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Home , Blepharitis, Chemosis, Hypertropia, Optic neuritis, Orbital cellulitis, Papilledema

9/11/2019

ER Volume Weekend: better things to do Weekend + hurricane scare 120

THE OPHTHALMIC 100 EMERGENCY 80 60

DEPARTMENT 40

Alison Bozung, OD, FAAO 20

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Age / DOB Chief complaint Acuity 67, F Double vision 3 65, M 2 19, F 2 18, F , eye 2 30, F Eye 2 17, M Flashes, 2 24, M Blind spot 3 52, M Acute loss of vision 2 28, M , sore 3 82, F Floaters, 3 30, M swelling 3 57, M Blurred vision, pain 2 58, M Diplopia, 1 month 4 67, F Loss of vision 2 12, M Red eye, pain 2 49, F Eyelid swelling 3 32, F Papilledema 2 46, F Diplopia 2

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Age / DOB Chief complaint Acuity 67, F Double vision 3 65, M Diplopia 2 19, F Papilledema 2 18, F Photophobia, red eye 2 30, F Eye pain 2 17, M Flashes, floaters 2 24, M Blind spot 3 CHIEF COMPLAINT: 52, M Acute loss of vision 2 28, M Red eye, sore 3 82, F Floaters, blurred vision 3 30, M Eyelid swelling 3 57, M Blurred vision, pain 2 58, M Diplopia, 1 month 4 EYELID SWELLING 67, F Loss of vision 2 12, M Red eye, pain 2 49, F Eyelid swelling 3 32, F Papilledema 2 46, F Diplopia 2

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Patient A

Patient A Patient B

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Differential diagnoses

■ ■ PRESEPTAL VS ■ Preseptal ■ Orbital cellulitis ■ Darcyocystitis ■ Acute allergic

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Preseptal vs Orbital Cellulitis Preseptal vs Orbital Cellulitis What’s the difference? Why does it matter?

■ Preseptal Cellulitis ■ Potential outcome.. – Infection and of the preseptal

■ Orbital Cellulitis – Infection and inflammation of the orbital contents

Merckmanuals.com

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Preseptal vs Orbital Cellulitis Preseptal vs Orbital Cellulitis Etiology Signs / Symptoms

■ Skin trauma / infected insect bites ■ Periorbital edema ■ Loss of vision with APD ■ Adjacent structures ■ Periorbital ■ Ophthalmoplegia / diplopia – Hordoelum ■ Tenderness ■ Pain on Moranecore.utah.edu – ■ Pain ■ Proptosis – ■ ■ Local or systemic infection ■ Fever – Middle ear, tooth infection, etc – Hematogenous spread

Eyerounds.org 13 14

Preseptal Cellulitis: Management Orbital Cellulitis: CT findings

Empiric treatment typically suffices – Augmentin ■ Orbital fat stranding – Cephalexin ■ Sinusitis – ■ Anterior displacement ■ Subperiosteal Suspect MRSA – Trimethoprim-Sulfamethoxazole – – Fluoroquinolones

Eyerounds.org 15 16

Orbital Cellulitis: Management

■ ER referral! ■ Emergent CT imaging ■ Admission Patient B – Surgical intervention indicated for subperiosteal abscess – IV 3-5 days – Discharge with oral antibiotics

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Dacryocystitis Dacryocystitis: Management Signs / Symptoms ■ Step 1: oral antibiotics ■ Rapid onset – Gram positive* ■ Erythematous, tender, and – Consider gram negative in distended lacrimal sac immunocompromised patients ■ Step 2: incision and drainage ■ +/- purulent discharge from punctum ■ Step 3: DCR if NLDO ■ Likely history of NLDO

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Age / DOB Chief complaint Acuity 67, F Double vision 3 65, M Diplopia 2 19, F Papilledema 2 18, F Photophobia, red eye 2 30, F Eye pain 2 17, M Flashes, floaters 2 24, M Blind spot 3 52, M Acute loss of vision 2 28, M Red eye, sore 3 “PAPILLEDEMA” 82, F Floaters, blurred vision 3 57, M Blurred vision, pain 2 58, M Diplopia, 1 month 4 67, F Loss of vision 2 12, M Red eye, pain 2 32, F Papilledema 2 46, F Diplopia 2 67, F Foreign body sensation 4

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Hyperemia / telangiectatic vessels Hyperemia? Patton’s folds

Elevated disc margin?

Cotton Wool Spot? Patient A Patient B Definitely edematous Are these just anomalous? 23 24

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Papilledema Bilateral edema

Swelling of the due to increased ALWAYS ASK these questions: – History of cancer Differential diagnoses: – New or frequent – Idiopathic intracranial hypertension (IIH) – Recent unintentional weight loss or gain – Space occupying lesion – Medications – Venous sinus – Diplopia – Obstructive – Transient visual obscurations (TVOs) – Pulsatile tinnitus

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Bilateral optic nerve “edema” Optic nerve edema

Avg RNFL > 116 90% sensitivity Evaluation Clinical Testing – OCT RNFL and specificity! Nasal RNFL > 92 – Disc edema – OCT RNFL + GCC – Disc hemorrhages – – Visual field Enlarged blind spot – Patton’s folds – Ultrasound – Absence of SVP – Autofluorescence – Ultrasound* Drusen hyperechoic or hyperautofluorescent – Autofluorescence

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Neuro-imaging for bilateral disc edema Signs of elevated ICP

■ What do I order? – MRI: mass lesions, hydrocephalus With contrast – MRV: venous sinus thrombosis

Radiopedia.org Researchgate.net Ajnr.org

Posterior Globe Transverse sinus Empty Sella Flattening stenosis

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IIH: diagnosis IIH: treatment

■ No mass or thrombosis on MRI + MRV ■ Most effective management? Studies show – Weight reduction (6% body weight) ■ Evidence of elevated ICP (one of following): improved VF, QOL, – Pulse synchronous tinnitus – , up to 4g daily and weight loss – 6th nerve palsy – Low sodium diet when combined – Optic nerve edema – Empty sella – Optic nerve sheath fluid ■ In vision threatening cases, optic nerve sheath fenestration may be indicated ■ Elevated CSF opening pressure – Normal CSF

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Patient A: IIH

Before and after diamox

Patient B Next plan? Get a scan.

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Age / DOB Chief complaint Acuity 2cm x 3cm pineal cyst 65, M Diplopia 2 18, F Photophobia, red eye 2 30, F Eye pain 2 17, M Flashes, floaters 2 24, M Blind spot 3 52, M Acute loss of vision 2 Obstructive 28, M Red eye, sore 3 hydrocephalus 82, F Floaters, blurred vision 3 57, M Blurred vision, pain 2 58, M Diplopia, 1 month 4 67, F Loss of vision 2 12, M Red eye, pain 2 46, F Diplopia 2 Next day 67, F Foreign body sensation 4 consult

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FLASHES + FLOATERS

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Are all retinal detachments created equally?

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Retinal Detachment 1. Is the macula on or off?

■ What are the most important things to consider? ■ Determination: 1. Is the macula on or off? – VA: not always reliable, subject to other factors 2. What kind of detachment is this? – OCT: better if available 3. Where are the retinal break (s)? 4. What can this patient expect from ? ■ Macula ON  Refer NPO/same day ■ Macula OFF  Refer for repair within the week since LOV noted – Sooner is better, but within reason.

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BCVA OD 20/200 BCVA OD 20/50

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2. What kind of detachment is this? ■ Rhegmatogenous – Most common Vitrectomy + gas/oil – Associated with retinal break(s) + laser – Typically has a corrugated surface

■ Exudative / serous – Associated with hyperpermeable process Treat the – May have shifting SRF underlying cause

■ Tractional

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2. What kind of detachment is this? Tractional Retinal Detachment ■ Rhegmatogenous – Most common – Associated with retinal break(s) Vitrectomy + gas/oil Scleral buckle + laser – Typically has a corrugated surface

■ Exudative / serous – Associated with hyperpermeable process Treat the – May have shifting SRF underlying cause

■ Tractional Treat the VEGF problem. – Associated with proliferative Surgery indicated if – Medical emergency? macula threatened.

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Tractional Retinal Detachment 3. Where are the retinal break(s)?

■ Lincoff’s Rule

■ Most important in macula-on RRDs, so you can have patient position better

■ If no tear visualized, consider exudative detachment

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Age / DOB Chief complaint Acuity 4. What can this patient expect after 65, M Diplopia 2 referral? 18, F Photophobia, red eye 2 30, F Eye pain 2 24, M Blind spot 3 ■ Same day referral, but they don’t always have same day surgery 52, M Acute loss of vision 2 – Still best to keep patient NPO just in case 28, M Red eye, sore 3 57, M Blurred vision, pain 2 58, M Diplopia, 1 month 4 ■ Still very high risk of vision loss with “macula-on” 67, F Loss of vision 2 12, M Red eye, pain 2 46, F Diplopia 2 ■ If gas is used, patient will 100% develop a 67, F Foreign body sensation 4 – Usually within 2-6 months 27, F Loss of vision 3

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ACUTE VISION LOSS

Patient A

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What’s going through our mind?

■ Is this arteritic or non-arteritic?

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Non-arteritic AION Arteritic AION (GCA)

■ Demographics ■ “Classic” signs + symptoms ■ Demographics ■ “Classic” symptoms – Older (age > 55, peak 70-79) – Middle and older age – Altitudinal defect – Female > male – Significantly decreased VA – Vasculopath – Vision loss upon awakening – Significantly depressed VF – Disc at risk – BCVA may be preserved ■ Review of systems – Pallid nerve edema – Disc drusen – Transient vision loss* – Nocturnal hypotension – New (70%) – Jaw claudication (50%) – – Fever (50%) – Medications: PDE-5 inhibitors – Polymyalgia rheumatica (40-50%) – – Temporal pain – Weight or appetite loss – Fatigue

Webeye.ophth.uiowa.edu 57 58

NA-AION A-AION Arteritic AION ■ Where do I refer? ■ Treatment: manage risk ■ Management consists of emergent – ER: IV steroids factors lab testing and treatment – TA : Oculoplastics, vascular surgery, plastic surgery – Control HTN – ESR – Manage cholesterol – CRP ■ What dose of steroids is administered? – Review medications – CBC (anemia) – 500-1000mg IV x 3d VERY careful taper over (dosage, timing, etc) 6-12 months. – Confirmatory test – Then prednisone taper – Sleep study referral ■ Temporal artery biopsy Improper taper can – Consider daily aspirin ■ Color doppler ultrasound ■ Can I start steroids before a biopsy? lead to breakthrough. – Absolutely. ■ Monitor monthly ■ Emergent referral – Biopsy should be done within 2 weeks.

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Optic : the two camps

1. “Classic” 2. All the other “optic neuropathies” – Demyelinating (MS) – Infectious ■ HIV ■ Lyme ■ Toxoplasmosis ■ Herpes virus ■ Tuberculosis – Inflammatory ■ ■ Systemic erythematosus ■ Radiation-induced Patient B ■ Neuromyelitis optica (NMO)

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Who gets optic neuritis? Diagnosis + prognosis

■ Demographics – Young to middle age (18-40) – Female >> male ■ MRI / w/wo contrast – Retrobulbar optic nerve enhancement ■ Key – +/- ovoid periventricular WM lesions – Pain (> 90%) – Retrobulbar (up to 70%) – Moderate vision loss ■ Incidence of developing MS – Symptoms increase over hour to days – At 15 years ■ 25% if no WM lesions IF your patient does not seem to follow the normal “rules”, be sure your differential is not limiting your exam. ■ 72% if WM lesions present

Cmaj.ca 63 64

ONTT Guidelines Optic neuritis in summary.. Management – IV methylprednisolone 1g x 3 days – Oral prednisone 1mg/kg x 11 days + taper 1 2

Benefits Do not use oral – More rapid visual improvement*1 steroids as – Halved the risk of conversion to MS*5 monotherapy. – Reduced risk of recurrent optic neuritis***10

Oral prednisone ALONE had nearly doubled risk of recurrent optic neuritis event, even up to 10 years later! Cmaj.ca 65 66

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Patient C Patient D

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Retinal artery occlusion: How much of an emergency is this? Etiology ■ Less than 3 hours – IOP lowering therapy / digital manipulation ■ Carotid atherosclerosis Visualizing an – Then referral to ER for stroke protocol ■ Cardiogenic emboli can help narrow down ■ Hypercoagulable state ■ More than 4 hours your search – Referral to ER for stroke protocol ■ Hematologic malignancy ■ Arteritis ■ Asymptomatic plaque – 1-2 weeks to primary care physician – CBC, lipid panel, ESR/CRP, carotid study, cardiac echocardiogram

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What happens next? Age / DOB Chief complaint Acuity 65, M Diplopia 2 18, F Photophobia, red eye 2 ■ Symptomatic carotid atherosclerosis 30, F Eye pain 2 – Indications for carotid endarterectomy (CEA) 28, M Red eye, sore 3 ■ Focal sudden neurologic symptom (i.e. ) 57, M Blurred vision, pain 2 ■ >70% CA stenosis 58, M Diplopia, 1 month 4 12, M Red eye, pain 2 46, F Diplopia 2 ■ Asymptomatic carotid atherosclerosis 67, F Foreign body sensation 4 – Medical treatment strategy ■ Statins, antiplatelet agents, treatment of HTN and DM

– Interventional: CEA + medical therapy ■ >80% CA stenosis

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CHIEF COMPLAINT:

DOUBLE VISION Patient A

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Eyelid edema Patient C Scleral + injection

Abduction Chemosis deficit Patient B

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What are we thinking about? Here’s what I ask all my patients.. ■ Cranial nerve palsy ■ Constant or intermittent? ■ Brain mass ■ Vertical, horizontal, or diagonal? ■ Thyroid eye ■ Worse in any particular gaze direction? ■ Orbital mass or inflammation ■ Myasthenia gravis ■ Associated with pain? ■ Brainstem lesion or infarct ■ Recent trauma? ■ Decompensated phoria

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How do you assess diplopia? Cranial nerve palsies: Quick tips

■ Cover test gives quantitative measure CN3 CN4 CN6 – Helpful in isolating CN palsies ■ “Down and out” ■ Vertical / diagonal ■ Can’t abduct eye – Provides baseline values to monitor for improvement ■ Ptosis ■ Park 3 step ■ exam is ■ Can be subtle paramount ■ “GOTS” worse ■ Vertical – Gaze Opposite – Tilt Same alternates on up – Applies to vs down gaze HYPER eye

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Diplopia Diplopia – that’s NOT a CN palsy ■ You isolate a cranial nerve. Are you done?? ■ Evidence of PROPTOSIS or INFLAMMATION ■ Don’t forget: – There’s more going on.. – Ensure no other CNs involved – Differentials: ■ When do we image? ■ Thyroid orbitopathy (usually bilateral) – All 3rds  MRI w/wo contrast + MRA – All 4ths  MRI w/wo contrast ■ Orbital inflammatory syndrome (OIS / NSOI / IOI) – 6ths  MRI w/wo contrast ■ Orbital mass ■ <50 yo ■ Orbital cellulitis ■ History not consistent with ischemic etiology

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Thyroid orbitopathy Non-specific orbital Orbital mass ■ Bilateral inflamation ■ Unilateral ■ Lid lag, lateral lid flare ■ Unilateral ■ Slow onset ■ Chemosis, conjunctival ■ Tender lacrimal gland ■ “Quiet eye” injection ■ Pain on EOM ■ Conjunctival injection

- TSH / TSI / T3 / T4 - Imaging: CT orbit - Rule out infectious - Imaging: MRI - CAS Score - Work up w/wo contrast - Optic nerve - Imaging: CT orbit compromise? - Likely PO steroid

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Internuclear Ophthalmoplegia (INO)

■ Unilateral adduction deficit ■ Damage to ipsilateral MLF – Ipsilateral 6th / contralateral 3rd nuclei

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Age / DOB Chief complaint Acuity 18, F Photophobia, red eye 2 28, M Red eye, sore 3 57, M Blurred vision, pain 2 12, M Red eye, pain 2 67, F Foreign body sensation 4

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CHIEF COMPLAINT:

PAINFUL RED EYE

Patient A

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Patient B Patient C

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Uveitis Signs / Symptoms

■ Photophobia, pain, injection ■ Circumlimbal flush ■ Anterior chamber cell + flare + KPs – May collect into – May spillover into vitreous

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Uveitis Uveitis Clinical Diagnosis Management

■ Differentiate location involved ■ Topical q1-2 hour – Anterior vs Posterior vs Panuveitis – i.e. difluprednate, acetate, etc ■ Granulomatous vs non-granulomatous ■ Topical cycloplegic BID ■ Assess for evidence of prior episodes – i.e. cyclopentolate 1%, atropine ■ Review of systems ■ When do we need to escalate therapy? – Respiratory, joints, skin, gastrointestinal, – Extensive involvement  not clearing with topical genital, neurologic ■ Prednisone 40-60mg**

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Episcleritis vs Real tips on differentiating the two..

■ Common adages: VS – “Vessels blanch with phenyl in episcleritis.” SCLERITIS – “Deep, boring pain is always scleritis.” ■ Realistically: – Injection can remain after phenyl in BOTH. – Globe is tender to palpation in scleritis. – Posterior injection more likely scleritis.

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Episcleritis vs Scleritis Why does it matter? Episcleritis Scleritis ■ Low complication rate ■ 60% chance of ocular complication – vs 13.5% in episcleritis ■ Relatively easy to treat ■ Potential for scleral thinning, severe pain, ■ Can be signal of systemic perforation inflammation ■ Likely need oral steroids or steroid-sparing – 30% systemic rheumatic agent disease, 5% infectious1 ■ Can be signal of systemic inflammation – 39% systemic rheumatic disease, 8% infectious1

1. Jabs DA, Mudun A, Dunn JP, Marsh MJ. Episcleritis and scleritis: clinical features and treatment results. Am J Ophthalmol. 2000;130(4):469-76. 101 102

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Episcleritis vs Scleritis Episcleritis vs Scleritis Work Up Management

■ Consider deferring work up for episcleritis ■ Stratify risk for adverse complication ■ Always work up scleritis ■ Both: – Oral NSAID, i.e. 800mg TID ■ ANCA panel (!!) important for scleritis ■ Episcleritis ■ Important: RF, CBC, Quant/PPD, FTA – Topical ■ Take ANA with grain of salt ■ Scleritis – Oral steroid, i.e. prednisone 1mg/kg/d (40-60mg ) * Prior to initiating oral steroid therapy, rule out infectious etiology (i.e. TB or )

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Corneal Ulcer: Examination

Pertinent Findings 1. Is this infectious? Epithelial defect 2. Does this need to be cultured? Presence of infiltrate(s) Stromal edema 3. Can I use empiric treatment? Stromal thinning 4. What are the risk factors for something “bad”? Anterior chamber Keratic precipitates Intraocular pressure Perineuritis Eye Pain Eye Sensitivity

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Patient A

Patient B 107 108

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Corneal Ulcer: Culturing

■ Slides for ■ Blood + chocolate ■ Thio + TSB

Patient C

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Treatment

■ Empiric treatment – 3rd or 4th generation fluoroquinolone

■ Generally speaking.. – Suspicious enough to culture should be treated with fortified antibiotics HERPETIC ■ 50mg/mL q1-2h, around the clock ■ Tobramycin 14mg/mL q1-2h, around the clock

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Herpetic Keratitis Signs

■ Epithelial dendrite ■ Geographic epithelial defect ■ Marginal infiltrate ■ Diffuse stromal edema ■ Interstitial vasculature

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Herpetic Simplex Keratitis Management ■ Epithelial – Topical or oral antiviral – Prophylactic Long term take-home: – Avoid steroids Prophylactic oral antivirals ■ Stromal reduce recurrence rates by 50%

– Topical or oral antiviral HEDS – Topical steroids

■ Endothelial – Oral antiviral – Topical steroids 115 116

Herpetic Zoster Keratitis Age / DOB Chief complaint Acuity Management 67, F Foreign body sensation 4 ■ Oral antiviral +/- topical steroid ■ Pain: capsaicin, gabapentin, TCAs ■ Incidence on the rise ■ Consider HIV testing – Younger than 50 – Multiple recurrences ZEDS – Particularly virulent disease ■ Zoster Study (2017-

2020) cdc.gov/shingles

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REALISTICALLY, CHIEF COMPLAINT: CHIEF COMPLAINT: 1. EYE PAIN HIGH IOP 2. BLURRED VISION 3. FOREIGN BODY SENSATION

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What causes high IOP?

■ POAG Likely ■ Acute angle closure ■ Neovascular glaucoma IOP 40mmHg ■ Posner-Schlossman syndrome Less ■ Uveitic glaucoma Likely ■ Herpetic keratouveitis ■ Fuchs heterochromic iridocyclitis ■ Aqueous misdirection Unlikely ■ Uveitis glaucoma syndrome (UGH)

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High IOP High IOP Examination tips Management

■ How long has this been going on? ■ First line therapy – Acute: corneal edema – Topical aqueous suppressants (b blocker, a agonist, CAI) – Chronic: no corneal edema ■ Why this doesn’t work sometimes.. ■ Any KPs or AC reaction? – Uveitis, PSS, herpetic ■ Watch out for too much beta blocker! – AV block / bradycardia ■ Assess angle depth by GONIOSCOPY OF BOTH EYES – Occludable angles? Less than 90 degrees PTM. – Assess for or angle neovascularization

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High IOP Angle closure Management

■ Second line therapy ■ Immediate goal: lower IOP – Oral osmotic agent (acetazolamide, methazolamide) ■ Who are we worried about? ■ Reduce corneal edema – Sulfa – Kidney stones – ■ Laser peripheral iridotomy

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Neovascular glaucoma

■ Immediate goal: lower IOP ■ Immediate goal:

■ Reduce corneal edema (if present)

■ PRP + intravitreal anti-VEGF

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Age / DOB Chief complaint Acuity

THANK YOU.

[email protected] IG: all_things_eye

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