Ophthalmology

Podcast 504: Ocular Compartment Syndrome

Contributor: Don Stader, MD

Educational Pearls:

  • The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS) 
  • Look for OCS when patients have face, head or direct eye trauma 
  • OCS will present with a swollen, bulging eye associated with pain and blurry vision. Typically diagnosed with an elevated intraocular pressure (>40)
  • OCS needs to be treated with a lateral canthotomy to help expand the area around the eye, reducing the pressure.
  • Can’t see the eye due to swelling? Use paper clips to make eyelid retractors!

References

Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9. doi: 10.1016/j.survophthal.2009.04.005. Review. PubMed PMID: 19539832.

Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PubMed PMID: 25524455.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast #446:  Retinal Detachment

Author: Dylan Luyten, MD

Educational Pearls:

  • 1:500 patients will experience a retinal detachment
  • Consider stroke on your differential (central retinal arterial occlusion)
  • Flashes and floaters are a common complaint with retinal detachments
  • Though patients may report fields of vision loss, visual acuity is often spared
  • Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED
  • These require urgent ophthalmologic consultation for surgical repair

References:

https://www.aliem.com/2014/03/ocular-ultrasound-retinal-detachment-posterior-vitreous-detachment/

Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2019 Jan 13. doi: 10.1111/acem.13682. [Epub ahead of print] PubMed PMID: 30636351.

 

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast #318: Nystagmus

Author: Erik Verzemnieks, M.D. 

Educational Pearls:

-Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication

-Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates)

-If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources

References:
Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. ?Annals of

Neurology.? 4(5):471-3.
Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive

alcohol intake. ?Journal of Clinical Neuroophthalmology?. 7(1):23-5.

Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. ?Journal of Emergency Medicine.? 18(4):447-51.

Podcast #255: Posterior Vitreous Detachment

Author: Erik Verzemnieks, M.D.

Educational Pearls

  • Posterior vitreous detachment is the tearing of the lining in the back of of the eye.
  • Patients often present with loss of vision and floaters.
  • Diagnosis can be made with US.
  • This is a benign diagnosis, but 10-15% can progress to retinal detachment , so follow up  with ophthalmology is recommended.

References: http://www.medscape.com/viewarticle/513226

Podcast #253: Total Eclipse of the Eye – Solar Retinopathy

Author: Nick Hatch, M.D.

Educational Pearls

  • Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors.
  • Solar retinitis may present hours-days after light exposure.
  • Patients will present with patchy loss of vision without pain, since the retina has no pain receptors.
  • In one study during an eclipse in the UK, of those who initially presented with vision loss due to solar retinitis, 92% recovered full vision.

References: Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ?: British Medical Journal. 1999;319(7208):469.

Podcast #145: Eye Injuries

acbd2571-f80b-492c-b937-5b9ab347ceb2Run Time: 3 minutes

Author: Jared Scott M.D.

Educational Pearls:

  • Patient profile: sustained blunt trauma to the face. On eye exam the left pupil is eccentric pulled to the side and vertically oriented, and there is a large dark space lateral to the iris.
  • This patient has Iridodialysis: localized separation or tearing away from the iris from the ciliary body.
  • Smaller separations are usually asymptomatic, but larger separations have vision loss, photophobia, and diplopia because light is not entering the pupil normally and additional light is entering the lense from the side of the iris.
  • Iridodialysis usually results from blunt trauma to the face including boxing, airbag deployment, high pressure water jets, etc.
  • Patients with large defects may go to surgery, where the surgeon slides the iris over and sutures it in place w/ 10-0 prolene.
  • Most patients have an associated hyphema – If the hyphema is very large the patient goes to the OR for a wash out.

Link to Podcast: http://medicalminute.madewithopinion.com/eye-injuries/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4759894/

Podcast #111: Diplopia

See fingersRun Time: 3 minutes

Author:  Eric Miller M.D.

Educational Pearls:

  • 6th nerve ocular palsy often presents with diplopia or double-vision. On examination, the pupils are normal and vision is normal, but one eye usually cannot move laterally.
  • There are three nerves that move the eye. The most important is the 3rd cranial nerve that moves the eye upward, medially and moves the eyelid. Second, is the 4th cranial nerve that moves the eye down and outward. Last is the 6th cranial nerve, or the abducens nerve, which moves the eye laterally. The 2nd cranial nerve or optic nerve gives the eye vision.
  • A 6th nerve palsy is not very serious but very common, usually caused by a neuropathy due to diabetes or hypertension. A 3rd nerve palsy is a more serious matter, usually indicating a CTA to rule out dissection as well as a neurologic consultation. A 4th nerve palsy is a very rare condition.
  • 80% of 6th nerve palsies improve on their own and are not associated with serious pathology. There is a small percentage that become worse and are often associated with aneurysm or arteritis.

Link to Podcast:  http://medicalminute.madewithopinion.com/diplopia/

References: http://www.ncbi.nlm.nih.gov/books/NBK217/

Podcast #95: Orbital Fractures

832aa7b9-fa84-4f5a-aedb-48834d8d34b6Run Time: 7 minutes

Author: Dr. Sam Killian

Educational Pearls:

  • Blunt trauma to the face is associated approximately 60% of the time with an orbital fracture – the most common type is called a blowout fracture.
  • The bones of the orbit are softer and weaker – blunt trauma dissipates energy throughout the eyeball complex so that the force is not just absorbed by the globe of the eyeball – acting like a crumple zone on a car.
  • Medial wall and floor are weakest parts – which is where the majority of orbital fractures occur – lateral wall and orbital rim fractures are associated with higher impact force.
  • Biggest complications with orbital fractures are to the globe itself such as an open globe or significant vision loss– this is the time to consult a facial surgeon emergently.
  • Most orbital fractures will heal on their own – 95% of all orbital fractures can be followed up and managed as an outpatient.

Link to Podcast:  http://medicalminute.madewithopinion.com/orbital-fractures/

References:  http://emedicine.medscape.com/article/867985-overview

 

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