• eyetube.net
• ophthobook.com free online opthalmology textbook
• See Hear Rural Health West au

Eye anatomy & physiology

• http://www.youtube.com/watch?v=HfuAR6kg1Iw
• http://youtu.be/Z8asc2SfFHM
• http://youtu.be/ajnsDVsP0Uk
• http://www.youtube.com/watch?v=hMHKJF31lBg
• http://www.youtube.com/watch?v=0HzWmldLDHI
• http://www.youtube.com/watch?v=KWkq7pvj8QI
• http://www.youtube.com/watch?v=HfuAR6kg1Iw

Opthalmic glossary

eyeglossary.net
from opthlalmology made ridiculously easy steven goldberg

amaurosis fugax transient loss of vision from retinal ischemia due to vasospasm or embolic obstruction of an arteriole

aphakia absence of lens.

asthenopia eyestrain (blurred vision, diplopia, headache) from excessive use of the eye.

blepharochalasis loose overhanging skin fold in upper lid.

Bruch’s membrane the membrane separating the pigment epithelium and choroid.

cataract lens opacity.

chalazion inflammation of a meibomian gland.

coloboma a developmental defect in the closure of the eye cup, leading to a gap in the inferior region of the retina and/or iris.

conjunctiva the thin transparent vascular membrane overlying the sclera and continuingon the under surface of the lids, in direct apposition to the tear film.

cycloplegia paralysis of accommodation.

dermatochalasis puffiness of skin in the upper lid with aging, commonly due to herniation of orbital fat.

diopter a unit referring to the converging (plus) or diverging (minus) ability of a lens.

diplopia double vision.

drusen small round yellow spots just outside the pigment epithelium, a benign degenerative condition. When in the optic nerve head, drusen appear as bumpy rapioca like excrescences, which should not be confused with papilledema.

dry eye syndrome irritation secondary to decreased tearing, as in Sjogrens syndrome may be treated with ocular lubricants like methylcellulose (Adsorbotear) and polyvinyl alcohol (Liquifilm tears).

episcleritis inflammation of the connective tissue lying between sclera and conjunctiva.

esotropia crossed eyes.

exotropia wall eyes

fornix the region where conjunctiva overlying the eye folds back to become the conjunctiva underlying the lid.

fundus the posterior area of the retina, particularly the area within view of the ophthalmoscope.

Goldmann perimeter a refined device for plotting visual field defects using lights of varying size and brightness.

hemianopia loss of vision in half of a visual field.

injection marked prominence of small vessels.

iridectomy surgical removal of iris tissue.

keratitis inflammation of the cornea.

limbus the junction zone between cornea and sclera.

lipaemia retinalis yellowcream coloring of retinal vessels due to markedly excessive lipids in the blood.

microphthalmia small eye.

myokymia twitching of eyelids, a benign transient condition possibly related to fatigue or tension; occurs unilaterally.

neovascularization formation of new blood vessels.

photophobia pain on exposure to bright light.

pinguecula a benign yellowish, soft, slightly elevated area found nasal or lateral to the cornea, typically nasal.

ptosis droopy lid.

quadrantopia loss of vision in one quandrant of a visual field.

slit lamp a specialized microscope for viewing the eye externally and internally; has attachments to alter the size, shape, brightness, and angulation of the light beam, and usually contains a tonometer for measuring intraocular pressure.

stye an inflamed pimple along the lid margin, representing an infection of a hair follicle or a small local gland.

superior colliculus the curved roof of the rostral midbrain, associated with various visual reflexes.

synechiae adhesions secondary to inflammation.

tangent screen a black screen designed to test for visual field defects by introducing test objects of various sizes in different positions of the visual field.

trachoma a viral disease of the eye in which follicles arise in the upper lid conjunctiva, followed by vascular invasion and scarring of the cornea, beginning at its 12 o’clock position.

trichiasis inward turning of eyelashes against the eye, often causing ocular irritation

visual field the extent of what the eye sees when looking forward.

Wilson’s disease a familial disorder of copper metabolism with cirrhosis of the livernand degeneration in the basal ganglia of the brain. Copper deposits in the lens (copper cataracts) and the peripheral cornea, as a greenishbrown ring (Kayser-Fleisher ring).

xerophthalmia drying and clouding of the cornea with vitamin A deficiency.

Eye examination

• http://hacking-medschool.com/opthalmic-exam
• http://meded.ucsd.edu/clinicalmed/eyes.htm
• 5 minute Eye Examination Dr Andrew Partner @ Pulse UK
• Visual Field Testing By Confrontation Dr Andrew Partner Pulse UK

Acuity
Absolutely essential even if only a rough guide. Can the patient count fingers and perceive objects in all four quadrants of the visual field?
Ensure that the eyelids are sufficiently open during test.

Inspection
Examine ocular structure from anterior to posterior: lids, bony orbit, conjunctiva, cornea. anterior chamber, iris, etc.

Light
A strong beam is essential and is more effective if concentrated as by a good pencil torch and shone obliquely.

Magnification
A convenient type is a binocular loupe fixed to a headband which can fit over spectacles if necessary leaving the hands
free. A Xl0 hand loupe provides greater magnification but its use requires practice.

Opthalmoscopy
for examining the posterior segment of the eye
Its use is facilitated by dilation of the pupil (after the likelihood of glaucoma has been excluded).
When examining myopic eyes do so with the patient wearing his spectacles.

FLUORESCEIN
Shows up cerneal epithelial lesions stain green in blue light.

Other equipment which may be required are sterile disposable hypodermic needles, cotton wool buds, epilation (block ended) forceps, sterile saline with IV giving set. eye pads,1 inch strapping (micropore), wire lid speculae.

The following should always be available in single dose units:
LA Drops Benoxinate or Ophthaine
Analgesic Diclofenac
Mydriatic Dilating Drops Homatropine 2%
Miotic Constricting Drops Pilocarpine 4%
AB Ointment and/or Drops Chloramphenicol or Sulphacetamide

Unless 24 hour prescribing is readily available. there should also be a supply of:
Systemic Antibiotic: Ampicillin (Penbritin)
Local Steroid Drops: Betamethasone
Steroid/Antibiotic Ointment: Betamethasone and Neomycin
Idoxuridine Drops: (Kerecid)
Acetazolamide 250mg tablets.

When examining closely. sit or stand on the same side of the patient as the eye under scrutiny. When carrying out treatment
it is most convenient to do so sitting at the head of a couch or reclining chair. with the patient lying supine. fixing his gaze on an object above his head.

CHILDREN are sometimes surprisingly co-operative. and such measures as sedation and general anaesthesia must be judged according to the urgency of the situation. In an emergency, such as cement inside the lids. if necessary wrap the child up in a blanket to prevent struggling, the arms should be separate inside the layers of blanket and. with an assistant steadying the head ‘and body, lay the child supine on a couch or the floor.

It may be difficult to separate the eyelids. and Casualty Departments should have a pair of curved wire lid speculae for this purpose, as well as sterile saline for irrigation by means of an I.V. giving set. or an undine, after liberal instillation of local anaesthetic drops.
While the child is restrained there will be an opportunity to check the cornea for abrasions or foreign bodies; treatment for this may be given immediately. or if necessary deferred in favour of a general anaesthetic later.

Acuity near/far with and without glasses/pinhole
Colour Vision Ishihara Charts
RAPD

Specialist Eye Examination

Opthalmoscopy

• http://hacking-medschool.com/opthalmic-exam
  http://www.youtube.com/watch?v=woUHtC0pqhA
• http://www.youtube.com/watch?v=uRkz_4u4QUQ
• http://youtu.be/kl11zib5TOs

Fundoscopy
DM/FT Disc Medial Fovea Temporal

Soft (cotton wool) exudates = poorly demarcated superficial ischemic areas with necrosis of the retina or localised oedema in the nerve fibre layers – indicate onset of accelerated hypertension and are reversible with good control.  Hard exudates are small deep deposits of lipids with well defined borders. they persist much longer than soft exudates.

Causes of exudates

• Hypertension
• DM
• SLE
• Leukaemia
• severe anaemia

Optic Nerve CN2

• AFRO
• Acuity
• Fields
• Reflexes (light/accomodation)
• Optic Disc (papilla)
• Disc CCCP colour contour cupping papilloedema

Optyse and WA panoptic opthalmoscope

WA Panoptic

Optyse

Slit lamp

• http://youtu.be/kl11zib5TOs
• http://youtu.be/09BVhyzWjY4
• http://youtu.be/3pvwi3Yal9o

Visual acuity

Visual acuity tedmontgomery.com

Snellen chart

Snellen chart mdsupport.org

Refractive disorders

• http://youtu.be/Z8asc2SfFHM
• Refractive errors merckmanuals.com
• refractiveeyedisorders.com
• umich.edu refractive errors

Contact lenses

Contact lenses merckmanuals.com

Refractive surgery

Refractive surgery merckmanuals.com

Colour vision

• Colour Vision @ DIY.com
• http://youtu.be/Jzl9VPnA3OY
• http://youtu.be/CWyrp3hu4KE

Eye clinic tests and procedures

Eye exam mayoclinic.com

Orthoptist

Orthoptics Oxford Eye hospital

Eye surgery

• Moorfields Eye Hospital
• rcophth.ac.uk

Referral guidelines eye conditions

Oxford NHS referral guidelines

Eye triage

Emergency
Sudden loss of vision with history of trauma
Impaled or penetrating foreign object
Severe contusions with evidence of increased intraocular pressure
Hyphema
Iris tears

Urgent
Traumatic mydriasis (dilation of pupil) with blurred vision or diplopia
Severe lid lacerations
Disturbance in vision in patient with history of glaucoma
Actinic injuries

Nonurgent
Ptosis
Soft tissue edema, ecchymosis without vision change
Eye Trauma Hyphaema
Hyphemas usually are the result of blunt trauma to the eye which results in a tear in the iris vasculature or subconjunctival hemorrhage.

Signs and Symptoms
Blood in the anterior chamber More difficult to detect in brown eyes than in blue eyes.
Decreased vision and increased pain
Due to increased intraocular pressure and distension of intraocular structures.

Interventions
Sit the patient in an upright position to assist in detecting the pooled blood
Patch bilaterally Immobilizes eyes and provides for resolution in hyphemas of 50% or less.
Depending on the size of the hyphema, surgical intervention may be necessary.(4)
Monitor for rebleeding, especially in the first five days after the trauma

Eyelid bruising does not necessarily indicate damage to vital structures. but important points must be elucidated:
(a) CAN THE PATIENT SEE? If necessary. open swollen lids digitally.
(b) IS THE EYEBALL INTACT? Check the integrity of the cornea, depth of anterior chamber and whether or not it contains blood (hyphaema).
Compare the pupil to the opposite side; does it react? Is there a red reflex through the pupil?
(c) OCULAR POSITION AND MOVEMENT: protrusion may indicate a retrobulbar haemorrhage, or the eye may be sunk back in the socket-enophthalmos, suggesting a” blowout” fracture of the bony orbit. which may also cause restriction ofocular movement and diplopia due to impaction of extraocular muscles in the fracture.
(d) BONY MARGIN: Irregularity of the bony margin may be palpated.
Always X-RAY: If “blowout” is suspected ask for tomograms.
OTHER INJURIES may require more urgent treatment. in which case it may be expedient to call the ophthalmologist to a casualty or orthopaedic department. Fractures of the bony margin may require the opinion of a faciomaxillary surgeon.
Rx Refer to eye department if signs indicate.

All patients presenting with eye injuries should have Visual Acuity recorded at each visit.
Patients with painful eye conditions should be prescribed oral analgesics, not LA drops.
Where the eye may have suffered penetration by a FB X-Ray of the Orbits should be performed.

Retinal Detachment Medscape

Chemical Burns

Welders Flash injury

Opthalmic Red Flags
chlamydial conjunctivitis (erythromycin/tetracycline/ung + po),
hyphemas (? intraocular pressure?),
subtle retinal detachment
intraocular foreign bodies (e.g. hammering metal against metal),
iridocyclitis,
optic neuritis (multiple sclerosis?)
periorbital/orbital cellulitis,
blowout or depressed fractures ? subconjunctival hemorrhage with no lateral and/or medial white sclera?, check eye movements diplopia?; infraorbital hypothesia?, subcutaneous or orbital emphysema?, CT scan required?).

do not use topical ophthalmic steroids (always refer; topical steroids can result in corneal perforation)
do not give topical ophthalmic anaesthetics for home use (well, maybe a “few” drops to go, e.g. abrasion of cornea, welding flash burn/may prevent a premature return visit)

Avoid delicate corneal treatment unless the eye/hand is reasonably steady – G.A. if necessary.
Avoid mydriatics whenever glaucoma is suspected-the condition might be aggravated (check AC depth).
Avoid local STEROID ocular therapy unless specifically indicated: it exacerbates herpes simplex keratitis.
Avoid excessive use of local anaesthetic drops for painful corneal conditions: this may delay healing.
GIST

Sudden visual loss refer immediately
temporal arteritis consider prednisolone 80 mg stat
acute angle closure glaucoma consider pilocarpine 4% drops every 5 mins
migraine consider referral if atypical or unsure of diagnosis

Painful and red: often need referral: glaucoma, herpes simplex, foreign body, abrasion.
Painful not red: often seen in general practice: stress, refractive error, beware GCA, retrobulbar neuritis.
Red not painful: conjunctivitis, subconjunctival haemorrhage. Temporal artery + fever = giant cell arteritis
Cloudy cornea and pupil dilation = glaucoma.

Flashers and floaters

• allaboutvision.com spots and floaters
• umich.edu floaters
• flashes and floaters
• clevelandclinic.org floaters and flashing lights
• retinahawaii.com flashes and floaters

Black spots or shapes suddenly occurring, and remaining in the patient’s sight often cause worry and annoyance. most are of little significance.

Sudden loss of vision

Anterior Ischaemic Optic Neuropathy (Temporal Arteritis)

Elderly headache jaw claudication temporal tenderness polymyalgia
Disc swollen
Check ESR Treat urgent hight dose steroids

CRO

also seen in TA/GCA above plus AF, infective endocarditis hypertension and disseminated atherosclerosis.

Bright “cherry red” spot on fovea + swollen optic disc
Arteries are attenuated +/- straky haemorrhages arounf=d the vessels
Veins are narrow
Optic disc is pale and atrophied
No light perception. APD
Check for carotid bruits
Refer for urgent treatment to prevent optic nerve atrophy
Rx IV diamox (acetazolomide) occular massage AC paracentesis

CRVO
= CRV thrombosis?
Venous congestion and numderous haemhoerrages with retinal oedema and papilloedema ( true papilloedema usually bilateral and affects vision late, CRVO unilateral and vision is affected early) =/- microaneurysms and collateral vessesls
CF large optic disc stormy sunset with engorged veins
No definitive Rx Perpheral vision may improve in 6-12 m
Causes
Hypertension
DM
Hyperviscosity syndrome (myeloma, myeloproliferative disorders)

Iritis acute anterior uveitis

• http://www.youtube.com/watch?v=CKb52tIlAlg&feature=related
• Acute anterior uveitis BMJ 2009
• uveitis information group

Uveitis/Iritis is an inflammation of the uveal tract, which contains the iris, cilary body, and choroid. Usually affects the anterior portion of the uveal tract and is categorized as iritis. It can be caused by inflammation, infection, or trauma. Symptoms include decreased vision, photophobia, pain with direct and consensual light reflex, red eye, and excessive tearing.

Inflammation of the iris which is occasionally associated with systemic disease such as spondylitis.
The most severe cases are usually recurrences.The eye becomes painful for no apparent reason over a day or two with photophobia and circumcorneal redness. often without visual disturbance (but it may be grossly reduced in severe cases).
Close inspection may reveal Keratic Precipitates. linear aggregations of inflammatory cells on the internal surface of the cornea.
There may be an hypopyon.
The pupil is usually normal or small, sometimes irregular.
The anterior chamber is of normal depth and contains inflammatory cells which are not normally visible.
R Dilate pupil with mydriatic drops. local steroid drops hourly. Always refer.

Acute glaucoma

http://hacking-medschool.com/acute-glaucoma

http://youtu.be/73D63azw0GU

Temporal arteritis (opthalmology)

• 250textbooks/neurology-temporal-arteritis
• 250textbooks/rheumatology-pmr
• Anterior Ischaemic Optic Neuropathy Medscape

Elderly patients with C.R.A. occlusion
History of headache, scalp tenderness and jaw claudication +/- PMR
ESR grossly elevated
Start high dosage steroids immediately to protect the OTHER eye from a similar catastrophe.

Central retinal artery occlusion CRAO

http://youtu.be/08wRyNCpTDU

sudden, unilateral, painless profound loss of vision,
commoner in arteriosclerotic patients
asent or reduced pupil reaction to direct light
Pale retina +/- red spot at the macula.
Refer stat – immediate treatment (within the hour) may re-establish circulation – needle decompression, ocular massage, IV heparin (5-10,000 units), tPA

Central retinal vein occlusion CRVO

• http://youtu.be/Y_l4ZNch0P8
• http://www.youtube.com/watch?v=Il8FnlSKroM&feature=related

monocular decrease in vision ? engorged veins and retinal hemorrhages ? refer immediately.

???A relatively small haemorrhagic disturbance in this area causes severe CENTRAL visual defects.
In YOUNG MYOPES this can occur spontaneously and be visible ophthalmoscopically.
In the ELDERLY haemorrhage and exudate may occur, and either may predominate in the appearance of this arteriopathic lesion. known as DISCIFORM DEGENERATION. Refer.

Gradual reduction of vision may be “Suddenly” discovered by the patient who closes the good eye for some reason.
Scattered flame shaped haemorrhages throughout the retina. and congested veins. One quadrant only may be affected.
Check BP. Refer. Secondary glaucoma is a late complication. and should be suspected in patients who have had a
CR. V. T. followed some WEEKS later by pain.

Retinal detachment

• http://www.youtube.com/watch?v=VQWT3Gn0ihA
• http://youtu.be/E6sMlv1EF24
• http://youtu.be/hFFlhKYXMuw

Flashers (flashing lights)
Floaters (looking through frogspawn)
Field Defect (half visual field like a curtain)
Lie patient flat (if cant see down below and sees flashing lights suggests upper detatchment)

@@@ Vitreous haemorrhage

http://youtu.be/rALSIg6Os8g

Diabetics with neovascularisation
Seen also in retinal detachment and bleeding disorders
Spontaneous absorption
Rx Photocoagulation of new vessels

Coles
Gradual Loss of Vision
Cerebral vascular accidents may involve the visual pathways.
The patient is usually arteriosclerotic.

Patients with sudden loss of one half of the visual field of EACH eye often report it as blindness “in one eye”. Testing by confrontation soon reveals the true defect which is caused by a lesion in the opposite cerebral hemisphere to the side of the field defect. This need not be accompanied by other neurological
signs but often is. Quadrantanopia may be found.

This rare occurrence is caused by vertebrobasilar artery insufficiency. There is no apparent ocular lesion but the patient cannot see. and usually no treatment is possible. Always refer to a neurologist.
Attacks of complete or partial painless loss of vision in one eye, which may sometimes be associated with transient neurological symptoms affecting the opposite side of the body. Due to carotid insufficiency.
Reduced carotid pulsation may be palpated. A bruit may be heard with a stethoscope.
Rx Refer, Carotid artery surgery may be possible. in order to prevent permanent damage.

This may occur when the balance of the extraocular muscles is upset, Palsies of the 3rd .4th and 6th cranial nerves can occur suddenly, with or without other neurological signs and symptoms. These defects may be transient. Always measure blood pressure and check urine for sugar.
If diplopia is intolerable cover one eye.

This may be present as pain in the ocular region or head. accompanied by double vision due to involvement of cranialnerves to extraocular muscles. Refer.

Partial or complete vitreous haemorrhage may occur from trauma and is diagnosed by a dull or absent red reflex throughthe pupil (it may accompany hyphaema). It usually clears. but further damage inside the eye may be revealed. Rest. Refer.
Eye Trauma Penetrating Injuries
Penetrating Trauma/Ruptured Globe
Penetrating trauma is usually observed in conjunction with impalement injuries from knives, pencils, knitting needles, or bullet wounds. A ruptured
globe is also seen, particularly in the elderly trauma victim, as a result of blunt trauma to a very thin region of the globe at the limbus or below the rectus.(1)
These penetrating injuries sever nerves and muscles of the eye with or without rupture of the globe itself. If the floor of the anterior cranial fossa is
penetrated, the frontal lobe of the brain is readily injured; meningitis, brain abscess, internal carotid artery tears, or hemorrhage can result. Retinal
detachment with painless “light flashes” and blurred vision often accompanies trauma (contusions) to the globe.

Signs and Symptoms
Loss of vision
Extreme pain and anxiety
Visible impaled or penetrating object, e.g. knife, knitting needle
Visible hemorrhage
Extrusion of vitreous or aqueous humor
Decrease in intraocular pressure

Interventions
Immobilize impaled or penetrating obje,s:ts immediately to prevent further damage to intraocular structures and surrounding tissue
Elevate head of bed to decrease intraocular pressure
Patch or bandage bilaterally
Instill NO medications if the trauma is perforating
Facilitate an ophthalmology consult
Prepare for admission to the hospital
Prepare for immediate surgical intervention
Eye Trauma Chemical Burns
Alkali ocular burns
? require prolonged irrigation prn (hours, days), for liquefaction necrosis. Wood ashes are alkaline, and can result in permanent ocular damage
? ocular alkali burns are also associated with automobile air-bag activation

Chemical burns of the eye occur primarily in industrial settings. Acid and alkali burns cause destruction of epithelial tissues and the conjunctiva with
subsequent scarring. Organic irritants such as pesticides and brake fluid usually cause edema of the cornea and conjunctiva but damage is usually
temporary. Proper identification of the chemical agent involved, its concentration, degree and duration of exposure and prehospital care administered
are critical,as well as whether the injured eye was irrigated at the time of injury with large amounts of water. Acid burns tend to penetrate tissue
slowly or superficially, but can result in vision loss if not adequately treated.
Alkaline substances are proteolytic and continue to burn, destroy, or lyse tissue resulting in ischemia and necrosis until they are removed.

ALKALI (lime) damage to the cornea is devastating. If any chemical enters an eye. irrigate PROFUSELY immediately, if necessary plunge head into a basin of water and force lids apart. Local anaesthetic drops facilitate irrigation which can be carried out most efficiently with saline from an IV giving set.
If delay in referral is unavoidable. instil mydriatic drops and , antibiotic ointment after thorough irrigation-analgesics may be necessary

Signs and Symptoms
Severe pain
Opaque cornea may be present
Interventions
As indicated in “Nursing .Care of Eye Trauma” plus:
Irrigate immediately with running water or normal saline. Be careful not to contaminate opposite eye, irrigate from inner to outer canthus for 30-60
minutes with lids open for acid burns and 60 minutes for alkali.
Assist with/remove any foreign objects
Check pH of eye surface periodically until the pH is 7.3-7.7 and again ten X minutes after irrigation is discontinued. Z
Instill prescribed topical anesthesia intermittently to diminish pain and increase ease of irrigation.
Instill prescribed antibiotic drops
Patch as indicated
Instill prescribed cycloplegic drops to relieve ciliary spasm and mydriatic agents to dilate pupils.
Facilitate ophthalmology consult, revaluate visual acuity and injury.

Vitreous opacities

http://youtu.be/4FJYeEGl98g

These vitreous opacilies are usually due to small haemorrhages. and may be seen through an ophthalmoscope. sometimes they may be found to be associated with flat retinal holes.
x Refer. This trealable condilion. if ignored. might later lead to the much more serious retmal detachment. Accompanying symptoms of flashes of light make the diagnosis more likely.
Spontaneous haemorrhage into the vitreous is a complication of diabetic retinopathy and some other condiltons (but thecommonest cause is trauma). It may cause loss of vision.There is a reduced or absent red reflex through the pupil. The patient should rest and be referred.

If gradually increasing think vitreos degeneration lens opacity or corneal scar

If sudden onset with flashing =/- decreased vision think vitreos detatchment, disc embolus, blocked blood vessel or retinal detachment

2 weeks post cataract surgery with CF may indicate infection vitreous detacment or haemorrhage or retinal detachment Check RAPD and dilate to examine retina

Orbital cellulitis

S.pyogenes, S.aureus
Ophthalmic emergency. Refer stat.

Orbital Cellulitis is an infection deep into the orbital septum and it can be life-threatening.
It is usually caused by S. pneumoniae, S. aureus, and Haemophilius influenzae, is usually associated with a sinus infection.
Patients typically present with pain, fever, and impaired EOM.
Impairment of EOM is a very important sign in differentiating between Periorbital cellulitis and orbital cellulitis.
Decreased visual acuity is a late finding. If this is not treated it can progress into cavernous sinus thrombosis, which is a life-threatening infection that spreads from the infected sinus to the orbital area.

http://www.youtube.com/watch?v=6YT6GAbkGKY

Cautionary Tale

Hypopion

Hypopion = pus in the anterior chamber
Hyphaema = blood in the anterior chamber

May result from infection at the site of a foreign body or an ulcer due to corneal exposure. Requiries immediate treatment to prevent intraocular extension.

There may be a circumscribed yellowish white patch in the cornea plus pus in the anterior chamber with a fluid level
Eye is very red especially close to the cornea.

CULTURE if possible before starting treatment
Antibiotic therapy. half hourly drops topically and systemically in maximum dosage.
Dilate the pupil with as many instillations of mydriatic drops as are necessary i.e. every quarter of an hour until pupil is dilated – it may be stuck down to the lens (posterior synechiae).

http://youtu.be/Yjdi6gXUlq8

Eye trauma

Blunt trauma
Deceleration Injuries – RTAs, sports injuries – can cause substantial damage as the vessels and nerves are torn from delicate eye structures.
Penetrating injuries – missiles, bullets, knives, explosion debris, broken glasses, hard contact lenses, letter bombs, fireworks, exploding car batteries and soft drink bottles, and aggressive recreational sports activities. Penetrating injuries are also more frequently seen in the elderly person who has been subjected to severe blunt trauma.
Chemical burns another type of penetrating injury, may damage the eyes, lids, and surrounding structures.

Concurrent Injuries
Due to the location of the eyes, eye trauma is frequently seen concurrently with head and facial trauma. It is critical to recall that actual life-threatening injuries MUST be treated before turning attention to the care of a painful, traumatized eye.
Severe, penetrating trauma to or near the eye can easily penetrate the fragile facial/sinus bones and cause direct injury to the brain, sever the optic nerve or extraocular muscles (without obvious external trauma to the visible sclera or anterior chamber), damage the lower lid, and/or disrupt the lacrimal apparatus. If the supportive tarsal plate is traumatized, the shape of the upper lid is altered significantly. Even when the lid is not completely penetrated, assessment of damage to underlying structures especially the cornea is necessary. Also lateral zygomatic or medial ethmoid orbital fracture can result in ligament avulsion.

Other Significant Facts
The assessment of eye injuries should NOT be forced in the field. The lids should NOT be forced open without the judicious and appropriate use of prescribed topical anaesthetic agents to facilitate opening of the lids and examining the eye without further injury. Additionally, the patient with eye injuries should not leave the emergency care setting without a complete exam of eye injuries.
Because eye injuries can quickly and easily result in diminished or lost vision and the inability to function in one’s occupational field, these injuries are a high priority for intervention. The examination of a swollen eye, deferred for several days, may contribute to serious injury or vision loss in both eyes.

PATHOPHYSIOLOGY AS A BASIS FOR SIGNS AND SYMPTOMS
Contusion of the soft tissue of the orbit with edema, bleeding, and discoloration of the lids results in one of the most frequently and readily encountered signs of eye trauma, the contused or “black” eye.
Soft tissue lacerations,especially of the lids, result from either blunt trauma to the thin skin of the lids as they decelerate on the underlying bone or from penetrating trauma. Ptosis seen in eye trauma frequently results from an upper lid injury, laceration of the levator palpebral superioris tendon, or accompanying gross oedema.

diplopia can occur from dislocated lens, optic nerve lesions, or retinal hemorrhage diplopia/double vision can be bilateral or unilateral.
Bilateral diplopia can result from contusion, tears, or trapping of the extraocular muscles (damaged cranial nerves III, IV, or VI) or limited globe movement associated with fractures, hematomas, or foreign bodies.
Unilateral diplopia results from a subluxed lens, oedema, haematoma in the orbit, macular oedema, or superior oblique or rectus muscle damage.

Blindness can occur in anterior or posterior chamber bleeds from trauma from optic nerve injuries, or globe destruction.

Sudden or immediate blindness can result from a hyphaema which fills the anterior chamber with blood, vitreous hemorrhage, severed optic nerve with or without basilar skull fracture, .globe disruption with extruded contents, occipital injury, or intracerebral hemorrhage

Blindness with an onset within hours of the trauma is associated with corneal ulceration, central retinal artery occluion from dressings or patches that are too tight, and retinal detachmeot. Blindness with a late onset is usually caused by retinal detachment, ocular infection, or traumatic cataracts

If on gentle palpation the globe feels soft the eye may be extruding through a lacerated conjunctiva. Vitreous or aqueous humor may be visible on or extruding from lacerations of the globe itself.

Blood levels seen inside the cornea result from anterior chamber bleeds. With the effect of gravity, the blood settles or “levels” when the patient sits upright.

A grossly pink or red eye is seen in subconjunctival hemorrhage as blood collects between the conjunctiva and sclera. While the condition may be frightening to the patient, the injury is generally not vision-threatening.

Pain is associated with most eye trauma. It results from irritation to the lid or globe by minute or large foreign objects, from extensive edema. or from underlying fractures.

NURSING CARE OF EYE TRAUMA
History
What was the mechanism of injury?
How the injury occurred identifies the risk of other concurrent injuries
Was the patient wearing eye protection such as goggles?
Protective eyewear serve as a barrier to protect and to slow the velocity of potentially penetrating foreign objects,
Was a foreign object involved? Is it still in the eye?
Was the foreign object metal, wood, or glass?
Metal objects are of particular concern as rust rings can form in the cornea from iron fragments. The iron rust ring formation may further impede vision as well as cause corneal deterioration if not removed.
Was the patient’s vision normal prior to this injury, and how is the vision now? Is it present, blurred, or double? Was onset gradual or acute?
Is there pain with bright light?(photophobia)

Does the patient usually wear corrective lenses, glasses, or soft/hard contact lenses?
Were they on or in at the time of the injury and are they on or in now?
Shattered spectacles may become foreign objects to penetrate the eye. Contact lenses should be removed as soon as possible.
Does the patient use eye medications, have a history of eye problems, hypertension, diabetes, or glaucoma?

Physical Assessment
INSPECTION
Note lid edema and ecchymosis
Observe ptosis
Assess lacerations
Identify gross trauma to the sclera, iris, and cornea
Identify gross/visible foreign objects
Note scleral and conjunctival redness, lacerations, tearing, and proptosis/enophthalmus or esotropia/exotropia
Note blepharospasm or blinking
Assess extraocular movements (EOMs), all six directions bilaterally
Assess pupil size, equality, shape, and direct and consensual response to light
PALPATION
Gently palpate eye and surrounding area for pain or tenderness
Obviously traumatized globe or eye with a penetrating or foreign object should NEVER be palpated as this increases the danger of penetration and/or increased intraocular .pressure.
Assess for anesthesia, caused by damage to the supraorbital nerve
Palpate for tenderness, crepitus, depression of frontal bone structures, and notching of the supraorbital ridge which indicate an increased risk of eye trauma

Diagnostic Procedures
XRAY often necessary to identify the presence of or extent of penetration by a foreign body.
OTHER
It is often necessary to obtain an order for topical anesthesia to enable the patient to cooperate with diagnostic exams.
Visual acuity with and without corrective lenses for each eye
This can be done by testing if and how clearly the patient can:
1) visualize bright light and finger motion or a moving object, 2) count the number of fingers held up by the examiner, and 3) read a wall mounted Snellen chart
or hand held Snellen card.
Visual fields from all directions with and without corrective lenses
These findings assist in documenting the presence of weak, torn, or paralyzed muscles.
Fluorescein stain identifies de-epithelialized areas made visible under cobalt bluelight. Abraded or lacerated areas show up as a green.

Slit lamp exam
This exam identifies hyphemas and foreign bodies in the anterior chamber.

Nursing Diagnoses
Actual
Pain, acute, related to tissue injury
Self-care deficit related to impaired response to visual stimuli
Self-concept, disturbance in: role performance, related to possibility of permanent damage to vision
Potential
Anxiety, related to diminished or lost vision
Expected Outcomes
Pain will be controlled as evidenced by:
Patient will rate pain on a 1-10 scale as decreased or absent
Absence of autonomic response to pain
Patient will perform activities of daily living at highest level possible.
Patient will verbalize understanding of alterations in role performance
necessary 10 function a1 desired level.
Patient will report decreased anxiety and/or demonstrate decreased restlessness.

Interventions
Apply prescribed topical anesthesia (tetracaine, proparacaine, butacaine, ophthetic) to prevent blepharospasm, to facilitate adequate assessment, and to diminish discomfort for traumatic injuries.
Immobilize visible pen·~trating objects to prevent further damage
Cover/patch BOTH eyes with a light dress~g to prevent eye motion and further pain and injury
NO pressure should be placed on the globe dUring this procedure since pressure can induce further damage or bleeding. The patch should be
taped from the medial forehead to lateral cheek area and secured tightly enough to prevent blinking.
Elevate head of bed. Instruct patient not to bend forward as this can increase intra=ocular pressure and thus cause pain and additional damage
to the eye.
Additional Interventions
Reassure and continue to orient patient to surroundings to decrease
anxiety and increase cooperation with treatment
Ensure one staff person or significant other remains with patient.
Facilitate referral to ophthamologist if there is blurred vision.
corneal clouding, hyphaema, or changes in extraocular muscle function, penetration
Patch eye if topical anesthetic has been instilled for protection of the eye until anesthesia wears off
Apply cool packs after assessment and initial interventions to decrease soft tissue edema and associated discomfort
Instruct about prevention of future injuries

Interventions to Prevent Complications
Place NO ocular steroids on eye tray to prevent misuse. These should be used only by an ophthalmologist as they may induce infections and glaucoma.
Use new tube/bottle of medication with each patient to prevent cross contamination
Fluorescein strips rather than drops are preferred for the same reason.
Do-not send topical anesthesia home with patient Continued use can promote breakdown of the corneal epithelium.
Instruct the patient to wear sunglasses to decrease photophobia and associated discomfort and excess tearing
Instruct patient not to squeeze eyelids as this increases discomfort and potential for injury
Keep eyes moist to prevent drying and exposure keratitis
Lubricating ointments should be placed within the lower lid margins priorto patching.

Tetanus immunization as indicated
Administer prescribed antibiotics to prevent infection in penetrating injuries
Administer prescribed antibiotics and steroids to prevent sympathetic opthalmia which can develop in the uninjured eye after unilateral penetrating eye trauma If not treated immediately, this can cause bilateral panuveitis, possibly an autoimmune response, which is a vision-threatening complication.

Ongoing Assessment
Monitor primary survey for life-threatening crises
Monitor pain for changes in characteristics, intensity, or location
Monitor vision for decrease or sudden’ loss
Assess globe for extrusion of contents especially after change in body position

Blunt Trauma

Periorbital contusion or  “black eye” is usually a benign injury.  Symptoms include ecchymosis of the lids, usually healing in 2-3 weeks.

Orbital fractures involve the orbital floor or the orbital rim.  A fracture of the orbital rim is called a “blowout fracture”.  It is a serious injury and is usually caused by direct blunt trauma to the eye causing an increase in the intraocular pressure to the point where the orbital floor fractures.    It is diagnosed by history and observations of periorbital ecchymosis, subconjunctival hemorrhage, periorbital edema, a sunken eye, an upward gaze, and complaints of diplopia.  These are usually non emergent unless there is visual impairment or associated globe injury.

Hyphema is when bleeding occurs into the anterior chamber.  Blood vessels of the iris rupture and leak into the clear aqueous fluid of the anterior chamber. A large clot can obstruct aqueous outflow and lead to secondary glaucoma.  Symptoms are pain, photophobia, and blurred vision.  A hyphema can be hard to see in dark colored eyes.

Subconjunctival hemorrhage is a harmless ocular condition usually caused by coughing, sneezing, or valsalva maneuvers.  A small blood vessel underneath the conjunctiva ruptures and bleeds. It is painless and a bright red patch can be seen on the sclera.

Penetrating Trauma

Periorbital wounds are injuries to the eyelids and surrounding periorbital tissue.  Check for globe injury and foreign bodies. Treat with routine wound care and suturing.

A ruptured globe is a major ocular emergency.  It presents as an unusually deep or shallow anterior chamber, altered light perception, hyphema, and sometimes vitreous hemorrhage, the pupil takes a teardrop shape with the tip pointing to the perforation.  Eye pain, and nausea are reported.

Impaled objects must be stabilized immediately which can be done with an eye shield. The other eye is patched to decrease eye movement. General anesthesia or aggressive pain management must be done.  Administer antiemetics to prevent retching.

Superficial Trauma

Corneal abrasions occur when a foreign body scratches, abrades, or denudes the epithelium.  Tearing, eyelid spasms, pain, foreign body sensation, and photophobia can occur.

Conjunctival/cornea foreign bodies are mostly caused by a dust particle.  Symptoms include photophobia, excessive tearing, and pain.  The goal is to remove the foreign body.

Intraocular foreign bodies are small and easily overlooked.  They are commonly caused by small fragments of metal or other small projectile.  Discomfort, decreased visual acuity, or a cat eye shaped pupil can occur.

Occular burns are an immediate threat to vision and can be broken down into three categories:

Chemical burns are the most urgent ocular emergency.
Acidic burns can cause immediate damage to the cornea by denaturing the tissues.  The cornea appears white and opaque.  No further damage is done once the initial contact is over because the acid is neutralized on contact.
Alkalali burns cause the cornea to opacify but continue to penetrate and damage the eye until removed.  Copious irrigation is required until pH is 7.5-8.

Thermal burns affect the eyelids but not usually the globe due to the reflex of the lid to close. These burns are treated like other burns.

Radiation burns are caused by ultraviolet or infrared light.  Ultraviolet radiation is absorbed by the cornea and produces keratitis and conjunctivitis.  Pain, tearing, photophobia, and foreign body sensation usually occur 8-12 hours after exposure.

Hyphaema

Hyphaema Medscape

http://youtu.be/28yfqXA2dcs

Haemorrhage in the anterior chamber after trauma.
Blood is usually absorbed within a few days without treatment.
However, patients are admitted to hospital for rest and observation because of the possibility of a secondary haemorrhage and glaucoma, which can occur within several days of the original injury.

Iris / lens damage

IRIS DAMAGE
Sphincter rupture with a distorted or dilated pupil or
iridodialysis

Lens Dislocation
http://youtu.be/rSTkziZ6YhA

No treatment: refer cataract which may develop later

http://youtu.be/UFJjqV73fpY

commotio retinae
Penetrating injuries involving the lens cause cataract.

Corneal/subtarsal FB

Easily missed/overlooked diagnosis.
Suspect from history; a piece of grit entered the eye and is not seen on ordinary inspection. Very irritable eye.
The patient is asked to open eyes and look downwards. Evert the eyelid by grasping the lashes and pulling them down. round and up while depressing the upper margin of the tarsal plate with a matchstick or glass rod.
The F.B, is seen on the conjunctiva and can be wiped off with a finger tip or cleanswab.
Corneal staining may reveal multiple scratches or large ulcer.

Often extremely painful. History usually relevant. metal grinding. etc.
F. B. visible on anterior surface of cornea.
x Instil local anaesthelic drops 2 or 3 limes. Steady eyelids of supine patient wilth one hand. and insist on his fixing gaze on adefinile object above. Remove F.B. with sterile hypodermic needle.

Special Note
If a rust deposit remains. or the F.B. is deeply embedded. do NOT scratch much: leave it and refer to an eye department:it is often easier to remove rust after 1 or 2 days. Very deep metallic F. B.s may require removal by magnet.
After Treatment
If the F.B. was only lightly embedded. it may not be necessary to pad the eye and bring the patient back; insert antibiotic ointment.
If the eye is sore. instil mydriatic drops.
If the F.B. left a large crater it will heal faster if the eye is padded for a day or two. and the patient should be seen again to make sure that healing is progressing. especially if the central part of the cornea is involved.

EYE pads
Some consideration should always be given to the problem of padding an eye: it is only advised when there is a painful defect
in the corneal epithelium which heals more quickly under a closed lid. and is more comfortable. Eye pads may cause greatINCONVENIENCE (drivers) and unless correctly applied may actually make conditions worse. quite apart from being useless. It may be more expedient to leave an eye unpadded and tell
the patient to go home and that the eye will heal quicker if kept shut.
Antibiotic ointment is always inserted after F.B. removal. If an eye pad is advised. then it is placed over tulle gras on the closed lids. and held on by a diagonal piece of strapping (micropore or Sellotape). A crepe bandage is then applied, just firm enough to prevent the patient from opening this eye
Padding is carried out daily until the corneal epithelial defectis nearly healed. If the eye remains irmable. continue mydriatic drops as well. Antibiotic ointment should be used twice daily for a further few days.

Corneal abrasion

Painful condition may be caused by trauma from such injuries as overlong contact lens wear. manipulation, or by a finger nail or twig poked into the eye. There is profuse lacrimation and it is often necessary to instil local anaesthetic drops in order to examine the eye. Fluorescein may be helpful in determining its extent.
R Treatment is the same as that described after removal of corneal foreign body: if the defect is slight. no pad. antibiotic ointment only. If the eye is very Sore, instil mydriatic drops, antibiotic ointment and pad. Large abrasions usually take less than 48 hours to heal if properly padded. Analgesics may be necessary.

This is a recurring corneal epithelial defect, usually in an area of cornea damaged previously, which may wake the patient atnight, presumably dUe to a reduced tear secretion causing a weak patch of epithelium to be shed, Treat as for any corneal abrasion.
STFB
Presence usually suspected from history; a piece of grit entered the eye and is not seen on ordinary inspection. Very irritable eye.
The patient is asked to open eyes and look downwards. Evert the eyelid by grasping the lashes and pulling them down. round and up while depressing the upper margin of the tarsal plate with a matchstick or glass rod. The F.B, is seen on the conjunctiva and can be wiped off with a finger tip or cIeanswab.
Insert antibiotic ointment.

CORNEAL ABRASION
Often extremely painful. History usually relevant. metal grinding. etc.
F. B. visible on anterior surface of cornea.
x Instil local anaesthelic drops 2 or 3 limes. Steady eyelids of supine patient wilth one hand. and insist on his fixing gaze on adefinile object above. Remove F.B. with slerile hypodermic needle.

Special Note
If a rust deposit remains. or the F.B. is deeply embedded. do NOT scratch much: leave it and refer to an eye department:it is often easier to remove rust after 1 or 2 days. Very deep metallic F. B.s may require removal by magnet.
After Treatment
If the F.B. was only lightly embedded. it may not be necessary to pad the eye and bring the patient back; insert antibiotic ointment.
If the eye is sore. instil mydriatic drops.
If the F.B. left a large crater it will heal faster if the eye is padded for a day or two. and the patient should be seen again to make sure that healing is progressing. especially if the central part of the cornea is involved.

EYE pads
Some consideration should always be given to the problem of padding an eye: it is only advised when there is a painful defect
in the corneal epithelium which heals more quickly under a closed lid. and is more comfortable. Eye pads may cause greatINCONVENIENCE (drivers) and unless correctly applied may actually make conditions worse. quite apart from being useless. It may be more expedient to leave an eye unpadded and tell
the patient to go home and that the eye will heal quicker if kept shut.
Antibiotic ointment is always inserted after F.B. removal. If an eye pad is advised. then it is placed over tulle gras on the closed lids. and held on by a diagonal piece of strapping (micropore or Sellotape). A crepe bandage is then applied, just firm enough to prevent the patient from opening this eye
Padding is carried out daily until the corneal epithelial defectis nearly healed. If the eye remains irmable. continue mydriatic drops as well. Antibiotic ointment should be used twice daily for a further few days.

This painful condition may be caused by trauma from such injuries as overlong contact lens wear. manipulation, or by a finger nail or twig poked into the eye. There is profuse lacrimation and it is often necessary to instil local anaesthetic drops in order to examine the eye. Fluorescein may be helpful in determining its extent.
R Treatment is the same as that described after removal of corneal foreign body: if the defect is slight. no pad. antibiotic ointment only. If the eye is very Sore, instil mydriatic drops, antibiotic ointment and pad. Large abrasions usually take less than 48 hours to heal if properly padded. Analgesics may be necessary.

This is a recurring corneal epithelial defect, usually in an area of cornea damaged previously, which may wake the patient atnight, presumably dUe to a reduced tear secretion causing a weak patch of epithelium to be shed, Treat as for any corneal abrasion.

Intraocular foreign body

IOFB @ EyeWiki.com

Always suspect this potentially blinding condition when there is a suggestive HISTORY such as injury while using a hammerand chisel-even when the eye looks relatively normal. The entry wound may be surprisingly difficult to see.
The F.B. may be visible anywhere in the eye, but it may be obscured by cataract formation in a damaged lens.
ALWAYS X-RAY TO EXCLUDE IOFB even if only a remote possibility. The chances of blindness and losing the eye increase rapidly while the F.B, remains. Usually they are metallic, often ferrous or steel allowing removal with the aid of a magnet.
Corneal Ulcer
Corneal ulcers
? herpes zoster?, herpes simplex?
L herplex gtts prn, refer.

Welding flash / arc eye

• betterhealth.vic.gov.au flash burns
• http://youtu.be/GG4IbYtgUys

Superficial Keratitis caused by UV light
Welders, “Sun lamp” users and Corneal Laser Surgery patients.
Pain, watering and photophobia after an initial delay of a few hours.
Fluorescein reveals pitted corneal surface.
Rx Local anaesthetic drops +/- topical diclofenac +/- mydriatic drops if the condition is severe.
Give frequent antibiotic ointment and send patient home to bed. to keep eyes shut.
Usually heals within 12 hours.

Chemical burns to eye

should be treated by copious irrigation of the conjunctival sac until the pH becomes and remains neutral. Particulate debris (eg cement dust) should be removed. Alkaline burns can be particularily troublesome as they tend to be deeper and more extensive than others.

Commotio retinae and retinal haemorrhages

• Ocular injuries RCSED
• Commotio Retinae Eyeweb.org
• Ocular Trauma Optometry review.com

Retinal bruising/haemorrhage as a result of blunt or contra-coup injury.
May be seen as whitish areas of oedema (commotio) and haemorrhages which may be bright red droplet shaped preretinal or more usually, intraretinal streaks or petechiae.
Particularly serious if the MACULA is involved: damage here may result in permanent visual impairment.
Great care is taken to exclude holes in the retina or a dialysis which can lead to detachment. Patients in whose eyes this type of damage is suspected should be rested kept quiet and be referred soon.

Eyelid problems