Manual of Eye Emergencies: Diagnosis and Management, 2e
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The right and left cavernous sinuses in the brain drain the superior and inferior ophthalmic veins from the orbit and face. It must be distinguished from a cavernous sinus thrombosis which causes a non-pulsatile exophthalmos. The latter is often due to infection carried to the sinus via the superior and inferior ophthalmic veins. A carotid-cavernous fistula and a cavernous sinus thrombosis are two causes of exophthalmos that can mimic orbital cellulitis see Fig.
What both conditions have in common with orbital cellulitis are conjunctival vascular engorgement and chemosis see Fig. Orbital cellulitis is usually unilateral; cavernous sinus thrombosis is commonly bilateral; and carotid-cavernous fistula is unilateral unless there are large connections between the right and left sinuses. Intracranial aneurysms most often occur in arterial junctions in the circle of Willis Fig.
Note the two abnormalities. Rupture of the aneurysm could result in sudden severe symptoms, including coma. Note in the image above an area of increased signal intensity white in the occipital cortex. However, a CT scan is usually performed first in the emergency room to be sure there is no bleeding. Only then can tPA be safely administered. Courtesy of Salim Samuel, MD. Lymph nodes Lymphatics from the lateral conjunctiva drain to the preauricular nodes just anterior to the ear.
The nasal conjunctiva drains to the submandibular nodes Fig. Enlarged or tender nodes help to distinguish infectious from allergic lid and conjunctival inflammations.
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Lacrimal system Fig. The tear film is made up of an outer oily component, a middle watery layer, and a deep mucous layer Fig. With most external eye infections, the tear film is highly infectious. In AIDS, only bloody tears are so far considered infectious. In any case, wash your hands between patient examinations. Type Source Oily Meibomian glands at edge of eyelid Watery Constant secretion by conjunctival glands and reflex secretion by the lacrimal gland in response to ocular irritation or emotion. All eye drops are more effective and have less systemic side effects if patients press on the puncta and close the eyes for 60 seconds.
This minimizes flow into the nose. Dry eye Tear production normally decreases with age and could result in a symptomatic dry eye keratoconjunctivitis sicca. Dryness may also occur from medications such as anticholinergics, tranquilizers, antihistamines, diuretics, or vitamin A deficiency. The latter may occur due to poor diet or malabsorption, which is increasing in incidence with the surging popularity of gastric bypass surgery used to treat obesity.
Loss of vision from vitamin A deficiency may result from dessication of the cornea due to dryness or from decreased function of the rod receptors in the retina, which requires this vitamin to produce the visual pigment rhodopsin. In these cases, the lacrimal gland is immunologically damaged. The Schirmer test measures tears on the surface of the eye. A drop of anesthetic is instilled and a strip of folded filter paper is placed inside the lateral lid Fig. Less than 10 mm of moist paper in 5 minutes is presumptive of a dry eye.
Dry eye is treated in the daytime with artificial tears and at night with ointments. There are many on the market. They vary mostly by their viscosity and whether they have preservatives. The patient often decides which one is best. In severely dry eyes, the puncta may be closed with punctal plugs Fig. Room humidifiers may be tried and oral flaxseed oil has been shown to be of value. Restasis cyclosporine ophthalmic emulsion 0.
Courtesy of EagleVision. Tearing epiphora Tearing is a very common complaint and often is minor enough so as not to require the work-up and treatment discussed below. There are two causes of epiphora tearing : 1 increased tear production due to emotion or eye irritation; or 2 normal tear production that cannot flow properly into the nose.
Tearing due to failure of drainage system Once emotion and irritation are ruled out as the cause of tearing, an evaluation is made of the patency of the ducts leading into the nose. An obstruction is presumed if fluorescein dye placed on the conjunctiva Fig. A - Tearing due to punctal and canalicular obstructions 1. Ectropion see Fig. Rx: Repair lid.
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Visibly narrowed puncta—It may be dilated using dilator Fig. Narrowed canaliculi are often due to medications and aging. The narrowed canaliculi and puncta can be dilated with progressively wider diameter punctal probes Fig. If the lumen is still inadequate, a self-retaining bicanalicular stent Fig. Traumatic laceration of the canaliculus can lead to an obstruction.
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Carefully repair tears using a pigtail probe Figs c and a. The probe is passed through the upper puncta toward the laceration. A silicone tube is threaded onto it and it is withdrawn. The probe is then passed through the lower puncta and the other end of the silicone tube is threaded onto it and it is withdrawn forming a continuous lumen to heal over the tube. Rarely, the canaliculus can be obstructed from Actinomyces israelii infection. In this case, incise canaliculus; remove sand-like concretions; and instill erythromycin ointment.
B - Tearing due to nasolacrimal duct obstructions In adults, it is often due to chronic nasal inflammation or aging. In infants, the distal opening of this duct in the nose—called the valve of Hasner—fails to open at birth.
It is usually treated at 6 months to 1 year of age in infants by irrigating through the puncta to the nose Fig. The same technique can be used in adults. Courtesy of FCI Ophthalmics. If it still remains closed, a new surgical opening in the nasal bone is created and the mucosa of the lacrimal sac is sutured to the nasal mucosa dacryocystorhinostomy. Besides tearing, an additional motivation for performing the latter surgical procedure is recurring infections of the lacrimal sac dacryocystitis; Fig.
Rx: massage the sac; nasal decongestant; local and systemic antibiotics; then a dacryocystorhinostomy to open the NLD.
Evaluation of the Red or Painful Eye
Lids Lid swelling is commonly due to allergy, in which case the edema clears with a telltale shriveling of the skin between episodes Fig. Dependent edema caused by body fluid retention affects the lids on awakening and the ankles later in the day. Hypothyroidism myxedema and orbital venous congestion due to orbital masses or cavernous sinus thrombosis or fistulas are less common causes of edematous lids. Dermatochalasis is loose skin Fig.
There may be palpable orbital fat that herniated through the orbital septum see Fig. A surgical blepharoplasty is performed for cosmetic reasons or if resulting drooping of the lid ptosis obstructs vision. Lid-margin lacerations must be carefully approximated to prevent notching.
Pass a silk suture through both edges of the tough tarsal plate using the gray line for accurate alignment Fig. The gray line delineates the mucocutaneous junction.
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Common skin conditions The lesions in Figs — are electively removed for cosmetic reasons. Xanthelasmas Fig. They are often inherited and sometimes associated with hypercholesterolemia. Verrucas warts Fig. Seborrheic keratosis Fig. Epidermoid inclusion cysts Fig.