Ocular Emergencies: From A to Z

1. Ocular Emergencies: From A to Z Sam Cady June 20th, 2014 Maine Eye Center

3. The world of specialists • With increasing medical complexity, most physicians width of knowledge has decreased as their depth of knowledge has increased.

4. If only….

5. The obvious…

6. So much information…

7. The 5 minute rule • Outside of your area of expertise, the vast majority of problems can be solved with a small knowledge base.

8. Have a plan • Be able to check a vision • Don’t be afraid to look at the eye • Know the basics about common and visually threatening eye diseases

9. Approach to Eye problems • Don’t be afraid and know the basics. • What’s the worst thing it could be? What’s the most common thing it could be? • What needs to be referred today and what can wait? • Where is the nearest ophthalmologist?

10. Approach • Don’t feel bad if you don’t know what it is. • Remember the 7 words that all ophthalmologists fear…. • “Is there a doctor on the plane?”

11. Anatomy

12. Normal Fundus

13. Case 1 • You are working a clinic in Caribou and an immigrant blueberry picker comes. • “Cannot see” • What do you want to do? • The most important two items of the eye exam are…… • What is the vision and what does the eye look like.

14. Basic Exam • Vision • Myopia • Presbyopia • Hyperopia • Astigmatism

15. Case 2 • You are moonlighting in the Miles ER on a Saturday. 60 year old female complaining of “spots” in her vision, OD only. • What do you want to do? • Vision 20/20 OU, she is myopic. No pain. Positive photopsia.

16. What if she had inferior visual field loss? How do you check for that?

18. Case 3 • 30 year old “my lid is red” • Vision normal. • Exam….

20. Case 4 • 20 year old soccer player hit in the eye with ball during game yesterday. Not seeing well. What do you want to know?

21. Case 5 • 50 year old male in good health mentions that his “eyes are sticky”. No pain, no change in vision. • Is the anisocoria worse in dim or bright light?

22. Pupil physiology • Is this an afferent pupillary defect (APD)? • Is the abnormal pupil small or large?

23. Sympathetics have a long course through upper thorax, neck and orbit. Parasympathetics follow the 3rd nerve. Autonomic nervous system

24. Is there anisocoria? • Is it worse in dim or bright light?

25. Case 6 • 55 year old complaining of eye redness for 3 days.

26. What if his eye looked like….

27. Our pt had an IOP of 60. • Treatment was successful and post laser IOP was in the mid teens with follow up over a year.

28. Angle Closure Glaucoma • More common in women>men, older>younger • Classically eye pain, redness, decreased vision. • Can be cause of localized HA. • Treatment is laser iridotomy.

30. Case 7 • 45 year old, complaining of HA, fatigue, blurred vision….. • Thirsty, frequent urination • Glucose 350

32. Sudden vision loss Ocular trauma Acute painful and/or red eye 3 categories

33. Sudden vision loss - history • Age of patient • Vascular risk factors • Unilateral vs. bilateral • Associated pain or redness • Timing • Transient vision loss • Duration • Pattern (shade or curtain, fade out, migrainous, etc) • Associated symptoms • HA, pulsatile tinnitus, stroke symptoms, jaw claudication, etc. • Worse with change in position?

34. Sudden vision loss - ddx • Central retinal artery occlusion • Central retinal vein occlusion • Ischemic optic neuropathy • Optic neuritis • Acute angle closure glaucoma • Retinal detachment • Vitreous hemorrhage • Transient vision loss • Amaurosis fugax (ophthalmic artery) • Migraine • Papilledema or optic disc drusen • Vertebrobasilar insufficiency

35. Central Retinal Artery Occlusion • Sudden painless unilateral vision loss • Count fingers vision or worse in 90% of patients • No proven treatment • Ocular massage, carbogen (95% O2, 5% CO2), lower intraocular pressure, anterior chamber paracentesis • Carotid studies and possible echocardiogram to look for emboli source • Carotid endarterectomy • Rule out temporal arteritis in elderly • Generally poor visual prognosis

36. Normal fundus

37. Central retinal artery occlusion

38. Central retinal vein occlusion • Sudden, painless vision loss • Initial visual acuity variable but important prognostic factor • Associated macular edema is now treated with anti-VEGF therapy with good results • Control vascular risk factors • Needs close follow up as it can lead to other complications: neovascular glaucoma, vitreous hemorrhage and macular edema

39. Ischemic optic neuropathy • Anterior vs. posterior • Arteritic vs. non-arteritic • Rule out temporal arteritis • History: age, HA, neck pain, temporal scalp tenderness, jaw claudication, fever, weight loss, polymyalgia rheumatica symptoms, premonitory transient visual loss • Exam: absent temporal pulse, temporal artery bruit, eye findings (sixth nerve palsy, ION, CRAO) • Work-up: ESR, CRP, platelets, temporal artery biopsy • Treatment: systemic corticosteroids

40. Optic neuritis • Mean age = 32 • F>M • History: painful vision loss usually over the course of 1-2 days or a week, pain with eye movement, maybe other multiple sclerosis symptoms (diplopia, numbness, weakness, bladder, Uhthoff’s phenomenon) • Exam: 65% normal optic disc; 35% disc edema, afferent pupillary defect, visual field defect • Work-up: MRI for MS, neuro consult • Treatment: +/- IV steroids depending on MRI result

41. Optic disc edema Optic disc drusen

42. Retinal detachment • 3 types • Rhegmatogenous • Traction • Exudative • Risk factors • High myopia • Previous eye surgery • Symptoms • Acute onset flashes, floaters, dark shadow • Urgent repair if “macula on”

43. Common etiologies Proliferative diabetic retinopathy Retinal tear Posterior vitreous detachment Retinal vein occlusion Trauma Uncommon etiologies Sickle cell retinopathy Retinal macroaneurysm Macular degeneration Large tumor Subarachnoid hemorrhage (Terson’s syndrome) Etc. Vitreous hemorrhage

44. Red Eye! • Dry eye and blepharitis • Contact lens overwear or other irritant • Subconjunctival hemorrhage • Conjunctivitis (allergic, infectious) • Iritis • Episcleritis and scleritis • Keratitis (corneal ulcer) • Acute angle closure glaucoma • Endophthalmitis

45. Orbital cellulitis? • Orbital signs • Proptosis • Chemosis • Decreased motility • Decreased vision (APD) • Need imaging Breast CA metastatic to eyelids and orbit

46. DDX for an acute red swollen eye with ORBITAL SIGNS • Orbital cellulitis • maybe fever and white count • comes from sinus disease • rarelydacryocysitis or post-surgical or dental infection or extension from preseptalcellulitis • need IV antibiotics • Trauma (include carotid-cavernous fistula here) • Idiopathic orbital inflammatory syndrome (IOIS) aka orbital pseudotumor • do not confuse with pseudotumorcerebri • Infiltrative diseases like sarcoid or Wegener's or thyroid orbitopathy

47. DDX for an acute red swollen eye with ORBITAL SIGNS, cont. • Tumors • Metastatic • breast cancer is by far the most common • may occur years after primary breast CA diagnosis • paradoxical enophthalmos due to fibrosis • neuroblastoma in children • Ruptured dermoid cyst (e.g. in children; contents inflammatory) • Lymphangioma and rhabdomyosarcoma often masquerade as an acute inflammatory orbital condition • Lymphoma • Mucocele, eosinophilicgranuloma, etc.

48. Overview of Ocular Trauma

49. Outline • Background and terminology • Chemical injuries • Eyelid lacerations • Anterior segment trauma • Open globe • Orbital trauma • Posterior segment trauma • Neuro-ophthalmic topics

50. Initial evaluation • Life-threatening injuries treated first • Assess mechanism of eye injury • History (including POH) • Full exam • Imaging (e.g. ultrasound, CT) • Assess severity of injury and prognosis • Treatment plan • Counsel patient and family