Ocular emergencies

Erin Moorcones, RN, MSN

The Eye

Anatomy and physiologyThe eyes are protected by bony structures, eyelids, and sclera. Lacrimal glands secrete tears, which continuously bathe eye to decrease friction and remove minor irritants.Light enters the eye through the cornea, passes through the lens, and reflected off the retina. Amount of light entering is controlled by iris.

Patient AssessmentA potential threat to vision is triaged as emergent, whereas patient with a reddened eye with no potential for vision loss could be non-urgent.

Visual AcuityVisual acuity should be done on all patients with eye or visual complaint, unless patient sustained chemical exposure to eye where irrigation is priority.

Pupil ExaminationIncludes assessment of shape, size, and reactivity.Up to 20-25% of population have unequal pupils ( physiologic anisocoria- pupils vary <1mm with brisk reaction to light) as a normal finding.FYI-

* oval pupil may indicate tumor or retinal detachment * teardrop pupil suggest ruptured globe- teardrop pointing to rupture site

Anterior segmentComposed of sclera, conjunctiva , cornea, anterior chamber, iris, lens and ciliary body.Inspect clearness of cornea.

• Ocular movement-• assess cranial nerves

General strategyHPI

* Pain- PQRST * Appearance of eye- swelling, redness,

aysmmetry * changes in vision, tearing, itching, discharge

PMH- *pre-existing disease- DM, htn, sicle cell * ocular- lenses, surgery, glaucoma, eye disease

Pysch/ social- * work environment, school, hobbies

Assessment

Consultation required

Age related considerations

Geriatric considerationsVision gradually dimishes until age 70, then rapidlyDecreased accuracy of visiontestingEye accomodation decreases with ageOlder adults complain of eye dryness.Cataracts more common with advancing age. 1 in 3 adults age 80 affected.More liekly to experience glaucoma, detached retna, retinal bleedingPEARLS-

* health referrals * Protected environment

Infections

Lid infections-Hordeolum- infection of eyelash oil gland. Apply warm compress 4 times a day with ophthalmic antibiotics

ChalazionInternal hordeolum caused by chronic inflammation.Patient presents with several weeks of painless, localized swelling. If it affects vision may have I&D

Herpes Simplex of eye

ConjunctivitisInflammatory condition of membrane that lines the eyelids and covers exposed surface of sclera.Causes- bacteria, virus, chlamydia/gonorrhea, chemical burns, foreign bodies,exposure to irritants.

AssessmentHPI

-redness, abrupt onset, unilateral/bilateral, pain, FB sensation, discharge, edema, itching, burning, feverPMH

-URI, contact with others, medications (steroids-may exacerbate infections, esp w/Herpes infections)Objective data-

-distress, visual acuity, cornea, pupil, conjunctiva, chemosis, discharge, eyelid edema

AssessmentDiagnostic-

culture, fluorescein stain, gram stainInterventions

- cleanse eyelids (inner-outer) - warm compress, bacterial/cool compress, viral - medications - education

Anterior Uveitis/IritisUveitis-inflammation of one or all the parts of the uveal tract (iris, ciliary body, choroid)S/S- intense unilateral pain, conjunctivitis, edema, lacrimation, photophobia.Posterior uveitis (choroiditis)- rare, seen in CMV infections associated with AIDS

Treatment-

Warm compress, dark enviornmentTopical steroid,Eye restf/u referral

Periorbital/Orbital Cellulitis

Key assessment pieces S/S- Temperature, Decreased pupillary reflexesDiagnostic- CT, culture, CBC, LPTreatment- warm compress, excision of abscess, antibiotics, F/u

Glaucoma

S/S- red eye, pain, HA, bluured vision, photophobia, n/v.Physical exam- decreased visual acuity, cornea-hazy, steamy, intraocular pressure 40-80, hardness to globe with palpation,Diagnostic- slit-lam, tonometryTreatment- beta antagonists, pilocarpine droops

Acute angle-closure glaucomaPACG increases with age and more common in women and eskimo’s and those of Asian decent.Estimated to be the cause of 46% of all cases of irreversible blindness.S/S- severe eye pain, fixed or slightly dilated pupil, foggy appearing cornea, severe headache, complaints of halo’s around lights, diminished peripheral visionTreatment- must decrease IOP quickly

Central retinal artery occlusionSudden, painless, unilateral loss of vision caused by thrombus/emboliPrompt recognition and intervention w/I 1-2 hrs of onset necessary.Treatment- referral ocular hypotensive drops carbon gas for vasodilation

TraumaBlunt trauma- caused by MVC, fall, assaultSymptoms include- ecchymosis, rednessResolution of bruising usually resolves in 2 weeks.

Orbital fractures• Involve the orbital floor and orbital rim• Orbital floor fracture, aka blowout fracture. Direct

trauma causes increase in IOP. Orbital contents may herniate into the maxillary or ethmoid sinuses.

• Diagnosis- by observation of periorbital ecchymosis, subconjunctival hemorrhage, periorbital edema, upward gaze and diplopia.

• CT or MRI • Orbital fractures not emergency unless visual

injury or globe injury present

HyphemaBleeding into anterior chamber of eye. Occurs when blood vessels of the iris rupture and leak into the clear aqueous fluid of anterior chamber.Symptoms- pain, photophobia, blurred visionTreatment- beta blockers to dec IOP, mydriatic agents, steroids, pain mgmt, anti emetics

Subconjunctival hemorrhageHarmless eye condition that is usually triggered by sneeze, cough, Valsalva.Symptoms- painless, bright red flat patchUsually reabsorbs in 2-3 weeks

Globe rupture

Foreign Body

Most common is dust particleOrganic FB have higher incidence of infection. Metallic FB leave rust ring unless removed w/I 12 hoursInert FB do not cause infection, but higher risk for penetration

Superficial Trauma

Corneal abrasion-FB such as contact scratches, abrades, or denudes optical epithelium. Damage to cornea exposes corneal nerves causing tearing, eyelid spasms, and pain.May need topical analgesic to get visual acuity. Assess eyelids to ensure no FB. Diagnosis with fluorescein.

Corneal lacerationOphthamolgy consult required.Present similar to corneal abrasion

Burns

Chemical Burns- from acids, alkalis. copious irrigation needed.• Thermal burns- usually affects

eyelids.• Radiation burns- UV or infrared