Download - 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