Aafp Fmx 2020

10/7/2020

Common Acute Eye Presentations

Dr. Ahmed Mian HonBSc, BEd, MD CCFP (EM) Staff ER Consultant Department of Emergency Medicine, Humber River Hospital and University Health Network Medical Director and Chair, Medical Education HRH ED Investigative Coroner, Province of Ontario Faculty DFCM/EM University of Toronto and DFM Queens' University

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The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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Disclosure

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had not conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

The following individual in a position to control content for this session have disclosed the following relevant financial relationships.

• Vu Kiet Tran, MD, MHSc(Ed), MBA, CHE disclosed a relationship with Elvium, Consultant or Advisory Board and Honorarium (Acute Pain Management).

All other individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

Learning Objectives 1. Perform a differential diagnosis for eye pain to determine sight threatening conditions from less serious conditions.

2. Identify and treat common eye conditions.

3. Explain the evidence around the use of topical and systemic antibiotics for common eye conditions

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Breakdown…

•After Anatomy, H and P, Tools can divide DDx approach into 3 groups:

•Infectious/Trauma/Vision Loss (Pain/Without Pain)

The Eye

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The Eye

•Three Layers:

•1. Outer wall (external fibrous layer) = Cornea and Sclera •2. Middle Vascular Layer = Choroid, Ciliary body and Iris •3. Internal Layer (Retina, Vitreous, Choroid and Optic Nerve)

•Lens separates outer and inner wall contents

History

•Keys are to find out if any vision loss, changes to appearance of the eye, any pain vs discomfort (pruritus/foreign body sensation), specific photophobia or injury via trauma

•Onset and time frame of symptoms

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Physical Exam

•Visual Acuity is the Vital Sign for the eyes! Good ol’ Snellen chart

Visual Acuity (VA) •Should use contact lenses / glasses if used regularly •If not available use pinhole testing of visual acuity (permits only parallel light rays unto macula - reducing refractory error and estimates corrected VA) •20 feet from chart and recorded as 20/x •Numerator = distance from which patient can read line (always 20) •Denominator = distance from which a person with normal vision can read same line •VA is the smallest line a patient can read with ½ of letters correct •Number of incorrect letters is listed after VA (20/x-y)

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Visual Acuity

•Can also be tested with a near card – Rosenbaum chart (36 cm – away from patient) •Allen chart in children •For patients with VA < 20/200 use finger counting at 3 feet

•May need topical anesthetic if in lots of pain

Physical Exam

•Check visual fields •Extraocular eye movements •Pupillary size and reaction to light (classic ‘swinging flashlight’) (if ‘afferent’ defect might have optic nerve disorder; Marcus-Gunn pupil visible by unequal pupils) •Examine lids, adnexa, conjunctiva, sclera, cornea, anterior chamber, iris, lenses, vitreous, IOP (toward end of exam) with tonopen and fundoscopy (better with dilatation) •Anterior segment and slit lamp examination with fluorescein

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Tools

AES Question

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Question 1

Which of the following is considered to be a VITAL SIGN for OCULAR ASSESSEMENTS

A. Blood Pressure B. Visual Acuity C. Respiratory Rate D. Heart Rate

Question 1

Which of the following is considered to be a VITAL SIGN for OCULAR ASSESSEMENTS

A. Blood Pressure B. Visual Acuity C. Respiratory Rate D. Heart Rate

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Ocular Infections •Pre-Septal Cellulitis (periorbital) and Orbital Cellulitis •Can lead to periosteal abscesses and even cavernous sinus thrombosis (if CN 3,4 or 6 involved) •Often after an URTI/Sinusitis •Pre-Septal Cellulitis is an infection of the eyelids and periocular tissues that is anterior to the orbital septum •Can be d/c on outpatient oral antibiotics •Post-septal becomes an infection posterior to the orbital septum which can be life/vision threatening and needs IV abx/drainage •Will have tearing, fever, erythema and warmth around the area with tenderness to the palpation of the lids and periorbital soft tissues

Ocular Infections : Orbital Cellulitis •Pain or decrease of extraocular eye movements +/- swelling to the orbital area with chemosis, proptosis / exophthalmos •Visual acuity may be blurred •Blood cultures not helpful •CT orbits needed and OPHTHO •Must give wide spectrum antibiotics (2nd/3rd Generation Cephalosporins) •Orbital abscess will need surgical debridement

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Orbital Cellulitis

AES Question

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Question 2

Which is NOT found in ORBITAL CELLULITIS

A. Pain on extraocular movements B. Change in visual acuity C. Erythema to and around eyelid D. Fixed mid-dilated pupil

Question 2

Which is NOT found in ORBITAL CELLULITIS

A. Pain on extraocular movements B. Change in visual acuity C. Erythema to and around eyelid D. Fixed mid-dilated pupil

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Eyelids

•Stye/External Hordeolum : Acute bacterial infection of the follicle of an eyelash and sebaceous glands along ‘lash line’ margin •Often appears as small pustule •If internal to ‘lash line’ then infects meibomian glands of lashes •Thus may be a larger more painful pustule •Warm compresses +/- topical erythromycin BID for 7-10 days may need systemic antibiotics if cellulitis develops •Chalazion (hailstone) is acute/chronic inflammation of eyelid due to blockage of aforementioned glands = lump often painless •Hard to discern vs internal hordeolum thus OPHTHO (I and D)

Stye and Chalazion

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Conjunctiva •Multiple etiologies lead to a “red eye” from an infectious perspective •Often if viral infection benign and self limited

•Must find that bacterial infection (even gonococcal), parasitic, fungal, allergic, toxic or chemical irritation or corneal herpetic involvement that may lead to vision loss without aggressive treatment •With bacterial also controversial…studies show 1-2 days resolution benefit vs no abx at all!

•If just cornea non-herpetic lesions then keratoconjunctivitis

Conjunctivitis •Painless uni/bi-lateral mucopurulent discharge often with eyelids closed – ‘morning crust’ is not enough •Conjunctiva is red and injected •Might get chemosis (edema of conjunctiva) •Staph/strep pathogens are common •Especially if wear contacts (concern for pseudomonas) should do abx TID for 5-7 days •If viral etiology (such as adenovirus) warm compress and time •May still have watery (or mild discoloured) discharge •Often after a URTI •Watch for HSV/HZV via fluorescein staining for lesions for punctate uptake for keratitis

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Conjunctivitis

Allergic Conjunctivitis

•Will have itching •May have swollen erythematous eyelids with injected / edematous conjunctiva •Remove culprit agent •?Seasonal •Moderate or more sx give antihistamines such as olopatadine topically

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Topical Steroids

•Never to be prescribed without DIRECT instruction and IMMEDIATE follow up with OPHTHO •As in the context of missed herpetic infection usage in this context may lead to permanent blindness •May also hasten iatrogenic cataracts/glaucoma

Cornea •HSV may affect eyelids, conjunctiva and cornea •May have hx of ‘cold sores’ or genital herpes with complaints of photophobia, pain, mild erythema of eye and decreased vision •Vesicular eruption may be present also along eyelid •Unilateral with possible pre auricular node inflammation •Ocular HSV ‘dendritic’ lesion : linear branching pattern with terminal bulb •Classic herpetic keratitis •Need to see OPHTHO 24-48 hours •Oral agents if severe systemic sx / topical at the minimum (antiviral agents such as viroptic one drop 6-9x / day)

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Corneal HSV Dendritic Lesion

Uveitis/Iritis/Keratitis

•Inflammation of the anterior segment of uveal tract •May extend to IRIS/CORNEA (KERATITIS) •Not a true emergency but does need follow up •Pain is due to ciliary nerves and muscle spasms which irritates TG nerve = photophobia •Flare cells may form from released WBCs

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Uveitis/Iritis/Keratitis •Often have photophobia and small pupil •Uni/bilateral pain •“White Spots” often if bacterial” •Iritis is inflammation of the anterior uveal tract •No FB sensation often severely photophobic and blepharospasm •Ciliary flush often red ring around around iris •No d/c and minimal tearing •Inflammatory cells / exudative “flare” in anterior chamber •Can be due to infectious/inflammatory processes

Hypopyon

•“Hypopyon” maybe associated with a life threatening infection of the cornea with a layer of white cells in the anterior chamber •Must see OPHTHO within hours

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AES Question

Question 3

Which of the following OPHTHALMIC drugs should NEVER EVER be given without OPHTHO consult and close follow up

A. Ketorolac (Ophthalmic) B. Tetracaine (Ophthalmic) C. Steroids (Ophthalmic) D. Moxifloxacin (Ophthalmic)

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Question 3

Which of the following OPHTHALMIC drugs should NEVER EVER be given without OPHTHO consult and close follow up

A. Ketorolac (Ophthalmic) B. Tetracaine (Ophthalmic) C. Steroids (Ophthalmic) D. Moxifloxacin (Ophthalmic)

Cornea - HZV

•Herpes Zoster Ophthalmicus •Shingles in first division of the trigeminal nerve distribution with ocular involvement •Rash does not cross midline and involves upper eyelid often V2/V3 branch may be affected •May have a lesion to nose (Hutchinson Sign) often ocular involvement •Pain, paresthesia, fever with malaise and headache with possible red eye, blurred vision, eye pain and photophobia •Other parts of eye may be involved (IRIS/UVEAL TRACT) •May have a ‘pseudodendrite’ (mucus plaque)

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Cornea - HSV

•Topical antivirals for 10 days •Possible erythromycin abx for prevention of bacterial infection •Pain control orally or topical cycloplegic agents (blocks pupillary sphincter and ciliary body) •If immunocompromised or systemic sx would need IV agents and admission •If have contact lens more prone to ‘keratitis’

Corneal Ulcer

•Serious infection from multiple layers of cornea = impaired vision/blindness •Develop from breaks in the epithelial barrier allowing access to underlying corneal stroma (break can be due to trauma/deep infection) •Contact lenses common culprit or ocular surgery, recent injury/trauma •Ask for any recent steroids/immunosuppressant meds •VA may be decreased if ulcer is in visual axis •Otherwise will have swelling, lid inflammation, discharge, photophobia, blurred vision and FB sensation

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Corneal Ulcers

•Treat aggressively with topical abx •OPHTHO consult for culture and scraping and if should use steroids •Ophthalmic fluoroquinolone every hour if bacterial •Cylclopegic for pain relief •NO PATCHING = increased melting and perforation •Prevent corneal scarring, perforation, glaucoma and cataracts

AES Question

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Question 4

Dendritic Corneal Lesions are Due to:

A. Syphilis B. Herpes Simplex C. Herpes Zoster D. Adenovirus

Question 4

Dendritic Corneal Lesions are Due to:

A. Syphilis B. Herpes Simplex C. Herpes Zoster D. Adenovirus

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Traumatic Injuries to Eyes: Conjunctiva •Conjunctival abrasion, laceration or FB are not as concerning as compared to similar injuries to other parts of the eye’s anatomy •Often only require a short course of topical abx (erythromycin ointment 0.5%) •Check for any globe rupture

•Subconjunctival Hemorrhage •Due to rupture of fragile vessels in this area for a number of reasons •Self limited within 2 weeks and harmless

Subconjunctival Hemorrhage

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Traumatic Injuries to Eyes: Cornea

•Epithelium fragile and gets damaged easily •Richly innervated thus painful •Epithelium regenerates q24-48 hours •Can easily get infected once damaged and iritis can often also occur

•Abrasions can be due to a number of reasons often innocuous (contact lens, fingernails, blown substances into eye) •Commonly FB sensation, photophobia and tearing, injection and blepharospasm

Traumatic Injuries to Eyes: Cornea

•VA unscathed unless in central visual axis (topical anesthetic gives relief)

•Abrasion is often visible to the naked eye as an area of irregular light reflection off the cornea or irregular corneal defect visible via fluorescein uptake

•If note a series of vertical corneal abrasions then likely a FB embedded in the upper eyelid/tarsal plate

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Traumatic Injuries to Eyes: Cornea

•If abrasion > 2mm consider cyclopentolate 1% topical TID •Topical NSAIDs such as ketorolac can help with pain relief and may need systemic adjuncts •Often may need antibiotics especially if contact lens or nail exposure • NO PATCH •Large or central axis abrasions should see OPHTHO •?Topical anesthetics…debate...one study supported overall literature states ‘avoid’ as inhibits healing and prevents blinking mechanism •?Eyepatch

Corneal Abrasion

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Corneal Lacerations •Full thickness ones may be characterized by iris changes, possibly hyphema and decreased VA and possibly globe trauma if any concerns in this regard move to CT orbits immediately

Corneal Foreign Bodies

•Often superficial and benign but penetration of a FB into globe may cause vision issues •Commonly pieces of metal, wood or plastic that maybe embedded into cornea •Metallic ones MAY form a ‘rust ring’ •FB sensation with accompanied blinking, tearing, vision changes and photophobia •Inflammatory reaction starts = dilation/inflammation of conjunctiva and edema of the eyelid •Always check under the eyelids as well (missing FB!)

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Corneal Foreign Bodies •If present for more than 24 hours will have a white ring surrounding •Do not try to remove the ‘rust ring’ leave this to OPHTHO (if metal) •Can be removed after topical anesthetic agents is given •Can use burr, cotton applicator or blunt end of a 25 gauge needle •Under slit lamp •If full thickness embedded corneal FB should be removed by OPHTHO •Discharge with topical abx and oral analgesia •Do not forget Tetanus !

Lid Lacerations

•Small ones (<1mm) even if near lid edge can heal on its own •If larger or medial canthus, lacrimal duct/sac, ’through and through’ and any associated severe trauma get OPHTHO involved

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Globe Rupture (Blunt or Penetrating)

•Open – Full thickness break of the eye wall (sclera and cornea) −Can be due to chemical reagents as well −Structures are compromised and eye can ‘deflate’

•Closed – Partial thickness wounds/lacerations and contusions −A wide range of lamellar structures and injuries such as corneal abrasions, viterous hemorrhage, commotio retinae

Blunt / Penetrating Eye Trauma •Assessment of VA, anterior chamber and integrity of the globe •GLOBE RUPTURE is the concern (OPEN/CLOSED) •Obvious if large hemorrhaging but not so much if a small corneal penetrating wound from a piece of metal that may have been launched from a grinder •Often direct trauma to the eyeball such as a fist or ball •Eyelids often will be swollen and shut with massive IOP increase •FB may be present…do not remove it and DO NOT push exam •Stop and shield eye (Do not add fluorescein/tetracaine) •Hyphema (rare spontaneous-sickle cell) may be evidence of significant ocular trauma along with ocular content expulsion •Need CT facial/orbit

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Blunt/Penetrating Trauma

•Penetration should be suspected with any puncture or laceration of the eyelid or swelling to periorbital area in the right context •Smaller the object that penetrates the greater the chance for occult injury (i.e. high velocity metal FB leading to abrasion to the cornea) •Sx of eye pain +/- VA changes, tear drop pupil, afferent defect, hemorrhagic chemosis and extensive subconjunctival hemorrhage should also raise suspicion

Globe Rupture

Hyphema

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Globe Rupture OPEN/CLOSED

Treatment:

1. Tetanus 2. Antibiotics 3. Patching 4. OPHTHO 5. Analgesia 6. Admission

Blow Out Fractures

•Most common site is the inferior wall (maxillary sinus) and medial wall (ethmoid sinus) •Inferior wall fractures may lead to entrapment of inferior rectus muscle = gaze restriction/diplopia •Medial wall fractures = SC emphysema •If isolated with no other injuries can see plastics/optho/oral maxofacial surgeons depending on your local practice •Oral abx and d/c home for follow up to ophtho to rule out any retinal detachments/tears

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A Note on Chemical Ocular Injury •Often from workplace and household cleaners = chemical burns •Concern is scarring of the cornea with permanent vision loss or eye damage from perforation of cornea •Alkali is worse than acid •Cause liquefaction = saponification (deep tissue penetration and denaturation) = BLINDNESS

•Tx = IRRIGATE with MORGAN LENS 2-3 L NS and regular pH checks +/- antibiotics

Alkali Damaging to the EYE!

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Acute Persistent Visual Loss

•At least 24 hours (one or both eyes)

Acute and Painful Vision Loss

•AACG (Acute Angle Closure Glaucoma) •Leads to increased IOP = optic neuropathy and vision loss •Due aqueous humour in ciliary area has its’ outflow impaired •Abrupt onset very painful +/- headache and blurred vision with N/V •Patient looks unwell •Often one eye and mid fixed dilated pupil with hazy and cloudy cornea and conjunctival injection •Eye maybe “hard” •IOP > 25 (upper limit of normal) with tonopen

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AACG

•Often misdiagnosed as a headache, GCA, SAH •Avoid irreversible damage to optic nerve

•Tx by lowering IOP by: −A) Block production of aqueous humor via B-blockers (timolol) or alpha adrenergic agonists, −B) Facilitate outflow of humour via miotic agents thus pupil constricts (pilocarpine 1-2%) and −C) Volume reduction of vitreous humor via mannitol •Need OPHTHO urgent

IOP : Tonopen

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AES Question

Question 5

Acute Glaucoma will lead to the all of following most likely symptoms EXCEPT

A. Headaches B. Purulent ocular discharge C. Fixed mid dilated pupil D. Change in visual acuity

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Question 5

Acute Glaucoma will lead to the all of following most likely symptoms EXCEPT

A. Headaches B. Purulent ocular discharge C. Fixed mid dilated pupil D. Change in visual acuity

Optic Neuritis

•Acute vision reduction can be idiopathic, or due to an acute viral infection such as MMR, herpes zoster or mono or first presentation of MS •Often unilateral but can be bilateral •Vision fields and color are affected •Fundoscopy exam shows edematous optic disk •MRI? •OPHTHO/NEURO

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Painless acute vision loss or reduction

•CRAO (Central Retinal Artery Occlusion) : Often sudden profound painless monocular vision loss # of causes (embolus, GCA, vasculitis, trauma, sickle cell disease, migrainous vasospasm, glaucoma) •May be preceded by amaurosis fugax •Afferent pupillary defect •Pale retina with cherry red macula •Tx based on evidence is lacking but aim is to restore flow MUST refer to OPHTHO

CRVO CRVO (Central Retinal Vein Occlusion):

•Thrombosis is the cause usually and is gradual/subacute •Standard risk factors DM, HTN, CVD etc… •Vague blurring to loss completely •Optic disc edema and diffuse retinal hemorrhages (“blood and thunder fundus”) •?Anticoagulants •Intravitreal injections of growth factor (VEGF), retinal laser •Refer to OPHTHO

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Flashes/Floaters •Monocular or Binocular (always intracranial) •Posterior segment of the eye is full of vitreous gel with age it contracts and separates from wall of the eye and in doing so pulls on retina (if complete – floaters) •Often also decreased VA/blurry •Common in elderly or nearsighted (MYOPIC) patients •Use of U/S (echogenic undulating membrane in the posterior to lateral globe that protrudes into vitreous) •OPHTHO URGENT referral within 24 hours

•Most of this also present in vitreous hemorrhage

Retinal Detachment

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Some comments…

•Bells’ Palsy and the Cornea (Exposure Keratitis) “dry eyes” •Papilledema = Evidence of ICP get blurred disc margins, cup is diminished/absent with flame shaped hemorrhages and VA preserved! •GCA

Key Highlights / Practice Recommendations

•Take a systemic approach •Know how to use a slit lamp •Always document visual acuity when possible •Look for signs of globe rupture (may be subtle) and other classic findings such as dendritic lesions for ocular HSV •Never give topical steroids •Very judicious usage of antibiotics for conjunctivitis even if suspect bacterial source… •Systemic symptoms or compromised state warrants IV abx/possible admission

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References

•Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition. Ocular Emergencies. Pages 1517-15483. Judith E. Tinitinalli et al.

•Uptodate; https://www.uptodate.com/contents/overview-of-eye- injuries-in-the-emergency- department?search=ocular%20emergencies&source=search_result &selectedTitle=1~30&usage_type=default&display_rank=1

Answer Key

1. B 2. D 3. C 4. B 5. D

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