Ocular Emergencies

OCULAR EMERGENCIES

Medical Conjunctivitis Iritis Periorbital Cellulitis Glaucoma Central Retinal Artery

Occlusion

Surgical Corneal Abrasion Extraocular Foreign

Bodies Retinal Detachment Orbital Fracture Chemical Burns Hyphema Eyelid Laceration Globe Rupture

Assessment

History / MOITime of occurrenceTreatment before arrivalAbnormal eye appearanceVisual acuity

Snellen’s Visual Fields Finger count

Assessment

TearingItchingDischarge Medical History

Ocular Systemic Medication

Always use contralateral eye for comparison

Assessment

Spasms of eyelidLesions, FB, Penetrating woundsPupilsEOMPosition and alignment of eye

Assessment

Conjunctiva and sclera for color and inflammation

Edema of lids, conjunctive, and/or corneaBloodOpaque, gray-white area of corneaHazy cornea

Assessment

PalpationIntraocular pressure: Do not do if

there is concern regarding globe

Things To Think About When Assessing

Younger males are at higher risk for serious injury

School-age children are more susceptible to conjunctivitis

Contact wearers are at greater risk for corneal abrasions and infection

Exposure to arc welding S/S develop 4-8 post exposure

Things To Think About When Assessing

Auto mechanics and service station attendants have potential for acid burns to face

Injuries occurring in the garden have increased potential for infection

Ball sports increase potential for eye injury

Diagnostics

Direct ophthalmoscopeTonometryFluorescein stainingSlit-lamp examLaboratory

Cultures CBC Coags

Diagnostics

RadiologyCT scanSoft tissue/orbit films for foreign

bodyFacial bonesSkull films

Priorities

ABCsPrevent further damagePrevent or minimize complicationsControl painRelieve anxiety or apprehensionEducation

Consultation Criteria

Penetrating ocular trauma

Chemical burns of the eye

Severe lid laceration

Glaucoma

Central retinal artery occlusion

Retinal detachment

Orbital fractureHyphemaPeriorbital

cellulitis

Age-related Pearls

Pediatric Delayed presentation due to children not noticing

gradual vision loss May need picture chart Infants and small children may need to be

restrained in blanket to facilitate exam

Age-related Pearls

Geriatric Vision diminishes gradually until 70 y/o and then

rapidly thereafter Decreased near vision Decreased accuracy of results from visual acuity

testing

Age-related PearlsGeriatric

Decreased accommodation to distances

Decreased lacrimal secretions Cataracts: at age 80 1 in 3

are affectedMore likely to experience

glaucoma, detached retina, and retinal bleeds

Medical Ocular Emergencies

Conjunctivitis

Inflammation of the conjunctivaCauses:

bacterial/viral inflammation allergies Chlamydia chemical burns FB flash burns Irritants URI

Conjunctivitis

Symptoms/Assessment Hyperemia Unilateral or bilateral Slight pain “Gritty” sensation Discharge

Mucopurulent Matting of eyelids and

lashes

Edema of eyelids Visual acuity: Normal Cornea: Clear Pupil: Normal Conjunctiva: red or pink

Conjunctivitis

Treatment Antibiotics

ointment/drops Obtain culture, if

indicated Cleanse eyes gently to

remove debris

Education Explain contagious

nature Medication admin. Asepsis Wipe from nose to

outer corner of eye Cleanse lid with baby

shampoo Avoid eye makeup Follow-up

IritisInflammatory process that includes the iris

and sometimes the ciliary bodyPredisposing conditions:rheumatic disease,

and syphillis

Iritis

Symptoms/Assessment Blurring of vision Unilateral pain Edema of upper lid Red eye Photophobia Decreased visual acuity Lacrimation

Redness at eyelash Clear to hazy cornea Small, irregular,

sluggish reaction of pupils

Pain on eye pressure Fluorescein stain Slit-lamp exam

Iritis

Treatment/Education Analgesics NSAIDs Cycloplegics to

paralyze ciliary muscle and spasms

Darkened environment

Rest eyes Warm compresses Shield eyes or dark

glasses Follow-up

Periorbital Cellulitis

Infection of the cells around the eyesA major ophthalmological emergency and is

potentially life threateningMay occur after trauma such as laceration or

an insect bitePneumococcal, staphylococcal, streptococcal

Periorbital CellulitisSymptoms/Assessment

Marked periorbital edema and erythema

Pain: severe that is aggravated by movement of eye

Conjunctival infection Fever

Visual acuity: Decreased

Decreases pupil reflexes

Paralysis of EOM Diagnostics

CT scan Culture Gram stain Blood culture

Periorbital Cellulitis

Treatment/Education Referral to

ophthalmologist Bedrest IV therapy IV antibiotics Warm compresses

Glaucoma

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

The aqueous fluid produce is greater than the amount leaving through the canal of Schlemm

Emergency SituationMay lead to irrecoverable blindness

GlaucomaSymptoms/Assessment

Red eye Severe, sudden-onset,

deep, unilateral pain Intense HA Decrease visual acuity Halos around lights N/V

Abdominal pain Hazy, lusterless cornea Pupils poorly reactive

or fixed Increased intraocular

pressure (>20 mm Hg) Rocklike harness

appearance Diagnostic

Tonometry

Glaucoma

Treatment/Education Referral to

ophthalmologist Analgesic Antiemetic Pilocarpine eyedrops Osmotic diuretic Supportive and

informative environment

Central retinal occlusion

Blockage of the the retinal artery by thrombus or embolus

True ocular emergency Prompt recognition and intervention must be obtained

within 1-2 hours of onset

Central retinal occlusion

Symptoms/Assessment Sudden unilateral loss

of vision Painless History of:

Thrombus or embolus HTN Diabetes Sickle cell disease Trauma

Visual acuity is limited to light perception in affected eye

Pupil reaction: dilated, nonreactive in affected eye

Central retinal occlusion

Treatment Referral to

ophthalmologist Digital massage of

globe by MD Supportive

environment

Possible IV therapy Anticoagulants tPA Low-molecular

weight Dextran Admission and

possibly surgery

Surgical Ocular Emergencies

Corneal AbrasionPartial or complete removal of an area of

epithelium of the corneaMost common eye injury seen in the ERCommon causes: FB, contact lenses,

exposure to UV light

Corneal Abrasion

Symptoms/Assessment Mild to severe pain Foreign body sensation Photophobia Normal to slightly

decreased visual acuity Injected conjunctiva Tearing Abnormal Fluorescein

stain

Corneal Abrasion

Treatment Topical analgesic Topical ophthalmic

antibiotic Tight patch to affected

eye for 12-24 hours

Education Follow-up care Proper patching

techniques Instillation of meds S/S of infection Use extra precaution

with activities requiring depth perception

Extraocular Foreign Body

Can enter as a result from hammering, grinding, working under cars, or working above the head

“Something going into my eye”Metal, sawdust, dust particlesMetal can form a rust ring on the cornea

Extraocular Foreign Body

Symptoms/Assessment Pain Foreign body sensation Tearing Redness Normal to slightly

abnormal visual acuity Fluorscein stain abnormal FB visualized

Diagnostics Magnifying lens Fluorescein stain Slit-lamp

Extraocular Foreign Body

TreatmentTopical anesthetic

Topical anesthetic inhibit wound healing and are toxic to corneal epithelium

Gentle irrigation with NS

FB removal with moist cotton swab, needle, eye spud if irrigation

Patch both eyes to reduce unsuccessful consensual movement

Possible admission

Extraocular Foreign Body

Education Instillation of

meds Patching

techniques Follow-up care Provide

preventative information

Retinal DetachmentSeparation of the retinal layers, with

accumulation of serous fluid or blood between the sensory retina and the retinal epithelium

Leads to decrease blood supply and oxygen to the retina

Most common cause: degenerative changes in the retina or vitreous body of the elderly

Sports direct head trauma

Retinal Detachment

Symptoms/Assessment Gradual or sudden

deterioration of vision unilaterally Cloudy, smoky vision Flashing lights Curtain or veil over visual

field No pain

Diagnostic Fundoscopy Visual acuity Slit-lamp exam

Retinal Detachment

Treatment Referral to

ophthalmologist Patch both eyes or

shielding to reduce eye movement

Bed rest, lying quietly Supportive and calm

environment Admission or transfer

Orbital fractureFracture of the orbit without a fracture of

the orbital rimCommon cause: blunt trauma from fist, ball,

or nonpenetrating objectThese fractures are associated with

entrapment and ischemia of nerves or penetration into a sinus

Orbital fracture

Symptoms/Assessment Hx of blunt trauma Diplopia Facial anesthesia Pain Sunken appearance of

the eye Limited vertical eye

movement

EOM abnormal Crepitus Periorbital edema,

hematoma, ecchymosis

Subconjunctival hemorrhage

Look for other injuries

Orbital fracture

Diagnostics Visual acuity Fundoscopy CT scan X-rays

Orbits Facial Waters’

Treatment/Education Ophthalmological

consult Analgesics Antibiotics Ice pack Refrain from blowing

nose Follow-up care Possible admission or

surgery

Chemical Burns

True ocular emergencyDistinction between acid and alkali exposure

must be madeImmediate irrigation

Chemical Burns

Symptoms/Assessment Pain Variable degree of

visual loss Chemical exposure Corneal whitening

Chemical Burns

Treatment Referral to

ophthalmology Irrigate with NS for

20-30 minutes Administer

cycloplegic Analgesics Eye patch Td

Hyphema

Blood in the anterior chamber from the iris bleeding

Usually result of blunt traumaSignificant risk of secondary bleeding in 3-5

days with outcomes poor

Hyphema

Symptoms/Assessment Blurred vision Blood tinged vision Pain Visualized blood in

anterior chamber at bottom of iris

Assess for other associated injuries

Hyphema

Treatment/Education Have patient sit upright

or bedrest with HOB 30° Patch or shield both

eyes Diuretics to decrease

intraocular pressure Refrain from taking

aspirin Refer to ophthalmologist Admission

Eyelid Laceration

Symptoms/Assessment MOI Visual disturbance Laceration Protrusion of fat Upper lid does not raise Assess for ocular injuries Bleeding

Treatment/Education Stop bleeding: Avoid

direct pressure on the eye

Surgical repair Topical analgesic Td Wound care S/S of infection Follow-up

Globe Rupture

Ocular EmergencyPenetrating or perforating injury

Globe Rupture

Symptoms/Assessment MOI

Blunt Penetrating

Sudden visual impairment or loss

Pain Asymmetry of globe Extrusion of aqueous or

vitreous humor

Direct visualization of FB

Irregularities in pupillary borders

Diagnostics CT scan MRI Orbit films Slit-lamp exam

Globe Rupture

Treatment Ophthalmological

referral Do not open eye Keep patient in Semi-

Fowlers position Patch/shield affected

both eyes IV analgesics IV antibiotics

Td Calm, supportive

environment Admission/Surgery If impaled object:

Secure it.

Do Not Remove IT!