Case 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.
Further history Moderate to severe headaches for previous 3 months Chewing food produced ache in her jaw Scalp tenderness when brushing hair Felt generally unwell during this period of time
Examination Acuity : hand movements right eye, 6/9 left eye Profound relative afferent pupillary defect Ophthalmoscopy of left eye normal Right optic disc abnormal Remainder of right retina normal
Giant cell arteritis 5-10% of all anterior ischaemic optic neuropathies 90% are “non-arteritic” ION Occlusive granulomatous vasculitis Untreated eventual loss of vision in both eyes Age 50 or older Clinical features ▫Loss of vision ▫Headache, scalp tenderness ▫Jaw claudication ▫Neck pain ▫Weight loss/malaise/ night sweats ▫Myalgia – association with polymyalgia rheumatica ▫Double vision
Signs ▫Reduced VA (<6/60) ▫Relative afferent pupil defect ▫Field deficit Altitudinal loss ▫Swollen, pale disc +- disc haemorrhages, cotton wool spots Superior + inferior optic disc swelling ▫Tender, thickened, nodular temporal vessels/absent pulses ▫CN 3/4/6 palsies Ix ▫Elevated ESR (mean 70)/CRP ▫Temporal artery biopsy Within 10 days of steroids
Treatment ▫Immediate Methylprednisolone 1g IV daily for 1-3 days Oral prednisolone 1-2mg/kg daily ▫High dose steroid for months ▫Side effect prophylaxis Prognosis ▫Risk of second eye – 10% if treated, 95% if untreated ▫Complications: TIA, CVA, neuropathies, thoracic artery aneurysms Bottom line ▫Arrange urgent inflammatory markers ▫Seek advice Safer to start treatment if any delay
Non-arteritic AION Insufficient circulation to crowded optic nerve local oedema, compromised circulation Associations ▫Diabetes, hypertension, disc morphology (small cup, crowded disc) ▫Smoking, hyperlipidaemia, anaemia, OSA Mean age 60yo Acuity usually better than 6/60, altitudinal field loss common No associated symptoms ESR, CRP, platelets – normal Lower risk to other eye – 20% at 5 yrs Treatment ▫No proven benefit anything in particular ▫Aspirin 75mg / day ▫Optimising risk factors
Case 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 eye Past history of metastatic lung carcinoma Past ophthalmic history – nil signifcant, but noticed blurred vision over past 8 weeks
Examination Acuity 6/6 right, light perception only left Pupils equal and round RAPD present right eye Full range of extraocular motility
Retinal detachment Retina has 2 layers Separation of neural retina from pigment epithelium ▫due to fluid entering this potential space (sub-retinal space) Most cases are rhegmatogenous (tear/ hole in neural retina) Non rhegmatogenous ▫Much less common ▫Tractional: pulled off by membranes (eg proliferative DR) ▫Exudative: breakdown of blood-retinal barrier (eg choroidal tumours, uveitis) ▫Usually less extensive detachment Pathogenesis ▫Vitreous is more firmly attached to retina in certain places Periphery Optic disc Bloood vessels
Rhegmatogenous retinal detachment Commonest form of RD Due to vitreous liquefaction + break in retina Clinical features ▫Flashes, floaters ▫Peripheral field loss (early) ▫Curtain-type field defect ▫Loss of central vision (macula) ▫Loss of red reflex ▫Vitreous – PVD, vitreal pigment +/- blood ▫Retinal breaks U-shaped, round holes Upper temporal quadrant in 60% ▫Detached retina Looks grey, balloons forward Retinal blood vessels on the surface Unilateral convex, corrugated dome
Vitreous liquefies due to aging ▫Collapse inwards ▫Floaters ▫Traction on retina at points of firmer attachment Flashes Floaters – vitreous opacities ▫2 possible outcomes Posterior vitreous detachment (PVD) Retinal tear Fluid can then can access to sub-retinal space ▫Retinal detachment ▫Loss of visual field in this area ▫Extension to macular = loss of central vision Vitreous detachment
Principles of management Position patient so dependent fluid moves away from macula Urgent referral for surgery ▫Relief of vitreoretinal traction Vitrectomy or indenting eye wall from outside (suture explant : scleral buckling) Augmented by injection of silicone oil or gas ▫Closure of retinal break ▫Drainage of subretinal fluid Needle puncture through sclera + choroid ▫Adhesion of detached retina to RPE External cryotherapy or internal laser inflammation of choroid + retina adhesion of layers
Key points ▫Flashes and floaters common Most will be PVD Should have a dilated exam to exclude tears ▫Check confrontation visual fields If loss more suspicious for detachment Urgent referral
Case 3: Acute red eye 64 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 history No past ophthalmic history Saw LMO yesterday ▫Impression of viral conjunctivitis, ▫Commenced chloramphenicol drops ▫Minimal relief. Vision now much worse.
Further history Severe pain in the right eye since for last 3 hours Associated frontal headache, malaise
Examination Visual acuity- counting fingers only in right eye, 6/6 in the left eye Right afferent pupillary defect Oval shaped pupil, fails to react to direct or consensual
Approach to treatment of AACG Immediate Systemic – acetazolamide 500mg IV stat (then 250mg oral, qid), analgesia, anti-emetic Carbonic anhydrase inhibitor – decreased aqueous production Ipsilateral eye B-blocker (eg timolol 0.5% stat, then bd) Decreased aqueous production Pilocarpine 2% (reverse the pupil block) Parasympathomimetics – ciliary contraction opens trabecular meshwork Sympathomimetic (eg apraclonidine a2 agonist 1% stat) decreased aqueous production + increased outflow Hourly IOP check Definitive management – Bilateral Nd-YAG Peripheral iridotomy
Case 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 gaze Systemic symptoms: productive cough, fevers over this time No significant past medical or ophthalmic history
Acuity – Right 6/18, left 6/6 Proptosis – 5mm on the right No RAPD Pain on all movements of right eye Limitation of elevation, adduction right eye, with accompanying diplopia Anterior segment Dilated conjunctival vessels in right eye Normal left eye examination Examination
Orbital vs Periorbital cellulitis Orbital cellulitis = ophthalmic emergency – S.pneumoniae, S.aureus, H influenzae – Risk Fx: sinus disease, local infection, trauma (septal perforation), ENT/ ophthal surgery – Hx: FEVER, MALAISE, PAINFUL, SWOLLEN orbit – O/E: Swollen lids +- chemosis, Proptosis, Painful eye movements, Optic nerve function (VA, colour, RAPD) – Complications: Local- keratopathy, raised IOP, CRVO, CRAO Systemic- orbital abscess, cavernous sinus thrombosis, meningitis, cerebral abscess!
Treatment of orbital cellulitis Admit Vital signs FBE, Blood cultures CT- orbit and sinuses IV Fluclox 1g qid or Cefuroxime 1g tds PLUS Metronidazole 500mg tds Majority need drainage of collection – diagnostic and therapeutic
Periorbital cellulitis Not an emergency, it’s not in the orbit! Similar organisms Much less severe Risk FX: local infection, URTIs Fx: fever, malaise, swollen lids, but no proptosis, pain on eye movement or optic nerve deficits INV: not necessary usually RX: oral fluclox 500mg qid for a week + metronidazole 400mg tds for a week
Case 5: Trauma A 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.
Globe rupture Clinical Features ▫Anterior rupture Herniating iris, oozing aqueous, vitreous, lens Severe subconjunctival haemorrhage hyphaema ▫Posterior rupture Suspect if deep AC but low IOP compared to other eye
Treatment of Penetrating FB, Globe rupture Prepare patient for urgent surgery Imaging ▫Plain XR ▫Ocular ultrasound ▫Orbital + facial bone CT High risk of endophthalmitis ▫Clear plastic shield ▫Systemic ABx: Ciprofloxacin, po, 750mg bd ▫Tetanus is required Take to theatre for primary repair
Orbital compartment syndrome Globe and retrobulbar contents encased within a fascial cone, bound by 7 rigid bony walls Anteriorly – medial and lateral canthal tendons attach eyelids to orbital rim Small increases in orbital volume forward movement of globe rapid rise in orbital tissue pressure If intraorbital pressure > central retinal artery pressure ischaemia Classically in retrobulbar haematoma (post op, trauma)
Symptoms of acute orbital compartment syndrome Eye pain Diplopia Loss of visual acuity Reduced ocular motility Proptosis
Indications for surgical intervention in orbital floor fractures Immediate ▫Persistent oculocardiac reflex ▫Young patient with white eye “trap-door’ fracture ▫Significant facial asymmetry < 2 weeks ▫Persistent symptomatic diplopia ▫Significant enophthalmos ▫Hypoglobus ▫Progressive infra-orbital hypoaesthesia
Chemical injuries Alkalis- liquefactive necrosis – penetrate further than acids (coagulative necrosis) Alkalis pH 14 : NaOH, oven cleaners, drain cleaners, plaster, fertilisers Acids pH 1: H2SO4, battery fluid, toilet cleaning fluid, bleach (Na hypochlorite) Prognostic factors ▫Agent, how much cornea is involved ▫Limbal involvement ▫Associated blunt trauma, thermal injury Complications ▫Corneal opacification ▫Conjunctival scarring ▫Ectropion, corneal ulcers
Chemical injuries Hx ▫What, when, how much ▫Wearing PPE ▫Sx: burning, itchy, gritty, vision loss ▫Mx: did they irrigate it Clinical Fx ▫Conjunctival injection or blanching ▫Haemorrhage, corneal abrasions ▫Corneal oedema ▫Perilimbal ischaemia (blanched vessels) ▫Raised IOP ▫Hughes’ classification: Grades 1 to 4 1 is clear cornea, no limbal ischaemia, good prognosis 4 is opaque cornea, 50% limbal ischaemia, poor prognosis
Treatment of Chemical injuries Immediate- copious irrigation (anything will do except acid/ alkali, water preferable!) Evert lids- remove particulate matter Admit px Topical Abx (preservative free chlorsig qid) Topical cycloplegia tds Topical lubricant (preserve free- celluvisc, 4/24 + paraffin nocte) Oral simple analgesia If raised IOP acetazolamide 250mg, qid + timolol 0.5% bd
Tips from the bosses Test the VA with and without pinhole Angle-closure glaucoma is uncommon If the patient’s pain does not disappear with anaesthetic drops, the cause is likely to be from deeper to the cornea Never start a patient on steroid drops without ophthalmology input