EMCrit.org

Ophthalmology

Slit Lamp Primer from ACEP

Eye Exam

Check pre-auricular lymph nodes, screen for stds, check upper teeth for cavities

OD-right, OS-left OU-Both

Document visual acuity.  If can not see big E (20/400) move them closer.  Then use counting fingers, then waving fingers and then light perception only LPO

make people curl their index finger into pinhole to correct absence of glasses

EOM

Pupillary Response to Light

Normal is 2.6 to 5 mm in fluorescent lighting.  Normal with bright light/pen light is 1.9-3.6 mm (Annals 41:2, 2003)

Swinging Flashlight test

for Afferent Pupillary Defect-swing light from good to bad eye, normally it should constrict, if it dilates, then there is an afferent defect

Fundoscopy

Slit Lamp

Measure IOP-normally <21

V-OD above OS c or s correction.  Use guiac card with multiple holes punched in it for correction.  Need 50% of a line correct to get credit for it                                            

LLL

lids, lashes, lacrimals

hordoleum, matting, lacs

C/S

conjunctiva, sclera

Bulbar vs. palpebral conjunctiva

Bulbar conjunctiva on globe of eye, covering sclera

Palpebral conjunctiva on inner part of eyelid; in conjunctivitis

Palpebral conjunctiva red out of proportion to bulbar conjunctiva; with corneal ulcers, iritis, scleritis,

Bulbar conjunctiva red out of proportion to palpebral conjunctiva

Quality of discharge: pus-like in bacterial infection, watery in viral infection; stringy, sticky discharge usually indicates allergy

Papillary vs follicular reaction: papillary reaction—dilated leaky blood vessel with localized chemosis; not helpful because present in all infectious and inflammatory conditions; follicles—little accumulations of lymphoid material in conjunctiva;

Follicles indicate viral or chlamydial infection, also seen in toxic reactions; swollen, tender preauricular node usually present when follicles present; flip upper eyelid to find best area to look for papillary and follicular reactions and foreign bodies

chemosis (edema of conjunctiva), injection, cobblestone, icterus

K

cornea

cloudy, uptake, streaming, FB, abrasion

Look for Seidel’s sign, streaming or clearing of fluroscein stain from punctured cornea

AC

ant. Chamber

cells, flare, blood, hypopyon, hyphema

Check for shallow angle-shine flashlight laterally, +  if shadow over nasal portion of iris

I/P/L

iris/pupil/lens

iritis, size, shape, displaced

Symptoms

curtain dropping=amaurosis fugax

Flashing lights-retinal detachment

Halos-glaucoma

Shine a light into the red eye, if it hurts, this is a bad sign (Fam Pract 20(4):425, 2003)

Documentation

OD=right, OS=left, OU=both

V         OD cc or sc

            OS                                                                                               

Pressures T (right over left, record time.  normal 8-20)

EOM

Pupils c mm

(SLE)

LLL                                                     (DFE) Fundi

C/S

K

AC                                                      

I

Eye Drops

Caps

Green=Miotics

Red=Mydriatics

Blue/Yellow Low/High Concentration B-Blockers

White=Anesthetic

Common Meds

Dilation best accomplished c phenylephrine 2.5% for onset of 15 min and 2-4 hr effect

Keterolac ophthalmic 1-2 drops q2-4h prn pain following corneal abrasions (Annals 2003;41:134-140)

Proparacaine 0.5% is probably the best ED anesthetic as it has rapid onset and lasts 15 minutes.  Tetracaine 0.5% is slower but lasts longer.

Erythromycin is broad spectrum, but there is resistance

Bacitracin is probably the way to go

Quinolones should be reserved for serious infections

Sulfacetamide is also a good choice

Genta/Tobra for resistant infections

Neomycin containing formulations often cause allergic reactions

Glaucotest $350 tonometer from Heine USA

Traumatic Eye Injuries

Facial Fxs

Get CT c thin orbital cuts

Eyelid Lacs

Get Plastics or Optho Consult for lid margin, canalicular system, levator or canthal tendons, orbital septum, significant tissue loss, or repair physician does not feel comfortable performing.

If you see fat, it is from orbital penetration as the eyelid has no fat.

Subconjunctival Hemorrhage

Can be from valsalva maneuvers

Differentiate between hemorrhagic chemosis (bulging; indicates open globe) and simple Subconjunctival hemorrhage (flat; reassure patient)

Confined to Subconjunctival space, hold NSAIDS for two days, goes through same stages of color change as a black eye

Corneal Abrasion

Rx c abx, pain control, tetanus, and possibly cycloplegics

If from contacts, artificial fingernails or vegetable matter, prescribe drops c pseudomonas coverage.  No patching.

Ofloxacin Ophthalmic 1-2 drops QID x 1 week

Document lid eversion, especially if abrasions are vertical lines (ice-rink sign)

Patching does not help (Annals 38:2)

Sodium azide which is converted to sodium hydroxide from airbags, need copious irrigation

Probably do not need Tetanus shots unless penetrating injury (

Mukherjee P et al: Tetanus prophylaxis in superficial corneal abrasions. Emerg Med

J 20:62, 2003;)

Foreign Bodies

Document negative Seidel’s

UV

Punctuate corneal lesions

Ocular Burns

If acid, coagulative so very little deep damage except for Hydrofluoric Acid which requires irrigation c CaGluc 1% and can cause systemic effects.

Alkali can cause deep burns

C either keep irrigating till neutral pH

Glue in Eye

Use any petroleum based ointment like bacitracin to speed eye opening

Pepper Spray

Vinegar

Coca Cola

50 % Sucrose/50%Fructose dissolved in Milk

Baby Shampoo

Corneal Laceration

Keep Head of bed at 30-45º in case of hyphema

Give antiemetics

Hyphema

All need consult b/c of possible visual loss

• Grade 0:  Small Flecks

• Grade I:  <33

• Grade II:  <50

• Grade III: >50

• Grade IV:  Total

Can cause narrow angle glaucoma

Other risk is rebleeding and permanent staining.

Elevate the head of the bed to 45, No NSAIDS, antiemetics and pain meds

Give atropine drops before narcotics to prevent miosis

no Acetazolamide in sicklers

Lens Dislocation/Subluxation

Get consult

Retrobulbar Hemorrhage

Take steps to reduce IOP as in closed-angle glaucoma

May need lateral canthotomy

Orbital Compartment Syndrome Treatment

visual changes, proptosis (often subtle; look directly at supine patient from head of bed), opthalmoplegia

Risks are recent surgery, fractures, trauma, and anticoagulated patient

Equipment

Local anesthetic (e.g., 1% or 2% lidocaine with epinephrine); mosquito hemostat; iris scissors; tissue forceps; gauze pads

Lateral canthotomy and cantholysis

1. Ensure adequate patient sedation and analgesia.
2. Position patient supine and begin irrigating the lateral canthal fold region with sterile irrigating solution.
3. Utilizing sterilizing technique, inject 1 cc of local anesthetic subcutaneously along the lateral canthal fold region. Anesthetize the tissue extending laterally from the canthal fold up to the orbital rim. Exercise caution to avoid inadvertent needle puncture to the globe.
4. Insert mosquito hemostats at the lateral palpebral fissure, with one blade anterior to and one blade posterior to the lid. Advance the tips of the hemostat laterally, until the orbital rim is encountered; clamp and compress the intervening tissue for at least 30 seconds (to minimize any ensuing bleeding).
5. Remove the hemostat and utilize the iris scissors to cut all tissue layers (from the skin down to the bulbar conjunctiva) along the lateral canthal fold, down to the lateral bone orbital rim (lateral canthotomy).
6. Retract the lower lid margin outward with a pair of hemostats or tissue forceps. This will facilitate identification of the LCT, which is located just posterior and inferior to the lateral canthal fold.
7. Dissection of the conjunctiva and fascial tissues with hemostats or iris scissors will be necessary to identify the LCT. A pocket of adipose tissue (Eisler’s pocket) will be encountered beneath the superficial fascial planes. The LCT lies just posterior to this adipose tissue collection. Once identified, the LCT must be completely severed (lateral cantholysis).

Globe Rupture

Shield both eyes

Antiemetics, pain control, sedation, dT

Vanco and Gentamycin

CT scan should include both axial and coronal sections at 3mm intervals

Traumatic Mydriasis

Efferent pupillary defect (EPD) b/c trauma to iris; usually benign.

Must be differentiated from an afferent pupillary defect (APD) which is an emergency secondary to optic nerve injury, retinal detachment, or vitreous bleeding.

Non-traumatic:   External/Swollen Eye Problems

Pinguecula

White or yellow growth on nasal side of conjunctiva

Pterygium

Triangular extension of conjunctiva over nasal side of cornea

Blepharitis

Usually infectious (S. aureus) of eyelid margins. 

Supportive care

Dacrocystitis

Infection of tear duct at medial canthus

Oral ABX, Pain Control, Refer to optho

Hordeolum

Hordeolum hurt (Acute)

S. Aureus is the usual culprit if infectious

Stye-external hordeolum, infection of Zeis glands

Meibomianitis-internal hordeolum, possibly from infection of meibomian glands or think rosacea (use systemic doxy)

Warm compresses and topical abx (ointments are probably better)

Usually erythromycin resistant, but bacitracin sensitive (Audiodigest)

Nasolacrimal infections respond to first gen. cephalosporins.

Chalazia

Greek for hailstone

Chronic stye (Remember the C is for chronic)

Non-tender

Warm compresses and refer for removal.  If for some reason suspect active infection, must use systemic abx, not topical.

Lagophthalmus

eyelids do not close completely; frequent problem after plastic surgery of eyelids; plastic surgeons often do not pay attention to underlying conditions that may complicate outcome; ask patient’s partner if patient sleeps with eyes open; difficult to elicit history of cosmetic surgery of eyelids

Contact dermatitis

15% to 20% of patients develop hypersensitivity reaction to neomycin (common agent; speaker tends to stay away from this medication); patients can develop reaction to almost any ophthalmic medication, including benzalkonium chloride (most common preservative in ocular medications); can also be caused by tape used after ocular surgery; treat with systemic antihistamines, cold compresses, and, if sure of diagnosis, local topical steroids

Periorbital (Preseptal)/Orbital Cellulitis

Preorbital if pt non-toxic, normal visual acuity, no proptosis, and painless & intact EOM

Treat c augmentin

Otherwise admit for IV ABX (Unasyn) and get CT Minus c Orbital Cuts axial and coronal

Consider mucormycosis in diabetics.  Consider aspergilliosis in HIV

kids get orbital cellulitis from spread of ethmoid sinusitis.  Even in adults, orbital cellulitis and abscesses are from sinus extension 70% of the time.

Non-traumatic:  The Red Eye

Conjunctivitis

Bacterial

will have purulent discharge

Antibiotics shorten duration, but are not really necessary.  It will allow a return to work/school in 48-72 hours.  If not better, pt should go to a specialist.

Staph, Strep, and Hemaphilius so aminoglycosides are not a good choice.  Fluoroquinolones are not necessary.  Use Polymixin/Trimephapin.  Use drops rather than ointments. 

Ask about STD sx

Viral

watery discharge, preauricular node, and follicular reaction

no treatment needed, infectious precautions,  adenovirus is just like the cold viruses, stays around forever

cold artificial tears.  Pt's are infectious for 7-10 days.  Use cold artificial tears and cold compresses.  Hand washing and reducing spread is most important.

Allergic

Itching/rubbing.  Atopic/allergy history.  Stringing, ropey discharge (like mozarella)

Topical antihistamines and systemic mast cell stabilizer

GC Conjunctivitis

Copious purulent discharge c preauricular nodes and injected sclera, eye pn

Systemic GC and Chlamydia Rx in addition to topical erythromycin

Keratitis

Bacterial Keratitis

Corneal ulceration

Edema

Anterior segment inflammation, cells flare

Photophobia

Broad Spectrum ABX drops-e.g. Quinolones

Get Consult

HSV Keratitis

Will see dendrites c staining

treat c acyclovir, fam, or val.

Fungal Keratitis

In diabetics or immunocompromised

Mucormycosis

Need ampho, debridement, possibly hyperbaric O2

Contact lens-related problems

“contact lens users are contact lens abusers”; overwear and abuse most common problem; overnight wear increases chances of corneal ulcer by 15- to 20-fold; lens abuse can lead to abrasions, infections, allergic and toxic reactions; sensitive-eye formulas proliferate because people develop allergies and toxic reactions to contact lens solutions; “get them out of the lens, get them out of the solutions, and that in and of itself will take care of most of these problems”; every contact lens wearer needs pair of glasses as backup

Corneal Ulcer

bulbar conjunctiva red out of proportion to palpebral conjunctiva; history of trauma or contact lens wear; signs and symptoms include pain, redness, light sensitivity, white spot on cornea; need immediate culture and treatment; “if you know it’s going to take them several hours or more to see somebody who’s going to do a culture on a plate (not in media) or start treatment, go ahead and start treatment yourself”; start fluoroquinolone drops immediately (two drops every 15 min for first 8 hr [throughout night], two drops every 30 min for next 16 hr); ophthalmologists often inject special fortified antibiotics; perforated cornea possible if left untreated (“this is why you want to start them right away”)

Subconjunctival Hemorrhage

distinct, dramatic appearance; patients panic; symptoms include blood-red eye, no pain, no decreased vision; patients demand to be seen, need reassurance; no treatment; resolves on own in 1 to 2 weeks

Iritis/Uveitis

Miosis of affected pupil, can be irregularly shaped with limbic blush

Consensual Photophobia-pain in affected eye when light shined in opposite

Pain c Accommodation-look far then at your finger

Will have cells (sparkles) and flare (smoke) on slit lamp exam

Cycloplegics give relief

Visual loss until resolution is frequent

Episcleritis

usually presents acutely; self-limited disease lasting 7 to 10 days (sometimes longer); not usually associated with pain or systemic disease

Scleritis

Sign of systemic disease

bulbar conjunctiva red out of proportion to palpebral conjunctiva; usually develops over days to weeks; insidious; deep boring pain and tender eye; diagnosis made by history and palpation; look for deep violaceous hue (putting phenylephrine in eye will shrink superficial vessels but not deep vessels); usually associated with systemic diseases; patient needs workup by ophthalmologist; can be associated with rheumatoid arthritis, Wegner’s granulomatosis, polyarteritis nodosa, syphilis

Sclera may look blue or purple b/c you can see through to vessels

Endophthalmitis

Infection of deep eye structures, usually post-operative. 

Hypopyon

Non-visible fundus

Horrible risk for poor outcome

Acute Angle Closure Glaucoma

Assoc. c family history of same

Sudden decreased vision c haloes and lights in field

Red eye

Pain

N/V, emesis, possibly presents only c red eye and abd pain

IOP usually 50-70, can usually be palpated

Painful, rock hard eye=diagnosis

·        A beta-blocker such as timolol 0.5% (Timoptic), 1-2 drops every 10-15 minutes times three, then one drop BID.

·        A parasympathomimetic such as pilocarpine 0.2%, one drop every 30 minutes until the pupil constricts, and then q6h.

·        Prednisolone 1% (Pred-Forte), one drop every 30-60 minutes to reduce inflammation.

·        Apraclonidine 0.5%, two drops, once; an alpha-2-agonist that reduces aqueous humor production and acts additively with the beta-blocker.

·        Acetazolamide (Diamox) 500 mg IV q12h or PO q6h. Because of the possibility of metabolic and respiratory acidosis, this medication should probably be avoided in patients with serious respiratory disease.  Also avoid in sicklers as it can induce crisis.

·        Mannitol 20% 1-2 g/kg IV over 30-60 minutes. Mannitol is a hyperosmotic agent that should be used with caution (if at all) in patients with congestive heart or renal failure. It may cause mental status changes, worsening headache, and dehydration.

·        Pilocarpine 2% for light eyes 4% for dark, 1 drop Q15 min x 8 doses

Non-traumatic:  Acute Visual Loss

Vitreous Hemorrhage

New floaters or shadows in visual fields

Consider Terson’s syndrome-SAH c vitreous hemorrhage

Retinal Detachment

Will see floaters and dark shadow over vision.  Yellow spots on retina

Consult for tacking

Central Retinal Artery Occlusion (CRAO)

Sudden loss of vision c afferent defect

Cholesterol emboli

Cherry Red fovea c pale optic nerve

Firm ocular massage 15 sec, repeat multiple times

Lower intraocular pressure c same rx as glaucoma

Carbogen (5% CO2, 95%O2)

Central Retinal Venous Occlusion

Blood and Thunder on fundoscopy

Cavernous Sinus Thrombosis

30% treated mortality

Usually from sinusitis or mid face furuncle that was squeezed, also

HA, N/V, vision loss, possible 6^th nerve palsy.  Periorbital cellulitis, meningeal signs

Contrast CT for DX

Heparin

Abx

CT

Possible Surgical intervention

Amaurosis Fugax

Usually bilat, if single eye usually presents with hemianopia (loss of half of visual field)

Non-traumatic:  Neuroopthalmology

Internucleur Opthalmoplegia

Binocular diplopia

Ipsilateral eye slow to adduct, contra has nystagmus c abduction

Associated c MS

Optic Neuritis

Gradual monocular visual loss

Pain c eye movement

20-40 year olds

assoc c MS

Temporal (Giant Cell) Arteritis

Unilateral vision loss

Afferent papillary defect

HA, Jaw claudication, tender temporal area

Get ESR, treat high dose steroids

Need biopsy

Anisocoria

Normal variant in 20% of the population

To differentiate Adie’s tonic pupil from 3^rd nerve palsy, instill pilocarpine 0.1%, If large pupil constricts and normal doesn’t then it is Adie’s. If both fail to constrict, then 3^rd nerve palsy or med usage.  Then instill pilocarpine 1%, if both constrict then 3^rd nerve palsy, if affected one doesn’t then med usage

Malingering

Place mirror in front of eye, should get no reaction in true blindness.  Also there should be afferent defect.

Refer to ophthalmologist: eye getting progressively redder and more inflamed after ocular surgery (indicates infection); “rock-hard” globe (indicates acute angle-closure glaucoma); white spot on cornea (indicates corneal ulcer)

Contact lens wearers: redness caused from contact lens or contact lens solution until proven otherwise; stop contact lens use in both eyes

Bulbar conjunctival redness greater than palpebral conjunctival redness: indicates serious problem, eg, iritis, corneal ulcer, scleritis; if globe tender, refer; if globe not tender may be episcleritis or subconjunctival hemorrhage

Palpebral conjunctival redness greater than bulbar conjunctival redness: dealing with conjunctivitis; can be managed in emergency department (ED); do not need to check for follicles; if preauricular node tender, patient has viral conjunctivitis or Chlamydia (Chlamydia if exudate pus-like, viral if watery); if preauricular node not tender, patient has either allergic conjunctivitis or bacterial conjunctivitis

Conjunctivitis: patients with bacterial conjunctivitis have crusted lids that stick together; patients with allergic form usually have history of allergy and complain of itchy eyes (allergy patients tend to downplay how much they rub their eyes, so ask patient’s partner)

Abbreviations commonly used by our Ophthalmology Friends (or how to read other

-subconjunctival hemorrhage: painless, no change in vision. Caution: a

-corneal abrasion: severe pain, tearing, blepharospasm

-contact lens-related abrasion: maintain suspicion of ulcer, always refer.

-globe Penetration: irregular pupil, flaccid globe, flat anterior

-super-Glue: copious irrigation

-traumatic iritis: pain, headache, tearing. Look for cells and flare.

-traumatic miosis or midriasis: Treatment not required.

-blowout fracture: orbital rim fracture and entrapment of muscle leads to

-hyphema: microscopic to "eight-ball". Watch IOP.

-intraocular foreign body: " metal on metal"

-corneal / Scleral lacerations: ophtho referral

-chemical burns: irrigate, irrigate, irrigate.

-UV keratitis: sunburn, welding. Pain, photophobia, diffuse punctate uptake.

-conjunctivitis: viral, bacterial, allergic, other. Itching, red, discharge.

-keratitis: pain, decreased vision. Bacterial, ulcers, viral, autoimmune, idiopathic.

-acute angle closure glaucoma: red eye, steamy cornea, mid- position pupil, pain,

-amaurosis fugax: graying of visual field, associated with TIA.

-central retinal artery occlusion: painless, total loss of vision, pale fundus

-central retinal vein occlusion: painless loss of vision of varying severity;

-retinal detachment: floaters, flashing lights, painless visual loss.

-migraine headaches: scotomas and scintillation followed by headache (usually).

Slit Lamp Exam

Retinal Detachment

Vascular: hypertensive crisis, pre-eclampsia, renal failure
Inflammatory: Vogt-Koyanagi-Harada syndrome, posterior scleritis, Acute Multifocal Placoid Pigment Epitheliopathy, pseudotumor cerebri
Infectious: tuberculosis, toxoplasmosis, syphilis, CMV
Trauma: post-surgical detachment
Autoimmune: sarcoidosis, polyarteritis nodosa, Goodpasture’s syndrome, SLE

Metabolic: protein-wasting enteropathy
Idopathic: central serous chorioretinopathy, pigment epithelial detachments
Neoplastic: choroidal tumors, retinal metastases
Congenital: nanophthalmos, uveal effusion syndome, Coat’s disease, optic pit, morning glory syndrome
 

Amaurosis fugax

is brief (often lasting less than 5 minutes), monocular and consists of "negative" symptoms such as greying of colours, blurring, fogging or complete loss of vision.