I just wanted to revisit the Trick of using bedside ultrasonography to diagnose retinal detachments. Be sure to use plenty of ultrasound gel and use the linear tranducer.
Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don’t have the fancy ophthalmology eyelid retractors?
Trick of the Trade
Use a Q-tip
I thought of this idea when I was rolling up a projector screen in a conference room. Why can’t we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to “roll” the eyelid out of the way.
Below are a series of photos of a woman with eyelid swelling from conjunctivitis. This technique provides a relatively painless way to retract the eyelid without placing pressure on the orbit itself. Although the images look like I am merely lifting the eyelid using the Q-tip, I am actually twirling the Q-tip.
Consent and photographs taken by Lourdes Adame
(Visual Aid Project member)
(Visual Aid Project member)
Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren’t used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies.
For the past several years, I’ve stopped using Morgan lens and have started using something that all Emergency Departments have — nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation.
- Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached to a 1 liter normal saline bag. The IV tubing fits snuggly into the nasal cannula tubing.
- Rest the nasal cannula prongs over the patient’s nasal bridge to irrigate the eyes.
- Then open up the flood gates!
- To avoid a huge deluge of fluid onto the patient and floor, be sure to have a way to catch the fluid. Some place multitudes of towels around the patient’s head to absorb the fluid.
- As an alternative solution to towels, I like Dr. Stella Yiu’s (Univ of Toronto) adaptation of my cut-out basin approach for irrigating scalp wounds. To avoid overflow spillage, she rests a Yankauer suction tip at the bottom of the basin to collect the irrigation fluid.
Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings.
The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?!
Using the slit lamp can be a challenge to learn, especially if you haven’t seen pathology before. In checking for anterior uveitis (i.e. iritis), you need to look for “cell and flare”. In theory, you know that you are looking for inflammatory cells and “flare”, which resembles a light beam being filtered through smoke.(more…)
In a sneak peek of my ACEP News’ Tricks of the Trade column, Dr. Patrick Lenaghan, Dr. Ralph Wang, and I will discuss how bedside ultrasonography can significantly improve your ocular exam.
Here is a classic example. A patient presents with acute onset right eye pain and blurry vision. She possibly has a field cut in her vision. Her pupils are a teeny 2 mm in size in the brightly-lit Emergency Department. You are having a hard time getting a good fundoscopic exam to comfortably rule-out a retinal detachment.