OCULAR EMERGENCIES CME

HOSPITAL SERI MANJUNG 4 / 11 / 2015

TOPIC OVERVIEW

1. Ocular anatomy2. Classification of ocular emergencies 3. History taking4. Eye examination5. Management

OCULAR ANATOMY

OCULAR EMERGENCIES

Ocular emergencies

Trauma

Penetrating

Blunt

Non-Trauma

Infection

Foreign body

Neuro-opthalmolog

y

HISTORY TAKING

RED EYE DANGER SIGNS

1. Decreased visual acuity2. Pain 3. Ciliary flush4. Pupillary asymmetry5. Irregular corneal light reflex6. Corneal infiltrate7. Photophobia8. Trauma

KEY QUESTIONS

1. Do you eye pain?2. Do you wear contacts lens?3. Do you have any associated symptoms?

– Decrease vision/vision loss– Photophobia– Diplopia – flashes/floaters

RED

EYEPAINFUL

Acute angle closure glaucoma

Scleritis

Uveitis

Keratitis

Corneal abrasion/ulcer

Trauma/chemical injury

PAINLESS

Conjunctivitis

Subconjunctival h’morrhage

Episcleritis

EYE EXAMINATION

SNELLEN CHART & PUPILLARY LIGHT REFLEX

OCULAR MOTILITY

ANTERIOR CHAMBER EXAMINATION

FUNDOSCOPY EXAMINATION

Chemical burns CRAOOrbital Hemorrhage

IMMEDIATE WITHIN MINUTES

EYE TONOMETER

Endophthalmitis

Orbital Cellulitis

Rupture Globe

IOFB

Macula-on RDAcute Glaucoma

Microbial Keratitis

cavernous sinus thrombosis

VERY URGENT WITHIN HOURS

orbital fractures

lid laceration

Hyphema

corneal abrasion corneal FB

Sudden or recent loss of vision

acute ocular motility problemsdiplopia,nystagmus,limited

movement macula off RD

VERY URGENT WITHIN

1 DAY

Painless

Hydrops

Abnormal cornea

Viterous h’morhage

RD

Abnormal fundus

CRAO

CRVO

AIONSUDDEN OR RECENT LOSS

OF VISION

PainfullBullous keratopathy Keratitis

Anterior uveitis AACG Pain on eye movement

Optic neuritis

SUDDEN OR RECENT LOSS

OF VISION

MANAGEMENT OF OCULAR EMERGENCIES

1. CHEMICAL OCULAR INJURY

• Acid and alkali burns are managed in a similar manner

• Eye should be irrigate immediately at the scene with sterile NS/Hartman solution (2L) until the pH is normal (pH 7.0 to 7.4)

• Refer ophthal team

2. RUPTURED GLOBE• Signs suggestive of ruptured eye

globe:– Severe subconjunctival

hemorrhage – Hyphema– Teardrop-shaped pupil– abnormal anterior chamber depth– irregular pupil– Extrusion of globe content– blindness

• Refer opthal team urgent!• Eye shield should be place ASAP,

do not patch

3. LID LACERATION• Eye lid lacerations that need

opthal referral include:– L/W 6 to 8 mm of the medial

canthus – L/W involving Lacrimal duct

or sac– L/W over Inner surface of

eye lid– L/W a/w ptosis– L/W involving the tarsal plate

or levator palpebrae muscle

• Lid laceration < 1 mm can heal spontaneously

4. CORNEAL FOREING BODIES

• Any corneal FB deep within the corneal stroma or in the central visual axis should be removed by an ophthalmologist

• All patients should be referred to ophthal team within 24 hours

5. BLOWOUT FRACTURES

• Commonly involve the inferior wall and medial wall

• Result in entrapment of the inferior rectus muscle causing diplopia on upward gaze

• Refer ophthal team

6. ACUTE ANGLE CLOSURE GLAUCOMA

• Symptoms: Eye pain + headache, cloudy vision, colored halos around lights, vomiting

• Signs:– Conjunctival injection – Corneal clouding – Increase IOP of 40 – 70 mmHg (normal 10 – 20)

• Rx:– Timolol 0.5% eyedrop – 1 drop stat, 2nd drop in 10 minutes – IV Acetazolamide 500mg – Pilocarpine 4% - 1 drop every 15 minutes (contraindicated in aphakic

and pseudophakic patient or in mechanical closure of the angle)– Refer opthal team

7. CENTRAL RETINAL ARTERY OCCLUSION (CRAO)

• Symptoms:– acute painless severe

monocular loss of vision – a/w hx of amaurosis fugax

• Signs:– Complete loss of vision– Marked afferent pupillary

defect (APD)– Fundoscopy reveal cherry

red spot • Rx:

– Refer ophthal team

8. CENTRAL RETINAL VEIN OCCLUSION (CRVO)

• Symptoms:– acute painless monocular

loss of vision • Signs:

– Fundoscopy reveal optic disc edema, cotton wool spots, retinal hemorrhage in all 4 quadrants (blood-and-thunder fundus)

• Rx:– Refer ophthal team

9. UVEITIS

• Symptoms:– Painful red eye, worse with

eye movement – Photophobia– Blurred vision

• Signs:– Conjunctival injection– Watery non-purulent D– Hypopyon– Consensual photophobia

• Rx:– Refer to ophthal team stat

10.KERATITIS

• Symptoms:– Photophobia– FB sensation– Tearing – Painful

• Signs:– Perilimbal injection – Hypopyon

• Rx:– Refer ophthal team stat

11.SCLERITIS• Symptoms:

– Severe boring eye pain, worse with movement

– Headache– Blurring of vision– Teary eye

• Signs:– Impaired visual acuity – Bilateral in 50%– Tender globe– Thinning of sclera resulting in a

bluish discoloration • Rx:

– Start oral NSAIDs & refer ophthal team stat

12.OPTIC NEURITIS• Symptoms:

– Unilateral LOV over hours to days

– Pain, worse with eye movement

– Visual loss commence as pain improves

• Signs:– Reduced VA– Painful RAPD

• Rx:– Stat eye consultation