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International Council of Ophthalmology

HANDBOOK FOR JUNIOR RESIDENTS AND MEDICAL STUDENTS

LEARNING EMERGENCY OPHTHALMOLOGY

Compiled by The Task Force on Undergraduate Teaching in Ophthalmology of the International Council of

Ophthalmology and based on their curriculum 2009

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Inthisbookletwehaveputtogethercommonophthalmicemergency

conditionsthatwethinkyouneedtoknowandkeyophthalmic

disorderswethinkyouneedtohaveseen.Therearedescriptionsand

colourpicturesoftheseconditions.Thispocketsizedbooksummaries

thekeypointsintheophthalmologycurriculumcompliedbytheTask

ForceoftheInternationalCouncilofOphthalmologyandisaformat

thatisveryportable!

SueLightman,DoNhuHonandPeterMcCluskey

OnbehalfoftheInternationalCouncilofOphthalmologyandVietnam

NationalInstituteofOphthalmology,HanoiMedicalUniversity2010

OtherContributingAuthorswiththanks

AnhDinhKim,AnhNguyenQuoc,ChauHoangThiMinh,DongPhamNgoc,HaTran

Minh,HonDoNhu,NgocDoQuang,QuanBuiDao,RichardAndrews,ThangNguyen

Canh,ThanhPhamThiKim,ThuyNguyenThiThu,ThuyVuThiBich,TungMaiQuoc,

VanPhamThiKhanh, VanPhamTrong,YenNguyenThu,SimonTaylor

Haveyouseen? Tickifyes

Doyouknowhowitiscausedandtreated?

Tickifyes

Noteforyou:Remembertolookitup

Trauma

Periorbitalhaematoma

Orbitalblowout

Lidlaceration

Subconjunctival

Haemorrhage

Chemicalburns–cornea

andconjunctiva

Foreignbody

Cornealabrasion

Hyphema

Iridodialysis

Cataract

Lenssubluxation/dislocation

Intraocularforeignbody

Scleralrupture

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PainfulRedEye

Chalazion

Dacryocystitis

Orbitalcellulitis

Conjunctivitis

Scleritis

Episcleritis

Viralkeratitis

Bacterialkeratitis

Shingles

Uveitis

Acuteangle-closure

glaucoma

Endophthalmitis

SuddenPainless Loss of

Vision

Vitreoushaemorrhage

Retinaltear/detachment

Centralretinalartery

occlusion

Centralretinalvein

occlusion

Others

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Proptosis

VIInervepalsy

TRAUMA

Oculartraumaisverycommon,especiallyindevelopingcountries.Itcaninvolveanypartoftheocularsystem,includingtheeyelids,globeandvisualpathways. Allpatientswithahistoryoftraumamusthaveafullophthalmicexamination.

Periorbitalhaematoma

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Haematoma(blackeye)isthemostcommonresultofbluntinjurytotheeyelid.Signs:Ecchymosis,sub-conjunctivalhaemorrhageManagement:Thiswillresolveonitsownandtreatmentisaimedatpatientcomfort.Coolcompressescanbeuseful. Incaseswithbilateralinvolvement,askull-basefractureneedstobeexcluded.

Orbitalblowout

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Ablowoutfractureoftheorbitalfloorisusuallytheresultofasuddenincreaseintheorbitalpressurecausedbyastrikingobject,suchasafistortennisball.

Signs:Theseincludeenophthalmos(sinkingoftheeyeballintotheorbit),diplopia(doublevision),infraorbitalnerveanaesthesiaandlimitationofupgazelimitation.ACTscanhelpstoevaluatethefracture.

Management:Surgicalrepairisoftenrequired.

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Lidlaceration

Lidlacerationsmustbeexploredthoroughlytoensurethelacrimalsystemisintact.Impropereyelidclosurecancauseexposurekeratopathy.

Management:minorlidlacerationsshouldberepairedbydirecthorizontalclosurewheneverpossible,inordertoarchivethebestfunctionalandcosmeticresults.Accurateappositionoftheeyelidmarginsiscritical.Majortissuelossneedsoculoplasticsurgery.Laceratedlacrimalductsshouldberepairedtomaintainnormalteardrainage.

Subconjunctivalhaemorrhage

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ThisisBloodundertheconjunctiva,andisusuallyunilateral,localisedandsharplycircumscribed;theunderlyingscleraisoftennotvisible. Thereisnoinflammation,painordischarge,andthevisualacuityisunchanged.Sometimes,therecanbeanassociationwithminorinjuries,includingeye-rubbing,anditismorecommonwithuseofanti-plateletagentsandanticoagulants.Management:Thisismostlyreassururance,butcheckingbloodpressureandcoagulationmaybeindicated.

Chemicalburnsofcorneaandconjunctiva

Mild

Moderate

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Severe

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Alkalis(bleach,cement)tendtopenetratedeeperintotheocularstructuresthanacids.Thisisanocularemergency,andtheinitialmanagementconsistsofcopiousirrigationoftheeyesundertopicalanaesthetic.Signsincludecornealhaze,limbalischaemiaandlossofepithelium.Management:Anacuteocularemergency.Immediate,prolongedandcopiousirrigationwithnormalsalineuntiltheocularpHremainsnormal.Intensivetopicalsteroids,antibioticsandLubricantsaregiven. Latermanagementmayincludelimbalstem cellgraftingforlimbalstemcellloss,butkeratoplastyorkeratoprothesis(artificalcornea)surgerymayberequiredfordensecornealscarring.

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SuperficialforeignBody Cornea

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Bulbarconjunctiva Signs:foreignbodyoncornealsurfaceorbulbarconjunctiva.Iftheforeignbodyisnotvisible,everttheeyelidstoexposeapossiblesubtarsalforeignbody.Management:topicalantibioticsafterremovaloftheforeignbody.

Cornealabrasion

Cornealepitheliumisscrapedandlostaftereyetrauma.Symptoms:sore,wateryeyewithblurredvision.Signs:redandwateryeye.Fluoresceinstaininginareawherecornealepitheliumislost.Management:topicalantibioticsandeyepadforsymptomaticrelief.

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Eyeglobeperforation Scleralrupture

Cornealrupture

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Thisresultsfromsevereblunttraumaandperforatingoculartrauma.Signs:softeye,protrudingiris,irregularpupil.Theperforatedeyeispronetoinfection(endophthalmitis). Latecomplicationsincludesympatheticophthalmia(inflammationoftheuveaofthenormalfelloweyethatoccurslateafterperforatinginjury)Management:Surgicalprimaryrepair.

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Hyphaema Mild

Severe

Bloodintheanteriorchamberfollowingblunttraumatotheeye.Symptoms:redeyeandseverelossofvisionfollowingtrauma.Signs:visiblebloodinanteriorchamberandcorneamayalsobestained.Eyemaybeverysoreifintraocularpressureisraised.Haematocorneacausescloudyvision.Management:BedrestAndtopicalatropinetoreducetheriskofrebleeding.Urgentassessmentbyophthalmologistisrequired,astreatmentofraisedintraocularpressureoranteriorchamberirrigationmayberequired.

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Iridodialysis

Adehiscenceoftheirisfromtheciliarybodyatitsroot.Symptoms:Thismaybeasymptomatic,oritmaycausemonoculardiplopiaandglare.Signs:misshapenpupil.Management:surgicaliridoplastymayberequired

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Cataract

Traumaticcataractmayarisefromdirectpenetratinginjurytothelens.Concussionmaycauseanimprintingofirispigmentontotheanteriorlenscapsuleandarosette-shapedcorticalopacity.Management:cataractextractionandintraocularlensimplantation

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Lenssubluxation/dislocation Lenssubluxation

Lensdislocatedintotheanteriorchamber

Lensdislocatedoutfromtheglobe

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Directtraumatotheeyemayresultinlenssubluxationortotaldislocation.Victimsmayexperiencereducedvision,monoculardiplopiaandintraocularhypertension.Management:lensremovalwith(usually)intraocularlensimplantation.

Intraocularforeignbody(IOFB)

Anteriorchamber

Lens

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Vitreous/retina

AnIOFBmaylodgeinanyoftheocularstructuresitpassesthrough,somaybelocatedanywherefromtheanteriorchamber,lenstotheretinaandchoroid.Foreignbodiesarepronetoresultininfection(endophthalmitis).Management:immediatereferraltoophthalmologistforremovalofforeignbody.

Siderosis

RetinaltoxicitycanbecausedbyanironIOFBremainingintheeyeforalongtime. Symptoms:reducedvisionSigns:dilatedpupil,rust-brownoryellowlensopacityandabolisedelectro-retinogram(ERG).Management:lateIOFBremovalmaynothelpvisualrecovery.

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PAINFULREDEYE Chalazion

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Inflammationofthemeibomianglandscauseslumpsintheeyelids.Signs:eyelidswelling,rednessandpain.Management:self-limited,topicalantibioticsandsurgicalremovalifnecessary.

Ophthalmiczoster(shingles)

ApainfulconditioncausedbyHerpeszosterinfection.Signs:whenthe1st

division(ophthalmicnerve)ofthe5th(trigeminal)cranialnerveisaffected,extremelypainful,blister-likelesionsappearontheface.Sometimes,thecornea,uveacangetinflammed.Management:anti-viraldrugsandanalgesics.

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Dacryocystitis

Infectionofthelacrimalsac–usuallysecondarytoobstructionofthelacrimalduct.Signs:atender,red,tenseswellingatthemedialcanthus.Maybeassociatedwithpreseptalcellulitis.Management:initialwarmcompressesandoralantibiotics.Sometimes,drainingandtearsacremovalmaybenecessary.

Orbitalcellulitis

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Thisisalife-threateninginfectionofthesofttissuesbehindtheorbitalseptum. Itismorecommoninchildren.Symptoms:fever,painandvisualimpairment.Signs:unilateral,tender,warmandredperiorbitallidoedema,proptosis,painfulophthalmoplegiaandopticnervedysfunction.CTscanshowsthickenedperioculartissues.Management:admissionandintravenousantibiotictherapy.

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Rhabdomyosarcoma

HighlymalignantorbitaltumorofstriatedmusclesinchildrenSymptoms:unilateraleyepain.Signs:reducedvision.Extremelyprogressiveexophthalmosorproptosis(buldgingorprotrusionoftheeyeball),redeye.Management:referraltooncologistsforexenteration,radiotherapyandchemotherapy.

Conjunctivitis

Inflammationoftheconjunctiva(amucousmembranethatcoverswhiteoftheeyeandinnersurfaceoftheeyelids)

Bacterialconjunctivitis

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Symptoms:Redstickyeyes,usuallybilaterally.Signs:redeyeswithpurulentdischarge.Nocornealoranteriorchamberinvolvement.Systemicallywell.Management:regularhygienetominimisesecretionbuildup,topicalantibioticsfor5days.

Viralconjunctivitis

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Contacthistorywithrecenteyeorupperrespiratorytractinfectionsymptoms(especiallychildren).Highlycontagious.Symptoms:burningsensationandwaterydischarge(differentfrompurulentexudateinbacterialinfections).Classicallybeginsinoneeyewithrapidspreadtotheother,oftenpre-auricularlymphadenopathy.Signs:eyeredandwatery.Swollenconjunctivaparticularlyinlids.Management:willresolveonownandtreatmentaimedatcomfort.Coolcompresses,regularlubricants(withoutpreservative).Antibioticdropsifindicated.Resolutionmaytakeweeks.

Allergicconjunctivitis

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Symptoms:eyesitch(++)andareredandsore.Signs:eyelidswellingand.papillae(tinyelevationonthepalpebralconjunctiva).Historyofatopye.gasthma,eczema.Management:removeallergenswherepossible,topicalanti-histamines,coolcompresses.

Episcleritis

Sectoralepiscleritis

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Diffuseepiscleritis

Inflammationofepisclera,theoutmostlayerofthesclera.Symptoms:milddiscomfort,tendernessandwatering.Signs:sectoralordiffuseredness.Management:topicalsteroid.Self-limiting.

Scleritis

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Thisisinflammationofthesclera.Inthemostsevereformscleralnecrosiscanoccur.Symptoms:Eyepainwhichradiatestoheadandwakespatientatnight.Signs:Theeyeisredandmayhavevisiblescleranodulesoranecroticpatch.Thescleramaybediscoloredandistendertopalpation.Thereisoftenanassociatedhistoryofrheumatoidarthritis,vascularorconnectivetissuedisease.Management:Urgent(sameday)referraltoanophthalmologist.Topicaland/orsystemiccorticotherapymayberequired.

Keratitis

Viralkeratitis

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Bacterialkeratitis

Fungalkeratitis

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Parasitickeratitis

Cornealinflammationfromvariousagentssuchasvirus,bacteria,fungiandparasite(acanthamoeba).Symptoms:Asore,redeye,oftenincontactlenswearerorfollowingtrauma.Signs:Whiteareaoncornea,maybeperipheralorcentral.Management:Urgent(sameday)referraltoophthalmologistforcornealscrapeandintensivetopicalantibiotic/antiviral/antifungaltherapy.Keratoplasty(cornealgraft)mayberequiredespeciallywhenthecorneaisperforated.

Uveitis

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Inflammationofanypartoftheuvealtract(iris,ciliarybodyandchoroid).Symptoms:photophobia,eyeredandsore,visionmayormaynotbeaffected.Signs:redeyewithciliaryinjectionaroundiris,anteriorchamberappearscloudyfromcellsandflare.Management:urgent(sameday)referraltoophthalmologistformydriasis,intensivesteroidtherapyandaetiologicalworkup.

Acuteangle-closureglaucoma

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Asuddenincreaseinintraocularpressureoccursowingtotoaclosedanteriorchamberanglewhichpreventsaqueousdrainage.Symptoms:Painfuleyewithsystemicsymptomsincludingheadache,nauseaandvomiting.Signs:MorecommoninAsianraces.Theeyeisred,verytenderandfeelshardonpalpation;thecorneausuallyhashazyappearance.Theanteriorchamberisshallowwithirregularsemi-dilatedpupil.Management:urgent(sameday)referraltoophthalmologist.Topicalpilocarpine,Aqueousinhibitorsandbetablockersmayhelptolowertheintraocularpressure.Laseriridotomyortrabeculectomyisindicatedaccordingtointraocularpressurelevelandwhethertheangleisopen.Additionalcataractextractionmayhelptoopentheangleandnormalizethepressure.

Endophthalmitis

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Mostcommonlyseenaftertraumaorintraocularsurgery.Symptoms:painfuleyewithlossofvision.Signs:lidswelling,discharge,redeye,hypopyon,reducedvision.Management:urgentreferraltoophthalmologistforvitreoussampling,intravitrealantibioticsandvitrectomy.

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SUDDENPAINLESSLOSSOFVISION

Vitreoushaemorrhage

Bleedinginthevitreouscavityseeninindividualswithdiabetesmellitus,cardio-vasculardiseasesandretinaldetachment.Symptoms:Suddenlossofvisionoftenwithfloaters.Signs:Reducedorabsentredreflex.Limitedornofundalview.Management:Refertoophthalmologistforultrasoundscantoensurethatthereisnounderlyingretinaldetachment. Avitrectomymayberequiredfornon-clearinghaemorrhage.

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Retinaltear/detachment

Retinaltear/detachmentoccurswhenthereisseparationofsensoryretinafromtheretinalpigmentepithelium.Mostcommonaetiologyisapredisposingretinalholetear–oftenassociatedwithmyopiabutmayfollowtraumaSymptoms:Painlesslossofvision.Thepatientmayhaveencounteredarecenthistoryofincreasednumberofvisualfloatersand/orvisualflashes.Theremaybea“darkshadow”inthevisionoftheaffectedeye.Signs:Greyareaofraisedretinaatsiteofdetachment. Thevisionwillbereducedifmaculabecomesdetached.Management:urgent(sameday)referraltoophthalmologistforsurgicalrepair(cryotherapywithgastamponadeand/orscleralbuckle).

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Centralretinalarteryocclusion

Blockedbloodflowinthecentralretinalartery,whichoftenoccursinoneeye.Symptoms:Suddenandpainlesslossofvision.Signs:Thevisualacuityisverypoor,atbestperceptionoflightorhandmovements,togetherwithaRelativeAfferentPupillaryDefect(RAPD).Fundusexamination:Paleretina(abnormalandasymmetricalredreflex),cherry-redspotatmaculaduetocilioretinalsparing.Delayedarterialfillingonfluoresceinangiogram.Investigation:urgent(sameday)ESRandCRPtoexcludegiantcellarteritis.

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Management:Urgent(sameday)referraltoophthalmologisttoseewhetheranyimmediatetreatmentispossible.Intensiveintraocularpressurelowering(ACinhibitorsandparacenthesis)mayhelpinsomecases.Awork-upforcausesofTransientIschaemicAttackswillneedtobearranged.

Centralretinalveinocclusion

Blockedbloodflowthroughthecentralretinalvein.Symptoms:Suddenandpainlesslossofvision.Signs:Dilatedtortuousveins,cottonwoolspots,opticdiscswelling,retinalhaemorrhagevisibleinallfourquadrantswhichmayobscuremuchoffundus

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detail. Predisposingfactorsincludeincreasingage,hypertensionanddiabetes,aswellasraisedintraocularpressure.InvestigationandManagement:Screenfordiabetesandhypertension,excludeglaucoma.Routinereferralforanophthalmologicalopinion.Fluoresceinangiographyisoftenperformedtoinvestigatehowischaemicthefundusis,andlasercanbeindicatedtopreventneovascularglaucomaandrecurrentvitreoushaemorrhage.

Papillitis

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Acuteinflammationofopticnerveisassociatedwithmoderatetoseverevisionloss.Longlastingpapillitisleadstoopticatrophy.Symptoms:suddenreducedvision,discomfortuponeyemovement.Signs:centralvisualfielddefect,opticdiscswelling,RelativeAfferentPupillaryDefect(RAPD).Management:excludemultiplesclerosis,infectionofmeninges,orbitaltissuesorparanasalsinuses.Intensivesystemiccorticotherapymayhelp.

Proptosis

AcuteorchronicexpansionofglobecontentswhichmaybeunilateralorbilateralSigns:mayhavecornealexposure,displacementofglobe,visionmayormaynotbeaffected,eyemovementsmaybeaffected,RAPDifopticnerveinvolved

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Management:imagingtodefinecauseofpropotosis.Investigationsasappropriatedependingonwhichorbitalstructuresareinvolvedwhichmayincludethyroidfunctiontestsandorbitalbiopsy

VIInervepalsy

Mainproblemforeyeisfailureofeyeidclosure socornealexposure.Maybeidiopathic(Bell’spalsy)orcausedbytrauma,tumour,infection,inflammationSigns:Varyinseveritybutfailuretocloseeyelidisthekeysign,maybeothersignsofVIIthnervepalsyManagement:ensureeyeclosureandlubricate.Mayrecover.Ifnotmayrequireprocedurestohelpwiththisegtarrsorraphy,weightsonupperlid.