Duke PA Occular Emergencies
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| What is essential in the immediate treatment of chemical burns to the eye | irrigation
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| When should treatment of a chemical burn to the eye begin (irrigation) | Before arrival at the emergency center
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| If a patient has a chemical burn to the eye with an acidic substance should an attempt be made to neutralized it by adding an alkaline substance | No
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| What should be done after 30 min of irrigation of an eye with a chemical burn | Check tear pH, if not 7, continue irrigation
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| Bleeding in the anterior chamber of the eye | hyphema
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| What are some of the general guidelines in the treatment of hyphema | Shield eye (no patch), bedrest (with b/r privileges), elevate head of bed to 30 degrees, topical atropine, no aspirin/NSAIDs, consider topical steroids, monitor intraocular pressure
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| What are some signs and symptoms of a corneal abrasion | Sharp pain/foreign body sensation, photophobia, tearing, fluorescein staining, conjunctival injection, swollen lid
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| When considering a corneal abrasion what should be in your differential | Dry eye/recurrent erosion syndrome, infectious keratitis (bacterial ulcer, HSV, acanthamoeba, fungal ulcer)
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| What do you include in the work-up of a corneal abrasion | Slit lamp exam with fluorescein, evert lids to rule out foreign body
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| What is the treatment for a corneal abrasion in a non-contact lens wearer | Erythromycin or Polytrim drops, cycloplegic agent, consider patch
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| What is the treatment for a corneal abrasion in a contact lens wearer | Must cover pseudomonas (tobramycin ointment, fluoroquinolone drop), cycloplegic agent, consider patch
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| When should a corneal abrasion be referred to an ophthalmologist | If not healed in 24 hours, abrasion related to contact lens wear, white corneal infiltrate develops
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| Focal loss of corneal stroma with overlying epithelial defect | Corneal ulcer
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| What is the number one risk factor for corneal infection | Contact lens wear (overnight, swimming)
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| What is the #2 risk factor for corneal infection | Trauma, corneal abrasion
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| What should you do if you suspect infectious keratitis | Call an ophthalmologist
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| What is the treatment for infectious keratitis | Broad spectrum antibiotic drops
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| What should be included in the workup for central retinal artery occlusion | ESR for temporal arteritis
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| What is the treatment for central retinal artery occlusion | Although no treatment has been proven to improve outcome you can try, lowering IOP with topicals, Diamox, anterior chamber paracentesis
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| The immediate treatment for angle closure glaucoma is to lower eye pressure, how is this done | Drops (timolol, dorzolamide, brimonidine), oral agents (Diamox, isosorbide), IV agents (mannitol), hold pilocarpine until seen by an ophthalmologist
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| What is endophthalmitis | Inflammation of the tissue inside the eye caused by bacteria (coag neg staph, SA, gram -), fungi, rarely viruses (Herpes simplex/zoster), or protozoa (acanth, toxplasafi), and is usually associated with eye surgery
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| What are the symptoms of endophthalmitis | Decreased vision, pain, redness (especially after eye surgery), blurred vision (pretty generic)
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| What is the treatment of endophthalmitis | Injection of intravitreal antibiotics or surgery ASAP
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| What is the most common etiologic agent of viral conjunctivitis | Adenovirus
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| What is the treatment for viral conjunctivitis | Supportive, throw out contact lens/case/solution, wash sheets/towels, wash hands religiously
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| For how long is viral conjunctivitis contagious | 2 weeks
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| Conjunctivitis in an infant, assume what organisms | Chlamydia and or gonorrhea
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| Gonococcal conjunctivitis requires __ treatment | Systemic
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| Acute, often red, infection of the sebaceous glands at the base of the eyelashes | Hordeolum
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| Chronic, often fibrotic, infection of the sebaceous glands at the base of the eyelashes | Chalazion
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| Treatment for hordeolum/chalazion | Start conservatively, warm compresses, erythromycin ointment, consider I&D, steroids sometimes injected to prevent recurrence
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| Inflammation along the eyelashes/meibomian glands (gritty burning eyes) | Blepharitis
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| Treatment of blepharitis | Warm compresses, lid scrubs, consider erythromycin ointment or doxycycline
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| Blepharitis with ulceration or lash loss consider __ | Cancer
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| What are risk factors for retinal detachment | Myopia, trauma, family history, cataract surgery, detachment in the other eye
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| What will happen to the pressure in an eye affected with a retinal detachment | May be lower
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| What is significant in the history of a retinal detachment | Flashes or floaters
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| What is the treatment for periorbital cellulitis | PO or IV antibiotics
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| Elderly man with history of monocular vision loss, jaw pain, and recent weight loss, what are you suspicious for | Giant cell/temporal arteritis
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| 29 year old woman with multiple sclerosis presents with acute loss of central vision in one eye, and pain with eye movements. What are you suspicious for | Optic neuritis
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| What is a stye | Acute infection of the oil gland at the lash line that appears as a pustule (aka external hordeolum)
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| Treatment for stye (external hordeolum) | Warm wet compresses 4x day, erythromycin ointment 2x/day for 7-10 days
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| Acute or chronic noninfectious inflammation of the eyelid secondary to meibomian gland blockage in the tarsal plate | Chalazion (internal hordeolum)
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| Why has gentamicin fallen out of favor for the treatment of bacterial conjunctivitis | High incidence of ocular irritation
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| Presents as monocular or binocular eyelash matting, mild to moderate mucopurulent discharge, and conjunctival inflammation | Bacterial conjunctivitis
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| Presents as a monocular or binocular watery discharge, chemosis, and conjunctival inflammation | Viral conjunctivitis
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| Treatment of viral conjunctivitis | Cool compresses 4x/day, naphazoline/pheniramine drops for conjunctival congestion or itching. Follow up in 7-14 days
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| Endophthalmos is a true __ | Ocular emergency
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| How do patients with endophthalmos present | Pain and visual loss
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| What is the initial empiric treatment for endophthalmos | Vancomycin and ceftazidime
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| A superficial infection of the eyelids that does not extend past the orbital septum. The eyelids become warm indurated and erythematous but he eye itself is not involved | Periorbital cellulitis (preseptal cellulitis)
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| A potentially sight and life threatening ocular infection deep to the orbital septum, typically as a result of spread from the ethmoid sinuses | Orbital cellulitis (postseptal cellulitis)
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| What should be done in the case of orbital cellulitis | Emergent CT of the orbits and sinuses, ophthalmologic consultation and admission for cefuroxime IV
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| How should superficial conjunctival abrasions be treated | Erythromycin ointment 2x/day for 2-3 days, ocular foreign body should be excluded
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| What is the preferred topical ocular anesthetic used when assessing a corneal abrasion | Proparacaine
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| How will a corneal abrasion appear during fluorescein stain when using cobalt blue light on slit lamp | It will fluoresce green
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| What is the treatment for a simple corneal abrasion | A cycloplegic (cyclopentolate, homatropine) for the pain, and a topical antibiotic (tobramycin, erythromycin, bacitracin/polymyxin)
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| What is the antibiotic treatment for a corneal abrasion for a person with contact lenses | Should include coverage for pseudomonas (ofloxacin or ciprofloxacin)
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| How are superficial corneal foreign bodies removed | Under slit lamp microscopy with a fine needle, eye spud, or ophthalmic burr. Proparacaine is used (also instilled in the unaffected eye to depress reflex blinking)
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| Who should remove a corneal foreign body deep within the corneal stroma, or in the central visual axis | An ophthalmologist
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| What do you do for a high risk lid laceration if an ophthalmologist is not immediately available to evaluate and treat | As long as all sight-threatening lesions have been excluded prescribe oral and topical antibiotics and gentle cold compresses with referral to an ophthalmologist in 24 hours
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| A hyphema should be dilated with __ to prevent pupillary movement from tearing damaged blood vessels | Atropine 1%
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| What orbital walls do blowout fractures commonly involve | Inferior and medial
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| Which muscle is usually entrapped in a blowout fracture, and what does it cause | Inferior rectus muscle. May cause restricted movement, resulting in diplopia on upward gaze
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| What must be avoided once a globe injury is suspected | Any further manipulation or examination of the eye
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| Severe subconjunctival hemorrhage, shallow or deep anterior chamber, hyphema, teardrop-shaped pupil, limited extraocular motility, extrusion of globe contents, reduction in visual acuity can all mean what | Ruptured globe
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| A bright green streaming appearance to fluorescein instilled into the tear layer (Seidel test) is pathognomonic for what | Penetrating trauma or ruptured globe
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| Treatment for ruptured globe | Call ophthalmologist immediately. Metallic eye shield, first gen cephalosporin, antiemetic (prevent Valsalva), tetanus update, CT to look for foreign body.
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| How long after the first 2L of irrigation fluid should you wait to check the pH in an eye that has suffered a chemical burn | 5-10 minutes
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| What should you do for an eye that has been chemically burned and continues to have an abnormal pH despite being irrigated with 8-10 L of fluid | The fornices should be inspected thoroughly and re-swept with a moistened tip applicator
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| What ocular condition classically presents with eye pain or headache, cloudy vision, colored halos around lights, conjunctival injection, a fixed mid-dilated pupil and increased IOP of 40-70 mmHg | Acute angle closure glaucoma
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| What is a normal range for IOP | 10-20 mm Hg
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| What can precipitate an attack of acute angle closure glaucoma in a patient with narrow anterior chamber angles | Movie theaters, reading, ill-advised use of dilatory agents or inhaled anticholinergics
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| What are some treatments used to reduce IOP | Timolol, apraclonidine, prednisolone acetate drops
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| What can you use to decrease pressure if the IOP is greater than 50 mmHg | Acetazolamide IV
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| What can you use to decrease IOP if it does not do so with first line agents after 1 hour | Give 1-2g/kg mannitol IV
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| Once IOP is below 40 mmHg in acute angle closure glaucoma, what can be given as long as the patient has an intact lens in place | Pilocarpine drops
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| Presents with acute vision loss with a particular reduction in color vision (red desaturation test), often painful especially with EOMs | Optic neuritis
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| What can often be detected in Optic Neuritis | Afferent pupillary defect
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| Presents as a sudden painless, severe monocular loss of vision, often associated with a history of amaurosis fugax | Central retinal artery occlusion
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| Causes acute, painless monocular vision loss. Examination shows optic disc edema, cotton wool spots, and retinal hemorrhages in all quadrants (blood and thunder fundus) | Central retinal vein occlusion
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| A systemic vasculitis that can cause a painless ischemic optic neuropathy | Giant cell arteritis
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| Who is the typical patient with giant cell arteritis | Women older than 50 years, often with a history of polymyalgia rheumatica
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| What are associated symptoms of giant cell arteritis | Headache, jaw claudication, scalp or temporal artery tenderness, fatigue, fever, and anorexia
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| What is may be seen on funduscopic exam with giant cell arteritis | Flame hemorrhages
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| What labs should be ordered when giant cell arteritis is suspected | Sed rate, c-reactive protein
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| What should be done if there is a strong suspicion of giant cell arteritis | The patient should be admitted for methylprednisolone 250 mg IV every 6 hours
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| What may be done if there is a low suspicion for giant cell arteritis | The patient may be discharged with prednisone with close follow up
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| Hyphema work-up | Assume open globe; poss CT (if suspect blow out fx); poss US to r/o vitreous hemo or retinal detach; SPE (pts w/SCD)
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