9/12/2017

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Ten Eye Problems you’ll

meet in the ER, and how

to Manage Them

Scott Kelly, MD, MPH

Howerton Eye Clinic

Austin, Texas

September 16th, 2017

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Hyperopia

“Farsightedness”

Myopia

“Nearsightedness”

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Pupils

• PERRL, not PERRLA!

• Accommodative Triad:

Accommodation,

Convergence, and

MIOSIS

• CN2- Edinger Westphal

Nucleus- CN3

Eye Pain Control

• Cycloplegics (Atropine,

Cyclyopentolate)

• Patching if Sharp pain

• Diamox/ IOP lowering

drops (Combigan, Co-

opt) if pressure >30

• Steroids (if not HSV

Epithelial Keratitis)

• Ointment/ Lubrication

• Proparicaine/

Tetracaine

• Ketorolac

• Heavy Narcotics

Good Idea Bad Idea

Patient 1

• 65 yo Man who noticed flashes of light while

working in his yard. He saw flashes of light for 4-

5 hours, which has now subsided. He now has a

C- shaped floater in his central vision.

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Posterior Vitreous Detachment (PVD)

• Detachment of Vitreous from Posterior Retina

• Has occurred in 66% of 66 year olds

• Flashes with large central floater

• May cause hemorrhage, retinal detachment

• 15% of symptomatic PVD will have a retinal

tear

Patient 2

• 35 year old white man with 2 day history of pain, redness,

photophobia in his right eye. This happened once before in the

opposite eye and resolved after 1-2 weeks of pain. Other ROS/

Medical history is negative.

Iritis/ Uveitis

• Intraocular inflammation

• May be Anterior, Posterior, Scleral,

Episcleral

• Treatment: Steroids, NSAIDs, Cycloplegia

• Order lab workup for 2nd episode, or for

Scleritis or Panuveitis

• Most commonly: Laboratory negative

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Lab Workup

• Head CT not indicated!

• Common Infectious Causes

• TB, Syphillis, HSV/ HZV

• Common Non Infectious Causes

• Sarcoid, RA, Psoriasis, SLE

• HLA B-27

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Patient 3

• 25 year old carpenter who was scratched in the eye by a piece of

plastic. He has severe pain, photophobia, and tearing when

opening his eye. His visual acuity is slightly reduced.

Corneal Abrasion

• Epithelium will heal in 2-3 days regardless of treatment

• Comfort: Patch or Bandage Contact lens

• Antibiotic drops, cycloplegia, +/- steroids

Corneal Ulcer

• Corneal ulcer= Supprative material

• Bacterial, Fungal, or Viral

• Needs Eye MD

• Culture first, then Fortified antibiotics,

Cycloplegia, +/- Steroid

• Pseudomonas, Gram + most severe

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Bacterial Keratitis

• Contact lens use, Abrasion biggest

risk factors

• Goal: 1) Treat Infection

2) Heal Epithelium 3) Improve Vision

• Consider Fungal infection with plant

material

• Not typically contagious

marginal keratitis

• Non-infectious infiltrates from Staph exotoxin secretion from lid

margins

• Treat lids, not cornea!

• Can also be due to Contact Lens intolerance

Patient 4

• 18 year old college student with 3 day history of red, swollen eyelid.

She feels like there is a knot in her lid that is mobile and painful to

the touch.

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Chalazion

• Blockage of Meibomian Gland

• Non-infectious, but can lead of Cellulitis

• Treatment:

• Reduce inflammation

• Treat Blepharitis

• Incise/ Curettage

• Steroid Injection (Caution)

Blepharitis/ Meibomian Gland

Dysfunction

• “Itching, Burning, Foreign Body Sensation”

• Anterior (Lashes)

• Seborrhea, Demodex

• Posterior (Meibomian Glands)

• Systemic inflammation/ Hormone

Demodex

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Rosacea

• Rhinophyma

• Telangiectatic vessels, pustules of

skin

• vascular inflammation of lid margins

• spill over inflammation on ocular

surface:

• Marginal Keratitis

• Staph Hypersensitivity

• Corneal Perforation

Rosacea Treatment Goals

• Reduce Eyelid inflammation

• Matrix Metalloproteinase 9 (MMP-9)

• Doxycycline, Azithromycin, Erythromycin

• Clean lids/ lashes

• Avenova/ Ocusoft Hypochlor

• Warm compresses

• Lubricate/ reduce tear osmolarity

• Treat Ocular Inflammation (Restasis, Xiidra)

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Dry Eye Syndrome

• #2 cause of visits to Ophthalmologists

• Most DES patients combo of Blepharitis and

Aqueous Tear Deficiency (ATD)

• Blepharitis causes poor tear film quality and

increased evaporation

• ATD more common in SLE, RA, Sjogren’s

• Tear replacement, increase Tear production, lid

hygiene/ improve tear quality

• Serum Tears

Patient 5

• 25 year old Kindergarten teacher who has a 2 day history of

photophobia, redness, pain and discharge in her left eye. She has

had runny nose and cough for the last 4 days.

Adenoviral (Epidemic)

KeratoConjunctivitis

• “Pink Eye”; you know real “Pink Eye” when

you see it

• Adenovirus 8, 19, 37 typically

• Very Contagious!!!!

• Red conjunctiva with Follicles, rope-like

discharge, lids stuck closed

• Cough/ runny nose; + Pre-Auricular Node

(PAN)

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Adenoviral Conjunctivitis

• Severe Cases= Conj Pseudomembranes

or Corneal Sub-epithelial Infiltrates

• Treatment:

• Supportive; Cool tears, compress

• +/- Steroids

• Normal Course: worsening for 5 days,

resolves 3 weeks

Bacterial Conjunctivitis

• Common but self limiting

• Over diagnosed

• Severe Forms: Chlamydia (chronic) and

Gonorrhea (hyperacute/ can perforate)

• Typically gram +; cultures not necessary

• Ocular symptoms similar to viral but localized

TIP: use a cheaper

generic antibiotic

(Cipro, Polytrim,

Tobramycin)

instead of brand

name

Patient 6

• 55 year old Hispanic man with 2 days

of right sided scalp and forehead pain.

A rash developed yesterday, and he

now has difficulty opening his eyelid.

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Herpes Zoster Ophthalmicus

• Unilateral, respecting midline

• Pain from inflamed nerves!

• Increased risk of ophthalmic involvement

with + Hutchinson’s sign (Nasociliary

Nerve V1)- Tip of nose

• Eye involvement may lag behind or

precede rash

Herpes Zoster Ophthalmicus

• Treat ideally < 4 days from onset:

• Valacyclovir 1 Gram TID 10 days

• Oral Prednisone for 10 days

• Bacitracin to skin lesions

• +/- Capsaicin

HZO Ophthalmic Complications

• Immune Keratopathy/ Scarring

• Neurotrophic Keratopathy

• Uveitis

• IOP Spike

• Retinitis/ Optic Neuritis

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Patient 7

• 25 yo Woman who has a 2 day history of a red,

painful left eye with photophobia and tearing. Her

right eye is normal. She has been under stress

recently, and attempted to deal with the stress

with a trip to the beach.

Herpes Simplex Epithelial

Keratitis

• Dendritic lesion with club-shaped ends

• Represents ACTIVE Virus; typically

HSV-1

• Other presentations:

• Geographic ulcer

• Stromal (Disciform) Keratitis

• Uveitis (Iris atrophy and high IOP)

HSV Treatment

• Valacyclovir 500mg TID

• Acyclovir 400mg 5x/day

• Trifluridine Drops 9x/day

• NO STEROIDS until epi

healed

• Cycloplegia

• Topical Steroid QID

• Valacyclovir 500mg daily

(prophylactic dose)

• Cycloplegia

Epithelial Stromal

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a) Healing epithelial

abrasion

b) Herpes keratitis

c) Dry eye syndrome

d) SLK

e) Exposure

f) Trichiasis

g) Blepharoconjunctivitis

h) Foreign body under lid

i) Neurotrophic keratopathy

j) Corneal abrasion

k) Lagophthalmos

d) SLK

f) Trichiasis

h) Foreign body

under lid

f) Trichiasis

g) Blepharoconjunctivitis

k) Lagophthalmos

c) Dry eye syndrome

e) Exposure

i) Neurotrophic

keratopathy

a) Healing epithelial

abrasion

j) Corneal abrasionb) Herpes keratitis

Patient 8

• 30 year old man with a 2 day history of worsening eye pain, eyelid

swelling, blurred vision, and pressure-like sensation around his

eye. He has had nasal congestion for the last week.

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Cellulitis

• MUST GET CT ORBITS/ FACE!

• Orbital Cellulitis:

• Eyelid/ edema

• Conjunctival Chemosis

• Proptosis

• Reduced ocular movement/

pain with eye movement

• +/- Pupillary Defect

• Preseptal Cellulitis:

• Eyelid/ edema

• No Chemosis/ Proptosis

• Abscess possible

Orbital Cellulitis

• Frequently extension from Paranasal

Sinuses

• Treatment

• Life- Threatening disease!

• Admit, ID consult, IV Antibiotics,

Drain Abscess

• Staph, Strep, H. flu

Preseptal Cellulitis• Usually adjacent infection or trauma

• Anterior to Orbital Septum

• Abscesses common

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Patient 9

• 65 year old truck driver that has noticed double vision for the last 2

days. He also is having trouble keeping his right eye open. He

denies other symptoms.

Cranial Nerve 3 Palsy

• CN3 Palsy: “Down and Out”

• Often Ptosis (Levator= Superior branch of CN3)

• Pupil-sparing: usually Ischemic

• Pupil- involving: Aneurysm (Posterior Communicating Artery)

until proven otherwise

• Diagnosis: Prompt MRI/ MRA!

• Ocular Myasthenia Gravis can Masquerade as CN palsy

Cranial Nerve 3 Palsy

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Patient 10

• A 70 year old woman is complaining of eye

pain, redness, haloes around light,

headache, nausea and vomiting.

• On exam, she has reduced vision, redness,

a cloudy cornea, and a fixed pupil. Her

IOP reading by tonopen is 55.

High Pressure

• Small stature

• Hyperopia

• Elderly

• No history of

Cataract

extraction

• Uncontrolled

Diabetes (or Vein

Occlusion)

• Viral Uveitis

• Trabeculitis or Iris

Chaffing

Angle

Closure

Neo-

vascular

Phaco-

morphicInflammatory

• Treatment:

• Lower IOP with Timolol, Brimonidine, Dorzolamide.

• Acetazolamide 500mg

• Prednisolone Acetate 1%

• +/- Zofran

• +/- IV Mannitol

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Primary Open Angle Glaucoma

• #2 cause of blindness in the world (ACG and POAG)

• 2% of US population above 40 yo

• Risks:

• Classic: Age, Race, FHx, Corneal Thickness, IOP

• New: Myopia, Vascular compromise

• Most IOP elevations NOT PAINFUL

Bonus: Patient 11

• 60 year old construction worker who was diagnosed with Diabetes

Mellitus Type II 5 years ago. Since then, he has been “controlling

his Diabetes with his diet, because he doesn’t feel bad”. He

doesn’t check his blood sugar, and his last Hemoglobin A1c was

10.

• He is complaining today of black spiderwebs in his vision of his

right eye. He says that his vision has been worsening over the last

3 months in both eyes.

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Diabetic Retinopathy

• Dot-Blot Hemorrhages, Venous

Beading, Hard Exudates,

Microvascular Abnormalities

• Neovascularization of Disc or

Retina with/ without Vitreous

Hemorrhage

ProliferativeNon-Proliferative

Treatment:

Pan-Retinal

Photocoagulation

Diabetic Macular Edema

• Seen in NPDR or PDR

• Hemorrhage or Hard Exudates in Macula

• #1 cause of vision loss in Diabetics

• Dx: OCT and Exam

• Tx: Anti-VEGF agents (Avastin, Lucentis, Eyelea)

• Focal Argon Laser

Diabetic Retinopathy

• #1 cause of irreversible blindness in the US

• Recommend HgA1c below 7.0

• Good HgA1c (at any time) has shown improved Retinopathy control

• AAO Preferred Practice Patterns 2016:

• DFE within 5 yrs of diagnosis Type 1 diabetics

• DFE yearly for ALL type 2 diabetics

• No DFE for gestational diabetes; however diabetic patients

who become pregnant are at increased risk of PDR

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Thank You

Bibliography

• The Wills Eye Manual, 5th Ed. Ehlers J and Shah C. 2008.

• AAO Preferred Practice Patterns. AAO.org.

• eyewiki.org