TCP Week 7 (Eye Emergencies and Vision Loss)

eye anatomy review

CN III, IV, and VI - innervates EOMs

Cornea - CN V1, very painful

Sclera - white

Lens

Retina - posterior eye. axons of ganglion cells become the optic nerve.

Choroid - VERY VASCULAR. highest blood flow in the body to supply the retina

meibomian glands produce

lacrimal glands produce

lipid part of tears

watery part of tears

what disease affects the optic nerve

glaucoma

what disease involves extra ocular muscles

thyroid eye disease (TED)

CN II

optic nerve, formed from the retina

CN V1 innervates

innervates the cornea

CN III innervates

superior rectus

inferior rectus

medial rectus

inferior oblique

CN IV innervates

superior oblique

the ONLY CN that exits posteriorly

CN VI innervates

lateral rectus

clouding of the lens (cataracts) occurs due to?

- aging

- sun exposure

- diabetes

- steroids

The three tunics of the eye are?

1) A fibrous tunic, consisting of the sclera behind and the cornea in front;

2) A vascular pigmented tunic, comprising, from behind forward, the choroid, ciliary body, and iris

3) A nervous tunic, the retina.

the visual pathway

cornea --> lens --> retina --> optic n. --> optic chiasm --> optic tract --> lateral geniculate nucleus --> thalamus --> occipital lobe

vision is processed in the occipital lobe

what sits below the optic chiasm

pituitary gland

pathology of this = bitemporal hemianopsia

eye is supplied by

eye = carotid a. supplies

opthalmic lobe = vertebrobasilar a. supplies

lacrimal drainage

Lacrimal gland --> punctum --> lacrimal sac

CN supply

CN 1 - Frontal lobe

CN 2 - Thalamus

CN 3-4 Midbrain

CN 5-7 Pons

CN 8-12 Medulla

• 8 gives eye info about head position

history taking for eye

DRFLOPS

Duration

Relief

Frequency

Location

Onset

Pain

Severity

eye complaints include

Ocular trauma - 27%

• 73% of trauma group had corneal abrasion

Conjunctivitis - 15% (allergy, viral, bacterial)

Retinal problems - 3.6% (usually trauma related)

Glaucoma - 2% (m/c AA, hispanic, latino)

episcleritis associated with

rheumatoid arthritis

THE RED EYE - differentiating feature

•Pain

•Itching

•Photophobia

•Systemic symptoms

•Discharge

•Visual loss

Corneal, pupil, and intraocular pressure changes

history questions and what ddx might they lead you towards?

Is vision affected? Acute change in vision is usually indicative of a visual pathway or globe problem

Foreign body sensation? Denotes active corneal process

Photophobia?

• Objective signs - difficulty opening eyes/trying to block out the light

• Patients with iritis have photophobia w/o foreign body sensation

Contact lens use? Red eye with discharge in a contact lens wearer would increase suspicion of keratitis

Trauma? Finger poke, object, blunt trauma

Discharge?

•Watery or purulent?

•Conjunctivitis - viral, bacterial, allergic

•Keratitis - opaque discharge with signs of photophobia and foreign body sensation

EXAMINATION OF THE EYE

acuity, visual fields, EOMs

Visual acuity: Smallest line read with one half of the letters correct

Confrontation visual fields: Visual field defects can represent pathology from occipital cortex to the optic nerve.

Extraocular movements: Can be impaired by restriction, interrupted or decreased innervation, or trauma.

EXAMINATION OF THE EYE

Pupillary reactions

Anisocoria can be acutely emergent or result of previous trauma

EXAMINATION OF THE EYE

lids and adenexa

•Periorbital skin, eyebrows, lashes, palpebral and bulbar conjunctiva, and lacrimal apparatus

•Trauma, infection, dysfunction, deformity, crepitus, or proptosis

•Palpate for subcutaneous emphysema (blow-out fractures) and step off deformities (trauma)

EXAMINATION OF THE EYE

Conjunctiva and Sclera

Subconjunctival edema, injection, inflammation, discharge, trauma, hypopyon, hyphema, foreign bodies.

EXAMINATION OF THE EYE

Cornea

Traumatic injuries, foreign bodies, hand tools.

EXAMINATION OF THE EYE

anterior chamber

•Hypopyon or hyphema

•Examine with a slit lamp

EXAMINATION OF THE EYE

lenses

Assess for opacities, lacerations, and subluxations

EXAMINATION OF THE EYE

IOP assessment

•Eye-care tonometer

•Tono-pen

EXAMINATION OF THE EYE

fundoscopic exam

May be difficult in acutely emergent conditions (iritis, keratitis, angle-closure glaucoma)

SLIT LAMP

- Provides a magnified view of the eye

- A thin slit can demonstrate the cornea, iris, and lens

WOOD'S LAMP

•Handheld ultraviolet light used to detect corneal abrasions, corneal ulcers and foreign bodies.

•Light appears as light purple or violet and in the presence of fluorescein will fluoresce damaged tissue.

STRABISMUS - ocular misalignment, 2 types

Ocular misalignment

• Manifest strabismus - deviation present under binocular viewing

• Latent strabismus - deviation present after occlusion of one eye

STRABISMUS - H&P and treatment

History & PE - visual acuity, cover-uncover test

Treatment: Patching or surgical correction

The Eye Emergency (CN III)

R CN III-downgaze

R CN III up-gaze

CN III palsy is a ____ until proven otherwise

aneurysm!! (likely at circle of willis - PCOM a.)

Cranial Nerve 3 palsy - Pupil involved ophthalmoplegia

lid will be down (ptosis)

Cranial Nerve 3 palsy - Pupil involved ophthalmoplegia

Medical emergency if pupil is dilated !!!!

•Complete pupil involvement - Send to ER .... 20% die within 48 hrs

•Relative pupil involvement (poor light reflex, slightly larger size)

•Pupil spared

Presentation of CN 3 palsy

- Ptosis - Levator muscle is affected

- "Down and Out"

- Limited ocular motility

- Complete or relative sparing of the pupil, in general a good sign

- May be painful

Cranial Nerve 3 palsy - Pupil involved ophthalmoplegia

complications

•90% of aneurysmal third-nerve palsies have pupil involvement.

•1/2 dx w/ aneurysmal third-nerve palsies have a subarachnoid hemorrhage within 2 wks

•1/2 of those patients who hemorrhage will die soon after

**A lack of anisocoria in an isolated third-nerve palsy does not rule out aneurysm or a compressive lesion**

Cranial Nerve 3 palsy - Pupil involved ophthalmoplegia

imaging

Catheter Cerebral Angiography is the best imaging tool, however, it may cause stroke or myocardial infarction in 1% - 2% of patients.

EXTERNAL EYE: lid laceration

•Needs thorough evaluation

•Evaluate for globe rupture, FB, penetration of the orbit, damage to eye structures

EXTERNAL EYE: lid laceration

treatment

- Superficial lacerations: suture with 6-0 nylon

- Significant laceration warrants ophthalmology consult

OPEN-GLOBE INJURY: ZONE OF INJURY

zone 1

opening of globe is limited to cornea or corneo-scleral limbus

OPEN-GLOBE INJURY: ZONE OF INJURY

zone 2

those that involve the anterior 5mm of the sclera (not more posterior than the pars plana)

OPEN-GLOBE INJURY: ZONE OF INJURY

zone 3

those that extend the full thickness into the sclera more than 5mm posterior to the limbus

THE RED EYE ddx

benign

Benign - stye, chalazion, hordeolum, blepharitis, subconjunctival hemorrhage, conjunctivitis (allergic, viral, bacterial),

dry eye syndrome, episcleritis

THE RED EYE ddx

urgent

Urgent - corneal abrasion, corneal foreign body, contact lens over wear (if not better in 24 - 48 hours).

Should be seen in 24 - 48 hours - iritis, viral keratitis, and scleritis.

THE RED EYE ddx

emergent

Emergent - Angle-closure glaucoma, hyphema, hypopyon, bacterial keratitis

EXTERNAL EYE COMPLAINTS

•Blepharitis

•Hordeolum

•Chalazion

•Entropion (lid in)

•Ectropion (lid out)

•Lid lacerations

Blepharitis

define, presentation, tx

Inflammation of the eyelids

Erythema, crusty with scaling debris that clings to lashes.

Eyelid hygiene, warm compresses, baby shampoo

Hordeolum

define, presentation, tx

stye!

Staph infection of the glands

Erythema, tender nodule on lid

Warm compresses, topical antibiotics (bactericidal preference!)

Chalazion

define, presentation, tx

Chronic granulomatous inflammation

Painless nodule within the eyelid

Glucocorticoid injection,

compresses, surgery

Periorbital/Preseptal cellulitis

treat with?

when the lid swells, treat to prevent orbital cellulitis

oral antibiotic

blepharitis treatment

•Lid scrubs

•Heat

•Tobradex - topical

Ectropion

management

Lid eversion

•Aggressive lubrication, artificial tears, gels, and ointments

•Surgical management if cornea becomes compromised from dryness and scarring.

Entropion

management

Lid inversion

•Eyelashes can cause corneal and conjunctival damage

•Treated with artificial tears/lubrication or contact lenses to protect the surface of the eye

•Botulinum toxin is helpful with spastic entropion.

•Surgical management

Dacrocystitis

organisms

Streptococcus pneumoniae

Staphylococcus species

Haemophilus influenzae

Dacrocystitis

presentation

•Risk of orbital cellulitis if untreated

•Pain, redness, swelling just below medial canthus

Dacrocystitis

treatment

Empiric antibiotic until culture available, ophthalmology consult.

Periorbital/Preseptal cellulitis

organisms

staphylococcus aureus

group A streptococcus

Periorbital/Preseptal cellulitis

what is it? tx?

structures anterior to orbital septum

treatment: Augmentin or 2nd or 3rd generation cephalosporin

Periorbital/Preseptal cellulitis

orbital cellulitis

orbital cellulitis

organisms

Streptococcus anginosus

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

S aureus

orbital cellulitis

presentation

Serious bacterial infection within the orbit

Fever, painful red eyelid, eye weakness, pain with eye movements, and proptosis

orbital cellulitis

diagnosis and treatment

Diagnosis - clinical diagnosis confirmed with CT of orbits and sinuses with contrast.

Admission - ophthalmology consult

- Vancomycin plus 3rd generation cephalosporin IV

CHANDLER'S CLASSIFICATION OF OCULAR AND ORBITAL INFLAMMATION

Stage 1: Inflammatory edema

Stage 2: Orbital cellulitis

Stage 3: Subperiosteal abscess

Stage 4: Orbital abscess

Stage 5: Cavernous sinus thrombosis

Life-threatening**

CONJUNCTIVITIS

•Allergic --> itchy

•Viral --> clear, runny

•Bacterial --> purulent

conjunctiva follicles

Sexually Transmitted Disease's on the "Ocular-Genital" Axis:

- Syphilis

- Chlamydia

- Pediculosis

- Gonorrhea (image)

- HIV

- Herpes (HSV)

- Hepatitis B

infectious keratitis - white circle/infiltrate is WBC (neutrophils, macrophages). can cause ulcer.

mcc = over wearing contact lens

CONTACT LENS COMPLICATIONS

Infectious keratitis

Painful red eye, may have reduced visual acuity, eyelid swelling and photophobia.

Corneal defects can be seen with fluorescein staining

Hypopyon

CONTACT LENS COMPLICATIONS

treatment

stop using contact!

•Urgent ophthalmology referral

•Fluoroquinolone (moxifloxacin)

•Do not patch eye!

CORNEAL ULCER

Serious condition involving multiple layers of the cornea

Ulcer develops due to breaks in the epithelium

CORNEAL ULCER

etiology

Can be bacterial, viral, fungal, or parasitic.

•S. pneumoniae and S. aureus

•Contact lens users can develop Pseudomonas infection

•Herpes simplex 1 and Herpes zoster viruses common in US

CORNEAL ULCERS

s/sx

symptoms

•photophobia, pain, and foreign body sensation

signs

•eyelid swelling and redness, tearing, conjunctival injection, corneal haziness

•slit lamp examination reveals flare and cells from iritis and occasionally a hypopyon

hypopyon

pus in the anterior chamber of the eye

CORNEAL ULCERS

treatment

Treat aggressively with topical antibiotics and oral analgesia

• Fluoroquinolone - Ciprofloxacin or ofloxacin - one drop every hour

• Topical steroids are relatively C.I. but may decrease the incidence of scarring and perforation

Emergent ophthalmology consult!

CORNEAL ULCERS

complications

complications include corneal scarring, corneal perforation, glaucoma, and cataracts.

herpes zoster ophthalmicus

cause and sx

Herpes zoster eruption in any branch of trigeminal nerve (CN V)

Pain, red eye, blurred vision, photophobia, watery discharge.

Dendritic lesions

herpes zoster ophthalmicus

complications

keratitis, anterior uveitis, ocular nerve palsies, and acute retinal necrosis

herpes zoster ophthalmicus

treatment

•Ophthalmology consult

•Antiviral agents

herpes zoster vs herpes simplex

herpes simplex keratitis

•Vision threatening emergency

•Recurrent corneal infections

herpes simplex keratitis

s/sx, PE

Pain, visual blurring, watery discharge

Exam: chemosis, decreased corneal sensation, dendritic lesions of the cornea, corneal ulcers

herpes simplex keratitis

treatment

Treatment: Ophthalmology referral

Topical or oral antivirals

SCLERITIS

associated with

Associated with systemic diseases: RA, vasculitis, infection, local trauma, sarcoidosis, IBD

SCLERITIS

s/sx

•The sclera is comprised of the anterior portion and a posterior portion.

•Pain, constant and boring, painful ocular movements, photophobia, globe tenderness to palpation

SCLERITIS

Diagnostics

CBC, CMP, UA, ESR, CRP may also need RF, ANA, ANCA

CXR for nodules and infiltrates (sarcoidosis and tuberculosis)

SCLERITIS

treatment

ophthalmology consult

SCLERITIS COMPLICATIONS

•Corneal changes

•Glaucoma

•Cataracts

•Posterior segment complications

SEVERE PAIN

ANTERIOR UVEITIS (aka iritis)

Inflammation of the uvea (middle portion of the eye)

Caused by inflammatory and infectious processes

ANTERIOR UVEITIS

s/sx, PE findings

•Pain and redness

•Slit lamp exam shows cells and flare in the anterior chamber

ANTERIOR UVEITIS

treatment

•Glucocorticoids to reduce inflammation

•Ophthalmology consult

DRY EYE - keratoconjunctivitis sicca

presentation and causes

Burning foreign body sensation, conjunctival injection, and photophobia.

Decreased tear production.

• Medications

• Sarcoidosis

• Sjogren's syndrome

DRY EYE - keratoconjunctivitis sicca

treatment

frequent application of artificial tears or lubricant eye drops

SUBCONJUNCTIVAL HEMORRHAGE

Focal, red region on the ocular surface

May be caused by trauma, contact lens use, elevated venous pressure, hypertension, coagulopathy

SUBCONJUNCTIVAL HEMORRHAGE

treatment

•Treat underlying issue.

•Self-limiting.

SUBCONJUNCTIVAL HEMORRHAGE

complications/reason

can be due to INR being off with warfarin use (coagulopathy)

PTERYGIUM

m/c where? what is it?

symptoms?

More common in tropical regions, due to prolonged sun exposure

Fibrovascular triangular encroachment on the cornea

Can cause redness and irritation