Ocular Emergencies

Capt RIFATMedical Officer7 Fd Amb

Anatomy of the Eye

OCULAR EMERGENCIES

Conjunctivitis, IritisPeriorbital CellulitisStyeGlaucomaCorneal

Abrasion,laceration,ulcer

Extraocular Foreign Bodies

Subconjunctival hemorrhage

Chemical BurnsRetinal DetachmentOrbital FractureHyphemaEyelid LacerationGlobe RuptureCetral retinal artery

occlusionRetrobulber Hematoma

AssessmentHistory Gross assessment External appearance Always use contralateral eye for comparison Edema of lids, Conjunctiva and sclera for color and inflammation Hazy cornea Opaque, gray-white area of cornea Lesions, Foreign body

Pupils

Fine assessmentDirect ophthalmoscopyTonometryFluorescein stainingSlit-lamp examInvestigations

Culture and sensitivityCBCPlain X ray of skull and orbitCT scan

Priorities

ABCsPrevent further damagePrevent or minimize complicationsControl painRelieve anxiety

Common Ocular Emergencies

Conjunctivitis

Inflammation of the conjunctivaCauses:

bacterial/viral inflammation allergies Chlamydiachemical burnsFBIrritants

SymptomsHyperemiaUnilateral or bilateralSlight pain“Gritty” sensationDischarge

SignsEdema of eyelidsVisual acuity: NormalCornea: ClearPupil: NormalConjunctiva: red or pink

TreatmentAntibiotics

ointment/dropsObtain culture, if

indicatedCleanse eyes gently to

remove debrisAnti histamine

Prevention Explain contagious

nature Medication admin. Wipe from nose to

outer corner of eye Cleanse lid Avoid eye makeup

Iritis

Inflammatory process that includes the iris and sometimes the ciliary body

Predisposing conditions:rheumatic disease, and syphillis

SymptomsBlurring of visionUnilateral painEdema of upper lidRed eyePhotophobiaDecreased visual acuity Lacrimation

Redness at eyelashClear to hazy cornea

Small, irregular, sluggish reaction of pupils

Pain on eye pressure

TreatmentAnalgesics

Cycloplegics to paralyze ciliary muscle Darkened environment

Rest eyesWarm compresses Shield eyes or dark glassesFollow-up

Periorbital Cellulitis

Infection of the cells around the eye

May occur after trauma such as laceration or an insect bite

Pneumococcal, staphylococcal, streptococcal

SymptomsMarked periorbital edema and erythema.

Pain: severe that is aggravated by movement of eye

.Conjunctival infection.Fever.

Signs

Visual acuity: Decreased

Decreases pupil reflexes

Paralysis of EOM

Treatment

BedrestIV antibioticsWarm compresses

GlaucomaAcute angle-closure glaucoma occurs when the distance between the iris and the cornea becomes inadequate or is blocked completely.

The aqueous fluid production is greater than the amount leaving through the canal of Schlemn.

May lead to irrecoverable blindness.

Pathophysiology

Aqueous humor produced by ciliary body, enters ant. chamber, drains via trabecular meshwork at angle to enter canal of Schlemm

In AACG, iris obstructs trabecular meshwork by closing off angle

Optic nerve damage

SymptomsRed eyeSevere, sudden-onset, deep, unilateral painIntense headacheDecreased visual acuityHalos (around lights)Visual loss (usually peripheral)Nausea/vomiting

Signs:Conjunctival congestionCorneal edemaMid-dilated, fixed pupilHazy, lusterless corneaIncreased intraocular

pressure (>20 mm Hg)Rocklike hardness

DiagnosticTonometry

Medical TxReduce production of aqueous humor Topical -blocker (timolol) Carbonic anhydrase inhibitor (acetazolamide) Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45

min)Or increase outflow Topical -agonist (phenylephrine) Miotics (pilocarpine 1-2%)Topical steroid (prednisolone acetate 1%)

Definitive Tx Laser peripheral iridectomy

Central retinal artery occlusion

Blockage of the the retinal artery by thrombus or embolus

Prompt recognition and intervention must be obtained within 1-2 hours of onset

Etiology:Emboli – cardiac, atherosclerotic, fatVasculitisCoagulopathySickle cell diseasesDiabetesHTN

Signs and Symptoms

Sudden onset monocular vision loss over seconds

PainlessVisual acuity is limited to light

perception in affected eyePupil reaction: dilated, nonreactive

in affected eye

Treatment of CRAO

Mannitol 0.25-2.0 g/kg IV or acetazolamide 500 mg PO once to reduce IOP.

IV anticoagulant, tPA

Oral nitrates

Lay the patient flat on his/her back Massage orbit. This is thought to help dislodge the clot from a larger to smaller retinal artery branch, minimizing area of visual loss.

Alkali burns more common and worse than acid

Alkali – saponification – denatures collagen, thromboses vessels

Household cleaners, fertilizers, drain cleaners

Acid – coagulation, H+ precipitates protein - barrier

Industrial cleaners, batteries, vegetablepreservatives

Chemical burns

Initial TreatmentImmediate copious irrigation

Topical anesthesia (tetracaine) Lids should be retracted and fornices swabbed Check pH with litmus paper after initial irrigation Continue irrigating until ph 7.0 – 7.3Once pH is stabilized Cycloplegic agent (0.25% scopolamine) Broad-spectrum antibiotic (ciprofloxacin,

ofloxacin, gentamicin, or tobramycin) should be applied.

Corneal Foreign bodyOften metallic foreign body following work injury.

Signs and symptoms: foreign body sensation, tearing, red, or painful eye. Pain often relieved with the instillation of anesthetic drops.

Stain with fluorescein stain and illuminate under blue fluorescent light (Wood’s lamp) is effective to see corneal epithelial defects.

TreatmentApply topical anesthetic

Remove foreign body with sterile irrigating solution or moistened sterile cotton swab

Never use needle

Apply antibiotic ointment

24-hour follow-up is mandatory

Refer if foreign body cannot be removed

Retrobulber hematoma

Hemorrhage into closed space of orbit IOP leading to vision loss from optic

nerve damage / retinal ischemiaClinical diagnosis:

Ocular pain, APD, proptosis, ophthalmoplegia, diminished vision, IOP

Immediate lateral canthotomy and cantholysis indicated if IOP > 40mmHg or vision loss

Corneal injuriesAbrasions, lacerations, ulcersSymptoms:

extreme eye pain, relieved with lidocaine drops.

Visual acuity usually decreased, depending on location of injury in relation to visual axis.

Inflammation leading to corneal edema

can decrease VA.Diagnosis: fluorescein staining to see

epithelial defect. Seidel’s test for aqueous

leakage to diagnose laceration.

Topical antibiotics and follow up with ophthalmologist.

For lacerations, <1 cm, topical antibiotics and discharge with follow up.

If >1 cm, refer to ophthalmologist to rule out globe rupture and for possible suture placement.Avoid contact lensesAvoid patching

Management of Corneal Injury

CONCLUSION

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