Emergency, Acute and Rapid Access Ophthalmology: Practical, Clinical and Managerial Aspects

137 Pages·2019·4.17 MB·English

by  Josephine Duvall-Young

Emergency, Acute
and Rapid Access
Ophthalmology
Practical, Clinical and Managerial
Aspects
Josephine Duvall-Young
121323
Emergency, Acute and Rapid Access
Ophthalmology
Josephine Duvall-Young
Emergency, Acute and Rapid
Access Ophthalmology
Practical, Clinical and Managerial Aspects
Josephine Duvall-Young
Ophthalmology Department
Wirral University Teaching Hospital NHS
Birkenhead
United Kingdom
ISBN 978-3-319-92368-0 ISBN 978-3-319-92369-7 (eBook)
https://doi.org/10.1007/978-3-319-92369-7
Library of Congress Control Number: 2018954715
© Springer Nature Switzerland AG 2019
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Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 What Is the Problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Defining the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 The Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Part I Clinical Aspects
2 Emergency Ophthalmology: Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Terrorist Attack or Major Incident . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Globe Penetration and Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 Retrobulbar Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.4 Orbital Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.5 Lid Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.6 Chemical and Thermal Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.7 Contusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.8 Minor Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.9 Local Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3 True Ophthalmic Emergencies: Non Traumatic . . . . . . . . . . . . . . . . . 17
3.1 Central Retinal Artery Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.2 Endophthalmitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4 Urgent Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1 Acute Angle Closure Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.2 Secondary Glaucomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.3 Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.4 Anterior Ischaemic Optic Neuropathy . . . . . . . . . . . . . . . . . . . . . . . 30
4.4.1 Giant Cell Arteritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.5 Orbital Cellulitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
v
vi Contents
5 Conditions Requiring Same Day Management . . . . . . . . . . . . . . . . . . 37
5.1 Corneal Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.1.1 Herpes Simplex Keratitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.1.2 Herpes Zoster Ophthalmicus (HZO) . . . . . . . . . . . . . . . . . . 39
5.1.3 Adenoviral Keratoconjunctivitis . . . . . . . . . . . . . . . . . . . . . 40
5.1.4 Bacterial Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.1.5 Contact Lens Associated Corneal Disease . . . . . . . . . . . . . . 42
5.1.6 Acanthamoeba Keratitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.1.7 Fungal Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.1.8 Non Infective Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.1.9 Allergic Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.1.10 Keratoconus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.1.11 Keratitis Secondary to Blepharitis . . . . . . . . . . . . . . . . . . . . 47
5.1.12 Idiopathic Keratitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.2 Scleritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.3 Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.1 Acute Anterior Uveitis (AAU) . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.2 Identifiable Associations of AAU . . . . . . . . . . . . . . . . . . . . 54
5.3.3 Inflammatory Chorioretinopathies . . . . . . . . . . . . . . . . . . . . 56
5.3.4 Lyme Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.3.5 Medical Evaluation of Uveitis Patients . . . . . . . . . . . . . . . . 57
5.3.6 Immunosuppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.4 Recent Onset or Progressive Ophthalmoplegias . . . . . . . . . . . . . . . 59
5.5 Transient Ischaemic Attack (TIA) . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6 Rapid Access: Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.1 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.1.1 Primary Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.1.2 Secondary Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6.2 Papilloedema and Disc Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.3 Subacute or Self limiting Angle Closure . . . . . . . . . . . . . . . . . . . . . 74
6.4 Neurological Visual Field defect . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.5 Optic Neuritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.5.1 Afferent Pupil Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.6 Anisocoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.7 Bell’s Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.8 Proptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
7 Rapid Access: Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.1 Retinal Vein Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.2 Central Serous Retinopathy (CSR) . . . . . . . . . . . . . . . . . . . . . . . . . 90
7.3 Choroidal Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
7.4 Choroidal Haemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7.5 Choroidal Naevus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Contents vii
7.6 Vitreous Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
7.7 Paraneoplastic Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
8 Referrals from Other Hospital Departments . . . . . . . . . . . . . . . . . . . . 93
8.1 Toxic Effects of Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
9 Paediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9.1 Neonates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9.2 Infants and Toddlers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.2.1 Poor Visual Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9.2.2 Developmental Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.2.3 Non Accidental Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.2.4 Strawberry Naevus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.2.5 Nystagmus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9.2.6 Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
9.2.7 Anisocoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
9.3 School Age Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
9.3.1 Optometry Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
9.3.2 Blepharitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
9.3.3 Intracranial Tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
9.3.4 Neurofibromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
10 Online Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Part II L eading an Emergency and Rapid Access Service
11 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
12 Organisation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
12.1 Volume and Workload Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 113
12.2 Workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
12.3 Walk in or Prebooked Service? . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
12.3.1 Walk in Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
12.3.2 Sorting Categories for Walk in Service . . . . . . . . . . . . . . 117
12.3.3 Prebooked Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
12.4 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
12.5 Equipment and Useful Reference Charts . . . . . . . . . . . . . . . . . . . . 121
12.5.1 Visual Acuity Recording . . . . . . . . . . . . . . . . . . . . . . . . . 123
12.5.2 Visual Acuity Measured Using Gratings
with Preferential Looking (Infants) . . . . . . . . . . . . . . . . . 123
12.5.3 Corneal Thickness Adjustments for IOP . . . . . . . . . . . . . 123
12.6 Protocols and Guidelines/Standard Operating
Procedures (SOP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
12.7 Patient Information and Education . . . . . . . . . . . . . . . . . . . . . . . . 127
viii Contents
12.8 Networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
12.9 Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Index ......................................................... 131
About the Author
Josephine Duvall-Young trained in general oph-

thalmology largely at the Princess Alexandra Eye
Pavilion in Edinburgh and took up a fellowship in
experimental eye research studying the mecha-
nisms of macular disease at the University of
Illinois under Professor MOM Tso. She was
appointed consultant ophthalmologist in the NHS
at Walton Hospital, now Aintree Hospitals,
Liverpool, and later at South Buckinghamshire
NHS Trust, developing a special interest in macular
and hereditary eye disease. She is currently a con-
sultant at Arrowe Park Hospital, Wirral University
NHS Trust. When she joined Arrowe Park in 2014,
she recognised the evolution of ophthalmology into
numerous subspecialties with the result that the
general ophthalmologist was a disappearing breed. She saw the need for a consul-
tant to take over the management of emergency and urgent patients and developed
an emergency and acute service within the ophthalmology department. Since then,
emergency and acute service has been recognised by the Royal College of
Ophthalmologists as a subspecialty of ophthalmology. Mrs. Duvall-Young has par-
ticipated in hospital management throughout her career and enjoys sharing her
managerial and clinical experience through teaching. She has been an examiner for
the FRCS(Ophth)Ed and the FRCOphth for over 20 years.
ix
List of Figures
Fig. 2.1 Icare rebound tonometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Fig. 3.1 Referral form to rapid assessment TIA and stroke clinic . . . . . . . . . 19
Fig. 5.1 Anatomy of the orbital apex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Fig. 5.2 Anatomy of the cavernous sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Fig. 6.1 OCT optic nerve transverse scan of an 18 year old patient
showing drusen outlined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Fig. 6.2 OCT of same patient as in Fig 6.1 showing that the nasal nerve
fibre layer thickness is within normal
limits despite the swollen appearance of the disc . . . . . . . . . . . . . . 71
Fig. 6.3 Autofluorescent image of the discs of a 14 year old showing
bilateral but asymmetric drusen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Fig. 6.4 The same patient as in Fig 6.3 showing drusen (dotted line)
protruding laterally creating a “boot shaped” SHS (solid line) . . . . 72
Fig. 6.5 OCT in raised ICP showing absence of SHS despite advanced
disc swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Fig. 6.6 OCT of a 37 year old patient with granular appearing drusen,
outlined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Fig. 6.7 Progressing disc swelling in IIH showing progression
of thickening of NFL particularly nasally between two scans . . . . . 73
Fig. 6.8 Anterior segment OCT showing closeable angle . . . . . . . . . . . . . . . 75
Fig. 6.9 Normal visual field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Fig. 6.10 Diagram of parasympathetic innervation of the pupil . . . . . . . . . . . 81
Fig. 6.11 Diagram of sympathetic innervation of the pupil . . . . . . . . . . . . . . 81
Fig. 6.12 Schematic electrodiagnostic traces . . . . . . . . . . . . . . . . . . . . . . . . . 85
Fig. 10.1 Screenshot of NICE evidence website home page . . . . . . . . . . . . . . 104
Fig. 10.2 Screenshot of Hospital Premium Collection literature search . . . . . 105
xi