A stepwise approach to eyes o.OStep 1: Check Eye Vitals.
Vision is PLACEHOLDER (L) and PLACEHOLDER (R)
Movements are normal in all directions, with no subjective or objective diplopia.
Visual fields (quadrants) are intact bilaterally.
IOP is measured at PLACEHOLDER with a DEVICE USED. (there is no concern for orbital compartment syndrome: under 20 normal, 20-40 suggests glaucoma, above 40 risk compartment syndrome)
Pupils are equal and reactive.
Step 1b (Trauma): Focused review for orbital compartment syndrome and orbital wall fractures
There is no proptosis, loss of vision, RAPD, or IOP>40.
(RAPD – no paradoxial dilatation when light is swung to the affected eye)
Movements are normal, with no subjective/objective diplopia on all movements.
No severe bony tenderness to periorbital area.
Step 1c (visual loss): Focused history to sus out risk factors for vision loss pathologies.
Patient has a history of PLACEHOLDER. Otherwise, there is no known history of the following: Vasculopathy eg HTN, Diabetes, thrombophilia (Risk retinopathy, CRAO), Shortsightness (risk detachment), Longsightedness (risk glaucoma), contact lens (keratitis, abrasion, ulcers), Eye Surgery or CTD/Vasculitis (Uveitis/iritis/glaucoma).
Step 2: Eye assessment front to back
No FB under eyelids. Orbital rim is intact with no focal bony tenderness to frontal bone / maxilla / zygoma. Pupils are equal (no aniscoria) with no evidence of penetrating injury or globe rupture. No corneal haze. No gross FB on flurorescein staining and blue light. Under microscopy/magnification (using slit lamp / ) reveals no corneal abrasion or foreign bodies.
Limbus / Sclera: Healthy limbus. No scleral oedema (chemosis) or injection. There is no ciliary flare to suggest a deeper opthalmic pathology (intraocular irritation: scleritis / iritis / cyclitis)
Anterior chamber: There is no hyphaema or lens irregularities/aniscoria.
Posterior Chamber: Normal red reflex. Opthalmoscopy reveals no overt vitreous haemorrhage or retinal detachment. No cherry red spot (CRAO). No haemorrhages (CRVO).
Step 3: Apply Heuristics
Conjunctivitis: evidenced by generalized conjunctival injection *without* ciliary flare. No evidence of uveitis/iritis (no flare in anterior chamber on slit lamp examination). No FB on cornea on microscopy. No FB under lids. All eye vitals (see above) are normal.
Iritis/Uveitis: evidenced by pain (usually deep aching and radiating), photophobia and possibly vision loss. Ciliary flush, consensual photophobia (pain felt in affected eye when light shown in opposite eye) and slit lamp demonstrates cells (“flare”) +/- hypopyon. Initial Tx: cycloplegics eg cyclopentolate 1 drop TDS. Opthal r/v within 48 hours.
Acute Angle Closure GLAUCOMA: acute painful eye with hazy fixed dilated pupil and raised IOP (> 21 (usually > 40mmHg), vision loss, NV, halos, photophobia. Assoc conjunctival injection, corneal oedema. Worse on transition from light to dark. Longsighted people are at risk. STAMP Rx: Supine. Timolol 0.5% q30min (dec aqeous production), Acetazolamide 500mg IV stat, then 250mg TDS. (dec aqeous prod), Mannitol 1g/kg IV (osmotic effect), Pilocarpine 1% q1h (causes meiosis to open up the angle). Opthal emergent referral for definitive tx (iridotomy / trabeculectomy).
**** ARTICLE IN PROGRESS ***
www.emtldr.com 
Leave a comment