dr. MUH. ABRAR ISMAIL, Sp.M, M.
Kes(K)
Calcaneus 05 210
Objectives
• Review ocular anatomy
• Understand basic ophthalmic workup
• Understanding differential diagnosis for:
– Red eye
– Visual loss
• Recognize and manage common ocular
emergencies
Modalities
• Skills
• Tools :
– Near vision card
– Penlight with blue filter
– Topical anesthetic
– Fluorescein strips
– Topical mydriatic
– Ophthalmoscope
• Keen observations
Review Ocular Structures
Definition
• Conditions that if left unattended for hours
could result in permanent blindness or even
loss of the eye
• Visual acuity - Snellen eye chart, counting fingers, light
perception
• CN II – VII - Pupils, visual fields, EOMs, facial droop
• Inspection/palpation of eye and surrounding structures -
Asymmetry, proptosis, enophthalmos, orbital rim
• Lids/ducts
• Slit lamp – Anterior segment
• Fundoscopy – Posterior segment
– Contraindications to dilation – significant head trauma,
suspected rupture, history of glaucoma
• Intraocular pressure - Goldman applanation tonometry,
Tonopen, palpation
Eye Exam
Anterior Segment
• Perform at slit lamp
– If not available, use ophthalmoscope
• Inspect
– Conjunctiva
– Cornea
– Anterior chamber
– Iris
– Lens
Estimating Anterior Chamber Depth
Tonometry
• Measures the intraocular pressure by calculating
the force required to depress the cornea a given
amount with a tonometer.
• IOP 10-20 is considered normal.
• In chronic open angle glaucoma, IOP can be 20-
30, and in acute angle closure glaucoma, IOP
can be greater than 40.
• Palpation Tn, Tn- Tn+
Emergencies
• Obvious trauma laceration, avulsion on
ocular structures
• Obscure trauma history of trauma, no
obvious penetration/ ocular surface foreign
body
• Sudden visual loss w/o pain retinal and
optic nerve problem
• Acute ocular pain acute glaucoma, ocular
inflammation
Workups
• Inspection Obvious trauma
Inspection obvious trauma
Workups
• Assess generals correlated trauma
• ATS
• Symptomatic analgesia
• Antibiotics
• Refer
• Laboratory???
Obscure trauma
• History of trauma
• Unable to access ocular structures
• Case
Role of Anesthesia
• General?
• Local anesthesia
Workups
• Eyepatch
• Antibiotics
• ATS
• Drops???
• Refer within 6 hours golden period
Obscure trauma foreign body
• Anesthesia
• Conjunctival foreign body removal with
cotton buds/ irrigation
Corneal foreign body
• Anesthesia
• Eyelid speculum
• removal with 23 G
needle steady
hands
• Refer with taping
Chemical burns
• Emergency!!! - Every minute counts
• Do not waste time on Hx
• Alkali burns more common and worse than
acid
– Alkali – saponification – denatures collagen,
thromboses vessels
• Household cleaners, fertilizers, drain cleaners
– Acid – coagulation, H+ precipitates protein - barrier
• Industrial cleaners, batteries, vegetable preservatives
Workups
• Wash wash and wash
• Refer for assessment
• Hx after irrigation
• pH Strips
• Eye ointment
Sudden Visual Loss
• Lens related : lens dislocation
• Retinal related :
– Retinal detachment
– CRAO
– CRVO
• Optic nerve related : AION
Lens related sudden visual loss
• Lens dislocation
Workups
• Decreased visual acuity
• Monocular diplopia
• Anterior segment inspection : obvious lens
dislocation
• Doubtful midriatics ophthalmoscope
• Refer within days
Retina and optic nerve related visual
loss
• Sudden decreased visual acuity drastic
• Blocked vision
• Anterior segments normal
• Pupillary response : RAPD (+)
Workups
• Pupil examination is critical
• Posterior segment evaluation
• Midriatics
• Refer immediately !!!
CRAO= Central Retinal Artery
Occlusion AMI on Eye
• Cherry Red Spot Appearance
• Crucial
• Within 90 minutes
• Ocular Decompression
• Oxygenation
Acute Ocular Pain
• Acute glaucoma
• Corneal abrasion
• Contact Lens-related Acute Red eye (CLARE)
Workups
• Visual acuity may
decreased
• IOP if high, acute
glaucoma
• Anterior segment
corneal edema,
shallow anterior
chamber acute
glaucoma
Workups contd..
• If high IOP analgesics
• reduce IOP by medication acetazolamide
• refer
Corneal abrasion/ CLARE
• Very frequent
• Obscured history of trauma
• Only red eye manifested
Symptoms :
– Tearing, photophobia,
blepharospasm, severe pain
– Fluorescein: dye uptake at
defect site
– Rule out foreign body
Workups contd..
• Anesthesia sudden relieve
• Eyelid taping
• Recover within 24-48 hours
• Analgetics
• Vit C
Emergencies??
Workups
• Visual acuity affected??
• Stable?
• History of trauma? Rule out laceration
• Massive refer
• Resolve within 3-14 days
• Symptomatic medication
Take home messages
• Anesthesia
• Eyelid speculum
• Pupillary assessment
• Refer with certitude
• Laboratory workups can wait
TERIMA KASIH
Hyphema
Hyphema management
• Head up
• Immobilization
• IOP control
• Atropine 1% prevent synechia, pain
• Anti-fibrinolytic
• Surgery:
Anterior Chamber Irrigation through
parasynthesis
