RVEEH practice guidelines

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

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

Caused by an interruption to sympathetic pathway causing a triad:

• miosis
• partial ptosis
• loss of hemifacial sweating (anhydrosis)

• 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)

• 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

Emed: AAG

• classified according to the predominant site of inflammation: anterior (anterior chamber), intermediate (vitreous), or posterior (retina or choroid)

Uveitis - review 2014