Lost in (the front)Your Eyes…

Anterior Pole

Senior Grand Rounds Presentation – Scott Burdette MD, MS

http://www.imisstheoldschool.com/archives/debbie-gibson-talks-25-years-since-electric-youth-to-billboard/

Why this?I had ommatophobia, a fear of eyes.

In regards to the ER

I hated it, despite finding bewilderment in

learning about them

Afraid of a horrible mistake – couldn’t imagine

being blind

How better to become more comfortable than to

do my grand rounds on it

We will be talking about the anterior pole

But since it’s in-service time I’ll throw in some

other buzz words

Case Presentation55 year old Caucasian female

Three days of worsening unilateral right sided

temple pain

Frontal HA w/ nausea and worsening blurry vision

Began at home while reading on porch

http://en.wikipedia.org/wiki/Glaucoma

What is it?Failure of drainage of trabecular system

Aqueous humor produced by ciliary bodies in

posterior segment

Circulate to anterior chamber

Reabsorbed through trabecular meshwork into

Canal of Schlemm

Drains into episcleral veins

Can cause loss of vision due to compression of

optic disc

Glaucoma

http://www.tedmontgomery.com/the_eye/eyephotos/index-grphc.html

Types of GlaucomaPrimary

Pupillary block

Posterior iris contracts against lens which

blocks humor flow from posterior to anterior

Pushes iris forward blocking meshwork

Secondary block

Uveitis

DM

Lens size malformations

Drugs (Topiramate/sulfas)

Choroid swelling (CRVO/post laser tx)

Risk Factors/PrecipitantsAge: especially greater than 60

Female

Hyperopia: eyeball too shallow/or cornea has too little curvature

FMH

Race: AsianHispanicAfrican American: 6-8* that of whites

PrecipitantsTopical mydriatics

Anticholinergic/sympathomimetic

Emotional stimuli

Accommodation

Dim lights

ExaminationDecreased VA

Pupil: fixed. Possibly irregular. Dilated.

Eye: Red. Serous discharge and corneal edema (both variable)

Slit lamp: shallow AC (closed). Injected conjunctiva. Corneal edema.

Tonometry : increased IOP

Normal 10-20

Fundoscopy

Impressive cupping

Spontaneous arterial pulsations

Rule out other pathology

Another can’t miss with potentially similar story

Impressive cupping

http://www.tedmontgomery.com/the_eye/eyephotos/index.html

Impressive Cupping

http://www.tedmontgomery.com/the_eye/eyephotos/index.html

ManagementOphthalmology Consult

Topical B-blocker: decreases production

Timolol: 1-2 drops of 0.5%

Carteolol

Topical cholinergic: miotic – contract ciliary muscle to

open meshwork

Pilocarpine: 2% for blue eyes and 4% for brown eyes

Give one hour post: pressure induced iris paralysis

Alpha Agonsit: decrease production and facilitate flow

Apraclonidine: 1% w/ 1-2 drops as single dose

CA inhibitor: decrease humor production

Acetazolamide: 500mg IV followed by 500mg PO

Management (cont.)Symptomatic Treatment

PRN antiemetics: to avoid further elevation of IOP

PRN analgesia

Elevate the HOB

Other Adjuncts

Topical steroids: prednisolone acetate 1%

Needling/corneal indentation

Ophthalmologist put needles into iris of patient in NZ

Reassessment: goal is 25% reduction from initial

presentation

Mimics?

Interesting FactsPeople with blue eyes have higher etOH

tolerance

….and abuse/addiction

http://www.unt.edu/rss/class/mike/5700/eyecol

oralcohol.pdf

All blue eyed people can be traced back to one

person living next to the black sea 10,000 years

ago; a polygenic trait – recessive like

Black Lemurs are the only other primate,

besides humans, to have blue eyes

http://www.independent.co.uk/environment/nature/on-the-brink-of-extinction-ndash-25-of-our-closest-relatives-1902990.html?action=gallery

Case Presentation2 year old chesty white male went to see Hardwell at

EDC Vegas. Danced all night to sweet drops. Pit was

cray, tons of fist pumps – caught one in the eye due to

looking so buff in his pink tank. Presents to ED with

complaints of red eye and “something in it”.

http://imagebank.asrs.org/file/7602/silicone-oil-in-anterior-chamber-with-hyphema

What is it?Hyphema

A collection of blood in the anterior chamber

Layers on position if not clotted

Risk Factors/Precipitants

DM neovascularization or recent surgery –

spontaneous

Sports without occular protection/Trauma

Sickle cell disease

Hx/PESickle cell?

Anticoagulation?

Trauma hx?

PE

Visual acuity

External examination: what is the percentage of

collected blood

Pupil reactivity

Tonometry

Slit lamp: Measure height, Assess for clots. Rule

out penetrating injury

Hyphema GradingGrade 1: layered up to 33% of anterior

chamber

Grade 2: layered 33% to 50%

Grade 3: layered from 51% to less than

100%

Grade 4: complete obliteration of anterior

chamber

AKA 8-ball hyphema

ManagementImaging not necessary unless concern for bony injury

Tx

Symptomatic tx: Analgesia and Antiemetics

Topical cycloplegics

Positioned upright: to avoid trabecular meshwork

occlusion

Eye shield

Complications

Secondary glaucoma – treat if it arises

rebleeding

What is the Disposition?

DispositionMost can go home

Follow up with ophthalmology in 24

hours

Admit

Those you don’t trust

Sickle cell patients

Those with secondary glaucoma

Other blood dyscrasias

Interesting FactsYour eye is the equivalent of a 576

megapixel camera

The human eye can distinguish about

10 million colors

Case Presentation33 year old male with eye trauma earlier today

while playing basketball. Dull ache of left eye

with light sensitivity, crying sensation, and

redness. Feels as if his vision is continually

worsening.

http://quizlet.com/20574046/pathoma-ent-flash-cards/

What is It?Iritis

Subset of uveitis

Uvea: choroid, ciliary body, and iris

Iris and ciliary body: iridocyclitis

Iritis: just iris

Types

Inflammatory: HLA B27, sarcoid, MS, bechets,

and kawasaki

Infectious: CMV, TB, syphilis, and lyme disease

Traumatic (this case)

Drug Induced (ie sulfas)

Exam FeaturesPupil with ciliary flush

Circumferential involvement of injected cornea

How is this different than conjunctivitis?

Painful red eye – often exacerbated with movements. May have irregular pupil

VA: may be normal to blurred

EOM: normal

Pupil: miosis

Direct and consensual photophobia

Cell and flare on slit lamp

Tonometry – to rule out glaucoma

Other symptoms: joints and pulmonary

Cell and Flare

https://roshreview.com

Uveitis Types

http://www.eyecalcs.com/DWAN/pages/v4/v4c032.html

Treatment/DispoTopical Steroids

Prednisolone 1% (pred forte)

Be vary wary

Increased IOP

Potentiate herpes keratitis or bacterial infection

Cycloplegics

Cyclopentolate (cylogyl)

Homatropine (isopto)

Ophthalmology referral

If original uncomplicated presentation – f/u in 24

hours

Refractory/infectious - admission

Asleep at the wheel?We spend 10% of out waking hours with

our eyes closed – blinking

You blink, on average, 12 times per

minute

Case PresentationAn 88 year old female 6 weeks post cataracts

surgery complaining of a red and itchy eye.

HypopyonLeukocyte collection in anterior chamber – most exogenous

Types:

Staph (coagulase negative) – common post cataracts surgery

Most due to exogenous flora in other countries but surgery most common in US; 70%

Staph aureus 10%

Bacillus cerus – post traumatic (TETANUS!!)

Endocarditis – staph aureus/strep spp

Fungal – candida

HSV

A subset of endopthalmitis

EndopthalmitisSurgical endopthalmitis occurs in 0.1-0.2 percent

of eye surgeries; cataracts being most common

Complication usually occurs within 6 weeks

However 75% within the first week

Keep in mind – some sterile inflammation

immediately following surgery

Labs usually don’t help

Less than 1/3 usually have white count over

10K

Symptoms/other

considerationsPain, itching, and photophobia; can have

decreased VA

Outside of bacteria

Bechet’s

Keratitis

Malignancy

Trauma

Exam/DispositionExam: white cells layered in AC. Red eye.

Chemosis. Lid edema. Conjunctival injection.

Treatment/disposition

Ophthalmology consult – potential for vision

loss

3rd generation cephalosporin

(pneumococcus is common)

Interesting FactsHumans and dogs are the only two

species to seek visual cues from other’s

eyes; dogs only do so with humans.

http://www.freelargeimages.com/the-starry-night-2345/

Mean DrugsDigoxin: yellow vision with halos

Van Gough

Anticholinergic: loss of accommodation, AAC

glaucoma

Bisphosphonates: uveitis

Rifabutin: uveitis

Sildenafil: blue vision, ischemic optic neuropathy

Sulfonamides: myopia

Topiramate: AAC glaucoma

Interesting FactsResearchers have used Tetris, with

favorably results, to treat lazy eye

http://www.ctvnews.ca/health/tetris-

can-help-correct-lazy-eye-

researchers-1.1249179

ConclusionLots of red herrings/similarities

Glaucoma: increased IOP, fixed w/ loss of

direct/consensual, failure of drainage, drop

pressure!!!!!

Hyphema: risk of rebleeding/glaucoma. Admit

sickle cell

Iritis: highest intensity surrounding limbus, miotic

pupil, pain with eye movements/photophobia, cell

and flare, other causes

Conjunctivitis has sparing

Hypopyon: post surgery, staph/strep, endocarditis

Conjunctiviti

s

Iritis Keratitis Glaucoma

Vision Normal Blurred Blurred Very Blurred

Pain None Moderate Severe Severe

Photophobia None Moderate Moderate Moderate

Discharge Purulent/Serou

s

None None/Slight None

Injection Limbic Sparing Perilimbic Perilimbic Diffuse

Cornea Clear Clear Clear to Cloudy Cloudy

Pupil Normal Miotic Normal Mydriasis

IOP Normal Low to Normal Normal Very elevated

The Red Eye Discrepancies

Citationshttp://www.tedmontgomery.com/the_eye/eyephotos/index.html

http://lifeinthefastlane.com/ophthalmology-befuddler-007-2/

http://emedicine.medscape.com/article/798811-treatment

http://lifeinthefastlane.com/ophthalmology-befuddler-030/

www.lifeinthefastlane.com/uveitis

http://www.emrap.tv/index.php?option=com_content&view=article&id=157:EMRAPTV57_iritis-testa

http://emedicine.medscape.com/article/798323-overview

http://emedicine.medscape.com/article/1201134-overview

http://emergencymedic.blogspot.co.nz/2011/06/hypopyon.html

https://www.vsp.com/eyes.html

http://www.unt.edu/rss/class/mike/5700/eyecoloralcohol.pdf

http://www.ctvnews.ca/health/tetris-can-help-correct-lazy-eye-researchers-1.1249179

http://www.factslides.com/s-Eyes

http://www.uptodate.com/contents/evaluation-of-the-red-eye

http://www.uptodate.com/contents/approach-to-the-adult-with-acute-persistent-visual-loss

http://www.uptodate.com/contents/bacterial-endophthalmitis