Acute Conditions Emergency – Retinal Artery Occlusion Ocular Emergencies – Chemical burns (alkali) – Temporal Arteritis Victoria M. Romaniuk, MD – Orbital compartment syndrome Clinical Instructor of Emergency Medicine University of Maryland School of Medicine Very Urgent – Perforation – Rupture – Acute glaucoma Acute Conditions Non Traumatic Red Eye Possible Causes Urgent – Orbital cellulitis Conjunctivitis – Orbital injury Corneal – Corneal ulcer Inflammation/Infection – Corneal abrasion Iritis (Uveitis) – Hyphema Acute glaucoma – Intraocular foreign body – Retinal detachment – Macular edema Non Traumatic Red Eye Anatomy Conjunctivitis Discharge type Etiology Purulent Bacterial Serous or clear Viral Stringy, white Allergic Pre-auricular lymph node enlargement: Viral 1 Non Traumatic Red Eye Non Traumatic Red Eye Bacterial Conjunctivitis Bacterial Conjunctivitis – Mucopurulent d/c – Staph, strep – Visual acuity good – Treatment: Antibiotic ointment or drops (Erythromycin, fluoroquinolone) Non Traumatic Red Eye Non Traumatic Red Eye Bacterial Conjunctivitis Gonococcal Conjunctivitis Gonococcal – Copious discharge – Pre-auricular adenopathy – Neonates: Bilateral, 3-5 days post vaginal delivery – Treatment: IV Penicillin – Can cause perforation Non Traumatic Red Eye Non Traumatic Red Eye Bacterial Conjunctivitis Viral Conjunctivitis Chlamydia (Inclusion) – Adenovirus – Lymphoid follicles – Frequently bilateral – Neonates: 5-14 days post vaginal delivery – Associated with URI – Adults: recurring symptoms, – Treatment: supportive ocular manifestation of STD – Treatment: Systemic (and topical) antibiotics 2 Case #1 Non Traumatic Red Eye A 31 yo female with red, Epidemic Keratoconjunctivitis (EKC) painful eyes, moderate Highly contagious: families, serous discharge for 5 days. swimming pools, eye clinics It began in the left eye, now Virulent strain of adenovirus with intense foreign body Keratitis which causes sensation, mild photophobia subepithelial opacities and blurred vision. Treatment: Ophthalmology referral, topical antibiotics to Her left eye is shown in the prevent secondary infection photograph. Non Traumatic Red Eye Non Traumatic Red Eye Allergic Conjunctivitis Episcleritis – Cobblestone papillae Minimally painful red eye under upper lid – Acute onset – Pet dander, pollen, – Can be diffuse or localized mold Simple or nodular – Treatment: Topical Reassurance, NSAID’s (topical antihistamines, or oral) may be helpful vasoconstrictor Non Traumatic Red Eye Episcleritis Scleritis Moderate to severe pain Gradual onset (days) Anterior & posterior Bilateral > 50% 3 Non Traumatic Red Eye Scleritis Infective – syphilis, TB, Zoster, leprosy Autoimmune – RA, WG, SLE, PN, Goodpasture ’s, Crohn ’s, sarcoid Metabolic - gout Non Traumatic Red Eye Non Traumatic Red Eye Scleritis Corneal Inflammation/Infection Treatment: Corneal Ulcer – High dose systemic steroids – Viral, bacterial, fungal, chemical, Vit A def – Systemic NSAID’s – Contact lens: – Topical cyclosporine Pseudomonas – Methotrexate – Look for associated hypopyon – Treatment: Immediate ophthalmology consult Non Traumatic Red Eye Corneal Ulcer Endophthalmitis Inflammation of intraocular cavities – Exogenous: “Conjunctivitis” following eye surgery – Endogenous: Septic emboli – Decreased vision, floaters, redness & pain Hypopion without ulcer – Treatment: Ophthalmology consult, hospitalization 4 Case #2 Non Traumatic Red Eye Chemical Burns A 32-year-old construction worker was Alkali Burn = Absolute injured when a lye Eye Emergency compound splashed into – Sodium hydroxide his eye. He arrives at the – Liquefaction necrosis ED 15 min after the – Treatment: Immediate irrigation injury. Ophthalmology consult Goal pH 6.8 – 7.4 The photograph illustrates the injured eye. Non Traumatic Red Eye Foam Party? Chemical Burns Acid Burns – Coagulation necrosis – Treatment: Ringer ’s lactate Non Traumatic Red Eye Corneal Inflammation Ultraviolet Keratitis Ultraviolet Keratitis – Welder ’s keratitis, Snow blindness, Tanning beds – Delayed Symptoms – Slit Lamp: Diffuse punctate keratopathy – Treatment: Cycloplegics, systemic analgesia Superficial Punctate Keratitis 5 Disorders of the Lids and Disorders of the Lids and Ocular Soft Tissues Ocular Soft Tissues Internal and external hordeolum (Stye) Chalazion Pterygium Disorders of Lids and Soft Tissue Disorders of the Lids and Pingueculum Ocular Soft Tissues Raised conjunctival nodular degeneration Dacryocystitis (sac) Dacryoadenitis (gland) – Medial unilateral mass – Temporal aspect of – Staph aureus upper eyelid – Topical and Systemic – Adults: bacterial antibiotics – Children: viral (mumps) – Children <4 years – Cool compresses/oral consider H. influenza antibiotics Disorders of the Lids and Disorders of the Lids and Ocular Soft Tissues Ocular Soft Tissues Dacryocystitis Dacryoadenitis Preseptal cellulitis – CT scan? – Warm compresses – Systemic antibiotics 6 Disorders of the Lids and Disorders of the Lids and Ocular Soft Tissues Ocular Soft Tissues Orbital Cellulitis – Unilateral proptosis – Swelling/Erythema of lids, pain with eye movement – Causes: Sinusitis (Ethmoid) Hematogenous < 2yo – Evaluation: CT scan – Treatment: IV antibiotics, surgical drainage? Non Traumatic Red Eye Case ##33 Uveitis A 35-year-old black Uvea woman is admitted for fever of unknown origin. – Iritis (anterior) She recalls several – Cyclitis (Intermediate) episodes of bilateral photophobia, decreased – Choroiditis (posterior) vision, and mild discomfort. Non Traumatic Red Eye Keratic Precipitates IritisIritis/Anterior/Anterior Uveitis Risk Factors – Idiopathic – Infectious – Trauma – Auto-immune/Systemic Lupus Rheumatoid Arthritis IBS Sarcoidosis 7 Non Traumatic Red Eye Iritis Cell and Flare Consensual photophobia Ciliary flush Slit Lamp: “Cells and Flare ” Treatment: Mydriatics, cycloplegics, and topical steroids Case #4 A 55-year-old man comes in for a routine physical examination. Your examination reveals the findings illustrated in the photograph in both optic discs. Non Traumatic Red Eye Glaucoma Acute Angle Closure Glaucoma Precipitated by mydriatics,changes in light N/V, headache Halos in vision Steamy cornea, mid- dilated nonreactive pupil Ciliary flush IOP > 40 8 Acute Angle Closure Glaucoma Penlight Shadow Test Non Traumatic Red Eye Case #5 Acute Angle Closure Glaucoma A 33-year-old man has recurrent episodes of left Treatment eye irritation for four years. – AA: topical alpha agonist These episodes last 5 to 6 – BB: topical beta blocker days, and have been treated with eye drops. – CC: topical corticosteroid and oral/IV carbonic anhydrase Currently, the patient has inhibitor foreign body sensation, – IV Mannitol & Glycerol photophobia, and tearing. – Topical Pilocarpine 1-2% – Peripheral Iridotomy Non Traumatic Red Eye Corneal Infection Herpes Simplex Keratitis – Localized pain/foreign body sensation – Fluorescein stain: dendritic pattern – Treatment: Antiviral agents, ophthalmology 9 Non Traumatic Red Eye Herpes Simplex Corneal Infection Herpes Zoster Ophthalmicus – Uniocular – Hutchinson ’s Sign Nasociliary nerve – Corneal pseudodendrite – Treatment: Ophthalmology referral, antiviral agents Case #6 Pale retina A 70-year-old man suffered a sudden and total loss of vision in one eye. He experienced no Acute Visual Loss pain or other symptoms. The fundus of the involved eye is depicted in the photograph. The opposite eye remains normal. “Cherry-red ” spot Central Retinal Artery Occlusion Central Retinal Artery Occlusion Embolism Thrombus Vasospasm Vasculitis Sickle cell Relative Afferent Pupillary Defect (Marcus Gunn Pupil) 10 Central Retinal Artery Occlusion Case #7 A 65-year-old woman c/o NO STANDARD THERAPY sudden, painless loss of vision in one eye. She has – Digital massage only “hand motion ” visual – Carbogen (95% O2 and acuity. The opposite eye 5% CO2), appears normal, and she – Acetazolamide (500mg IV) complains of no systemic – Anterior chamber symptoms. paracentesis The fundus of the involved – Ophthalmology consult eye is illustrated. – Hyperbaric consult “Blood and Thunder ” Central retinal vein occlusion Acute Visual Loss Acute Visual Loss Optic (Retrobulbar) Eclipse Burn (Solar Hysterical Blindness Retinopathy) Neuritis – Conversion disorder – Loss of central vision – Photocoagulation of macula – Optokinetic drum – elicits optokinetic – Eye pain with – Loss of central vision nystagmus movement – “Gun Barrel ” central – Medicolegally, diagnosis must – Unilateral optic disc visual field defect swelling be made by ophthalmologist – Multiple sclerosis Case #8 Acute Visual Loss A 65-year-old man has had several Amaurosis Fugax episodes of momentary – Fleeting uniocular visual loss blindness in one eye – Vasospasm secondary to atherosclerosis over the past year. These episodes usually have lasted from seconds to minutes. Hollenhorst Plaques 11 Case #9 Acute Visual Loss A 70-year-old woman suffered sudden but painless loss of vision in one eye. She also has experienced headaches and shoulder pain during the past several months. The affected eye is shown in the photograph. Her other eye remains normal. Acute Visual Loss Temporal Arteritis – Anterior Ischemic optic neuropathy – Frequently assoc with amarousis fugax – Treatment: IV Methylprednisolone – Immediate consult with ophthalmologist and neurologist Diabetic Retinopathy Microaneurysms Cotton wool spots Retinopathies Hemorrhage (dot-blot, flame) New vessels- Proliferative retinopathy 12 Case #10 Acute Visual Loss A 60-year-old