COMMON EYE PRESENTATIONS TO THE ED

Caroline LimOphthalmology Registrar SCGH

5 June 2014

ANATOMY

CORNEAL AND ANTERIOR SEGMENT CASES

CASE 1

• 28 year old female presents to the ED with a 1 day history of a sore red left eye, monthly contact lens wearer

• Usually removes them at night but accidentally left them in

• No significant POHx other than contact lens wear

• No PMHx

SIGNS

Dx = infected corneal ulceration (note - opacity in white light)

MANAGEMENT

• Need to treat empirically for pseudomonas• Chloramphenicol does not cover pseudomonas• Send contact lens, case and solution for MCS • Does the ophthalmology registrar need to culture the

ulcer? Depends on the size- generally don’t scrape anything <1mmx0.5mm (will show you how to measure lesions later)• Otherwise: corneal scrapes (microbiology deliver the

specimen slides to ED)

MANAGEMENT CONTINUED

• Hourly antibiotic drops: Small ulcer (?<2mm):1. Hourly ocuflox (ofloxacin) for 36-48 hours day and

night OR2. Hourly ocuflox during the day and tobramycin

ointment at nightHomatropine TDS or cylopentolate TDS (anticholinergic) that reduce ciliary muscle spasm and therefore help pain• Large ulcer (?>2mm) : Admission, Hourly gentamicin

(GN) and cephazolin (GP), homatropine/cyclopentolate

CASE 2

55 year old female scratched eye with edge of a book

No POHxNo significant PMHx

Dx – uncomplicated large corneal abrasion

HOW DO YOU KNOW IF ITS INFECTED?

A = Look for signs of inflammation (opacity in white light)

MANAGEMENT

• Chloramphenicol drops or ointment• Will resolve within a few days

CASE 3

35 year old male, presents with a sore red left eye for 6 days, not responding to chlorsig drops from the GP

DENDRITIC ULCER

• Caused by herpes virus: either by self-inoculation or retrograde spread through the nerve root

• Management: Aciclovir ointment (zovirax) 5x/day (90% are resolved after 2 weeks of treatment)

• Follow-up in the eye clinic

CASE 4

• 33 year old female presents with a 3 days history of increasingly painful unilateral red eye, photophobic +++

• Non-contact lens wearer• No previous episodes• What could it be?

ACUTE ANTERIOR UVEITIS (AAU)

AAU

• Inflammation of the iris and ciliary body• Topical prednefrin forte eye drops (hourly to 2

hourly initially)• Dilate the pupil with homatropine or

cyclopentolate (reduces pain and prevents synechaie- adhesions)

• Refer

HOW TO LOOK FOR CELLS

• Like dust in an attic window when you shine a bright torch through the window

• Bright torch= brightest light on slit lamp• Dust is tiny= high magnification on slit lamp• Cells look like dust• Focus on the anterior chamber • Learn to see cells in the anterior chamber by

looking at hyphaema patients

CASE 5

• 65 year old gentleman, presents with sudden onset of very painful left eye, blurred vision, seeing haloes, nausea

• DDx?

Acute Closed Angle Glaucoma

MANAGEMENT

• Check IOP (will show you how to do it later)• Acetazolamide 250mg-500mg IV or oral if unable to

give IV (CI renal failure, renal stones)• Topical beta blocker (timolol 0.5%)• Topical carbonic anhydrase inhibitor (brinzolamide)• Topical a-agonist (brimonidine)• Topical steroid (to help reduce corneal swelling)• Admit• If the above fails: IV mannitol

TRAUMA

Case 6

22 year old male, punch to the left eye, vision blurry

Hyphema

MANAGEMENT

• Rule out an orbital fracture: feel for bony tenderness, check eye movements (if limitation in eye movements- may suggest a fracture as one of the extra-ocular muscles may be entrapped), check for diplopia (results if eyes aren’t aligned- indicates one of the muscles may be entrapped)

• Look for corneal abrasions, exclude globe rupture• Measure intraocular pressure

MANAGEMENT CONTINUED

3 principles of management:1. Control inflammation• Topical steroids (prednefrin forte) 6x/day (red blood cells

induce inflammation, therefore suppress inflammation until RBC resorb)

2. Prevent a re-bleed: • Dilate the pupil (risk of re-bleed when iris moves)-

Homatropine QID, atropine• Bed rest, 45 degrees• +- admission if large3. Monitor and manage raised IOP

Case 7

• 35 year old male, fall from tree• Left eye red swollen and proptosed, acutely

painful, reduced visual acuity

Retrobulbar Haemorrhage

TRAUMATIC RETROBULBAR HAEMORRHAGE

• Signs: Proptosis with resistance to retropulsion, vision loss, RAPD, tight eyelids, limited EOM

• If optic neuropathy :immediately releaseorbital pressure with lateral canthotomyand cantholysis

CASE 8

• 60 year old female, tripped in the garden and hit eye on a rock

PEI/Globe rupture: MANAGEMENT

• CT: exclude fracture/intraocular foreign body• Tetanus prophylaxis• Keep eye padded• Keep fasted, surgery within 24 hours• IV antibiotics: ciprofloxacin has best

penetration into eye and covers GN• Globe repair: prevents risk of orbital cellulitis

and intracranial abscess

Seidel’s Test

Case 9

• 45 year old female, splash of chemical peel into right eye

• Self-irrigated, now in ++ pain

MANAGEMENT

• Alkalis penetrate more deeply than acids• Topical anaesthetic (amethocaine, oxybupricaine)• Irrigate with Morgan lens• Wait 5-10 minutes after irrigation is stopped to allow the

dilutant to be absorbed• Measure pH: continue irrigation until pH is neutral (7)• Evert lids and sweep the fornices with wet cotton bud• Topical antibiotics (chlorsig), lubricants (remember

Vaseline on cracked lips)• We often add a topical steroid

CELLULITIS

Case 10

45 year old male, recent sinusitis, presents with swollen erythematous skin around right eye

CAUSES OF ORBITAL CELLULITIS

• Direct extension from an infection of: Paranasal sinus (especially ethmoiditis) Focal orbital infection (dacryoadenitis,dacryocystitis, panopthalmitis) Dental infection- Complication of orbital trauma - Complication of orbital surgery or paranasal

sinus surgery

MANAGEMENT

• May be difficult to tell clinically therefore requires CT scan of orbits and sinuses- looking for orbital inflammation and sinus disease

• FBC, CRP• Blood cultures• IV antibiotics: Flucloxacillin and Ceftriaxone• Admission• ENT referral if sinus disease

POSTERIOR SEGMENT CASES

CASE 11

• 60 year old female presents with 2 day history of flashes. Flashes seem to be worse at night time

• Also reports seeing flies and cobweb in vision. Noticed some blurring of vision initially but it has cleared

WHAT ELSE WOULD YOU LIKE TO KNOW ON HISTORY

• Curtain/veil over vision?• Myopic/cataract surgery/trauma?

DIFFERENTIAL DIAGNOSIS

• Posterior vitreous detachment• Retinal tear• Retinal detachment• Vitreous haemorrhage

POSTERIOR VITREOUS DETACHMENT

POSTERIOR VITREOUS DETACHMENT

• Vitreous separates from the retina• Can be a normal part of ageing• Complications: retinal tear and retinal detachment• Mx of uncomplicated PVD:- Eye review in coming days toexclude tear/detachment- Retinal tear/detachment

advice

RETINAL TEAR

RETINAL TEAR

Management: laser the edges of the retina (in clinic) to seal off the tear and prevent detachment

RETINAL DETACHMENT

• Flashes/floaters/curtain/veil over vision• Management: surgery (timing depends on if

the macula is on or off)

CASE 12: SUDDEN LOSS OF VISION

Retinal artery occlusion (1st 3 images) Normal eye

CASE 13: SUDDEN LOSS OF INFERIOR VISUAL FIELD

Branch retinal artery occlusion

CASE 14: SUDDEN PAINLESS LOSS OF VISION

COMMON TROUBLE SHOOTS

• I put fluoroscein in and the whole cornea is green? too concentrated / much dye (consider diluting)

• I checked the pressure and its 42 in both eyes but the eye looks fine? Incorrect measurement (not central cornea / too much pressure)

• Why do we need to check vision with the pinhole occluder? reduce refractive errors (ie. watery eyes)

• Why did you choose that steroid (Flarex/FML/Maxidex/Prednefrin forte)? increasing ocular penetration Flarex (superficial) – FML – Maxidex - Prednefrin forte (deepest) - choice dependent on pathology being treating

WHAT THE HECK DID THE EYE REG WRITE?

HOW TO USE A SLIT LAMP QUESTION AND ANSWER