Ocular EmergenciesOcular Emergencies

OCULAR EMERGENCIESOCULAR EMERGENCIES

MedicalMedical• ConjunctivitisConjunctivitis• IritisIritis• Periorbital CellulitisPeriorbital Cellulitis• GlaucomaGlaucoma• Central Retinal Central Retinal

Artery OcclusionArtery Occlusion

SurgicalSurgical• Corneal AbrasionCorneal Abrasion• Extraocular Foreign Extraocular Foreign

BodiesBodies• Retinal DetachmentRetinal Detachment• Orbital FractureOrbital Fracture• Chemical BurnsChemical Burns• HyphemaHyphema• Eyelid LacerationEyelid Laceration• Globe RuptureGlobe Rupture

AssessmentAssessment

History / MOIHistory / MOI Time of occurrenceTime of occurrence Treatment before arrivalTreatment before arrival Abnormal eye appearanceAbnormal eye appearance Visual acuityVisual acuity

• Snellen’sSnellen’s• Visual FieldsVisual Fields• Finger countFinger count

AssessmentAssessment

TearingTearing ItchingItching Discharge Discharge Medical HistoryMedical History

• Ocular Ocular • SystemicSystemic• MedicationMedication

Always use contralateral eye for Always use contralateral eye for comparisoncomparison

AssessmentAssessment

Spasms of eyelidSpasms of eyelid Lesions, FB, Penetrating woundsLesions, FB, Penetrating wounds PupilsPupils EOMEOM Position and alignment of eyePosition and alignment of eye

AssessmentAssessment

Conjunctiva and sclera for color and Conjunctiva and sclera for color and inflammationinflammation

Edema of lids, conjunctive, and/or Edema of lids, conjunctive, and/or corneacornea

BloodBlood Opaque, gray-white area of corneaOpaque, gray-white area of cornea Hazy corneaHazy cornea

AssessmentAssessment

PalpationPalpation• Intraocular pressure: Do not do if Intraocular pressure: Do not do if

there is concern regarding globe there is concern regarding globe

Things To Think About When Things To Think About When AssessingAssessing

Younger males are at higher risk for Younger males are at higher risk for serious injuryserious injury

School-age children are more School-age children are more susceptible to conjunctivitissusceptible to conjunctivitis

Contact wearers are at greater risk for Contact wearers are at greater risk for corneal abrasions and infectioncorneal abrasions and infection

Exposure to arc welding S/S develop 4-8 Exposure to arc welding S/S develop 4-8 post exposurepost exposure

Things To Think About When Things To Think About When AssessingAssessing

Auto mechanics and service station Auto mechanics and service station attendants have potential for acid burns attendants have potential for acid burns to faceto face

Injuries occurring in the garden have Injuries occurring in the garden have increased potential for infectionincreased potential for infection

Ball sports increase potential for eye Ball sports increase potential for eye injuryinjury

DiagnosticsDiagnostics

Direct ophthalmoscopeDirect ophthalmoscope TonometryTonometry Fluorescein stainingFluorescein staining Slit-lamp examSlit-lamp exam LaboratoryLaboratory

• CulturesCultures• CBCCBC• CoagsCoags

DiagnosticsDiagnostics

RadiologyRadiology• CT scanCT scan• Soft tissue/orbit films for foreign Soft tissue/orbit films for foreign

bodybody• Facial bonesFacial bones• Skull filmsSkull films

PrioritiesPriorities

ABCsABCs Prevent further damagePrevent further damage Prevent or minimize complicationsPrevent or minimize complications Control painControl pain Relieve anxiety or apprehensionRelieve anxiety or apprehension EducationEducation

Consultation CriteriaConsultation Criteria

Penetrating Penetrating ocular traumaocular trauma

Chemical burns Chemical burns of the eyeof the eye

Severe lid Severe lid lacerationlaceration

GlaucomaGlaucoma

Central retinal Central retinal artery occlusionartery occlusion

Retinal Retinal detachmentdetachment

Orbital fractureOrbital fracture HyphemaHyphema Periorbital Periorbital

cellulitiscellulitis

Age-related PearlsAge-related Pearls

PediatricPediatric• Delayed presentation due to children Delayed presentation due to children

not noticing gradual vision lossnot noticing gradual vision loss• May need picture chartMay need picture chart• Infants and small children may need to Infants and small children may need to

be restrained in blanket to facilitate be restrained in blanket to facilitate examexam

Age-related PearlsAge-related Pearls

GeriatricGeriatric• Vision diminishes gradually until 70 y/o Vision diminishes gradually until 70 y/o

and then rapidly thereafterand then rapidly thereafter• Decreased near visionDecreased near vision• Decreased accuracy of results from Decreased accuracy of results from

visual acuity testingvisual acuity testing

Age-related PearlsAge-related PearlsGeriatricGeriatric

• Decreased accommodation Decreased accommodation

to distancesto distances• Decreased lacrimal secretions Decreased lacrimal secretions • Cataracts: at age 80 1 in 3 Cataracts: at age 80 1 in 3

are affected are affected• More likely to experience More likely to experience

glaucoma, detached retina, and glaucoma, detached retina, and retinal bleedsretinal bleeds

Medical Ocular EmergenciesMedical Ocular Emergencies

ConjunctivitisConjunctivitis

Inflammation of the conjunctivaInflammation of the conjunctiva Causes: Causes:

• bacterial/viral inflammation bacterial/viral inflammation • allergies allergies • ChlamydiaChlamydia• chemical burnschemical burns• FBFB• flash burnsflash burns• IrritantsIrritants• URIURI

ConjunctivitisConjunctivitisSymptoms/AssessmentSymptoms/Assessment

• HyperemiaHyperemia• Unilateral or bilateralUnilateral or bilateral• Slight painSlight pain• ““Gritty” sensationGritty” sensation• DischargeDischarge

MucopurulentMucopurulent Matting of eyelids and Matting of eyelids and

lasheslashes

• Edema of eyelidsEdema of eyelids• Visual acuity: NormalVisual acuity: Normal• Cornea: ClearCornea: Clear• Pupil: NormalPupil: Normal• Conjunctiva: red or Conjunctiva: red or

pinkpink

ConjunctivitisConjunctivitis

TreatmentTreatment• Antibiotics Antibiotics

ointment/dropsointment/drops• Obtain culture, if Obtain culture, if

indicatedindicated• Cleanse eyes gently Cleanse eyes gently

to remove debristo remove debris

EducationEducation• Explain contagious Explain contagious

naturenature• Medication admin.Medication admin.• AsepsisAsepsis• Wipe from nose to Wipe from nose to

outer corner of eyeouter corner of eye• Cleanse lid with Cleanse lid with

baby shampoobaby shampoo• Avoid eye makeupAvoid eye makeup• Follow-upFollow-up

IritisIritis Inflammatory process that includes Inflammatory process that includes

the iris and sometimes the ciliary the iris and sometimes the ciliary bodybody

Predisposing conditions:Predisposing conditions: rheumatic rheumatic disease, and syphillisdisease, and syphillis

IritisIritisSymptoms/AssessmentSymptoms/Assessment

• Blurring of visionBlurring of vision• Unilateral painUnilateral pain• Edema of upper lidEdema of upper lid• Red eyeRed eye• PhotophobiaPhotophobia• Decreased visual Decreased visual

acuity acuity • LacrimationLacrimation

• Redness at eyelashRedness at eyelash• Clear to hazy corneaClear to hazy cornea• Small, irregular, Small, irregular,

sluggish reaction of sluggish reaction of pupilspupils

• Pain on eye pressurePain on eye pressure• Fluorescein stainFluorescein stain• Slit-lamp examSlit-lamp exam

IritisIritisTreatment/EducationTreatment/Education

• AnalgesicsAnalgesics• NSAIDsNSAIDs• Cycloplegics to Cycloplegics to

paralyze ciliary paralyze ciliary muscle and spasmsmuscle and spasms

• Darkened Darkened environmentenvironment

• Rest eyesRest eyes• Warm compresses Warm compresses • Shield eyes or dark Shield eyes or dark

glassesglasses• Follow-upFollow-up

Periorbital CellulitisPeriorbital Cellulitis

Infection of the cells around the eyesInfection of the cells around the eyes A major ophthalmological emergency A major ophthalmological emergency

and is potentially life threateningand is potentially life threatening May occur after trauma such as May occur after trauma such as

laceration or an insect bitelaceration or an insect bite Pneumococcal, staphylococcal, Pneumococcal, staphylococcal,

streptococcalstreptococcal

Periorbital CellulitisPeriorbital Cellulitis

Symptoms/AssessmentSymptoms/Assessment• Marked periorbital Marked periorbital

edema and erythemaedema and erythema• Pain: severe that is Pain: severe that is

aggravated by aggravated by movement of eyemovement of eye

• Conjunctival infectionConjunctival infection• FeverFever

• Visual acuity: Visual acuity: DecreasedDecreased

• Decreases pupil Decreases pupil reflexesreflexes

• Paralysis of EOMParalysis of EOM• DiagnosticsDiagnostics

CT scan CT scan CultureCulture Gram stainGram stain Blood cultureBlood culture

Periorbital CellulitisPeriorbital Cellulitis

Treatment/EducationTreatment/Education• Referral to Referral to

ophthalmologistophthalmologist• BedrestBedrest• IV therapyIV therapy• IV antibioticsIV antibiotics• Warm compressesWarm compresses

GlaucomaGlaucoma

Acute angle-closure glaucoma occurs Acute angle-closure glaucoma occurs when the distance between the iris when the distance between the iris and the cornea becomes inadequate and the cornea becomes inadequate or is blocked completelyor is blocked completely

The aqueous fluid produce is greater The aqueous fluid produce is greater than the amount leaving through the than the amount leaving through the canal of Schlemmcanal of Schlemm

Emergency SituationEmergency Situation May lead to irrecoverable blindnessMay lead to irrecoverable blindness

GlaucomaGlaucomaSymptoms/AssessmentSymptoms/Assessment

• Red eyeRed eye• Severe, sudden-onset, Severe, sudden-onset,

deep, unilateral paindeep, unilateral pain• Intense HAIntense HA• Decrease visual acuityDecrease visual acuity• Halos around lightsHalos around lights• N/VN/V

• Abdominal painAbdominal pain• Hazy, lusterless Hazy, lusterless

corneacornea• Pupils poorly reactive Pupils poorly reactive

or fixedor fixed• Increased intraocular Increased intraocular

pressure (>20 mm pressure (>20 mm Hg)Hg)

• Rocklike harness Rocklike harness appearanceappearance

• DiagnosticDiagnostic TonometryTonometry

GlaucomaGlaucoma

Treatment/EducationTreatment/Education• Referral to Referral to

ophthalmologistophthalmologist• AnalgesicAnalgesic• AntiemeticAntiemetic• Pilocarpine Pilocarpine

eyedropseyedrops• Osmotic diureticOsmotic diuretic• Supportive and Supportive and

informative informative environmentenvironment

Central retinal occlusionCentral retinal occlusion

Blockage of the the retinal artery by Blockage of the the retinal artery by thrombus or embolusthrombus or embolus

True ocular emergencyTrue ocular emergency• Prompt recognition and intervention Prompt recognition and intervention

must be obtained within 1-2 hours of must be obtained within 1-2 hours of onsetonset

Central retinal occlusionCentral retinal occlusion

Symptoms/AssessmentSymptoms/Assessment• Sudden unilateral loss Sudden unilateral loss

of visionof vision• PainlessPainless• History of:History of:

Thrombus or embolusThrombus or embolus HTNHTN DiabetesDiabetes Sickle cell diseaseSickle cell disease TraumaTrauma

• Visual acuity is Visual acuity is limited to light limited to light perception in perception in affected eyeaffected eye

• Pupil reaction: Pupil reaction: dilated, dilated, nonreactive in nonreactive in affected eyeaffected eye

Central retinal occlusionCentral retinal occlusion

TreatmentTreatment• Referral to Referral to

ophthalmologist ophthalmologist • Digital massage of Digital massage of

globe by MDglobe by MD• Supportive Supportive

environmentenvironment

• Possible IV Possible IV therapytherapy

AnticoagulantsAnticoagulants tPAtPA Low-molecular Low-molecular

weight Dextranweight Dextran Admission and Admission and

possibly surgerypossibly surgery

Surgical Ocular EmergenciesSurgical Ocular Emergencies

Corneal AbrasionCorneal Abrasion Partial or complete removal of an Partial or complete removal of an

area of epithelium of the corneaarea of epithelium of the cornea Most common eye injury seen in the Most common eye injury seen in the

ERER Common causes: FB, contact lenses, Common causes: FB, contact lenses,

exposure to UV light exposure to UV light

Corneal AbrasionCorneal AbrasionSymptoms/AssessmentSymptoms/Assessment

• Mild to severe painMild to severe pain• Foreign body sensationForeign body sensation• PhotophobiaPhotophobia• Normal to slightly Normal to slightly

decreased visual acuitydecreased visual acuity• Injected conjunctivaInjected conjunctiva• TearingTearing• Abnormal Fluorescein Abnormal Fluorescein

stainstain

Corneal AbrasionCorneal Abrasion

TreatmentTreatment• Topical analgesicTopical analgesic• Topical ophthalmic Topical ophthalmic

antibioticantibiotic• Tight patch to Tight patch to

affected eye for 12-affected eye for 12-24 hours24 hours

EducationEducation• Follow-up careFollow-up care• Proper patching Proper patching

techniquestechniques• Instillation of medsInstillation of meds• S/S of infectionS/S of infection• Use extra Use extra

precaution with precaution with activities requiring activities requiring depth perceptiondepth perception

Extraocular Foreign BodyExtraocular Foreign Body

Can enter as a result from Can enter as a result from hammering, grinding, working under hammering, grinding, working under cars, or working above the headcars, or working above the head

““Something going into my eye”Something going into my eye” Metal, sawdust, dust particlesMetal, sawdust, dust particles Metal can form a rust ring on the Metal can form a rust ring on the

corneacornea

Extraocular Foreign BodyExtraocular Foreign Body

Symptoms/AssessmentSymptoms/Assessment• PainPain• Foreign body sensationForeign body sensation• TearingTearing• RednessRedness• Normal to slightly Normal to slightly

abnormal visual acuityabnormal visual acuity• Fluorscein stain Fluorscein stain

abnormalabnormal• FB visualizedFB visualized

DiagnosticsDiagnostics• Magnifying lensMagnifying lens• Fluorescein stainFluorescein stain• Slit-lampSlit-lamp

Extraocular Foreign BodyExtraocular Foreign Body

TreatmentTreatment• Topical anestheticTopical anesthetic

Topical anesthetic Topical anesthetic inhibit wound inhibit wound healing and are healing and are toxic to corneal toxic to corneal epitheliumepithelium

• Gentle irrigation Gentle irrigation with NSwith NS

• FB removal with FB removal with moist cotton swab, moist cotton swab, needle, eye spud if needle, eye spud if irrigation irrigation

• Patch both eyes to Patch both eyes to reduce unsuccessful reduce unsuccessful consensual consensual movementmovement

• Possible admissionPossible admission

Extraocular Foreign BodyExtraocular Foreign Body

EducationEducation• Instillation of Instillation of

medsmeds• Patching Patching

techniquestechniques• Follow-up careFollow-up care• Provide Provide

preventative preventative informationinformation

Retinal DetachmentRetinal Detachment Separation of the retinal layers, with Separation of the retinal layers, with

accumulation of serous fluid or blood accumulation of serous fluid or blood between the sensory retina and the retinal between the sensory retina and the retinal epitheliumepithelium

Leads to decrease blood supply and oxygen Leads to decrease blood supply and oxygen to the retinato the retina

Most common cause: degenerative changes Most common cause: degenerative changes in the retina or vitreous body of the elderlyin the retina or vitreous body of the elderly

Sports direct head traumaSports direct head trauma

Retinal DetachmentRetinal Detachment

Symptoms/AssessmentSymptoms/Assessment• Gradual or sudden Gradual or sudden

deterioration of vision deterioration of vision unilaterallyunilaterally

Cloudy, smoky visionCloudy, smoky vision Flashing lightsFlashing lights Curtain or veil over Curtain or veil over

visual fieldvisual field

• No painNo pain

DiagnosticDiagnostic• FundoscopyFundoscopy• Visual acuityVisual acuity• Slit-lamp examSlit-lamp exam

Retinal DetachmentRetinal Detachment

TreatmentTreatment• Referral to Referral to

ophthalmologistophthalmologist• Patch both eyes or Patch both eyes or

shielding to reduce shielding to reduce eye movementeye movement

• Bed rest, lying Bed rest, lying quietlyquietly

• Supportive and calm Supportive and calm environmentenvironment

• Admission or transferAdmission or transfer

Orbital fractureOrbital fracture Fracture of the orbit without a Fracture of the orbit without a

fracture of the orbital rimfracture of the orbital rim Common cause: blunt trauma from Common cause: blunt trauma from

fist, ball, or nonpenetrating objectfist, ball, or nonpenetrating object These fractures are associated with These fractures are associated with

entrapment and ischemia of nerves entrapment and ischemia of nerves or penetration into or penetration into

a sinusa sinus

Orbital fractureOrbital fracture

Symptoms/AssessmentSymptoms/Assessment• Hx of blunt traumaHx of blunt trauma• DiplopiaDiplopia• Facial anesthesiaFacial anesthesia• PainPain• Sunken appearance of Sunken appearance of

the eye the eye• Limited vertical eye Limited vertical eye

movement movement

• EOM abnormalEOM abnormal• CrepitusCrepitus• Periorbital edema, Periorbital edema,

hematoma, hematoma, ecchymosisecchymosis

• Subconjunctival Subconjunctival hemorrhagehemorrhage

• Look for other Look for other injuriesinjuries

Orbital fractureOrbital fracture

DiagnosticsDiagnostics• Visual acuityVisual acuity• FundoscopyFundoscopy• CT scanCT scan• X-raysX-rays

OrbitsOrbits FacialFacial Waters’Waters’

Treatment/EducationTreatment/Education• Ophthalmological Ophthalmological

consultconsult• AnalgesicsAnalgesics• AntibioticsAntibiotics• Ice packIce pack• Refrain from blowing Refrain from blowing

nosenose• Follow-up careFollow-up care• Possible admission or Possible admission or

surgerysurgery

Chemical BurnsChemical Burns

True ocular emergencyTrue ocular emergency Distinction between acid and alkali Distinction between acid and alkali

exposure must be madeexposure must be made Immediate irrigationImmediate irrigation

Chemical BurnsChemical BurnsSymptoms/AssessmentSymptoms/Assessment

• PainPain• Variable degree of Variable degree of

visual lossvisual loss• Chemical exposureChemical exposure• Corneal whiteningCorneal whitening

Chemical BurnsChemical Burns

TreatmentTreatment• Referral to Referral to

ophthalmologyophthalmology• Irrigate with NS for Irrigate with NS for

20-30 minutes20-30 minutes• Administer Administer

cycloplegic cycloplegic • AnalgesicsAnalgesics• Eye patchEye patch• TdTd

HyphemaHyphema

Blood in the anterior chamber from Blood in the anterior chamber from the iris bleedingthe iris bleeding

Usually result of blunt traumaUsually result of blunt trauma Significant risk of secondary bleeding Significant risk of secondary bleeding

in 3-5 days with outcomes poorin 3-5 days with outcomes poor

HyphemaHyphema

Symptoms/Symptoms/AssessmentAssessment• Blurred visionBlurred vision• Blood tinged visionBlood tinged vision• PainPain• Visualized blood in Visualized blood in

anterior chamber at anterior chamber at bottom of irisbottom of iris

• Assess for other Assess for other associated injuriesassociated injuries

HyphemaHyphemaTreatment/EducationTreatment/Education

• Have patient sit upright Have patient sit upright or bedrest with HOB 30or bedrest with HOB 30°°

• Patch or shield both Patch or shield both eyeseyes

• Diuretics to decrease Diuretics to decrease intraocular pressureintraocular pressure

• Refrain from taking Refrain from taking aspirinaspirin

• Refer to ophthalmologistRefer to ophthalmologist• AdmissionAdmission

Eyelid LacerationEyelid Laceration

Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Visual disturbanceVisual disturbance• LacerationLaceration• Protrusion of fatProtrusion of fat• Upper lid does not raiseUpper lid does not raise• Assess for ocular Assess for ocular

injuriesinjuries• BleedingBleeding

Treatment/EducationTreatment/Education• Stop bleeding: Stop bleeding:

Avoid direct Avoid direct pressure on the eyepressure on the eye

• Surgical repairSurgical repair• Topical analgesicTopical analgesic• TdTd• Wound careWound care• S/S of infectionS/S of infection• Follow-upFollow-up

Globe RuptureGlobe Rupture

Ocular EmergencyOcular Emergency Penetrating or perforating injuryPenetrating or perforating injury

Globe RuptureGlobe RuptureSymptoms/AssessmentSymptoms/Assessment

• MOIMOI BluntBlunt PenetratingPenetrating

• Sudden visual Sudden visual impairment or lossimpairment or loss

• PainPain• Asymmetry of globeAsymmetry of globe• Extrusion of aqueous Extrusion of aqueous

or vitreous humor or vitreous humor

• Direct visualization Direct visualization of FBof FB

• Irregularities in Irregularities in pupillary borderspupillary borders

• DiagnosticsDiagnostics CT scanCT scan MRIMRI Orbit filmsOrbit films Slit-lamp examSlit-lamp exam

Globe RuptureGlobe RuptureTreatmentTreatment

• Ophthalmological Ophthalmological referralreferral

• Do not open eyeDo not open eye• Keep patient in Semi-Keep patient in Semi-

Fowlers positionFowlers position• Patch/shield affected Patch/shield affected

both eyesboth eyes• IV analgesicsIV analgesics• IV antibioticsIV antibiotics

• TdTd• Calm, supportive Calm, supportive

environmentenvironment• Admission/SurgeryAdmission/Surgery• If impaled object: If impaled object:

Secure it. Secure it.

Do Not Do Not Remove IT!Remove IT!

Questions????Questions????