OPHTHALMOLOGY: PEARLS & PITFALLS...• Tsai, James C. Oxford American Handbook of Ophthalmology....

Sahand Ensafi PA, CCPA, B.H.Sc.,Department of Emergency Medicine,

University Health Network

Assistant Professor, DFM, PAEP, McMaster University

ePBL Facilitator, PA Program, University of Toronto

OPHTHALMOLOGY:

PEARLS & PITFALLS

SPECIAL THANKS

• Dr. Jason Kwok, Resident Physician, Department of

Ophthalmology and Vision Services, University of Toronto

• UHN Department of Ophthalmology

DISCLOSURES

• No Disclosures

Overview

• 3 Cases

• Common ED Eye

Presentations

• Emphasis on common pitfalls and

how to improve

CASE 1

• 65 year-old male with sudden onset of painless vision “loss”

in right eye.

CRAO - PITFALLS

• Lack of timely assessment

of “vision loss”

• Incomplete assessment of

visual acuity

• Hours before “classic”

findings

CRAO - PEARLS

• High index of suspicion

• CRAO = History

• Sudden/severe vision loss

• CF HM LP

• RAPD

CRAO – ACT FAST

• STROKE of the eye

• CBC, lytes, coags, ECG

• ?GCA

• Consider ESR/CRP

especially if age > 50

• Time is of the essence

CASE 2

• 62 year-old female with gradually increasing

“deep/boring” right-eye pain and redness x 2

weeks.

RED EYE - PITFALLS

• Locking on benign causes vs

glaucoma

• Quick to diagnose

“conjunctivitis”

• Incomplete History

• Lack of physical exam

?SCLERITIS ?EPISCLERITIS

CASE 2: SCLERITIS

• Severe pain

• ?Connective Tissue Disease

• Scleral Thinning

• Vision Changes

• ?Phenylephrine

• Fixed vessels

CASE 3

• 45 year-old, myopic male with flashes and floaters in the

right eye x 1day. No curtain or VF defect. Visual Acuity –

10/25 Right and 10/10 Left.

FLASHES/FLOATERS - PITFALLS

• Lack of guidelines around referral / follow-up

CASE 3 - ?RETINAL DETACHMENT

• Follow – up?

• 1. Hollands H, et al. Acute-Onset Floaters and Flashes: Is this Patient at Risk for

Retinal Detachment? JAMA 2009;302(20):2243-2249.

FOLLOW – UP: TAKE HOME MESSAGE

• Flashes and Floaters?

High risk features – urgent referral

1) Subjective or objective decrease in vision

2) Visual field defect

Low risk features – elective referral (1 - 2 weeks)

1) Stable symptoms (weeks to months)

2) Absence of high risk features above

SUMMARY

Acute Vision Loss

• High index of suspicion for CRAO

• If truly acute – act fast!

Red Eye

• Severe Pain

• Blue hue

• Fixed Vessels

Flashes/Floaters

• Subjective or objective vision change or visual field defect?

THANK YOU!

REFERENCES

• Friedman, Neil J., Peter K. Kaiser, and Roberto Pineda. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Philadelphia, PA: Saunders/Elsevier, 2009. PDF.

• Hockberger, Robert S., and Ron M. Walls. "Acute Visual Loss." Rosen's Emergency Medicine - Concepts and Clinical Practice 8th Ed. Ed. John A. Marx. 8th ed. Vol. 1. N.p.: Elsevier, n.d. 968-81. Print.

• Hollands H, et al. Acute-Onset Floaters and Flashes: Is this Patient at Risk for Retinal Detachment? JAMA 2009;302(20):2243 -2249.

• Jogi, Renu. Basic Ophthalmology. New Delhi: Jaypee Brothers Medical, n.d. PDF.

• Long, Brit. "Acute Visual Loss in the Emergency Department: Pearls and Pitfalls - Emdocs." Emdocs. Emdocs, 26 Apr. 2016. Web. 10 Oct. 2016.

• Tintinalli, Judith E. "Eye Emergencies." Tintinallis Emergency Medicine A Comprehensive Study Guide . 7th ed. N.p.: McGraw Hill, 2011. 1517+. Print.

• Tsai, James C. Oxford American Handbook of Ophthalmology. Oxford: Oxford UP, 2011. Print.

• Hockberger, Robert S., and Ron M. Walls. ”Red and Painful Eye." Rosen's Emergency Medicine - Concepts and Clinical Practice 8th Ed. Ed. John A. Marx. 8th ed. Vol. 1. N.p.: Elsevier, n.d. Print.

• Pflipsen, Matthew, et al. “Evaluation of the Painful Eye.” American Family Physician, 15 June 2016, www.aafp.org/afp/2016/0615/p991.html.