“So That All May See” Acute Ophthalmology

Acute Medicine – Newcastle Royal College of Physicians | Northern Region

26th February 2019

Mr W. W. Woo BSc (Hons), MBBS (Lond), FRCOphth Consultant Ophthalmic Surgeon & Service Sunderland Eye Infirmary

Sunderland Eye Infirmary

• Stand alone Ophthalmology Hospital • City Hospitals Sunderland NHS Foundation Trust • Substantive Consultants: 23 • 7 sub-specialties • SAS Doctor: 1 • Fellows (Research / Post-CCT): 2 • ST Trainees: 10 • FY2: 1, GP Trainee: 1 SEI Numbers - 2017

• 100,000 outpatient appointments • 7,600 cataract surgery cases • 2 x dedicated cataract theatres (CTC) • 2,500 “other” surgical cases • 2 x main eye theatres • 16,700 intravitreal injections • 33,000 eye casualty visits • 24-hour “walk-in” Eye Casualty • Ward / GP / Optometry referrals

Objectives

• How to approach a patient with an acute ophthalmic problem

• Common acute ophthalmic problems

• When and how to refer – Is it appropriate? How to approach a patient with an ophthalmic problem

• Relax! Most pathologies directly visible, deducible from history

• Focused clinical history

• Thorough clinical examination

• Do I need to discuss this patient with the on-call ophthalmologist?

• Anything I can do in the immediate setting that will impact eventual clinical outcome? National Eye Institute Photos and Images Catalogue https://nei.nih.gov/photo Focused Clinical History Common Presenting Complaints

• What is the presenting problem?

• • Sudden Visual Loss • Swollen • Trauma • • • Post-op related problems • Neurological Red Eye – Broad Approach

• Significant proportion of referrals

• Two main groups – 1. With pain and blurring of vision (BoV) 2. Little / no pain, normal vision Red Eye, Painful, BoV

• Generally more serious / sight threatening than painless & normal vision

• Important differentials: • Acute angle closure glaucoma • Corneal abrasions / ulcers • Foreign body • Endophthalmitis • Red Eye, No Pain, Good Vision

• Mostly self limiting conditions

• Main differentials: • • • Subconjunctival haemorrhage Red Eye – Key Questions (1)

• Contact use? • Always consider • Discuss with Ophthalmologist if unsure • Type of lens (overnight use? daily vs monthly) • Duration of last use

• Sticky discharge • Non specific but suggests infective conjunctivitis (viral / bacterial) Red Eye – Key Questions (2)

• Past History • Iritis – recurrence? • Recurrent corneal abrasions – RCE

• Recent Ophthalmic Surgery • Endophthalmitis • Post-op inflammation / iritis • Protruding sutures • Raised intraocular pressures Red Eye – Key Questions (3)

• Obvious aetiology? • Chemical injury • Foreign Body • Trauma

• Systemic associations? • Autoimmune disease • Diabetes • Multiple Sclerosis • Vascular disease Visual Loss – Broad Approach

• Generally either painful or painless.

• Painful acute visual loss • Usually suggests anterior pathology • NB - • Redness / discharge / light sensitivity

• Painless acute visual loss • Usually posterior pathology • Bilateral suggests more central cause • Sudden onset = distressing ++ • Remember amaurosis fugax / migraine Painful Visual Loss

• Red eye • Foreign body • Corneal ulcer • Endophthalmitis • Acute angle closure • Uveitis • Trauma

• Eye Not Red • Optic neuritis Painless Visual Loss

• Transient monocular visual loss, “curtain coming down” – spontaneous resolution • Amaurosis fugax • Preceding flashing lights / floaters (photopsia) / head trauma / previous surgery • • History of diabetes / previous laser treatment • Vitreous haemorrhage Painless Visual Loss

• Headache / jaw claudication / elderly • with arteritic anterior ischaemic (AAION) • PMR

• Known Diabetic / Hypertensive / smoker • Retinal vascular occlusion

• Bilateral visual loss – think neurological • Stroke • Raised intracranial pressure • Migraine Clinical Examination

Clinical Examination (1)

• Visual acuity • Measure for individual eyes • Any improvement with pinhole? • Top no. - chart distance (normally 6m) • Bottom no. - how far down the chart patient can read. • If unable to see chart, try counting fingers (CF), hand movements (HM), perception of light (PL), no perception of light (NPL).

Example: • 6/9 = chart read at 6m, patient reads down to line normally visible from 9m away Clinical Examination (2) • Confrontational Visual Fields

• Extra-ocular movements

• Pupillary Examination • Size difference • Direct + consensual reflex • Relative Afferent Pupillary Defect (RAPD) • If present indicates disease in affected eye. Slit Lamp Examination General Approach • Anterior to posterior approach

National Eye Institute Photos and Images Catalogue https://nei.nih.gov/photo

National Eye Institute Photos and Images Catalogue https://nei.nih.gov/photo

Slit Lamp Examination Eyelids / Lashes

• Oedema / erythematous / warm

• Evert lids – Foreign body?

• Purulent Discharge

• / Meibomianitis

• Lid retraction / / Gallery www.retinagallery.com laceration Slit Lamp Examination

Conjunctiva /

• Palpebral follicles / papillae Injection

• Bulbar Conjunctiva injection Laceration chemosis (swelling)

Is the eye red? Necrotising anterior with scleral thinning Slit Lamp Examination

Cornea • Clarity (scar, oedema) • Epithelial Defects (abrasions / ulcers) • Foreign Body

Anterior Chamber • Shape – Deep & well formed / Shallow • Flare • Cells • Hyphaema – blood in AC • Hypopyon – pus in AC Corneal graft failure Corneal vascularisation and haze Peri-limbal conjunctival injection Hyphaema – blood in AC Retina Gallery www.retinagallery.com Intraocular infection – pus in AC Slit Lamp Examination

Iris • Shape – is the round? previous laser / surgery penetrating injury rubeosis

Lens • Position – subluxation • Intra-lenticular foreign body • Cataract Retina Gallery www.retinagallery.com prolapse. Slit Lamp Examination

Vitreous

• Tobacco dusting (Shaffer sign) • Pigment in anterior vitreous • Suggestive of significant retinal pathology (tear / detachment)

• Posterior vitreous detachment / vitreous condensation / Weiss ring

• Haemorrhage Slit Lamp Examination

Retina

• - Colour (pale / white) - Contour (disc oedema) - CD ratio (cupping) - Haemorrhage

• Macula - Exudate (yellow / white) - Haemorrhage (red) - Pigmented changes Slit Lamp Examination

Retina

• Peripheral retina - Haemorrhage - Exudates - Detachment / tear (pale yellow)

National Eye Institute Photos and Images Catalogue https://nei.nih.gov/photo Objectives

• How to approach a patient with an acute ophthalmic problem

• Common acute ophthalmic problems

• When and how to refer – Is it appropriate? Acute Angle Closure

Presentation • Severely painful red eye • Haloes, blurred vision • Nausea and vomiting • Hypermetropic (long sighted) • SSRIs, anti-muscarinic drugs

Examination • VA severely reduced • hazy, shallow AC • Fixed, semi-dilated pupil • Hard eye to digital palpation (!!!)

Management • Immediate referral • Early recognition essential in preventing visual loss Chemical Injury

Presentation • Alkaline vs acid injury • Time of injury • Painful ++ / Photophobic

Examination • Normal or reduced vision • Corneal oedema • Epithelial defect • Limbal ischaemia

Management • Immediate, copious irrigation in A&E / surgery (LA drops) • pH documentation • Remember to evert eyelids!

** Refer to Ophthalmology ASAP following irrigation ** Dua HS et al. A new clasiffication of ocular surface burns Br J Ophthalmol 2001; 85: 1379-1383. Corneal Ulcers

Presentation • Painful, photophobic • History of herpetic , cold sores • * Immunocompromised individuals * • * Prior contact lens use *

Examination • Reduced VA • Epithelial defect • Hypopyon, corneal haze

Treatment • Herpetic keratitis – Aciclovir ointment 3%, 5x / day • Bacterial ulcer • Topical antibiotics • CL users – Topical fluoroquinolone 1st line (ofloxacin, ciprofloxacin drops)

**Speak to Ophthalmologist** Retina Gallery www.retinagallery.com Corneal Abrasions

• Similar presentation to ulcers • History of trauma usually • Usually responds quickly to treatment

Treatment • Patch vs no patching • Chloramphenicol drops / ointment QDS Retina Gallery www.retinagallery.com Corneal Foreign Body

• Presentation • Acutely painful eye • Watering, gritty sensation • History of object entering eye

• Examination • Vision – may be normal • Evert eyelids! • Slit lamp examination inc. fluorescein • Attempt removal • L.A. drops • Cotton bud • Green needle • Topical antibiotics

** Speak to Ophthalmologist ** Retina Gallery www.retinagallery.com Acute Anterior Uveitis

Presentation • Painful red eye • • Treated for resistant conjunctivitis • Systemic associations, previous episodes

Examination • Circumciliary injection • AC cells / flare • Keratitic precipitates

Management • Refer patient • Will require topical steroids, mydriatics • Further investigations if bilateral / recurrent Conjunctivitis

Presentation • Extremely common! • Gritty / uncomfortable but not painful • Discharge + sticky eyes • Bilateral (viral, allergic), unilateral (bacterial) • Unwell contacts, URTI

Examination • Chemosis • Conjunctival injection • Normal VA (unless viral keratitis – blurred vision)

Treatment • Self limiting • Topical antibiotics (chloramphenicol / fucithalmic) • Sodium Cromoglycate, Olopatidine (allergic) • Refer if not responding • Beware STI – Chlamydia / Gonorrhoea (recurrent) Central / Branch Retinal Vein Occlusion (CRVO /BRVO)

Presentation • Painless blurred vision – sudden / insidious

Examination • VA reduced (variable) • Relative afferent pupillary defect (severe CRVO) • Extensive haemorrhages • Distended retinal veins • Blurred discs

Management • Refer to Ophthalmology • No immediate treatment • Screen for hypertension, diabetes and glaucoma • FBC, ESR. CRP, SPE, TFT • Risk of neovascular glaucoma • May be treated with laser pan-photocoagulation (PRP) Retina Gallery www.retinagallery.com Central / Branch Retinal Artery Occlusion (CRAO / BRAO)

History • Sudden painless visual loss • Complete (CRAO) or partial (BRAO) • Arteriopath / smoker

Examination • Profound reduction in VA – CF / PL / NPL • RAPD • Cherry-red spot (CRAO) • Emboli • Carotid bruits? AF?

Management • Immediate referral especially if the visual loss is < 6 hrs • Aspirin • IV acetazolamide and massage • TIA clinic referral Retina Gallery www.retinagallery.com Retinal Detachment

History • Floaters, flashes of light • Curtain coming across the vision • Previous RD / cataract surgery / FHx /

Examination • VA variable • defect • Greyish retina, hole and tear visible

Management • Refer based on symptoms • Surgical management Retina Gallery www.retinagallery.com Ischaemic Optic Neuropathy

Presentation • Sudden visual loss • Persistent headache, general malaise • Jaw claudication, scalp tenderness • AAION (GCA, arterial inflammation) vs NAION

Examination • Profound visual loss • 6/60 or less (AAION), less severe (NAION) • RAPD • Swollen optic disc • Tenderness over temporal artery (GCA) / scalp tenderness • Artery is usually not palpable.

Management • Immediate referral (only if visual symptoms!) • Raised ESR, CRP - AAION • Temporal artery biopsy – definite diagnosis • Systemic steroids – IV / PO Retina Gallery www.retinagallery.com Objectives

• How to approach a patient with an acute ophthalmic problem

• Common acute ophthalmic problems

• When and how to refer – Is it appropriate? Referral Guidelines

Immediate Within hours Same week Not needed Red eye Red eye: Red eye: Viral / bacterial •Acute angle closure** •Uveitis •Persistent / recurrent conjunctivitis •Post-op pain / BOV •Corneal ulcer conjunctivitis Minor corneal Trauma Trauma: Sudden visual loss: abrasions •Chemical burn** •Blunt trauma (if no •CRVO / BRVO •Corneal laceration** rupture) Episcleritis •Globe perforation** Facial nerve palsy Swollen lids: unless there is severe Suspected GCA with •Pre-septal cellulitis corneal exposure then no ophthalmic Sudden visual loss: within 24 hours. symptoms (refer to •GCA + AAION** • rheumatology) •CRAO/BRAO Sudden visual loss: Painful III nerve palsy •Vitreous •PCA aneurysm haemorrhage (needs urgent CTA) •Retinal tears / detachment (24-48 hr) •NA-AION

**Immediate referral regardless of time of day Summary

• Focused history, methodical examination

• Large proportion of pathology visible

• Do not miss / delay referring: • Acute angle closure • Chemical burns (irrigate first) • / severe trauma • Corneal ulcers • GCA with AAION Acknowledgements - Images

• Hugh Harris (Medical Photographer, SEI) • Image copyrights - SEI • National Eye Institute • Free to use (educational purpose) • Retinal Gallery • Free to use (educational purpose) @EyeDoctor_Woo Questions?

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