Emergencies in Rural Practice
Amy Freeman
Hello, everyone. I can see everyone coming in. I will just wait a little bit longer. Welcome, everyone. Okay, I will kick us off. Welcome, everyone, to the latest instalment of our Rural Health Webinar series. My name is Amy Freeman, and I will be hosting tonight's webinar. This instalment of the Rural Health Webinar series will explore common ophthalmological presentations and emergencies in rural general practice. The webinar will be presented by Associate Professor Khristopher Rallah-Baker. Associate Professor Rallah-Baker is a highly respected ophthalmologist and is one of the founding members of the Australian Indigenous Doctors Association, a director on the Federal Board of the Royal Flying Doctor Service, technical advisor to the Fred Hollows Foundation, and chair of the Vision 2020 Indigenous Committee.
We would like to begin tonight's webinar by acknowledging the traditional owners of the lands that we are coming together from, and the land on which this event is being broadcast. I would like to pay our respects to their elders, past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening.
RACGP Rural would also like to thank our sponsor, Medical Insurance Protection Society (MIPS). MIPS membership includes comprehensive indemnity cover for the provision of health care to individuals. MIPS exists to promote honourable practice and protect the interests of its members. MIPS also provides a range of benefits in addition to insurance covers such as the 24-hour medicolegal support and accredited risk education workshops. We do greatly appreciate their support of this webinar series tonight.
Just before we start, we have got just a couple of housekeeping things to cover. Participants are set on mute to ensure that the webinar is not disrupted by background noise, but we do encourage you all to use the chat function or Q&A function to ask questions. When using the chat function, we do ask that you address your questions and comments to all panellists and attendees rather than just the panellists, and this allows everyone to be able to see your questions and comments. Finally, this webinar has been accredited for one-hour educational activities CPD, and to be eligible for this, you must be present for the entire duration of the webinar.
We do kindly ask that you complete the short evaluation at the end of the webinar, which will only take a few minutes and will help us improve the format and content for the future. By the end of this webinar, the participants will be able to 1) Identify common eye presentations that require immediate treatment. 2) Identify common eye presentations that require urgent, but not immediate treatment. 3) Identify early clinical features common in ophthalmic emergencies. 4) Discuss the how and what of urgent ophthalmic diagnoses.
For now, I will hand it over to our facilitator for this evening, Associate Professor Rallah-Baker. Thank you.
Associate Professor Khristopher Rallah-Baker
Thanks very much for the introduction and thanks, everybody for attending this evening. So, as was introduced, I am Kris Rallah-Baker. I am the country's only indigenous ophthalmologist at the moment, and I have done quite a bit of work in Rural and Remote Ophthalmology across Australia, right across from Western Australia, Top End and through Queensland. So, I have a fair understanding of some of the difficulties in terms of accessing services for our rural colleagues. So, welcome everybody to this evening. My background is, as I said, I am Indigenous, I am Warangal and Yagara on my mother's side, so my people are from the Tully area in North Queensland and the Brisbane Basin and Wiradjuri and my father's side. I would also just like to acknowledge all the different lands on which we sit today. I am currently in the Noosa hinterland on Gubbi Gubbi country and acknowledge elders past, present and emerging, as well as my indigenous brothers and sisters who may be attending.
We will start off with the talk now. There are a number of slides to get through and we will be finished by the hour, but I think the first challenge that I thought about when I was asked to do this topic and put the presentation together was what is the critical knowledge needed when you are out there in rural or remote practicing and someone walks through the door with an eye problem? It really, in my mind, boiled down to in hours is relatively easy to manage. There is always an ophthalmic registrar available in the public system at the end of a phone, and of course, my private colleagues work mostly Monday to Friday, pretty standard hours. So, during the day time for any of these diagnoses, I would encourage you to contact the ophthalmologist during daylight hours. The difficulty arises though, after hours, so I have divided up the diagnoses between those requiring immediate opinion from an ophthalmologist. That means ringing someone at whatever ungodly time it might be that you are working and the patient walks through the door, and those diagnoses that that need to be managed at a local level with urgent intervention, but which can be discussed with the ophthalmologist in the morning.
Now, it is important because there are not many of us around as ophthalmologists and even fewer of us who are available after-hours, so you know, I counsel people to always be judicial, and I am sure everyone is on this call judicial with our use of resources after-hours, because we do not want to make unnecessary calls as all poor registrars in the public system experience after-hours. So, we might begin with the talk and really, in summary, all of these are urgent cases. If it's during office hours, particularly Monday to Friday, I would say call your local friendly ophthalmologist and then we will drill down specifically into those that can wait until the morning and those who you have to call someone about absolutely now. The caveat, of course, for any of these is if you are not sure, then always call, but I will try and give some tips around how to get through the minefield.
We might have the next slide. Thanks. Right. It is a fairly large list, and there are certainly more ophthalmic emergencies that we all run the risk of having walked through our door, but those that require an immediate call to an ophthalmologist, irrespective of the hour of the day, are endophthalmitis, an acute angle closure, a suspected giant cell arteritis, particularly if there is vision involvement and a true orbital cellulitis, and I say true orbital cellulitis to distinguish it from a preseptal cellulitis. Those which can wait until the morning hours, with caveats again, are a carotid cavernous fistula, but urgent neurosurgical input is required for that, a contact lens related keratitis can wait, sort of. Ideally, that would be addressed straight away, but you know if you have got eight hours until working hours, then that is reasonable to hold. Chemical burns after immediate emergency intervention. A retrobulbar haemorrhage after immediate emergency intervention. Orbital floor fractures with caveats that I will go through. Retinal artery occlusions, suspected retinal detachments, and vitreous haemorrhages.
We will have the next slide. Thanks. The first list we will begin with is the list where I would expect a call from whoever is at the other end at whatever hour it might be for advice, and this is not end of the Midas. In terms of history, the most common scenario is the patient has undergone some sort of intraocular surgery, and in Western medicine, the most common operation that would fit that would be a cataract operation. So, the patient will present generally beyond 24 hours after their operation. The reason for that is there is a sterile endophthalmitis that can present in the first 24 hours called TASS, but the one that we really worry about is your infective endophthalmitis. So, your bacterial endophthalmitis tends to present 24 to 72 hours after surgery. As I said, most commonly that is cataract surgery, and these people will come in complaining of a red, painful eye, and generally their vision will be worse. You can have presentations of a bacterial endophthalmitis after the 72-hour mark, and in fact it can be even up to a week. There is also an entity called a chronic bacterial endophthalmitis, which can present usually a month or more later, but it is less likely to come in for emergency access because of an acute concern with pain and reducing vision. That tends to be something the ophthalmologist will deal with when the patient comes back for review, and of course, there is a fungal endophthalmitis, which is a different entity, and again, generally much slower.
So, someone's had cataract surgery or intraocular surgery in the last 24 to 72 hours, and they have a red painful eye and their vision is going down, then that definitely requires waking up the ophthalmologist. Ideally, that would be the operating surgeon, but that person is not always available for one reason or another. Now, the picture that we have here is a fairly obvious endophthalmitis. The features are that we have an injected conjunctiva. The patient will be in pain. The pressures are probably elevated, and of significance is the hypopyon or the layer of white blood cells and pus down the bottom. If you see that, they need to be sorted immediately, and what the ophthalmologist would suggest happens is to give the patient, generally speaking, it would be one of the fluoroquinolones oral or IV and then package the patient up and get them into the nearest tertiary referral centre or the operating ophthalmologist.
Look, if you are at Rural and Remote, then that is probably going to be RFDS or an equivalent service. So, you do not want them hanging around. You want to get them into the ophthalmic service, and nowadays the general approach would be to do an urgent vitrectomy, and that gives the patient the best outcome or the best prognosis, it still may not be good.
So, we will have the next slide. Thanks.
Amy Freeman
We have just got a raised hand. Will you be happy to…
Associate Professor Khristopher Rallah-Baker
Oh, yeah. That is fine. Yeah. Raised hand is fine.
I am in Q&A. I can see one comment. I cannot see any slides, so hopefully the slides are working. I cannot see any questions in there, so I might roll on. If you have any questions, I am happy to answer them as we go through. Just type them into the Q&A.
Amy Freeman
Okay. Next slide.
Associate Professor Khristopher Rallah-Baker
Yeah. So, the second instance where my colleagues and I would want to be woken up in the night, and where you would definitely call the ophthalmologist is the acute angle closure crisis. It is a diagnosis that when I was doing time in ED as a resident and a principal house officer, it haunted all of us. I have to say, it is a reasonably rare entity, and even during my training at tertiary referral centres as an ophthalmic registrar, it really was not common that it came through, but when it did come through, it could not be anything else. It really could not be mistaken for anything else, and if I was the, you know, the non-ophthalmologist out there in rural and remote and one of these patients came in, there is no way I would be sitting on my hands waiting until the morning because they are in extreme pain, and some people on the call may have seen it. So, these people come in with severe ocular pain, a headache, nausea, and often vomiting. It really is quite spectacular the way they present. When you examine them, they will look similar to this picture and you do not need a slit lamp, you can even use a torch. So, the vision will be significantly reduced. Depending on the pressure, they may have quite bad or total corneal oedema, so you may not be able to see much of the intraocular content. It will be a very shallow anterior chamber if you look in there, and in this picture, if you look at the interface between the beam of light and the iris inferiorly, then you can see that there is really very, very little space, and that is because the anterior chamber has collapsed.
Generally speaking, with an acute angle closure crisis, these people are generally hyperopic and have a cataract in situ, and what happens is an anatomical issue where the cataract becomes large enough, and it is a creeping progression, and then all of a sudden that will block off their trabecular meshwork and the pressures will go right up, and it can be up to 60 at times. So, these are fairly spectacular presentations. You want to get them through straight away. You want to call whoever is available. If you have Diamox in in the cupboard or wherever you are, the ophthalmologist will probably suggest that you give them that and again, pack them up and get them through fairly immediately for attention.
Someone else has made a comment that there is difficulty viewing the slides, so if we could just have a look into that, please. They should be showing, they are coming from RACGP's end. So, and of course, the treatment with these patients is to get the pressure down one way or the other. The ophthalmologist will give either Diamox or if it is recalcitrant, IV mannitol. It is not something that is generally given in the emergency department, so it is about tamponading any further pressurise and getting them seen pretty quickly. Sorry. We just got some comments about the slides coming up on the Q&A.
And then, of course, they will end up with a YAG peripheral iridotomy, and because they are usually due to a hypermature cataract, they move pretty quickly towards cataract surgery once the eye has settled and cooled down. So, reassuringly, these presentations are not that common, but these patients will come in, they will be in severe pain, they will have a red eye, they will have fixed pupil, cloudy cornea, shallow anterior chamber, and you can, in fact, digitally palpate the eye. They will often feel very, very firm, and if you are lucky enough to be in a centre that has a Tono-Pen or an equivalent, then you can use that. So, I think they are just reloading in slides. Hopefully, that works for everybody.
Amy Freeman
I have just reloaded. If someone could let me know if this is visible. Thank you very much.
Associate Professor Khristopher Rallah-Baker
All right. Well, it is working. Is it? Great. Okay. Excellent. All right.
Well, we might move to the next slide now if there are no questions about that, and I am happy to answer questions at the end as well. So, the next diagnosis where I want to be woken up at whatever time is if you suspect it is a giant cell arteritis. Now, I do not want to hear about a giant cell arteritis that does not involve the eye, of course, but unfortunately, a lot of the time giant cell arteritis as a diagnosis does involve the eye, but the presentation may not be that obvious to those who have not worked in Ophthalmology.
There have been a number of cases that when I was a training registrar, the physicians, in fact, in tertiary referral centres would send patients through with the question of "Well, this patient has these, you know, unusual symptoms and can you check the eye please", and with all due respect to our colleagues, the physicians, it was surprising: 1) How rare they thought that giant cell arteritis is. 2) How rarely they ask the appropriate questions. I suspect it is actually more underdiagnosed than what is recognised. We find it all the time in Ophthalmology. So, you must ask if the patient is over 55 years old and they present with a vision change, now that can be reduced vision or loss of vision or even double vision. So, any patient over the age of 55 with a new-onset double vision, giant cell arteritis has to be considered as a cause.
The next questions relate to the general systemic symptoms of giant cell arteritis, and they are headache, and these can go on for months and months, and it can be mild or severe. Jaw claudication, so when you chew your food, do you get a sore jaw? When you swallow your food, do you have neck pain? Unexplained weight loss, nausea, scalp tenderness and temporal pain. They may also, and not uncommonly, will describe a number of months of just not feeling right, and if they have diplopia, then they may demonstrate other nerve palsies as well. So, any vision change in someone, particularly if it is severe and these patients can present with a unilateral no perception of light. In a patient over the age of 55, you must go down the path of then inquiring about giant cell arteritis. It is out there. I think it is significantly underdiagnosed. Make the clinical diagnosis, and if they have lost vision or they have double vision, then you must involve the ophthalmologist straight away.
Now, the other people who need to be involved, of course, are the physicians and the treatment is urgent IV methylprednisolone 1 g per day for three days and the commencement of a tapering dose of oral prednisolone at 1 mg/kg, with a minimum dose of 100 mg. So, they are whopping doses and you have to get on to it hard and fast, but that is something for the physicians and the ophthalmologists. As the rural generalist, your job is to pick up the diagnosis, and you can, if you suspect it clinically, then I would not muck around with bloods, particularly if you have limited services. Do not worry about the ESR, CRP, full blood count. If you suspect it and you think this is what it is, call because the sooner they have the methylprednisolone into the system, the better it will be, and ESR, CRP, you can take the bloods if RFDS or whoever is coming along, stick them with the patient, they can do them at the other end.
Now, the reason why they lose vision is in the picture I have, it is a frontal photograph of the right eye, and we can see gross optic nerve swelling and I have seen this in individuals. In one case or two cases stick out in my mind. One was a lady who was referred up at a tertiary referral centre. She had been in hospital for six weeks. The physicians could not explain why she was unwell, and then she started getting some visual symptoms. Just her vision was a little bit off, and she had not been tested for giant cell arteritis. On questioning, it was fairly obvious what was happening, and she was a giant cell arteritis. There was another fellow from the town of Alpha and I was on call that evening, and this fellow 88 years old, was fit as a fiddle, lived on his own, independent, and he had had a sudden, painless vision loss in one of his eyes. The cold front came through. They sent them immediately, and this is what his optic nerve looked like. Tragically, that gentleman we started him on his IV methylprednisolone and his high dose oral steroids and tragically, the rheumatologist a number of weeks later started reducing his prednisolone, and unfortunately for him, it was too fast and he actually became no perception of light in both eyes. So, it can be a devastating diagnosis. Not only he had lost one eye, but he actually ended up losing both eyes and I suspect that he ended up in care. So, an independent 88-year-old man ended up in care and blind. So, you must pick it up.
Can I have the next slide, please? The next case where we want to be woken up is a case of actual orbital cellulitis. Now, there are key features that will make the clinical diagnosis of orbital cellulitis. It is nice to have scanning to confirm it, but it is not essential. If it is a good going orbital cellulitis, you should be able to pick it up from the other end of the room, and that is because they have proptosis, which can be quite significant. They have severe pain on eye movement, and because the orbit is involved and there is optic nerve compression, they often have optic nerve signs. The easiest of which to determine in the rooms is an RAPD (Relative Afferent Pupillary Defect). So, to pick that up, you want to do the swinging torch test, and you want to look for the affected pupil opening too quickly when the light hits it. That is a clinical diagnosis. We have some good going pictures here, and what those pictures are demonstrating is the periocular swelling, but a preseptal cellulitis can look like that. What differentiates your true orbital cellulitis is the pain behind the eye, and in this series of pictures, most significantly, the reduction in eye movement. So, this person will have not only pain on eye movement, but you can see when they are supraducting on the right, the left eye is remaining fixed and central and that eye will be bulging. If you had an exophthalmometer, it is probably coming out by a good 4 or 5 mm, but I would not do that on one of these patients. It is painful even in normal circumstances, but it will be proptosed.
On the scan, what you will see is you will see a collection within the orbit, and that is not only a vision threatening diagnosis, but of course, a life threatening diagnosis, because there is the chance that they are most commonly bacteria, that the bacteria can break through into the intracranial cavity, and then you end up with a disseminated meningitis and in the worst case, encephalitis. That or orbital cellulitis. Your preseptal cellulitis can appear similar to this, but they will not have an RAPD. They will not have pain on eye movement. They will be able to move their eyes normally, and they will not have proptosis. If you do not have an exophthalmometer, which I do not expect many generalists will have, you can actually place your fingers on the eyes gently because it is painful. You can actually just palpate them and you will feel that one eye is a little anterior to the other or you can look down from above them, and you look at the position of the eyelids or the eye, and you will see that one sits slightly proud of the other. So, that is something we need to call.
Now, what is the ophthalmologist going to do in the short term? Well, the ophthalmologist will obviously be interested in engaging and give some advice around what to do with the eye, but critically, what needs to happen is actually ENT needs to be dragged out of bed and they need to come into theatre and they need to drain the orbit. There is a crossover with the orbit between ophthalmic orbital surgeons and ENT surgeons, but in the emergency scenario, it will be the ENT surgeon who will be coming in to drain this and that needs to be done, sort of, you know, yesterday type thing. So, I would not sit on this.
We will go back one, and I have a question here. My apologies for the delay. It says is it possible to diagnose giant cell arteritis without a biopsy using ultrasound, for example? It is possible to diagnose giant cell arteritis based on history as well as ESR, CRP and full blood count. To nail the diagnosis, a temporal artery biopsy is required. A single biopsy in a positive giant cell arteritis will confirm 97-98% of cases. There is 2-3% of cases that will be a real giant cell arteritis, but you will have a negative biopsy. In that case, you do the other side and that takes you up pretty much 99%. I have had a case where both biopsies were negative, but clinically it was a giant cell arteritis and it responded like a giant cell arteritis. So, you treat it anyway because obviously it is a life threatening diagnosis. The key with the biopsy is that you need at least 20 mm because you can get skip lesions. There is also a question that is often asked around, oh well does the biopsy need to be within a week of the onset of symptoms. The answer to that is no. What the pathologist will look for even in a treated giant cell arteritis is a destruction of the lamina propria.
Anyway, one of the histological lamellae within the within the arterial wall, and they will just see destruction and removal of that layer, so you can get a diagnosis. So, even if they are fully treated and they are down the line, you still can confirm the diagnosis, but in answer to the question directly, can you diagnose an ultrasound? No. The gold standard is to take a temporal artery biopsy. Some ophthalmologists will do that. I have certainly done plenty in my time, but in most, well, most tertiary referral centres, if the patient comes in with symptoms, the ophthalmologist or the registrar will do the biopsy, and if they come in and the physicians have diagnosed them, they do not have ophthalmic or visual involvement, then it will be the vascular surgeons. In the private system where I now mostly work, most of the biopsies go across the vascular surgeons. So, we have covered off on orbital cellulitis.
They are the ones that we want to hear about. You know, they are the ones where the patient is going to come significant harm very, very quickly if nothing is done immediately. The next group of people are all urgent cases. As I said at the very beginning of the talk, if you have an urgent case and you are not sure, there is always someone at the end of the phone, but for these ones, if you are confident in the diagnosis, then they can wait until the morning. Now, this particular diagnosis, the diagnosis of vitreous haemorrhage is one that we get a lot of calls about after-hours in Ophthalmology, but it is in fact something that can be reasonably easily identified, and if it is after-hours can be held until the morning. So, these patients will come in with a sudden, painless loss of vision in one eye. It is very rare to have a bilateral vitreous haemorrhage. They are often diabetic or they have some sort of known intraocular proliferative disorder. They might have had an old vein occlusion or something. So, they are either diabetic or they have a history of vascular problems within the eye, and the quick and easy way to determine is this a vitreous haemorrhage is pull out your torch light and just or, you know, even your direct and have a look for a red reflex. If there is no red reflex and they have that background, and they are often elderly patients, then it is going to be a vitreous haemorrhage. Now, there are cases of vitreous haemorrhage that can result from a retinal tear, and in those situations, they will require vitreoretinal surgery to clear the vitreous haemorrhage, and then they will require photocoagulative laser around the tear, but again, I do not know of any vitreoretinal surgeons who will be operating at 2 or 3 a.m. in the night. It is microsurgery. That surgery is best performed when the surgeon is fully rested, and when you have your normal, fully qualified subspecialty surgical staff at hand. So, if there is no red reflex, even if it is a retinal tear with a vitreous bleed, which is the minority of these, they can wait until the morning. So, just remember to look for a red reflex. Obviously, this is to do with adults. Children are a different story.
So, we have a question, which relates to the last case, swollen eyelids. In a patient with swollen eyelids, for example, from orbital cellulitis or trauma, it could be difficult to examine the eye due to pain and swelling. Any tips for examining the globe? So, the first tip, if you have a painful globe or eye from any cause, is in fact to start with some topical anaesthetic. So, oxybuprocaine or tetracaine are the ones usually in the fridges in most departments and most clinics around the place. So, put some of that in, because the pain might actually be coming from an epithelial defect. If you put that in and they are still in extreme pain, then and we will come to this diagnosis, they may well have a retrobulbar haemorrhage, in which case it is a clinical diagnosis or as I said, if it is an orbital cellulitis, that also is a clinical diagnosis. You can part the eyelids as long as you are confident that there is no globe rupture or penetrating eye injury, then that is a reasonable approach.
We will round off on our vitreous haemorrhage. So, look for red reflex in an adult, sudden, painless vision loss. It should be reasonably easy to determine. In the photo, sometimes you will see blood behind the lens or in the anterior chamber, but not all the time.
We will have our next slide, please. So, the next one people worry a lot about and I think quite reasonably so is a suspected retinal detachment. The emergency retinal detachment is in fact the one where the macula is still attached, and in that situation, the patient will still maintain a good visual acuity, so they will be able to go quite a way down the chart, but history is important with this. You want to ask about history of flashes or floaters and if there is a proper retinal detachment, they will describe a field loss. Now, most retinal detachments are supratemporal, and then in reducing order of frequency, so supratemporal, supranasal, infratemporal and infranasal. If it is inferior, then it generally had been there for a couple of weeks. If they are superior because of gravity, they generally come down much, much faster. They may describe a curtain closing, but what you want to do is, the quick and low resource way to do it is just do a visual fields of confrontation. So, close your eye, cover your eye, look at my nose with your eye and you just go, how many fingers, how many fingers, how many fingers, how many fingers? If there is a quadrant or a hemisphere or more missing, then you need to be very suspicious of a retinal detachment, particularly in the setting of recent flashes or floaters.
The other group that you need to be worried about more than anybody else is if they are short sighted. If they are myopic and they will generally know if they are short-sighted or not, particularly if they have a big script of, you know, -4, -5 or above. Now, do you need to call the VR surgeon in the middle of the night with a retinal detachment? No. For the same reasons I said with the vitreous haemorrhage. If it is 1 or 2 or 3 in the morning, that is not a good time to wake the microsurgeon because it is not going to make an enormous amount of difference over the next 5 hours until the sun is up and all the usual subspecialty staff are in. You really want your subspecialty nurses, your theatre nurses and all of your equipment in place by the time you go in to repair that detachment, and you also want to be well rested as a surgeon. People do worry about retinal detachments. If it is a couple of hours overnight or even if it is, you know, 11 o'clock in the night, it is going to be okay, and you can make the call at 8 a.m. the next morning. It is very unlikely it is going to progress.
If you are an emergency department, it is reasonable to keep the patient in the emergency department and lie them down and just make sure they are comfortable and still. If you do not have that, then as long as they go home and they are comfortable and still, and the call is made as soon as possible in the morning. The other option is if you are a long, long way out and you think it is a retinal detachment, then you can, in fact, arrange transport into the next major centre where the vitreoretinal surgeon is, so that at least they are ready and waiting in the morning or available, you know, at least in the same town, you know, flying to Brisbane or whatever.
We will have the next slide, please. The next diagnosis is vein and artery occlusions. Now, these can present very similarly to a vitreous haemorrhage. The difference is that these people will have a normal red reflex. So, sudden, painless vision loss, usually elderly, similar sort of demographic to your vitreous haemorrhages, and they may be diabetic as well. Often and most commonly vasculopaths obviously, but in this case you are going to shine your direct ophthalmoscope in the eye and you are going to see a normal red reflex. Now, the pictures I have here, if you are lucky enough to have a pan-retina scope where you are working or a slit lamp, and you have a few skills with a lens, then on the left hand side of the presentation, that is what a central retinal vein occlusion looks like. So, you have 360 degrees of scattered intraretinal haemorrhages, often described as flame haemorrhages, and they are contained within the retina itself. So, your vitreous is clear, and often if it is a full ischaemic vein occlusion, the vision will be very bad. If it is non-ischaemic, the vision might not be too bad, but really, all bets are off the table in terms of where they are going to end up. It is a bit of a long pathway for them. They are probably going to end up with macular oedema or need injections into the eye, but that is something that the ophthalmologists can sort out the next morning. In fact, probably the ophthalmologists will want to look in and confirm the diagnosis and then get the patient back in a month's time and watch them pretty closely on a monthly basis for at least the first 3 to 4 months, to ensure that there is no sudden neovascularisation that occurs in the eye. Neovascularisation itself can then result in vitreous haemorrhages.
Then, on the right hand side, we have a picture of a retinal artery occlusion. You can see the cherry red spot, and that cherry red spot is the macular. The reason why that is red is because the retina is very thin there, and the blood supply to that area is choroidal rather than retinal, and the occlusion affects the retina rather than choroid. So, you have a choroid shining through with this normal vascular colour and then the overlying retina for the end of the 360 degrees. The remaining eye, of course, is bleached because it is starved of blood. So, that is what you will see if you are lucky enough to have a look at the back. So, just remember normal red reflex, sudden vision loss, often vasculopaths, I will have a look the next morning.
We have a question. If you are a rural and your closest surgery centre is via flight, is there any high altitude flight risk for ophthalmic emergencies such as angle closure glaucoma or retinal detachment? Short answer, no. The only time you really need to worry about altitude is if the patient has had a retinal detachment repair recently and gas has been put into the eye, and that can even be. So, patients who have had a retinal detachment from Toowoomba, they go down to Brisbane for their retinal detachment repair. They actually have to wait around for a good four weeks for the gas to reabsorb, because even the climb to Toowoomba can result in expansion of the gas, and then what happens is you actually end up with a central retinal artery occlusion because the pressure is so high, it just blocks off supply to the eye. So, that is a disaster. No one wants that, but in terms of if they are not operated on yet then no, the altitude will not be a problem. Particularly if, you know, if you have got an angle closure and you have already got some tips from the ophthalmologist or you have managed to get either some mannitol on board, that is pretty rare, but if you have got some mannitol or a bit of Diamox, Diamox is generally pretty easy to find in most EDs, the pharmacy usually has a stash.
We will have the next slide please. I think we are doing right off time. I am due to finish by 7.30, so I will wrap it on for another 10 minutes and then we will try and have 10 minutes of Q&A. Okay, and I have another question before I roll on. That is tips for clinically diagnosing adenovirus or viral from bacterial infection. I am assuming this is in the context of a conjunctivitis. So, basically most conjunctivitis are viral. They usually start in one eye and end up in the other eye. They are highly infectious. The most common cause is an adenovirus. You can send off a swab. Is it helpful? No. Conjunctivitis is generally treated with Chlorsig, though, the cure all Chlorsig. In the case of bacterial conjunctivitis, it acts more as a lubricant than anything else, but can you tell clinically? Not really. No. They talk about a bacterial being unilateral, but the vast majority of it is, in fact, viral. They may or may not have had a recent respiratory prodrome because the adenovirus that causes, you know, sort of the cold, the winter sniffs and sniffles is commonly causative of conjunctivitis as well.
Okay. Orbital fractures. We have talked about infections behind the eye. We have not talked about what happens when someone has been out partying Saturday night and they have got a hit to the eye or whatever might have happened. So, this definitely requires urgent Maxillofacial's opinion. Do not wake the ophthalmologist up in the middle of the night, please, with this. The one situation that would require immediate decompression with the Maxillofacial surgeons is, in fact, an ophthalmic sign, but again, the ophthalmologist will give the instruction to please contact the Maxillofacial surgeon for release of an entrapped muscle.
Now, the most common scenario is that there is entrapment of the inferior rectus in a trapdoor fracture. So, the fracture happens, inferior rectus goes in, it gets caught in there, and then there is a reflex called the oculocardiac reflex. In that scenario, because it is most often inferior rectus, you get the patient to look up and it will hurt and the eye will be restricted, but very importantly their pulse will plummet. If it is really bad, they will become faint, and if they are not lying down, they will drop on the floor. So, that is a situation that requires urgent decompression because if the muscle remains trapped in the orbital floor, of course, it will become ischaemic and then you will end up with an absolute disaster with a vertical diplopia because the inferior rectus will not work properly, and my strabismus colleagues will have to work very hard to even get a semblance of a reasonable outcome. So, that is the one situation where they do need urgent surgery. The beauty of an orbital floor fracture, if there is anything good about them, is that they, if it is a true fracture like the one in the scan, they will not actually end up with a retrobulbar haemorrhage because it auto-decompresses into the sinus, but these guys, you do need to call the Maxillofacial surgeon, especially if they have the oculocardiac reflex, but I can have a look at it. Usually a couple of days will give them because they are usually pretty swollen.
We will have the next slide. Thanks.
Now, retrobulbar haemorrhage. So, this is the situation that can be from trauma, but unlike having an orbital floor fracture, this is a closed injury, and what it is, is it is a compartment syndrome of the orbit. Now, this is an emergency, and this is something that cannot wait for the ophthalmologist, even calling the ophthalmologist. It is a clinical diagnosis. Generally, these people present to the emergency department. So, it has to be made in the emergency department. Emergency physicians are trained in how to do a cut down, and again, it is a clinical diagnosis. If you think there is a retrobulbar haemorrhage, if you think it is an orbital compartment syndrome, you cannot wait for the scan. You have to diagnose it. If it turns out it is not, it is okay. That is irrelevant. The lids will heal. No one is going to get up to you. No one is going to sue you, but if you wait around for the ophthalmologist to answer the phone, or wait around an hour or two for the scan, it is usually a CT scan, then you will be liable because you should have acted as soon as the patient came in. So, these patients have pain, proptosis and vision loss, and they look spectacular. You cannot miss the proptosis. The eye will be pushing out. They will have limited eye movements and you must proceed immediately to a cut down. Do not call the ophthalmologist, do not collect $200, just go straight through like this is a, you know, straight around. What you want to do is a cut down., so clinical appearance is as on the photo on the left, you can see there is restriction of the globe. In fact, that globe looks like it is inferotemporally abducted, and it will not move very well. Although the patient looks like they are comfortable, they will be in very, very bad pain. History of trauma, of course, and you then need to move to the cut down.
So, on the right hand side, you need to identify the lateral canthus, so, just there. Some people will put in anaesthetic, some people will not. It does not really matter because they are in a lot of pain, but either way whatever you do, anaesthetic or no anaesthetic, you need to get yourself a pair of arteries, crimp down on the lateral canthus, squash it, crush it, take a pair of blunt, straight scissors, put them down and cut, and you want to cut straight down a couple of centimetres down the lateral canthus. So, that is the cantholysis. Then you need to do the canthotomy, and there are good videos on this. When you strum down in that hole behind the conjunctiva, you will feel like a guitar string. That is the lateral canthal tendon. You must cut the lateral canthal tendon. Otherwise, you will not release the blood. I have seen quite a few cases where there has been a cut down, but they have not done the cantholysis, and that just does not fly. So, if you are in an ED, you have to know how to do this. A case that I will never forget was I was up in Darwin and the ED had called me at 3 a.m. saying we think we have a retroorbital haemorrhage. I said, why are you calling me? Has it not been done yet? The answer was no, we do not know how to, and that will not fly. That is not an excuse. Anyway, I went in , and that patient, did not have it, you know, clinically they did not have it, and they had also taken the liberty of doing a CT scan. So, if it was, again, they were liable, but I went back the next morning to check the patient and then across the corridor, there was another patient with trauma. I looked at them and lo and behold, that one was a retrobulbar haemorrhage. So, they totally missed the patient with the actual retrobulbar haemorrhage and had sort of inappropriately called about the one who did not. So, just be aware of this.
This is not uncommon, and what actually happened, I ended up talking to the ED, and they got in a bunch of pig's heads because it is a part of emergency physician training, and emergency physicians are required to know how to do this. They got in some pig's heads and learnt how to do it. So, for those on this call tonight who are not sure about this, please, please, please have a look at the videos. If you can get your hands on a pig head or something similar, just do it because it really will get you out of a lot of trouble as well as the patient. Once it is done and once it is decompressed, the emergency is over. Obviously, you know, there may be other systemic issues that need to be sorted, so please attend to them, but I do not need to know at 3 a.m. about this because the treatment is in that emergency department and immediate, do not wait for the scan.
We have got questions come through. At times, orbital cellulitis can look similar to mild retrobulbar haemorrhage. Is there any clinical sign to differentiate the two? Yes, there is. So, history is a big one. If a retrobulbar haemorrhage, there needs to be trauma to cause it. The other thing is there is a significant difference in the pattern of the redness. So, you will have a deep infective erythema in the upper and/or lower eyelids in an orbital cellulitis, whereas you will have the sort of the more bruised appearance, the more purpley colour if it is a haemorrhage. So, you can tell the difference by looking at them and I encourage you to jump on Google Images or something similar and just look up the two and there is a colour difference, but it is big on history. So, your orbital cellulitis generally is brewing for a couple of days. They do not suddenly come on whereas your retrobulbar haemorrhage, there is a history of trauma and they have come in to see you with head trauma and you know huge swollen eye. So, you are not going to look at that and go, I think that is an orbital cellulitis, like, you are just not. So, again, fundamentals go back to history, go back to presentation, and you will have, a good guide from there.
Can we have the next slide, please? I think we are probably getting pretty close. It is 7:19. Quickly, chemical burns. Must, must, must know about these. They have to be treated again in ED. I can see the next day, but the treatment is in ED or in your clinic, wherever you are. Alkali are worse than acids, so you must ask the agent, and powders are worse than fluids. So, you must ask what went in the eye. The worst of all, which is unfortunately very common, is concrete, and it is the worst because it is alkali because there is lime in the concrete and it is powder, and what will happen is if you do not wash out that eye properly, you might do a good flush out and they might have a Roper-Hall grade I burn when they leave your care in the evening and the next morning they will come back with a grade IV. That is because the concrete dust, if you do not wash it properly, can get stuck under the eyelids, and that can just leach out alkali solution the whole evening and wipe out the eye. So, these are very easily missed. Now, what do you do? Well, first assess them. So, ask them the history, does not need to be a long history. What happened to you? What went in your eye? That is all you need to know. Put some oxybuprocaine. So, topical anaesthetic. They are going to be in pain. Get them out of pain, put topical in. Then what you are going to need to do, you are going to sit them up on a bed. You are going to get a friendly nurse or someone to help you, a kidney dish on the side, and you are going to pour at least 3 litres of normal saline into that eye, at least. When I say pour it in, do not use the Morgan's lenses. They are useless. They are pointless, especially if there is powder, having that slow trickle does not help. It will just encourage the powder to dissolve and create an alkali mass. You want to take the normal saline bag sticky giving set in and open it up and just flush it. Now, I am not comfortable generally until I have put about 6 litres in there. They are still going to be in pain, but I really want to make sure there is absolutely nothing. Have a look at the Roper-Hall classification system. On the right hand side, we have some pictures of what the presentation will look like. I mean, it is pretty severe grade I at the top, but you can see the epithelial defect. Otherwise, there is no limbal ischaemia, and you can see iris details. Then we have got a grade II, which is the second one down. You can see there is a little bit of limbal ischaemia.
The limbal ischaemia is obviously between your cornea and your conjunctiva, and you should have a nice pink hue. You should be able to see little vessels there. Limbal ischaemia, you cannot see the vessels. It is just a ring of white, and you will have some iris detail loss. If it is a I or a II and you wash them out properly, they are going to have a good outcome, but you know, obviously get the ophthalmologist have a look the next day. For III and IV, really it does not matter what you do, it is going to be a disaster, but you still have to try your best. You have still got to wash it out. You have still got to try and neutralise the Ph, and then as I said the next morning, the ophthalmologist will start the long journey of trying to rehabilitate them, but have a look at the Roper-Hall. Just be familiar with your classification. It is easy. It is, you know, I, II, III, IV, and you can tell just by looking at it, but the key with this is you must, must, must work out what the agent was and you must, must, must wash out the eye with at least 3 litres of normal saline.
Okay, a couple of questions. Any tips to differentiate between a ruptured globe and swollen eyelids from trauma and retrobulbar haemorrhage? I mean, a ruptured globe, unless it is a retrobulbar rupture, they are going to have iris material and, you know, bits and pieces of eye everywhere. So, you definitely do not want to put any pressure on that., and in fact, that should have been up in the first lot of cases penetrating eye injury. You definitely want to get a penetrating eye injury through to the ophthalmologist like now, like wake them up. If you have ever seen one, most of the time they are obvious. They can be subtle, but most of the time they are obvious. Swollen eyelids from trauma. Well, key, if you think, you know, you are worried about a ruptured globe, then do not put any pressure on the eye, but again your ruptured globe is not going to be proptosed. It is not going to be sitting forwards.
If anything, it is going to be, you know, a bit soft and flat. So, they do look different clinically. I had a patient who I thought had retrobulbar haematoma, turned out to be a ruptured globe, performed a lateral canthotomy. Look, no one is going to hang you if genuinely if you think clinically it is a retrobulbar haemorrhage and you have done a cut down, it turns out to be a ruptured globe, then look, you should not be hung for that. In fact, in very rare instances in severe trauma, you can actually have ruptured globe and retrobulbar haemorrhage. So, that definitely you want to do a cut down. So, you should not be criticised if you genuinely think it is a retrobulbar haemorrhage and if it is a ruptured globe, that will be dealt with. Yeah, that is reasonable.
There are going to be difficult cases that are going to be difficult to work out. As I said at the very beginning, I am just giving you a bit of an oversight to try and help people out, but always, always, always if you are worried about something, then there is an ophthalmologist on the end of the line. I am just hoping to give just a few tips for the more straightforward cases.
We have got 5 minutes. So, next slide. Contact lens keratitis.
This one is important to pick up. Red eye, often backpackers and month long or fortnightly extended wear contact lens is the usual culprit. Very rarely they are daily disposable contact lenses, and they will come with a red eye. They may or may not have an obvious white spot like on the photo there. If it is pseudomonas, they can cause a rupture of the cornea within 24 hours. So, you definitely want to have them seen within 24 hours, but again, they have come in, you know, it is usually 11:00 at night, 12:00 at night. They cannot sleep. They have had a bit of a red, irritated eye that day. Have a look, but put some oxybuprocaine in. It might help a little bit with the pain, but it can be helpful in the diagnosis because it will not take the pain away completely. If it is an epithelial defect, the pain will settle.
If it is anything in the stroma, the pain will remain, and I would just babysit them till the morning. Should you start topical antibiotics? Controversial. Fluoroquinolones are the drug of choice, Ocuflox or ciprofloxacin, but what will happen is that that will contaminate the samples when they take the next day for microscopy culture and sensitivity. So, if it is not too bad and it is early onset, you can hold onto it as long as they are seen within 24 hours. Obviously, if the whole cornea is covered in infiltrate, well, yeah. Okay. You are going to want to call someone. So, again clinical presentation. You know, we are all sensible. We are all doctors. We know what we are doing.
Next slide. So CCF, we do not see many of these. There are different types. The one that you want to worry about is the post-trauma. So, a young person post trauma. Again, clinical diagnosis. It will be a pulsatile exophthalmos. So, you put your finger on there, you will feel it moving. It is the one time an ophthalmologist might use a stethoscope, you know, stick it on there, you will hear a bruit, and they will have ecchymosis. They can be, you know, pretty spectacular when they present. Again, young person with trauma. You know, if they have those features, you probably want to start thinking CCF. You can also have a low flow. They generally tend to be older vasculopaths. They are not as urgent. They' will have these funny little corkscrew vessels, and they will usually report a painless red eye for a while. If it is the acute trauma-induced CCF, well, then, you know, they are going to need urgent neurosurgical intervention, and then the ophthalmologists can follow up the next day. We do get these presenting in Ophthalmology, no doubt about it, but normally they are the slow flow type, you know, with the not so pulsatile red eye for a few weeks, corkscrew vessels and they are generally low flow or what they call indirect CCF.
Next slide. I think we are coming to the end. We are certainly almost about done. Yeah. There we go. So, that is the presentation this evening. I hope that was of some assistance. Again, if you are worried about something or you have questions, there is always someone at the end of the phone, but if it is one of these diagnoses that you are confident to diagnose and you are comfortable that is what it is, then if it is in that sort of second list, you can wait till the next morning, but the first list, which I should have put penetrating eye injury. My apologies for that. That first list of four, then certainly you are going to be wanting to wake up whoever is on the end of the phone.
Any other questions? We have just about hit time. It is 7:28 at my end anyway. We have two more minutes. I am happy to answer any last questions. Otherwise, we might wrap it up. No. All right. Well, thanks everybody for attending. I hope that was of some assistance, and, you know, some practical use.
Amy Freeman
Thanks, and I think there are a lot of things in the chat there. Thank you very much. Associate Professor Rallah-Baker, that was really great, really informative. I have certainly learned a lot. From RACGP, RACGP Rural would like to thank our sponsor again, Medical Insurance Protection Society (MIPS), and also thank everyone joining us this evening. A reminder to please complete the evaluation that will pop up in a moment when the webinar session closes. It takes no more than a minute to complete, and then a certificate of attendance will become available on your CPD statements within the next few days, but if there are any non-RACGP members who would like a certificate of attendance, please just email us at rural@racgp.org.au. Do not forget to tune into any of our other free monthly webinars held on the first Thursday of every month. Thank you very much.
On that note, I will end the webinar for everyone, so you can have a wonderful evening. Enjoy the rest of your night. Thank you.