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Casualty
- 1. What conditions to expect How to get help History Examination Common (less serious) conditions Rarer but more serious conditions Helpful websites The Eye in Casualty: a seminar
- 2. What conditions to expect: working in pairs, (2 minutes) think of: • Common (less serious) conditions, e.g. • Rarer but more serious conditions If time, work out how you would refer, treat
- 3. Feedback…………what conditions to expect • Common (less serious) conditions, e.g. – Conjunctivitis – Corneal abrasion – Foreign body – Blunt eye injury • Rarer but more serious conditions – Acute glaucoma, acute uveitis – Central retinal artery occlusion – CVA – Giant Cell arteritis – Papilloedema – Retinal bleeding: maculopathy or diabetes – Severe trauma
- 4. • Common less serious – Conjunctivitis--------------- – Corneal abrasion----------- – Foreign body--------------- – Blunt eye injury------------ • Rarer serious conditions – Acute glaucoma, acute uveitis – Central retinal artery occln – CVA------------------------- – Giant Cell arteritis--------- – Papilloedema--------------- – Retinal bleeding: maculopathy or diabetes – Severe trauma-------------- – Orbital cellulitis----------- again in pairs, (2 minutes) think of best method of referral/treatment
- 5. • Common less serious – Conjunctivitis--------------- – Corneal abrasion----------- – Foreign body--------------- – Blunt eye injury------------ • Rarer serious conditions – Acute glaucoma, acute uveitis – Central retinal artery occln – CVA------------------------- – Giant Cell arteritis--------- – Papilloedema--------------- – Retinal bleeding: maculopathy or diabetes – Severe trauma-------------- – Orbital cellulitis----------- – diagnose/treat – diagnose/treat – diagnose/treat – diagnose/treat/refer – diagnose, refer urgently – diagnose, refer urgently – diagnose, refer urgently to RMO – diagnose, refer with diagnosis – refer to neurosurgeon (?via RMO) – diagnose, semi-urgent referral – diagnose, start treatment, refer urgently – urgent RMO/paediatrician Feedback answers
- 6. Referral: severe problems/out of hours, Eye Casualty, City Hospital Immediate Chemical burn, plaster under upper lid Irrigation+++ refer Refer asap (even at night) Severe trauma GCA CRAO Acute glaucoma Orbital cellulitis (to paediatrician for IV Rx?) Trauma: examine gently/carefully ESR Hours (if present after 11pm, best to seek advice, some seen next morning) Retinal detachment Hypopyon uveitis Corneal abscess Most milder uveitis present in evening can be treated next day Refer to eye clinic or to GP (optometrist should check?) Retinal vein occlusion Macular haemorrhage (Cataract Dry eyes) Treat in A & E •Conjunctivitis •Corneal abrasion •Foreign body •Sub-tarsal •Lid infections that may need flucloxacillin
- 7. Referral: severe problems/out of hours, Eye Casualty, City Hospital Immediate Refer asap (even at night) Hours (if present after 11pm, best to seek advice, some seen next morning) Refer to eye clinic or to GP (optometrist should check?) Treat in A & E Chemical burn, plaster under upper lid Severe trauma GCA CRAO Acute glaucoma Orbital cellulitis (to paediatrician for IV Rx?) Retinal detachment Hypopyon uveitis Corneal abscess Retinal vein occlusion Macular haemorrhage (Cataract Dry eyes) •Conjunctivitis •Corneal abrasion •Foreign body •Sub-tarsal •Lid infections that may need flucloxacillin Irrigation++++ refer Trauma: examine gently/carefully ESR Most milder uveitis present in evening can be treated next day Will be many conditions you’re unsure of. Exclude more urgent problems; ring for advice.
- 8. History Later………., as we go along
- 9. Examination • Lids • Everting upper lid • Visual acuity • Visual fields • Pupils • Conjunctiva • Anterior chamber…later • Red reflex • Discs • Eye movements…later if time
- 10. Lids • Pain & redness = inflammation • Severe swelling = ? Orbital cellulitis
- 11. Lids: evert upper lid Evert lid with cotton bud
- 13. Visual fields p a p e r
- 14. p a p e r
- 15. Pupils
- 16. Red reflex Check red reflex from 10 cm, focusing on iris
- 17. Check discs & retina • Dim light • pupils, eyelids, red reflex • Patients look in distance, 15o up • Try not to obstruct sight in other eye, otherwise examined eye will move. • Look 15o medially, to see the optic nerve first. • Going close increases field of view • Optic nerve first • Move along vessels • Find macula last (this will make pupils small) • Dilating pupil makes examination easier, quicker and more complete. But it is time consuming, and is rarely needed to exclude papilloedema .
- 21. Examination……….in pairs, 5 minutes • Eye movements • Fields • Pupils • Red reflex • discs
- 22. Slides, with a few questions Lids Conjunctivitis Foreign body & cornea Anterior segment (uveitis/glaucoma) Retina Optic nerve Major trauma Previous eye surgery
- 23. Give out quiz for later, in pairs, 2 minutes, what is the treatment/plan Corneal abrasion Diagnose how………… treat………………… Foreign body Diagnose how………… treat………………… iritis findings………………………. Refer? …comments…………… Acute glaucoma findings………………………. Refer? …comments…………… Chemical burn Treat……………………………. Which is worst chemical…………..
- 24. Lids A chalazion some ‘point’ with pus needing draining: some lid infections need systemic antibiotics Severe infections like this orbital cellulitis need admission (often under paediatricians) and IV antibiotics
- 25. Corneal abrasion Staining with fluorescein drops shows any active corneal lesion
- 27. Foreign body
- 28. Foreign body & fluorescein drops •Fluorescein drops do not sting and are comfortable for children (all other drops sting). •Arc eye: wake up with pain at night, due to an ultraviolet (welding) flash earlier in the day.
- 29. Conjunctiva & anterior chamber Conjunctivitis No pain Watery eye Gritty, something in eye Iritis/acute glaucoma Achy eye Tender % fixed/sluggish pupil Glaucoma..eye hard
- 30. Conjunctivitis Conjunctivitis: no pain, red eyes, irritable, watery/ thin discharge (viral), itchy (possible allergic).
- 31. Conjunctivitis Thick discharge = bacterial conjunctivitis
- 32. Treatment foreign body/conjunctivitis Remove foreign body Fluorescein excludes corneal ulcers Chloramphenical drops qid (ointment tid), mild cases Severer cases 2 hourly drops Conjunctivitis is very infectious Refer severe cases
- 33. Examples of nastier corneal problems •Dendritic ulcer (acyclovir x5 day x 10d) •Corneal abscess •Giant papillary conjunctivitis •pterygium
- 34. Pain & irritation Ache Inflammation (acute glaucoma, iritis, episcleritis etc) Gritty scratchy eye, as though there is something there Foreign body/ abrasion/ulcer (=uneven surface) Watery red eye No pain conjunctivitis Severe knife like pain trigeminal neuralgia, spasms: history important
- 35. Iritis • Achy eye, misty vision, • Previous attacks lasting weeks, HLA B27 symptoms= iritis Ciliary injection
- 36. Iritis cont. ‘dust’ particles = cells ‘smoke’= protein
- 37. Hypoyon in severe uveitis Iritis cont.
- 38. Iritis cont. Dilating pupil reveals adhesions: = posterior synechiae
- 39. Acute glaucoma • Achy eye, misty vision • Previous mild episodes with haloes • Pupil fixed (sluggish), semi- dilated • Eye feels hard Press eye with 2 fingers..Try this on your own eye
- 40. n o r m a l s h a llo w a n t e r io r c h a m b e r Acute glaucoma cont
- 41. Acute glaucoma cont (2)
- 42. Complete quiz now, in pairs, Corneal abrasion Diagnose how………… treat………………… Foreign body Diagnose how………… treat………………… iritis findings………………………. Refer? …comments…………… Acute glaucoma findings………………………. Refer? …comments…………… Chemical burn Treat……………………………. Which is worst chemical…………..
- 43. feedback answers Corneal abrasion Diagnose how………… treat………………… Foreign body Diagnose how………… treat………………… iritis findings………………………. Refer? …comments…………… Acute glaucoma findings………………………. Refer? …comments…………… Chemical burn Treat……………………………. Which is worst chemical………….. History, pain, scratchy: examn chloramphenicol drops qid History, pain, scratchy: examn chloramphenicol drops qid Medical history, ache, misty vision, examn, : ciliary injection Ocular history, ache, nausea, abdo pain, headache misty vision, examn, : semidilated, hard eye Irrigate, fluorescein ammonia>alkalli>acid
- 44. Posterior segment: vision affected Symptoms
- 45. Central vision Central visual changes suggest macular disease: refer to Eye casualty same week
- 46. Sudden, most of sight, or part TIA: retinal emboli, central/branch retinal artery occlusion
- 47. retinal artery occlusion If within 3 hours of onset, can dislodge clot (massage, IV diamox, AC paracentesis) Refer ASAP, aspirin ESR (10% are GCA)
- 48. Loss of sight over weeks/days/hours • Retinal detachment, with flashes/floaters • Ischaemic optic neuropathy (older patients) (%GCA with GCA symptoms) • With pain on movement: optic neuritis (younger patients) • Retinal vein occlusion • Eye conditions: may lose top/bottom half of sight
- 49. Retinal detachment 1. Vitreous gel liquifies (floaters) 2. May pull retina if attached (flashes) 3. Causes a hole 4. Fluid enters hole 5. Retina peels off (more floaters, vision affected) 6. Dilate pupil, with careful look usually obvious, refer same day
- 50. Loss of sight over months • Cataract • Many other problems, dilate pupil………… • red reflex • Retina • discs
- 51. Visual symptoms: quiz, in pairs, 2 minutes, what are the causes………. Misty vision Aches………… No ache………………… Sudden onset visual loss …………………. Specific symptoms Give examples………………………. Loss of sight on one side What may be going on?…………. ……………………………………. Episodes of visual loss …………………………………. Clues………………………….. Blurred vision with flashes and floaters ……………………………….
- 52. Visual symptoms Misty vision If eye aches, acute glaucoma/uveitis No ache, cataract/retinal disease etc Sudden onset visual loss Vascular Specific symptoms E.g. GCA, optic neuritis, HZO Loss of sight on one side Differentiate eg right side of BOTH eyes (CVA), or ONE eye alone (eye disease) Episodes of visual loss TIAs: occur suddenly, resolves over minutes Blurred vision with flashes and floaters retinal detachment/vitreous haemorrhage
- 53. Eye general health: 1 • What is the history? – Vomiting – Nausea – Stomach not tender – Headache? – Sight GOOD – Papilloedema – Refer to RMO/neurosurgeon healthy
- 54. • Loss of sight 2 days ago, one eye • Headaches 1 week • Shoulder pains months • Weight loss months • Jaw aches eating • unwell months • Test needed: • ESR high • Giant cell arteritis • (if eye OK, refer to RMO) Eye general health: 2
- 55. • Episcleritis • Scleritis • No steroid drops from casualty • Herpes zoster: – IV antiviral if immunosuppressed Eye general health: 3
- 56. Eye & major trauma Birmingham and Tamworth are increasingly violent. A careful eye exam will exclude problems. Sometimes the eye is impossible to examine (as lids are shut). Refer/ask on-call eye SPR to assess. Causes: fist, glass bottle, car windscreen.
- 57. Eye & major trauma: perforating glass bottle, car windscreen, dart Tetanus, antibiotic, refer (ring first), starve for operating theatre
- 58. Eye & major trauma: blunt Fist, foot, squash ball: blunt eye injury, refer many Hyphaema: % retinal detachment also
- 59. Eye & major trauma: blunt cont. Fist, foot, squash ball: orbit injury Double vision: Globe itself fine, but floor of orbit fractured, and inferior rectus muscle tethered = blow out fracture
- 60. Eye & previous eye surgery There are many possible problems after ocular surgery: refer, sometimes urgently
- 61. Visual fields
- 62. • Common conditions less serious, need to treat (includes antibiotics, chloramphenicol) • Serious conditions: history provides a clue, but a careful examination through a dilated pupil and ophthalmoscope excludes most major pathology • Generally provide an escape plan “see your doctor if it does not get better” etc • Serious conditions always need expert advice • Only really ‘immediate’ action is for chemical burn such as plaster under the lids…irrigate profusely. • ASAP retinal artery occlusion, GCA • Within hours..acute glaucoma • Retinal detachment same day, operation next day often • Many ‘none’ urgent conditions present; local optometrists help with less urgent • RMO or nursing colleague can provide useful advice, as can on-call time in Eye Casualty Summary
Notas del editor
- What conditions to expect: Common (less serious) conditions, e.g. Rarer but more serious conditions
- How should these patients be treated? Common less serious Conjunctivitis_______________________________________________________________________________ Corneal abrasion ____________________________________________________________________________ Foreign body _______________________________________________________________________________ Blunt eye injury _____________________________________________________________________________ Rarer serious conditions Acute glaucoma, acute uveitis _________________________________________________________________________________ Central retinal artery occln______________________________________________________________________ CVA _______________________________________________________________________________________ Giant Cell arteritis_____________________________________________________________________________ Papilloedema _________________________________________________________________________________ Retinal bleeding: maculopathy or diabetes __________________________________________________________ Severe trauma ________________________________________________________________________________
- How should these patients be treated? Common less serious Conjunctivitis_______________________________________________________________________________ Corneal abrasion ____________________________________________________________________________ Foreign body _______________________________________________________________________________ Blunt eye injury _____________________________________________________________________________ Rarer serious conditions Acute glaucoma, acute uveitis _________________________________________________________________________________ Central retinal artery occln______________________________________________________________________ CVA _______________________________________________________________________________________ Giant Cell arteritis_____________________________________________________________________________ Papilloedema _________________________________________________________________________________ Retinal bleeding: maculopathy or diabetes __________________________________________________________ Severe trauma ________________________________________________________________________________
- Corneal abrasion Diagnose how………… treat………………… Foreign body Diagnose how………… treat………………… Iritis findings………………………. Refer? …comments…………… Acute glaucoma findings………………………. Refer? …comments…………… Chemical burn Treat……………………………. Which is worst chemical…………..
- Top: A Subtarsal foreign body. Need to evert lid..use a cotton bud. Fluorescein drops show up any scratch/abrasion. Easier to see with a blue light, but an ordinary light is sufficient. Should the foreign body be removed? Yes no What is the treatment? ………………………………………………………………………………………. Does this need referral? Yes no Bottom A corneal foreign body.
- A corneal foreign body. With local anaesthetic drops first (benoxinate or amethocaine or lignocaine), use a sterile green needle (holding it flat against the cornea) to remove the foreign body. You cannot do this if you are tired! Sometimes a blunt piece of sterile plastic may be safer. There may be a rust ring left, but this heals (an ophthalmologist can remove a dense rust ring.)
- Conjunctiva/corneal quiz, complete in pairs Corneal abrasion Diagnose how………… treat………………… Foreign body Diagnose how………… treat………………… Iritis findings………………………. Refer? …comments…………… Acute glaucoma findings………………………. Refer? …comments…………… Chemical burn Treat……………………………. Which is worst chemical…………..
- Visual symptoms quiz, complete in pairs Misty vision Aches………… no ache………………… Sudden onset visual loss …………………. Specific symptoms Give examples………………………. Loss of sight on one side What may be going on?…………. ……………………………………. Episodes of visual loss …………………………………. Clues………………………….. Blurred vision with flashes and floaters ……………………………….