Conference Review – Ophthalmology

Thanks for this review written by Dr. Jen Cotton, PGY2 OSU EM Resident

Painful Eye

What should be the steps taken to examine the painful eye in the emergency department?

Ask Essential History:

  • Associated vision loss, trauma, change in appearance of eye, onset sudden v gradual, duration of symptoms, circumstances surrounding onset (while hammering, sawing, moving lawn), foreign body sensation
  • History of diabetes, carotid stenosis, atrial fibrillation; previous eye surgeries or problems, baseline vision, contact usage, intraocular lens implant, previously pupil irregularities  
  • If foreign body, ulcer, or open globe suspected, tetanus up to date?

Physical Exam:

  • Assess vision: visual acuity. If unable to see letters then can pt see fingers, movement, or light
  • Pupil size/equalness/roundness, visual field testing (by confrontation), extra-ocular movement, overall appearance of eye, lid eversion
  • Examine mouth, ears, and nose (hutchinson sign)
  • Slit lamp, fluorescein stain, intraocular pressure

What is the differential diagnosis for the painful eye in the emergency department?

Outside Eye: chalazion, hordeolum, blepharitis, septal cellulitis, optic neuritis

Surface of Eye: corneal abrasion, corneal ulcer, conjunctivitis, chemical burn, herpes keratitis, herpes zoster ophthalmicus, ultraviolet keratitis

Internal to Eye: anterior uveitis, scleritis, endophthalmitis, acute angle closure glaucoma

Which of the above diagnoses are vision threatening?

Acute angle closure glaucoma, optic neuritis, uveitis, septal cellulitis, herpes zoster ophthalmicus, anterior uveitis, scleritis, endophthalmitis, chemical burns/ultraviolet keratitis

If you are at an outside hospital, what are causes of eye pain that require transfer to a hospital with ophthalmology?

Corneal ulcer, endophthalmitis, vitreous hemorrhage/detachment, globe rupture, corneal laceration, some lid lacerations, hyphema, retrobulbar hematoma, acute angle closure glaucoma

List the initial management of acute angle glaucomoa. What about anterior uveitis? Or corneal ulcer?  Or Optic Neuritis?

Acute angle glaucoma- IV mannitol, pilacarpine 1-2%, acetizolimide, timolol .5%, apraclonidine 1%), ophthalmology for definitive treatment

Anterior uveitis- ophthalmology consult, long­acting cycloplegic agent (homatropine for pain)

Corneal ulcer- topical abx, ophthalmology consult,  cyclopentolate 1% (for pain)

Optic Neuritis – MRI and ophthalmology/neuro

Other Tips from Small Group

  • Use an Allen card for kids
  • For a rough estimate of normal intraocular pressure, gently press your own eye and compare to patient
  • Must press eye 4-10 times with a tonopen for an average pressure
  • Consensual photophobia suggestive of iritis
  • Eyelid lacerations within margins of orbit, especially lid margins, should be closed by ophthalmology/plastic surgery


Painless Eye

List a differential diagnosis for painless vision loss? What about painless red eye?
Painless –  central retinal artery occlusion, central retinal venous occlusion, temporal arteritis, cataracts, vitreous hemorrhage or detachment, amaurosis fugax, TIA, cortical blindness, retinal detachment, diabetic retinopathy, complex migraine, macular degeneration, functional blindness, optic neuritis

Painless Red Eye – subconjunctival hemorrhage, allergic conjunctivitis, pterygium

What requires ophthalmology consult in ED?
Most causes of vision loss, especially central retinal artery/venous occlusion, mac on retinal detachment, vitreous hemorrhage/detachment, optic neuritis.

What is an APD? In what conditions do you see it?
Afferent pupillary defect. Asses for this with a swinging light test. This indicates an optic nerve disorder, opacification from vitreous hemorrhage, or retinal pathology; essentially anything that prevents signal of light hitting retinal to pass to successfully transmit along optic nerve.

Discuss the diagnosis of temporal arteritis. How does the patient present? What disease is it associated with? What is the management? Does a lab test rule it out?
Temporal arteritis is a primarily clinical diagnosis in the ED, in which painless ischemic optic neuropathy results in profound visual loss. Diagnosis is made via temporal artery biopsy. Aside from vision loss symptoms may include headache, jaw claudication, myalgias, fatigue, fever, anorexia, and temporal artery tenderness. It is treated with IV steroids if there is vision loss. Normal ESR/CRP does not rule out this condition, as the sensitivity of each test is in the 80s.

Why is the diagnosis of a CRAO time sensitive? What can you do to manage vision loss from CRAO?
Central retinal artery occlusion causes irreversible loss of visual function after approximately 4 hours, so very time sensitive. There is no proven treatment at this time, but recommendations include ocular massage, reducing IOP (acetazolamide, timolol), breath into a bag (respiratory acidosis induces retinal vasodilation). Ophthalmology should be consulted immediately. Intra-arterial TPA is being studied with some success, but no definite protocols exists for this yet.