Trauma to the Eye

Whenever you are given a scenario with trauma to the eye, offer pain medications and then proceed to history.

1. Ask for mechanism of injury (Blunt/Penetrating)
2. Vision Problems
3. Palpate the orbit rim and maxillary sinus
4. Look for lacerations at medial canthus
5. Document Visual Acuity & Field of Vision
6. Eye Movements
7. Tetracaine & Fluoroscein Staining
8. Eversion of Eyelid to look for FB
9. Slit Lamp Examination
10. Look for corneal tear or lens displacement
11. Look at fundus for retinal hemorrhages
12. If penetrating injury, refer to ophthalmology, Get a CT Orbit
13. Tetanus prophylaxis
14. Steroids & Analgesic with Antibiotic drops
15. Admit the Kid and discharge the adults
16. Eye Patching does not help in Corneal tear.

HYPHEMA:

Collection of blood in Anterior Chamber

Visual Acuity must be documented

Topical Steroid

Spontaneous resolution in many cases

Chances of rebleed in 3 - 5 days

Ophthalmology Clinic Referral

Oral Analgesic

PAPILLEDEMA

Any increase in Intracranial pressure can give rise to papilledema.

(Remember it this way increase pressure in your head and you can not think of anything.... aka.... Brain needs sugar ... So you grab a doughnut..) So when you look at the fundus, look for a pale doughnut (Cupping of disc) with radial retinal lines like spokes on doughnut.

If unilateral think of GLIOMA

Causes

1. Raised ICP : Trauma, Tumor, Infections (Meningitis, Encephalitis), Bleeding
2. Malignant HTN
3. Isotretoin overdose
4. GBS
5. Lyme Disease

Signs: Headache, Blurry Vision, Loss of Vision

Investigation:

CT/MRI

LP

Treatment:

Cause should be addresses

Diuretics like Mannitol or Acetazolamide

CSF Drainage

Retinal Detachment

• Diabetic who has short vision (Sightedness)
• Sudden painless loss of vision preceded by floaters or flashes or cloudy vision
• Fundus: Dark with coagulated protein like appearance in fundus

Diabetic & Hypertensive Retinopathy

What I know about DM Retinopathy is look for neovascularization.
There may be flame shaped hemorrhages, cotton wool spot in both. (Remember to burn the cotton wool with flames in DM, HTN, CRVO)

 Below: Diabetic Retinopathy (Look the Neovascularization)

CRVO (Central Retinal Venous Occlusion)

• Painless mono-ocular vision loss
• More common than CRAO
• Examination: Afferent Pupillary Defect (Direct Reaction sluggish/Consensual reaction present)
• Fundus: Stormy Sunset Appearance, Engorged veins, Cotton wool spots and Flame Shaped Hemorrhages

• Risk Factors: DM, HTN, Smoking, Old Age, Glaucoma, Atherosclerosis, Polycythemia
• Refer to Ophthalmology  & Treat the underlying cause

Central Retinal Artery Occlusion

CRAO

• Painless mono-ocular vision loss
• Embolic Episode
• Examination: Afferent Pupillary Defect (Direct reaction loss/reduced, consensual reaction is present)
• Fundus: Pale Optic Disc, Cherry Red Macula

• Management:

1. Urgent Ophthalmology referral
2. Massage the globe
3. S/L Nitrate
4. Acetazolamide 500 mg IV and Timolol eye drops to reduce IOP

Loss of Vision

Painless Loss of Vision

1. CRVO
2. CRAO
3. Retinal Detachment
4. Vitreous Hemmorhage
5. Amaurosis fugax 

Painful Loss of Vision (GAIN)

1. Acute angle Closure Glaucoma
2. Arteritis Temporal
3. Injury: Corneal injury,ulcer 
4. Neuritis: Optic neuritis

Ophthalmoscopy

A very informative video demonstrating the proper method to perform an ophthalmoscopy. The steps to perform are so simplified and useful. The steps could be utilized in the MCEM OSCE Teaching station that asks for teaching a student how to perform an ophthalmoscopy.

(Credit: EyeMovies)

Retinitis Pigmentosa

Inherited Retinal Degenerative disease ( Positive Family History)

Associations: Lawrence Moon Beidl Syndrome, Abetalipoprteinemia, Refsum's Disease, Usher's Syndrome, Friedrich's Ataxia

Symptoms: Night Vision Loss (Rods are Affected early), Tunnel Vision (Loss of Peripheral Vision), Altered Color Vision

Fundus: Bone Shaped spicule pigments deposits in periphery, Macula is preserved.

Refer to Ophthalmology & Genetic Counseling Clinic