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Ophthalmology for the F2

Emergency Medicine Doctor and


Basic Slit Lamp Usage

Ian Yeung MRCOphth


SHO Ophthalmology, Eye Clinic
Royal Hampshire County Hospital, Winchester
Lecture Structure
• Conditions and Management
– Anterior segment
• Trauma
– Posterior segment

• Ophthalmology in Hampshire

• Basic slit lamp skills


– demonstration
Take home message
• If you are worried, speak to your local
friendly eye department
Anterior/Posterior Segment

• Anterior/Intermediate/Posterior Uveitis
Orbital Cellulitis
• Preseptal and orbital
• Refer Paediatrics
– Admit. Treat as for sepsis
• Ophthalmology
– Optic nerve involvement
– CT orbits (?abscess) then drain
• ENT
– Nasoendoscopy (?source?), Sinus washout
Orbital Septum

• Extension of the periosteum


Preseptal
Orbital Cellulitis
Orbital
Cellulitis
Conjunctiva
• Subconjunctival haemorrhage

• Bacterial conjunctivitis
• Viral (Adenoviral) conjunctivitis
• Allergic conjunctivitis
Subconjunctival haemorrhage
• Reassure
• Discharge
Bacterial
conjunctivitis
• One eye
• occ. Chloramphenicol
qds 1/52
• Discharge
• If severe, suggest
– GP or eye clinic f/u
– Or contact eye clinic if
worsens
– Conjunctival/tear swabs
• Bacterial, viral,
chlamydial
Adenoviral
conjunctivitis
• Recent flu symptoms
• Follicles
• Cervical lymphadenopathy
• Lubricants
– g. Gel Tears BE qds prn
• If severe, eye clinic f/u in a few
days

• Public health issues


– Clean your equipment!
Allergic
conjunctivitis
• Atopic patients
• Bilateral
• “Itch”
– cobblestone papillae
• Remove allergen if possible
– PO antihistamines
– g. Opatanol bd
– g. Gel Tears qds BE prn
• Eye clinic f/u soon to confirm
– If severe, speak to us
Lid eversion
Cornea
• Corneal abrasions
• Arc Eye
• Herpes simplex keratitis

• Contact Lens (CL) problems


– Corneal ulcers due to contact lens

• Trauma
• Corneal foreign bodies
– Rust rings
• Chemical injuries
Corneal
abrasions
• History of trauma
• occ. Chloramphenicol
qds 1/52

• Analgesia prn
• Discharge
• TCI/SOS
Arc Eye
• 6-12 hours post exposure
– bilateral
• Punctate epithelial defects

• Treatment
– occ. Chloramphenicol
qds
– +/- pressure patch to
worst eye for
24 hours
– Analgesia prn
– Discharge
Herpes Simplex
Keratitis
• HSV type 1 virus
• Corneal dendrite

• occ. Zovirax 5/day 10/7

• Eye clinic f/u within a few


days
• TCI/SOS
• If worried, speak to us
Contact Lens (CL) Problems
• Speak to us
• Stop contact lens
use
CL Corneal
ulcers
Corneal Trauma
Corneal
foreign bodies (FB)
• Removal
– g. Benoxinate/Oxybuprocaine or
g. Amethocaine/Tetracaine

– Cotton wool bud and


syringe/green needle option

• Tx and f/u as per corneal


abrasion

• Rust Ring
– F/u in eye clinic in
2-3 days
FB removal
technique
Intraocular
foreign bodies
• History
– High speed metal
– Grinding
– Hammering
• Unexplained subconj
haemorrhage
• Orbital X-rays
– Eyes up/down if possible
• Refer to us
Chemical
injuries
• g. Benoxinate or
Amethocaine BE

• 1 Litre N/Saline thru a giving


set
– Wash fornices and wash out
FB
– Evert lids if possible

• Check pH
• Repeat till
– pH equal in both eyes
– pH neutral (approx 7)
Chemical injuries
• pH original chemical if
possible
– Alkali is worse (pH > 8)
• Deeper penetration
• Speak to us
• If severe, speak to us
Mild chemical injury
• Treat as per corneal abrasion
• PO Vitamin C (if alkali/severe)

• F/u in eye clinic if


you are worried
• TCI/SOS
Other
trauma
Orbital
fracture
• Upgaze restriction
Lid laceration
– Full thickness or involving lid margin
• Refer to us
– Partial thickness
• Can be repaired by an EM department if you’re happy
Full thickness or lid
margin lacerations
• Refer to us
Blunt trauma
• Globe rupture
• Hyphaema
Traumatic
Hyphaema
Globe rupture
Penetrating trauma
• Corneal lacerations
– Siedels test
• Scleral lacerations
– Shield please
– NOT pad please
Siedels Test
• Aqueous leak
• 2% Fluorescein
Other Anterior Segment
• Iritis/Anterior Uveitis
• Acute Angle Closure Glaucoma
Iritis
Anterior Uveitis
Iritis Cells
and Flare
• Take home message
Acute angle
closure glaucoma
• Feels hard on palpation
• Corneal oedema
• Fixed, mid-dilated pupil
Acute angle closure glaucoma
• Lower ocular pressure
• Peripheral iridotomies
Other
• Ring us about all postop eye surgery
patients

• Postop eye surgery (cataract surgery)


– Endophthalmitis
Endophthalmitis
Posterior Segment and Retina
Retina
• Retinal detachment
• Giant cell arteritis
• Sudden painless loss of vision
– Central retinal artery occlusion
– Central retinal vein occlusion
Retinal symptoms
• Flashing lights
• Floaters
• Shadow

• Dilated fundal examination


– Unable to drive 6 hours
post dilation
• Tropicamide 1% (short acting)
• Cyclopentolate 1% (long acting)
Retinal
detachment

• Same day referral


• Visual acuity
– Macula on or off
• Unlikely to do a
vitrectomy overnight
Posterior Vitreous Detachment
Neuro-ophthalmology
• Painful 3rd nerve palsy
– Subarachnoid haemorrhage

• Homonymous hemianopias
• Bitemporal hemianopia
3rd nerve palsy
• Pupil involved –surgical 3rd n palsy
– ?circle of willis aneursym

• Pupil sparing – medical 3rd n palsy


– ?diabetes/microvascular
Homonymous hemianopia
• Speak to medics
• Right homonymous hemianopia
– ?Left occipital SOL or CVA?

Left eye Right eye


Ophthalmology in Hampshire
Weekday Ophthalmology
• Royal Hampshire County Hospital (RHCH)
– Weekday service
– 0900 -1700
– Ring eye clinic
– Or bleep 247 or 248
On Call Ophthalmology
• Eye Casualty
Southampton General Hospital (SGH)
– 1700-2100 weekdays
– 0900-1400 weekends

• For advice/referrals 24 hours a day


– Ring Eye Casualty, speak to
Sister/Nurse in charge
• She will automatically refer you to Ophthalmology
SHO/SpR if she cannot be of help
Take home message
• If you are worried, speak to your local
friendly eye department
References
• 1. Britain RPSoG. British National Formulary 50. 50th ed: Royal
Pharmaceutical Society of Great Britain, 2005.
• 2. Denniston A. MP. Oxford Handbook of Ophthalmology.
Paperback ed. Oxford: Oxford University Press, 2006.
• 4. Kanski J. Clinical Ophthalmology. 5th ed. London:
Butterworth Heinemann, 2003.
• 5. Kunimoto DY KK, Makar MS. The Wills Eye Manual. 4th ed.
Philadelphia: Lippincott Williams & Wilkins, 2004.
• 6. Webb LA. Manual of Eye Emergencies: Diagnosis and
Management. Paperback ed. London: Butterworth-Heinemann
Ltd, 2004.
Any questions?

ian.yeung@cantab.net
Thank you
Basic Slit Lamp Skills
Demonstration