Senior Report 6.15

Case Presentation by Dr. Kevin Sprague

A 66 year-old female presents to the Emergency Department for an unrelated complaint.  You notice her eyes do not appear symmetric.  She later reports that 3 weeks prior she was hit in her left eye and had loss of vision that she attributed to swelling.  The eye was originally painful, but it is not today.  She did not seek medical attention.  She has no light perception in the left eye.  Fluorescein stain was applied.

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Questions:

1) What is the most appropriate next step in the acute management of this condition?

a)  measure orbital pressure

b)  administer topical timolol

c)  place a protective eye shield

d)  start broad-spectrum IV antibiotics

e)  emergent ophthalmology consultation

2) The patient above starts vomiting and then aspirates.  Which medication is relatively contraindicated?

a)  zofran

b)  lidocaine

c)  rocuronium

d)  succinylcholine

3) What is the most appropriate method for applying an eye shield for a globe rupture?

a) metal eye shield

b)  soft padded eye shield

c)  plastic eye shield

d)  pressure dressing

 

Answers

1) c

This patient has a delayed presentation of a scleral (globe) rupture.  Classically, this follows blunt trauma and patients present with decreased vision and pain.  The blunt trauma causes a sudden increase in intraocular pressure resulting in a scleral rupture.  The most common sites are the insertion of the intraocular muscles or the limbus.  When rupture occurs at the limbus, a teardrop pupil may be observed.  The patient may have bloody chemosis or severe subconjunctival hemorrhage.  This patient clearly had chemosis and subconjunctival hemorrhage that is less appreciated after fluorescein stain.  This patient also had a positive Seidel test.  The fluorescein stain has infiltrated the anterior chamber.  Below is a link to a youtube video demonstrating a positive Seidel test.

http://www.youtube.com/watch?v=GlFcAv0DR4c

The first step in managing an acute globe rupture is to protect the eye from further examination or manipulation by placing a protective eye shield (and not take pictures).  Also have the patient avoid rapid eye movements. The next steps include IV antibiotics, tetanus update, NPO, and emergent ophthalmology consultation.  Timolol is not indicated.  Measuring pressure is contraindicated.

2)  d

Some texts advocate giving zofran prophylaxis since vomiting will increase intraocular pressure.  Succinylcholine can increase intraocular pressure and is therefore relatively contraindicated.

3)  a

A metal shield is the first choice.  When a metal shield is not available, a makeshift shield using plastic, paper, or styrofoam cup is the next best option.  Any eye shield that makes contact with the eye or applies pressure is contraindicated.

Sources:

Marx, Hockberger, Walls.  Rosen’s Emergency Medicine, 7th Edition.  Mosby Elsevier, Philadelphia. 2010. p. 864

Robers and Hedges. Clinical Procedures in Emergency Medicine, 5th Edition. Saunders Elsevier. 2010. p. 1154

One Response

  1. 1.
    2. ?*
    3.

    * “Theoretical classical teaching states that the use of succinylcholine is contraindicated […] but […] given the need for rapid airway management in a patient with penetrating ocular injury, RSI with succinylcholine and an induction agent is appropriate.” Rosen’s p.864

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