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Ocular Emergencies

DR SATHIYAN KARUNANITHI
MD (AIIMS)
OPHTHALMOLOGIST AND RETINAL
SURGEON
OBJECTIVES

 IDENTIFICATION OF OCULAR EMERGENCIES


 CLASSIFICATION IN TERMS OF ACUTENESS
AND LOCATION
 TRIAGING
 DIAGNOSTICS
 MANAGEMENT
 MEDICOLEGAL LIABELITIES
OCULAR EMERGENCIES

 Medical  Surgical
 Conjunctivitis  Corneal Abrasion
 Extraocular Foreign
 Iritis
Bodies
 Periorbital Cellulitis
 Retinal Detachment
 Glaucoma  Orbital Fracture
 Central Retinal Artery  Chemical Burns
Occlusion  Hyphema
 Eyelid Laceration
 Globe Rupture
Assessment

 History / MOI
 Time of occurrence
 Treatment before arrival
 Abnormal eye appearance
 Visual acuity
 Snellen’s
 Visual Fields
 Finger count
Assessment

 Tearing
 Itching
 Discharge
 Medical History
 Ocular
 Systemic
 Medication

 Always use contralateral eye for comparison


Assessment

 Spasms of eyelid
 Lesions, FB, Penetrating wounds
 Pupils
 EOM
 Position and alignment of eye
Assessment

 Conjunctiva and sclera for color and inflammation


 Edema of lids, conjunctive, and/or cornea
 Blood
 Opaque, gray-white area of cornea
 Hazy cornea
Assessment

 Palpation
 Intraocular
pressure: Do not do if there is
concern regarding globe
Things To Think About When Assessing

 Younger males are at higher risk for serious


injury
 School-age children are more susceptible to
conjunctivitis
 Contact wearers are at greater risk for corneal
abrasions and infection
 Exposure to arc welding S/S develop 4-8 post
exposure
Things To Think About When Assessing

 Auto mechanics and service station attendants have


potential for acid burns to face
 Injuries occurring in the garden have increased
potential for infection
 Ball sports increase potential for eye injury
Diagnostics

 Direct ophthalmoscope
 Tonometry
 Fluorescein staining
 Slit-lamp exam
 Laboratory
 Cultures
 CBC
 Coags
Diagnostics

 Radiology
 CT scan
 Soft tissue/orbit films for foreign body

 Facial bones

 Skull films
Priorities

 ABCs
 Prevent further damage
 Prevent or minimize complications
 Control pain
 Relieve anxiety or apprehension
 Education
Consultation Criteria

 Penetrating ocular  Central retinal


trauma artery occlusion
 Chemical burns of  Retinal detachment
the eye  Orbital fracture
 Severe lid  Hyphema
laceration  Periorbital cellulitis
 Glaucoma
Age-related Pearls

Pediatric
 Delayed presentation due to children not noticing gradual
vision loss
 May need picture chart
 Infants and small children may need to be restrained in
blanket to facilitate exam
Age-related Pearls

Geriatric
 Vision diminishes gradually until 70 y/o and then rapidly
thereafter
 Decreased near vision
 Decreased accuracy of results from visual acuity testing
Age-related Pearls
Geriatric
 Decreased accommodation
to distances
 Decreased lacrimal secretions

 Cataracts: at age 80 1 in 3
are affected
 More likely to experience glaucoma,
detached retina, and retinal bleeds
Medical Ocular Emergencies
Conjunctivitis

 Inflammation of the conjunctiva


 Causes:
 bacterial/viral inflammation
 allergies
 Chlamydia
 chemical burns
 FB
 flash burns
 Irritants
 URI
Conjunctivitis
Symptoms/Assessment
 Hyperemia  Edema of eyelids
 Unilateral or bilateral  Visual acuity: Normal
 Slight pain  Cornea: Clear
 “Gritty” sensation  Pupil: Normal
 Discharge  Conjunctiva: red or pink
 Mucopurulent
 Matting of eyelids and lashes
Conjunctivitis

Treatment Education
 Antibiotics  Explain contagious nature
ointment/drops  Medication admin.
 Obtain culture, if  Asepsis
indicated  Wipe from nose to outer
 Cleanse eyes gently to corner of eye
remove debris  Cleanse lid with baby
shampoo
 Avoid eye makeup
 Follow-up
Iritis
 Inflammatory process that includes the iris and
sometimes the ciliary body
 Predisposing conditions:rheumatic disease, and
syphillis
Iritis

Symptoms/Assessment
 Blurring of vision  Redness at eyelash
 Unilateral pain  Clear to hazy cornea

 Edema of upper lid  Small, irregular,

 Red eye
sluggish reaction of
pupils
 Photophobia
 Pain on eye pressure
 Decreased visual acuity
 Fluorescein stain
 Lacrimation
 Slit-lamp exam
Iritis

Treatment/Education
 Analgesics  Rest eyes
 NSAIDs  Warm compresses
 Cycloplegics to paralyze Shield eyes or dark
ciliary muscle and glasses
spasms  Follow-up
 Darkened environment
Periorbital Cellulitis

 Infection of the cells around the eyes


 A major ophthalmological emergency and is
potentially life threatening
 May occur after trauma such as laceration or an
insect bite
 Pneumococcal, staphylococcal, streptococcal
Periorbital Cellulitis
Symptoms/Assessment
 Marked periorbital edema  Visual acuity:
and erythema Decreased
 Pain: severe that is  Decreases pupil
aggravated by movement of reflexes
eye  Paralysis of EOM
 Conjunctival infection  Diagnostics
 Fever  CT scan
 Culture
 Gram stain
 Blood culture
Periorbital Cellulitis

Treatment/Education
 Referral to
ophthalmologist
 Bedrest

 IV therapy

 IV antibiotics

 Warm compresses
Glaucoma

 Acute angle-closure glaucoma occurs when the


distance between the iris and the cornea becomes
inadequate or is blocked completely
 The aqueous fluid produce is greater than the
amount leaving through the canal of Schlemm
 Emergency Situation
 May lead to irrecoverable blindness
Glaucoma
Symptoms/Assessment
 Red eye  Abdominal pain
 Severe, sudden-onset, deep,  Hazy, lusterless cornea
unilateral pain
 Pupils poorly reactive or
 Intense HA fixed
 Decrease visual acuity  Increased intraocular
 Halos around lights pressure (>20 mm Hg)
 N/V  Rocklike harness
appearance
 Diagnostic
 Tonometry
Glaucoma

Treatment/Education
 Referral to
ophthalmologist
 Analgesic
 Antiemetic
 Pilocarpine eyedrops
 Osmotic diuretic
 Supportive and
informative environment
Central retinal occlusion

 Blockage of the the retinal artery by thrombus or


embolus
 True ocular emergency
 Prompt recognition and intervention must be obtained within
1-2 hours of onset
Central retinal occlusion

Symptoms/Assessment
 Sudden unilateral loss of  Visual acuity is
vision limited to light
 Painless perception in affected
 History of: eye
 Thrombus or embolus  Pupil reaction:
 HTN dilated, nonreactive
 Diabetes in affected eye
 Sickle
cell disease
 Trauma
Central retinal occlusion

Treatment
 Referral to
ophthalmologist
 Possible IV therapy
 Digital massage of globe
by MD  Anticoagulants
 Supportive environment  tPA
 Low-molecular weight
Dextran
 Admission and possibly
surgery
Surgical Ocular Emergencies
Corneal Abrasion
 Partial or complete removal of an area of
epithelium of the cornea
 Most common eye injury seen in the ER
 Common causes: FB, contact lenses, exposure to
UV light
Corneal Abrasion
Symptoms/Assessment
 Mild to severe pain
 Foreign body sensation
 Photophobia
 Normal to slightly
decreased visual acuity
 Injected conjunctiva
 Tearing
 Abnormal Fluorescein
stain
Corneal Abrasion

Treatment Education
 Topical analgesic  Follow-up care
 Topical ophthalmic  Proper patching
antibiotic techniques
 Tight patch to affected eye  Instillation of meds
for 12-24 hours  S/S of infection
 Use extra precaution with
activities requiring depth
perception
Extraocular Foreign Body

 Can enter as a result from hammering, grinding,


working under cars, or working above the head
 “Something going into my eye”
 Metal, sawdust, dust particles
 Metal can form a rust ring on the cornea
Extraocular Foreign Body

Symptoms/Assessment Diagnostics
 Pain  Magnifying lens
 Foreign body sensation  Fluorescein stain
 Tearing  Slit-lamp
 Redness
 Normal to slightly abnormal
visual acuity
 Fluorscein stain abnormal
 FB visualized
Extraocular Foreign Body

Treatment
 Topical anesthetic  FB removal with moist
Topical anesthetic inhibit cotton swab, needle, eye
wound healing and are spud if irrigation
toxic to corneal  Patch both eyes to
epithelium reduce unsuccessful
 Gentle irrigation with
consensual movement
 Possible admission
NS
Extraocular Foreign Body

Education
 Instillation
of meds
 Patching techniques

 Follow-up care

 Provide preventative
information
Retinal Detachment
 Separation of the retinal layers, with
accumulation of serous fluid or blood between
the sensory retina and the retinal epithelium

 Leads to decrease blood supply and oxygen to the


retina

 Most common cause: degenerative changes in the


retina or vitreous body of the elderly

 Sports direct head trauma


Retinal Detachment

Symptoms/Assessment Diagnostic
 Gradual or sudden  Fundoscopy
deterioration of vision  Visual acuity
unilaterally  Slit-lamp exam
 Cloudy, smoky vision
 Flashing lights
 Curtain or veil over visual
field
 No pain
Retinal Detachment

Treatment
 Referral to
ophthalmologist
 Patch both eyes or
shielding to reduce eye
movement
 Bed rest, lying quietly
 Supportive and calm
environment
 Admission or transfer
Orbital fracture
 Fracture of the orbit without a fracture of the
orbital rim
 Common cause: blunt trauma from fist, ball, or
nonpenetrating object
 These fractures are associated with entrapment
and ischemia of nerves or penetration into
a sinus
Orbital fracture

Symptoms/Assessment
 Hx of blunt trauma  EOM abnormal
 Diplopia  Crepitus
 Facial anesthesia  Periorbital edema,
 Pain hematoma,
 Sunken appearance of ecchymosis
the eye  Subconjunctival
 Limited vertical eye hemorrhage
movement  Look for other
injuries
Orbital fracture

Diagnostics Treatment/Education
 Ophthalmological consult
 Visual acuity
 Analgesics
 Fundoscopy  Antibiotics
 CT scan  Ice pack
 X-rays
 Refrain from blowing nose
 Follow-up care
 Orbits
 Possible admission or
 Facial
surgery
 Waters’
Chemical Burns

 True ocular emergency


 Distinction between acid and alkali exposure must be
made
 Immediate irrigation
Chemical Burns

Symptoms/Assessment
 Pain

 Variable degree of visual


loss
 Chemical exposure

 Corneal whitening
Chemical Burns

Treatment
 Referral to
ophthalmology
 Irrigate with NS for
20-30 minutes
 Administer
cycloplegic
 Analgesics
 Eye patch
 Td
Hyphema

 Blood in the anterior chamber from the iris bleeding


 Usually result of blunt trauma
 Significant risk of secondary bleeding in 3-5 days
with outcomes poor
Hyphema

Symptoms/Assessment
 Blurred vision
 Blood tinged vision

 Pain

 Visualized blood in
anterior chamber at
bottom of iris
 Assess for other
associated injuries
Hyphema
Treatment/Education
 Have patient sit upright or
bedrest with HOB 30°
 Patch or shield both eyes
 Diuretics to decrease
intraocular pressure
 Refrain from taking aspirin
 Refer to ophthalmologist
 Admission
Eyelid Laceration

Symptoms/Assessment Treatment/Education
 MOI  Stop bleeding: Avoid
 Visual disturbance direct pressure on the eye
 Laceration  Surgical repair
 Protrusion of fat  Topical analgesic
 Upper lid does not raise  Td
 Assess for ocular injuries  Wound care
 Bleeding  S/S of infection
 Follow-up
Globe Rupture

 Ocular Emergency
 Penetrating or perforating injury
Globe Rupture

Symptoms/Assessment
 MOI  Direct visualization of FB
 Blunt  Irregularities in pupillary
 Penetrating borders
 Sudden visual impairment or
loss  Diagnostics
 Pain  CT scan
 Asymmetry of globe  MRI

 Extrusion of aqueous or  Orbit films


vitreous humor  Slit-lamp exam
Globe Rupture

Treatment
 Ophthalmological referral  Td
 Do not open eye  Calm, supportive
 Keep patient in Semi- environment
Fowlers position  Admission/Surgery
 Patch/shield affected both  If impaled object: Secure
eyes it.
 IV analgesics
 IV antibiotics Do Not
Remove IT!

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