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 Myopia “Farsightedness” “Nearsightedness” 2 9/12/2017 Pupils • PERRL, not PERRLA! • Accommodative Triad: Accommodation, Convergence, and MIOSIS • CN2- Edinger Westphal Nucleus- CN3 Eye Pain Control Good Idea Bad Idea • Cycloplegics (Atropine, • 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 Keratitis) • 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 floater in his central vision. 3 9/12/2017 Posterior Vitreous Detachment (PVD) • Detachment of Vitreous from Posterior Retina • Has occurred in 66% of 66 year olds • Flashes with large central floater • May cause hemorrhage, retinal detachment • 15% of symptomatic PVD will have a retinal tear Patient 2 • 35 year old white man with 2 day history of pain, redness, photophobia 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/ Uveitis • Intraocular inflammation • May be Anterior, Posterior, Scleral, Episcleral • Treatment: Steroids, NSAIDs, Cycloplegia • Order lab workup for 2nd episode, or for Scleritis 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 visual acuity is slightly reduced. Corneal Abrasion • Epithelium will heal in 2-3 days regardless of treatment • Comfort: Patch or Bandage Contact lens • Antibiotic drops, cycloplegia, +/- steroids Corneal Ulcer • Corneal ulcer= Supprative material • Bacterial, Fungal, or Viral • Needs Eye MD • Culture first, then Fortified antibiotics, Cycloplegia, +/- Steroid • Pseudomonas, Gram + most severe 6 9/12/2017 Bacterial Keratitis • Contact lens 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 cornea! • Can also be due to Contact Lens intolerance Patient 4 • 18 year old college student with 3 day history of red, swollen eyelid. 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 Cellulitis • Treatment: • Reduce inflammation • Treat Blepharitis • 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) • Doxycycline, 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 Tears 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) KeratoConjunctivitis • “Pink Eye”; you know real “Pink Eye” when you see it • Adenovirus 8, 19, 37 typically • Very Contagious!!!! • Red conjunctiva with Follicles, rope-like discharge, lids stuck closed • Cough/ runny nose; + Pre-Auricular Node (PAN) 10 9/12/2017 Adenoviral Conjunctivitis • 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 • Retinitis/ Optic Neuritis 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 (Iris 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) Dry eye syndrome d) SLK e) Exposure f) Trichiasis g) Blepharoconjunctivitis h) Foreign body under lid i) Neurotrophic keratopathy j) Corneal abrasion k) Lagophthalmos 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, blurred vision, 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! • Orbital Cellulitis: • Preseptal Cellulitis: • Eyelid/ edema • Eyelid/ edema • Conjunctival Chemosis • No Chemosis/ Proptosis • Proptosis • Abscess possible • Reduced ocular movement/ pain with eye movement • +/- Pupillary Defect Orbital Cellulitis • Frequently extension from Paranasal Sinuses • Treatment • Life- Threatening disease! • Admit, ID consult, IV Antibiotics, Drain Abscess • Staph, Strep, H. flu Preseptal Cellulitis • Usually adjacent infection or trauma • Anterior to Orbital Septum • Abscesses 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 Ptosis (Levator= Superior branch of CN3) • Pupil-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 Cataract Chaffing extraction • Treatment: • Lower IOP with Timolol, Brimonidine, Dorzolamide. • Acetazolamide 500mg • Prednisolone Acetate 1% • +/- Zofran • +/- IV Mannitol 17 9/12/2017 Primary Open Angle Glaucoma • #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 Hemoglobin A1c was 10. • He is complaining today of black spiderwebs in his vision of his right eye. He says that his vision has been