Emergency Ophthalmology

1. An Ophthalmology Refresher
Tiki Ewing
Ophthalmology Registrar SCGH

2. Referrals
• E-referrals checked daily
• Details – why, what (include VA), when
• Friday is AM clinic only – make referrals early
• Is the patient well enough to come to clinic?

3. Examination
• New pro-forma - please use it
• Visual acuity (with distance glasses if uses or
without), then with pinhole)
• Pupils (please don’t dilate unless you are confident they are normal, or
discussed if abnormal)
• Movements
• Colour vision (red saturations/eye handbook)
• Confrontational fields

4. Slit Lamp
Tips:
• Practice makes perfect
• You are most welcome to join us in
clinic for practice sessions
• Dilute the 2% fluorescein
• Cobalt blue vs red free (green)
• Looking for cells: 1x1mm2 beam,
brightest light, high magnification

5. • IOP (post slit-lamp)
• Fundoscopy
Tonopen
- Well anaesthetised eye
- Sterile cover
- Hold like a pencil, plan to
patients cheek
- Other hand lifts upper lid
from orbital rim
- NO PRESSURE on globe
- If patient is squeezing in
discomfort, can artificially
raise IOP
- 1295 : 95=accuracy

6. SERIOUS FEATURES
• Visual acuity reduced
• Significant pain  doesn’t significantly reduce with
topical local
• Patient’s only eye
• Multiple eye drops/prolonged course
• Recent surgery
SERIOUS CONDITIONS
Acute angle closure glaucoma
Endophthalmitis
Orbital cellulitis

7. 25yr old man, 1 week of red, discharging left eye, itchy and light sensitive

10. Adenoviral Conjunctivitis
How to differentiate from other types
• Burning, watery or mucopurulent D/C, painful
pre-auricular lymph node, corneal involvement,
pseudomembrane
• 7 species of adenovirus, 54 serotypes, many, but
not all cause conjunctivitis
• Can survive on dry surfaces or in water for weeks
• No known cure
• Remains infective for up to 2 weeks

11. What about chlorsig
• HEAVILY OVER USED
Evidence:
• Of cases GPs thought were bacterial conjunctivitis only 50%
were
• Randomised placebo controlled study in Kids (who are
more likely to have bacterial conjunctivitis), chlorsig vs
saline (blinded), cure within 7days in 85% chlorsig, 80%
saline.
• Evidence suggests managing conservatively with lubricants
and cool compresses for 3 days, if not improving then
consider it

12. 34yr old presents with a watery, red,
aching eye, with photophobia

15. Uveitis/Iritis
• Inflammation of the uveal tract
• Immune mediated
• Classification
– Anterior
– Intermediate
– Posterior
– Panuveitis
Tips
• PMHx relevant
• Looks closely at pupil reactivity
• Poor dilation
• Extremely rare to be bilateral
• Acutely photophobic

18. Herpetic Corneal Infections
• HSV-1: Coldsores and Keratitis
• HSV-2: Genital Herpes
• VZV: Chicken pox, shingles, HZO
HSV
• Debridement, topical therapy (or oral, not
both unless immunocompromised)
• What about Steroids ?

19. Herpes Zoster Ophthalmicus

20. • Not all need referral
• Hutchinson’s Sign
• Eye involvement
– Conjunctivitis
– Keratitis (pseudodendrites)
– Uveitis
– Retinitis
• Topical Antivirals have questionable role
• Start PO antivirals early – reduces post herpetic
neuralgia only
– 800mg Aciclovir 5x or 1g Valtrex TDS (PBS covered)

22. Episcleritis
• Sectoral inflammation of episcleral vessels (sometimes
diffuse)
• Mild-moderate tenderness over area
• Can have fluorescein stain over area
• Vision is NORMAL
Treatment: artificial tears  Oral NSAIDs  topical steroids
DDx
• Scleritis
– Older, known immune-mediated disease, deep severe pain,
scleral as well as overlying vessel inflammation
– No blanching with topical phenylephrine (2.5%)

23. Foreign Body Red Flags
• ? Penetrating injury
• Over visual axis
• Residual material you are
unable to remove
• Infiltrate or AC reaction
• Best outcome if as much
of the rust ring is
removed in first attempt
• However if deep and
central, can leave for it to
migrate to surface

24. Corneal Infiltrate

25. 85yr old man
Visual loss right eye
“Salt rinse” this morning,
now ? Left eye
disturbance
Wife terminal cancer
VA: R CF, L 6/12 (NIPH)

26. 75year old lady
Visual loss right eye overnight
Painless
CT head NAD
Sent form JHC to SCGH ophthalmology
for review ? Ocular cause

28. Posterior Vitreous Detachment
• Occurs due to the liquefaction of vitreous gel with age
• Occurs in 60% of 80yr olds
• 20-30% have complications such as a retinal hole/tear or detachment
• Risk factors crucial in our triaging (myope, Hx tear or detachment,
recent eye surgery or trauma to eye, FHx)
• You cannot adequately assess with a direct ophthalmoscope, these
patients need referral

29. General Tips
• Check visual acuity, use pinhole
• Check optic nerve function
• Check the cornea
• Consider dilating
• Please be honest