OCULAR EMERGENCIES M R SHOJA SHAHEED SADOUGHI UNIVERSITY

OCULAR EMERGENCIES. M. R. SHOJA SHAHEED SADOUGHI UNIVERSITY 12/15/2021 EYE EMERGENCIES 1

EYE ANATOMY 12/15/2021 EYE EMERGENCIES 2

SUDDEN LOSS OF VISION • Usually Unilateral, Pain-less • Rapid onset, if due to vascular cause • More gradual if due to inflammation 12/15/2021 EYE EMERGENCIES 3

Causes of sudden visual loss • Vascular – occlusion – Ischemic optic retinal vein occlusion – retinal artery neuropathy • Retinal detachment • Vitreous hemorrhage 12/15/2021 EYE EMERGENCIES 4

1. Central retinal vein occlusion (CRVO) • Systemic causes – Age – Hypertension – Hyperviscosity • Ocular causes – Raised IOP 12/15/2021 EYE EMERGENCIES 5

BRVO 12/15/2021 EYE EMERGENCIES 6

Central retinal artery occlusion(CRAO ) • Visual loss profound • RAPD • Pale retina, thread • like retinal vessels Cherry red spot (can see normal choroidal circulation at fovea where the retina is thinnest) 12/15/2021 EYE EMERGENCIES 7

Causes of CRAO • Emboli from the heart – – – from calcific valves vegetations thrombus • Carotid artery disease – fibrinoplatelet – calcific • Inflammatory • GIANT CELL ARTERITIS 12/15/2021 EYE EMERGENCIES 8

Clinical Features of CRVO • VA Moderate to severe loss • Relative afferent pupil defect (RAPD) • Retinal haemorrhages • Dilated/engorged, dark, tortuous veins • Retinal ischaemia/Cotton wool spots • Optic disc swelling/retinal oedema • Neovascularisation 12/15/2021 EYE EMERGENCIES 9

Retinal Detachment • Sudden onset of flashes/floaters • Shadow in vision • Myopic patients • Management – usually surgical 12/15/2021 EYE EMERGENCIES 10

Blunt Ocular Trauma: Posterior segment (3) | Retina - retinal tear => retinal detachment - commotio retina - macular hole 12/15/2021 EYE EMERGENCIES 11

Ocular infections 12/15/2021 EYE EMERGENCIES 12

Orbital Cellulitis In 3% of acute sinusitis Pain, proptosis, chemosis Mucopurulent rhinorrhea Motility defect, globe displacement Decreased vision, pupillary signs 12/15/2021 EYE EMERGENCIES 13

BACTERIAL KERATITIS 12/15/2021 EYE EMERGENCIES 14

Predisposing factors Trauma 32 (39%) Ocular diseases 28 (34. 1%) Previous ocular surgery 8 (9. 8%) Contact lens 8 (9. 8%) Diabetes Systemic disease 6 (7. 3%) R. Arthritis 12/15/2021 EYE EMERGENCIES 15

Acute Red Eye Uniocular No Pain Binocular Pain Subconjunctival. H Scleritis HZO Bacterial. C Episcleritis Anterior uveitis Viral. C Pterygium A. C. glaucoma Allergic. C Conjunctivitis Bacterial Keratils VKC 12/15/2021 EYE EMERGENCIES 16

Red Eye 12/15/2021 EYE EMERGENCIES 17

Primary Angle Closure Glaucoma (PACG) Epidemiology: 1 - Age 2 -Gender Eastern Asia 3 -Race less in black 4 -Heriditary 5 -Refractive Error 6 -Seasonal Incidence (10% of all glaucoma , 5 -10% bilatesal) 12/15/2021 EYE EMERGENCIES 18

Findings Diminished vision Ciliary flush , corneal Edema Elevated Iop (40 -75 mm. Hg ) Shallow Anterior Chamber Dilated , vertically Oval nonreactive pupil. Cell and Flare in Ac Hyperemic Swollen optic disk 12/15/2021 EYE EMERGENCIES 19

CONGENITAL GLUCOMA 12/15/2021 EYE EMERGENCIES 20

Stevens-Johnson syndrom Acute bullose mucocutaneous disease Hypersensitivity reactions to drugs Pseudomembrane, fibrosis, Dry Eye 12/15/2021 EYE EMERGENCIES 21

Chemical Burns ] Can be: - acid - basic A true ocular emergency => basic ] Immediate irrigation essential 12/15/2021 EYE EMERGENCIES ] 22

Chemical burns • Treatment in the first ten minutes has a major impact on the final outcome. • In all chemical eye injuries, immediate, continuous irrigation with clean water is a priority. • Chemical burns are generally the most urgent emergencies. 12/15/2021 EYE EMERGENCIES 23

¯ Chemical Burns: ¯ Initial Management __________________ Ø Instill anesthetic drop (topical) Check and remove foreign bodies Institute copious irrigation Ø Refer promptly to ophthalmologist Ø Ø Irrigation of chemical burns should be initiated before arrival to emergency room 12/15/2021 EYE EMERGENCIES 24

Eye Injuries: ] Blunt trauma Ø Contusion Ø Rupture ] Sharp: Penetrating trauma Ø With foreign body Ø 12/15/2021 Without foreign body EYE EMERGENCIES 25

Foreign Body 12/15/2021 EYE EMERGENCIES 26

Penetrating Trauma: IOFB-Intra-Ocular Foreign Body Metal Fe (siderosis) Cu (chalcosis) ¯ Non-metal Organic Non-organic ¯ 12/15/2021 EYE EMERGENCIES 27

Blunt Ocular Trauma: Anterior segment (2) | Cornea - corneal erosion - corneal foreign body ] § § § Symptoms: Pain Tearing Foreign-body sensation 12/15/2021 EYE EMERGENCIES 28

CORNEAL ABRASION & LACERATION 12/15/2021 EYE EMERGENCIES 29

Corneal erosion: Symptoms ] § § § Treatment: Topical antibiotic Patch over eye Topical cycloplegia 12/15/2021 EYE EMERGENCIES 30

EYE PROTECTION 12/15/2021 During EYE EMERGENCIES SURGERY 31

Blunt Ocular Trauma: External(1) Eye lids - hemorrhage - laceration ] Conjuctiva - hemorrhage - laceration ] 12/15/2021 EYE EMERGENCIES 32

OCULAR HEMORHAGE 12/15/2021 EYE EMERGENCIES 33

Blunt Ocular Trauma: Anterior segment (3) ] Iris - HYPHEMA - Mydriasis - Iridodialysis - Angle recess 12/15/2021 EYE EMERGENCIES 34

Hyphema – ] physician management: Ø Assume globe is ruptured Ø Shield eye and refer to ophthalmologist ] Ophthalmologic management: Ø Restricted activity Ø Protective metal shield Ø Topical cycloplegic +/- corticosteroids 12/15/2021 EYE EMERGENCIES 35

• OCULAR TRAUMA 12/15/2021 EYE EMERGENCIES 36

Complete Eye Examination Ø Visual Acuity Ø External exam Ø Motility exam Ø Pupils Ø Ø Anterior segment Intraocular pressure Ophthalmoscopy Ø Peripheral vision Ø 12/15/2021 EYE EMERGENCIES 37

Blunt Ocular Trauma: Anterior segment (3) ] Iris - hyphema - traumatic mydriasis: light, reading - angle recession, iridodialysis 12/15/2021 EYE EMERGENCIES 38

Blunt Ocular Trauma: Anterior segment (3) ] Iris - hyphema - traumatic mydriasis: light, reading - ruptures of pupillary sphincter - angle recession, iridodialysis 12/15/2021 EYE EMERGENCIES 39

Blunt Ocular Trauma: Anterior segment (2) | Lens - cataract - dislocated lens 12/15/2021 EYE EMERGENCIES 40

Blunt Ocular Trauma Posterior segment (3) | Retina - retinal tear - commotio retina - macular hole 12/15/2021 EYE EMERGENCIES 41

Blunt Ocular Trauma: Posterior segment (4) | Choroid - choroidal break | Sclera - scleral rupture | Optic Nerve: - traumatic optic neuropathy - avulsed optic nerve 12/15/2021 EYE EMERGENCIES 42

Blunt Ocular Trauma: Posterior segment (4) | Choroid - choroidal break | Sclera - scleral rupture: open globe | Optic Nerve: - traumatic optic neuropathy - avulsed optic nerve 12/15/2021 EYE EMERGENCIES 43

Penetrating Trauma: ] Reduced IOP is common with globe laceration or rupture. ] Evaluate cautiously to avoid extrusion of intra-ocular contents 12/15/2021 EYE EMERGENCIES 44

Penetrating Trauma: When globe rupture is suspected ¯ Stop examination ¯ Shield the eye (do not patch) ¯ Give tetanus prophylaxis ¯ Refer immediately to ophthalmologist 12/15/2021 EYE EMERGENCIES 45

Penetrating Trauma: Penetrating site of IOFB ] ] Cornea - 79% Sclera - 21% 12/15/2021 EYE EMERGENCIES 46

Penetrating Ocular Trauma : | Cornea: laceration, irregular corneal reflex ] Iris: prolapse, irregular pupil ] Lens: traumatic cataract ] Retina: retinal detachment 12/15/2021 EYE EMERGENCIES 47

History ¯ ¯ General Ocular - Vision - Is one eye affected, or both? - What is your current level of vision? - Was vision normal prior to trauma? 12/15/2021 EYE EMERGENCIES 48

Eye Trauma ] Primary goal: Patient care and preservation of vision ] Early, accurate emergency diagnosis and treatment ] Appropriate ophthalmologic referral 12/15/2021 EYE EMERGENCIES 49

THANKS FOR YOUR ATTENTION 12/15/2021 EYE EMERGENCIES 50