Ophthalmic Ophthalmic EmergenciesEmergencies

By : O. Ahmadi, MD. By : O. Ahmadi, MD. Professor Assistant of Esfahan Professor Assistant of Esfahan

Medical School, Emergency Medical School, Emergency Department of Al-Zahra HospitalDepartment of Al-Zahra Hospital

By definition, an ophthalmic By definition, an ophthalmic emergency requires immediate emergency requires immediate medical attention to avert permanent medical attention to avert permanent visual impairment. visual impairment.

Recognize the signs and symptoms Recognize the signs and symptoms of these emergencies, obtain an of these emergencies, obtain an ophthalmic consult, and manage the ophthalmic consult, and manage the patient until the patient is seen by an patient until the patient is seen by an ophthalmologist. ophthalmologist.

Top 10Top 10

1. Trauma – blunt1. Trauma – blunt2. Trauma – penetrating2. Trauma – penetrating3. Trauma – burn3. Trauma – burn4. Infection – contact lens4. Infection – contact lens5. Infection – viral, HSV/HZV, bacterial5. Infection – viral, HSV/HZV, bacterial6. Neurovascular – CRAO, CRVO6. Neurovascular – CRAO, CRVO7. Neurovascular – Diabetes7. Neurovascular – Diabetes8. Neurovascular – AACG8. Neurovascular – AACG9. Neurovascular – TA9. Neurovascular – TA10. Neurovascular - RD10. Neurovascular - RD

TraumaTrauma

If chemical exposure, to what If chemical exposure, to what chemicals? chemicals?

If blunt or penetrating trauma, what If blunt or penetrating trauma, what was the object and where did it was the object and where did it strike? strike?

Loss of consciousness Loss of consciousness Use of power tools Use of power tools

Inflammatory conditionsInflammatory conditions

Recent illness, surgery, trauma, or Recent illness, surgery, trauma, or infection infection

Contact lens wearer/Agriculture worker Contact lens wearer/Agriculture worker Autoimmune diseases (rheumatoid Autoimmune diseases (rheumatoid

arthritis, sarcoidosis, ankylosing arthritis, sarcoidosis, ankylosing spondylitis, or Reiter's syndrome) spondylitis, or Reiter's syndrome)

Infection (herpes simplex, herpes zoster, Infection (herpes simplex, herpes zoster, Lyme disease, or tuberculosis) Lyme disease, or tuberculosis)

Malignancy Malignancy

Neurovascular conditions Neurovascular conditions Sudden onset of vision changesSudden onset of vision changes

Central retinal artery occlusion: Central retinal artery occlusion: • Hypertension, Hypertension, diabetesdiabetes, coagulation abnormalities, , coagulation abnormalities,

trauma, hemoglobinopathies, or cardiac disorders trauma, hemoglobinopathies, or cardiac disorders Arteritic ischemic optic neuropathy: Arteritic ischemic optic neuropathy:

• Severe vision loss (no light perception), headache, scalp Severe vision loss (no light perception), headache, scalp tenderness, jaw claudication, fever, and proximal joint tenderness, jaw claudication, fever, and proximal joint stiffness stiffness

Acute angle-closure glaucoma: Acute angle-closure glaucoma: • Pain, diaphoresis, nausea, and vomiting; ascertain Pain, diaphoresis, nausea, and vomiting; ascertain

patient's activity at the time patient's activity at the time Retinal detachment: Retinal detachment:

• Floaters or flashes of light followed by decreases in Floaters or flashes of light followed by decreases in visual field or acuity visual field or acuity

Ophthalmic TermsOphthalmic Terms Amaurosis fugax Amaurosis fugax Transient blindness. Transient blindness. BoxcarringBoxcarring The segmented appearance of the arteries or veins The segmented appearance of the arteries or veins

with a severe embolus. with a severe embolus. Cells and flareCells and flare WBCs (cells) in the anterior chamber and the WBCs (cells) in the anterior chamber and the

reflection of light (flare) on protein shed from the inflamed iris or reflection of light (flare) on protein shed from the inflamed iris or ciliary body. ciliary body.

ChemosisChemosis Edema of the bulbar conjunctiva, causing swelling Edema of the bulbar conjunctiva, causing swelling around the cornea. around the cornea.

Ciliary flush Ciliary flush Circumcorneal conjunctival injection. Circumcorneal conjunctival injection. Hollenhorst plaquesHollenhorst plaques Cholesterol emboli that appear as Cholesterol emboli that appear as

glistening yellow deposits occluding the retinal vasculature. glistening yellow deposits occluding the retinal vasculature. Hyphema Hyphema Blood in the anterior chamber of the eye. Blood in the anterior chamber of the eye. HypopyonHypopyon The layering of WBCs inferiorly in the anterior The layering of WBCs inferiorly in the anterior

chamber of the eye. chamber of the eye. MetamorphopsiaMetamorphopsia Distortion of the visual image resulting in Distortion of the visual image resulting in

cloudy, foggy, or wavy vision. cloudy, foggy, or wavy vision. Oblique flashlight test Oblique flashlight test The shining of a flashlight tangentially The shining of a flashlight tangentially

from the lateral canthus toward the medial canthus so as to reveal from the lateral canthus toward the medial canthus so as to reveal a shadow on the medial aspect of the iris. Assesses anterior a shadow on the medial aspect of the iris. Assesses anterior chamber depth.chamber depth.

Relative afferent pupillary defect Relative afferent pupillary defect The absence of direct The absence of direct pupillary response to light but intact consensual response to light. pupillary response to light but intact consensual response to light. Assesses optic nerve function.Assesses optic nerve function.

Facts to elicit from the historyFacts to elicit from the history

General General • Are both eyes affected or only one? Are both eyes affected or only one? • Time of onset Time of onset • Recurrence Recurrence • Events preceding the current state Events preceding the current state • Recent history of ocular disease or surgery Recent history of ocular disease or surgery • Other diseases, specifically cardiac, vascular, or Other diseases, specifically cardiac, vascular, or

autoimmune autoimmune • Family history for ocular problems Family history for ocular problems • Current medications or recent changes to medicationsCurrent medications or recent changes to medications• Changes in vision (lost, blurred, or decreased vision; Changes in vision (lost, blurred, or decreased vision;

diplopia, sudden or gradual) diplopia, sudden or gradual) • Visual acuity before the current event Visual acuity before the current event • Other symptoms (pain, nausea, vomiting) Other symptoms (pain, nausea, vomiting)

History, physical exam, and History, physical exam, and laboratory studies laboratory studies

Focused H & PFocused H & P In case of chemical burn, irrigate first talk/look In case of chemical burn, irrigate first talk/look

laterlater Visual acuity— Visual acuity— the vital sign of the eyes the vital sign of the eyes External anatomy External anatomy

• trauma, neuromuscular compromise, skin rash/vesicles, trauma, neuromuscular compromise, skin rash/vesicles, foreign bodies, or deviations from normal anatomy foreign bodies, or deviations from normal anatomy

• both eyes both eyes Pupillary response Pupillary response

• damage to the optic nerve may not be seen for weeksdamage to the optic nerve may not be seen for weeks• relative afferent pupillary defect - early sign often relative afferent pupillary defect - early sign often

develops within seconds of ischemia or optic nerve develops within seconds of ischemia or optic nerve damagedamage

Extraocular eye movements, and Visual Fields Extraocular eye movements, and Visual Fields

TonometryTonometry• Tonopen or digitalTonopen or digital

Slit Lamp Slit Lamp • L/L, SC, K, AC, I, LL/L, SC, K, AC, I, L

FundusFundus CT – image of choiceCT – image of choice Labs Labs

• ESR, CRP, CBC/diffESR, CRP, CBC/diff Path Path

• Corneal scraping, TA BxCorneal scraping, TA Bx

Traumatic injuries Traumatic injuries EPIDEMIOLOGY AND PATHOPHYSIOLOGYEPIDEMIOLOGY AND PATHOPHYSIOLOGY

2,500,000 traumatic eye injuries /yr 2,500,000 traumatic eye injuries /yr USAUSA• 40,000-60,000 lead to visual loss40,000-60,000 lead to visual loss

40% of all new cases of monocular 40% of all new cases of monocular blindness blindness

80% occur in men 80% occur in men average age 30average age 30

Chemical TraumaChemical Trauma

alkaline exposure alkaline exposure • lye, ammonia found in household cleaners, lye, ammonia found in household cleaners,

fertilizers, and pesticides fertilizers, and pesticides • destroys cell structure destroys cell structure • more dangerous than an acid exposure more dangerous than an acid exposure

because penetrate and have a prolonged effect because penetrate and have a prolonged effect Acid exposureAcid exposure

• car battery, bleach, and some refrigerants car battery, bleach, and some refrigerants • Only penetrate through epitheliumOnly penetrate through epithelium

Corneal ScarringCorneal Scarring

Copious IrrigationCopious IrrigationImmediate, copious30 minutes – Morgan Lenslactated Ringer's solution Normal pH—between 7.3 to 7.6

Blunt trauma Blunt trauma Superficial FB – flourescein stainSuperficial FB – flourescein stain fractures, hemorrhage, or damage to the fractures, hemorrhage, or damage to the

globe or adnexa globe or adnexa • Fx sharp edges that can cause entrapment or Fx sharp edges that can cause entrapment or

damage to the muscle or globe damage to the muscle or globe • Retrobulbar hemorrhage - analogous to Retrobulbar hemorrhage - analogous to

compartment syndrome compartment syndrome elevated intraocular and extraocular pressures, elevated intraocular and extraocular pressures,

causing permanent damage causing permanent damage HyphemaHyphema

• warrants suspicion for penetrating trauma, warrants suspicion for penetrating trauma, orbital fracture, acute glaucoma, or retinal orbital fracture, acute glaucoma, or retinal detachment detachment

CT for fracture, retrobulbar CT for fracture, retrobulbar hemorrhage, laceration, or hemorrhage, laceration, or intraocular foreign body intraocular foreign body

control swelling and pressure control swelling and pressure • Cold compresses Cold compresses • Nasal decongestants Nasal decongestants • Lateral canthotomyLateral canthotomy

tetanus prophylaxis tetanus prophylaxis

Rx Corneal AbrasionRx Corneal Abrasion

CycloplegiaCycloplegia Topical antibioticTopical antibiotic

• 44thth generation cephalosporin – generation cephalosporin – (Vigamox,Zymar)(Vigamox,Zymar)

• Ointment – Ointment – (Ciloxan)(Ciloxan)

• No aminoglycoside – No aminoglycoside – (Tobrex, Gent)(Tobrex, Gent)

Topical NSAIDTopical NSAID• anesthesiaanesthesia

NO patch unless 90% involvementNO patch unless 90% involvement Don’t need strong pain controlDon’t need strong pain control

Preseptal CellulitisPreseptal Cellulitis• Warm compressWarm compress• Oral AbxOral Abx

Orbital CellulitisOrbital Cellulitis• IV AbxIV Abx• CTCT• ENT consult for surgical evalENT consult for surgical eval• Beware mucormycosis in Beware mucormycosis in

diabetic/immunocompromised ptsdiabetic/immunocompromised pts

Hyphema Hyphema

r/o rupturer/o rupture Fox shield all timesFox shield all times Restrict activity (BRP only)Restrict activity (BRP only) Cycloplegia, corticosteroidsCycloplegia, corticosteroids Control intraocular pressureControl intraocular pressure r/o sickle/sickle trait r/o sickle/sickle trait 10-20% rebleed rate cx 10-20% rebleed rate cx

• corneal staining, glaucomacorneal staining, glaucoma

Penetrating InjuryPenetrating Injury

r/o rupturer/o rupture• If rupture no further exam - EUAIf rupture no further exam - EUA

eye protected – fox shieldeye protected – fox shield CT CT systemic antibiotics initiated- NOT systemic antibiotics initiated- NOT

topicaltopical NPO, time of last mealNPO, time of last meal tetanus prophylaxistetanus prophylaxis

Lid repairLid repair

Avoid retraction of lid marginAvoid retraction of lid margin• Gray line to gray lineGray line to gray line

Check canilicular system Check canilicular system Remove FBRemove FB Tetanus prophylaxisTetanus prophylaxis

penetrating/lacerating trauma penetrating/lacerating trauma

damage or destroy anatomic damage or destroy anatomic structures structures

compromise protective outer layers, compromise protective outer layers, increasing the risk of infection increasing the risk of infection

Sympathetic ophthalmia Sympathetic ophthalmia • <2%<2%

Inflammatory conditions Inflammatory conditions EndophthalmitisEndophthalmitis

• inflammation in the vitreous chamber inflammation in the vitreous chamber • staphylococci, streptococci,staphylococci, streptococci, Bacillus cereus, Bacillus cereus,

Haemophilus influenzaeHaemophilus influenzae, and , and CandidaCandida • IVDA and pts with indwelling catheters, penetrating IVDA and pts with indwelling catheters, penetrating

traumatrauma Anterior uveitis or iritisAnterior uveitis or iritis

• inflammation in anterior eye structures inflammation in anterior eye structures • potential for elevated pressures potential for elevated pressures • Causes: trauma, autoimmune diseases, infection, or Causes: trauma, autoimmune diseases, infection, or

malignancymalignancy KeratitisKeratitis

• Inflammation of the cornea Inflammation of the cornea • Causes: bacterial, viral, or fungal infection Causes: bacterial, viral, or fungal infection • Can rapidly cause blindness or perforation Can rapidly cause blindness or perforation • immune complexes inflammatory cpd.immune complexes inflammatory cpd. corneal scarcorneal scar

Common Corneal PathogensCommon Corneal Pathogens BacteriaBacteria

• Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus aureus, Pseudomonas aeruginosa, acanthamoebaacanthamoeba

• CL: Extended-wear, wearing while swimming, CL: Extended-wear, wearing while swimming, homemade saline solution, and inadequate disinfectionhomemade saline solution, and inadequate disinfection

Herpes VirusHerpes Virus• simplex (HSV)- most frequent cause of corneal blindness simplex (HSV)- most frequent cause of corneal blindness

in the United States in the United States • zoster (HZV)- not necessarily an emergent problem zoster (HZV)- not necessarily an emergent problem

FungusFungus• Fusarium, CandidaFusarium, Candida • trauma to the eye involving plants or soil trauma to the eye involving plants or soil

Agricultural workers, persons in warm climates more at riskAgricultural workers, persons in warm climates more at risk• gray-white opacity w/ feathery border, +/- satellite gray-white opacity w/ feathery border, +/- satellite

lesions lesions

HSV = EmergencyHSV = Emergency• usually unilateral clear vesicles on an usually unilateral clear vesicles on an

erythematous base that progress to erythematous base that progress to crusting (can be bilateral), does have to crusting (can be bilateral), does have to follow dermatomefollow dermatome

• Prior hx of soresPrior hx of sores• Dendrite has true terminal bulbs that Dendrite has true terminal bulbs that

stain well (HZV terminal bulbs adhere to stain well (HZV terminal bulbs adhere to the epithelium and do not stain well)the epithelium and do not stain well)

HSV RxHSV Rx• Self limiting – leaves scarSelf limiting – leaves scar• Systemic acyclovirSystemic acyclovir• trifluorothymidine 1% drops (Viroptic) 9/day or trifluorothymidine 1% drops (Viroptic) 9/day or

vidarabine 3% ointment (Vira-A), 5/day x 14 vidarabine 3% ointment (Vira-A), 5/day x 14 days days

Very corneal toxic – reserve for confirmed casesVery corneal toxic – reserve for confirmed cases

HZV Rx (not always emergency)HZV Rx (not always emergency)• SupportiveSupportive• AcyclovirAcyclovir• Artificial tears, erythro oint (Ilotycin)Artificial tears, erythro oint (Ilotycin)

NO SteroidsNO Steroids

Inflammatory ConditionsInflammatory Conditions

Symptoms:Symptoms:• pain, photophobia, or decreased visual pain, photophobia, or decreased visual

acuity, esp. with consensual stimulusacuity, esp. with consensual stimulus Signs:Signs:

• SLE - "cell and flare”, adhesions SLE - "cell and flare”, adhesions irregularly shaped pupilsirregularly shaped pupils

• Lower or Higher IOP Lower or Higher IOP Bilateral or RecurrentBilateral or Recurrent

• Warrents search for systemic causeWarrents search for systemic cause

UveitisUveitis

EndophthalmitisEndophthalmitis• worsening pain, redness, and decreased vision worsening pain, redness, and decreased vision

esp in setting of recent sxesp in setting of recent sx• floaters, purulent discharge, or fever floaters, purulent discharge, or fever • eyelid edema, decreased red reflex, hypopyon, eyelid edema, decreased red reflex, hypopyon,

or corneal abscess or corneal abscess • Leukocytosis, diagnostic vitrectomy with Leukocytosis, diagnostic vitrectomy with

cultures and smear cultures and smear • culture contact lenses or caseculture contact lenses or case

Keratitis Keratitis • red eye, photophobia, decreased vision, or red eye, photophobia, decreased vision, or

discharge discharge • Foreign body sensation and inability to open Foreign body sensation and inability to open

the eye the eye • Fluorescein- dendrites or ulcerations Fluorescein- dendrites or ulcerations • SLE: corneal opacification, ciliary flush SLE: corneal opacification, ciliary flush

Do Not Patch Possible InfectionsDo Not Patch Possible Infections Endophthalmitis RxEndophthalmitis Rx

• intravitreal Abxintravitreal Abx• vitrectomyvitrectomy

Keratitis RxKeratitis Rx• CycloplegiaCycloplegia• Corneal scrapingCorneal scraping

c & s, stain (gram/geimsa)c & s, stain (gram/geimsa)• BacterialBacterial

44thth gen cephalosporin/ topical azithromycin (Vigamox/ gen cephalosporin/ topical azithromycin (Vigamox/ Azasite, Ciloxan/ Erythro)Azasite, Ciloxan/ Erythro)

• FungalFungal NatamycinNatamycin Tectonic PKPTectonic PKP

Uveitis/IritisUveitis/Iritis• Cycloplegia – pain relief, prevent miotic scarringCycloplegia – pain relief, prevent miotic scarring• CorticosteroidsCorticosteroids• IOP controlIOP control

Neurovascular conditions Neurovascular conditions

central retinal artery occlusion central retinal artery occlusion (CRAO), nonarteritic(CRAO), nonarteritic

arteritic anterior ischemic optic arteritic anterior ischemic optic neuropathy (AION)neuropathy (AION)

acute angle closure glaucoma (ACG)acute angle closure glaucoma (ACG) retinal detachment (RD) retinal detachment (RD)

CRAOCRAO

thrombus, embolus, or vasculitis thrombus, embolus, or vasculitis blocks blood flow to the central blocks blood flow to the central retinal artery, resulting in ischemia retinal artery, resulting in ischemia and infarction of the retina and infarction of the retina

CRAOCRAO

Hypertension 2/3 patients Hypertension 2/3 patients structural cardiac pathology and carotid structural cardiac pathology and carotid

atherosclerosis ½ ptsatherosclerosis ½ pts diabetes mellitus ¼ ptsdiabetes mellitus ¼ pts coag abnl, hemoglobinopathiescoag abnl, hemoglobinopathies

• esp in younger ptsesp in younger pts trauma trauma 30% to 50% have giant cell or temporal 30% to 50% have giant cell or temporal

arteritis arteritis

AIONAION

advanced age, white race, female advanced age, white race, female gender, family history gender, family history • Mean age 70Mean age 70• Incidence in patients older than 80 is Incidence in patients older than 80 is

approx 1% approx 1%

SymptomsSymptoms• Unilateral severe vision lossUnilateral severe vision loss• Scalp/forehead tendernessScalp/forehead tenderness• Jaw claudicationJaw claudication• +/- polymyalgia rheumatica+/- polymyalgia rheumatica

SignsSigns• APDAPD• ON edemaON edema• Elevated ESR, CRPElevated ESR, CRP

men, ESR > age/2; women, ESR > (age + 10)/2 men, ESR > age/2; women, ESR > (age + 10)/2

ACGACG anterolateral portion of the iris occludes anterolateral portion of the iris occludes

the canal of Schlemm the canal of Schlemm retinal ganglion cell death and irreversible retinal ganglion cell death and irreversible

vision loss vision loss Stimulates strong vasovagal responseStimulates strong vasovagal response

• Nausea/vomitting can lead to met acidosisNausea/vomitting can lead to met acidosis Etiology - pupillary block 90%Etiology - pupillary block 90%

• aqueous flow from the posterior chamber is aqueous flow from the posterior chamber is occluded where the lens meets the iris occluded where the lens meets the iris

• posterior chamber pressure builds, bowing the posterior chamber pressure builds, bowing the iris and narrowing the angle until the outflow iris and narrowing the angle until the outflow pathway is obstructedpathway is obstructed

age > 30 yrsage > 30 yrs• Peak age 55-70Peak age 55-70

Eskimo or Asian ethnicityEskimo or Asian ethnicity• Eskimo 40x incidence of whitesEskimo 40x incidence of whites

hyperopia hyperopia female genderfemale gender

• 3-4x >risk than males3-4x >risk than males first-degree relative with ACG first-degree relative with ACG

RDRD

vitreous separates from the retinal vitreous separates from the retinal pigment epithelium pigment epithelium • FlashesFlashes

Separation fibrous aggregates on the Separation fibrous aggregates on the vitreal posterior surfacevitreal posterior surface• prevents light rays from reaching retinaprevents light rays from reaching retina

Separation at retinal vessel may leak Separation at retinal vessel may leak blood into the vitreous bodyblood into the vitreous body• Floaters, blurred visionFloaters, blurred vision

Macular involvement can lead to severe, Macular involvement can lead to severe, permanent vision loss permanent vision loss

1 in 15,000 persons each year 1 in 15,000 persons each year 50 yrs age50 yrs age Risk factors: retinal hole, Risk factors: retinal hole,

inflammation, trauma, previous eye inflammation, trauma, previous eye surgery, myopia, and family hxsurgery, myopia, and family hx

TreatmentsTreatments

CRAOCRAO• break up the embolus or move it downstream break up the embolus or move it downstream

to minimize retinal damageto minimize retinal damage More likely if begun within 8 hours of onset of More likely if begun within 8 hours of onset of

symptoms symptoms

• digital pressure applied to the globe several digital pressure applied to the globe several times for a few seconds, repeated every few times for a few seconds, repeated every few minutes minutes

• decrease intraocular pressure decrease intraocular pressure IV acetazolamide, 500 mg, topical ß-blockerIV acetazolamide, 500 mg, topical ß-blocker

• rebreathe CO2 from paper bag (carbogen)rebreathe CO2 from paper bag (carbogen)

AIONAION• high-dose corticosteroid if vision losshigh-dose corticosteroid if vision loss

IV methylprednisolone, 250 mg Q 4hr x 3 d IV methylprednisolone, 250 mg Q 4hr x 3 d initially, then 60 mg Q 6hrinitially, then 60 mg Q 6hr

• TA bx within 2 weeksTA bx within 2 weeks

ACGACG• Reduce IOP with medication followed by Reduce IOP with medication followed by

surgery surgery topical pilocarpine 2% Q 5 min x 3, timolol topical pilocarpine 2% Q 5 min x 3, timolol

0.5% x 1, acetazolamide 500 mg orally or IV 0.5% x 1, acetazolamide 500 mg orally or IV laser iridectomylaser iridectomy

• Control Pain and vomiting Control Pain and vomiting • Prophylactic iridectomy of fellow eyeProphylactic iridectomy of fellow eye

RDRD• immediate surgical interventionimmediate surgical intervention

diathermy, cryotherapy, or laserdiathermy, cryotherapy, or laser

• patient supine with head turned to the patient supine with head turned to the same side as the detachment same side as the detachment

• PX worsens with macular involvement & PX worsens with macular involvement & duration duration

ConclusionConclusion

History and physical exam can help History and physical exam can help make a prompt and accurate make a prompt and accurate diagnosis of ophthalmic emergencies diagnosis of ophthalmic emergencies

Important to administer appropriate Important to administer appropriate therapies until the ophthalmologist therapies until the ophthalmologist can assess the patient can assess the patient