Ophthalmologic Emergency Research Articles

Bilateral irreversible visual loss due to arteritic anterior optic ischemic neuropathy

Introduction: Anterior optic ischemic neuropathy (AOIN) is the most frequent cause of visual loss in giant cell arteritis (GCA). As blindness is rarely reversible, the main therapeutic goal is to prevent bilateral disease by immediate initiation of high-dose intravenous steroids. Approximately, one third of patients present with bilateral visual impairment. Case Report: A 77-year-old patient, came to the Ophthalmology Emergency Room for sudden loss of vision in the left eye (OS) to no light perception (NLP) with two days duration and significant narrowing of the visual field in the right eye (OD) with 10 hours duration. Fundus examination revealed swelling and pallor of the optic disc in both eyes (OU). Laboratory examination showed elevated ESR (56 mm/h) and CRP (5.24 mg/dl). Temporal artery biopsy (TAB) proved granulomas and fibrosis within the vessel wall. Immediate Methylprednisolon 1gm was administered intravenously for five days, followed by oral Prednisone 1mg/kg for four weeks with tapering of 10 mg per month. The patient was put on diabetic and low sodium regimen. During the 3rd day of treatment, vision OD dropped to NLP. Despite continuing systemic steroid therapy, vision remained unchanged. Two months following discharge, the patient died from myocardial infarction. Conclusion: Irreversible bilateral blindness occurred in a patient with arteritic AOIN, while he was on systemic steroids, probably due to late presentation, when vision was already affected bilaterally.

Current treatment of central retinal artery occlusion: a national survey.

Central retinal artery occlusion (CRAO) is an ophthalmological emergency, the retinal analog of a stroke. To date there is no consensus or national guidelines on how this disorder should be managed. As academic neurologists and ophthalmologists treat CRAO frequently, we set out to understand how these clinicians approach patients with CRAO with a national survey. We identified university-associated teaching hospitals offering vascular neurology, neuro-ophthalmology and/or retina fellowships in the US and asked the directors of the programs to respond to questions in an open response format to profile the acute management of CRAO at their institution. We found remarkable heterogeneity in the approach to acute treatment of patients with CRAO among the 45 institutions that responded to the survey. Only 20% had a formal policy, guideline or white paper to standardize the approach to treatment. The primary treating physician was an ophthalmologist, neurologist, or neuro-ophthalmologist 44, 27, and 4% of the time, respectively; 24% were co-managed acutely by neurology and ophthalmology. Intravenous fibrinolysis was offered to selected patients in 53% of institutions, and was the preferred initial treatment in 36%. When the acute treatment team involved a vascular neurologist, fibrinolysis was more likely to be considered a first-line treatment (p<0.05). Anterior chamber paracentesis, ocular massage and hyperbaric oxygen therapy were offered 42, 66 and 7% of the time, respectively, while 9% of institutions offered no treatment. Anterior chamber paracentesis was more likely to be offered at programs where neurologists were not involved in treating CRAOs (p<0.001). At 35% of institutions, patients with acute CRAO were not routinely referred to a general emergency room for initial evaluation and treatment. Carotid imaging was routinely obtained by 89% of programs, magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, laboratory screening for an inflammatory state by 27% and retinal angiography by 30%. The thoroughness of vascular risk factors' screening was greater in programs that routinely referred acute CRAO cases to the emergency department. This survey shows that there is significant variability in treatment practices for acute CRAO in the US. Because of the high cerebrovascular and cardiovascular risk reported in this population of patients, it is notable that the approach to risk factor screening is also highly variable and many programs do not routinely refer patients to an emergency department for urgent evaluation. Finally, there appears to be equipoise among treatment teams regarding the efficacy of systemic fibrinolysis, as 53% of programs report a willingness to treat at least some patients with this modality.

Corneal bacterial infections: A practical approach

SummaryBecause of their potential to permanently impair vision or perforate the eye, bacterial corneal ulcers are an ophthalmologic emergency. “ ey usually follow an insult (sometimes minor) in the corneal epithelium that provides an entry for bacteria. “ e increased use of soft contact lenses in recent years has led to an important rise in the occurrence of bacterial ulcers (especially aggressive Gram‐ bacteria). In this course you will learn about the new concepts in bacterial ulcers diagnosis and treatment.

Human dirofilariasis in the eyelid caused by Dirofilaria repens : An imported case

Abstract Clinical case The case concerns a 33-year-old Ukrainian woman, who came to the Ophthalmology Emergency Service, stating that she had a “worm” under the skin of her upper left eyelid that wriggled at night and bit her. A complete examination revealed a subcutaneous foreign body, which showed a filarial appearance and seemed to crawl under the skin. It was surgically removed to discover a live parasite, PCR-identified as Dirofilaria repens . Discussion Humans are accidental hosts in the cycle of Dirofilaria. There are only 8 reported cases of subcutaneous infection in Spain. Due to global warming, D. repens has become an emerging infectious agent in Central Europe countries such as Ukraine. The findings in this case are discussed.

Is Intravenous Thrombolysis Safe and Effective in Central Retinal Artery Occlusion? A Critically Appraised Topic

Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency associated with poor visual recovery. There is a dilemma regarding the appropriate treatment, as formal guidelines are lacking. Despite being considered an ocular equivalent of cerebral infarction, the time window of intravenous (IV) thrombolysis administration for maximum efficacy and safety in CRAO remains uncertain. To critically assess the current evidence regarding the safety and effectiveness of IV thrombolysis in the treatment of patients with CRAO. The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, and content experts in the fields of vascular neurology and ophthalmology. A recent patient-level meta-analysis was selected for critical appraisal. The study compared the visual recovery rates after IV thrombolysis in CRAO against the natural history of this illness and conservative therapies (ocular massage, anterior chamber paracentesis, and/or hemodilution). Time to thrombolytic therapy administration had a significant impact on visual recovery in CRAO (P<0.001). IV thrombolysis within the first 4.5 hours after symptom onset resulted in recovery of vision in 50.0% of the patients [95% confidence interval (CI), 32.4%-67.6%]. The rate of visual recovery was nearly 3 times higher than in the natural history cohort [odds ratio, 4.7 (95% CI, 2.3-9.6); P<0.001], with a 32.3% absolute risk reduction and a number needed to treat of 4.0 (95% CI, 2.6-6.6). There was no significant difference in the recovery rate after thrombolysis compared with the natural history cohort for those patients treated after 4.5 hours. No major hemorrhages occurred after alteplase administration in this meta-analysis. IV thrombolysis in CRAO seems to be safe and effective within the first 4.5 hours of symptom onset. A clinical decision based on this meta-analysis alone cannot be made due to several limitations. A randomized controlled clinical trial of early IV alteplase administration in CRAO is necessary to provide evidence-based therapeutic guidance.

Work-Related Eye Injuries: A Relevant Health Problem. Main Epidemiological Data from a Highly-Industrialized Area of Northern Italy.

The province of Modena is one of the most industrialized areas of Northern Italy. The medical records of the Ophthalmological Emergency Department (OED) of Modena University Hospital were studied: there were 13,470 OED accesses in 2014 and in 754 cases that an occupational eye injury occurred. The frequency of work-related eye injuries (3‰) was lower compared to other published studies, but the absolute number is still relevant, showing the need for more adequate prevention, especially in metal work, construction work, and agriculture, where the worst prognoses were observed. Intervention programs must be implemented as early as possible in the working life, considering that the frequency in younger workers is about double that of the oldest age class (3.5‰ vs. 1.8‰), and special attention should also be given to foreigners, who have a 50% higher injury risk. Furthermore, the planning of specific interventions for eye-injured workers may be useful, considering that a previous injury does not appear to encourage the adoption of preventive interventions, and a subgroup of eye-injured workers have a potential risk for new injuries. Finally, the data presented here indicates how OED records, integrated with specific occupational information, can be applied for studies on work-related eye injuries.

The efficacy of hyperbaric oxygen therapy in the treatment of central retinal artery occlusion

Central retinal artery occlusion (CRAO) is an ophthalmological emergency. Various treatment modalities have been tried, but none have shown to alter natural history of the disease. Hyperoxia can restore retinal...

Prospective study on ocular motility limitation due to orbital muscle entrapment or impingement associated with orbital wall fracture

IntroductionThe recommended urgent surgical management of ocular motility restriction due to orbital muscle entrapment or impingement associated with orbital wall fracture needs to be elucidated. AimTo evaluate the importance of the time from injury to surgery for the outcome in ocular motility and diplopia, the time lapse of ocular motility, diplopia and hypesthesia recovery. Material and methodsPatients with entrapment or impingement of orbital contents due to orbital wall fracture were followed up prospectively over 1year regarding ocular motility, diplopia, hypesthesia and cosmetic deformity. Results21 patients (10 entrapments and 11 impingements) were included and treated surgically. The median time from injury to surgery was 36 (8–413)h for the entrapment group and 168 (48–326)h for the impingement group. The median time from study inclusion to surgery was 0 (0–1) days for the entrapment group and 1.0 (0.2–4.8) days for the impingement group. All the patients had ocular motility limitation and diplopia at the inclusion. Ocular motility improved gradually and was normal at final visit. Diplopia resolved gradually in all patients except in two with non-disturbing diplopia, at the final visit. Forced duction test was positive in 90% of the patients in the entrapment group and 70% in impingement group. At final visit, hypesthesia was found in none of the patients in the entrapment group but in 4 patients in the impingement group. ConclusionsIn this, the first prospective long term follow up of orbital wall fractures with ocular motility restriction, we did not find any significant correlation between the time from injury to surgery and the outcomes in ocular motility and diplopia. An entrapment requires surgery as soon as possible; however, the surgical reduction is at least as important as surgical timing. Surgery should be delayed until it can be performed by an experienced surgeon. Ocular motility restriction causing diplopia due to impingement is not an ophthalmologic emergency and surgery is recommended if the diplopia and ocular motility has not improved over time. Clinical examination of ocular motility and not CT scan findings is crucial to determine whether a limitation of ocular motility exists or not.

Anti-myelin oligodendrocyte glycoprotein antibodies: Magnetic resonance imaging findings in a case series and a literature review

Myelin oligodendrocyte glycoprotein is a protein exclusively expressed on the surface of oligodendrocytes and myelin in the central nervous system. Antibodies against myelin oligodendrocyte glycoprotein were initially detected in children with demyelinating syndromes, and more recently reported in a broad spectrum of central nervous system demyelinating diseases in adults, including neuromyelitis optica spectrum disorders and bilateral optic neuritis. Patients with myelin oligodendrocyte glycoprotein antibody-associated demyelination appear to have unique clinical and radiological features. To the best of our knowledge a series of Italian patients with optic neuritis and positivity to myelin oligodendrocyte glycoprotein antibodies has not yet been reported and the paper on myelin oligodendrocyte glycoprotein antibodies are more focused on clinical features, diagnosis and outcome than on the radiological appearance, so we want to retrospectively report magnetic resonance imaging features of a group of eight patients, who came to our Ophthalmologic Emergency Department for optic neuritis and were found seropositive for myelin oligodendrocyte glycoprotein antibodies, comparing our data with the findings described in the literature.

VEGF-A is increased in exogenous endophthalmitis

ObjectiveExogenous endophthalmitis is an ophthalmologic emergency defined by panocular inflammation. Vascular endothelial growth factor A (VEGF-A) contributes to inflammation by promoting chemotaxis of monocytes and granulocytes and by increasing vascular permeability. The purpose of this article is to determine if VEGF-A is elevated in the vitreous samples obtained from individuals with exogenous endophthalmitis. MethodsVitreous samples from individuals with exogenous endophthalmitis (n = 18) were analyzed via Luminex assay and enzyme-linked immunosorbent assay for the cytokines VEGF-A, tumor necrosis factor (TNF), interleukin 6 (IL-6), IL-8 (chemokine [CXCL]-8), IL-1β, IL-10, IL-12p70, IL-33, interferon (IFN)-γ, IFN-α, IFN-β, chemokine ligand (CCL)-3, IL-2, IL-5, IL-15, CXCL-10, CCL-2, IL-1Ra, CCL-5, IL-17, and CCL-11. Vitreous samples obtained at the time of macular hole surgery served as controls (n = 8). ResultsConcentrations of VEGF-A were significantly elevated in vitreous samples from individuals with exogenous endophthalmitis compared with macular hole (p < 0.001). VEGF-A was significantly upregulated in individuals with exogenous endophthalmitis after cataract surgery (p = 0.001), vitrectomy (p = 0.024), and intravitreal injection (p = 0.012). VEGF-A concentrations were similar in both culture-positive and culture-negative populations (p > 0.05). In a linear regression model, levels of VEGF-A correlated significantly with the chemokine CXCL-8 (p = 0.028). ConclusionsWe demonstrate that VEGF-A is potently upregulated in exogenous endophthalmitis. This observation provides a foundation for future studies of targeted VEGF-A blockade in the management of endophthalmitis.

Satisfacción usuaria en urgencia oftalmológica: evaluación de la consistencia interna y validez de constructo de un instrumento aplicado en Chile

Ocular trauma is a distressing condition feared by the general public. To evaluate the construct validity and internal consistency of an instrument to measure the level of user satisfaction in patients treated at an Ocular Trauma and Ophthalmological Emergency Unit. A survey to measure user satisfaction was applied to patients consulting at the Ocular Trauma Unit in a public hospital on April 2014. Internal consistency and construct validity from the estimated Cronbach alpha coefficient and factor analysis were assessed. Surveys answered by 138 patients aged 45 ± 15 years (93% men), were analyzed. The reliability obtained for the final questionnaire was 0.88. The factor analysis yielded four factors responsible for explaining 74.1% of the total variance, related to "quality of clinical information", "treatment by health care personnel", "lighting conditions, environment and noise" and "waiting time and overall assessment of service". These results allow to consider the instrument as a useful and reliable tool that can be applied to ophthalmological emergency service users in Chile.

Profile of occupational eye injury at an ophthalmologic emergency department.

Eye injury is the most frequent reason for visits to ophthalmological emergency departments, being one of the leading causes of avoidable blindness worldwide and having considerable socioeconomic impact on health systems and populations. To establish the epidemiologic profile of eye injuries caused by work accidents, visual sequelae and socioeconomic impact. A retrospective, cross-sectional study was conducted by reviewing the medical records of patients with occupational eye injury treated at an ophthalmologic emergency department from April to August 2016. A total of 112 patients were included, all of them male. The most affected age group was 31 to 35 years old, and the main professional category the one of mechanics; foreign bodies on the eye surface represented 85% of injuries; 72% of patients sought specialized treatment more than 12hours after the accident; and for 86% this was their first treatment at the company. Half of the patients used personal protective equipment. In most cases the final visual acuity after injury was not impaired. Although most patients did not remain with visual sequelae, occupational eye injury resulted in loss of working days and expenses with medication. Studies such as the present one contribute to the mapping of the investigated problem and to the formulation of preventive strategies.

Investigate the number and characteristics of patients presented to ophthalmology emergency room in a general hospital, types of ocular cases, the sources of referral and disposal of all new cases

Investigate the number and characteristics of patients presented to ophthalmology emergency room in a general hospital, types of ocular cases, the sources of referral and disposal of all new cases

Contingent Valuation Analysis of an Otolaryngology and Ophthalmology Emergency Department

Specialty emergency departments (EDs) provide a unique mechanism of health care delivery, but the value that they add to the medical system is not known. Evaluation of patient preferences to determine value can have a direct impact on resource allocation and direct-to-specialist care. To assess the feasibility of contingent valuation (CV) methodology using a willingness-to-pay (WTP) survey to evaluate specialty emergency services, in the context of an ophthalmology- and otolaryngology-specific ED. Contingent valuation analysis of a standalone otolaryngology and ophthalmology ED. Participants were English-speaking adults presenting to a dedicated otolaryngology and ophthalmology ED. The WTP questions were assessed using a payment card format, with reference to an alternative modality of treatment (ie, general ED), and were analyzed with multivariate regression. Validated WTP survey administered from October 14, 2014, through October 1, 2015. Sociodemographic data, level of distress, referral data, income, and WTP. A total of 327 of 423 (77.3%) ED patients responded to the WTP survey, with 116 ophthalmology and 211 otolaryngology patients included (52.3% female; mean [range] age, 46 [18-90] years). The most common reason for seeking care at this facility was a reputation for specialty care for both ear, nose, and throat (80 [37.9%]) and ophthalmology (43 [37.1%]). Mean WTP for specialty-specific ED services was $377 for ophthalmology patients, and $321 for otolaryngology patients ($340 overall; 95% CI, $294 to $386), without significant difference between groups (absolute difference, $56; 95% CI, $-156 to $43). Self-reported level of distress was higher among ear, nose, and throat vs ophthalmology patients (absolute difference, 0.47 on a Likert scale of 1-7; 95% CI, 0.10 to 0.84). Neither level of distress, income, nor demographic characteristics influenced WTP, but patients with higher estimates of total visit cost were more likely to have higher WTP (β coefficient, 0.27; SE, 0.05; adjusted R2 = 0.17 for model). Patients with eye and ear, nose, and throat complaints place a mean explicit value on specialty emergency services of $340 per visit, relative to general emergency care. Ultimately, CV data using WTP methodology are useful in valuing patient preferences in monetary terms and can help inform state-wide resource allocation and the availability of direct-to-specialist care.

Management of Transient Monocular Vision Loss and Retinal Artery Occlusions

ABSTRACTAcute transient or permanent retinal occlusive disease requires prompt medical attention and can be an ophthalmological emergency. Central retinal artery occlusion leads to permanent and severe monocular visual loss in the majority of patients. Transient monocular vision loss leaves no permanent deficits, but requires the same level of clinical vigilance, as it portends possible future adverse events, including loss of vision and stroke. Acute treatment options remain limited, and secondary prevention of cerebral ischemic events is the mainstay of management. This article reviews the current evidence for managing patients with retinal ischemia.

Prise en charge des urgences ophtalmologiques en structure des urgences : étude multicentrique rétrospective

The growing shortage of working ophthalmologists makes it more difficult for the patient to access ophthalmological care, especially in an emergent context. These patients are thus taken to general emergency departments for ophthalmologic problems. To observe the epidemiological characteristics of ophthalmic patients in general emergency centers and question the emergency physicians on their practice of ophthalmology. A retrospective epidemiological study was conducted in the emergency departments of Rennes, Lorient and Saint-Brieuc over a period of three months. The demographic characteristics, diagnoses, examinations and procedures performed, opinions obtained from ophthalmologists and patient outcomes were studied. A qualitative study by online questionnaire was sent to the emergency physicians. Seven hundred and eighty-one patients were included, mainly men (68%) under 35years (45%). The most frequent diagnosis was extra-ocular foreign body (32%). An ophthalmologist opinion was requested in 79% within 24hours. The online questionnaire was sent to 74emergency physicians: 92% of them were willing to participate in additional training, 90% had sufficient means to practice ophthalmology in the emergency room. Emergency physicians could handle the most frequent ophthalmological emergencies, extra-ocular foreign bodies and minor trauma, with adapted material resources, autonomy for these conditions, and willingness for ophthalmologic training. Protocols could be proposed in order to optimize the care of these patients.

Dirofilariasis palpebral causada por Dirofilaria repens: un caso importado

Clinical caseThe case concerns a 33-year-old Ukrainian woman, who came to the Ophthalmology Emergency Service, stating that she had a «worm» under the skin of her upper left eyelid that wriggled at night and bit her. A complete examination revealed a subcutaneous foreign body, which showed a filarial appearance and seemed to crawl under the skin. It was surgically removed to discover a live parasite, PCR-identified as Dirofilaria repens. DiscussionHumans are accidental hosts in the cycle of Dirofilaria. There are only 8 reported cases of subcutaneous infection in Spain. Due to global warming, D. repens has become an emerging infectious agent in Central Europe countries such as Ukraine. The findings in this case are discussed.

Clinical characteristics of 679 cases from an Ophthalmologic Emergency Department at night

Objective To investigate the clinical characteristics of patients in the Ophthalmologic Emergency Department (OED) at night. Methods The records of 679 patients attending to the OED of the First Affiliated Hospital of Zhengzhou University at night (from 5: 30 p. m. to 8: 00 a. m. of the next morning) were collected from Aug. 2012 to Jul.2013. The gender, age, career, visiting time, initial diagnosis, emergency treatment and visual outcome were analyzed. Results In this study, for the patients younger than 60 years old, there were more male patients than female. For the patients more than 60 years old, there were more female patients than the male. Peasants(33.3%) and workers(29.9%) accounted for the majority proportion of the patients, followed by preschool children(17.5%) and students(15.0%). The most common diseases in OED were ocular trauma(83.9%), ocular surface inflammation(13.4%) and acute primary angle closure glaucoma(PACG, 2.2%). There was significant difference between male and female(χ2=41.943, P=0.000) in those three types of diseases. The proportion of patient admitted to the OED were 54.8%, 36.1%, 9.1% in the period of 22: 00-03: 00 o'clock, 17: 30-22: 00 o'clock and 03: 00-08: 00 o'clock, respectively. Among the 679 cases, 563 cases(82.9%) required hospital admission, 508 eyes of 487 cases (63.6%) underwent emergent operations, in which 41 eyes of 33 cases (5.1%) were treated by multiple combined operations. The final best corrected visual acuity (BCVA) of less than 0.05 occurred in 38 eyes (6.0%), 0.05~0.25 in 176 eyes (27.6%), and ≥0.3 in 423 eyes (66.4%). Conclusion Ocular trauma, ocular surface inflammation, and acute PACG are the three main diseases in OED from 17: 30 to 08: 00 of the next day. The largest number of patients visiting OED was in the period of 22: 00~03: 00 o'clock. Most of the patients need emergent surgeries. Key words: Ophthalmologic emergency, night; Characteristics, clinical; Trauma, ocular

Patterns of ophthalmic emergencies presenting to a referral hospital in Medina City, Saudi Arabia

BackgroundData are required on ophthalmic cases that present to the emergency eye clinics in Madinah, Saudi Arabia for proper allocation of healthcare resources. ObjectivesTo determine the frequency and various diagnoses of patients presenting to the A&E at Ohud Hospital, Madinah, Saudi Arabia. MethodsData was collected prospectively for all patients who presented to the A&E ophthalmology clinic from June 2014 to September 2014. The data was analyzed and presented using frequency of incidence and percentages. Chi-square tests were used to evaluate the diagnoses based on age, sex and nationality. P≤0.05 indicated statistical significance. ResultsThe study sample included 868 patients. The male-to-female ratio was 1.1:1.0. The main age categories included patients ≥45years of age (256 patients) and 251 patients between the ages of 15–30years. Various types of Conjunctivitis was the most common diagnosis, reported in 282 patients (32.5%), and followed by dry eye syndrome in 156 (18%) patients. Nasolacrimal duct obstruction in 156 patients (18%). Eyelid infections were detected in 102 patients (12%), corneal abrasion in 102 patients (9.3%). Various eye traumas was diagnosed in 30 patients (3.5%), increased intraocular pressure (IOP) in 17 patients (2%), ruptured globe in 2 patients (0.2%) and various other non-emergency pathologies in the remaining eyes. There were no significant differences in patient’s characteristics and categories of diagnoses. ConclusionNon-emergent ophthalmic cases were the most common reason for the ophthalmology emergency room visits. It was observed that most cases could be referred to outpatient departments and potentially be managed by primary healthcare providers. This would be more cost effective and will also allow for better management of vision threatening ocular emergencies.

MR imaging findings of endophthalmitis.

Endophthalmitis is a sight-threatening ophthalmologic emergency. The clinical diagnosis is often challenging, and delayed diagnosis may exacerbate the poor visual prognosis. B-scan ultrasonography or spectral domain optical coherence tomography are imaging aids at the clinician's office. Cross-sectional imaging such as CT and particularly MRI can also help in the assessment of disease extent or complications. MR imaging findings are rarely described in the literature. Here, we discuss the spectrum of imaging findings of endophthalmitis and correlate them with key anatomic and pathophysiologic details of the globe. Early disease is often subtle on MR imaging with thick uveal enhancement, while advanced disease demonstrates retinal/choroidal detachment, vitreal exudates and peribulbar inflammation. Other noninfectious inflammatory diseases of the globe can show similar findings; however, MR diffusion-weighted images help identify infectious exudates and evaluate response to therapy. Knowledge of the spectrum of imaging findings of this disease is important for radiologists and help in the management decision process.