COMMON OCULAR EMERGENCIES

Mahmoud Tawfik ,MD AFHSR

WHAT IS MOST IMPORTANT ORGAN IN BODY ?

So ocular emergencies for all medical staff is very important that if u safe ptn eye as u safe his life

So all of us must know 1st Aid in ophtha cases as we know CPR

My lecture looks like BLS

You will be never blamed if you cann’t treat cardiac arrest case but will be very impressed if you fail to maintain life tell code blue team arrive

OBJECTIVES

How non ophthalmologist triaging and give 1st aid of ocular emergencies

IOP

INTRODUCTION

EYE EXAMINATION

visual acuityPupillary light reflex

ocular motility

external eye

Orbit : proptosisPeriorbital skin Lid, conj

indirect ophthalmoscopy

Direct ophthalmoscopy

Slit lamp

Ant segment examination Fundus examination

USEFUL TOOLS

Near vision cardPenlight with blue filterTopical anestheticFluorescein stripsTopical mydriatic

ESTIMATING ANTERIOR CHAMBER DEPTH

ALGORITHM FOR DIAGNOSING

Key worrisome clinical findings (ophtho referral needed):

Pain: Pain in eye often indicates more serious intraocular pathology (iritis, glaucoma).

Visual acuity: if decreased, usually more serious cause.

Pupil: if sluggish

Pattern of redness: CILIARY FLUSH (Redness worse near cornea, usually

serious intraocular cause

RED EYE: KEY HISTORICAL QUESTIONS

DO YOU HAVE PAIN ?Biggest distinguishing factor between emergent and non-emergentDo you wear contacts? (increased risk of keratitis-corneal infection)Do you have any associated symptoms ?

Decreased visionphotophobia/diplopiaflashes/floatersHalos/N/V/Abd painAny above require referral

Main differential of red eye:

Conjunctivitis (infectious/noninfectious)Trauma, Foreign bodySubconjunctival hemorrhageAngle closure glaucomaIritis/uveitisKerititisScleritis, episcleritis

Ocular Emergencies

Trauma Non-Trauma

Blunt Penetrating Eye Neuro-

ophthalmology

Chemical burns

CRAO

Orbital Hemorrhage

IMMEDIATEWithin minutes

Endophthalmitis

Orbital Cellulitis

Rupture Globe

IOFB

Macula-on RDAcute Glaucoma

Microbial Keratitis

Very URGENTWithin hours

cavernous sinus thrombosis

Urgent Within 1 day

orbital fractures

lid laceration

Hyphema

corneal abrasioncorneal FB

Sudden or recent loss of vision

acute ocular motility problems

diplopia,nystagmus,limited movement

macula off RD

SUDDEN OR RECENT LOSS OF VISION

Painless

Hydrops

Abnormal cornea

viterous hge

RD

Abnormal fundus

CRAOCRVO

AION

PainfullAbnormal cornea

Bullous keratopathyKeratitis

Abnormal fundus

Optic neuritis

anterior uveitis

AACG

Pain on eye movement

MOST COMMON EMERGENCIES CASES

DIAGNOSIS,MANGEMENT

CHEMICAL BURN

Tap water

Emergency Treatment:Saline Copious irrigation (until neutral pH):, may range from a few liters to many liters (more than 8 to 10 L

Treatment should be instituted IMMEDIATELY,

even before talking history

Lids should be retracted and fornices swabbed for particulate matter

Once pH is stabilized

Cycloplegic agent Broad-spectrum

antibiotic

RUPTURED GLOBETrauma leads to corneal or scleral disruption and extravasation of intraocular contents .Can lead to:Irreversible visual lossEndophthalmitis

Hypotony

pain, decreased vision

Hyphema

Loss of AC depth

“tear-drop” pupil which points toward laceration subconjunctival hemorrhage

Stop the examination

Cover with eye shield , DO NOT PATCH.

CT head and orbit to evaluate for concomitant facial/orbital injury.

NPO

Tetanus

Systemic AntibioticsRepair.

Central Retinal Artery Occlusion

Sudden severe monocular vision loss over seconds

90% VA CF or less

Etiology:Emboli – cardiac, atherosclerotic

Narrow arteriolesOptic disc and retinal pallorCherry red spot at fovea

Must have VERY high index of suspicion, especially in patients with appropriate risk factors.

Immediate referral. Retina irreversibly damaged (100 min)

Mannitol or acetazolamide to reduce IOP .

Carbogen inhalation

Oral nitrates

Lay the patient flat on his/her back

Globe Massage.

Paracentesis.

Signs and symptoms

“black coming down over visual field ”

Bright flashes of light (photopsia)

Increasing floaters

Decreased visual acuity (macula off)

Retinal detachment

separation of neurosensory layer of retina from underlying choroid and retinal pigment epithelium

KEY MANAGEMENT POINT- know “classic” presentation so you can refer to an ophthalmologist quickly.

Acute Angle Closure Glaucoma (AACG)- Pain (sever brusting )

Halos (around lights)

Nausea/vomiting

Conjunctival injection (ciliary flush)

Corneal edema

Mid-dilated, fixed pupil

IOP ( stony hard)

Medical TxReduce production of aqueous humorTopical -blocker (timolol 0.5% - 1- 2 gtt)Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)Or increase outflowTopical -agonist (phenylephrine 1 gtt)Miotics (pilocarpine 1-2%)Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H

Definitive TxLaser peripheral iridectomy

RETROBULBAR HEMATOMA

Acute orbital compartment syndrome 2° to blunt or penetrating trauma

Hemorrhage into closed space of orbit

IOP leading to vision loss from optic nerve damage / retinal ischemia

Immediate lateral canthotomy and cantholysis indicated if IOP > 40mmHg or vision loss

APD ,

Proptosis

Ophthalmoplegia

Diminished vision

IOP

ORBITAL BLOWOUT FRACTUREEnophthalmosDiplopiaImpairment of eye movementOrbital emphysema

CT should include axial and coronal cuts

Periorbital Cellulitis (Preseptal Cellulitis)Warm, indurated, erythematous eyelids only

Orbital Cellulitis (Postseptal Cellulitis)Warm, indurated, erythematous eyelids only

Treatment:Hospital admission for IV Cefuroxime

Fever, toxicity, proptosis, painful ocular motility, limited ocular excursion

emergent orbital and sinus CT

foreign body sensation, tearing, red, or painful eye .

Linear epithelial defects suggestive of

foreign body under the eye lid

Often metallic foreign body following work injury

Remove foreign body

Topical AB

Corneal FB

5 .CORNEAL INJURIES(ABRASIONS, LACERATIONS, ULCERS)

Symptoms :extreme eye pain, relieved with lidocaine drops.Visual acuity usually decreased, depending on location of injury in relation to visual axis .

Diagnosis :fluorescein staining to see epithelial defect .

Seidel’s test

Topical antibiotics and follow up with ophthalmologist

Avoid contact lenses

Avoid patching.

CORNEAL INJURIES

Seidel’s test: Concentrated fluorescein is dark orange but turns bright green under blue light after dilution .

This indicates aqueous leakage which is diluting the green dye.

+ve >>>> laceration

HYPOPON (AC PUS )

Endoopthalmitis Microbial keratitis

Iritis

Very urgent refferal

LID LACERATION

Eyelids don’t have fat

Orbital fat usually protrudes through septal lacerationsFat in the lid laceration confirms the diagnosisHigh incidence of globe penetration and intraocular foreign bodiesHigh risk for orbital cellulitis

Take care check lid margin

Medial injuries may affect lacrimal passages

Hopefully I convey my message to my

colleges today together we will safe ptns eyes