Check the volume required for the catheter balloon. \200 Wash hands and don sterile glove s. \200 Clean the external genitalia with antiseptic solution and surround with a sterile \201 eld. Slowly insert local anesthetic into the urethra. \200 Gently massage the local anesthetic down the urethra and wait for a few minutes for the LA to take effect. Holding the penis at right angles to the body, insert the lubricated catheter. The catheter should pass easily into the bladder with drainage of urine. If any resistance or dif \201 culty is encountered, stop and seek senior assistance. Once urine appears, advance the catheter a few centimeters further before in \202 ating the balloon. Connect the catheter to a closed drainage system and tape the tubing to the upper thigh. Ensure that the foreskin is not left retracted \200\224 this could result in paraphimosis. 522 CHAPTER 10 Surgery Testicular problems Remember that any pain of testicular origin may be initially referred t o the abdomen. Testicular torsion Testicular torsion is most frequently seen in children and young adults. Any suspicion of testicular torsion should prompt immediate referral. The condition is cov ered fully on b Inguinal and scrotal swellings, p.700. Acute epididymitis Causes For those aged <35 years, infection with chlamydia or gonococcus is com- monly responsible. Acute epididymitis in those aged > 35 years is usually secondary to UTI and associated with underlying urinary tract pathology. Clinical features There is typically a gradual onset of progressive testicular ache, with sub- sequent swelling of the epididymis and testis. There may be a history of dysuria or urethral discharge. The patien t may be pyrexial. The epididymis is acutely tender, with the testis lying low in the scrot um. Advanced, late cases may have progressed to abscess formation. Investigations Send an M SU and take a urethral swab (take lab advice regarding the correct media for chlamydia). Management The chief initial concern is to ensure that testicular torsion is not being miss ed: if there is any possibility of this ( b Inguinal and scrotal swellings, p.700), refer u rgently. Treatment of acute epididymitis comprises antibi- otics (eg cipro \202 oxacin for 2 weeks), analgesia, and rest. Some patients require admission; others may be managed on a n outpatient basis. Urology investigation and follow-up will be required, so involve the ur ologist early. Patients with suspected chlamydia or gonococcus require appropriate advice a nd contact tracing of sexual partners. Orchitis Orchitis may present as epididymo-orchitis, an extension of bacterial epididymitis (see above). Orchitis of viral origin may also occur \200\224 typically mumps, following \211\210 5days after parotitis. Mumps orchitis may be unilateral or bilateral and can occu r in the absence of overt parotitis. Rarely, orchitis is secondary to tuberculosis (TB) or syphilis. Treatment All patients with orchitis require analgesia and follow-up. If there is any possibility of bacterial infection, antibiotics are indicated (see above). Testicular lumps Patients may present to the ED with scrotal/testicular lumps. Causes are v aried and include: hydrocoele, inguinal hernia, epididymal cyst, epidi- dymitis, orchitis, and testicular tumor. Many patients will be managed appropriately by referral back to GP or to an outpatient clinic. Be particu- larly wary of an apparent epididymo-orchitis which ha s failed to respond to antibiotics \200\224 it could be an atypical presentation of a test icular tumor. Testicular trauma \200\224See b p.352. 523 PENILE PROBLEMS AND PROSTATITIS Penile problems and prostatitis Paraphimosis Paraphimosis occurs when the foreskin is left retracted, thereby causing swelling of the glans, which results in dif \201 culty replacin g the foreskin to its proper position. Untreated, tissue necrosis may develop. Paraphimosis may be iatrogenic, occurring after urethral catheterization. Treatment Initially attempt r eduction by manual decompression, which may require the use of Entonox , IV sedation, or LA (a small amount of topical 1 \200\2232 % lidocaine gel or injection of 10mL plain 1 % l idocaine around the base of the penis). Digital pressure may allow the glans to d in size, prior to the foreskin being delivered back into its usual position. If unsuccessful, refer to the surgical team for reduction under GA or dorsal slit of the prepuce followed by later circumcision. Priapism Priapism is persistent (and usually painful) penile erection. Causes \200 Iatrogenic (following intra-cavernosal injection of one or more of: papaverin e, alprostadil, vasoactive intestinal polypeptide, phentolamine for impotence). Others: leukemia, myeloma, sickle cell disease, spinal injury, drugs (eg sildena \201 l [V iagra], phenothiazines, cannabis, cocaine), renal dialysis. Management Priapism is a urolog ical emergency. Refer urgently to the urology team. Initial emergency treatment of a prolon ged ( > 6hr) arti \201 cial erection (ie following an intra-cavernosal drug injection or o ral sildena \201 l) is to aspirate 50mL of blood from each corpus cavernosum through a 19G butter \202 y needle into a 50mL syringe with a Luer lock. Urethritis This usually presents with dysuria/urinary frequency, re \202 ecting underlying STD. Refer for appropriate investigation, treatment, and follow-up. Prostatitis In \202 ammation of the prostate may be acute or chronic and present in a vari ety of ways (fever, urgency, frequency, perineal pain, urethral dis- charge). PR examinatio n reveals a tender prostate. Urinalysis demonstrates protein. Refer for further investigati on and treatment. Penile trauma Minor super \201 cial tears These are relatively common. Most involve the fr enulum. The patient complains of pain and bleeding following sexual intercourse. Bleeding u sually responds to local pressure (if this is not successful, consider tissue glue or refer to the surgical team). Once bleeding has stopped, advise a period of abstinence from sexua l activity ( \211\210 10 days) to allow healing to occur and prevent recurrence. Fracture of the penis This occurs infrequently. It involves injury to the tunica albuginea of the erect penis. The result is penile tenderness and swelling. Refer to the urolo- gist for urgent surgical exploration, evacuation of haematoma and repair. 524 CHAPTER 10 Surgery Ureteric colic New onset \202 ank/back pain in the elderly may represent a leaking aortic aneurysm (even if haematuria is present). Causes Calculi or blood clots may cause ureteric (or \200\230renal \200\231) colic. Colick y pain is produced by ureteric obstruction, i intraluminal pressure, and muscle spasm. Calc uli most commonly consist of calcium oxalate and/or calcium phosphate. Less common are magn esium ammonium phosphate (associated with UTIs and urea-splitting organisms, such as Proteu s ), urate, and cystine stones. are associated with hypercalcaemia, hyperoxaluria and Calculi hyperuricaemia. \200\230Stag horn \200\231 calculi in the collecting system predispose to infections. Calculi may form throughout the length of the renal tract. They vary in size from tiny part icles to large \200\230stones \200\231 in the bladder. They cause symptoms from local obst ruction, infection, and rarely may ulcerate through the wall of the structure in which they are present. Clinical features The most common presenting symptoms are pain from obstruction or UTI and/ or haematuria. Constant dull, severe, loin discomfort is associ- ated with excruciating col icky pain, spreading to the respective iliac fossa, testis, tip of penis or labia. The pain may cause the patient to move or walk about. Nausea, vomiting, pallor, sweating are common . There is frequently a previous history of stone disease \200\224 ask about this and whet her there is any past history of renal disease. Ask about urinary and GI symptoms. Apart from loin tenderness, abdominal examination is usually normal, but check the haemodyn amic status, pulses, bruits and the abdominal aorta, as a ruptured aortic aneurysm can pres ent in a similar fashion ( b p.530). Pyrexia or rigors suggest associated infection. Micros copic (sometimes frank) haematuria is common. Symptoms are usually relieved when the stone passes into the bladder, but larger calculi may then cause obstruction at the bladder neck or the urethra producing acute urinary retention. Bladder calculi may present with symptoms of UTI and/or bladder irritation (frequency, dysuria, strangury, and haematuria). 525 URETERIC COLIC Investigations \200 Urinalysis and MSU: blood on stix testing is present in > 80 % of pat ients with proven stones. A pH > 7.6 implies associated infection with urea splitting organ isms. U&E, creatinine, glucose, Ca 2 + , PO 4 2 \200\223 , urate levels. \200 \200\230KUB \200 \231 X-ray: 90 % of urinary calculi are radio-opaque. X-ray is \211\210 50 % sensitive and \211\210 70 % speci \201 c for the diagnosis of ureteric calculi and is a very useful fo llow-up of patients with known stones. Common sites for calculi include the pelvi-ureteric and vesico-ureteric junctions. Remember that the ureters lie adjacent to the tips of the sp inal trans- verse processes. Use USS/Doppler instead in pregnant patients or those with renal disease. CT without contrast is \211\210 95 % sensitive and \211\210 95 % speci \201 c and has th e advantage of assisting diagnosis of other causes of abdominal and/or loin pain. Intravenous urography (IVU) is the most accurate investigation when CT is not available or where endoscopic or surgical treatment is contemplated. A delayed nephrogram on the affecte d side at 5min is common. As contrast enters the collecting system, the site and degree of the obstruction can be assessed. Treatment Give IV opioid titrated to effect, together with an NSAID (either IV keto- ralac, or oral/rectal diclofenac). Do not use antispasmodics, anticholinergics and \200\230pushi ng \202 uids \200\231. \200 Aim to discharge patients (with arrangements for appropriat e outpa- tient investigation) when symptoms have completely resolved, and in whom the CT/IV U shows no obstruction. Note that in some patients the process of becoming pain-free merely represents complete obstruc- tion. Admit (for further investigation and treatment) patients whose pain persists, or in whom in vestigation con \201 rms continued obstruction, infection, sepsis or renal impairment. 526 CHAPTER 10 Surgery Abscesses An abscess is a localized collection of pus resulting in a painful soft tissue ma ss that is often \202 uctuant, but surrounded by \201 rm granulation tissue and erythem a. The cause is usually bacterial, resulting from minor trauma to the epithelium/mucosa or blockage of apocrine glands. A history of a pre- vious lump at the site suggests infection of a sebaceous cyst. Check BMG in all patients. For patients with recurrent abscesses, check for signs of hidradenitis suppurativa, diabete s, in \202 ammatory bowel disease, and malignancy. Ask about steroid use. Treatment Incision and drainage A general surgical principle is that a collection of pus re quires drainage. On occasions, depending upon local policy, it may be appropriate to do thi s in the ED. Some abscesses (eg face, breast, perineum, pediatric) require specialist atten tion. Regional, parenteral, or GA may be needed to supplement LA which works poorly in this situation. Technique Incise along the length of the \202 uctuance and deep enough to enter the cavit y. An elliptical incision will prevent premature closure and re-accumulation of pus. Send p us for culture. Ensure that loculi in the cavity are gently broken by the use of a curette. Consider inserting a loose antiseptic wick in the cavity to ensure drainage and prevent pr emature closure. Antibiotics are not indicated in patients with normal host defenses as long as the abscess is localized. Evidence of surrounding or spreading infection may warrant antibiotics (eg co -amoxiclav or penicillin + \202 ucloxacillin) and on occasions, admission (see below). Refer the following: \200 Those who are systemically unwell (pyrexial, tachycardic, rigor s), immuno-compromised and those not responding to treatment. Abscesses secondary to IV drug misuse. \200 Those with infection in certain anatomical si tes: face ( i risk of cavernous sinus thrombosis), those potentially involving the airway ( sublingual abscesses, Ludwig \200\231s angina), axillary, groin, retropharyngeal, perineal, and breast abscesses. Those with extensive or progressing cellulitis/lymphangitis. These patients may require IV antibiotics (eg co-amoxiclav or \202 ucloxacillin + penicillin), analgesia and surgical d rainage. Take blood for FBC, clotting studies and blood culture. Treat sepsis/septic shock where necessary ( b p.59). 527 ABSCESSES Breast infection Lactational breast abscess These are usually peripherally located and due to Staph. aureus . Local discomfort proceeds to painful swelling. Overlying skin may be red . Extreme cases may undergo necrosis and spontaneous discharge. Treatment If seen prior to frank abscess formation, consider antibiotic treatment alone \200\224 prescribe a penicillinase-resistant antibiotic. If there is any suspicion of an ab scess, refer for needle aspiration \200\224 if pus is found, drainage will be needed. Enco urage the infant to feed from the contralateral breast whilst the affected side is emptied of milk manually or by breast pump. Non-lactational breast abscess Typically affects the 30 \200\22360-year age group, usually peri-areolar, recurrent, and related to duct ectasia/ periductal mastitis. Refer for needle aspiration, culture, and antibiotics (metronidazole and \202 ucloxacillin). Note that in \202 ammatory breast cancer may mimic septic mastitis and breast abscess. Incision of neo plastic lesions may have disastrous results. Perineal abscesses See b Anorectal problems, p.518. 528 CHAPTER 10 Surgery Cellulitis and erysipelas Cellulitis (see b Infected wounds and cellulitis, p.413) Cellulit is re \202 ects bacterial skin infection (usually streptococcal, occasion- ally staphyloco ccal). It can occur in association with a skin wound acting as a portal of entry for infect ion (eg athlete \200\231s foot), but it may also occur without any obvious breach in the sk in. Ascertain whether or not there is evidence of systemic upset or any background problems , such as immuno- de \201 ciency, diabetes, or steroid therapy. The area of affected skin is red, warm to the touch with poorly de \201 ned margins. Check T and look for lymphangitis and/or lymphadenopathy. Treatment depends upon the nature a nd extent of clinical \201 ndings as follows: \200 Treat patients who have localized li mb infection and no evidence of systemic upset with oral antibiotics (either phenoxymethylp enicillin + \202 ucloxacillin or co-amoxiclav or erythromycin) and arrange follow-up in 2 4 \200\22348hr. Admit patients who are systemically unwell or have spreading infection (eg lymphangitis ext ending above the knee from an area of cellulitis on the foot). Obtain venous access, take b lood cultures and start IV antibi- otics (either benzylpenicillin + \202 ucloxacillin or co-amoxiclav). Patients with cellulitis of the face (particularly around the eye) are at risk of signi \201 cant intracranial complications (notably cavernous sinus thrombosis) \200\224 start I V antibiotics and refer for admission to the ophthalmology team. Erysipelas This streptococcal infection is limited to the more super \201 cial parts of th e skin, resulting in an area of redness and heat with clearly de \201 ned margins. Treat w ith antibiotics as outlined for cellulitis above, except that phenoxymethylpenicillin alone (500mg PO qds for 7 days) suf \201 ces in most cases. Necrotizing fasciitis See b Streptococcal infections, p.234. 529 COMPLICATIONS OF VARICOSE VEINS Complications of varicose veins Occasionally, patients may attend the ED with complications of their varicose veins. Bleeding from varicose veins Patients with chronic venous hypertension associated with vari cose veins have a signi \201 cant risk of hemorrhage from the dilated thin-walled veins wh ich commonly surround the area of lipodermatosclerosis at the ankle. Hemorrhages may be pro fuse and suf \201 cient to cause hypovolemic shock. In extreme cases, this may even cause death. Treatment Control bleeding by elevating the leg, applying a non-adherent dressing an d pressing \201 rmly. Follow this with appropriate bandaging; unless there is evidence of occlusive arterial disease (varicose veins and arterial disease frequently co-exist in the elderly). Some patients may require resuscita- tion with IV \202 uids. Refer for admissi on those who were shocked at presentation, those who have subsequently bled through the ban daging, those with occlusive arterial disease, and those who live alone. All patients will require surgical outpatient follow-up \200\224 advise patients who are discharged about \201 rst aid measures in the event of a rebleed. Super \201 cial thrombophlebitis This occurs most frequently in patients with varicose vei ns or prothrom- botic states (eg underlying in \202 ammatory and malignant conditions). It usually manifests itself with redness, tenderness and induration along the course of the i nvolved vein. Treatment Bed rest, elevation, and analgesia (NSAID). Pain typically d over 1 \200\2232 weeks and the patient is left with a hard thrombotic cord. Super \201 cial thro m- bophlebitis is only rarely associated with DVT, but occasionally thrombosis spreads from the long saphenous vein to involve the femoral vein. If there is any question of deep vein involvement, request an USS. If the thrombotic process involves the sapheno-femoral juncti on or the ilio-femoral system, refer for anticoagulation ( b p.170). Venous ulcers Venous (varicose) ulcers tend to be chronic and recurrent. They are typi- cal ly found on the medial side of the ankle. There is often associated derma- titis with surro unding brown discolouration, thickening of the skin and leg oedema. There is often mixed ve nous and arterial disease, especially in the elderly. Although ischaemic ulcers tend to lie on the lateral aspect of the ankle, exclude ischaemic ulceration by checking the periphera l pulses (request Doppler in patients with oedematous legs). Look for areas suspicious of m alignant change, which may rarely occur in chronic ulcers (Marjolin \200\231s ulcer). Treat ment Clean the ulcer with normal saline and dress it with either paraf \201 n gauze or col loidal dressing. Follow this with \201 rm bandaging (unless there is co- existing arteria l disease) and advise leg elevation when the patient rests. Avoid dressings with topical an tibiotics and indiscriminate use of oral anti- biotics. Prescribe oral antibiotics (eg co-a moxiclav) only if there is cellulitis. Liaise with the GP about the need for surgical outpa tient follow-up and to arrange for redressing by the district nurse. 530 CHAPTER 10 Surgery Ruptured abdominal aortic aneurysm Middle-aged and elderly people frequently develop abdomi nal aortic aneu- rysms. Rupture is relatively common and responsible for a large number of deaths, many of which occur suddenly out of hospital. Even when the patient reaches hospita l alive, there is a signi \201 cant mortality. The patient \200\231s best chance of surviv al lies with early diagnosis, prompt resuscitation and rapid transfer to theater. Most aneu rysms are saccular and found in the infrarenal portion of the aorta \200\224 hemorrhage af ter rupture is usually into the retroperitoneum. Aneurysm extension to involve the renal ar teries renders surgery more dif \201 cult and i risk of post-operative complications. History Presentation is highly variable, ranging from PEA cardiac arrest to painless sudden collapse of obscure origin, through to a classical history of central abdominal and lower back pain in a patient with a known aneurysm. Pain is usually a feature: typically sudden i n onset and severe in nature. Examination The seriously ill patient may present a characteristic picture: distressed, pal e, sweating, tachycardic, and hypotensive, with mottled skin of the lower body and a tender pulsatile abdominal mass. One or both femoral pulses may be absent. Diagnosis Ruptured aortic aneurysm is not infrequently misdiagnosed as ureteric colic. Adop t a low threshold of suspicion in any middle aged or elderly patient who presents with back pain, abdominal pain or collapse. In some patients (eg the obese), it may be dif \201 cul t to be certain about the presence of a pul- satile abdominal mass. In such cases, assume t hat the problem is a ruptured abdominal aortic aneurysm and commence resuscitative measures , whilst appropriate experts are summoned and relevant emergency con \201 rmatory investig ations (eg USS or CT scan) are performed. It may be safer and quicker to perform USS in the ED, rather than transfer the patient for CT scan. Management \200 Provide high \202 ow O 2 . \200 Obtain venous access with 2 large bor e venous cannulae. \200 Send blood for FBC, U&E, glucose, baseline coagulation screen, LF Ts and emergency X-matching (10U red cells + 8U platelets + 8U fresh frozen plasma). Provide IV analgesia (eg morphine titrated according to response). \200 Provide IV anti-e metic (eg cyclizine 50mg). \200 Give IV \202 uids as necessary, but avoid excessive \202 uid resuscitation. Treat major hypovolaemia, but accept moderate degrees of hypotensio n (systolic BP > 90mmHg). In general, patients who are conscious and passing urine require minimal IV \202 uid therapy until they reach theater. Obtain a CXR. \200 Insert a urinary catheter and a radial arterial line and record an ECG . \200 Call the vascular surgeon and anesthetist at an early stage: aortic cross- clamping is the mainstay of resuscitation in the unstable patient. Ensure that other relevant staff (eg emergency theater staff) are informed. 531 ACUTE LIMB ISCHAEMIA Acute limb ischaemia Clinical features Irrespective of the cause, the cardinal features of acute limb ischaemia are summarized by the 6 P \200\231s: \200 Pain. \200 Paraesthesia (later anesthesia). \200 Pallor (later mottled, cyanosed). \200 Pulselessness. \200 P aralysis (due to muscle damage \200\224 this may be irreversible after 4 \200\2236hr). \200 Perishing cold. Where an acute arterial occlusion occurs in a previously normal limb, the features of ischaemia will be i because of the absence of a developed collateral circu lation. In the absence of a traumatic cause (either direct arterial injury, or indirect inj ury such as compartment syndrome \200\224 b Crush syndrome, p.398) the commonest causes ar e embolism or thrombosis. Embolic Cardiac sources account for > 80 % (AF, post MI, prosthetic valves, atrial myxoma, vegetations, and rheumatic heart disease). Acute embolic events affect the legs much more o ften than the arms (ratio 5:1). Artery bifurca- tions are affected most commonly. Risk fact ors Diabetes, smoking, hypertension, hypercholesterolaemia. Past history Ask about previous transient ischaemic attack (TIA), stroke, MI. Examination A clear demarcation between normal and ischaemic skin suggests an embolic cause of an acutely ischaemic limb. Look for potential sources of emboli (irregular pulse, abnor mal heart sounds, murmurs, valve clicks, etc.). Check all pulses in both the affected and c ontralateral limbs. The presence of normal pulses in the contralateral limb suggests an emb olic cause, whereas absent contralateral pulses makes thrombosis more likely (even if a pot ential embolic source exists). Investigations ECG, CXR, U&E, CK, FBC, coagulation screen, ABG, urinalysis (checking for my oglobin), cross-match. Cardiac and/or abdominal USS may be required and if thrombosis in si tu is suspected, angiography indicated. Thrombotic Thrombosis may develop acutely at the site of atheromatous disease. A previous h istory of intermittent claudication/vascular impairment is likely. The other limb is also l ikely to have features of chronic vascular insuf \201 ciency (muscle wasting, hair loss, u lceration). Treatment \200 Give appropriate pain relief (usually IV opioid). \200 Correct hypovolae mia and other causes of low \202 ow states as necessary. \200 Re-vascularization is req uired within 6hr to avoid permanent muscle necrosis (and subsequent need for amputation) an d metabolic effects (such as rhabdomyolysis and renal failure). If the cause is embolic, em bolectomy is required. If thrombotic, angiography will de \201 ne the site and extent of t he lesion: thrombolysis reconstructive surgery is then undertaken. This page intentionally left blank 533 Chapter 11 Ophthalmology Approach to eye problems Ophthalmological trauma Corneal trauma Contact lens problems Sudde n visual loss The red eye 534 536 538 539 540 542 534 CHAPTER 11 Ophthalmology Approach to eye problems History Always take a full ophthalmic history. Which eye is affect ed (are both)? What is the disturbance? Are there \202 ashing lights or \202 oaters? Ho w quickly did the symptoms come on? How does it affect the patient \200\231s lifestyle (job , reading, watching TV)? Ask about prior ophthalmic/optician treatment and take a full medi cal and drug history. Family history of glaucoma may also be relevant. Always measure visual acuity of patients presenting with eye problems. Patients with potent ially serious pathology include those with: \200 Sudden visual loss. \200 Signi \201 c antly d VA. \200 Penetrating eye injuries. \200 Chemical burns of the eye (these requir e immediate treatment and specialist referral). Have a low threshold for involving an ophthalmologist if a patient who is already blind in one eye, presents with a problem with the \200\230good eye \200\231. Examination Visual acuity (VA) is the key to eye examination: measure this \201 rst. Fail ure to document VA may constitute negligence Use a Snellen chart, read at 6m, for each eye separately. Allow patients to use glasses if available, if not employ a pinhole (made using a needle through a piece of card). Use of a pinhole eliminates refractive error. VA is expressed as: Distance from chart in m/no. of line on chart (normal vision is 6/6) For example, a patient whose VA is recorded as Right eye 6/5; Left eye 6/60 can read the bo ttom line with the right eye, but only the top line with the left eye. If patients read add itional letters of the line below, record using + number of extra letters (eg 6/12 + 2). Bring patients unable to read chart at 6m forward until they can read the chart (eg 3/60 = top line read at 3m). Very poor vision: try counting \201 ngers or detecting hand movemen t at 1m, or light perception. A hand-held chart at 30cm is an alternative if a full Snellen chart is unavailable \200 \224 ability to read small print implies normal VA for that eye. For patients who are illit erate, there is an alternative chart with various different versions of the letter \200 \230E \200\231 \200\224 ask the patient to state which directions the 3 limbs of the lette r point. 535 APPROACH TO EYE PROBLEMS Pupils Record pupil size, shape, direct, and consensual responses to light and accommodatio n. Eye movements Check full range and ask about diplopia. Look for nystagmus. Visual \201 elds Check carefully in patients with visual loss. Fundoscopy In a darkened room, \201 rst note the presence of a red re \202 ex. A lost or d red re \202 ex is an abnormal \201 nding, typically caused by vitreous hemorrhage, ca taracts, or major corneal abrasions. Assess the optic disks, look for retinal hemorrhages a nd vessel abnormalities. Direct assessment Under a bright light look for in \202 ammation or FBs. Subtarsal examination If there is a possibility of FB, evert the upper eyelid by pressing d own lightly over the upper lid with a cotton bud or orange stick and rotating the lid upwar ds over it. Ask the patient to look down throughout. Slit lamp examination Learn how to use a slit lamp. It allows a detailed view of conjunctiv a, cornea, and anterior chamber. Fluorescein staining reveals corneal abnormalities, partic ularly when viewed under blue light, when abrasions appear green. Fluorescein is available either in drop form or dried onto a strip. Remember that \202 uorescein can permanently s tain clothes and contact lenses. Intraocular pressure Digital assessment is unreliable. Formal measurement of intra-ocular p ressure is useful, but requires training and is left to the eye specialist in many departme nts. Temporal arteries Palpate for tenderness if temporal arteritis is a possibility. LA drops to aid examination Sometimes, blepharospasm prevents satisfactory examination. Con sider LA drops (1 or 2 drops of 1 % amethocaine/tetracaine or 0.4 % oxybupro- caine. 0.5 % proxymetacaine causes less stinging and is useful in children). Never discharge patients wi th a supply of local anesthetic drops . Notes on ophthalmological treatments Antibiotic ointment and drops Apply to the lower forni x (between lower eyelid and sclera) then ask the patient to keep the eye shut for 1 \200 \2232min. Ointment has the advantage over drops in that it lasts longer: for example, chlor amphenicol ointment needs to be given 4 times a day, whereas drops need to be given every 2 hr initially. Theoretical concerns about aplastic anemia are not well-founded (see the BNF ). Eye pads Previously recommended following the administration of LA drops and for patients w ith corneal abrasions, they tend not to be useful unless the pad seals the eyelid shut. Driving Advise patients not to drive until their vision has returned to normal (this partic ularly applies after use of mydriatic agents). In addition, advise patients not to drive wh ilst wearing an eye pad. Document the advice given in the notes. 536 CHAPTER 11 Ophthalmology Ophthalmological trauma Blunt eye injuries Blunt injury to the face may result in injury to the orbit or its bony margins. Compression of the eye in an antero-posterior direction (eg squash ball or \201 st) can cause a \200\230blow-out \200\231 fracture of the \202 oo r of the orbit. Orbital compartment syndrome and blindness can arise from a retrobulbar haematoma . Unless diagnosed and treated as an emergency, optic nerve ischaemia develops and the patient can l ose sight in the affected eye within a few hours. Proptosis, reduced eye movements, reduced visual acuity and pain all point to a retrobulbar haematoma. There may be an afferent pupi llary defect. Assessment \200 Look for proptosis. \200 Check visual acuity. \200 Check pupillary re \202 exes. \200 Check for enophthalmos and d infra-orbital nerve sensation, both found in a blowout fracture. Document range of eye movements, looking in particular for entrapment of the extra-ocular muscles. Look for a hyphaema (a horizontal \202 uid level in the anterior chamber when the patient is upright). It can cause pain, photophobia, blurred vision and can i intra-ocular pressur e, causing nausea and vomiting. \200 Stain the cornea and examine using slit lamp for cor neal abrasions. \200 Ophthalmoscopic examination may reveal lens dislocation, hyphaema, v itreous, subhyaloid, or retinal hemorrhage. Sometimes retinal oedema ( \200\230commotio ret inae \200\231) may be seen as white patches with diffuse margins on the posterior pole of t he eye. X-ray if there is bony tenderness or clinical evidence of orbital or facial bone fracture. Treatment Any patient suspected of a retrobulbar haematoma requires an emergency lateral ca nthotomy. This should be performed by an ophthalmologist or a trained emergency physician, under local anesthetic in the ED, and reduces the retro-orbital pressure. Nurse patients with obvious globe injury head up at 45 . Refer urgently. Provide prophylactic oral antibiotics (eg co-amoxiclav) for uncomplicated facial or orbital fractures, and arrange for maxillofacial follow-up, with advice to avoid nose-blowing in t he meantime. 537 OPHTHALMOLOGICAL TRAUMA Penetrating eye injuries Suspect intraocular foreign body if there is a history of hammerin g or work involving metal on metal. Find out if protective glasses were worn. Ascertain whe ther a small foreign body traveling at speed may have pen- etrated the orbit (eg during gri nding, hammering, chiseling). Failure to suspect and diagnose these injuries can have serio us consequences. Assessment \200 Check visual acuity. \200 Look for pupil irregularity. \200 Look for puncture/entry wounds on both aspects of the eyelids, the cornea and sclera. Corneoscleral wounds are often situated inferiorly, due to upturning of the eyeball as the patient blinks . Examine the anterior chamber. There may be a shallow anterior chamber, air bubbles, a \202 at cornea, de \202 ated globe and a positive Seidel \200\231s test (dilution of \202 uorescein by aqueous humor leaking from the ante- rior chamber). Look for a hyphaema. \200 Look for vitreous hemorrhage on fundoscopy. X-ray all patients with possible globe penetration (consider also CT or USS) Give analgesia, tetanus prophylaxis, IV antibiotics (eg 1.5g cefuroxime), and refer all pat ients with penetrating eye injuries immediately to an ophthalmologist, even if there are ot her major injuries needing attention at the same time. Never manipulate or try to remove embedded objects (eg darts). 538 CHAPTER 11 Ophthalmology Corneal trauma Conjunctival FB The typical history is of dust or grit blown into an eye by the wind. The FB usually gravitates into the lower fornix \200\224 remove with a cotton bu d. Subtarsal FB FBs may not gravitate into the lower fornix, but may remain stuck under the upper eyelid. The patient reports pain on blinking. Fluorescein staining reveals character istic vertical corneal abrasions (the cornea has been likened to an \200\230ice rink \200 \231). Evert the upper eyelid and remove the FB with a cotton bud. Discharge with topical a ntibiotic (eg chloramphenicol oint- ment qds or fusidic acid eye drops). Corneal abrasions Often result from a newspaper or \201 ngernail in the eye. Irritation, photo- phobia, and lacrimation occur. Use LA drops and \202 uorescein staining to examine the cornea. Exclu de FB or penetrating injury. Prescribe regular antibiotic ointment (eg chloramphenicol) and oral analgesia. An eye patch which seals eyelids closed will aid the symptoms and recovery . If the patient is very uncomfortable, consider instilling a drop of 1 % cyclopentolate to dilate the pupil (this reduces iris spasm) or a drop of 0.1 % diclofenac. Advise the patie nt not to drive until vision has returned to normal. Advise also to return for review if sy mptoms continue beyond 36hr. Corneal foreign body Instill LA and attempt removal with a cot ton bud. If unsuccessful, remove with a blue (23G) needle introduced from the side (ideally using a slit lamp). Ensure that the patient \200\231s head is \201 rmly \201 xed and c annot move for- wards onto the needle: it can help for the operator \200\231s hand to rest lightly on the patient \200\231s cheek. After complete removal of the FB, check that the an terior chamber is intact, instill and prescribe antibiotic ointment, and advise the patient to return if symptomatic at 36hr. Refer patients with large, deep or incompletely removed FB, or if a rust ring remains. Arc (welder \200\231s) eye/ \200\230snowblindness \200\231 E xposure to ultraviolet light can cause super \201 cial keratitis. Climbers/skiers, welders , and sunbed users who have not used protective goggles develop pain, watering, and blephar ospasm several hours later. LA drops allow examination with \202 uorescein staining, reve aling multiple punctate corneal lesions. Consider instilling a drop of 1 % cyclopentolate o r 0.1 % diclofenac into both eyes. Discharge with an eye pad, oral analgesia, and advice no t to drive until recovered. Anticipate resolution within 24hr. Do not discharge with LA dro ps. Chemical eye burns Chemical burns from alkali or acid are serious. Triage urgently ahea d, check Toxbase and provide immediate eye irrigation with lukewarm normal saline for at le ast 20min, or until the pH of tears has returned to normal (7.4). A 1L bag of 0.9 % saline with standard IV tubing is ideal. LA may be needed to enable full irrigation. Identify the substance involved and contact Poisons Unit. Refer alkali and acid burns immediately. Super glued eyelids Wash with warm water. The eye will open within 4 days. If the patient reports a FB sensation, this may represent a lump of glue, which may cause an abrasion if left unt reated: refer to the ophthalmologist. 539 CONTACT LENS PROBLEMS Contact lens problems Contact lenses are of two basic types: hard or soft. Soft lenses, com posed of hydrogels, are more comfortable to wear. Avoid using \202 uorescein with contact lenses, as permanent staining may occur. \200\230Stuck lens \200\231 Most contact lens users are adept at removing their contact le nses. New users, however, not infrequently experience dif \201 culty in their removal. Moi sten soft lenses with saline, then remove by pinching between \201 nger and thumb. Specia l suction devices are available to help remove hard lenses. \200\230Lost lens \200\231 Patients may present concerned that they are unable to \201 n d their contact lens and cannot remember it falling out. Check under both eyelids carefully (evert the upper lid if the lens is not immediately apparent) and remove the offending len s, if present. Hypersensitivity and overuse Preservatives in lens cleaning \202 uid cause itching and ma y evoke a reaction. Advise to stop using the lenses, give local antibiotic ointment and arr ange ophthalmological follow-up. Acanthamoeba keratitis This is a protozoal infection of the cornea which occurs in contact lens users, associated with poor lens hygiene or swimming whilst wearing contact lenses. Th e eye becomes painful and red. Corneal oedema and ulceration develops. If acanthamoeba infe ction is suspected, refer immediately for ophthalmological care. Other problems Treat and refer conjunctivitis, corneal abrasions, or ulcers apparently rela ted to contact lenses as outlined opposite. Advise avoidance of use of both contact lenses until the problem has resolved. 540 CHAPTER 11 Ophthalmology Sudden visual loss Sudden visual loss requires emergency assessment and treatment. Amaurosis fugax The patient describes temporary loss of vision in one eye, like a \200\230 curtain coming down \200\231, with complete recovery after a few seconds to minutes. The ca use is usually a thrombotic embolus in the retinal, ophthalmic, or ciliary artery, originat ing from a carotid atheromatous plaque. Refer urgently to the ophthalmology team. Central retinal artery occlusion The central retinal artery is an end artery. Occlusion is usually embolic (check for atrial \201 brillation and listen for carotid bruits), causing sudden painless d VA to counting \201 ngers or no light perception. The patient may have a history of amaurosis fugax. Direct pupil reaction is sluggish or absent in the affected eye, but it reacts to consensual stimulation (afferent pupillary defect). Fundoscopy reveal s a pale retina, with a swollen pale optic disc and \200\230cherry red macula spot \200 \231 (the retina is thinnest here and the underlying choroidal circulation is normal). Reti nal blood vessels are attenuated and irregular: there may be \200\230cattle-trucking \200 \231 in arteries.