ࡱ> `  bjbjss*j8%7778V7|7|Z0Z8Z8"|8|8|8>>>XXXXXXX$L[h]l Y?{=0>?? Y|8|8YQQQ?|8|8XQ?XQQr XT{X|8N8 7?Hz_XXLY0ZmX ^P ^{X ^{X >">Q>>>>> Y Y}QX>>>Z????177  A2#(6)2 4##! 2###"2" @#7H- 2'0 8@ 422 (Eye Emergency) 9I*- 2"A"L'4 1" #0*2$2 '18#0*L 2"+%12#@#5"2#*-1(6)2A"L5 5 *2!2# C+I2##'A%0'44 1"B#5H@G 2'0 8@ 422DI -*2@+85H3C+I@4B#1%H2'DI9I- C+I2##1)2B#5H@G 2'0 8@ 422 #0*2#L2#@#5"#9I @7I-+2'4 2 chemical burn corneal ulcer preseptal cellutitis orbital cellutitis central retinal artery occlusion '452##'2@7H-'44 1" 2#12#@#5"2#*- *25H +I-##"2" 1(6)2A"LDI#1@-*2##0-2#*- @7H-C+I1(6)2H-@I2 1I@#5" 3@I2*9H@#5" (5 25) - '2!*31 - 2'0 8@ 422 - '452##1)2C 2'0 8@ 422 A03, ##"2"2##' '44 1" A%02##1)2B# chemical burn (10 25) A03, ##"2"2##' '44 1" A%02##1)2B# corneal ulcer (10 25) A03, ##"2"2##' '44 1" A%02##1)2B# preseptal cellutitis (10 25) A03, ##"2"2##' '44 1" A%02##1)2B# orbital cellutitis (10 25) A03, ##"2"2##' '44 1" A%02##1)2B# central retinal artery occlusion (10 25) @4B-2*C+I 12! (5 25) *7H-2#*-A%01(9#L @-*2##0-3##"2" 8 2'0 8@ 422 Slide 8 2'0 8@ 422 A%0@#7H- 2" Slide +1*7--H2@4H!@4! 3.1 "(-1L "(D9%"L . Ocular Examination B#4!L(4#4 1L--@ G -AH 2529. Daniel Vanghan. Taylor Asbury, Khalid F. Tabbara General Ophthalmology. Twelfth edition Applecton & Lange 1989. Frank G.Berson. Basic Ophthalmology. Sixth edition 1993. 2##0@!4% *1@$4##!1(6)2A"LC 1I@#5" *1@$4##!A%02#'44 1"C2##'9IH'"--1(6)2A"L 2# 12! - 4#2" %2#*-  *2#@!5@I22 chemical burn  9IH'"5H!5#0'14*2#@!5@I22 @G 2'05HI-DI#12##1)215 H-5H032##' +#7- 1#0'14-7H B" 1) %I22I'" normal saline +#7- Ringer s lactated solution -"H2I-" 30 25 -2C I"2 2+"-#H'!1 eye speculum @7H- H'"C+I%I22DI*0'!26I 2#%I22'#6+12%H2% A%0@4%4@%7-2#H'!I'" 2) +%12%I22A%I' 5 25 C I#02) Litmus A05H@%7-2%H2 I2'H2 pH "1D!H@G%2 '#%I22 I3DI pH 5H@G%2 -22# : @7-2 I32D+% '2 2#!-@+G%% #H'!1#0'14-*2#@!5 @I22 -22#A* : AH'2!#8A# DI@G 1) Mild !5 1.1) Corneal epithelial defects 1.2) faint haziness - cornea 1.3) D!H!5 ischemic necrosis - conjunctiva +#7- sclera 1.4) !5 focal areas - conjunctival chemosis, hyperemia A%0/+#7- hemorrhages 2) Moderately severe 2.1) chemosis A%0 perilimbal blanching 2.2) corneal edema A%0 opacity @+G iris details D!H 1@ 2.3) minimal ischemic necrosis - conjunctiva A%0 sclera 2.4) !5 anterior chamber reaction 3) Very severe 3.1) blurring of pupillary outline 3.2) blanching of conjunctival A%0 scleral vessels 3.3) increased intraocular pressure 2##' : I- 1#0'146@'%25H@4@+8 4-*2#@!5 A%0#0"0@'%25H9*2#@!5 H-5H0DI#12#%I22 #'!6#0"0@'%25H%I22 2##'9'2!#8A# B"C I fluorescein staining A%0"1I-@4@%7-2 @7H-+2 foreign bodies A%0'1 IOP I'" 2##1)2 : C#2"5H!5 mild to moderate burn 1) Removed residual chemicals 2) Cycloplegic 3) Topical antibiotic ointment 4) Pressure patch 24 1H'B! C#2"5H!5 moderate to severe burn 1) Admit @7H-#' IOP A%0 corneal healing 2) Debride necrotic tissue 3) Topical antibiotic 4) Cyclo plegic 5) Topical steroid ( eg. prednisolone acetate 1% +#7- dexamethasone 0.1%) C#55H!52#-1@* - cornea +#7- anterior chamber reaction !2 6) Pressure patch 7) Antiglaucoma medications 8) Lysis conjunctival adhesion B"C I glass rod #H'!1 antibiotic ointment 2#42!% '#42!9IH'"%- B"@ 20C*12+LA#+%19*2#@!5 "2+"- steroid 5HC I'#+"8+%12'15H 7 @7H-2-23C+I@4 melting - cornea DI +%121I-2I-C+II32@5"! +#7- lubricating ointment C#2"5H!52A+I 6H@G 2'0A# I-2!!2 *H'C#55H@G!2 -2I-3 tarsorrhaphy, conjunctival flap +#7- mucous membrane graft #H'!I'"  Preseptal Cellulitis  +!2"6 2#4@ 7I-- sott tissue #4@'@%7-2 5H-"9H+I2H- orbital septum !2C@G'1" preschool @42@ 7I- Haemophilus influenzae @G*2@+8+%1 #-%!2@G@ 7I- S. aureus A%0 Streptococci -2@ 7I- anaerobes C#55H!5 foul - smelling discharge +#7-A%5H!5 necrosis !2 +#7-!5#0'149*1'L1 *2@+8 : @42!52A% +#7- "1#2" 6H*2!2#AHDI@G 1) 2 upper respiratory tract +#7- middle ear (non suppuraive preseptal cellulitis) @42@ 7I- H. influenzae type +#7- B +#7- Streptococcus pneumoniae H22 vascular A%0+#7- lymphatic system B"!1C @G-2"8#0+'H2 6 @7- 6 2 5 (@ %5H" 20 @7-) 2) 24'+1 +#7-#4@'C%I@5" B"!2@G@ 7I- Herpes simplex, varicellar zoster 3) post traumatic preseptal cellutitis B"!20@42@ 7I- S. aureus A%0 S. pyogenes -22# : ' '! A -@%7-2, DIH3 F -22#A* : eye lid erythema, edema, warmth and tenderness, no proptosis, no pain with eye movement, conjunctival chemosis, red - purple discoloration -4'5H4@ 7I- 2#'44 1"A"B# 1) orbital cellulitis 2) chalazion 3) allergic eyelid swelling 4) viral conjunctivitis with eye lid swelling 5) cavernous senus thombosis 6) Erysipeles 7) other orbital disorders 2##' : 1) #0'14 2) complete ocular examination 3) Gram s stain A%0 culture I2!5A% 4) CBC 9 differential A%0 blood culture C severe case +#7-!5DI 5) check vital sign 6) CT scan brain and orbit C#2"5H!5#0'14 Trauma 7) Lumbar puncture #2"5H!5 menigeal sign 1. Antibiotic therapy 2##1)2 : A. Mild preseptal cellulitis and age > 5 years: Amoxicillin/clavulanate (e.g., Augmentin) (20-40 mg/kg/day po in 3 divided doses in children) (250-500 mg po q 8 hours in adults) or cefaclor (e.g., Ceclor) (20-40 mg/kg/day po in 3 divided doses in children, maximum dose 1 g/day) (250-500 mg po q 8 hours in adults) If penicillin allergic, then: Trimethoprim/sulfamethoxazole (e.g., Bactrim) (8 mg/kg/day trimethoprim and 40 mg/kg/day sulfamethoxazole po in 2 divided doses in children) (160 mg trimethoprim and 800 mg sulfamethoxazole po bid in adults) If penicillin and sulfa allergic, then: Erythromycin (30-50 mg/kg/day po in 3-4 divided doses in children) (250-500 mg po q 6 hours in adults) NOTE Oral antibiotics are maintained for 10 days. B. Moderate-to-severe preseptal cellulitis or any one of the following: ( Patient appears toxic. ( Patient may be noncompliant with outpatient treatment and follow-up. ( Child ( 5 uears old. ( Suspect H. influenza. ( No noticeable improvement or worsening after a few days of po antibiotics. Admit to the hospital for IV antibiotics as follows: Nafcillin or oxacillin (150 mg/kg/day iv in 6 divided doses in children) (1-2 g iv q 4 hours in adults) and ceftazidime (30-50 mg/kg iv q 8 h (maximum of 6 g/day( in children) (1-2 g iv q 8 hours in adults) 2. Warm compresses to the inflamed area tid prn. 3. Polymyxin B/bacitracin ointment (e.g., Polysporin) to the eye qid if secondary conjunctivitis is present. 4. Tetanus toxoid if needed 5. Exploration and debridement  Orbital cellulitis  +!2"6 2#4@ 7I-C#4@'5H-"9H%6H- orbital septum B"!5*2@+82 1) 2#4@ 7I-- ethmoid sinusitis H-"5H*82@ 7I- S. pneumoniae #-%!2 @G streptococci, S. aureus, H. influenzae A%0 non-spore-forming anaerobes DIAH peptostreptococci, Bacterorides A%0 Fusobacterium 2) direct inoculation secondary to trauma A%0 surgery 3) 4@ 7I-2-'1"'0C%I@5" 4) Hematogenous spread -22# : DI '(5#)0 2'! 2#!-@+G%% -22#A* : conjunctival chemosis, proptosis reduction of extraocular muscles 2#'44 1"A"B# : 1) orbital pscudotumor 2) rhabdomyosarcoma 3) metastatic tumor (neurobla*,>BNRr@ F R T   Z ^ l < > 8 : ۺۺ۩ۺۺ۩ۺۺۺۺۺۤۺۏۺۺۺۺۺۺۺۺ h\>*CJ OJQJ^JaJ h\ h\ h\5CJ OJQJ\^JaJ h\CJ OJQJ^JaJ #h\5CJ OJQJ\^JaJ h\CJ OJQJ^JaJ h\CJ$aJ$h\CJ$aJ$ h\o(8@BT  \ ^  * l ^ & F & F & F$a$Ԙ : Nz|~.fhDn"tv^ & F & F h^`h^ & F & F;]; & Fp^p: D H b d t v BJNX\vx ">nv~"*.RZbh6Dlxv\^prh\ h\h\CJ OJQJ^JaJ h\CJ OJQJ^JaJ V^nnp$a$$a$ & F24xz L^fnp02lx*,NVlpνh\CJ OJQJ^JaJ h\CJ OJQJ^JaJ h\5CJ(OJQJ\^JaJ( h\5CJ$OJQJ\^JaJ$h\ h\.jh\CJ OJQJU^JaJ mHnHu h\5CJ OJQJ\^JaJ 4pz|*2NP^t|0>dj "*:Lhv~ NP~ 6 8 F x οοοοοοοοοοοοοοοοοοοοοοοοοοοοοοοοοοh\CJ OJQJ^JaJ h\CJ OJQJ^JaJ h\5CJ OJQJ\^JaJ #h\5CJ OJQJ\^JaJ K`~DrN&Hbdfhh 333333344,404J4\444&5:5Z555566_9`9}9~9999ппп jh\CJ OJQJ^JaJ h\6CJ OJQJ]^JaJ h\5CJ OJQJ\^JaJ #h\5CJ OJQJ\^JaJ h\CJ OJQJ^JaJ h\CJ OJQJ^JaJ ;3^444X5Z555616i66666'7G7y77708Y8j88888888$a$889[9y9999P::::;;T;z;;<<<v<<<<<<<<<<$a$$a$9999::;;1;2;D;E;<<<<<===R=t=====>$>2>@>H>>>>>4?:????@<@၅rrrrrrrrrrrrh\CJ OJQJ^JaJ h\.jh\CJ OJQJU^JaJ mHnHu j]h\CJ OJQJ^JaJ j[h\CJ OJQJ^JaJ h\6CJ OJQJ]^JaJ jh\CJ OJQJ^JaJ h\CJ OJQJ^JaJ jh\CJ OJQJ^JaJ )<<<<<<<<<==4>>X??@:@<@@@4A6A^AAADhhh.i$a$$a$<@F@H@P@V@X@h@j@t@v@@@@6AVAXABh hh.h@hni|iiijjkk2k:knk~kpq(q.q0qDqVq`qqqqqqssss tοοοονοοοοοοοοοοοΥΓ h\5CJ$OJQJ\^JaJ$#h\5CJ$OJQJ\^JaJ$.jh\CJ OJQJU^JaJ mHnHuUh\CJ OJQJ^JaJ h\CJ OJQJ^JaJ h\5CJ OJQJ\^JaJ #h\5CJ OJQJ\^JaJ 3stoma C@G CA breast C9IC+ H) 4) necrotic retinoblastoma with orbital involvement 5) myositis of extraocular muscle 6) leukemia, lymphoma 7) malignant lacrimal tumor 2##' : 1) #0'14 2) evaluation for proptosis, mass 3) complete ocular examination and extraocular molitity 4) Smear and culture C#2"5H!5 discharges 5) CBC, Blood culture 6) CT scan C#2"5H!5 proptosis +#7- motility restriction 2##1)2 : Bacterial or infectious (but unidentified) etiology If mild-to-moderate: Amoxicillin/clavulanate (e.g., Augmentin) Adults: 250-500 mg po q 8 hours. Children: 20-40 mg/kg/day po in 3 divided doses. Alternative treatment: Cephalexin (e.g., Keflex) Adults: 250-500 mg po q 6 hours. Children: 25-50 mg/kg/day in 4 divided doses. If moderate-to-severe, hospitalize and treat with: Ticarcillin/clavulanate (e.g., Timentin) Adults: 3.2 grams iv q 4-6 hours. Children: 200 mg/kg/day iv in 4 divided doses. Alternative treatment: Cefazolin (e.g., Ancef) Adults: 500-1000 mg iv q 6-8 hours. Children: 50-100 mg/kg/day iv in 3-4 divided doses. systemic antibiotics '#C+I-"H2I-" 7-14 '1 C#2"5H!5 abscess '#3 incision and drainage I'" 2'0A# I- 1) cavernous sinus thrombosis 2) Meningitis 3) Subdural or epidural or brain abscess 4) loss of vision 4.1) Endophthalmitis 4.2) increased intraocular of intraorbital pressure 4.3) direct infection of optic nerve 5) Septicemia  2#4@ 7I--#02 Corneal ulcer  -22# : 2A, '2, %1'A*, #012#!-@+G%%A%0!5 discharge -22#A* : +12'!, mucopurulent discharge, circumcorneal injection, #02 @GA%, !5 loss - tissue, CI epithelial !5 infiltration, stromal edema, !5 fold C 1I Descemet, anterior chamber reaction, hypopyon, C#2"5H@G!20'H2!5 posterior synechiae, hyphema A%0I-+4DI 0@+G!5 focal white opacity C 1I stroma -#02, !5 epithelial defect 6H"I-!4*5 fluorescein *2@+8 : 1. Bacteria @G*2@+85HH-"5H*8 6'#1II-**1"'H2@G bacteria H-5H04*9LDI'H2@G*2@+82@ 7I--7H 2. Fungus : !1@4C#2"5H2!+%1 traumatic corneal injury 27  @ H 4HD!I, CD!I B"40!5%1)0-D!H 1@%I2" +#7-%I-!#-I'" satellite lesion *2!2##'DII'" fresh smear, Giemsa stain +#7-22#@20@ 7I-#2 Sabouraud s agar 3. Acanthamoeba C9IH'"5HC I@%*L*1!1*B"C II3"2D!H9*8%1)0+#7-C*H'H2"I3CH- !5-22#'2!2, A%!5%1)0@G'A+' *2!2# acanthamoeba cyst B"C I Giemsa stain +#7- cultured  nonnutrient agar 5H!5 E. coli 4. Herpes simplex virus !5-22#- recurrent eye disease +#7-!5#0'14@G!2H- !5 vesicles 5H@%7-2 +#7- dendritic lesion 5H#02 9IH'"5H@G recurrent herpes simplex keratitis -2!5 bacterial superinfection DI 2#'44 1"A"B# : 1. Sterile ulcer (non infectious) !1C9IH'"5H!5B#2@4!-"9HH- @ H dry eye syndrome, Rheumatoid arthritis +#7- collargen vascular disease -7H, Vitamin A deficiency B"0!5 anterior chamber inflammation I-"!2, %@20@ 7I-0D!H6I 2. Subepithelial infiltrate 2!+%1 viral conjunctivitis (EKC) *H'!20@G bilateral, #0'14@ 5"%1, itchy red eye #H'!1!5 discharge !2H- 3. Staphylococcal hypersensitivity %1)0@G peripheral corneal infiltrate, bilateral, B"0!5 clear space #0+'H2 H' infiltrate A%0 limbus; anterior chamber reaction I-"!2 4. corneal infiltrate 2 immune reaction -@%*L*1!1* +#7-I3"2%I2@%*L 0!5%1)0@G multiple, small subepithelial infiltrate B"!5 intact epithelium %8! 5. Residual corneal foreign body +#7- rust ring 2##' : - 2#0'14 - 2##' "I-!I'" fluorescein +#7-9 epithelial loss @+7-#4@'5H!5 infiltrate '12-A% - corneal scraping 3D"I-!A%0@20@ 7I- 2##1)2 : 1. #- shield D!HI-C IAH42 (eye pad) 2. Cycloplegic 3. Topical antibiotics - C9IH'"5HD!HDIC*H@%*L*1!1* C+I Broad spectrum topical antibiotics - C9IH'"5HC*H@%*L*1!1* C+I tobramycin +"-8 1-2 1H'B! @7H-2 *H'C+ H0@G@ 7I- Pseudomonas auruginosa 4. Subconjunctival antibiotics - Gentamicin 20-40 mg #H'!1 Cefazolin 100 mg. C#2"5H!5-22##8A# !2 5. C+I#1)21'D'ICB#"22%C#5H-D5I 1. A severe sight-threatening infection 2. C#2"5HD!H*2!2#0+"-"2DI2!5HA"LI-2#  2#-81- central retinal artery Central Retinal Arterial Occlusion, CRAO  -22# : 2!1'%-"H2 1%1, D!H' !1@GI2@5"' *H'!2*2"20!1'@+G@5"AH1 4I'+#7-#1#9IA* -20!5#0'14- amourosis fugax !2H- -22#A* : !52# 52'--#0*22 +#7-!5 superficial opaciication C#4@' porterior pole !5%1)05H*31 7-  cherry re spot #4@' macular !52#@*5"- afferent pupillary defect, retinal arterioles !52A% !5%1)0- segmentation +#7- Boxcarring %+%-@%7- arterioles, 2#1I-2!5 emboli C+%-@%7- +#7-@+G#4@' macula 5H@%5I"I'" cilioretinal artery @H 16I 2#'44 1"A"B# : 1. Acute ophthalmic artery occlusion !10D!H!5 cherry red spot AH0@+G retina 1I+!2' 5, 2##1)2@+!7- CRAO 2. Arteritic ischemic optic neurophathy !1C-2"8!2'H2 55 5 0!5-22# acute severe visual loss 0!5#0'14'(5#)0#4@' Temporal #'!1I+1(5#)0, jaw claudication, '%I2!@7I-, -H-@%5", I3+1%, !5 afferent pupillary defect, optic disc '! 5 A%0!5 ESR *96I!2@G%1)0*31  3.  Cherry red spot I-A"2*2@+8-7H DIAH Tay-Sachs disease !1C-2"8I-" !5-22#2 systemic -7H F #H'!I'" A%0!1@G1I*-2 *2@+8 : 1. Embolus *H'C+ H!22 Caroid artery A%0+1'C 2. Thrombosis 3. Giant cell arteritis (GCA) -2@G*2@+8- CRAO +#7- ischemic optic neuropathy ##28#! 1. Marck A. Friedberg, Christopher J. Rapuano, : Office and emergency room diagnosis and treatment of eye disease. J.B. Lippincott Company, 1990. 2. Vaughan D., Asbury T.; General Ophthalmology, 12th ed. California, Lange Medical Publisher, 1989. 3. John V. Linberg ; Oculoplastic and Orbital Emergency. Appleton and Lange 1990. 4. 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