Ophthalmologic

Rapid Review

• Background
  • Common corneal foreign bodies include metal, glass, plastic, wood, and sand. Must be removed in a timely manner to prevent infection and ocular necrosis
• Indications
  • Foreign body in the cornea
• Contraindications
  • Intraocular foreign body, hyphema, corneal laceration, multiple foreign bodies
• Complications
  • Incomplete removal, conjunctivitis, epithelial injury, corneal perforation.

Pearls

• Use a small needle for removal (30 or 25 gauge needle). You can also try to remove with cotton swab or irrigation to minimize corneal damage. 
• After removal, repeat fluorescein exam and look for Seidel defect to ensure that you did not perforate the cornea.

Deep Dive

• Corneal Abrasions and Foreign Bodies (Merck Manual)

Rapid Review

• Background
  • Occurs when the eyelids slip behind the midcoronal plane of the eye in a proptosed eyeball. Orbicularis oculi spasm maintains luxation. Early reduction is required to minimize visual impairment
• Indications
  • Spontaneous or traumatic globe luxation
• Contraindications
  • No absolute contraindications. Globe rupture is a relative contraindication. 
• Complications
  • Failure to reduce, retained lashes.

Pearls

• Topical anesthetic drops (tetracaine, proparacaine) can reduce pain and decrease belpharospasm, allowing the provider to reposition the globe more easily. 
• When manually reducing, gentle pressure should be applied to the sclera. Avoid putting any pressure on the cornea. 

Deep Dive

• How to Reduce a Globe Sublux in the Emergency Department (EP Monthly)

Rapid Review

• Background
  • Lateral canthotomy is the surgical exposure of the lateral canthal tendon, +/- incision of the inferior branch of the tendon (cantholysis), to relieve intraorbital pressure.
• Indications
  • Orbital compartment syndrome (w/ acute loss of vision acuity, proptosis, or IOP > 40)
• Contraindications
  • Suspected globe rupture
• Complications
  • Globe injury, lacrimal gland/artery injury, incomplete cantholysis, bleeding, infection

Pearls

• All equipment being used during the procedure (needle, hemostats, scalpel) should be directed away from the eye
• If the IOP is still > 40 mmHg after cutting the inferior canthal tendon, you may need to proceed with incision of the superior canthoal tendon.

Deep Dive

• Lateral Canthotomy and Cantholysis (emDocs)

Rapid Review

• Background
  • Examination of the eye under magnification to identify pathology within the anterior aspect of the eye and help provide treatment for ocular foreign body removals.
• Indications
  • Evaluation of red eye complaints
  • Suspected corneal foreign body 
• Contraindications
  • None
• Complications
  • None

Pearls

• To maximize comfort, avoid focusing the beam directly on the patient’s eye when you start.
• If looking at the entire eye at once, use a broad beam. Use the narrow beam when evaluating the anterior chamber specifically. This also helps with patient comfort.

Deep Dive

• Mastering Minor Care: Slit Lamp Exam (Taming the SRU)

Rapid Review

• Background
  •  Diagnostic test that measures intraocular pressure.. Early detection of abnormal intraocular pressure can prevent irreversible vision loss
• Indications
  • Suspected glaucoma, ocular trauma w/o globe rupture, before/after ophthalmic surgical procedures.
• Contraindications
  • Infection, unhealed corneal abrasions/ulcers, ruptured globe
• Complications
  • Infection, corneal abrasion, aggravation of ruptured globe.

Pearls

• Tonometry can be very uncomfortable for the patient. Consider applying topical anesthetic (tetracaine, proparacaine, etc.) to the affected eye ahead of time.
• Do not hold the eye during the procedure; this may give a falsely high reading. Try to avoid pulling up/down on the eyelids as well.

Deep Dive

• Acute Angle Closure: Mastering Tonometry (The Procedural Pause)