolEnsure pressure drops within an hourWhy would they prefer bright light? Miosis allows a bit more drainage of the anterior chamber. May give history of headaches at sunset. By the time of an acute attack- pt will usually be photophobic.Why do they see halos?- corneal edema secondary to transudation of fluid into corneal stroma from high intraocular pressure.Drops are not very effective because pressure gradient will not allow drops to diffuse into the eye. Systemic therapies are what will work best.
27Acute angle closure glaucoma Complete occlusion of the anterior chamber angle by iris tissue
28Iritis Causes: Infections, eye disorders, systemic disorders Trauma, autoimmune disorders, VZV, lyme disease, leukemia/lymphoma, idiopathicPhotophobia and dull acheUrgent referral to ophthoGet baseline IOP and start Predforte drops and cycloplegicsBrucellosisAtypical mycobacteriaInfectious causes:LeptospirosisLeprosyCat scratch diseasePropionibacteriumLyme diseaseWhipple's diseaseTuberculosisSyphilisCytomegalovirusViralHerpes zosterHerpes simplexEpstein-BarrMumpsHuman T cell leukemia virusHIV-1VacciniaRubeolaFungalWest Nile virusCandidiasisBlastomycosisAspergillosisCryptococcosisCoccidioidomycosisParasitic (protozoan/helminthic)SporotrichosisHistoplasmosisCystercercosisAcanthamoebaToxocariasisPneumocystis cariniiOnchocerciasisToxoplasmosisUveitis syndromes confined primarily to the eyeBirdshot choroidopathyAcute retinal necrosisAcute multifocal placoid pigmentary epitheliopathyGlaucomatocyclitic crisisFuch's heterochromic cyclitisLeber's neuroretinitisIridocorneal endothelial syndromeImmune recovery (reconstitution) uveitisPars planitisMultifocal evanescent white dot syndromeSubretinal fibrosisSerpiginous choroidopathyPunctate inner choroidopathyTraumaSympathetic ophthalmiaSuspected immune mediated causes of uveitisBehcets diseaseAnkylosing spondylitisCrohn's diseaseDrug or hypersensitivity reactionKawasaki's diseaseJuvenile rheumatoid arthritisInterstitial nephritisPsoriatic arthritisMultiple sclerosisSarcoidosisRelapsing polychondritisReactive arthritisSystemic lupus erythematosusSjögren's syndromeVitiligoVasculitisUlcerative colitisVogt Koyanagi Harada syndromeMasquerade syndromesLeukemiaIschemiaGiant retinal tearsPigmentary dispersion syndromeOcular melanomaLymphomaRetinitis pigm
29Ciliary flare of iritis Intense injection at limbus
31Subconjunctival hemorrhage CausesValsalvaCoagulopathyPresentationVisual acuityAbsence of painAbsence of photophobiaAbsence of dischargeShould resorb in 1-2 weeksIf traumatic- consider ruptured globe, hyphema.
32This eye is not red And that is the problem. Alkali chemical burn- large corneal epithelial defect and scleral ischemia.This eye should be irritated and red. The white color is a poor prognostic indicator, signifying ischemia. As a result, scar tissue and neovascularization may develop obscuring the entire cornea.
33You have only minutes to diagnose and irrigate Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosisYou have only minutes to diagnose and irrigateMorgan lens, many litresAfterward:confirm pH, slit lamp exam for corneal defect, r/o deposits in conjunctival recesses.What kind of necrosis does an alkali burn cause?—liqueaction necrosis. Acids cause coagluation necrosis, which creates a gel-like barrier to deeper damage.If necessary, sedate the patient in order to irrigate the eye. Patient may be out of control due to pain.