Acute Conditions  Emergency – Retinal Artery Occlusion Ocular Emergencies – Chemical burns (alkali) – Temporal Arteritis Victoria M. Romaniuk, MD – Orbital compartment syndrome Clinical Instructor of Emergency University of Maryland School of Medicine  Very Urgent – Perforation – Rupture – Acute

Acute Conditions Non Traumatic Possible Causes  Urgent –  – Orbital  Corneal – / –  Iritis () –  Acute glaucoma – Intraocular – – Macular

Non Traumatic Anatomy Conjunctivitis

Discharge type Etiology Purulent Bacterial Serous or clear Viral Stringy, white Allergic

Pre-auricular enlargement: Viral

1 Non Traumatic Red Eye Non Traumatic Red Eye Bacterial Conjunctivitis Bacterial Conjunctivitis – Mucopurulent d/c – Staph, strep – 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 (EKC) painful , 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  which causes sensation, mild subepithelial opacities and .  Treatment: referral, topical antibiotics to Her left eye is shown in the prevent secondary infection photograph.

Non Traumatic Red Eye Non Traumatic Red Eye

– Cobblestone papillae  Minimally painful red eye under upper lid – Acute onset – Pet dander, , – Can be diffuse or localized mold  Simple or nodular – Treatment: Topical  Reassurance, NSAID’s (topical , or oral) may be helpful vasoconstrictor

Non Traumatic Red Eye Episcleritis

 Moderate to severe  Gradual onset (days)  Anterior & posterior  Bilateral > 50%

3 Non Traumatic Red Eye Scleritis

 Infective – , 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 : – Topical cyclosporine Pseudomonas – Methotrexate – Look for associated – Treatment: Immediate ophthalmology consult

Non Traumatic Red Eye Corneal Ulcer  Inflammation of intraocular cavities – Exogenous: “Conjunctivitis” following – Endogenous: Septic emboli – Decreased vision, , 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 – : 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 ()

Disorders of Lids and Soft Tissue Disorders of the Lids and Pingueculum Ocular Soft Tissues  Raised conjunctival nodular degeneration  (sac)  (gland) – Medial unilateral mass – Temporal aspect of – Staph aureus upper – Topical and Systemic – Adults: bacterial antibiotics – Children: viral () – Children <4 years – Cool compresses/oral consider H. 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  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





 IBS



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  N/V, headache  Halos in vision  Steamy , mid- dilated nonreactive  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 days, and have been treated with eye drops. – CC: topical and oral/IV carbonic anhydrase Currently, the patient has inhibitor foreign body sensation, – IV Mannitol & Glycerol photophobia, and tearing. – Topical 1-2% – Peripheral Iridotomy

Non Traumatic Red Eye Corneal Infection

 Keratitis – Localized pain/foreign body sensation – 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 A 70-year-old man suffered a sudden and total loss of vision in one eye. He experienced no pain or other symptoms. The 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 – (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 ) Neuritis – Conversion disorder – Loss of central vision – Photocoagulation of macula – Optokinetic drum – elicits optokinetic – Eye pain with – Loss of central vision movement – “Gun Barrel ” central – Medicolegally, diagnosis must – Unilateral defect swelling be made by ophthalmologist –

Case #8 Acute Visual Loss A 65-year-old man has had several  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 – Frequently assoc with amarousis fugax – Treatment: IV – Immediate consult with ophthalmologist and neurologist

Diabetic Retinopathy

 Microaneurysms  Cotton wool spots  Hemorrhage (dot-blot, flame)  New vessels- Proliferative retinopathy

12 Case #10 Acute Visual Loss A 60-year-old obese woman complains of general malaise and has no ocular complaints. The fundus photograph illustrates the findings in both eyes.

Dot Blot Hemorrhages

Case #11

Proliferative Retinopathy Laser Photocoagulation A 55-year-old man has complained of morning occipital headaches for several months. His headaches have recently become more frequent and severe. The appearance of the fundus was similar in both eyes.

AV Nicking Acute Visual Loss

 A-V nicking  Retinal arterial narrowing Copper wire  Flame hemorrhages  Cotton wool spots 

Silver wire

13 Hypertensive Retinopathy Retinopathies

 30 year old presents with 6 month history of fever, weight loss, , and rash.

CMV (“pizza pie ”)

Case #12

This 42-year-old woman had been in good health until today, when she NeuroNeuro--ophthalmologyophthalmology suddenly developed in all fields of gaze. The accompanying photograph was taken while the patient was looking up.

Anatomy CN III:

CN IV

CN VI

CN III

14 NeuroNeuro--OphthalmologyOphthalmology NeuroNeuro--OphthalmologyOphthalmology  Third Nerve Palsy – Supplies levator palpebrae, ocular Horner ’s Syndrome muscles and carries parasympathetic • fibers to • Meiosis – Signs: • Anhydrosis  Ptosis • Cause: Pancoast tumor,  Deviation of the eye: down and out carotid dissection, aortic  Dilated Pupil aneurysm – Diabetic III nerve palsy may spare pupil – Cause: Posterior communicating artery aneurysm Right Horner ’s Syndrome

NeuroNeuro--OphthalmologyOphthalmology NeuroNeuro--OphthalmologyOphthalmology

 Sixth Cranial Nerve  – Abducens: Innervates – Signs: lateral rectus – Signs: Loss of abduction  Diplopia – Cause: Intracranial  Ptosis tumors ~ 30% – Spares pupil – Diagnosis: Tensilon test Right Abducen’s Nerve Palsy

Visual Loss

Trauma

15 Trauma Trauma  Lid Lacerations  Conjunctival Lacerations – Only skin of lid: close – Usually minor with 6-0 or 7-0 nylon – Positive fluorescein dye – Five anatomical areas – Repair if > 1cm (ophtho) where expertise is needed: – Suspect:  Retained foreign body  Lacrimal canaliculi  Orbital fracture  Levator  Scleral rupture  Orbital septum  Canthal tendons – Empiric topical antibiotics  Lid margins +/- patch

Trauma Trauma

 Corneal Abrasions  Foreign Bodies – Rust Ring: Metallic – Positive fluorescein stain Removed with burr or – “Ice Rink Sign ” 18g needle. – Contacts: pseudomonas Alternative: Refer within – Treatment: 24-48 hrs

 Topical cycloplegic – Wooden Splinters: Must be removed by slit lamp.  Topical antibiotic Watch for fungal infection .

Trauma

 Perforation – Suspect with penetrating wound of lid – – Teardrop pupil – Seidel Test – Treatment:

 Rigid metal eye shield

 Ophthalmology consult

16 Trauma Trauma

 Globe Perforation – Systemic antibiotics – Tetanus prophylaxis – NPO – Protect the eye!!!

Case #13 Trauma A 25-year-old medical student was struck in the eye with a ball while playing racquetball. He was not wearing protective eye gear at the time.

The injured eye is shown .

Trauma Trauma

 Hyphema  Traumatic Dislocated Lens – Hyphema: Hemorrhage in anterior chamber – Blunt trauma – Rebleed in 5 days, worse than initial bleed (most – Marfan ’s syndrome common) – Iridodonesis: trembling of – Consider sickle cell lens with shaking of head – Tx: Ophthalmology – Treatment: can be delayed  Assume globe is ruptured for several weeks  Shield eye

 25% of pts have other ocular

17 Trauma Orbital Floor Fracture

 Blow-Out Fracture of – Inferior rectus muscle entrapment – Infraorbital nerve involved – Pain and diplopia in upward gaze – Tx: Ophtho referral for surgery if diplopia

Trauma Trauma

 Intraocular Metallic Foreign Body – Pounding metal most common – May present 1-2 days after injury – Non localizing pain – Diagnosis: XR/CT or ultrasound – Treatment: Surgical removal

 Treat like

Trauma Air Bag Injuries

 Traumatic Iritis – Blunt trauma  Sodium azide releases sodium – Photophobia/decreased hydroxide visual acuity – Ciliary flush  Screen for alkali burn: pH – Slit Lamp: Cells and flare measurement – Treatment: Short-acting mydriatic , cycloplegic  Associated blunt trauma

18 Cyanoacrylate Glue Trauma

 Vitreous and Retinal  Household superglues – Hemorrhage chemical keratitis – Blunt trauma  Treat with topical antibiotics – Loss of  Do not force open – Retinal detail obscured – Torn retinal or uveal

Trauma

 Retinal Detachment – Painless – Lowering or raising of curtain – Flashing in peripheral vision – “Dunes on a beach ”

Trauma Orbital Compartment Syndrome OCS (OCS)  Ocular pain, proptosis,  Acute elevation of intraorbital pressure afferent pupillary defect,  Ocular dysfunction diminished vision  Retrobulbar hemorrhages most likely cause  Chemosis, increased IOP, , diminished  Irreversible damage and retinal retropulsion of globe, ischemia within 90 minutes ophthalmoplegia

19 OCS OCS

Treatment  Surgical intervention (primary)  Immediate lateral canthotomy & cantholysis  Within one hour of injury & ocular dysfunction  Medical therapy is adjunctive

20 Side Effects of Topical Steroids

 Enhance corneal penetration of herpes virus  Steroid induced glaucoma  formation  Potentiates fungal corneal ulcers

Color Codes for Color Codes for Ophthalmic Ophthalmic Top Color Action Examples Red Pupil dilation (Mydriasis) (Mydriacyl)  Red – Dilate Pupil Pilocarpine constriction  Green – Constrict () Yellow Caution -Maleate  Yellow - Caution Clear or White Topical Proparacaine anesthesia Irrigation solutions Lubricants

Case #14 A 75-year-old man suffered bilateral but asymmetric decrease in vision. Initially, the patient had problems with distance vision; he is now experiencing difficulty with both distance and near vision. Cataract

21 Good luck on the test!

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