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OPHTHALMOLOGY: PEARLS & PITFALLS...• Tsai, James C. Oxford American Handbook of Ophthalmology....
Transcript of OPHTHALMOLOGY: PEARLS & PITFALLS...• Tsai, James C. Oxford American Handbook of Ophthalmology....
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.