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Home , Cycloplegia, Lagophthalmos, Orbital cellulitis, Scleritis

9/12/2017

Ten Eye Problems you’ll meet in the ER, and how to Manage Them

Scott Kelly, MD, MPH Howerton Eye Clinic Austin, Texas September 16th, 2017

1 9/12/2017

Hyperopia “Farsightedness” “Nearsightedness”

2 9/12/2017

Pupils

• PERRL, not PERRLA!

• Accommodative Triad: , Convergence, and

• CN2- Edinger Westphal Nucleus- CN3

Eye Pain Control

Good Idea Bad Idea

• Cycloplegics (, • Proparicaine/ Cyclyopentolate) Tetracaine

• Patching if Sharp pain • Ketorolac

• Diamox/ IOP lowering • Heavy Narcotics drops (Combigan, Co- opt) if pressure >30

• Steroids (if not HSV Epithelial )

• Ointment/ Lubrication

Patient 1

• 65 yo Man who noticed flashes of light while working in his yard. He saw flashes of light for 4- 5 hours, which has now subsided. He now has a C- shaped in his central vision.

3 9/12/2017

Posterior Vitreous Detachment (PVD)

• Detachment of Vitreous from Posterior

• Has occurred in 66% of 66 year olds

• Flashes with large central floater

• May cause hemorrhage,

• 15% of symptomatic PVD will have a retinal tear

Patient 2

• 35 year old white man with 2 day history of pain, redness, in his right eye. This happened once before in the opposite eye and resolved after 1-2 weeks of pain. Other ROS/ Medical history is negative.

Iritis/

• Intraocular

• May be Anterior, Posterior, Scleral, Episcleral

• Treatment: Steroids, NSAIDs,

• Order lab workup for 2nd episode, or for or Panuveitis

• Most commonly: Laboratory negative

4 9/12/2017

Lab Workup

• Head CT not indicated!

• Common Infectious Causes

• TB, Syphillis, HSV/ HZV

• Common Non Infectious Causes

• Sarcoid, RA, Psoriasis, SLE

• HLA B-27

5 9/12/2017

Patient 3

• 25 year old carpenter who was scratched in the eye by a piece of plastic. He has severe pain, photophobia, and tearing when opening his eye. His is slightly reduced.

Corneal Abrasion

• Epithelium will heal in 2-3 days regardless of treatment

• Comfort: Patch or Bandage Contact

• drops, cycloplegia, +/- steroids

Corneal Ulcer

• = Supprative material

• Bacterial, Fungal, or Viral

• Needs Eye MD

• Culture first, then Fortified , Cycloplegia, +/- Steroid

• Pseudomonas, Gram + most severe

6 9/12/2017

Bacterial Keratitis

• use, Abrasion biggest risk factors

• Goal: 1) Treat Infection 2) Heal Epithelium 3) Improve Vision

• Consider Fungal infection with plant material

• Not typically contagious

marginal keratitis

• Non-infectious infiltrates from Staph exotoxin secretion from lid margins

• Treat lids, not !

• Can also be due to Contact Lens intolerance

Patient 4

• 18 year old college student with 3 day history of red, swollen . She feels like there is a knot in her lid that is mobile and painful to the touch.

7 9/12/2017

Chalazion

• Blockage of Meibomian Gland

• Non-infectious, but can lead of

• Treatment:

• Reduce inflammation

• Treat

• Incise/ Curettage

• Steroid Injection (Caution)

Blepharitis/ Meibomian Gland Dysfunction

• “Itching, Burning, Foreign Body Sensation”

• Anterior (Lashes)

• Seborrhea, Demodex

• Posterior (Meibomian Glands)

• Systemic inflammation/ Hormone

Demodex

8 9/12/2017

Rosacea

• Rhinophyma

• Telangiectatic vessels, pustules of skin

• vascular inflammation of lid margins

• spill over inflammation on ocular surface:

• Marginal Keratitis

• Staph Hypersensitivity

• Corneal Perforation

Rosacea Treatment Goals

• Reduce Eyelid inflammation

• Matrix Metalloproteinase 9 (MMP-9)

• , Azithromycin, Erythromycin

• Clean lids/ lashes

• Avenova/ Ocusoft Hypochlor

• Warm compresses

• Lubricate/ reduce tear osmolarity

• Treat Ocular Inflammation (Restasis, Xiidra)

9 9/12/2017

Dry Eye Syndrome

• #2 cause of visits to Ophthalmologists

• Most DES patients combo of Blepharitis and Aqueous Tear Deficiency (ATD)

• Blepharitis causes poor tear film quality and increased evaporation

• ATD more common in SLE, RA, Sjogren’s

• Tear replacement, increase Tear production, lid hygiene/ improve tear quality

• Serum

Patient 5

• 25 year old Kindergarten teacher who has a 2 day history of photophobia, redness, pain and discharge in her left eye. She has had runny nose and cough for the last 4 days.

Adenoviral (Epidemic)

• “Pink Eye”; you know real “Pink Eye” when you see it

• Adenovirus 8, 19, 37 typically

• Very Contagious!!!!

• Red with Follicles, rope-like discharge, lids stuck closed

• Cough/ runny nose; + Pre-Auricular Node (PAN)

10 9/12/2017

Adenoviral

• Severe Cases= Conj Pseudomembranes or Corneal Sub-epithelial Infiltrates

• Treatment:

• Supportive; Cool tears, compress

• +/- Steroids

• Normal Course: worsening for 5 days, resolves 3 weeks

Bacterial Conjunctivitis

• Common but self limiting

• Over diagnosed

• Severe Forms: Chlamydia (chronic) and Gonorrhea (hyperacute/ can perforate) TIP: use a cheaper generic antibiotic • Typically gram +; cultures not necessary (Cipro, Polytrim, Tobramycin) • Ocular symptoms similar to viral but localized instead of brand name

Patient 6

• 55 year old Hispanic man with 2 days of right sided scalp and forehead pain. A rash developed yesterday, and he now has difficulty opening his eyelid.

11 9/12/2017

Herpes Zoster Ophthalmicus

• Unilateral, respecting midline

• Pain from inflamed nerves!

• Increased risk of ophthalmic involvement with + Hutchinson’s sign (Nasociliary Nerve V1)- Tip of nose

• Eye involvement may lag behind or precede rash

Herpes Zoster Ophthalmicus

• Treat ideally < 4 days from onset:

• Valacyclovir 1 Gram TID 10 days

• Oral Prednisone for 10 days

• Bacitracin to skin lesions

• +/- Capsaicin

HZO Ophthalmic Complications

• Immune Keratopathy/ Scarring

• Neurotrophic Keratopathy

• Uveitis

• IOP Spike

• /

12 9/12/2017

Patient 7

• 25 yo Woman who has a 2 day history of a red, painful left eye with photophobia and tearing. Her right eye is normal. She has been under stress recently, and attempted to deal with the stress with a trip to the beach.

Herpes Simplex Epithelial Keratitis

• Dendritic lesion with club-shaped ends

• Represents ACTIVE Virus; typically HSV-1

• Other presentations:

• Geographic ulcer

• Stromal (Disciform) Keratitis

• Uveitis ( atrophy and high IOP)

HSV Treatment Epithelial Stromal

• Valacyclovir 500mg TID • Topical Steroid QID

• Acyclovir 400mg 5x/day • Valacyclovir 500mg daily (prophylactic dose) • Trifluridine Drops 9x/day • Cycloplegia • NO STEROIDS until epi healed

• Cycloplegia

13 9/12/2017

a) Healing epithelial abrasion b) Herpes keratitis c) d) SLK e) Exposure f) g) Blepharoconjunctivitis h) Foreign body under lid i) Neurotrophic keratopathy j) k)

f) Trichiasis c) Dry eye syndrome d) SLK g) Blepharoconjunctivitis e) Exposure f) Trichiasis k) Lagophthalmos i) Neurotrophic h) Foreign body keratopathy under lid

b) Herpes keratitis j) Corneal abrasion a) Healing epithelial abrasion

Patient 8

• 30 year old man with a 2 day history of worsening eye pain, eyelid swelling, , and pressure-like sensation around his eye. He has had nasal congestion for the last week.

14 9/12/2017

Cellulitis

• MUST GET CT ORBITS/ FACE!

• : • Preseptal Cellulitis:

• Eyelid/ edema • Eyelid/ edema

• Conjunctival • No Chemosis/ Proptosis

• Proptosis • possible

• Reduced ocular movement/ pain with

• +/- Pupillary Defect

Orbital Cellulitis

• Frequently extension from Paranasal Sinuses

• Treatment

• Life- Threatening !

• Admit, ID consult, IV Antibiotics, Drain Abscess

• Staph, Strep, H. flu

Preseptal Cellulitis

• Usually adjacent infection or trauma

• Anterior to

• common

15 9/12/2017

Patient 9

• 65 year old truck driver that has noticed double vision for the last 2 days. He also is having trouble keeping his right eye open. He denies other symptoms.

Cranial Nerve 3 Palsy

• CN3 Palsy: “Down and Out”

• Often (Levator= Superior branch of CN3)

• -sparing: usually Ischemic

• Pupil- involving: Aneurysm (Posterior Communicating Artery) until proven otherwise

Cranial Nerve 3 Palsy

• Diagnosis: Prompt MRI/ MRA!

• Ocular Myasthenia Gravis can Masquerade as CN palsy

16 9/12/2017

Patient 10

• A 70 year old woman is complaining of eye pain, redness, haloes around light, headache, nausea and vomiting.

• On exam, she has reduced vision, redness, a cloudy cornea, and a fixed pupil. Her IOP reading by tonopen is 55.

High Pressure Angle Phaco- Neo- Inflammatory Closure morphic vascular • Small stature • Elderly • Uncontrolled • Viral Uveitis Diabetes (or Vein • Hyperopia • No history of Occlusion) • Trabeculitis or Iris Chaffing extraction

• Treatment:

• Lower IOP with Timolol, Brimonidine, Dorzolamide.

• Acetazolamide 500mg

• Acetate 1%

• +/- Zofran

• +/- IV Mannitol

17 9/12/2017

Primary Open Angle

• #2 cause of blindness in the world (ACG and POAG)

• 2% of US population above 40 yo

• Risks:

• Classic: Age, Race, FHx, Corneal Thickness, IOP

• New: Myopia, Vascular compromise

• Most IOP elevations NOT PAINFUL

Bonus: Patient 11

• 60 year old construction worker who was diagnosed with Diabetes Mellitus Type II 5 years ago. Since then, he has been “controlling his Diabetes with his diet, because he doesn’t feel bad”. He doesn’t check his blood sugar, and his last A1c was 10.

• He is complaining today of black spiderwebs in his vision of his right eye. He says that his vision has been worsening over the last 3 months in both eyes.

18 9/12/2017

Diabetic

Non-Proliferative Proliferative • Dot-Blot Hemorrhages, Venous • Neovascularization of Disc or Beading, Hard Exudates, Retina with/ without Vitreous Microvascular Abnormalities Hemorrhage

Treatment: Pan-Retinal Photocoagulation

Diabetic

• Seen in NPDR or PDR

• Hemorrhage or Hard Exudates in Macula

• #1 cause of vision loss in Diabetics

• Dx: OCT and Exam

• Tx: Anti-VEGF agents (Avastin, Lucentis, Eyelea)

• Focal Argon Laser

Diabetic Retinopathy

• #1 cause of irreversible blindness in the US

• Recommend HgA1c below 7.0

• Good HgA1c (at any time) has shown improved Retinopathy control

• AAO Preferred Practice Patterns 2016:

• DFE within 5 yrs of diagnosis Type 1 diabetics

• DFE yearly for ALL type 2 diabetics

• No DFE for gestational diabetes; however diabetic patients who become pregnant are at increased risk of PDR

19 9/12/2017

Thank You

Bibliography

• The Wills Eye Manual, 5th Ed. Ehlers J and Shah C. 2008. • AAO Preferred Practice Patterns. AAO.org. • eyewiki.org

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