3Case 1: Sudden visual loss 70 yo female brought to emergency by neighbour. She reports that half an hour previously her vision in right eye has suddenly been lost. There has been no improvement since. The eye is not painful or red.Past ophthalmic history: early cataracts in both eyes.Past history: angina, hypertension. Both well controlled with medication.
4Further history Moderate to severe headaches for previous 3 months Chewing food produced ache in her jawScalp tenderness when brushing hairFelt generally unwell during this period of time
5Examination Acuity : hand movements right eye, 6/9 left eye Profound relative afferent pupillary defectOphthalmoscopy of left eye normalRight optic disc abnormalRemainder of right retina normal
7Giant cell arteritis5-10% of all anterior ischaemic optic neuropathies90% are “non-arteritic” IONOcclusive granulomatous vasculitisUntreated eventual loss of vision in both eyesAge 50 or olderClinical featuresLoss of visionHeadache, scalp tendernessJaw claudicationNeck painWeight loss/malaise/ night sweatsMyalgia – association with polymyalgia rheumaticaDouble visionShort posterior ciliary artery vasculitis ischaemic necrosis of optic nerve head
8Signs Ix Reduced VA (<6/60) Relative afferent pupil defect Field deficitAltitudinal lossSwollen, pale disc +- disc haemorrhages, cotton wool spotsSuperior + inferior optic disc swellingTender, thickened, nodular temporal vessels/absent pulsesCN 3/4/6 palsiesIxElevated ESR (mean 70)/CRPTemporal artery biopsyWithin 10 days of steroids
9Treatment Prognosis Bottom line Immediate Methylprednisolone 1g IV daily for 1-3 daysOral prednisolone 1-2mg/kg dailyHigh dose steroid for monthsSide effect prophylaxisPrognosisRisk of second eye – 10% if treated, 95% if untreatedComplications: TIA, CVA, neuropathies, thoracic artery aneurysmsBottom lineArrange urgent inflammatory markersSeek adviceSafer to start treatment if any delay
10Non-arteritic AIONInsufficient circulation to crowded optic nerve local oedema, compromised circulationAssociationsDiabetes, hypertension, disc morphology (small cup, crowded disc)Smoking, hyperlipidaemia, anaemia, OSAMean age 60yoAcuity usually better than 6/60, altitudinal field loss commonNo associated symptomsESR, CRP, platelets – normalLower risk to other eye – 20% at 5 yrsTreatmentNo proven benefit anything in particularAspirin 75mg / dayOptimising risk factors
11Case 2 : Sudden vision loss (2) 45 yo female referred from oncology unit with sudden, painless vision loss in her right eye.Progressive loss of upper vision in right eyePast history of metastatic lung carcinomaPast ophthalmic history – nil signifcant, but noticed blurred vision over past 8 weeksPainless visual lossNo headache, jaw claudication, pain on EOM
12Examination Acuity 6/6 right, light perception only left Pupils equal and roundRAPD present right eyeFull range of extraocular motility
14Retinal detachment Retina has 2 layers Separation of neural retina from pigment epitheliumdue to fluid entering this potential space (sub-retinal space)Most cases are rhegmatogenous (tear/ hole in neural retina)Non rhegmatogenousMuch less commonTractional: pulled off by membranes (eg proliferative DR)Exudative: breakdown of blood-retinal barrier (eg choroidal tumours, uveitis)Usually less extensive detachmentPathogenesisVitreous is more firmly attached to retina in certain placesPeripheryOptic discBloood vessels
15Rhegmatogenous retinal detachment Commonest form of RDDue to vitreous liquefaction + break in retinaClinical featuresFlashes, floatersPeripheral field loss (early)Curtain-type field defectLoss of central vision (macula)Loss of red reflexVitreous – PVD, vitreal pigment +/- bloodRetinal breaksU-shaped, round holesUpper temporal quadrant in 60%Detached retinaLooks grey, balloons forwardRetinal blood vessels on the surfaceUnilateral convex, corrugated dome
16Vitreous detachment Vitreous liquefies due to aging Collapse inwards FloatersTraction on retina at points of firmer attachmentFlashesFloaters – vitreous opacities2 possible outcomesPosterior vitreous detachment (PVD)Retinal tearFluid can then can access to sub-retinal spaceRetinal detachmentLoss of visual field in this areaExtension to macular = loss of central vision
17Principles of management Position patient so dependent fluid moves away from maculaUrgent referral for surgeryRelief of vitreoretinal tractionVitrectomy or indenting eye wall from outside (suture explant : scleral buckling)Augmented by injection of silicone oil or gasClosure of retinal breakDrainage of subretinal fluidNeedle puncture through sclera + choroidAdhesion of detached retina to RPEExternal cryotherapy or internal laser inflammation of choroid + retina adhesion of layers
19Key points Flashes and floaters common Most will be PVDShould have a dilated exam to exclude tearsCheck confrontation visual fieldsIf loss more suspicious for detachmentUrgent referral
20Case 3: Acute red eye64 year old male presents to emergency with red swollen, watery right eye for the past 2 days, but now sudden deterioration of vision.No significant medical historyNo past ophthalmic historySaw LMO yesterdayImpression of viral conjunctivitis,Commenced chloramphenicol dropsMinimal relief.Vision now much worse.
21Further history Severe pain in the right eye since for last 3 hours Associated frontal headache, malaise
22ExaminationVisual acuity- counting fingers only in right eye, 6/6 in the left eyeRight afferent pupillary defectOval shaped pupil, fails to react to direct or consensual
26Acute angle closure glaucoma (AACG) Glaucoma – progressive optic neuropathy1% over 40 yo, 3% over 70 yoPrimary open angle glaucoma (POAG) – 1/3Secondary glaucoma – 1/3AACGUsually primaryRisk factorsEpidem: Age >40, female, Chinese, SE AsiansAnatomical: Pupil block, crowding of AC angle prevents access to trabecular meshwork
27Clinical features of AACG Pain (periocular, headache, abdominal)Blurred visionHaloesNausea / vomitIpsilateralRed eyeRaised IOP (usually 50-80mmHg)Corneal oedema (hazy cornea)Diminished red reflexFixed semi-dilated pupilDue to iris ischaemiaContralateral angle is narrowBilateral shallow AC
31Case 4: The swollen, painful eye 21 year old female presents to emergency with increasing swelling and pain of the right eye region for past 10 days.Associated diplopia in up and left gazeSystemic symptoms: productive cough, fevers over this timeNo significant past medical or ophthalmic historyB blockers – diminish function of ciliary epithelium
33Examination Acuity – Right 6/18, left 6/6 Proptosis – 5mm on the right No RAPDPain on all movements of right eyeLimitation of elevation, adduction right eye, with accompanying diplopiaAnterior segmentDilated conjunctival vessels in right eyeNormal left eye examination
34Orbital vs Periorbital cellulitis Orbital cellulitis = ophthalmic emergencyS.pneumoniae, S.aureus, H influenzaeRisk Fx: sinus disease, local infection, trauma (septal perforation), ENT/ ophthal surgeryHx: FEVER, MALAISE, PAINFUL, SWOLLEN orbitO/E: Swollen lids +- chemosis, Proptosis, Painful eye movements, Optic nerve function (VA, colour, RAPD)Complications:Local- keratopathy, raised IOP, CRVO, CRAOSystemic- orbital abscess, cavernous sinus thrombosis, meningitis, cerebral abscess!
36Treatment of orbital cellulitis AdmitVital signsFBE, Blood culturesCT- orbit and sinusesIV Fluclox 1g qid or Cefuroxime 1g tds PLUS Metronidazole 500mg tdsMajority need drainage of collection – diagnostic and therapeutic
38Periorbital cellulitis Not an emergency, it’s not in the orbit!Similar organismsMuch less severeRisk FX: local infection, URTIsFx: fever, malaise, swollen lids, but no proptosis, pain on eye movement or optic nerve deficitsINV: not necessary usuallyRX: oral fluclox 500mg qid for a week + metronidazole 400mg tds for a week
39Case 5: TraumaA 26 year old male is brought to emergency late at night with sudden blurred vision and pain in the right eye after being assaulted.He states he was struck with a glass bottle to the right side of his face in an assault.Past medical and ophthalmic history are unremarkable.
41Globe rupture Clinical Features Anterior rupture Posterior rupture Herniating iris, oozing aqueous, vitreous, lensSevere subconjunctival haemorrhagehyphaemaPosterior ruptureSuspect if deep AC but low IOP compared to other eye
43Treatment of Penetrating FB, Globe rupture Prepare patient for urgent surgeryImagingPlain XROcular ultrasoundOrbital + facial bone CTHigh risk of endophthalmitisClear plastic shieldSystemic ABx: Ciprofloxacin, po, 750mg bdTetanus is requiredTake to theatre for primary repair
45Orbital compartment syndrome Globe and retrobulbar contents encased within a fascial cone, bound by 7 rigid bony wallsAnteriorly – medial and lateral canthal tendons attach eyelids to orbital rimSmall increases in orbital volume forward movement of globe rapid rise in orbital tissue pressureIf intraorbital pressure > central retinal artery pressure ischaemiaClassically in retrobulbar haematoma (post op, trauma)
46Symptoms of acute orbital compartment syndrome Eye painDiplopiaLoss of visual acuityReduced ocular motilityProptosis
48Lateral canthotomy Perform lateral canthotomy, as follows. Clean the area with sterile saline.Inject approximately 1 mL of lidocaine 1-2% with or without epinephrine into the lateral canthus.Apply a hemostat/clamp with one side anterior and one side posterior to the lateral canthus and advance until the rim of the bony orbit is felt.Clamp for seconds.Perform the lateral canthotomy by carefully cutting through the crushed, demarcated line to the orbital rim/lateral fornix to avoid traumatizing the orbit, as in the image below.Cantholysis is performed by identification and disinsertion of the inferior crus of the lateral canthal tendon, which should allow free mobility of the lower lid margin.
51Indications for surgical intervention in orbital floor fractures ImmediatePersistent oculocardiac reflexYoung patient with white eye “trap-door’ fractureSignificant facial asymmetry< 2 weeksPersistent symptomatic diplopiaSignificant enophthalmosHypoglobusProgressive infra-orbital hypoaesthesiaDecreased HR when traction on EOM / compression of eyeballDue to trigeminal afferents + vagus n synapse via afferents from trigeminal going to visceral motor nucleusof vagus n
53Chemical injuriesAlkalis- liquefactive necrosis – penetrate further than acids (coagulative necrosis)Alkalis pH 14 : NaOH, oven cleaners, drain cleaners, plaster, fertilisersAcids pH 1: H2SO4, battery fluid, toilet cleaning fluid, bleach (Na hypochlorite)Prognostic factorsAgent, how much cornea is involvedLimbal involvementAssociated blunt trauma, thermal injuryComplicationsCorneal opacificationConjunctival scarringEctropion, corneal ulcers
54Chemical injuries Hx Clinical Fx What, when, how much Wearing PPE Sx: burning, itchy, gritty, vision lossMx: did they irrigate itClinical FxConjunctival injection or blanchingHaemorrhage, corneal abrasionsCorneal oedemaPerilimbal ischaemia (blanched vessels)Raised IOPHughes’ classification: Grades 1 to 41 is clear cornea, no limbal ischaemia, good prognosis4 is opaque cornea, 50% limbal ischaemia, poor prognosis
55Treatment of Chemical injuries Immediate- copious irrigation (anything will do except acid/ alkali, water preferable!)Evert lids- remove particulate matterAdmit pxTopical Abx (preservative free chlorsig qid)Topical cycloplegia tdsTopical lubricant (preserve free- celluvisc, 4/24 + paraffin nocte)Oral simple analgesiaIf raised IOP acetazolamide 250mg, qid + timolol 0.5% bd
56Tips from the bosses Test the VA with and without pinhole Angle-closure glaucoma is uncommonIf the patient’s pain does not disappear with anaesthetic drops, the cause is likely to be from deeper to the corneaNever start a patient on steroid drops without ophthalmology input