SAEM Clinical Images Series: Workout Gone Wrong

hyphema

A 28-year-old male presented to the ED for evaluation of an injury to his right eye. While working out with an exercise band, it snapped back, hitting the patient in the right eye. He experienced blurry vision and excess eye tearing immediately after the incident occurred. The patient also developed gross blood over the front of the eye.

Vitals: Temp 98°F, HR 73, BP (135/77), RR 16, SpO2 99%

HEENT: Gross blood in the anterior portion of the right eye (grade I). The right pupil is dilated with minimal responsiveness to light. Visual Acuity: OD 20/70, OS 20/10, Both 20/10. Pressure: OD (21), OS (16). Decreased visual field on the right when compared to the left. Staining with tetracaine and fluorescein did not reveal any evidence of corneal abrasion or ulceration. Left eye is atraumatic in appearance.

Neurologic: Alert and oriented x3

Non-contributory

A Hyphema is a collection of blood in the anterior chamber of the eye due to the tearing of the iris root vessels.

The most common cause is blunt trauma to the eye. Spontaneous hyphemas can also occur and are often associated with sickle cell disease. It can be caused by ocular surgery and neoplastic disease, as well.

Take-Home Points

  • Hyphemas are an ocular emergency and should prompt immediate consultation with an ophthalmologist.
  • Patients should elevate the head of the bed to 45 degrees since layering of the blood is gravity-dependent.
  • Treatment usually involves the administration of steroidal and cycloplegic ophthalmic drops.
  • Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., & Yealy, D. M. (2020). 241. In Tintinalli’s emergency medicine: A comprehensive study guide. essay, McGraw-Hill Education.
  • Traumatic Hyphema. Wikem. (2020, March 18). Retrieved January 11, 2023, from https://www.wikem.org/wiki/Main_Page

SAEM Clinical Images Series: Not Your Usual Irritated Eye

eye irritation

In July 2022, a 32-year-old male with a past medical history of HIV (on antiretroviral therapy, CD4 390, viral load undetectable) presented to the emergency department with constitutional symptoms and a rash for 4-5 days. His symptoms included malaise, body aches, subjective fevers, a sore throat, tender, swollen neck glands, body rash, and irritation of his left eye. He also noticed fluid-filled vesicles on his face, neck, trunk, and extremities. He denied travel outside the U.S. but reported a recent trip to New Orleans. He denied any new sexual partners or known exposure to individuals with similar symptoms.

Vitals: BP 135/83; Pulse 104; Temp 100.2 °F (37.9 °C); Resp 22; SpO2 99%

Constitutional: Alert, no acute distress

HEENT: 1×1 mm raised lesion to the left medial canthus/caruncle. No appreciated LAD. Oropharynx is clear and moist, and mucous membranes are normal.

Cardiovascular: Tachycardia, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, unlabored respirations.

Abdominal: Soft. Non-tender.

Skin: Numerous 5-6 mm erythematous macules, bland fluid-filled vesicles, and umbilicated lesions throughout the face, neck, trunk, and extremities.

Complete Blood Count (CBC): WBC: 19.5 10^3/mcL, Hemoglobin: 15.2 gm/dL, Hematocrit: 43.6%, Platelet count: 325 10^3/mcL

Comprehensive Metabolic Panel (CMP): Within normal limits

RPR titer: Reactive, 1:4

Syphilis antibody IgG and IgM: Positive

Orthopoxvirus DNA: Pending

HIV RNA: Pending

The patient has Monkeypox with involvement of the caruncle of the left eye. The patient tested positive for non-variola orthopoxvirus DNA. Ophthalmology was consulted and did not find any other signs of compromise to the eye and recommended treatment with artificial tears. The patient received 14 days of Tpoxx. The patient’s eye lesion and symptoms resolved and he was discharged on hospital day eight.

Ocular lesions are a rare presentation of the monkeypox virus. There is limited literature documenting eye involvement and pictographic examples of its presentation. During the current outbreak, ocular involvement has been used as a criteria for hospital admission. The most commonly seen ophthalmologic lesions include a vesicular rash of the orbital and periorbital skin (25%), focal conjunctiva lesions, blepharitis, and conjunctivitis. Rarely, lesions can process to corneal ulcerations, keratitis, and vision loss. Given the late risk of vision loss in cases of ocular manifestations, clinicians should be aware of the varied presentation of ocular lesions associated with the monkeypox virus.

Take-Home Points

  • While rare, ocular involvement of Monkeypox is associated with vision loss, and should be promptly identified and addressed by a clinician.
  • If there is ocular involvement of primarily cutaneous pathology, a thorough eye exam is indicated in the initial assessment of the patient.
  • Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. Ophthalmic manifestations of monkeypox virus. Eye (Lond). 2023 Feb;37(3):383-385. doi: 10.1038/s41433-022-02195-z. Epub 2022 Jul 27. PMID: 35896700; PMCID: PMC9905463.
  • Kumar N, Acharya A, Gendelman HE, Byrareddy SN. The 2022 outbreak and the pathobiology of the monkeypox virus. J Autoimmun. 2022 Jul;131:102855. doi: 10.1016/j.jaut.2022.102855. Epub 2022 Jun 25. PMID: 35760647; PMCID: PMC9534147.
  • Thornhill, John P., et al. “Monkeypox virus infection in humans across 16 countries—April–June 2022.” N Engl J Med. 2022 Aug 25;387(8):679-691. doi: 10.1056/NEJMoa2207323. Epub 2022 Jul 21. PMID: 35866746.

SAEM Clinical Images Series: Two Pupils for the Price of One

pupil

A 24-year-old female with no pertinent PMHx presents to the ED with a chief complaint of eye pain. She reported a 10-day history of worsening right eye pain following being punched in that eye. She had been managing her pain with ice and had not taken any OTC medications. Her mom convinced her to go to the ED and she first went to an outside hospital, but was referred to come to our institution. She endorsed photophobia and blurry vision but denied double vision. She further noted occasional left-sided headaches.

Vitals: Within normal limits

General: The patient is alert and conversant. No apparent distress.

HEENT: NC, AT. Mucous membranes moist. Neck supple. Minimal pain with EOM. No double vision in right eye. Right eye discoloration at superior portion. Divided abnormal pupil. Mild superior periorbital swelling. Visual acuity: Right – 20/400, Left – 20/25

CV: Regular rate and rhythm.

Resp: Clear to auscultation bilaterally.

Abd: Soft, non-tender, non-distended.

Neuro: Alert. Motor and sensation grossly intact.

MSK: Moves all extremities, no joint pain or tenderness.

Skin: No obvious rashes or skin lesions.

Non-contributory

This is traumatic iridodialysis. It is typically related to significant blunt trauma to the eye that pulls the iris away from the ciliary body at the scleral spur [1]. That is what causes the split appearance or “two pupil” phenomenon.

Take-Home Points

  • Whenever you have a two-pupil phenomenon consistent with traumatic iridodialysis, the differential should always include penetrating injury to the globe, globe rupture, scleral rupture, hyphema, and lens dislocation. These additional findings may warrant urgent surgical repair or close monitoring of IOP. [2]
  • Consider bedside ultrasound to rule out posterior pathology (retinal detachment, vitreous hemorrhage, etc.).
  • Always refer to Ophthalmology, more urgently if the trauma was recent vs multiple days out (as in this case).
  • Knoop KJ, Palma JK. Iridodialysis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250455915
  • Gurwood AS. Cut at the root. Review of Optometry. https://www.reviewofoptometry.com/article/cut-at-the-root. Published November 19, 2012. Accessed January 2023.

By |2024-02-25T20:54:51-08:00Mar 1, 2024|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Retrobulbar Spot Sign

vision

A 59-year-old male with no known past medical history other than an incidental abdominal aortic aneurysm presented with sudden onset, painless vision loss in his left eye. The patient was watching TV two days prior when he saw a “brightness” in his left eye and then progressive blurriness until his vision faded away, all occurring within the span of a minute. At the time of presentation, he only sees a speck of light from that eye. He denied associated pain, flashes, floaters, jaw claudication, the sensation of a “curtain falling”, prior vision problems, or a history of blood clots.

Eyes: Eyelids and lashes normal. Visual acuity: 20/30 OD, Light Perception OS. EOMI. PERRL. OD visual fields intact. Afferent Pupillary Defect OD. Normal conjunctiva. IOP 16 OD, 14 OS. Otherwise CN 3-12 intact.

Complete blood count (CBC): Within normal limits

Basic metabolic panel: Creatine 1.3 (unknown baseline)

ESR: Unmarkable

Central Retinal Artery Occlusion (CRAO) is an ocular emergency that presents as acute painless monocular vision, caused by ischemia and infarction to the retina via thromboembolic disease to the central retinal artery. It requires immediate consultation with ophthalmology as well as neurology as it is considered a stroke equivalent.

The case described above and several previously published case studies highlight the utility of POCUS in identifying CRAO via the retrobulbar spot sign (RBSS) within the optic nerve in a rapid, non-invasive manner that can be done prior to waiting for dilation for a fundoscopy exam. This has the potential to expedite consultations with specialty teams and treatment.

Several studies also reveal the potential of POCUS to predict the etiology of CRAO (arterio-arterial embolization vs cardio-embolic vs vasculitis) and thus to predict the success of thrombolytic treatment in CRAO. In a prospective monocenter study of 46 patients with ophthalmologically confirmed CRAO, embolism from large artery atherosclerosis (LAA, i.e. carotids or aortic arch) was the etiology in 27 patients, cardioembolic in 10 patients, vasculitis in 5 patients, and unknown in 4 patients. Out of the LAA patients, 59% had RBSS compared with only 20% in cardioembolic and 0% in the vasculitis patients. Within the 11 patients that underwent thrombolysis, statistically significant visual improvement occurred in all 4 patients with RBSS negative CRAO, while the 7 patients with RBSS positive CRAO had persistent visual impairment with persistent occlusion of their arteries. This study concludes that their results support the hypothesis that RBSS is seen due to calcium deposits that will not be dissolved with thrombolysis. Another small single-center German study points out the utility of seeing RBSS as 100% specific for an embolic cause of CRA, excluding temporal arteritis from the differential.

Take-Home Points

  • POCUS can guide us in diagnosing a patient with painless vision loss prior to more time-consuming fundoscopy exam.
  • Stroke workup for CRAO is necessary, and don’t forget about secondary prevention/risk stratification which must be part of the management.
  • RBSS may predict poor response to systemic thrombolysis.

  • Ertl M, Altmann M, Torka E, Helbig H, Bogdahn U, Gamulescu A, Schlachetzki F. The retrobulbar “spot sign” as a discriminator between vasculitic and thrombo-embolic affections of the retinal blood supply. Ultraschall Med. 2012 Dec;33(7):E263-E267. doi: 10.1055/s-0032-1312925. Epub 2012 Sep 21. PMID: 23023446.
  • Nedelmann, Matt et al. “Retrobulbar Spot Sign Predicts Thrombolytic Treatment Effects and Etiology in Central Retinal Artery Occlusion” American Heart Association (AHA). Stroke. 2015;46:2322–2324 https://doi.org/10.1161/STROKEAHA.115.009839
  • Smith, Austin T et al. “Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions.” Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine vol. 39,1 (2020): 197-202. doi:10.1002/jum.15073

By |2024-01-28T21:19:20-08:00Jan 29, 2024|Ophthalmology, SAEM Clinical Images, Ultrasound|

SAEM Clinical Images Series: Dangerous Eye Drainage

orbital abscess

A 32-year-old man with a history of traumatic globe rupture from a stab wound two months ago, status post repair, presented to the emergency department for worsening right eye pain and green malodorous drainage for the past three days. These symptoms started when he got a fleck of sawdust in the right eye about four days prior to presentation, which he was able to brush out with his finger. He described the pain as severe, throbbing, constant, and non-radiating. He had been unable to open the right eyelid for three days, both due to pain and from the thick sticky discharge that adhered his eyelids together. He reported that his vision had been normal before these symptoms started. On review of systems, he reported nausea that started on the day of presentation but otherwise denied any vision loss or pain in the other eye.

General: Nontoxic appearing but seemed quite uncomfortable.

Eye: On inspection, he had substantial right upper and lower eyelid swelling and erythema, with a green discharge dripping from the palpebral fissure. There was a well-healed scar on the bottom eyelid. The lateral canthus appeared inferiorly displaced. The patient was unable to open his right eye actively, and was unable to tolerate passive opening due to severe discomfort, despite pain medication.

White blood cell (WBC) count: 9.1 x 10^3 /uL with 80.4% neutrophils

Complete metabolic panel (CMP): Within normal limits

Procalcitonin:<0.05 ng/mL

Lactate: 1.4 mmol/L

Cultures from the eye revealed penicillin-sensitive Streptococcus pneumoniae.

Pain with extraocular movements should be present in orbital cellulitis due to inflammation of the structures deep within the orbit. Although not sensitive, proptosis, leukocytosis & fever, chemosis, or any visual impairment should raise concern for orbital cellulitis.

In this patient, displacement of the lateral canthus likely represents a mass effect from his orbital abscess. This abscess is seen lateral to the globe on imaging. On ultrasound, it appears as a heterogeneous isoechoic collection that abuts the right globe. A hyperechoic structure between the orbit and this collection with shadowing raises the possibility of a foreign body. Debris is also visible throughout the right globe and within the anterior chamber. On CT scan, the abscess is described as a rim-enhancing fluid collection that adheres to the lateral rectus muscle. The hyperdense foreign body is again seen on CT, as well as a small focus of air within the anterior chamber.

Take-Home Points

  • Orbital abscess is an uncommon but vision-threatening ocular emergency, which can come from traumatic injury to the globe (as with this case), sinus/nasal infections, or as a complication of dental procedures.
  • The most common organisms responsible for orbital abscesses are Streptococci species (including Strep. pneumoniae and Strep. pyogenes), Staphylococcus aureus (including methicillin-resistant Staph. Aureus), and Pseudomonas aeruginosa.
  • Surgical management is necessary in almost all cases of orbital abscess, with just under 50% of all patients achieving complete visual recovery.

  • Krohel GB, Krauss HR, Winnick J. Orbital abscess. Presentation, diagnosis, therapy, and sequelae. Ophthalmology. 1982 May;89(5):492-8. doi: 10.1016/s0161-6420(82)34763-6. PMID: 7099569.
  • Zawadzki T, Komisarek O, Pawłowski J, Wojtera B, Bilska-Stokłosa J, Osmola K. Orbital Abscess-Two Case Reports with Review. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 2):1334-1343. doi:10.1007/s12070-021-02486-z

By |2023-10-22T20:48:41-07:00Oct 23, 2023|HEENT, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Contact Your Nearest Ophthalmologist

cornea

A 29-year-old female with a past medical history of migraine headaches presented to the emergency department (ED) for several hours of bilateral eye pain, redness, and decreased visual acuity. The patient is a contact lens wearer. The night prior to presentation at 18:00, the patient inserted her contacts that she had washed and soaked in a hydrogen peroxide (H2O2) cleaning solution. She removed the contacts five hours later at 23:00, at which time she noted her eyes to feel drier than normal but did not note significant pain with removal, significant trauma, or a partial contact removal. For the eye dryness and mild irritation, she rinsed her eyes with her contact solution. She woke up the following day at 6:00 with severe, bilateral eye pain, blurry vision, and difficulty opening her eyes due to pain. She again washed her eyes with contact solution which resulted in worsening pain while also noting a “fizzing” sensation in her eyes which prompted her presentation to the ED at 10:00. She denied any foreign body sensation, known trauma, or experiencing similar symptoms previously.

General: Mildly uncomfortable appearing

Eyes: Bilateral corneal injection with mild tearing. No foreign body on lid eversion. Uncorrected visual acuity of 20/200 in the right eye and 20/30 in the left eye. Extra-ocular movements intact. Right eye pressure measured 18 mmHg and left eye 17 mmHg. pH 7.0 in both eyes.

Fluorescein uptake represents defects in the cornea that allow for this dye to pool. For this case, this represents trauma caused by contact lens removal as the uptake covers the areas where contacts are placed.

Given the location and size of these defects, antibiotic drops should be promptly initiated, and prompt ophthalmologic evaluation should be obtained.

Take-Home Points

  • Corneal abrasions can occur in both eyes at once.
  • Timely administration of antibiotic drops and ophthalmology evaluation is crucial to prevent progression to corneal ulcer and the need for corneal transplant.

  • Cope JR, Collier SA, Rao MM, Chalmers R, Mitchell GL, Richdale K, Wagner H, Kinoshita BT, Lam DY, Sorbara L, Zimmerman A, Yoder JS, Beach MJ. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections–United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Aug 21;64(32):865-70. doi: 10.15585/mmwr.mm6432a2. PMID: 26292204; PMCID: PMC5779588.
  • Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR – Contact lens complications. Cont Lens Anterior Eye. 2021 Apr;44(2):330-367. doi: 10.1016/j.clae.2021.02.010. Epub 2021 Mar 25. PMID: 33775382.
  • U.S. Food and Drug Administration. (2022, August 16). Hydrogen Peroxide Solution. Hydrogen Peroxide Solution | FDA. Retrieved September 5, 2022, from https://www.fda.gov/medical-devices/contact-lenses/hydrogen-peroxide-solution

By |2023-09-05T15:24:04-07:00Sep 11, 2023|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: My Eye Looks Different

cone

A 29 year-old-male with a past medical history of left eye enucleation secondary to a gunshot wound several years prior presents to the Emergency Department (ED) for blurry vision, redness, and concern for a deformity to his right eye. The patient states symptoms started 2-3 months ago and he initially thought symptoms were due to allergies and recalls rubbing his eye a lot. Over the past 3-4 days, he noticed an acute decline in his vision with what the patient describes as a “cloudy bump” appearing during that time. The patient normally does not wear contacts or corrective lenses but states his vision is very blurry and he is now having difficulty reading. He also reports photophobia and mild eye pain. Review of systems is negative for any fevers, headache, eye discharge, or any recent falls or trauma.

Vitals: BP 125/83; Pulse 70; Temp 97.6 F (36.4 C); Resp 17; SpO2 100%

Constitutional: No acute distress, lying in stretcher comfortably.

Head: No visible traumatic injuries. No peri-orbital edema or facial swelling.

Eyes:

  • OD: Edematous cone-shaped protrusion with central haziness. V-shaped deformity to lower lid margin noted on downward gaze. The patient reports no pain when performing extraocular movement testing which is intact and pupil is reactive to light. Visual fields intact. There is no fluorescein uptake upon Wood’s Lamp exam and IOP is 18. VisualAcuity OD 20/200.
  • OS: Eye prosthesis in place.

Nose: No foreign bodies.

Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.

Neck: Normal range of motion.

Corneal hydrops secondary to keratoconus.

Keratoconus is a degenerative, multifactorial, non-inflammatory disorder of the cornea that causes bilateral thinning of the cornea and distorted vision. The corneal thinning leads to a structural weakness in the collagen fibers that causes the characteristic bulging, “cone-shaped” cornea. If the thinning is significant enough, a break in collagen fibers and Descemet’s membrane lead to sudden edema which appears as a corneal opacification. This complication is known as corneal hydrops and causes sudden eye pain and decreased visual acuity. Patients with keratoconus present in young adulthood with progressive blurry or distorted vision. Risk factors include connective tissue disorders and Down syndrome as well as a familial history of keratoconus. There is also a risk in patients with a history of eye rubbing as was the case with this patient. The initial treatment for keratoconus is corrective eyewear for refractive correction.

The clinical hallmark of keratoconus is the cone-like protrusion of the cornea. The bulging may eventually lead to “Munson’s sign”, a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward that is seen in advanced keratoconus.

Take-Home Points

  • Suspect keratoconus in patients with a history of constant eye rubbing, developmental delay (i.e. Down Syndrome), and in patients with connective tissue disorders.
  • Munson’s Sign is a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward.
  • Initial treatment of keratoconus is conservative management with prompt ophthalmology follow-up.

  • V. Mas Tur, C. MacGregor, R. Jayaswal, D. O’Brart, N. MaycockA review of keratoconus: Diagnosis, pathophysiology, and genetics Surv Ophthalmol, 62 (6) (2017), pp. 770-783
  • Gold J, Chauhan V, Rojanasthien S, Fitzgerald J. Munson’s Sign: An Obvious Finding to Explain Acute Vision Loss. Clin Pract Cases Emerg Med. 2019 Jul 8;3(3):312-313. doi: 10.5811/cpcem.2019.5.42793. PMID: 31403106; PMCID: PMC6682229.
  • Gialousakis, John P. “Management of Acute Corneal Hydrops in a Patient with Keratoconus: a Teaching Case Report.” The Journal of the Association of Schools and Colleges of Optometry, vol. 45, 2020.
  • Greenwald MF, Vislisel JM, Goins KM. Acute Corneal Hydrops. EyeRounds.org. August 3, 2016; Available from: http://EyeRounds.org/cases/241-acute-corneal-hydrops.htm
  • Stack L, Sheedy C, Bales B. Corneeal Hydrops: A Complication of Keratoconus. Visual Diagnosis Ophthalmology. Published 2015 Dec 11. Available from: https://www.emra.org/emresident/article/corneal-hydrops-a-complication-of-keratoconus/

By |2023-04-05T14:07:32-07:00Apr 17, 2023|HEENT, Ophthalmology, SAEM Clinical Images|
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