OPT 317 Trauma, HA, Retinal Breaks

What are some S/S of corneal abrasions?

pain

photophobia

tearing

corneal staining

(-) infiltration

injection

AC rxn

(-) Seidel sign

How do we tx a corneal abrasion?

debride loose epithelium

abx gtts or ung for prophylaxis

cycloplegia for pain

DPP

bandage CL

pain meds = topical NSAIDs, oral opioids, gabapentin, pregabalin

Which types of corneal abrasion should we NOT patch?

dirty wound = vegetative, fingernails, CL wearer

What are some S/S of foreign bodies?

FB sensation

pain

history of FB in eye

staining around FB

(-) Seidel sign

What is the tx for foreign bodies?

check for intraocular FB if high velocity object

DLE

remove FB with speed, needle, magnet, forceps

Alger brush to remove rust ring

tx as corneal abrasion

What are some S/S of conj lacerations?

redness

subconj heme

"eye is bleeding"

NaFl pooling in area

(-) Seidel test

What is the tx for conj lacerations?

push edges together with applicators

patch

suture larger lacerations

What are some S/S of intraorbital FB?

Hx of trauma

+/- pupil involvement

+/- VA affected

(+) Seidel test

What is the tx for intraorbital FB?

CT to determine depth of FB

DON'T remove FB at slit lamp

refer for OR consult for irrigation of wound, suturing

What 3 things do we specify in our ICD-10 codes for any trauma?

the injury and eye = corneal FB, eyelid laceration, contusion

how it happened = pecked by turkey, struck by a ball

where it happened = athletic court, courtyard of prison

What are the 3 options for the 7th digit in the ICD-10 injury code?

A = initial

D = subsequent

S = sequelae

What is the difference between primary vs secondary HA?

primary = cannot be attributed to known structural, toxic, metabolic abnormalities

secondary = definable abnormalities that causes the HA

What S/S may indicate a HA is secondary?

HA after age 55

jaw/scalp/chewing pain

ONH swelling

fever

altered behaviour

stiff neck

decreased vision

neuro signs

pre-retinal hemes

What warrants a migraine being considered chronic?

15+ days per month

Migraines make up what % of all HA?

54%

Migraines affect what % of the US population?

13%

Migraines are 3x more common in which gender?

females >>> males

What is the pathophysiology of migraine?

brain has reduced threshold to stimuli (triggers, menstrual cycle, sleep cycle) = cortical excition, starting in visual cortex (aura) = followed by spreading wave of depression that moves anteriorly = BV dilation in meninges = pain

What 3 components contribute to trigeminal afferent activation in migraine pathophysiology?

neuropeptide release = CGRP, VIP

pain signal pathway = trigeminocervical nociceptors around eyes send signal to thalamus

BV dilation/contraction = only causes HA in migraneurs!

What are some features of aura?

scintillation patterns build in intensity = marching aura moves across VF

What is the difference between classic vs common migraine?

classic = with aura = 20%

common = without aura = 80%

What are some symptoms of migraine?

HA typically in periorbital or retro-orbital areas, onset in 20-60min

nausea/vomiting

photophobia

phonophobia

What are some tx for migraine?

R/O accom and BV issues

avoid triggers

pain relievers = NSAIDs, aspirin, opioids

botox

refer to PCP/neuro for triptans, ergots, CGRP blockers, anti-nausea meds, TCAs, glucocorticoids, anti-seizure meds

What is the pathophysiology of an ocular migraine?

vasopasm in retinal/post ciliary circulation = ischemia to retina, choroid, ONH = artery attenuation and occlusion DURING attack only = monocular visual changes

Accoridng to the IHS, what are the 5 main criteria to classify something as an ocular migraine?

2+ attacks minimum

reversible, monocular visual changes

HA during or within 60min of visual changes

normal eye exam between attacks

no other disorder causing it like CRAO, focal ischemia, optic actrophy, NAION/AAION, CRVO

What is the tx for ocular migraine?

R/O TIA from embolus, vascular disease

What do we call aura WITHOUT headache?

acephalgic migraines AKA typical aura without headache

What is the most common type (90%) of HA?

tension type HA = unilateral or bilateral tightness/aching in frontal, temporal, occipital regions

+/- neck symptoms

+/- sleep abnormalities

When are tension type HA most likely to happen during the day?

4-8am

OR

4-8pm

What is a cluster HA?

severe, boring/burning unilateral pain for 45-60mins that often onset at sleep (peak in spring and fall) = clusters of HA for 8-12 weeks = remission for 12-18 mos

Aside from the severe retro-orbital or temporal pain, what are some other symptoms in cluster HA?

trigeminal ANS symptoms:

lacrimation

rhinorrhea

ptosis

pupil constriction

facial flushing

conj injection

What demographics are most often affected by cluster HA?

males almost exclusively

age 20-30

What typically causes WWOP?

hyper-reflectance of ellipsoid portion of PR inner segments

What is the tx for WWOP?

prophylactic photocoagulation possible d/t small association with retinal tear

What is lattice degeneration?

inner retinal layer thinning with...

abnormal pigmentation

RPE hyperplasia

attenuated/sheathed BV

strong vitreal adhesion at edge = increased risk of tears/holes

Present in 8% of the population, who is more likely to get lattice degeneration?

myopes esp moderate to high myopia

What is the tx for lattice degeneration?

monitor for retinal tears, RD

prophylactic laser

What is snailtrack degeneration?

similar to lattice, but different appearance d/t microglial cells containing lipoprotein

Is snailtrack degeneration more or less likely to have strong vitreous traction at the edge (compared to lattice)?

less likely

What are atrophic retinal holes?

progressive retinal thinning causing a break in the retina = liquified vitreous may enter = surrounding fluid cuff = RD

What indicates that an atrophic retinal hole has been present for 3+ months and is stable?

pigment around hole = reactive RPE hyperplasia

What is an operculated retinal hole?

vitreoretinal traction pulls an operculum of retina that will overly the retinal hole

What is the difference between intrabasal vs juxtabasal operculated retinla holes?

intrabasal = within vit base = held down better

juxtabasal = next to vit base = greater risk of RD

What is the tx for operculated retinal holes?

monitor if <1DD fluid cuff

refer for photocoagulation if >2DD fluid cuff, symptomatic, aphakic, Hx of RD

What is retinoschisis?

splitting of internal layers of sensory retina, often bilateral and IT

What is the difference between flat vs bullous retinoschisis?

flat = split occurs at OPL

bullous = split occurs anterior to OPL (thin inner wall)

How can we differentiate retinoschisis from RD? 3 ways.

schisis does NOT move with eye movements

schisis has true retina colouration (not white)

schisis CAN see choroid details beneath

What is the tx for retinoschisis?

monitor

refer for photocoagulation if holes

What are some signs of RD?

F/F

(+) tobacco dust sign

APD if significant

reduced IOP

iritis

retina looks opaque, folded/corrugated

Is mac on or mac off RD a greater emergency?

mac on bc still can save macula, whereas mac off has worse prognosis

What are some signs that a RD has been present for a while?

pigment demarcation line

taut surface of RD

thinned retina

intraretinal cysts

intraretinal exudates