AOCOPM Midyear Educational Meeting March 8-11, 2018
I. Introduction II. Objectives
Epidemiology of Ocular Injuries
Michael B. Miller, D.O., O.D., M.P.H. Review of Anatomy Wellstar Occupational Medicine Examination of eye Atlanta, GA
Examine eye for trauma and foreign bodies
Manage chalazia, styes, corneal abrasions, foreign bodies
Ocular Trauma Occupational Ocular Trauma
“Epidemiological data on eye injuries In US, 280,000 work-related tx in ED are still rare or totally lacking in large 1999 (Am J Ind Med 2005) parts of the world.” J Clin Ophth Res 2002, BLS est 65,000/year 2016 2009, BLS est. 2.9/10,000 full time 90 % are preventable workers requiring 2 or more days off Prevalence rates vary a great deal (5- NIOSH Work-RISQS query shows 15%) 134,000 in 2015 Approx 50% work-related Non-traumatic ocular illnesses (allergic conjunctivitis) grossly underreported
Occupational Ocular Trauma Risk Factors- Ocular Trauma
Majority are males BLS est. 60% fail to wear proper eye Most are in age 25-44 protection incl. side/top shields Metalworkers at highest risk Use of tools (unskilled use increases risk 48X) Others: agriculture, construction, manufacturing Performing unusual task (< 1 day/week) Types of injuries: Abrasions, FB/splash, Working overtime (3X inc risk) Conjunctivitis, Burns, Contusion, Distraction, fatigue, Rushed Open/Penetrating wound, Assoc with sleep duration not stat signif
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PPE Effect- Ocular Trauma Anatomy
44% reported eye injury despite PPE (Occ Med, Jan 2009) Reported increase use of PPE during work following eye injury (from median 20% to 100%) (Workplace Health Safety, 2012) Role of provider education in prevention….Yuge!
Anatomy of the orbital septum Anatomy of the eye and surrounding structures
IV. Elements of Eye Elements of Eye Examination- Examination Office equipment
Visual Acuity Penlight Pupil light reflexes and corneal reflexes Topical anesthetic (tetracaine, ophthaine) Extraocular muscles/cover test Dilating drops (Mydriacyl, Cyclogyl) Eye pads/ paper tape/tincture of Visual fields- confrontation and Amsler grid benzoin/ointment (Lacrilube or E-mycin) Red reflex/ophthalmoscopy Irrigating solution (Dacriose) Biomicroscopy (slit lamp examination) Fluorescein strips Intraocular Pressure (IOP) Woods light Sterile swabs Occluder Snellen chart/tumbling E chart/Allen cards
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V. Pediatric/Well child eye exam Pediatric eye exam
Newborn Red Reflex- dark room, use Infants ( 6 months – 3 years) ophthalmoscope at 1 foot In addition to above: Pupillary response Fixation and Following (CN III, IV, VI) Observe for eye deviation Corneal light reflex (Hirschberg) Observe for congenital cataracts Cover test
Pediatric eye exam Pediatric eye exam
Children ( 3 years – 5 years) Children age 6 years and older Start to use visual acuity tests- Snellen, Use Snellen chart for visual acuity Tumbling E
V. Developmental landmarks VI. Frequency of examinations
Newborn- Unable to fix and follow High risk infants (premature, maternal before age 3 months factors, child abuse, Systemic disease) 6 months-2 years: Fix and follow a face, High risk children and young adults toy, or light African-American over 20 yrs 3 yrs-5 yrs: 20/40 or better Hx of eye disease/problems 6 yrs: 20/30 or better Hx of systemic illness Family hx of eye disease (glaucoma)
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Screening methods for refraction in infants and Frequency of Examinations children
Age 20 – 39: At least one exam Age 40-64: Exam every 2-4 years Age > 65: Exam every 1-2 years
Vision development Ophthalmia neonatorium
Hirschberg Test and Purkinje Images Pseudostrabismus Child with esotropia
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Modified fluorescein dye disappearance test VI. Visual Acuity
Blurred vision is the most common eye chief complaint Snellen fraction: Numerator is testing distance, denominator is distance at which object subtends angle of 5 minutes of arc/or distance at which normal eye can see the object Recorded without (sc) and with (cc) correction at 20 feet (optical infinity) and 16 inches. Right eye, left eye, both eyes (OD, OS, OU)
Visual Acuity Visual acuity
Recording of results: Pinhole: If VA is worse than 20/30 20/20 If VA improves, patient has uncorrected 20/60 –2 refractive error otherwise suspect media 10/400 opacity, retinal disorder, or optic nerve Counting fingers (CF at 5 feet) disease Hand motion (HM at 5 feet) Light perception (LP) or No light perception (NLP) with or without projection
Visual Acuity The Snellen optotype
Macular function can be tested using “auto-ophthalmoscopy” or “entoptic phenomenon” Intact macula: patient sees images of retinal vessels
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Visual acuity charts Visual acuity charts
Visual acuity charts Visual acuity notations
Notations for recording near visual acuity Titmus and random-dot-E stereoacuity tests
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Titmus and random-dot-E stereoacuity tests VII. Pupillary exam
Normal round, 3-5 mm Anisocoria-unequal sized pupils, normal in up to 20% Semi-dark room, bright light, Direct and consensual reaction should be equal
Pupillary exam Pupillary Exam
Afferent pupil defect: optic nerve Efferent defect: Either in Parasym or Sympathetic system Direct light: pupil dilates CN III defect: no direct response, pupil Consensual and near response: normal dilated, no near response, no consensual Adie’s Tonic pupil: slow direct, near and consensual response, pupil dilated (decreased peripheral reflexes) Argyll-Robertson: miotic pupil, no direct or consensual response, normal near response (light-near dissociation)- midbrain lesion seen in sarcoid, multiple slerosis
Pupillary Exam Pupillary exam
Sympathetic system: Physiologic anisocoria Horner’s syndrome: pupil constricted, normal reactions to light, near (ptosis, Unequal size, normal reaction to light , miosis, anhydrosis) near, consensual
Amaurotic/blind eye: dilated pupil, no reaction to light, near, consensual
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Pupillary light reflex Evaluating the pupillary light response
Evaluating pupil size Evaluating pupil size
Diagnosing relative afferent pupillary defect in the presence of an efferent pupillary defect Extraocular muscle exam
EOM actions (LR6 SO4)3 Primary position of gaze Corneal light reflex- nasal to center of cornea Cover/Uncover test to test for phoria or tropia Alternate cover test- can measure amount of deviation Red lens test/Maddox rod test Six cardinal positions of gaze- note limitations
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Cover-uncover test Alternate-cover test
Corneal light reflex tests for ocular misalignment The Worth-4-Dot test
Pseudostrabismus Use of glasses to correct accomodative esotropia
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Use of bifocal glasses to correct accommodative Use of glasses to correct accomodative esotropia esotropia
Use of bifocal glasses to correct accommodative esotropia Child with esotropia
VIII. Visual field exam Traquair's island of vision
Normal visual field: Superior 50, Nasal 60, Inferior 70, Temporal 90 Test each quadrant- count fingers Simultaneous temporal and nasal fields- checks for extinction phenomenon (count fingers or red bottle tops) Amsler grid- central 10 degrees- monocular
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Traquair's island of vision Confrontation visual field testing
Amsler grid Tangent screen
Goldmann manual kinetic perimetry Automated static perimetry
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Automated visual field printout IX. Biomicroscopy (Slit lamp)
General inspection Cornea Anterior chamber Conjunctiva Lids/lashes Lens
Types of biomicroscopic illumination Types of biomicroscopic illumination
Types of biomicroscopic illumination Types of biomicroscopic illumination
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Types of biomicroscopic illumination Types of biomicroscopic illumination
Types of biomicroscopic illumination X. Fundus exam
Direct ophthalmoscopy Start with plano (0) power at 10 inches Note red reflex then add + power to focus on front of eye then add – power to focus from front to back of eye as you get closer to eye with scope Optic nerve head- note size of disc and central depression (cup) as a ratio called cup to disc ratio (CDR)- normal ratio is .3 or less and bilaterally symmetric Fovea and light reflex is lateral (temporal) to disc Note retinal artery and vein size as A/V ratio (normally 2/3 or greater)
Fundus exam Papilledema
Dilated exam Tropicamide (Mydriacyl) 1% Neosynephrine 2.5%
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XI. The Red Eye Evaluation of Red Eye
Differential Dx Is vision affected? Acute conjunctivitis Check visual acuity! Foreign body sensation? Acute iritis Photophobia? Acute glaucoma Trauma? Corneal trauma/abrasion Contact lens wearer? Corneal fluorescein staining? Discharge?-purulence- bacterial
Red Eye Evaluation Red Eye Evaluation
General observation-penlight exam Pupil reaction- small if iritis, keratitis, abrasion Topical anesthetic (Tetracaine, Opthaine)? Pattern of redness- “ciliary flush”- injection at Keratitis-corneal abrasion/contact lens limbus and indicates iritis, angle closure, or overwear, photophobia keratitis Iritis- no fb sensation, photophobic Corneal opacity/fb? White area= infectious Angle closure glaucoma- general distress, HA, keratitis malaise, nausea, vomiting, dull ache, decreased acuity, mid-dilated pupil, poor Anterior chamber- hypopyon or hyphema? direct response
Red Eyes Managed by Primary Care Red Eyes- Referral Needed
Conjunctivitis (bacterial, viral, allergic) Angle closure glaucoma Corneal abrasion Hyphema Corneal foreign body Hypopyon Contact lens overwear Iritis Subconjunctival hemmorhage Keratitis/corneal ulcer Blepharitis Stye Chalazion
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Acute conjunctivitis/bacterial conjunctivitis Bacterial conjunctivitis
Common Empirical therapy Moderate to copius discharge/matting of Broad spectrum- Polytrim, Ocuflox, lashes Quixin, Sulfacetamide No effect on vision Erythromycin ophthalmic oint at night No pain If cornea intact- Tobradex, Maxitrol, Clear cornea Pred-G, Vasocidin Staph A., H.influenza,Strep pneu, Use qid to q1h depending on severity Pseudomonas a. Advise patient very contagious/hygiene
Viral Conjunctivitis Viral Conjunctivitis
Serous discharge, pre-auric nodes, No work or school until no discharge injection, lid edema, fever, sore throat Hygiene (PCF), corneal infiltrates, bilateral Topical steroids/combination med if (EKC), subconj. hemmorhage cornea intact- Pred Forte/Tobradex bid- Adenoviruses qid Tell patients- sx get worse for 7-10 days Highly contagious before getting better, resolve in 3-6 Usually self-limiting weeks
Chlamydial Conjunctivitis Allergic conjunctivitis
Consider if chronic red eye no better with Hx of seasonal allergies/Itching, photophobia, burning and conj other therapy injection Thin, watery discharge if seasonal Corneal pannus, corneal infiltrates, follicles, Ropy, thick discharge with large papillae if vernal conjunctivitis pre-auric node, mucus or stringy discharge Pre-treatment with Crolom, Alomide, Alocril, Alamast, Optivar, Patanol x 4 weeks with recurrent seasonal allergies Sexually active teens, young adults, neonatal Tx- mild cases, cold compresses, artificial tears, Lacrilube, OTC Tx- Oral TCN for 3 weeks, Erythromycin for 3 topical decongestants weeks, Doxycycline for 1 week, or Avoid rubbing eyes! Moderate to severe- Patanol or Livostin, topical NSAID (Acular, Azithromycin 1 gram- single dose Voltaren) Topical tx- Erythromycin, sulfacetamide tid x 3 Topical steroids (Alrex, Vasocidin, Vexol, Flarex) if very weeks symptomatic Topical Cyclosporine 2% gtts qid if steroids ineffective Oral antihistamines
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Giant Papillary Conjunctivitis XII. Corneal/Conjunctival (GPC) Foreign Body
Associated with soft contact lens wear Check for corneal perforation/anterior Fb sensation, itching, excess mucus and chamber large (1 mm) papillae on upper lid conj Fluorescein- look for aqueous leakage thru Weeks to years after starting CL wear wound (Seidel’s sign) (mean= 18 months) Topical anesthetic (ophthaine, tetracine) Tx= stop CL wear, new lenses, preservative Evert upper eyelid free solutions Remove with swab, spud, needle, or burr Artificial tears, Topical antihistamines under slit lamp (Patanol), topical steroids in severe cases If fb is in visual axis, advise regarding possible scarring and loss of acuity
XIII. Corneal Abrasion XIV. Chalazion
Visual acuity, Size, shape, location, depth Painless nodules in lids Anterior chamber reaction (may have Granulomatous inflamm of Meibomian glands secondary iritis) Topicals won’t help Topical anesthetic- limit instillation Hot compresses/massage qid Woods Lamp or Slit Lamp with fluoroscein Kenalog 10/ml- use up to 0.3ml from 5%); topical antibiotics, analgesia. Severe palpebral side and 30 gauge needle pain- topical NSAIDs (Acular, Voltaren) Depigmentation may occur- don’t use if dark Patching may help pain if abrasion over 50% skin of cornea- not if contact lens wearers Biopsy if recurrent to r/o sebaceous gland Ca because of risk of infection If CL wearer-Ciloxan, Ocuflox, Tobrex
XV. Hordeolum (stye) XVI. Preseptal cellulitis
Painful, swollen lid with pustule (this Painful, swollen lid, normal vision and differentiates from chalzion) motility; no proptosis Staph infection of glands Not systemically ill/may follow sinusitis Topicals won’t help Staph, Gr. A Strep, Strep pyogenes Oral antibiotics (Diclox, E-mycin, TCN, Limit spread to posterior septum with Amoxil x 10 days) immediate oral antibiotics (Amoxicillin, I&D if external Augmentin, E-mycin, IV Nafcillin,Oxacillin if severe) May result in chalazion if chronic
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XVII. Orbital cellulitis XVIII. Blepharitis
Pain, red, swelling, proptosis, vision loss, loss Inflamm of lid margins and lashes of motility, systemically ill, fever Red, collarettes (fibrin around lashes), Spread from teeth, sinus, lid penetration madarosis (loss of lashes), trichiasis (inturned Staph, Strep, H. flu lash), plugged glands, conjunctivitis Potential- intracranial infection, septicemia, Lid hygiene- tearless shampoo, commercial cavernous sinus thrombosis scrubs (Ocu-clear, Lid Scrub, Lid Wipes) Immediate hospital/ IV antibiotics Moderate, severe, chronic- topical or oral (Cefuroxime, Cefoxitin, Ceftriaxone, meds: Sulfacetamide, Tobramycin, E-mycin, Ticar/Clavulanate) Polysporin bid-qid Excessive inflamm and pain- use combo meds: Tobradex, Maxitrol, Blephamide, Vasocidin
XIX. Dacryocystitis XX. Episcleritis
Nasal aspect, lower lid Sectoral injection, cornea clear, mild Mucopurulent discharge pain Fever, severe red swelling Young adults, self-limiting (2-3 days), Anaerobes:Pepto-streptococcus, Propionibacterium, Fusobacterium most freq usually idiopathic, may be assoed with pathogens RA, SLE, IBD, Gout, Sarcoidosis) If afebrile- oral antibiotics (Augmentin, Topical mild steroids (FML, Pred-mild) q Ceclor), topical antibiotics, warm compresses 4 h; cold compresses, artificial tears If febrile- hospitalized with IV Ancef
XXI. Scleritis XXII. Pinguecula/itis
Severe, boring pain, photophobia, decreased Yellow, lipid-like deposits at limbus of vision, tearing exposed conjunctiva Scleral vessels dilated, deep red in sector or Degeneration of collagen in conjunctiva diffuse pattern results in dryness, irritation, Tx- cycloplegia, topical steroid, oral NSAID, Older population, environmental exposures, oral prednisone Solar/UV light Consider underlying systemic disorder: RA, Ocular lubricating drops: Tears Naturale II, SLE, Gout, Syphilis, Zoster, Ankylosing Lacrilube, Refresh PM spondylitis, Wegener’s granulomatosis Topical steroids: Pred Mild, Vexol, Pred Forte, Tests: CBC, ESR, RF, ANA, HLA-B27, FTA- Inflamase Forte ABS, CXR, S-I joint films
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XXIII. Pterygium XXIV. Ocular Trauma
Raised, red, triangular wedge, Have A,B,Cs been addressed? fibrovascular growth on nasal limbus What was vision before injury and after injury? UV light exposure, warm dry climates or Is there past hx of amblyopia dust/smoke Did it occur at work? Topical decongestants (Naphcon-A); Eye protection and what type? steroids (FML, Vexol, Pred-mild) Chemical exposure/eye irrigated? Surgery if in visual axis/ cosmesis Paresthesias around the eye? Last oral intake?
Ocular Trauma Ocular Trauma
Visual acuity is most important element Iris check with transillumination-tears, Examine bony structure of orbit for anisocoria, mydriasis displacemnt Lens instability (phacodonesis) due to rupture Blowout fx accompanies blunt trauma of zonules Enophthalmos, restricted motility, lid Traumatic cataract anesthesia Traumatic vitreous hemm Tx broad spectrum antibiotics Retinal trauma- hemm, fb, choroidal tears, Thorough check for globe perf retinal tears, commotio retinae Hyphema- tx strong cycloplegia and bed rest Intraocular fb- remove within 12-24 hours x3-5 days. Check IOP.
Ocular trauma-chemical burn Blow Out Fracture Alkali more serious than acid Acids create initial burn then cease, alkali penetrat4cornea to Signs: edema, ecchymosis of lid destroy stroma, and endothelium Restriction of motility especially vertical Copious flush with salline Orbital crepitus (subcut emphysema) Test with litmus paper; If ph 6-8, dc lavage Hypoesthesia of ipsilateral cheek, entrap of infraorb nerve, Debride necrotic tissue with slit lamp Risk of medial wall fx is orbital cellulitis Swabs in fornices CT of orbits- axial and coronal views Cycloplegic and broad spectrum antibiotic If entrapment, with diplopia, surgery in 10-14 days to allow for resolution of hemm and Pressure patch if large area (50%) edema Add topical 1%prednisolone acetate q 2-4. Medial wall fx- start Keflex, E-mycin qid x14 Monitor IOP d. Medial wall fx resolves spontaneously in 3-
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Commotio retinae Hordeolum
Adenovirus infection: clinical features, diagnosis, and treatment Subconjunctival hemorrhage
Giant papillary conjunctivitis Scleritis
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Seborrheic blepharitis is probably the most common Episcleritis in rheumatoid arthritis cause of anterior lid margin involvement
Correlation of recurrence with pterygium morphology Asymmetry of the optic cups
Asymmetry of the optic cups Traumatic hyphema
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Cortical cataract Posterior subcapsular cataract
Less severe nonproliferative diabetic retinopathy Preseptal cellulitis
A 14-year-old girl who presented with a red, sensitive Streptococcal bacterial cellulitis secondary to orbital right lower eyelid trauma
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Nasolacrimal sac massage Dacryocystitis
Conjunctivitis Dacryocystitis in a boy aged 16 years
Hemorrhagic conjunctivitis Dacryocystitis in a neonate aged 2 weeks
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Acute conjunctival chemosis An 8-year-old girl with "allergic shiners"
Hypopyon in juvenile rheumatoid arthritis Band keratopathy in juvenile rheumatoid arthritis
Punctate epithelial erosions, punctate epithelial Peripheral thinning of the cornea keratitis, and punctate subepithelial infiltrates
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Herpes infection of the eye Optic nerve drusen
Acute anterior uveitis Anterior segment complications of closed-globe injury
Thelazia gulosa
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XXVI. Skills Stations
Slit Lamp Evaluation of the Eye Eyelid eversion using slit lamp Corneal foreign body removal with slit lamp Fluorescein staining of the eye/Woods Lamp
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