Ophthalmologic EmergenciesOphthalmologic Emergencies

William Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency Department of Emergency MedicineMedicine

Ophthalmologic emergenciesOphthalmologic emergencies

Sudden loss of visionSudden loss of vision– Central retinal artery occlusionCentral retinal artery occlusion– Central retinal vein occlusionCentral retinal vein occlusion– Retrobulbar neuritisRetrobulbar neuritis– Amaurosis fugaxAmaurosis fugax– Retinal detachmentRetinal detachment– Acute iritisAcute iritis

Central retinal artery occlusionCentral retinal artery occlusion

Sudden monocular painless, complete loss of Sudden monocular painless, complete loss of visionvision

Fundoscopic exam: pale retina with macular red Fundoscopic exam: pale retina with macular red spotspot

Treatment Treatment – stat opthy consultstat opthy consult– Intermittent digital massage of the globeIntermittent digital massage of the globe– Increase CO2 (arteriolar dilatation) – carbonic Increase CO2 (arteriolar dilatation) – carbonic

anhydrase inhibitor (ie acetazolamide)anhydrase inhibitor (ie acetazolamide)– Definitive tx – paracentesis of the anterior chamberDefinitive tx – paracentesis of the anterior chamber

Central retinal vein occlusionCentral retinal vein occlusion

Sudden monocular Sudden monocular painless, and near painless, and near complete loss of complete loss of visionvision

Fundoscopic exam: Fundoscopic exam: chaotic, blood-chaotic, blood-streaked retinastreaked retina

Stat ophthalmology Stat ophthalmology consultconsult

Optic neuritisOptic neuritis

Progressive loss of Progressive loss of central vision central vision May be painful, May be painful, scotoma, flashing scotoma, flashing lightslightsPeripheral vision Peripheral vision preservedpreservedAssociated with Associated with multiple sclerosis in multiple sclerosis in 25% of cases25% of cases

Amaurosis fugaxAmaurosis fugax

Fleeting painless loss of monocular visionFleeting painless loss of monocular vision

Due to minute emboli of the central retinal Due to minute emboli of the central retinal arteryartery

Consult neurology for TIAConsult neurology for TIA

Retinal detachmentRetinal detachment

PainlessPainless

Prodromal floaters or Prodromal floaters or flashing lights, flashing lights, followed by “lowering followed by “lowering curtain”curtain”

Opthy consultOpthy consult

Acute iritisAcute iritis

Painful blurred visionPainful blurred vision

Will cover in more detail under Red Eye Will cover in more detail under Red Eye in a few slidesin a few slides

Red eyeRed eye

Acute angle closure glaucomaAcute angle closure glaucoma

Acute iritisAcute iritis

ConjunctivitisConjunctivitis

Herpes simplex keratitisHerpes simplex keratitis

Corneal ulcerationCorneal ulceration

Chemical conjunctivitisChemical conjunctivitis

Corneal abrasionsCorneal abrasions

Acute angle closure glaucomaAcute angle closure glaucoma

Sudden severe unilateral ocular pain and Sudden severe unilateral ocular pain and decreased visual acuitydecreased visual acuityPatients may present with headache or nausea, Patients may present with headache or nausea, blurred vision or rainbow halosblurred vision or rainbow halosPrecipitous increase in IOP leads to blindness Precipitous increase in IOP leads to blindness within a few days if left untreatedwithin a few days if left untreatedIn patients predisposed (ie far sighted, In patients predisposed (ie far sighted, cataracts), pupil dilatation is often precipitant cataracts), pupil dilatation is often precipitant event (sympathomimetics, parasympatholytics, event (sympathomimetics, parasympatholytics, stress, fatigue, darkness)stress, fatigue, darkness)

Acute angle glaucomaAcute angle glaucoma

Red eyeRed eyeNonreactive mid-dilated Nonreactive mid-dilated pupilpupilCorneal edemaCorneal edemaShallow anterior Shallow anterior chamberchamberHigh intraocular High intraocular pressure (60-90)*pressure (60-90)*Hazy corneaHazy cornea

Normal IOP = < 20Normal IOP = < 20

Treatment glaucomaTreatment glaucoma

Stat opthy consult for definitive tx – iridectomyStat opthy consult for definitive tx – iridectomy

Timolol – beta blocker Timolol – beta blocker

Pilocarpine – parasympathomimeticPilocarpine – parasympathomimetic

Acetazolamide (diamox) – carbonic anhydrase Acetazolamide (diamox) – carbonic anhydrase inhibitorinhibitor

MannitolMannitol

50% glycerol – oral hyperosmotic – if patient can 50% glycerol – oral hyperosmotic – if patient can tolerate po – give in place of mannitoltolerate po – give in place of mannitol

TimololTimolol

Timoptic solution – beta blockerTimoptic solution – beta blocker

Decreases aqueous humor formationDecreases aqueous humor formation

0.5% solution – 1-2 drops at 10-15 min 0.5% solution – 1-2 drops at 10-15 min intervals x 3, then 1 drop every 12 hoursintervals x 3, then 1 drop every 12 hours

PilocarpinePilocarpine

ParasympathomimeticParasympathomimetic

Produces miosisProduces miosis

2% solution – 1 drop every 30 minutes 2% solution – 1 drop every 30 minutes until the pupil constricts, then 1 drop every until the pupil constricts, then 1 drop every 6 hours6 hours

Side effects: bradycardia, hypotension, Side effects: bradycardia, hypotension, sweating, tremorssweating, tremors

AcetazolamideAcetazolamide

DiamoxDiamox

Carbonic anhydrase inhibitorCarbonic anhydrase inhibitor

Inhibits aqueous humor formationInhibits aqueous humor formation

Cross reactive allergen with sulfaCross reactive allergen with sulfa

500 mg IV every 12 hours or 500 mg po 500 mg IV every 12 hours or 500 mg po every 6 hoursevery 6 hours

Side effects: respiratory depression, Side effects: respiratory depression, metabolic acidosismetabolic acidosis

MannitolMannitol

20% 1-2 grams/kg IV over 30-60 minutes20% 1-2 grams/kg IV over 30-60 minutes

Increases blood osmolality, creating a Increases blood osmolality, creating a gradient that draws water from the vitreous gradient that draws water from the vitreous cavitycavity

Side effects: headache, confusion, CHF, Side effects: headache, confusion, CHF, dehydrationdehydration

Acute iritisAcute iritis

Blurred vision, photophobia, ocular painBlurred vision, photophobia, ocular painExam: ciliary flush, anterior chamber cells Exam: ciliary flush, anterior chamber cells and flare, constricted pupil, decreased and flare, constricted pupil, decreased visual acuity, lower IOPvisual acuity, lower IOPTreatment: Treatment: – Cycloplegics – ie Homatropine – dilates the Cycloplegics – ie Homatropine – dilates the

eyeseyes– Topical steroids Topical steroids – Close opthy follow upClose opthy follow up

Acute iritisAcute iritis

conjunctivitisconjunctivitis

Nonpainful red eyeNonpainful red eye

Bacterial, viral, Bacterial, viral, allergicallergic

Herpes simplex keratitisHerpes simplex keratitis

Red eye with foreign Red eye with foreign body sensationbody sensation

Dendritic fluorescein Dendritic fluorescein uptakeuptake

Treat: acyclovir drops, Treat: acyclovir drops, cycloplegicscycloplegics

Steroids Steroids contraindicatedcontraindicated

Opthy consultOpthy consult

Corneal ulcerationCorneal ulceration

Red, painful eyeRed, painful eye

White flocculent infiltrate of the cornea on White flocculent infiltrate of the cornea on slit lamp examslit lamp exam

Slit lamp may reveal a hypopyon Slit lamp may reveal a hypopyon

– anterior chamber exudateanterior chamber exudate

May lead to corneal destruction and May lead to corneal destruction and perforationperforation

Admit, IV antibioticsAdmit, IV antibiotics

Corneal ulcerationCorneal ulceration

Chemical conjunctivitisChemical conjunctivitis

Alkali burnAlkali burn – absolute ocular emergency – absolute ocular emergency– Liquefactive necrosis – worseLiquefactive necrosis – worse– Immediate irrigation to continue until pH returns to 7.0 Immediate irrigation to continue until pH returns to 7.0

– 7.5 and opthy consult– 7.5 and opthy consult– Only opthy emergency in which visual acuity is not Only opthy emergency in which visual acuity is not

indicated until after therapy has begunindicated until after therapy has begun

Acid burnsAcid burns– Coagulative necrosisCoagulative necrosis– Immediate irrigation as above and opthy consultImmediate irrigation as above and opthy consult

Alkali burnsAlkali burns

Corneal abrasionsCorneal abrasions

Foreign body sensation and photophobiaForeign body sensation and photophobiaDiagnose: fluorescein uptake with slit lamp Diagnose: fluorescein uptake with slit lamp exam, rule out foreign body with double upper lid exam, rule out foreign body with double upper lid eversioneversionSuspect foreign body if “ice rink sign” – fine Suspect foreign body if “ice rink sign” – fine linear abrasions in upper 1/3 cornealinear abrasions in upper 1/3 corneaRule out corneal ulceration Rule out corneal ulceration Do not use steroid drops – as it may be difficult Do not use steroid drops – as it may be difficult to rule out early HS keratitisto rule out early HS keratitisTreat: antibiotic ointment/drops, analgesicsTreat: antibiotic ointment/drops, analgesicsPrognosis is very goodPrognosis is very good

Corneal abrasionCorneal abrasion

Traumatic eye injuriesTraumatic eye injuries

Corneal lacerationCorneal lacerationPerforated globePerforated globeIntraocular foreign bodyIntraocular foreign bodyHyphemaHyphemaBlow-out orbital fractureBlow-out orbital fractureTraumatic lens dislocationTraumatic lens dislocationTraumatic mydriasisTraumatic mydriasisTraumatic iritis or retinal detachmentTraumatic iritis or retinal detachment

Corneal lacerationCorneal laceration

Tear shaped pupil – from prolapse of the Tear shaped pupil – from prolapse of the irisiris

Small black fragments representing iris Small black fragments representing iris pigment may be seen and initially pigment may be seen and initially mistaken for a foreign bodymistaken for a foreign body

May not see the laceration itselfMay not see the laceration itself

Treat: metal shield, stat opthy consult for Treat: metal shield, stat opthy consult for surgical repairsurgical repair

Corneal lacerationCorneal laceration

Perforated globePerforated globe

Suspect if penetrating wound to the eyelidSuspect if penetrating wound to the eyelid

Decreased visual acuity, soft globe (do not Decreased visual acuity, soft globe (do not palpate however)palpate however)

Fundoscopic exam may reveal vitreous Fundoscopic exam may reveal vitreous hemorrhagehemorrhage

Treatment: Metal shield, stat opthy consult Treatment: Metal shield, stat opthy consult for surgical repairfor surgical repair

Intraocular foreign bodyIntraocular foreign body

Patient often gives a history of striking Patient often gives a history of striking metal on metalmetal on metalMay be initially painless, but then patient May be initially painless, but then patient develops monocular pain and decreased develops monocular pain and decreased visual acuityvisual acuityMay not see the woundMay not see the woundDiagnosis: CT scan, ultrasound or plain x-Diagnosis: CT scan, ultrasound or plain x-ray of the globeray of the globeTx: Opthy consult for surgical removalTx: Opthy consult for surgical removal

Orbital foreign bodyOrbital foreign body

HyphemaHyphema

Hemorrhage in the Hemorrhage in the anterior chamberanterior chamberSee blood/vitreous See blood/vitreous line in inferior iris line in inferior iris directly or on slit lamp directly or on slit lamp examexamTreatment: bed rest, Treatment: bed rest, head of bed elevation, head of bed elevation, ophthy admit, ophthy admit, steroids, mioticssteroids, miotics

Blow-out orbital fractureBlow-out orbital fracture

Blunt globe trauma (ie fist to eye) Blunt globe trauma (ie fist to eye) transmits forces that may lead to orbital transmits forces that may lead to orbital floor fracturefloor fractureInferior rectus muscle may prolapse Inferior rectus muscle may prolapse through the fracturethrough the fracturePain and diplopia or loss of upward gaze, Pain and diplopia or loss of upward gaze, enophthalmos (sunken eye), infraorbital enophthalmos (sunken eye), infraorbital anesthesiaanesthesiaOpthy consultOpthy consult

Blow out fractureBlow out fracture

ENT emergenciesENT emergenciesEmergent Ear DisordersEmergent Ear Disorders– Auricular HematomaAuricular Hematoma – blunt trauma – blunt trauma

Untreated, can result in cartilage necrosis Untreated, can result in cartilage necrosis (“cauliflower ear”)(“cauliflower ear”)Tx – needle aspiration, compression dressing, +/- AbsTx – needle aspiration, compression dressing, +/- Abs

– PerichondritisPerichondritis – admit for IV abs – admit for IV abs

– Otitis externaOtitis externa – swelling of the external canal, – swelling of the external canal, pain with movement of the auriculapain with movement of the auricula

Tx: Abs/steroid combination ear drops after placing Tx: Abs/steroid combination ear drops after placing an ear wickan ear wick

Auricular hematomaAuricular hematoma

EarEar

Malignant Otitis ExternaMalignant Otitis Externa – immunocompromised pt – immunocompromised pt

Pseudomonas aeruginosaPseudomonas aeruginosaDeep pain with movement of TMJ, granulation tissue on Deep pain with movement of TMJ, granulation tissue on the floor of the auditory canal at bony-cartilage junctionthe floor of the auditory canal at bony-cartilage junction

Facial nerve paralysis Facial nerve paralysis multiple CN involvement multiple CN involvement meningitismeningitis

Tx: stat ENT consult for surgical debridement and IV Tx: stat ENT consult for surgical debridement and IV antibioticsantibiotics

Malignant otitis externaMalignant otitis externa

EarEarRamsay-Hunt syndromeRamsay-Hunt syndrome– Vesicular (Herpes zoster) rash of ext auditory canal and Vesicular (Herpes zoster) rash of ext auditory canal and

auricleauricle– Usually with sensorineural hearing loss and facial nerve Usually with sensorineural hearing loss and facial nerve

paralysisparalysis– Treatment: admit for IV acyclovir and steroidsTreatment: admit for IV acyclovir and steroids

Foreign bodyForeign body– Tools for removal – irrigation (not vegetable matter), Tools for removal – irrigation (not vegetable matter),

alligator forceps, suction, hook, cerumen loopalligator forceps, suction, hook, cerumen loop– Live insects should be stupefied with lidocaine or mineral Live insects should be stupefied with lidocaine or mineral

oil prior to removaloil prior to removal

Tympanic membrane ruptureTympanic membrane rupture – ENT referral – ENT referral

Otitis media Otitis media – hopefully you all know what this is– hopefully you all know what this is

Ramsay hunt syndromeRamsay hunt syndrome

NoseNoseEpistaxisEpistaxis– Anterior most common – Kiesselbach’s plexusAnterior most common – Kiesselbach’s plexus– Posterior often due to uncontrolled HTNPosterior often due to uncontrolled HTN– Rule out coagulopathyRule out coagulopathy– Silver nitrate or cauterySilver nitrate or cautery– Oral antibiotics if nasal pack Oral antibiotics if nasal pack

Foreign bodiesForeign bodies – suction, ear curette, forceps – suction, ear curette, forceps

Acute sinusitisAcute sinusitis – nasal and oral decongestant, – nasal and oral decongestant, antibiotics (augmentin, macrolide, 2antibiotics (augmentin, macrolide, 2ndnd or 3 or 3rdrd cephalosporin) if sxs > 1 weekcephalosporin) if sxs > 1 week

Complications of sinusitisComplications of sinusitis

Pott’s puffy tumor – Pott’s puffy tumor – osteitis of anterior frontal osteitis of anterior frontal sinus wall sinus wall frontal lobe frontal lobe abscessabscess

MeningitisMeningitis

Acute periorbital cellulitis Acute periorbital cellulitis – around the orbit– around the orbit– Tx: admit for IV AbsTx: admit for IV Abs– CT scan to rule out CT scan to rule out

orbital cellulitis orbital cellulitis (surgical emergency)(surgical emergency)

Cavernous sinus thrombosisCavernous sinus thrombosis

High feverHigh fever

Toxic appearingToxic appearing

Chemosis, CN 3 & 6 Chemosis, CN 3 & 6 palsies, papilledemapalsies, papilledema

Lethargy, coma or Lethargy, coma or seizures seizures

DX: CT, MRIDX: CT, MRI

MucormycosisMucormycosis

Fungal sinusitis in Fungal sinusitis in immunocompromised immunocompromised patient patient

Nasopharyngeal Nasopharyngeal necrosisnecrosis

CN palsies CN palsies

IV antifungal AbsIV antifungal Abs

High mortality rateHigh mortality rate

ThroatThroat

Pharyngitis – Grp A strep Pharyngitis – Grp A strep – treat to prevent complications and acute treat to prevent complications and acute

rheumatic fever and ARHDrheumatic fever and ARHD– glomerulonephritis not prevented by Absglomerulonephritis not prevented by Abs

Mononucleosis – EBVMononucleosis – EBV– Pharyngitis, fever, cervical lymphadenopathyPharyngitis, fever, cervical lymphadenopathy– Splenomegaly in 50%Splenomegaly in 50%– Dx: monospot, Dx: monospot, atypical lymphocytes atypical lymphocytes– Tx: fluid, rest, steroids, avoid ampicillin (rash), Tx: fluid, rest, steroids, avoid ampicillin (rash),

contact sports/trauma (splenic rupture)contact sports/trauma (splenic rupture)

Ludwig’s anginaLudwig’s angina

Bilateral cellulitis of the floor of the mouthBilateral cellulitis of the floor of the mouth

True emergency (airway obstruction)True emergency (airway obstruction)

Elderly, debilitated men (alcohol abuse)Elderly, debilitated men (alcohol abuse)

Dx: CLINICAL: brawny edema of Dx: CLINICAL: brawny edema of submandibular area, febrile, protruding submandibular area, febrile, protruding elevated tongue, respiratory distresselevated tongue, respiratory distress

Tx: IV antibiotics (clindamycin or Unasyn Tx: IV antibiotics (clindamycin or Unasyn or Pcn + metronidazole) + airway or Pcn + metronidazole) + airway protectionprotection

Ludwig’s anginaLudwig’s angina

Peritonsillar abscessPeritonsillar abscess

Fever, trismus, dysphagiaFever, trismus, dysphagia

Adolescents, young adultsAdolescents, young adults

Enlarged inflamed tonsil extending mediallyEnlarged inflamed tonsil extending medially

Displaces uvula to opposite sideDisplaces uvula to opposite side

ENT consult for I & D, IV Abs (Pcn or ENT consult for I & D, IV Abs (Pcn or Clindamycin or Unasyn with Metronidazole), Clindamycin or Unasyn with Metronidazole), IV fluids, IV steroidsIV fluids, IV steroids

Peritonsillar abscessPeritonsillar abscess

Retropharyngeal abscessRetropharyngeal abscess

Children aged 6 mos – 3 yrsChildren aged 6 mos – 3 yrs

Staph aureus, grp A strep, anaerobesStaph aureus, grp A strep, anaerobes

Fever, neck pain, muffled voice, dysphagiaFever, neck pain, muffled voice, dysphagia

Child prefers to lie supine (do not force to sit up)Child prefers to lie supine (do not force to sit up)

Diagnosis: prevertebral edema on lateral soft tissueDiagnosis: prevertebral edema on lateral soft tissue

neck X-rayneck X-ray

Tx: ICU admit for IV Abs and ENT surgical drainageTx: ICU admit for IV Abs and ENT surgical drainage

PCN or Clindamycin or Unasyn with MetronidazolePCN or Clindamycin or Unasyn with Metronidazole

EpiglottisEpiglottisAbrupt high fever, sore throat, stridor, dysphagiaAbrupt high fever, sore throat, stridor, dysphagiaPicture: child is drooling, stridorous, sitting up with Picture: child is drooling, stridorous, sitting up with chin forward and neck extendedchin forward and neck extendedAny age – children more worrisome Any age – children more worrisome H influenza, grp A strep, Branhamella catarrhalisH influenza, grp A strep, Branhamella catarrhalisDx: thumb print sign on ST lateral neck x-rayDx: thumb print sign on ST lateral neck x-rayTx: cricothyrotomy set up at bedside, intubation by Tx: cricothyrotomy set up at bedside, intubation by ENT in OR if possible, ICU admit for IV antibiotics, ENT in OR if possible, ICU admit for IV antibiotics, humidified oxygen, IV fluidshumidified oxygen, IV fluidsCeftriaxone with Clindamycin or Vancomycin; or Ceftriaxone with Clindamycin or Vancomycin; or Unasyn Unasyn

CroupCroup

Inflammation of the larynx and subglottic airwayInflammation of the larynx and subglottic airway

Parainfluenza most common (RSV, adenovirus)Parainfluenza most common (RSV, adenovirus)

2-3 days of URI sxs, worsening to a barking cough, 2-3 days of URI sxs, worsening to a barking cough, hoarse voice, and stridoroushoarse voice, and stridorous

Rare after age 6Rare after age 6

Diagnosis: steeple or pencil sign on AP soft tissueDiagnosis: steeple or pencil sign on AP soft tissue

neck x-rayneck x-ray

Tx: steroids (0.6 mg/kg dexamethasone PO x 1),Tx: steroids (0.6 mg/kg dexamethasone PO x 1),

humidifed oxygen (cool), racemic epinephrinehumidifed oxygen (cool), racemic epinephrine

Pencil signPencil sign

What is it?What is it?

THE ENDTHE END

ANY QUESTIONS?ANY QUESTIONS?