5. Terminology
Keratitis = inflammation of
cornea
Blepharitis = inflammation of
the eyelid
Iritis = inflammation of Iris
Uveitis = inflam of uvea,
(middle layer-iris, ciliary body
and choroid)
Anterior uveitis (most
common) – inflam. iris and
ciliary body aka “Iritis”
Intermediate uveitis –
inflam. ciliary body
Posterior uveitis – inflam.
choroid
Diffuse uveitis - all
6. History/Examination
Glasses? Contact Lenses?
Previous eye
conditions/trauma/surgery/med
s
Visual Acuity
Snellen chart x/y
X is distance from chart (ie 6
metres)
Y is smallest font size read
Eg Normal 6/6, just top line
6/60
Vision less than 6/60 count
no. of fingers/hand
movements/light perception
Pin hole corrects refractory
error to 6/9 or better
7. Examination
Visual Fields
Evert eyelids-local
anaesthetic (Amethocaine)
aids thorough eye exam
Eye movements “H” CN III,
IV, VI palsies, fatigability
(myasthenia)
8. Examination
Ophthalmoscopy: dark, dioptric to zero, pt focus on
corner of room
Pupils
Reflex
Symmetry
Cornea
Lens
Humour
Retina-Fundoscopy-dilate pupil-Tropicamide
Can use cobalt blue light with fluorescein
9. Examination
Slit Lamp-where is it?
Lateral canthus at black line on frame
Pt to look at examiners R ear when examining R eye
Joystick to focus
Cobalt blue light for fluorescein-NOT green light filter.
But Fluorescein dye appears green under blue light
10. Painful Red Eye
Case:
65yo F, 1/52 increasing
R unilateral eye pain
assoc n/v, Dx as
migraine
o/e
visual acuity reduced
hazy cornea
fixed mid-dilated pupil
hard eyeball
11. Acute Angle Closure
Glaucoma
Females in 60-70s, esp. Asians/Eskimos, +ve FHx
defined as
> 2 of
ocular pain,
nausea/vomiting,
intermittent blurred vision with halos
and at least 3 of:
conjunctiva injection
corneal epithelial oedema = hazy
mid-dilated non-reactive pupil
IOP >21 mmHg can be >60 mmHg
shallower chamber in the presence of occlusion.
12. Acute Angle Closure
Glaucoma
Aqueous humor
produced by ciliary body
(posterior chamber)
passes thu pupil into ant
chamber drained via trabecular
meshwork and canal of
Schlemm in the angle.
Contact between the lens and the
iris blocks flow, pressure in
posterior chamber - iris bows
forward closing angle – reduce
drainage
Precipitated by dilated pupil-
darkness, stress, medications
(anticholinergic, sympathomimetic)
Chronic open angle- no pain no
attacks-slow progressive vision
loss
13. Acute Angle Closure
Glaucoma
Intra-ocular pressure
measurement: Normal
10-20mmHg
Goldman applanation
tonometer: attached to the slit
lamp
Storz/Schiotz Tonometer
Tono-Pen handheld electronic
contact tonometer ($3000)
14. Acute Angle Closure
Glaucoma
Mx Ophthal. referral
Acetazolamide 500mg IV
Topical beta-blocker
Topical steroid
Analgesics/Anti-emetics/Supine
Once pressure-induced ischemic paralysis of the iris
resolves around 1 hour post initial Rx then:
Pilocarpine: a miotic (constricts pupil) – opens angle,
should be administered every 5 mins for 30 mins
Laser peripheral iridotomy performed 24-48 hours after
IOP is controlled is definitive treatment
16. Painful Red Eye
Case:
45yo F with unilateral
red, painful eye
PHx Crohn’s Disease
o/e blurred vision,
perilimbal injection,
Slit lamp
“floaters/debris in
anterior chamber”
17. Acute Anterior Uveitis (Iritis)
Unilateral, painful red eye, blurred vision,
photophobia, and tearing
Peri-limbal injection, worse closer to
limbus: (conjunctivitis= worse further from
limbus)
Visual acuity may be decreased
Examine anterior chamber with Slit lamp
Increase in protein content of aqueous
causes an effect known as “flare”,
looks “smokey”
White or red blood cells may be
observed in the anterior chamber
Severe cases - inflam. cells
accumulate as sediment in ant.
chamber = Hypopyon
20. Painful Red Eye - Eyelid
Chalazion - eyelid cyst inflam. of
blocked meibomian gland -usually
painless and larger. Rx warm
compresses/antis/usually resolve
can inject steroids/surgically
remove
Stye – infection (staph) of the
sebaceous glands at base of the
eyelashes. Rx warm compress,
pull out eyelash, antis
Blepharitis – inflam. eyelid can be
infective. Rx warm wet compress/
antis
Herpes Zoster – vesicular rash,
can cause infection of all parts of
eye. Nasociliary branch
involvement predicts serious
complications: ocular inflam. and
corneal denervation. Mx Opthal
ref, Acyclovir
24. Case
60yo M Sudden, painless
loss of vision L eye,
previous
partial/intermittent loss of
vision over a few days
PHx IHD, HT, DM
L eye light perception
only, relative afferent
pupillary defect
Fundus: pale,
arteries/veins narrowed
25. Central Retinal Artery
Occlusion
Embolism
Most commonly cholesterol,
cardiac (assoc HT,DM) can be
calcific, bacterial, Giant cell
arteritis
Amaurosis Fugax : transient
loss of vision lasting seconds
to minutes, can precede
Mx Urgent ophthal referral
Decrease intra-ocular pressure
Acetazolamide/Anterior
chamber paracentesis
Move clot
Pulsed ocular compression
Anticoagulate
Intra-arterial fibrinolysis
26. Central Retinal Vein Occlusion
Sudden painless loss of vision
R/F: age, HT, DM,
prothrombotic disorders
Types: Non-ischaemic and
Ischaemic
Signs: Decreased visual
acuity, Relative Afferent
pupillary Defect, abnormal red
reflex
Fundus haemorrhage (“Stormy
sunset”)
Mx Ophthal referral
Anticoag, aspirin
Surgery incl. Laser
photocoagulation
27. Optic Neuritis
Vision loss (esp. colour) over hours-days,
pain with eye movements, central scotoma
Usually unilateral, F 18-45yo may be 1st
presentation of demyelinating disease-MS
Swollen optic disc
May have other neurology
Mx Ophthal referral, IV
IV steroids
33. Corneal foreign body
Dirt/glass/metal (rust ring)
Velocity of impact
Signs of penetration
Removal
Local
25G needle, lateral
approach using slit lamp
Dental burr for rust ring
(adherent rust ring may
loosen with Chlorsig/patch
for 24hrs as the cornea
heals, may recall pt)
34. Chemical burns
Acids: toilet/pool cleaner,
battery fluid
Alkalis (more harmful): lime,
mortar/plaster, drain cleaner,
oven cleaner, ammonia
Immediate Mx: LA copious
irrigation with fluid-bag of
N/Saline + Morgan Lens until
pH 7.5, test aquity
Degree of vascular blanching
(esp at limbus) proportional to
severity of burn
Chlorsig, Ophthal. referral
35. Blunt Trauma - Haemorrhage
Subconjunctival Hemorrhage
usually benign, if spont. Check BP/
Coags
If cant see post border ?Orbital #
Hyphaema: blood in anterior
chamber
If >1/3 = damage to drainage
angle, risk glaucoma
Mx shield/patch/semi-
recumbent/rest +/-
sedation/admission
no NSAIDs, Ophthal. Ref.
Recurrent bleeding in 10% esp
with early mobilization
Hemorrhage vitreous or retina, can be
accompanied by a retinal detachment.
Iris damage can result in poor pupil
reactivity = Traumatic mydriasis.
Misleading Neuro signs
Lens can be damaged or dislocated
and a cataract may develop
36. Blunt trauma - Orbital blowout
fracture
Usually inferior wall since weakest
Signs:
Diplopia/Ophthalmoplegia from
muscle entrapment. Tethering of
inferior rectus prohibits the upward
movement of the globe.
Proptosis from swelling or
retrobulbar hemorrhage and later
Enophthalmos from loss of volume
Infraorbital nerve entrapment- numb
cheek/upper teeth
Epistaxis
30% incidence of a ruptured globe in
conjunction with orbital fractures.
(Wilkins RB, Havins WE. Current treatment of blow-out
fractures. Ophthalmology. May 1982;89(5):464-6)
37. Blowout Fracture
Mx
Repair: Indicated if
significant diplopia or
cosmetically unacceptable
enophthalmos. Most
surgeons will wait 10 to 14
days following the trauma
to allow for resolution of the
associated edema and
hemorrhage
Medical : if no
diplopia/enophthalmos
o antis/no nose blowing/?
steroids
38. Ruptured Globe
May be from blunt or
penetrating trauma
Occurs at thinnest part:
Limbus (Visible with slit lamp)
Insertions of the extra-ocular
muscles (reduced eye
movements, loss red reflex
from vitreous haemorrhage)
Around the optic nerve
Signs:
Pupil : peaked, teardrop-
shaped, or otherwise irregular
Seidel’s Sign
Enophthalmos (recession of
the globe within the orbit)
Exophthalmos from retrobulbar
hemorrhage
39.
40. Ruptured Globe
Ix: CT most sensitive
Mx : Anti-emetics/analgesics/prophylactic
antibiotics/tetanus/fast
Urgent Ophthal. referral always requires surgical
intervention.
? Suxamethonium in open globe injury
controversial, weigh up risk to airway Mx and
theoretical risk of ocular extrusion and ask opthal.
41. Penetrating Eye Trauma
Easily missed since may seal over and abnormal signs may
be subtle
High risk with high velocity eg metal striking metal and glass
Leave bodies insitu until surgery
Signs:
Distorted pupil
Cataract
Prolapsed black uveal tissue on the ocular surface
Vitreous hemorrhage.
Seidel’s Sign
Shallow/flat anterior chamber or bubbles in anterior chamber
Mx as for ruptured globe
42. Lid Lacerations
Require Ophthal. ref. if:
Torn lid margins - must
be closed accurately
Lacrimal ducts damage
Any suspicion of a
foreign body or
penetrating eyelid injury
Mx refer/Tetanus/iv antis/
antiemetics/shield eye
44. Golden Rules
Always check visual acuity
Always attempt to open eye early and
examine pupil/acuity etc in trauma
Beware Dx unilateral conjunctivitis until more
serious disease is excluded
Don’t D/C pt with LA drops - impedes healing,
further injury may occur to anaesthetized eye.
Don’t start Steroid drops without
ophthalmology r/v
45. References
Globe Rupture, J Robson, Feb 16 2007, www.emedicine.com
Handbook of ocular disease, 2000 - 2001 Jobson Publishing,
www.revoptom.com/handbook/hbhome.htm
P T Khaw et al, Clinical review “ABC of Eyes- Injury to the eye”
BMJ 2004;328:36-38 (3 January)
Cameron et al, Textbook of Adult Emergency Medicine, Second Ed, Churchill
Livingston, 2004
Eye Emergency Manual, NSW Ophthalmology Service, 2007
Retinal Detachment, G Larkin , Apr 7, 2008 www.emedicine.com
Acanthamoeba, N Crum-Cianflone, Jun 30 2008, www.emedicine.com
Facial Trauma, Orbital Floor Fractures (Blowout), A Cohen, Dec 18 2006,
www.emedicine.com
Glaucoma, Acute Angle-Closure, A Darkeh, Oct 3 2007, www.emedicine.com
Scleritis, T Gaeta, Apr 14 2008 www.emedicine.com
Wilkins RB, Havins WE. Current treatment of blow-out
fractures. Ophthalmology. May 1982;89(5):464-6
Editor's Notes
Equipment: Morgan Lens Ophthalmoscope Fluorescein Eye drops-Amethocaine/Tropicamide Tonopen Ref process at Cabrini
Conjuctiva-Bulbar, Palpebral
palpebral conjunctiva lines the lids
Normal ICP
Bowie-L eye permanently dilated pupil from trauma at child
RELATIVE AFFERENT PUPILLARY DEFECT: L light in R eye, L constricts, light swings to L eye, L dilates since reduced light transmission on L