Grand Rounds Recap - 4/15/15

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Ocular Emergencies with Dr. Titone

Blood supply to the eye is from the Internal Carotid and drainage is through cavernous sinus.  Bony eye septum is an improtant structure that separates the superficial structures from the deeper structures that have direct communications with the brain.

Key historical factors: recent eye procedures, eye drop use, contact lens use, occupational history, UV ligh exposure

Physical exam of the eye

  1. Visual acuity: vital sign of the eye
    1. Acute change: disease of globe or visual pathway
    2. Gradual: corneal disease, glaucoma, iritis
  2. Inspection: invert the eyelids
  3. Pupillary exam
  4. Extraocular movements
  5. Visual fields: total blindness of 1 eye = optic nerve, other visual field cuts = brain
  6. Funduscopy and tonometry

Irrigate first if concern for chemical exposure: time is eye

Optokinetic nystagmus: is this patient actually blind? if vision is intact, the pt will have horizontal nystagmus

Tunnel vision is physiologically impossible and is a sign of factitious disorder

Afferent pupillary defect: when you shine light into unaffected eye, both eyes constrict. when you shine light into affected eye, optic nerve does not see the light and dilates the eye

Central Retinal Artery Occlusion = retinal stroke

Central Retinal Artery Occlusion.  From Ted Montgomery, http://tedmontgomery.com/the_eye/eyephotos/index.html

Central Retinal Artery Occlusion.  From Ted Montgomery, http://tedmontgomery.com/the_eye/eyephotos/index.html

  • Painless vision loss in 1 eye
  • Cherry red spot and pale retina on fundoscopy
  • Usually embolic, though can be due to hypercoagulation, giant cell arteritis, decreased forward flow (hypotension), vasculitis, trauma
  • Treatment
    • Ocular massage
    • Topical timolol
    • IV acetazolamide
    • Inhaled CO2
    • Emergent ophtho consult: direct infusion of tPA, hyperbarics
Central Retinal Vein Occlusion. From Ted Montgomery, http://tedmontgomery.com/the_eye/eyephotos/index.html

Central Retinal Vein Occlusion. From Ted Montgomery, http://tedmontgomery.com/the_eye/eyephotos/index.html

Central Retinal Vein Occlusion

  • No good treatment
  • Painless monocular vision loss

Acute Angle Closure Glaucoma

Cause = Impedence of aqueous humor flow

Symptoms

  • Photophobia, halos around lights
  • Abrupt painful unilateral vision loss

Physical Exam

  • Fixed midposition pupil
  • Hazy cornea with conjunctiva injection
  • IOP > 30 mm Hg

Can cause vision loss within an hour due to optic nerve ischemia

Treatment

  1. Reduce IOP and volume of aqueous humor: IV mannitol
  2. Block humor production: topical timolol, acetazolamide, apraclonidine (alpha 2 agonist)
  3. Facilitate humor outflow: topical pilocarpine (cholinergic) will constrict the pupil
  4. Comfort: sedation, anti emetics, analgesia
  5. Emergent ophtho consult: definitive treatment is laser iridectomy

Retinal detachment

  • Flashes of lights, decreased visual acquity, painless, intact visual fields
  • IOP is normal-low
  • Can be peripheral only, and not obvious on fundoscopy unless eye is dilated
  • Needs dilated exam within 24 hours
  • Prolonged macular detachment leads to permanent vision loss
  • Can see on US

Alkali burns

  • Irrigate first, ask later
  • Topical anesthetic prior to irrigation
  • Do not neutralize with acid
  • Check pH and irrigate until pH < 7.4
  • Topical antibiotics

Acid burns - more rapid destruction but less serious

UV burn - superficial punctate staining of cornea

Quick hits

  • Iritis: small pupil with normal IOP
  • Conjunctivitis: normal pupil and pressure
  • Endophthalmitis: microbial infection of globe
    • Vanc/gent or vanc/rocephin
  • Sudden and painful vision loss: acute angle glaucoma, migraine
  • Painful and gradual: optic neuritis, uveitis
  • Painless and gradual: cataract, macular degeneration, diabetic retinopathy
  • Painless and sudden: CRAO, CRVO, retinal detachment

Thyroid Emergencies with Dr. Goel

1. Hypothyroidism

  • Affects 13% of population
  • Most common cause is Hashimoto thyroiditis
  • Very vague symptoms
  • Check TSH and free T4: in acute illness TSH is not very accurate
  • Treatment: levothyroxine, starting with 50-75 dose

2. Myxedema coma

  • Bradycardia, AMS, fluid overload, hypotension, hypothermia
  • Usually presents in winter months in pts > 60
  • Frequently precipitated by infection
  • High mortality
  • HypoNa, hypoglycemia on labs
  • Depressed metabolism
  • EKG: sinus bradycardia with diffusely inverted T waves
  • CXR: pleural effusions, cardiomegaly 2/2 pericardial effusion
  • Can use APACHE II score for severity
  • Treatment
    • Levothyroxine loading dose 300-600 and then daily dose
    • Stress dose steroids until adrenal dysfunction ruled out
    • Broad spectrum abx until infection ruled out

3. Hyperthyroidism

  • Affects 1.3% of population
  • Most comon cause is Graves disease
  • Varied symptoms: hypermetabolic

4. Graves Ophthalmopathy

  • 30-50% of Graves pts will  have some sort of eye complaint (proptosis, blurry vision)
  • Grading is based on proptosis, limitation of eye movements and vision loss
  • Treat with long course of high dose steroids
  • May need orbital radiation or surgical decompression
  • Good ophtho follow up

5. Thyrotoxic periodic paralysis = hyperthyroidism + severe hypoK

  • More common in men
  • Sudden onsent of paralysis (usually lower extremities) and hypoK
  • Often worse in AM and after meals
  • HypoK during acute episode only
  • Treatment: replete K, no more than 90 mEq/24 hours

6. Thyroid storm

  • Tachycardia, hyperthermia
  • Diagnostic score: Burch&Wartofsky score
    • Temp, CNS manifestation, GI symptims, pulse, CHF symptoms, precipitant history
    • Predicts whether pt with hyperthyroidism will go into thyroid storm
  • Rare, but mortality 30%
  • Usualy due to noncompliance with therapy or infection

Treatment

  1. Block hormone production: propylthiouracil or methimazole
  2. Block release: Iodine, lithium
  3. Block peripheral effects: beta blocker, steroids

Leadership Curriculum with Dr. Stettler

  • Leadership is communication, conflict management, vision, money management
  • Vision = understanding who must be part of your mission
  • Conflict management = moving group towards a common goal
  • How to run a meeting
    • Know your stakeholders and who needs to be present
    • Start with what the problem is and the rationale for your idea
    • Viability of the project: logistics, buy in
    • Financial aspects: return on investment, financial commitment
  • How to pitch an idea: provide a concrete idea and anticipate questions prior to your presentation. Address potential concerns from major stakeholders.