Week 43: Ophtho (EENT 1/3)

In ANY case of chemical exposure to the eye the first step is irrigation of the eye, and while pH should ideally be measured immediately it should NOT delay irrigation. Note that tetracaine is an acidic substance and if administered prior to pH measurement it may give a false reading.  The pH of this patient’s eye is 8, and the goal pH of the eye should be 7.0-7.4  and irrigation should continue until that is achieved to prevent further liquefactive necrosis in this case (remember that acidic injury causes coagulative necrosis and basic injury causes liquefactive necrosis).  Emergent Ophtho consult is indicated. Once the goal pH is met, the eye should subsequently be stained with fluorescein and examined for any abrasion or ulceration.

This image depicts Seidel’s sign (fluorescein moves away as contents (which appear yellow-green) leak out at site of globe rupture). When a globe rupture is suspected you should avoid any manipulation of the eye (tonometry is contraindicated!). While awaiting emergent ophthalmology consultation for operative repair, a CT orbit should be performed to rule out posterior ocular injury as well as identification of the foreign body. A tetanus vaccine should be documented as up-to-date, as well as prophylactic systemic antibiotics, any pain should be adequately controlled, and anti-emetics provided (to prevent further extrusion of ocular contents due to increased intraocular pressure when vomiting).

Patient is presenting with a Grade I hyphema. Treatment recommendations for a mild hyphema are bed rest, head of bed elevation to encourage layering out of red blood cells and clot formation. Ophtho follow up and discussion of risk of rebleeding from clot contraction are also indicated.  Only severe cases of Grade IV aka “eight-ball” hyphema require surgical drainage/admission.  An exception to this management plan is sickle cell patients, in which a hyphemia is emergent and requires ophtho consultation immediately.  Additionally, anti-coagulation medications may cause or increase risk of developing a hyphema.

Diffuse superficial punctate keratitis (SPK) is usually an acute process arising from contact lens complications, UV exposure from welding or snow blindness, chemical exposure, topical eye medication toxicity, or in extreme dry eye cases. Symptoms include red eye, pain, photophobia, foreign body sensation, +/- mildly decreased visual acuity. Defining features of SPK on fluorescein stain include: pinpoint corneal epithelial defects that enhance. Classically, pain is relieved by the instillation of anesthetic drops, suggesting corneal epithelial involvement.

Non-contact lens wearers with a small amount of SPK should receive artificial tears +/- lubricating ointment. Severe amounts of SPK should also receive topical antibiotics such as erythromycin ointment for 3-5 days. Ophthalmology followup is usually on a non-emergent basis.

Contact lens wearers with a small amount of SPK should discontinue contact lens use until the condition resolves, with artificial tears +/- lubricating ointment. Severe amounts of SPK should also receive topical antibiotics such as fluoroquinolone or tobramycin. Urgent ophthalmology followup should be given.

A hordeolum or stye is an abscess of the eyelid. It presents with pain, erythema, and swelling. Most resolve without intervention. Warm compresses for 15 minutes four times a day may help facilitate drainage. If the hordeolum does not improve in one to two weeks, the patient should be referred to an ophthalmologist for potential incision and drainage or antibiotics.

mnemonic: the Hordeolum is HOT and the Chalazion is COLD, but regardless of what it is warm compress you’ll hold

The hordeolum is an infectious process so will be inflammed and painful, while the chalazion is a painless “cold” cyst, regardless first line treatment is conservative

Retinal detachment’s should be suspected in patient’s with monocular vision loss symptoms. They can be seen in older diabetic patients, however should be suspected in younger patients with trauma such as motor vehicle crashes, skydiving, bungee jumping, and other activities with sudden deceleration forces are risk factors. Patients with myopia (such as this patient) are at higher risk of traumatic retinal detachment. Diagnosis can be made with indirect ophthalmoscopy or ultrasound. Ultrasound will show a discrete hyperechoic retinal line projecting out from the posterior globe.  Patients usually present with painless vision changes, including flashes of light, floaters, or the classic “curtain-like” loss of vision. Retinal detachment is an ophthalmologic emergency and early intervention can prevent worsening of the detachment.

Involvement of the macula is important to determine. If the retinal detachment involves the macula (“mac on”) it is LESS emergent than if the macula is not involved (“mac off”), this is because emergent surgical correction can salvage the macula in a “mac off” situation.

Retinal detachment is usually a thicker line which will not cross over the optic nerve as the retina is an extension of the nerve. This is in comparison to posterior vitreal hemorrhage which appears as a whispy thin line which can cross over the optic nerve. See the video link below.

http://5minsono.com/rdvd/

This patient presents with dacryocystitis and should be treated with oral anti-staphylococcal antibiotics. Dacryocystitis is an acute infection of the lacrimal sac secondary to lacrimal duct obstruction. Given the obstruction of the lacrimal duct, topical abx treatment of the eye alone will not provide penetration into the infected area. It is typically caused by Staphylococcus aureus. Symptoms include swelling, redness, pain and tenderness to palpation over the lacrimal sac. Diagnosis can be aided with a fluorescein stain, aka fluorescein disappearance test, which sill either show lack of clearance of fluorescein dye to the eye over 5 minutes or fluorescein spilling out as tears (normal eye will clear fluorescein in <5 minutes). In addition to oral antibiotics, patients should be treated with warm compresses and gentle massage of the area. Complications of improperly treated dacryocystitis include peri-orbital and orbital cellulitis.

This patient’s fluorescein exam is consistent with a corneal abrasion. It is caused by direct mechanical damage, leading to a partial-thickness corneal injury. Athletes, contact lens wearers, welders, and glass workers may present more often with these injuries. Diagnosis is confirmed when fluorescein dye highlights the usually linear or punctate abrasions. Multiple vertical corneal abrasions may indicate a retained foreign body beneath the eyelid. Corneal abrasion fluorescein exam findings are not to be confused with open globe injuries (streaking of the dye from the site of injury), corneal ulcers (circular patches of dye uptake with ragged, “heaped up” edges), and herpes simplex keratitis (dendritic pattern uptake). Patients commonly present with eye pain and tearing with a usually known mechanism of injury. The mainstay of treatment includes pain control, infection prophylaxis, updating tetanus as needed and preventative care to avoid abrasions in the future. For non-contact wearers prescribe erythromycin ointment, as this does not cover pseudomonal infections, contact lens wearers should be prescribed  ciprofloxacin or tobramycin ophthalmic drops

A lateral canthotomy should be performed in this woman who presents with classic symptoms for a traumatic injury causing retrobulbar hematoma and resultant orbital compartment syndrome. She displays the triad of symptoms including loss of vision, ophthalmoplegia, and proptosis. A retrobulbar hemorrhage from a ruptured infraorbital or ethmoidal artery with intact orbital walls may lead to orbital compartment syndrome. Loss of vision is irreversible 60–100 minutes after the onset of ischemia and so lateral canthotomy and inferior cantholysis should be performed in order to decompress the orbit and preserve vision. Intraocular pressure-lowering agents such as intravenous carbonic anhydrase inhibitors, topical beta-blockers, alpha agonists, and intravenous mannitol are temporizing measures.

This patient has traumatic endopthalmitis. Suspicion should be high in any patient with recent trauma or intraocular surgery and signs/symptoms of infection or with hypopyon (purulent/white layering of fluid in anterior chamber). Manipulation of the eye should be avoided due to concern for globe rupture in this patient (e.g. ocular US/tonometry). A stat CT orbit is indicated to examine for foreign body. Systemic antibiotics are indicated in traumatic endopthalmitis, treatment should be broad-spectrum and common courses include vanc/ceftazidime. While at DRH vanc/cefepime is commonly used to treat various infections, BE AWARE that cefepime has relatively poor penetration into the vitrea and is not recommended. Common pathogens include staph/strep and oddly enough bacillus cereus.  Topical antibiotics alone are insufficient. It is essential to consult ophthalmology as definitive management is generally surgical: vitrectomy and intra-vitreal abx injection.