High risk Ophthalmology no personal financial relationships for - - PDF document
2/16/2014 conflicts of interest High risk Ophthalmology no personal financial relationships for David Duong, MD MS products or services in this talk University of California, San Francisco Department of Emergency medicine objectives
David Duong, MD MS University of California, San Francisco Department of Emergency medicine
products or services in this talk
Diagnosis
CORNEAL FOREIGN BODY
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immediately
the injury and with a corneal drill
spasm
removal
Can J Rural Med 2013
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high risk lacerations?
ALL OF THEM
lacerations involving the: tarsal plate lid margin nasolacrimal system
injuries
so get Va, assess EOM, RAPD, etc. Va helps to risk stratify for eye emergencies
EM Clin NA. 2008
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manipulation)
pain meds, sedation)
Diagnosis
HYPHEMA
<33% (Grade 1) microhyphema good prognosis eye shield HOB >30 deg cycloplegia
no NSAIDS
90% visual acuity prognosis 20/50 or better. HOB >30 deg to prevent synechiae cycloplegia only if no incr IOP referral to monitor for incr IOP and rebleeding within 5 days.
33-50% (Grade 2)
>50% (Grade 3 & 4) ↑ IOP (>24) sickle cell
eye shield HOB >30 deg no NSAIDS
topical B-blocker if increased IOP. c/s may also recommend steroid drops
sickle cell disease or trait
up
pain, and decreased vision. On exam, you see corneal cloudiness and diffuse conjunctival injection with ciliary flush.
drops?
mannitol?
(timolol, apraclonidine, prednisolone, pilocarpine are acceptable)
presenting IOP
Choong et al. Eye. 1999
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Hollands et al. JAMA 2009
refer a vision threatening condition to prevent further vision loss or restore vision
Hollands et al. JAMA 2009
PVD can lead to retinal tears 14% prevalence 33-46% of retinal tears lead to retinal detachment
diagnostically helpful for retinal tear
increased risk of retinal tear; younger age is not less likely to have retinal tear
discuss evidence behind recommendations from the JAMA paper
baseline 14% prevalence of retinal tear in those with PVD worse vision no change 45% probability
9% probability of retinal tear
Hollands et al. JAMA 2009
baseline 14% prevalence of retinal tear in those with PVD vitreous hemorrhage LR = 10 vitreous pigment LR = 44 62% probability
88% probability
besides allergy and glaucoma - there is no absolute contraindication for pupillary dilation for a good exam. 1 gtt tropicamde + 1 gtt phenylephrine and wait 20 minutes
vision
need pictures or videos or vitreous hemorrhage and pigment - assess via slit lamp or direct
root atlas has a video of retinal detachment
subjective visual acuity loss
PVD diagnosis (more floaters or vision reduction)
decreased left eye vision 2 hours. Va OS = cannot read the eye chart or count fingers, but can see hand motion.
Diagnosis
CENTRAL RETINAL ARTERY OCCLUSION
ESR & CRP)
hrs)
paracentesis or thrombolytics)
Fraser et al. Cochrane review. 2009
CRAO
for 2d with mild eye pain. She has decreased Va, a + RAPD on the left, and swollen optic disc. nl slit lamp exam.
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work-up
ONTT - 457 patients with optic neuritis IV methylprednisolone was associated with faster recovery in visual fxn and a lower 2-year risk of development of multiple sclerosis. but did not affect long term outcome Oral prednisone was associated with an increased incidence of recurrent
Beck et al. NEJM. 1993
david.duong@emergency.ucsf.edu
Video of a baby crying before this slide?
unwillingness or open the eye after 1 day of treatment
eye
raise IOP
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Can start to fix and follow at 2 months
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