Eye concerns are a common reason for elderly patients to visit the ED. Their causes can range from benign to serious, time-sensitive, vision-threatening entities. In this episode, ophthalmologist and retina-specialist Dr. Bryan Hong talks us through his approach and initial management of four common ophthalmologic emergencies.
See more notes below the audio player!
Acute angle-closure glaucoma
- Case: 76yo female with a history of hyperopia (far sightedness), the patient may have had “perfect vision without glasses” as a child but became increasingly dependent on reading glasses at a relatively young age (presbyopia). The patient complains of intermittent “migraine” or headache over eyes that radiate from eyes in low lighting or at dusk/dawn. Tonight she had sudden onset severe left sided eye pain, headache, and associated nausea which brought her to the ED. The patient may have had recent laser treatment or surgery, retinal problems, recent dilation, sulfa medications.
- Evaluation: Check visual acuity, pupils (fixed and mid dilated), pressure if possible. Pain, blurred vision, colored haloes around lights, frontal headache, nausea, vomiting. Slit lamp exam if you have one: conjunctival injection; fixed, mid-dilated pupil.
- Management: Severe permanent damage can occur to optic nerve within hours. Lowering of IOP is urgent. Give maximum topical IOP lowering agents, oral or IV carbonic anhydrase inhibitor, and in some cases mannitol. Recheck IOP in 1 hour. If cannot lower IOP within first 2-3 hours, immediate ophthalmology consult. The medications we discussed in the podcast include:
- Timolol 0.5% (Beta-blocker)
- Brimonidine 0.1% (Alpha-2 agonist)
- Latanoprost 0.005% (Prostaglandin analog)
- Dorzolamide 2% (Carbonic anhydrase inhibitor)
Give the above 4 drops each 5 minutes apart, then check pressure at the 1 hour mark. If refractory or if very high pressures, consider:
- Prednisolone acetate 1% (steroid)
- Acetazolamide 500mg IV or PO (carbonic anhydrase inhibitor)
- Mannitol 1-2g/kg IV (to reduce IOP)
- Case: 55yo Male high myope complains of 1 day of new floaters in the left eye preceded by flashes of light.
- Evaluation: Vision, pupils, pressure (always if possible). Confrontational fields to grossly localize defect. If available, ultrasound scan of eye looking for retinal detachment – can be misleading because vitreous hemorrhage or posterior vitreous detachment can masquerade as retinal detachment. A view of the fundus will usually be clear with a direct ophthalmoscope unless the picture is muddied by vitreous hemorrhage.
- Management: Needs urgent or emergent ophthalmology consult. The retina should be re-attached within 24hours of symptom onset. Keep NPO after midnight in case emergency surgery is warranted.
- Case: 62 year old Type 2 diabetic with new “chunky floaters” which have turned into cobwebs.
- Evaluation: Vision, pupils, pressure. The patient may or may not have reasons to have proliferative retinopathy, but would still get an ultrasound if it is available. You can get a gross idea of how dense the hemorrhage (or any other media opacity) is by using direct ophthalmoscope and shining the biggest brightest beam and checking for red reflex from a couple feet away. The view of the fundus will be impeded by hemorrhage to varying extent.
- Management: There is so much overlap between signs and symptoms of vitreous hemorrhage, posterior vitreous detachment, and RD that all complaints of “flashes, many new floaters, or curtain over vision” should be referred to an ophthalmologist for a same or next day consult. They should keep their HOB elevated and try to keep their eyes still to allow the blood to settle so that the retina can be better visualized.
Temporal or Giant Cell Arteritis
- Case: 87 year old man with h/o HLD and HTN comes in with sudden painless vision loss left eye. He has been having recent headaches and intermittent unexplained fevers. May be associated with a headache at the time of the presentation.
- Evaluation: Vision, check for APD! This is a disease of the very old, and it must ALWAYS be ruled out in an older patient with stuttering vision loss, because it is initially unilateral but can rapidly become bilateral without treatment. Look for history of unintentional weight loss, scalp tenderness, jaw claudication, polymyalgia rheumatica, or any other cranial nerve palsies (especially 6th nerve)—thorough evaluation of all CN nerves. Order Sed Rate, CRP, and CBC (thombocytosis). Look at nerve for pale, swollen disc with possible flame hemorrhages.
- Management: IV Steroids should be given immediately if suspecting GCA. Methylprednisolone 250 mg IV q 6 hrs for 12 does, then prednisone 80-100mg PO daily. Ophthalmology consult should be called for next day evaluation and for temporal artery biopsy within 1 week of steroid initiation, or earlier if the diagnosis is not clear.
More to come in Part 2….
Image credit . This podcast uses sounds from freesound.org by Jobro and HerbertBoland
This is excellent. I’m an internist and as such I see a majority of elderly. I am a bit fuzzy (no pun intended) on the red reflex and its importance in vitreous hemorrhage. The other issue is the APD eval in GCA. Does this separate nerve damage from retinal infarction or ischemia?
Thanks for listening!! Here is Bryan Hong’s reply: “The red reflex is more of a subjective measure of media clarity. In a normal eye, there is prefect clarity of cornea, lens, and vitreous which allows for the light being shone into the eye to reflect without obstruction off the retina. Try looking for red reflex on a young healthy patient to get a sense of what “normal” looks like. The APD evaluation is primarily useful for evaluating asymmetric damage to the optic nerve. A very large portion of retina must be damaged or ischemic before an APD appears, so for our purposes we assume APD signals nerve damage. Notably: vitreous hemorrhage or dense cataract never results in an APD.”
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