Lecture 6: Eye Emergencies/Slit Lamp
CC: “my left eye hurts and it’s blurry”
HPI: 25 yo male was riding in the back of a car (at 3:30am) “minding my own business” when someone threw a brick through the window and showered the car with glass
Soc hx (drinking since 4pm yesterday)
What is this? Important Physical exam findings? How to treat?
RUPTURED GLOBE (WITH FOREIGN BODY)
1. H&P- trauma, pain with decreased vision
2. PE and Labs/Radiographic Studies- hemorrhage all over, decreased ocular motility, hyphema, shallow/deep ant chamber, iridodialysis, cyclodialysis, hypotony (decreased eye pressure), subluxed lens (shifted), common retinae (edema and whitening), retinal breaks (shearing force), optic neuropathy, exposed uvea or vitreous (it is not dirt! Do not touch it!)
3. Management- do not manipulate, r/o foreign body with CT, will require surgery
What do you do if there is still an object impaled in the globe?
Leave it in place until in the OR
Which has a worse chemical burn- acids or alkaloids?
Worst than acid
Saponification of fatty acids
Cell membranes break down
Denatures & precipitates protein
Less severe damage
H&P, Physical exam findings, Treatment for chemical burns?
1. H&P- alkaloid (worse- saponification of fatty acids and it penetrates deeper) vs acid?, varies from clear cornea to opaque cornea, no limbal ischemia to 50% limbal ischemia, white is BAD
2. PE and Labs/Radiographic Studies- can grade the severity of the chemical burn, check pH w/ strips
3. Management- FLUSH with water or saline, check for particulate material all around eye with sweeping, doxy and vitamin C, control IOP, ophth will prescribe topical steroids
CC: decreased vision OS
HPI: 65yo WM with a 3 day history of increased floaters and flashing lights. He states he noticed a decrease in vision and curtain moving across his vision this morning.
POHx: cataract surgery 2 years ago, but previously was a -8.00 Myope
What is this? What are the key signs and symptoms? What does Physical exam show, and what are the risks?
1. H&P- flashes, floaters, curtain over vision, decreased vision
2. PE and Labs/Radiographic Studies- retinal break allows liquid into subretinal space; detached retina, tobacco dust (pigmented cells), decreased IOP, vitreous hemorrhage
3. Management- surgical intervention (pneumatic retinopexy, scleral buckle, pars plana vitrectomy), macula on- urgent; macula off- non-emergent
4. Risks- age, prior history of RD, high myopia, family history, lattice degeneration, trauma, cataract surgery
What is the difference between macula on and macula off with retinal detachment?
macula on- they can still have ok vision with immediate surgery and keeping the macula attached
macula off- the macula can not usually be saved, thus the need for surgery is non emergent
CC: decreased vision
HPI: 14yo AAM who while playing football with friends was distracted and the point of ball hit him in left eye. Pt c/o pain and severely decreased vision OS.
Vision OD 20/20, OS Hand motion
IOP: OD 12 OS 35
1. H&P- after trauma, pain, blurred vision
2. PE and Labs/Radiographic Studies- layered blood in anterior chamber. Need exam of both ant and post segment. NEED TO KNOW SICKLE CELL STATUS. IOP is very important
3. Management- bedrest w/ BRP, elevate head of bed, eye shield, cycloplegia (to immobilize iris and prevent rebleed), stop ASA/NSAIDs, topical steroids. Control IOP with beta blocker, alpha-agonist, and Diamox (only if not Sickle Cell). Can require ant chamber wash out. PREVENT THE REBLEED!
Two types of hyphema (depending on filling of blood)
Total hyphema = 8 ball
Microhyphema = suspended RBC’s
May layer out with time
Difference in treatment between non-sickle cell and sickle cell patients presenting with hyphmea
Topical beta blocker, alpha-agonist (lphagan) if older than 5 yo
If medical therapy fails, add oral Acetazolamide (Diamox; CA inhibitor)
NO DIAMOX (causes acidosis which promotes sickling)
What is this? What usually causes this?
40 y/o WF c/o fever, chills, headache, diplopia, pain, red eye, proptosis and hx of extensive surgical dental work 1 week prior.
1. H&P- red eye, pain, blurred vision, headache, Diplopia, edema erythema, chemosis, injection, proptosis, decreased ocular motility, pain upon movement. From any previous surgery, fx, etc that will open up eye to bacteria.
2. PE and labs- CT w/wo contrast
3. Treatment- broad spectrum abx, consult ENT if sinus involved, check for meningitis and cavernous sinus syndrome if not improving, r/o mucormycosis. Surgery needed if abscess found.
CC: “Eye pain and redness in the right eye”
HPI: 68 yo M had cataract surgery in Michigan 10 days ago, c/o 4 days of pain, redness and decreased vision
Meds: “some eye drops the surgeon gave me, but I couldn’t afford the refills”
Soc hx: smokes ½ ppd, drinks 3 or 4 cocktails daily
1. H&P- sudden onset of decreased vision, redness, eye pain, ant and post chamber inflammation, hypopyon, chemosis, decreased red reflex. Usually post op, trauma, endogenous origin (ports, IV, lines), phacoanaphylaxis (lens particulate left after sx), sympathetic ophthalmia (body attacks normal eye after trauma)
2. PE and labs- CT to r/o intraocular foreign body
3. Treatment- vitrectomy w/wo steroid, abx, cycloplegia (to help with photophobia), tetanus shot
CC: Double vision and droopy left eyelid for 2 days
HPI: 50 yo M with drooping of left eyelid over past 3 days. When he raises his eyelid, he experiences severe diplopia that goes away if he let’s the eyelid drop. Pt c/o mild pain OS
PMHX: HTN, DM, CAD
Third Nerve Palsy
1. H&P- binocular double vision
2. PE and Labs- fixed, dilated pupil; eye down and out; ptosis; external ophthalmoplegia (except for CN IV and VI); ocular and neuro exam; CT/CTA, MRI/MRA if pupil involving, MUST CHECK for aneurysm or tumor causing compression (or any other cause); if pupil sparing, check for ischemic microvascular dz, cavernous sinus syndrome, giant cell arteritis. Must check back w/in 3 months if no improvement.
3. Management- treat underlying abnormality, can use occlusion patch or prisms, strabismus sx can be considered
CC: Headache and decreased vision in the left eye
HPI: 84yo WF with several week history of left temporal headache. She has noticed decreasing vision over last couple of days
PMHX: pt with 15 lb weight loss in last 2 months
ROS: pt also reports h/o jaw claudication, shoulder pains, and low grade fever
Temporal Arteritis or Giant Cell Arteritis
1. H&P- sudden painless loss of vision, unilateral then rapid progression to bilateral, above 50 yrs, headache, jaw Claudication, scalp tenderness, arthralgias, anorexia, weight loss, fever,
2. PE and Labs- APD w/ vision loss, swollen and pale optic nerve, visual field defect, palpable tender non-pulside temporal artery, stat ESR and CRP
3. Management- requires temporal artery biopsy w/in 2 weeks of systemic steroid therapy (steroids is to prevent vision loss in other eye)
24 yo WM presents with pain and diplopia in R eye secondary to being punched in the face at a bar fight. His R eye has infraorbital nerve anesthesia and opthalmoplegia, where the gaze is limited in an up-down fashion. There is also positive enophthalmos.
What is this? How would you treat?
Orbital Floor Blow-Out Fracture
1. H&P- usually trauma to globe or orbit
2. PE and Labs- subconjunctival hemorrhage, bilateral ring hematomas around eye, basal skull fracture, periocular ecchymosis and edema, infraorbital nerve anesthesia, ophthalmoplegia (limited to up-down gaze), diplopia, enophthalmous (sunken in eye)
3. Management- release of entrapped tissue