FIG. 230-7. (Plate9). Positive Seidel test showing aqueous leaking through a full-thickness corneal wound. Aqueous will turn fluorescein lime-green under a cobalt-blue light as it oozes through the wound while being observed at the slit lamp.

FIG. 230-8. (PlateJO). Hyphema secondary to blunt trauma. Note the blood filling the lower half of the anterior chamber and hazy appearance of cornea suggesting increased IOP.

FIG. 230-9. (PlateJI). Corneal ulcer with hypopyon. The ulcer is seen as a shaggy white corneal infiltrate surrounding the borders of the epithelial defect. The hypopyon represents the accumulation of white cells layering out in the lower one-sixth of the anterior chamber.

FUNDUS The optic nerve, macula, and retina can be viewed with a direct ophthalmoscope in the ED. A dilated pupil makes it easier to see these structures, and unless the patient has a rare contraindication (narrow angles without a previous peripheral iridectomy), dilation can be performed if a posterior segment view is needed. Dilation can be achieved by using one drop of 1% tropicamide (Mydriacyl) in Caucasians and one drop each of 1% tropicamide and 2.5% phenylephrine

(Neo-Synephrine) in all others. A dilated examination is particularly important if an intraocular foreign body, central retinal artery occlusion (CRAO), or retinal detachment is suspected. A vitreous hemorrhage from diabetes or trauma can obscure or significantly reduce the view of the posterior pole. In these patients an ophthalmologist may need to perform an ultrasound-B scan to evaluate the posterior segment. An indirect ophthalmoscope provides an excellent three-dimensional view of the optic nerve and retina but requires extensive practice to use and generally is not a tool for the nonophthalmologist.

INTRAOCULAR PRESSURE The eye remains consistently "inflated" because of a delicate balance between intraocular aqueous fluid production and outflow. Intraocular pressure [(IOP)/tension] can decrease due to reduced ciliary body production (some cases of iritis and uveitis) or loss of globe integrity (perforating injury). An increase in IOP occurs when intraocular fluid production exceeds outflow (glaucoma, hyphema). The normal IOP is 10 to 21 mmHg, and three main methods are used to achieve a measurement. Applanation tonometry is the preferred method by ophthalmologists and physicians trained in using this slit-lamp attachment. Practice and previous experience is recommended, however. The Tonopen, a handheld instrument for measuring intraocular pressure, has gained popularity because it is easier for a nonophthalmologist to use and has reasonable accuracy on edematous corneas owing to high intraocular pressure (attacks of acute angle closure). The Schi0tz tonometer is another instrument that can be readily used if a Tonopen is not available. All methods require an anesthetized cornea and a cooperative patient. Care must be taken to avoid any pressure on the globe with your fingers when holding the lids open, as this will cause a falsely high reading. The lids should be held open, with the fingers compressing the lids against the bony rims of the orbit. The method used should always be recorded. In recording the IOP, refer to the glossary of terms, abbreviations, and notations.

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