===== Eyes ===== [[https://eyeandear.org.au/health-professionals/clinical-practice-guidelines/|RVEEH practice guidelines]] ====Corneal FB==== Red Flags: *Exclude mechanism suggestive of penetrating eye injury (e.g. hammering, glass) *Deep or penetrating corneal FB *Exclude multiple foreign bodies (FBs), e.g. subtarsal *Corneal FB in visual axis *Corneal infection – corneal infiltrate/anterior chamber (AC) reaction (cells) Slit lamp examination under LA looking for: *Conjunctival injection *Evert upper lid to rule out subtarsal FB *FB details: describe FB material (organic, metallic, plastic etc.), position on cornea, depth (assess using slit beam), number, presence of rust *Corneal infiltrate (white haze around CFB): if present indicates possible microbial keratitis *AC cells: may indicate presence of infection *Stain with fluorescein to check for epithelial defect or PEI (Penetrating Eye Injury) *PEI suggested by: *deep or full thickness FB, *Seidel test positive (fluorescein becomes diluted with aqueous) *shallow or flat AC *irregular pupil *iris transillumination defect, *FB in AC, vitreous or retina *lens opacity Management: *removal with horizontal, tangential, leveled hypodermic needle with bevel up facing *burr may be used perpendicular to cornea for rust ring removal only *may leave some brown rust toward limbus but none toward center - referral to ophthalmology if unable. Only minor yellow stain permissible toward center *double pad eye for 1/24 post procedure - avoids rubbing if new FB as patient will be unaware *chloramphenicol drops or ointment qds for 3-4/7 *cycloplegic drop x1 only to reduce muscle spasm and consequent pain = most common reason for representation *paracetamol regularly until healed ====Golden Eye Rules (according to Colvin) ==== {{ :wiki:head_and_neck:updated-golden-eye-rules-v081211-1.pdf |abbreviated handbook of rules - RVEEH}}\\ 1. Always test and record vision\\ 2. Never pad a discharging eye\\ *allow it to drain 3. Any blurred vision requires prompt investigation\\ 4. refer squint (strabismus) when it is 1st detected because\\ *children do not grow out of squints *intraocular pathology must be excluded *amblyopia requires treatment (often caused by strabismus, refractive problem, deprivation of light eg cataract) 5. Irritable eyes are often dry *Dry Eyes - need tear supplements *Blepharitis - remove crusting *Chronic Allergy - avoid steroids 6. Beware the unilateral red eye *foreign body *corneal ulcer/keratitis *uveitis *acute glaucoma 7. Refer patients with eyelid ulcers - may be BCC 8. Conjunctivitis is almost always bilateral *bacterial conjunctivitis responds well to antibiotics *pre-auricular lymphadenopathy may indicate viral cause *recurrent - may indicate blocked naso-lacrimal duct 9. A corneal abrasion should heal in 24 hours if the cause is removed *antibiotic ointment and pad *review daily *UV flash burns may need sedation *excude dendritic ulcer 10. Never use steroids if herpes simp1ex is suspected *may be painless *recur with scarring *early referral 11. Retinal detachment requires referral *Warning signals of retinal detachment include floaters, flashes and field defects. 12. More mistakes in medicine are made by not lookinq than not knowing *Eye examination requires illumination and magnification. *local anaesthetic drops should not be used for continued relief *fluorescein for highlighting abrasions and ulcers 13. Prevent corneal exposure - during general anaesthesia 14. Steroids are dangerous. Complications of steroids include *Corneal Perforation with herpes simplex. *open angle glaucoma *Cataract formation. *Infection (fungal). 15. If there is a corneal abrasion, look for a foreign body - evert lid. Look for eyelashes 16. Leave some foreign bodies alone *Never attempt to remove foreign bodies that are deep central corneal, intra-ocular or intra-orbital. Refer patients with these foreign bodies. 17. Consider an intra-ocular foreign body *especially if hammering or other high speed injury *be suspicious if entry wound appears trivial *XRay 18. Sudden loss of vision is an emergency *elderly - suspect temporal arteritis *retinal artery or vein occlusion, macular haemorrhage 19. penetrating eye injury is an emergency *pad eye - no drops or ointment *systemic antibiotics if delay to surgery 20. With facial and lid injuries first exclude eye injury *eyelid laceration requires accurate apposition of lid margin 21. Using the ophthalmoscope *Pupil dilatation aids diagnosis. Tropicamide 0.5% (Except in head injury) 22. Irrigate chemical burns *local anaesthetic, evert lid and irrigate copiously for 15mins 23. Optic discs are easily seen *papilloedema - blurred margins and patient has good vision *optic neuritis - reduced vision, eye movement pain and afferent pupil defect +/- abnormal disc *ischaemic optic neuropathy - painless loss vision, swollen disc, afferent papillary defect 24. Behind the black eye there may be a blunt eye injury *diplopia - suspect blowout fracture *hyphaema - may indicate severe injury 25. Transient blindness can be serious *carotid artery disease - retinal emboli may be visible *migraine aura 26. Blindness in diabetes mellitus is largely preventable 27. Hypertensive retinopathy *usually indicates long standing or severe HT *prone to retinal vein or artery occlusion *visual loss may be presenting symptom of malignant hypertension 28. Headaches are rarely due to a refractive cause *ocular cause - acute glaucoma, iritis, scleritis *extra-ocular - look for signs of temporal arteritis 29. Visual field defects are ocular (horizontal) or central (vertical) *vertical - homonymous hemianopia, bitemporal field defects *horizontal - branch artery occlusion, open-angle glaucoma, retinal detachment 30. Pupil examination – differential diagnoses *Irregular pupil –iritis, injury, surgery. *Dilated pupil –third nerve palsy (may be due to head injury), amphetamines, glaucoma drops (dipivefrine) *Constricted pupil –Horner’s syndrome, narcotics, glaucoma drops (pilocarpine), iritis *Afferent pupil defect –retinal artery occlusion or optic nerve lesion. 31. Cataract surgery is the most common eye operation 32. Chronic open-angle-glaucoma requires screening *There are no early signs or symptoms. *familial *optic disc cupping and visual field loss 33. Acute angle closure glaucoma is rare *It is rare in people younger than 60. *pain, blurred vision and haloes, nausea and vomiting *shallow ant chamber, red eye, hazy cornea, fixed mid-dilated oval pupil *start pilocarpine and diamox 34. Urgent admission for the following *Hyphaema *Hypopyon. *Penetrating eye injuries. *Severe chemical burns. *Acute glaucoma. 35. Beware of herpes zoster ophthalmicus if the nose is involved *external branch - eye likely involved *early systemic treatment required ==== Horner's syndrome ==== Caused by an interruption to sympathetic pathway causing a **triad**: *miosis *partial ptosis *loss of hemifacial sweating (anhydrosis) == Causes: == *brainstem stroke *tumour or syrinx of preganglionic neuron or lesion of postganglionic neuron, or middle cranial fossa tumour *brachial plexus trauma *tumour or infection of lung apex *dissecting carotid aneurysm or carotid artery ischaemia *migraine *pain around face or neck - suggestive of dissection *pain around shoulder or arm - suggestive of Pancoast tumour (apical lung tumour) ====Flashing lights/Floaters==== ====Acute Angle Closure Glaucoma==== *defined as the apposition of iris to the trabecular meshwork *Presentation: *Sudden severe ocular pain *redness, blurry vision, headache, and nausea and vomiting *may see haloes around lights as a result from corneal edema. *can be precipitated by acute pupillary dilation eg. bright lights in cinema, antihistamines... Beware use of mydriatic for eye exam as may trigger pain. *the may be a history of intermittent partial closure - mild pain, blurred vision and occasionally sense of haloes *Slit-lamp examination: *may be difficult as patient will be sensitive to light and may have trouble keeping eye open with tearing. *conjunctival injection *fixed or sluggish and mid-dilated pupil *shallow anterior chamber *corneal epithelial oedema (cloudy cornea) and bullae urgent ophthalmological referral for intervention to reduce intra-ocular pressure [[https://emedicine.medscape.com/article/1206956-clinical|Emed: AAG]]\\ ====Uveitis==== *classified according to the predominant site of inflammation: anterior (anterior chamber), intermediate (vitreous), or posterior (retina or choroid) [[https://www.aafp.org/pubs/afp/issues/2014/1115/p711.html|Uveitis - review 2014]]