ALL IMP & GENERALIZED OCULAR EMERGENCIES.pptx

It is a ppt covering all ocular emergencies.

1. OCULAR EMERGENCIES Presenter: MAJ ATIYA IQBAL SUPERVISOR: COL FAKHAR HUMAYUN SI (M)

2. ACUTE ANGLE CLOSURE GLAUCOMA Presentation and management: Depends on etiology of angle closure, severity, and duration of attack. Severe , permanent damage may occur within several hours

3. Compression gonioscopy is essential to determine if the trabecular blockage is reversible and may break an acute attack. Topical therapy with β-blocker ([e.g., timolol 0.5%] caution with asthma or COPD ) Cholinergic agonist (e.g., pilocarpine 1%-2%) α2 agonist (e.g., brimonidine 0.1%) prostaglandin analogues (e.g ., latanoprost 0.005%) CAI (e.g., dorzolamide 2%) Topical steroid (e.g., prednisolone acetate 1%) may be useful.

4. Systemic CAI (e.g., acetazolamide 250 to 500 mg i.v. or two 250 mg tablets p.o . in one dose if unable to give i.v .) if reduction in IOP is urgent or if IOP is refractory to topical therapy .. If IOP reduction is urgent or refractory to therapies listed above, repeat topical medications and give osmotic agent (e.g., mannitol 1 to 2 g/kg i.v . over 45 minutes [a 500 mL bag of mannitol 20% contains 100 g of mannitol]).

5. When acute angle closure glaucoma is the result of: Phakic pupillary block or angle crowding : Historically, pilocarpine, 1% to 2%, every 15 minutes for two to three doses

6. Topiramate - or sulfonamide-induced secondary angle closure: Immediately discontinue the inciting medication. Consider cycloplegia ( e.g., atropine 1% b.i.d . or t.i.d .). Consider hospitalization and treatment with intravenous hyperosmotic agents and intravenous steroids (methylprednisolone 250 mg i.v. every 6 hours) for cases of markedly elevated IOP unresponsive to other treatments. In phacomorphic glaucoma , the lens should be removed as soon as the eye is quiet and the IOP controlled, if possible.

7. Address systemic problems such as pain and vomiting. For pupillary block (all forms) or primary angle crowding: If the IOP decreases significantly, definitive treatment with laser (YAG) PI or surgical iridectomy is performed once the cornea is clear and the anterior chamber is quiet, typically 1 to 5 days after attack . Patients are discharged on a regimen of maintenance dose IOP-lowering drops and oral medications.

8. For secondary angle closure : Treat the underlying problem. Consider argon laser gonioplasty to open the angle (particularly in plateau iris syndrome or nanophthalmos , break the PAS). Goniosynechiolysis can be performed for chronic angle closure of <6 months duration . Systemic steroids may be required to treat serous choroidal detachments secondary to inflammation.

9. PENETRATING EYE INJURIES

10. Mechanical ocular trauma CLOSED GLOBE Contusion Lamellar laceration OPEN GLOBE Rupture Laceration( penetrating and perforating)

11. OPEN GLOBE INJURY PENETRATION Single full thickness wound Without exit wound Retained intraocular foreign body

12. Main signs and symptoms Redness of eye Congestion Lacrimation Photophobia Swollen Eyelids Itchy/Watery Eyes Blurring or Loss of Vision Change in Pupil Shape Blood or Fluid Leakage from the Eye Foreign Object Penetrating Eye

13. EFFECTS OF PENETRATING INJURIES Mechanical effects : Laceration of the conjunctiva, corneal lacerations,Vitreous hemorrhage, rupture of globe, retinal tears and detachments, scarring which leads to cataract and glaucoma. And Intra ocular foreign bodies . Introduction of infection : The entrance of the wound may serve as a route of entry for pyogenic bacteria,which may lead to the formation of abscess of cornea, purulent iridocyclitis or Endophthalmitis Sympathetic Ophthalmitis : It is a complication of penetrating injury. Visual impairment

15. Effects Of Penetrating Ocular Injuries

16. MANAGEMENT In general always suspect more extensive injury than may be readily apparent and search carefully for any defects in the integrity of the globe or intraocular foreign bodies Ophthalmic sequelae of Blunt trauma subconjuctival haemorrhage , hyphema , lens dislocation, orbital wall fractures, iridodialysis , angle recession, subsequent glaucoma, iris sphincter rupture, traumatic iritis , posterior segment alterations, traumatic optic neuropathy.

17. Medical reception center Make the patient comfortable Take vital signs Assess the degree of damage Take Visual Acuity Torch examination Distant Direct Ophthalmoscopy Documentation

18. GENERAL PRINCIPLES Determine the nature and extent of any life-threatening problems History – circumstances, timing, likely object Ocular examination (minimal handling) Eyes Orbits Application of eye pad Psychological (avoid negative reassurance !!!!!!!) Referral to eye specialist

19. Principles of surgical repair PRIMARY REPAIR Undertaken immediately Preserve integrity of the globe Remove the dead and devitalized tissue Preserve as much normal tissue as possible Close any open wounds Prevent / treat any nidus of infection SECONDARY REPAIR 10 – 14 days after primary repair Clear opacities of the media Stabilize abnormal vitreoretinal interactions

20. Prophylaxis of Endophthalmitis Antibiotics Enucleation (when nothing to salvage)

21. Traumatic Hyphema General mgt: Head end elevation of bed, restrict physical activities, protective eye shield Medical mgt: IOP control, control of pain, prevention of re-bleeding (oral or topical steroids, oral Amicar which is aminocaproic acid. Surgical intervention is required when: Medical management is not successful for 4-5 days to clear hyphema , In case of uncontrolled glaucoma when IOP > 50 mmHg for more than 5 days Corneal endothelial staining Large or Total hyphemaand active bleeding in anterior chamber

22. Orbital Fracture, Globe laceration Orbital fracture mgt: Nasal decongestants, ice pack application, don’t blow the nose, anti- biotics , surgical repair (urgent only if entrapped muscle, oculocardiac reflex, white eyed orbital floor blow out fracture). Globe Laceration: Seidel test Avoid aapplying pressure, Avoid MRI if metallic foreign body suspected Apply eye shield, CT scan/ Ultrasound General mgt (anti-emetics, pain relievers, TT inj , anti- biotics ) Globe repair surgery

23. Removal of IOFB TECHNIQUE OF REMOVAL OF IOFB depends on : Chemical composition Location Size of IOFB Clarity of media Phakic status Toxicity of IOFB

24. DOs and DONTs DO NOT flush the eye with any liquids other than saline or warm water even better just do not touch the eye DO NOT remove the object out of the eye DO NOT put any pressure on the eye Do NOT rub your eye. Reassure the person and advise against rubbing If the injury is severe, place a moist pad and loosely bandage the eye

25. CHEMICAL INJURY Acid burns Alkali Burns Signs and symptoms: Pain, watering, discomfort Conjunctival hyperemia Chemosis Epithelial erosions Corneal edema or haze A/C reaction Corneal opacification Limbal ischemia

26. Emergency Management Instil the topical anaesthetic agent Copious irrigation with normal saline or ringers lactate to be done for 15-30mins or until PH is maintained Double eversion of upper lid Debridement of necrotic areas of corneal epithelium

27. Medical Management steroids cycloplegics topical antibiotics oral ascorbic acid Tetracyclines Acetyl cystein 10% drops Monitor IOP Dermatology opinion- periocular skin injury

28. Surgical Management EARLY: -Advancement of tenon capsule with suturing to the limbus - Limbal stem cell transplantation -Amniotic membrane grafting -Gluing or keratoplasty

29. LATE: -Division of conjunctival bands and symblepharon -Conjunctival or mucous membrane grafting -Correction of eyelid deformities - Keratoplasty - Keratoprosthesis

30. ENDOPHTHALMITIS Causes: Exogenous (post-surgery, post-traumatic) Endogenous (Sepsis) Acute (Staphylococcus infection) Chronic ( Propinibacterium acnes)

31. Signs and Symptoms Blurring of vision Ocular pain Conjuctival swelling Corneal edema Floaters A/C inflammation Hypopyon Vitritis

32. Management   PRIMARY OBJECTIVES Control and eradicate infection Manage complications Preserve vision SECONDARY OBJECTIVES Symptomatic relief Remove pupillary membrane in miosis Maintain globe integrity

33. Treatment Modalities Antimicrobial treatment Corticosteroids Supportive treatment Vitrectomy

34. Management Acute exogenous endophthalmitis Emergent vitreous tap Broad spectrum anti-biotic injection ( Vancomycin 1mg/ 0.1 ml, Ceftazidime 2mg/ 0.1 ml) With or without steroid inj 400 microgram/0.1 ml) Severe vision loss, vitectomy considered Endophthalmitis Vitrectomy Study (PL positive vision due to endophthalmitis post-surgical, vitrectomy was found superior)

35. CORNEAL ABRASIONS

36. Corneal abrasion is the most common eye injury. They frequently result from eye trauma retained foreign bodies improper contact lens use. It occurs because of a disruption in the integrity of the corneal epithelium or because the corneal surface is scraped away or denuded as a result of physical external forces.

37. Corneal Abrasion Causes: fingernail scratch, contact lens wear, UV burns from welding Symptoms: severe pain, foreign body sensation, tearing, sometimes decreased vision Signs: blepharospasm , fluorescein staining of abrasion

38. Management CHLORAMPHENICOL ointment BD to the affected eye for 5 days. If they are very photophobic, put 1 drop of CYCLOPEN. Patch the eye for 4–6 hours if the abrasion is very painful or >50% of corneal surface, BCL option Never patch an ulcer. Removal of rust ring if easily possible. DON'T GIVE OUT TOPICAL ANAESTHETICS to take home Advise patient to not wear contact lens for 2 weeks. Counsel patient it may be painful for 2 days.

39. Patching technique Apply topical antibiotic treatment Ensure lid is closed over cornea and tape gauze pad over eyelid Generally not required for small abrasions  Indicated for: 1) Very symptomatic and photophobic patients- 4-6hr patching. 2) Large abrasions >50% corneal surface- 24hr patch

40. Follow up Reasons for follow‐up in Ophthalmology clinic : If there is corneal ulcer/infiltrate or hypopyon Visual loss (>2 lines on Snellen chart) The abrasion is affecting the patient's “only‐seeing” eye Contact lens wearer with corneal ulceration L arge defect > 40% of corneal area Delayed healing, failure to re- epithelialise after 3-4 days

41. LID LACERATION

42. Management Very small lacerations (<1 mm) at the lid edge can heal spontaneously. Consider the possibility of corneal laceration and globe rupture in all full-thickness lid lacerations. Partial-thickness lid lacerations usually repaired. Repair can be delayed by 12-24 hours. Use non-absorbable 6-0 or 7-0 vicryl suture.

43. Deep lacerations medial to the punctum potentially can transect the canalicular system Instillation of fluorescein dye in the eye with subsequent appearance in the wound indicates loss of canalicular integrity. Canalicular laceration : Repair and Silastic tube stenting within 24 to 36 hours Oral cephalexin ( Keflex R ) first generation cephalosporin, 500 mg twice daily , and topical erythromycin ophthalmic ointment four times daily .

44. When to call senior Eyelid lacerations that involve the lid margin those within 6 to 8 mm of the medial canthus Involving the lacrimal duct or sac. those involving the inner surface of the lid . wounds associated with ptosis those involving the tarsal plate or levator palpebrae muscle need repair by an oculoplastic specialist.

45. CORNEAL and CONJUCTIVAL FB

46. Symptoms and signs Symptoms: Foreign body sensation, tearing, history of trauma Signs : Critical. Conjunctival or corneal foreign body with or without a rust ring. Other. Conjunctival injection, eyelid edema, mild AC reaction, and SPK.

47. Work up History : Determine the mechanism of injury (e.g., metal striking metal, power tools or weed-whackers). Always keep in mind the possibility of an intraocular foreign body (IOFB ) visual acuity : Document visual acuity before any procedure.

48. 3. Slit lamp examination: Locate and assess the depth of the foreign body pupil irregularities &iris tears transillumination defects (TIDs), capsular perforations, lens opacities, hyphema , AC shallowing (or deepening in scleral perforations), asymmetrically low IOP in the involved Evert the eyelids and inspect the fornices for additional foreign bodies Perform a fluorescein examination to disclose any corneal abrasions caused by the foreign body

49. 4- Fundoscopy : Dilate the eye and examine the posterior segment for a possible IOFB (INTRAOCULAR FOREIGN BODY). 5-Investigations : B-scan ultrasonography, Computed tomography (CT) scan of the orbit, biomicroscopy (UBM) to exclude an intraocular or intraorbital foreign body. Avoid magnetic resonance imaging (MRI) if there is a history of possible metallic foreign body.

50. Management Corneal Foreign Body Apply topical anesthetic . Remove the corneal foreign body with a foreign body spud, fine forceps, or small-gauge needle at a slit lamp. Multiple superficial foreign bodies may be more easily removed by irrigation. Remove the rust ring as completely as possible on the first attempt. Measure the size of corneal epithelial defect . If there is concern for full-thickness corneal foreign body, exploration and removal should be performed in the operating room

51. Conjunctival Foreign Body Remove foreign body under topical anesthesia. Multiple or loose superficial foreign bodies can often be removed with saline irrigation. A foreign body can be removed with a cotton-tipped applicator soaked in topical anesthetic or with fine forceps. For deeply embedded foreign bodies, consider pretreatment with a cotton-tipped applicator soaked in phenylephrine 2.5% to reduce conjunctival bleeding . Sweep the conjunctival fornices with a cotton-tipped applicator. if there is a significant conjunctival laceration topical antibiotic (e.g., bacitracin ointment, trimethoprim/ polymyxin B drops, or fluoroquinolone drops q.i.d .) may be used. Preservative-free artificial tears may be given as needed for irritation.