emergency ophthalmology

An Ophthalmology Refresher

Tiki EwingOphthalmology Registrar SCGH

Referrals

• E-referrals checked daily• Details – why, what (include VA), when • Friday is AM clinic only – make referrals early• Is the patient well enough to come to clinic?

Examination

• New pro-forma - please use it• Visual acuity (with distance glasses if uses or

without), then with pinhole)• Pupils (please don’t dilate unless you are confident they are normal, or

discussed if abnormal)

• Movements• Colour vision (red saturations/eye handbook)• Confrontational fields

Slit Lamp

Tips:• Practice makes perfect• You are most welcome to join us in

clinic for practice sessions• Dilute the 2% fluorescein• Cobalt blue vs red free (green)• Looking for cells: 1x1mm2 beam,

brightest light, high magnification

• IOP (post slit-lamp)

• Fundoscopy

Tonopen- Well anaesthetised eye- Sterile cover- Hold like a pencil, plan to

patients cheek- Other hand lifts upper lid

from orbital rim- NO PRESSURE on globe- If patient is squeezing in

discomfort, can artificially raise IOP

- 1295 : 95=accuracy

SERIOUS FEATURES

• Visual acuity reduced• Significant pain doesn’t significantly reduce with topical

local• Patient’s only eye• Multiple eye drops/prolonged course• Recent surgery

SERIOUS CONDITIONSAcute angle closure glaucoma

Endophthalmitis

Orbital cellulitis

25yr old man, 1 week of red, discharging left eye, itchy and light sensitive

Adenoviral Conjunctivitis

How to differentiate from other types• Burning, watery or mucopurulent D/C, painful pre-

auricular lymph node, corneal involvement, pseudomembrane

• 7 species of adenovirus, 54 serotypes, many, but not all cause conjunctivitis

• Can survive on dry surfaces or in water for weeks• No known cure• Remains infective for up to 2 weeks

What about chlorsig• HEAVILY OVER USED

Evidence:• Of cases GPs thought were bacterial conjunctivitis only 50%

were

• Randomised placebo controlled study in Kids (who are more likely to have bacterial conjunctivitis), chlorsig vs saline (blinded), cure within 7days in 85% chlorsig, 80% saline.

• Evidence suggests managing conservatively with lubricants and cool compresses for 3 days, if not improving then consider it

34yr old presents with a watery, red, aching eye, with photophobia

Uveitis/Iritis• Inflammation of the uveal tract• Immune mediated• Classification

– Anterior– Intermediate– Posterior– Panuveitis

Tips• PMHx relevant• Looks closely at pupil reactivity• Poor dilation• Extremely rare to be bilateral• Acutely photophobic

Herpetic Corneal Infections

• HSV-1: Coldsores and Keratitis• HSV-2: Genital Herpes• VZV: Chicken pox, shingles, HZO

HSV• Debridement, topical therapy (or oral, not

both unless immunocompromised)• What about Steroids ?

Herpes Zoster Ophthalmicus

• Not all need referral• Hutchinson’s Sign• Eye involvement – Conjunctivitis– Keratitis (pseudodendrites)– Uveitis– Retinitis

• Topical Antivirals have questionable role• Start PO antivirals early – reduces post herpetic

neuralgia only– 800mg Aciclovir 5x or 1g Valtrex TDS (PBS covered)

Episcleritis• Sectoral inflammation of episcleral vessels (sometimes

diffuse)• Mild-moderate tenderness over area• Can have fluorescein stain over area• Vision is NORMALTreatment: artificial tears Oral NSAIDs topical steroids

DDx• Scleritis

– Older, known immune-mediated disease, deep severe pain, scleral as well as overlying vessel inflammation

– No blanching with topical phenylephrine (2.5%)

Foreign Body Red Flags• ? Penetrating injury• Over visual axis• Residual material you are

unable to remove• Infiltrate or AC reaction

• Best outcome if as much of the rust ring is removed in first attempt

• However if deep and central, can leave for it to migrate to surface

Corneal Infiltrate

85yr old manVisual loss right eye

“Salt rinse” this morning, now ? Left eye disturbance

Wife terminal cancer

VA: R CF, L 6/12 (NIPH)

75year old ladyVisual loss right eye overnight

PainlessCT head NAD

Sent form JHC to SCGH ophthalmology for review ? Ocular

cause

Posterior Vitreous Detachment• Occurs due to the liquefaction of vitreous gel with age• Occurs in 60% of 80yr olds• 20-30% have complications such as a retinal hole/tear or detachment• Risk factors crucial in our triaging (myope, Hx tear or detachment, recent eye

surgery or trauma to eye, FHx)• You cannot adequately assess with a direct ophthalmoscope, these patients

need referral

General Tips• Check visual acuity, use pinhole• Check optic nerve function• Check the cornea• Consider dilating• Please be honest