Regions Hospital Emergency Medicine

Eye Anatomy

Basic Examination Visual Acuity Tonometry Pupillary Reaction Ocular Motility Visual Field Testing External Examination Ophthalmoscopy

48 yo F who was doing some cleaning at home and splashed some kind of cleaning solution in her eye. Her eye is now extremely painful with blurred vision. What do you suspect with A? with B? Which is more dangerous? AB

Chemical Burns Alkali Burns Acid Burns Liquefactive necrosis Continue to penetrate cornea long after exposure Eg. Ammonia, lye, lime Coagulative necrosis Typically confined to superficial tissue Eg. Exploding car batteries (sulfuric acid), lab chemicals

Treatment? COPIOUS IRRIGATION!!!

36 yo M who was carrying a pencil at work when he fell, landing with his face on the pencil. Comes to the ED complaining of eye pain, lacrimation, and blurred vision. Pupil is irregularly shaped and non-reactive. What if it looked like A? like B? A B

What test do you want to do? Seidel’s test

Corneal Laceration Intense pain, lacrimation, and photophobia Reduced visual acuity Bubbles in the anterior chamber Treatment? No unnecessary manipulation Eye shield Emergent ophtho consult

Globe Rupture Similar presentation to corneal laceration but full- thickness Eye often rotates upwards as it closes as a protective reflex Treatment? Avoid intraocular pressure measurements!!! No unnecessary manipulation Eye shield to protect the eye Emergent ophtho consult

26 yo mechanic who was welding and felt something shoot into his eye. Now complaining of severe eye pain, redness, and tearing.

Ocular Foreign Body Treatment? Apply proparacaine eye drops Removal: Cotton swabs 18-gauge needle Electric drill for rust ring removal

86 yo F with sudden onset painful vision loss. She has diffuse corneal edema, marked conjunctival injection, and corneal hazing. Pupil is mid-range and fixed.

Acute Angle-Closure Glaucoma Presentation Sudden painful vision loss Conjunctival injection, corneal edema, corneal hazing Markedly elevated intraocular pressures >50 mm Hg Pathophysiology Angle between the cornea and iris is reduced due to shallow anterior chamber resulting in relative block of flow of aqueous humor

Treatment? Elevate head of bed >30 degrees to improve drainage 5 Medications Timolol (Beta blockade) Alphagan (decreases aqueous humor) Acetazolamide (decreases aqueous humor) Pilocarpine (increase aqueous humor drainage) Oral mannitol (dehydrates aqueous humor) Must be given 5 minutes apart Acute Angle-Closure Glaucoma

63 yo F with HTN, DM, and ischemic heart disease presents with sudden, painless vision loss in the left eye.

Retinal Artery Occlusion Fundoscopic exam : Retinal swelling “Cherry red spot” Treatment? Relief of vasospasm by increasing PCO2 Rebreathing techniques Breathing 95% O2, 5% CO2

75 yo M with gradual onset painless vision loss over the course of the day.

Central Retinal Vein Occlusion Deterioration more gradual Often secondary to diabetes or hyperviscosity syndrome Fundoscopic exam “Blood and thunder” Treatment? Aimed at treating underlying medical condition and relieving ouflow obstruction (eg. laser) 1/3 completely resolve, 1/3 stay the same, 1/3 worsen

29 yo F presents with darkening vision in her right eye. Symptoms were sudden in onset and preceded by flashers/floaters.

Retinal Detachment Presentation Often present initially with floaters and flashing lights Progress to dark area encroaching on the central vision US highly accurate for detecting retinal detachment Treatment? Ophtho consult for surgical repair Normal Ocular US Retinal Detachment

Conjunctivitis Symptoms typically include redness, discharge, and pain Could be viral vs bacterial Viral more likely to be bilateral with URI symptoms Bacterial more likely to be unilateral with discharge Treatment? Antibiotic eye drops to both eyes

Corneal Abrasion Most common corneal pathology in the ED Present with pain, redness, and tearing Pain relieved with proparicaine eye drops Treatment Antibiotic drops Ophtho f/u

Corneal Ulcer Present with severe eye pain, redness, tearing, foreign body sensation, sensitivity to light, blurred vision More common in contact users Most likely offending agent: Pseudomonas Treatment: Urgent ophtho referral Antibiotic eye drops Discontinue use of contacts

Herpes Keratitis (HSV) Present with localized pain and foreign body sensation Caused by herpes simplex virus Fluorescein staining reveals classic branching or dendritic pattern Treatment Eye drops Ophtho referral Do NOT give steroids unless told to do so by ophtho

How do you tell this difference between A &B A B

Periorbital Cellulitis Orbital Cellulitis Infection of soft tissue superficial to orbital septum Secondary to focal infection, trauma, sinusitis, or bacteria Treatment? PO antibiotics Often arise from adjacent sinuses or skin/eyelid infection Symptoms: Pain with EOM, eyelid swelling, redness, discharge, blurred vision, protrusion Treatment? IV antibiotics

Hordeolum or “Stye” Infection of the glans caused by Staph Aureus Treatment? Warm compresses

Chalazion Chronic granulomatous infection No acute inflammatory signs Treatment None Can refer to optho if bothersum

Now let’s slit lamp!!!