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Thread: Alarm Bells in Ophthalmology

  1. #1
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    Mar 2007
    Leeds, United Kingdom
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    Cool Alarm Bells in Ophthalmology

    Nadeem Ali, Philip Griffiths and Scott Fraser

    01 Do not forget giant cell arteritis in any patient over 50 with sudden visual loss, even without pain.
    02 Painful, red eye with vomiting – think of acute glaucoma.
    03 Falling vision with pain after cataract surgery is intraocular infection until proved otherwise.
    04 An unwell child with tender, puffy lids may develop intracranial infection.
    05 Flashes and floaters are potential symptoms of retinal detachment.
    06 Sudden onset of double vision may herald life-threatening neurology.
    07 Eye trauma that is high-velocity or from a sharp object – rule out penetrating injury.
    08 Sticky eyes in a neonate could be sight-threatening.
    09 A white pupil in a child is a life-threatening tumour until proved otherwise.
    10 Thyroid eye disease can cause blindness.


    1 Giant cell arteritis (GCA)

    Always think of GCA (¼ superficial temporal arteritis) in patients over 50 who complain of visual loss without eye pain. Untreated, the central retinal arteries can occlude and the patient can be blind in both eyes within a day. Other
    symptoms to ask about include headache, temple pain, scalp tenderness (pain on brushing hair), jaw claudication (pain on
    chewing), muscle stiffness, weight loss and fever. Occasionally, none of these symptoms are present (occult GCA). CRP is more sensitive a test than ESR. Superficial temporal artery biopsy can confirm the diagnosis and is not affected by prior steroid treatment.

    Action: Check confrontation fields, feel the temporal arteries (hard, tender or pulseless). Do ESR, CRP and FBC. Refer immediately to ophthalmology (to rheumatology if GCA without visual symptoms). Start high-dose per oral prednisolone (or
    IV hydrocortisone) if the picture fits.

    2 Acute closed-angle glaucoma (ACAG)

    ACAG can blind if left untreated. It classically presents with a unilateral painful red eye, with malaise and nausea. Sufferers are usually ‘long-sighted’ – they wear glasses that magnify their eyes. Occasionally, the presenting symptom can be vomiting with abdominal pain or headache. ACAG can be misdiagnosed, therefore, as an acute abdomen or as an intracranial event. Some patients report a few weeks or months of episodes of pain and misting of the vision in the evenings, with haloes or rainbows around lights. These represent intermittent, subacute attacks. The crucial sign is a fixed, mid-dilated pupil. If the pupil constricts normally to light, ACAG is practically excluded.

    Action: Refer immediately to ophthalmology. Give IV acetazolamide if there is any delay in transfer. For history of intermittent attacks only, refer urgently.

    3 Postsurgical endophthalmitis

    Falling vision following intraocular surgery sets an ophthalmologist’s pulse racing. Endophthalmitis is a microbial intraocular infection that can permanently destroy the vision. It is a rare complication of any intraocular procedure, most commonly cataract surgery. Falling vision and increasing pain are typical. Other suspicious signs are floaters, increasing
    photophobia and discharge.

    Action: Refer immediately to ophthalmology.

    4 Orbital cellulitis

    If a child (or even adult) with tender, puffy eyelids is unwell, consider orbital cellulitis. The risk is intracranial spread of infection causing cavernous sinus thrombosis and meningitis. Headache, pyrexia, reduced vision, proptosis and
    limited, painful eye movements are suggestive features. The absence of systemic symptoms makes preseptal cellulitis
    (where the infection is confined to the superficial tissues) more likely.

    Action: Check the temperature. Refer immediately to ophthalmology, urgently in the absence of systemic features.

    5 Retinal detachment

    Floaters are opacities in the vitreous cavity. They shift on movements of the eyes and get in the way of the vision. Patients describe them as dots, circles, cobwebs, hairs. They are often accompanied by flashing lights, like white sparkles, in the periphery of the visual field. Flashes and floaters are symptoms of an almost universal, and mostly benign, condition (posterior vitreous detachment), but also of a sight-threatening condition – retinal detachment. History alone cannot distinguish between the two. If the patient also reports a ‘shadow’ coming across their vision over hours or days (not minutes), retinal detachment should be assumed.

    Action: Refer all new onset of flashes and floaters urgently to ophthalmology; immediately if accompanied by field loss or reduced vision.

    6 Diplopia

    Sudden onset of double vision may herald life-threatening neurology. The most serious cause is a painful third nerve (oculomotor) palsy, which may be caused by an aneurysm of the posterior communicating artery. The signs are limited
    elevation, depression and adduction, with ptosis. The axiom that an unaffected pupil excludes a compressive cause should
    not be relied upon.
    A sixth nerve palsy causes limitation of abduction. It may be a false localising sign in raised intracranial pressure.
    Palsy of the fourth cranial nerve is harder to diagnose, but it rarely indicates life-threatening disease. It may cause vertical
    diplopia, which increases on looking to one side, and reduces on looking to the other side.

    Action: For third nerve palsies with pain and pupil involvement, refer immediately to neurosurgery. In other cases, refer immediately to ophthalmology or neurology.

    7 Penetrating eye injury

    Anyone who gives a history of ocular trauma followed by reduced vision needs full ophthalmic assessment. Sudden onset of ‘floaters’ is also worrying. The history of the event is crucial – certain scenarios, however trivial they may sound, should ring alarm bells. High-velocity impacts such as metal striking metal (hammer on chisel) have a high incidence of
    penetrating fragments. Sharp objects are worrying – broken glass, metal, wood, plastic. Have a lower threshold of suspicion
    in children where history may not be accurate. The eye may appear grossly normal – refer on the basis of history alone.

    Action: Refer immediately to ophthalmology. Put a shield or pad over the eye – do not let it touch the eyeball.

    8 Ophthalmia neonatorum

    Ophthalmia neonatorum is conjunctivitis within the first month of life. The commonest causes are staphylococcal and streptococcal infections, which are either self-limiting or respond quickly to topical antibiotics. Chlamydia is increasingly common and can easily be overlooked. Gonococcus is the most serious cause, as it progress very rapidly and can lead to corneal perforation – it is therefore sight-threatening. Rarely, fulminant systemic infection develops. Both chlamydia and gonococcus are contracted from the mother during delivery. Purulent discharge within the first week of life is gonococcal
    until proved otherwise. Chlamydial conjunctivitis tends to present in the second week.

    Action: Refer immediately to ophthalmology or paediatrics. Parents may need genitourinary investigations. Ophthalmia neonatorum is a notifiable disease.

    9 Leukocoria

    A white pupil (leukocoria) is often first noticed by parents looking at photographs of their children in which a normal ‘red eye’ is missing. There are many causes of leukocoria, the most serious of which is retinoblastoma, a life-threatening tumour.

    Action: Confirm the loss of the normal, red pupil reflex with a direct ophthalmoscope from a distance. Refer urgently to ophthalmology.

    10 Thyroid eye disease

    Thyroid eye disease can occur in any thyroid state (hypo-, eu-, or hyper-) and the classical appearance is familiar to most doctors. A report of falling vision is worrying. The condition can cause sight loss either through corneal exposure and ulceration, or through optic nerve compression at the orbital apex. The former is more likely with obviously proptotic eyes, but the latter without obvious proptosis, so the first glance should not reassure.

    Action: Check visual acuity and colour vision. Refer immediately to ophthalmology.
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

  2. #2
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    Do you have something for paediatrics only?

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