Ocular Emergencies Ocular Emergencies

Abdulrahman Al-MuammarAbdulrahman Al-Muammar

College of MedicineCollege of Medicine

King Saud UniversityKing Saud University

What Should you learn from What Should you learn from this lecture?this lecture?

Early recognition of ocular emergencies will Early recognition of ocular emergencies will determine final visual outcomesdetermine final visual outcomes

-Penetrating trauma-Non penetrating injury-Corneal ulcer-Chemical burns-Acute angle closure glaucoma-Orbital cellulitis-Retinal detachment

Proper historyFull assessment

Initial management Referral planning

Bright lightBright light

Pupil examination-Is it round?-Is it regular?-Is it reactive?

Visual acuity-Determine light perception-Appreciate hand motion-Count fingers-See things across the clinic-Visual acuity chart

Ocular movement

Lid-Ecchymosis-Laceration-Foreign body-Orbital asymmetry

Conjunctiva-Chemosis-Hemorrhage-Foreign body-Uveal prolapse

Cornea-Haze-Pus-Iris prolapse-Fluorescein staining-Seidel test

Anterior chamber-Blood -Pus-Flat

Corneal UlcerCorneal Ulcer

• Ocular pain, redness and discharge Ocular pain, redness and discharge with decrease vision and white lesion with decrease vision and white lesion on the corneaon the cornea

Corneal UlcerCorneal Ulcer

• Prompt diagnosis of the etiology by Prompt diagnosis of the etiology by doing corneal scraping doing corneal scraping

• Treatment with appropriate antimicrobial Treatment with appropriate antimicrobial therapy are essential to minimize visual therapy are essential to minimize visual lossloss

Contact lens wearerContact lens wearer

• Any redness occurring for patients who wear Any redness occurring for patients who wear contact lens should be managed with contact lens should be managed with extreme cautionextreme caution

• Remove lensRemove lens• Rule out corneal infectionRule out corneal infection• Antibiotics for gram negative organismsAntibiotics for gram negative organisms• Do not patchDo not patch• Follow up with ophthalmologist in 24 hoursFollow up with ophthalmologist in 24 hours

Chemical InjuriesChemical Injuries

• A vision-threatening emergencyA vision-threatening emergency

• The offending chemical may be in the The offending chemical may be in the form of a solid, liquid, powder, mist, or form of a solid, liquid, powder, mist, or vapor.vapor.

• Can occur in the home, most commonly Can occur in the home, most commonly from detergents, disinfectants, solvents, from detergents, disinfectants, solvents, cosmetics, drain cleanerscosmetics, drain cleaners…..…..

Chemical InjuriesChemical Injuries

• Can range in severity from mild irritation Can range in severity from mild irritation to complete destruction of the ocular to complete destruction of the ocular surfacesurface

• ManagementManagement• Instill topical anestheticInstill topical anesthetic• Check for and remove foreign bodiesCheck for and remove foreign bodies

Chemical InjuriesChemical Injuries

• Immediate irrigation essential, preferably Immediate irrigation essential, preferably with saline or Ringer’s lactate solution, for with saline or Ringer’s lactate solution, for at least 30 minutesat least 30 minutes

Chemicals InjuriesChemicals Injuries

• Irrigation should be continued until neutral Irrigation should be continued until neutral pH is reached (i.e.,7.0)pH is reached (i.e.,7.0)

• Instill topical antibioticInstill topical antibiotic• Frequent lubricationsFrequent lubrications• Oral pain medicationOral pain medication• Refer promptly to ophthalmologistRefer promptly to ophthalmologist

Corneal and Conjunctival Foreign Corneal and Conjunctival Foreign BodiesBodies

• ManagementManagement• Instill topical anestheticInstill topical anesthetic• Removal of the foreign bodyRemoval of the foreign body• Topical antibioticTopical antibiotic• Treat corneal abrasionTreat corneal abrasion

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

• Result from peripheral iris blocking the Result from peripheral iris blocking the outflow of fluidoutflow of fluid

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

• Present with pain, redness, mid-dilated pupil Present with pain, redness, mid-dilated pupil with decrease vision and coloured haloes with decrease vision and coloured haloes around lightsaround lights

• Severe headache or nausea and vomitingSevere headache or nausea and vomiting• Intraocular pressure is elevatedIntraocular pressure is elevated• Can cause severe visual loss due to optic Can cause severe visual loss due to optic

nerve damagenerve damage• Medical Tx and peripheral laser iridotomy will Medical Tx and peripheral laser iridotomy will

be curative in most casesbe curative in most cases

Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

• Medical Tx and peripheral laser Medical Tx and peripheral laser iridotomy will be curative in most casesiridotomy will be curative in most cases

Preseptal CellulitisPreseptal Cellulitis

Preseptal CellulitisPreseptal Cellulitis• Lid swelling and erythemaLid swelling and erythema• Visual acuity ,motility, pupils, and globe are Visual acuity ,motility, pupils, and globe are

normalnormal

Preseptal CellulitisPreseptal Cellulitis

• EtiologyEtiology• Puncture woundPuncture wound• LacerationLaceration• Retained foreign body from traumaRetained foreign body from trauma• Vascular extension, or extension from Vascular extension, or extension from

sinuses or another infectious site sinuses or another infectious site ( e.g.,dacryocystitis, chalazion)( e.g.,dacryocystitis, chalazion)

• OrganismsOrganisms• Staph aureus – Streptococci- H.influenzaeStaph aureus – Streptococci- H.influenzae

Preseptal CellulitisPreseptal Cellulitis

• Management:Management:• Warm compressesWarm compresses• Systemic antibioticsSystemic antibiotics• CT sinuses and orbit if not better or +ve CT sinuses and orbit if not better or +ve

history of traumahistory of trauma

Orbital CellulitisOrbital Cellulitis

• PainPain

• Decreased visionDecreased vision

• Impaired ocular motility/double visionImpaired ocular motility/double vision

• Afferent pupillary defectAfferent pupillary defect

• Conjunctival chemosis and injectionConjunctival chemosis and injection

• ProptosisProptosis

• Optic nerve swellingOptic nerve swelling

Orbital CellulitisOrbital Cellulitis

• Management:Management:• AdmissionAdmission• Intravenous antibioticsIntravenous antibiotics• Nasopharynx and blood culturesNasopharynx and blood cultures• Surgery maybe necessarySurgery maybe necessary

Orbital CellulitisOrbital Cellulitis

Retinal DetachmentRetinal Detachment

• SymptomsSymptoms• Flashes, floaters, a curtain or shadow Flashes, floaters, a curtain or shadow

moving over the field of visionmoving over the field of vision• Peripheral and/ or central visual lossPeripheral and/ or central visual loss

Retinal DetachmentRetinal Detachment

Ocular traumaOcular trauma

HyphemaHyphema• Can occur with blunt or penetrating injuryCan occur with blunt or penetrating injury• Blood in the anterior chamberBlood in the anterior chamber

HyphemaHyphema

• Can lead to high intraocular pressureCan lead to high intraocular pressure• Detailed history (Sickle cell)Detailed history (Sickle cell)• ManagementManagement

• Bed restBed rest• Topical steroidTopical steroid• Topical cycloplegicTopical cycloplegic• Antifibrinolysis agents (Tranexamic acid)Antifibrinolysis agents (Tranexamic acid)• Surgical evacuationSurgical evacuation

Ruptured globeRuptured globe

• Suspect a ruptured globe if:Suspect a ruptured globe if:• Bullous subconjunctival hemorrhageBullous subconjunctival hemorrhage• Uveal prolapse (Iris or ciliary body)Uveal prolapse (Iris or ciliary body)• Irregular pupilIrregular pupil• HyphemaHyphema• Vitreous hemorrhageVitreous hemorrhage• Lens opacityLens opacity• Lowered intraocular pressureLowered intraocular pressure

If globe ruptured or laceration is If globe ruptured or laceration is suspectedsuspected

• Stop examinationStop examination

• AntiemeticsAntiemetics

• Shield the eyeShield the eye

• Systemic antibioticsSystemic antibiotics

• Give tetanus prophylaxisGive tetanus prophylaxis

• Refer immediately to ophthalmologistRefer immediately to ophthalmologist

Orbital FracturesOrbital Fractures• -Periorbital edema• -Ecchymosis + tenderness to palpation along the inferior orbital rim • -Subconjunctival hemorrhage• -Enophthalmos• -Hypoesthesia of the cheek and upper gum• -Subcutaneous emphysema• -Palpable step-off of the orbital rim

Thank youThank you