Examination of the Eye in the Emergency Room

1. Examination of the Eye in the Emergency Room Christopher Calandrella D.O. PGY2

2. Case • C/C My right eye hurts. Time 9:35 pm • HPI: 23 y/o F. complains of right eye pain since 4 pm that day after removing colored contact lens used only for cosmetic reasons. Pain is described as buring sensation. Vision is blurry and also complains of headache. Pt. attempted to remove contact lens and felt immediate pain. Contact was in from that am and no other trauma occurred to eye. Eye turned red. 1st occurence. No hx. fever, vomiting, diarrhea, or other compaints. Last used lens cleaner day prior. “Light bothers my eyes.” • Headache is not worst ever. Located anteriorly, non-radiating.

3. Pmhx: denies Surg: c sxn Meds: none All: none Soc: denies tob./ill/EtOH Fam hx. denies No fever, change of vision prior. No corrective lenses. No cough, no SOB, no abdominal pain, no pedal edema ROS and History

4. Basic of Examination • Directed Detailed history • Physical Examination Visual Acuity External Eye Confrontation of Visual Fields Pupils Ocular Motility Anterior Segment Fundus Intraocular Pressure

5. Sudden painless monocular vision loss with hx a fib or c.s. Eye pain with hx of working with metal Flashing lights or curtain veil Central Retinal Artery Occlusion Projectile corneal or Intraocular foreign body Retinal detachment Detailed History

6. Anatomy

7. Visual Acuity • Snellen Eye Chart • If pt. wears glasses and are not available use pinhole testing. • If patient cannot read, then document number of fingers held up. • Hand motion at 2 ft. • If fails hand motion, document light perception.

8. External Eye • Examine periorbital skin and lids for trauma, infection, dysfunction, deformity, crepitus, proptosis, subcutaneous emphysema, and step off deformities

9. Confrontation of Visual Fields • Screening starts in temporal fields. • Ask patient to look in examiner’s eyes. • Place hands two feet apart, lateral to patients ears. Move slowly and record when patient visualizes them. Newer Methods

10. Occular Motility • Ask pt. to keep head midline. May require holding pt. head at times with hand on forehead. • Moves a finger or use pencil to trace an H in air midline approximately 2 feet distance from patients head. Pause during upward and lateral gaze to detect nystagmus.

11. Using the Slit lamp • A little history: • Since the 1800s, clinicians have searched for a better way both to magnify and to illuminate the anterior segment of the eye. • In 1891, Aubert developed the first true binocular stereoscopic microscope. • In 1911, Gullstrand introduced a slit illuminator device. • The microscope and the illuminator were combined by Henker in 1916 • Goldmann improved the mechanical supports for the microscope and the illuminator and in 1937 Putti exam eye of cyclops 1613 optics geometry

13. Other slit lamps

14. Anterior Segment and CorneaUsing the Slit lamp • Slitlamp permits detailed evaluation of external eye injury and is the definitive tool for diagnosing anterior chamber hemorrhage and inflammation. • From: Roberts; Clinical Procedures in Emergency Medicine, 4th ed., Copyright © 2004 Saunders, An Imprint of Elsevier

15. Uses of the Slit Lamp • Lids and lashes may be inspected for blepharitis and pointing of a lid abscess (hordeolum). The inner canthus and lacrimal punctum may be better viewed for evidence of dacryocystitis.   • The anterior chamber may be examined for cells (e.g., red and white blood cells) and “flare.” • Collections of layered blood or pus called hyphema or hypopyon. Graded by the percentage of the vertical diameter of the visible iris. • Foreign bodies that have penetrated the cornea may be found floating in the anterior chamber. • Spiraling muscle fibers may be seen in acute angle-closure glaucoma. If the beam is shown almost coaxially with the examiner's line of sight such that the red reflex is elicited, tears in the iris may be seen by light returning through the iris itself instead of just through the pupil

16. Indications Abrasions Foreign Bodies Iritis Also facilitates FB removal and is also used in conjunction with most applanation tonometers Contraindications Patients who cannot tolerate an upright sitting position Indications and Contraindications

17. Basics • The lowest setting is adequate for routine examination and will preserve bulb life. • Use a high-intensity setting when examining the anterior chamber with a narrow slit beam. • The patient should be comfortable and the patient's forehead should be firmly against the headrest, with the chin in the chinrest.

18. Basics • Magnification: Usually low powers, such as 10× or 16×, are the most useful. A higher power is helpful when the anterior chamber is examined for cells and flare and when the cornea is examined in minute detail. • The light source is mounted on a swinging arm. There are knobs to vary the width and the height of the light beam. There are also filters that can be "clicked" in; only white and blue filters are usually needed. • The vertical alignment is preferred for routine examinations in the ED.

19. Procedure: Scanning • For examination of the patient's right eye, the light source is swung to the examiner's left at a 45° angle while the microscope is directly in front of the eye. • The slit beam is set at the maximum height and the minimum width using the white light. To scan across the patient's cornea, one first focuses the beam on the cornea by moving the entire base of the slitlamp forward and backward. • One then moves the whole base left and right to scan across. • The 45° angle between the microscope and the light source should be the default position. • The most common mistake is to try to scan by swinging the arm of the light source in an arc. • The examiner scans across at the level of the conjunctiva and the cornea and then pushes slightly forward on the base or joystick and scans at the level of the iris. • A reduced depth of the anterior chamber should lead to suspicion of a corneal perforation or a predisposition to angle-closure glaucoma.

20. Seating and light position

21. Procedure: Flourescein • Essentially the same as scanning except a blue filter is used after flourescein is applied. • The blue filter is "clicked" into position, and the beam is widened to 3 or 4 mm. • Patient can tolerate a wider beam without photophobia if it is blue. • Corneal defects are sought with this setup.

22. Modified Seidel’s Test • Useful for corneal abraisions. • Eye is anesthetized and held open. • Cobalt blue filter is used. • Leakage of aqueous humor through a penetrating wound appears as a lime green fluid oozing into a dark violet surface.

23. Modified Seidel’s Test WRONG! Is this the correct way?

24. Stain Patterns

25. Positive Seidel’s Test

26. Dendritic lesions in Herpes

27. Seidel with Leakage

28. Procedure: examining chamber • The slit beam should be shortened to 1mm • As for prior procedures : room lights should be turned off. • High magnification should be selected. • Angle the light source to 45-60 degrees.

29. Procedure • Check Anterior chamber for clarity and presence of hyphema or hypopyon. • Light beam should be focused on the pupillary margin. • Then pull back the joy stick to focus on the cornea. Move focus inward halfway between the iris and the cornea. • This will focus on the center of the aqueous humor to allow visualization of cells drifting. • Flare is described as “Headlights in fog”

30. Where to look for flare Appearance of the left eye during anterior chamber examination under low power: a, corneal epithelium; b, corneal stroma; c, corneal endothelium; d, anterior chamber (potential location of cells or flare); e, iris; f, lens reflection. The slit of light shines in the temporal to nasal direction at 45° to the anterior surface of the cornea.

31. Flare and cells • May indicated acute injury • May indicate chronic Uveitis or chronic iritis. • Flare is an increase in aqueous humor protein content which is common with inflammatory proces.

32. Hyphema

33. Hypopyon Intravitreal Kenalog injection

34. Summary • The 3 prior procedures described above (Scanning, Seidel’s and Anterior chamber) take only appoximately 1 minute per eye. • Experience with the instrument enhances the ability of the user. • Therefore: Practice, Practice, Practice!

35. Other • Conjuntivitis • Generally presents with mucopurulent discharge and inflammation. • The cornea is clear without flourescence staining.

36. Contact lens Flouroquinolone Ciloxan Ocuflox Treat for 5-10 days with one drop every 1-4 hours. Be aggressive for Pseudomonas. No contact lens Typically treat immuno-compromised Broad spect. Antibiotic Polytrim Erythromycin One drop four times daily for 5-7 days Bacterial Conjunctivitis Treatment

37. Trauma • Examples of blunt injuries include orbital blowout fracture, orbital and lid contusions, iris injury, ruptured globe traumatic iritis, subconjunctival hemorrhage, hyphema--blood in the anterior chamber, retinal hemorrhage, commotio retinae, vitreous hemorrhage, choroidal rupture, retinal tears, and retinal detachment.

38. Severe Inflammation

39. Thank you for your time.