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.