Division of Emergency Medicine Stanford School of Medicine
Challenges of Eye Complaints
• Similar complaints (redness, pain, visual changes) may represent benign or vision threatening etiologies • Rapid diagnosis and therapy can be vision saving • Visual loss is devastating for the patient and physician • Most residents are uncomfortable with eye complaints
General Approach to Eye Complaints
• History - onset, trauma, history of same, discharge, perceived vision, field defects, associated symptoms (halos, headaches), allergies Physical Exam - Visual acuity, general inspection (pupils, obvious foreign bodies, discharge, lid eversion), fundoscopy, visual fields, slit lamp (cornea, anterior chamber)
Everting the eyelid
Common Eye Lid Disorders
• Blepharitis - Acute or chronic eyelid inflammation, causing crusting of the lids (infectious vs. allergic) • Stye - Acute staph infection of an eyelid follicle • Chalazion – meibomian gland cyst (painless, non infectious) often confused with a stye
Many causes of the “Red Eye”
• A middle-aged man comes in with complaints of a painful red eye. • He said the pain developed after coming out of a movie theater. “It feels like a migraine” (headache, nausea, vomiting) “The lights have halos around them” • What’s the probable diagnosis?
Acute Angle Closure Glaucoma
• What are findings on physical exam?
– Visual acuity: – Conjunctiva: – Cornea: – Pupil: – Anterior chamber:
What is the anterior chamber
Shallow anterior chamber
• How can you demonstrate a shallow anterior chamber? • OBLIQUE FLASHLIHGHT TEST
Acute Angle Closure Glaucoma
• What is a normal intra-ocular pressure (IOP)? • How do you measure the IOP?
Another “Red Eye”
• Patient presents whose right eye is red, painful and very sensitive to light. • When you shine the penlight in her left eye, it causes her pain in the right (affected) eye. • What diagnosis does it suggest?
Iritis
• What might you find on examination of the anterior chamber by slit lamp?
– Headlights in the fog – Dust in a sunbeam
Cell and Flare
My baby’s got pink eye
• A patient in a big hurry comes in to see you. She is disheveled and scantily dressed. She says, “my baby’s got the pink eye • She has a 5 day old infant with a bilateral eyelid swelling and a thick purulent discharge from both eyes.
My baby’s got the pink eye
Should you just give her the antibiotic drops? • What’s the diagnosis? • Where did the baby get the infection? • Does mom need to be treated?
•
Eye pain and FB sensation
• A middle-aged man complains of a foreign body sensation in the left eye • Fluoroscein staining of the cornea reveals the following lesions. Diagnosis? • Should we initiate therapy with steroids? • Complications? • Stain everyone!
Red painful eye in a contact lens wearer
• A patient who wears contact lenses presents with a painful red eye • Diagnosis? • Treatment?
Eye pain in a contact lens wearer
• Never patch a contact lens wearer • Advisable to cover for Pseudomonas in a contact lens wearer • No benefit to pressure patching in terms of rate of healing or pain reduction
Painful eye. Diagnosis?
Another red eye
• A three-year old child presents with erythema and swelling around the left eye. • The Pediatric resident says, “It’s periorbital cellulitis; start the kid on antibiotics and send him home.” • Are you comfortable with that?
Sudden painless visual loss
• The nurse has an elderly man with a history of CAD and TIA's who says he can’t see anything out of his left eye. The loss of vision was sudden and painless. • What diagnosis does this presentation suggest?
Central retinal artery occlusion (CRAO)
• How long before this visual loss becomes permanent? • Physical exam findings?
– Visual acuity/field: – Pupillary exam: – Retina:
• Doctor, I see flashes of light and a curtain has dropped over my right lower visual field… • Diagnosis?
• Doctor, I can’t see well out of my right eye. It’s hazy and there are floaters… • Diagnosis?
Traumatic Conditions of the Eye
Poked in the eye!
• A young boy presents to the ER after having been poked in the eye by another student. • He is being seen by a resident who is just about to measure the child’s intraocular pressure when you yell “STOP!!!!!!” • Why are you so uptight? • Now what should you do?
FB sensation
• A young male presents to the ER with foreign body sensation to this left eye. • He was pounding a nail and felt something get into his eye. • You examine patient and find that other than some photophobia, his exam is normal. • You are about to discharge him when the attending says, hold on just a minute. What could you have possibly missed? • How do you make the diagnosis?
Positive Seidel’s
• You carefully examine the patient and place fluorescein in his eye. You see the fluorescein streaming. • What is this called? • What does it signify?
Drain cleaner in the eye
• A patient comes to the ER having gotten some drain cleaner in her eye and it's causing her a lot of pain. • The triage nurse tells her the wait to be seen is 1 hour and the patient becomes irate and starts to leave. • You happen to overhear this conversation • What should you do? Why? • Treatment? • How long?
Baseball versus eye
• A young male presents to the ER after having been hit in the eye with a baseball. He says, "I keep seeing double when I look up". • Diagnosis? • Pathophysiology? • Treatment?
BLOWOUT FRACTURE
Pathophysiolog y
Signs:
• Crepitus/tenderness over orbital rim or maxilla
Symptoms: • Diplopia • Epistaxis
• • • •
Periorbital subQ emphysema Limitation of EOM Enophthalmos Anesthesia of the ipsilateral cheek and upper lip - WHY? • Periorbital ecchymoses/swelling
Blunt Trauma
• The patient may also have a hyphema • Make sure to look with a slit lamp • Some may be microscopic - Blurred vision - Risk of re-bleed, glaucoma
Blunt Trauma
• They may also have a subconjunctival hemmorhage or lens dislocation.
Eyelid laceration
• A young child presents to the emergency department with a small laceration of her left upper eyelid. • What's that protruding from her laceration? • What does it signify?
“Eyelids don’t have fat”
• Orbital fat usually protrudes through septal lacerations • Fat in the lid laceration confirms the diagnosis • High incidence of globe penetration and intraocular foreign bodies • High risk for orbital cellulitis