Case Analysis III Final

Dr. ML (Emergencies and Urgencies pt 1/2)

what may cause transient “loss of vision”?

more common (few sec)

• papilledema

more common (few min)

• amaurosis fugax

• vertebrobasilar artery insufficiency

more common (10-60 min)

• impending CRVO

• ischemic optic neuropathy

• glc

• sudden change in BP

• CNS lesion

• optic disc drusen

• giant cell arteritis

what may cause painless loss of vision for longer than 24 hrs?

sudden, painless (more common)

• retinal artery or vein occlusion

• ischemic optic neuropathy

• vitreous hemorrhage

• RD

• optic neuritis

• other retinal or CNS disease

gradual, painless (more common)

• cataract

• RE

• open-angle glc

• chronic retinal disease

• chronic corneal disease

• optic neuropathy/atrophy

what may cause painful loss of vision longer than 24 hrs?

• acute-angle closure glc

• optic neuritis

• uveitis

• corneal hydrops

• non-physiologic visual loss

what may cause monocular double vision?

more common

• RE

  • astigmatism → monocular

  • strab → binocular

• corneal opacity/irregularity

• cataract

less common

• dislocated natural lens/lens implant

• macular disease

• RD

• non-physiologic

what may cause binocular double vision?

intermittent

• myasthenia gravis

• intermittent decompensation of an existing phoria

constant

• 6th, 3rd, 4th nerve palsy

• orbital disease

• cavernou sinus/superior orbital fissure syndrome

• status post ocular sx

• status post-trauma

• intranuclear ophthalmoplegia

• vertebrobasilar artery insufficiency

• other CNS lesions

• spectacle problem

what may cause flashes of light?

• RD, retinal break

• PVD

• migraine (diagnosis of exclusion)

• rapid eye movements

• trauma

less common

• CNS disorders

• retinitis

“true” anterior segment ocular emergencies

• chemical burn

  • have pt start treating it on site - flush w water

• corneal laceration

• acute angle closure

• orbital cellulitis

• trauma-related issues - penetrating ocular injuries

• vision threatening - corneal ulcer (microbial keratitis)

”true” posterior segment ocular emergencies

• RD

• CRAO (Central retinal artery occlusion)

• arteritic ischemic optic neuropathy (AION, AAION)

• CNIII palsy w blown pupil

• bilateral optic nerve elevation (papilledema)

• transient visual obscuration/amaurosis fugax

manipulation of the eye in susceptible individuals will induce a ____

induce a strong parasympathetic reaction

• any bodily function controlled by parasympathetic system can be affected

• may lose sphincter control, urinate, defecate during episode

  • vomiting common

• pts don’t faint quietly, may lat 30-90 sec

potential signs and symptoms of fainting (vasovagal syncope)

• tunnel vision

• blurry vision

• pale skin, cold clammy sweat

• lightheadedness, nausea

• dilated pupils

• twitching

• slow, weak pulse

types of seizures

• focal seizures (60%)

• generalized seizures

  • “grand mal” seizure (1-3 min, lose control)

• epileptic seizures are rare

cal 911 if it lats more than 3 min

anti-seizure meds

1st line meds for tonic-clonic seizures

• valprioc acid (Depakene, Depakote)

• lamotrigine (Lamictal)

• topiramate (Topamax)

1st line for partial seizures

• carbamazapine (Tegretol)

• phenytoic (Dilantin)

• oxcarbazepine (Trileptal)

*phenobarbital most common for very young children

common signs and symptoms of heart attack (MI)

• chest pain/discomfort

• upper body discomfort (arm, back, jaw, etc)

• SOB (shortness of breath)

• cold sweat, feeling tired for no reason, nausea

• listen and look, then CAB (compressions, airway, breathing)

types of strokes

• hemorrhagic

• ischemic

• “stroke to eye”

signs and symptoms of stroke

FAST

• Facial drooping

• Arm weakness

• Speech difficulty

• Time to call emergency services

define anaphylaxis

severe type I allergic response

• pt exposure, snacks/food in office

• injection of epi-pen

  • clean area, prepare tissue, hold leg firmly near injection site and inject perpendicularly (usually upper of middle of outer thigh), swing and push auto-injector firmly until it clicks, hold at least 3 sec

normal BP? elevated BP?

normal: less than 120 and less than 80

elevated: 120-129 and less than 80

stage 1 HTN? stage 2 HTN? hypertensive crisis?

stage 1: 130-139 or 80-89

stage 2: 140 or higher or 90 or higher

hypertensive crisis: higher than 180 and/or higher than 120

immediate management of ocular chemical injuries

lavage for 30 min

• topical anesthetic q15-20 min

• litmus eval (pH paper)

immediate management of corneal laceration/open globe

• fox shield the eye

• photodocument for meicolegal purposes

• avoid topical meds and seek immediate repair

signs and symptoms or acute angle closure

• pain, photophobia

• blurred vision

• halos around lights

• severe headache, nausea, vomiting

• closed angle in involved eye

• acutely elevated IOP

• corneal edema

• narrow angle in the other eye

• injection, mid-dilated pupil, shallow chamber

immediate management of acute angle closure

gonio and IOP eval

• in-office pressure lowering

signs and symptoms of orbital cellulitis

• blurred vision

• red eye, pain

• fever

• diplopia, headache

associated with

• sinus infection

• orbital fracture

• focal infection around the eye

• secondary to complications of orbital sx or retained FB

signs

• eyelid edema

• erythema, warmth, tender

• chemosis, injection, proptosis

• restriction or pain with eye movement

management of orbital cellulitis

immediate

• look for APD, EOM, extensive hx

refer

• blood work, CBC with differential

• CT scan of orbits and sinuses

• lumbar puncture and neuro consult

should improve in about 1 day

signs and symptoms of RD

• flashes, floaters

• curtain or shadow moving in vision

• vision loss

• pigment/RBC in anterior vitreous

• PVD

• decreased IOP in affected eye

• movement of tissue within eye

ddx of RD

• PVD

  • with retinal tear

  • with retinal tear and vitreous heme

• rhegmatogenous RD

management of RD

• immediate referral for eval with retinal specialist

• pt will need bed rest until surgical repair

what are some emergencies may require calling 911?

• vasovagal syncope (fainting)

• epileptic seizures

• cardiac and respiratory arrest

• stroke

• malignant hypertension/hypertensive crisis

• anaphylaxis

management of vasovagal syncope (fainting)

• don’t let the pt fall

• can handle in office without EMS assistance

• never leave the pt alone

• protect yourself with gloves when contacting bodily fluids

• turn pt head or lean them over slightly while holding garbage can under their face

what triaging questions can be asked?

• why are you interested in getting eye exam?

• emergency or routine exam?

• symptoms? when did they start?

*PFE = not an emergency

urgency vs. emergency

urgency = need to see them STAT

emergency = refer out IMMEDIATELY

what minimum 4 points need to be asked during an emergency red eye case hx?

TADD

• Time of day - when does it occur (morning, evening)

• Association - what are you doing when it happens

• Duration - how long it happens (once in awhile, nonstop)

• Description - which eye

what subjective pertinent negatives need to be documented in an emergency red eye case?

± chemical to eye

± CL wear

± previous occurrence

± pain (with or without light)

± discharge

± redness

look see feel for red eye

look

• redness, swelling, whiteness or spots, discharge

see

• blurry vision, blacked out area, distortion, light changes, vision coming and going

feel (ask pt)

• pain, itching, light sensitivity, FBS

tips for taking BCVAs in an emergency red eye case

monocular for both eyes

• don’t remove CL if they wore them in

• even if the red eye only affects one eye, check the unaffected eye as the baseline

• if VA worse than 20/30 do PH

in an emergency red eye case, pupils testing and EOMs will show:

pt will feel pain when the pupil restricts, pain on eye movement

• pain on direct (red eye is OD, light in OD) = ulcer

• pain on consensual (red eye is OD, light in OS) = severe ulcer (cells/flare)

pertinent negatives of an emergency red eye (post seg)

± staining

± AC reaction

± follicles or papillae

± preauricular nodes

± flashes/floaters

± holes/tears

when would you perform a DFE for an emergency red eye?

if indicated based on hx → metal on metal FB, flashes/floaters, decreased BCVA w/o ant seg finding

• usually dilate 1 eye only

• BIO + scleral depression if flashes/floaters, vitreo-retinal tuft, peripheral lattice, holes, Shafer’s sign

management of globe protrusion (non emergency “emergency”)

globe leaves socket, still attached by optic nerve

• SL manipulation, CL A/R, lid eversion

• systemic hx: TED, ocular tumor, other causes of proptosis

• stay calm, undo lid manipulation

  • lean pt back (use gravity to advanatage)

  • gently massage globe with lids until it returns to socket

_____ is unilateral, painless, severe vision loss

central retinal artery occlusion (CRAO)

• occurs in seconds

• if cilioretinal artery → less vision loss