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Ocular EmergenciesOcular Emergencies
OCULAR EMERGENCIESOCULAR EMERGENCIES
MedicalMedical• ConjunctivitisConjunctivitis• IritisIritis• Periorbital CellulitisPeriorbital Cellulitis• GlaucomaGlaucoma• Central Retinal Central Retinal
Artery OcclusionArtery Occlusion
SurgicalSurgical• Corneal AbrasionCorneal Abrasion• Extraocular Foreign Extraocular Foreign
BodiesBodies• Retinal DetachmentRetinal Detachment• Orbital FractureOrbital Fracture• Chemical BurnsChemical Burns• HyphemaHyphema• Eyelid LacerationEyelid Laceration• Globe RuptureGlobe Rupture
AssessmentAssessment
History / MOIHistory / MOI Time of occurrenceTime of occurrence Treatment before arrivalTreatment before arrival Abnormal eye appearanceAbnormal eye appearance Visual acuityVisual acuity
• Snellen’sSnellen’s• Visual FieldsVisual Fields• Finger countFinger count
AssessmentAssessment
TearingTearing ItchingItching Discharge Discharge Medical HistoryMedical History
• Ocular Ocular • SystemicSystemic• MedicationMedication
Always use contralateral eye for Always use contralateral eye for comparisoncomparison
AssessmentAssessment
Spasms of eyelidSpasms of eyelid Lesions, FB, Penetrating woundsLesions, FB, Penetrating wounds PupilsPupils EOMEOM Position and alignment of eyePosition and alignment of eye
AssessmentAssessment
Conjunctiva and sclera for color and Conjunctiva and sclera for color and inflammationinflammation
Edema of lids, conjunctive, and/or Edema of lids, conjunctive, and/or corneacornea
BloodBlood Opaque, gray-white area of corneaOpaque, gray-white area of cornea Hazy corneaHazy cornea
AssessmentAssessment
PalpationPalpation• Intraocular pressure: Do not do if Intraocular pressure: Do not do if
there is concern regarding globe there is concern regarding globe
Things To Think About When Things To Think About When AssessingAssessing
Younger males are at higher risk for Younger males are at higher risk for serious injuryserious injury
School-age children are more School-age children are more susceptible to conjunctivitissusceptible to conjunctivitis
Contact wearers are at greater risk for Contact wearers are at greater risk for corneal abrasions and infectioncorneal abrasions and infection
Exposure to arc welding S/S develop 4-8 Exposure to arc welding S/S develop 4-8 post exposurepost exposure
Things To Think About When Things To Think About When AssessingAssessing
Auto mechanics and service station Auto mechanics and service station attendants have potential for acid burns attendants have potential for acid burns to faceto face
Injuries occurring in the garden have Injuries occurring in the garden have increased potential for infectionincreased potential for infection
Ball sports increase potential for eye Ball sports increase potential for eye injuryinjury
DiagnosticsDiagnostics
Direct ophthalmoscopeDirect ophthalmoscope TonometryTonometry Fluorescein stainingFluorescein staining Slit-lamp examSlit-lamp exam LaboratoryLaboratory
• CulturesCultures• CBCCBC• CoagsCoags
DiagnosticsDiagnostics
RadiologyRadiology• CT scanCT scan• Soft tissue/orbit films for foreign Soft tissue/orbit films for foreign
bodybody• Facial bonesFacial bones• Skull filmsSkull films
PrioritiesPriorities
ABCsABCs Prevent further damagePrevent further damage Prevent or minimize complicationsPrevent or minimize complications Control painControl pain Relieve anxiety or apprehensionRelieve anxiety or apprehension EducationEducation
Consultation CriteriaConsultation Criteria
Penetrating Penetrating ocular traumaocular trauma
Chemical burns Chemical burns of the eyeof the eye
Severe lid Severe lid lacerationlaceration
GlaucomaGlaucoma
Central retinal Central retinal artery occlusionartery occlusion
Retinal Retinal detachmentdetachment
Orbital fractureOrbital fracture HyphemaHyphema Periorbital Periorbital
cellulitiscellulitis
Age-related PearlsAge-related Pearls
PediatricPediatric• Delayed presentation due to children Delayed presentation due to children
not noticing gradual vision lossnot noticing gradual vision loss• May need picture chartMay need picture chart• Infants and small children may need to Infants and small children may need to
be restrained in blanket to facilitate be restrained in blanket to facilitate examexam
Age-related PearlsAge-related Pearls
GeriatricGeriatric• Vision diminishes gradually until 70 y/o Vision diminishes gradually until 70 y/o
and then rapidly thereafterand then rapidly thereafter• Decreased near visionDecreased near vision• Decreased accuracy of results from Decreased accuracy of results from
visual acuity testingvisual acuity testing
Age-related PearlsAge-related PearlsGeriatricGeriatric
• Decreased accommodation Decreased accommodation
to distancesto distances• Decreased lacrimal secretions Decreased lacrimal secretions • Cataracts: at age 80 1 in 3 Cataracts: at age 80 1 in 3
are affected are affected• More likely to experience More likely to experience
glaucoma, detached retina, and glaucoma, detached retina, and retinal bleedsretinal bleeds
Medical Ocular EmergenciesMedical Ocular Emergencies
ConjunctivitisConjunctivitis
Inflammation of the conjunctivaInflammation of the conjunctiva Causes: Causes:
• bacterial/viral inflammation bacterial/viral inflammation • allergies allergies • ChlamydiaChlamydia• chemical burnschemical burns• FBFB• flash burnsflash burns• IrritantsIrritants• URIURI
ConjunctivitisConjunctivitisSymptoms/AssessmentSymptoms/Assessment
• HyperemiaHyperemia• Unilateral or bilateralUnilateral or bilateral• Slight painSlight pain• ““Gritty” sensationGritty” sensation• DischargeDischarge
MucopurulentMucopurulent Matting of eyelids and Matting of eyelids and
lasheslashes
• Edema of eyelidsEdema of eyelids• Visual acuity: NormalVisual acuity: Normal• Cornea: ClearCornea: Clear• Pupil: NormalPupil: Normal• Conjunctiva: red or Conjunctiva: red or
pinkpink
ConjunctivitisConjunctivitis
TreatmentTreatment• Antibiotics Antibiotics
ointment/dropsointment/drops• Obtain culture, if Obtain culture, if
indicatedindicated• Cleanse eyes gently Cleanse eyes gently
to remove debristo remove debris
EducationEducation• Explain contagious Explain contagious
naturenature• Medication admin.Medication admin.• AsepsisAsepsis• Wipe from nose to Wipe from nose to
outer corner of eyeouter corner of eye• Cleanse lid with Cleanse lid with
baby shampoobaby shampoo• Avoid eye makeupAvoid eye makeup• Follow-upFollow-up
IritisIritis Inflammatory process that includes Inflammatory process that includes
the iris and sometimes the ciliary the iris and sometimes the ciliary bodybody
Predisposing conditions:Predisposing conditions: rheumatic rheumatic disease, and syphillisdisease, and syphillis
IritisIritisSymptoms/AssessmentSymptoms/Assessment
• Blurring of visionBlurring of vision• Unilateral painUnilateral pain• Edema of upper lidEdema of upper lid• Red eyeRed eye• PhotophobiaPhotophobia• Decreased visual Decreased visual
acuity acuity • LacrimationLacrimation
• Redness at eyelashRedness at eyelash• Clear to hazy corneaClear to hazy cornea• Small, irregular, Small, irregular,
sluggish reaction of sluggish reaction of pupilspupils
• Pain on eye pressurePain on eye pressure• Fluorescein stainFluorescein stain• Slit-lamp examSlit-lamp exam
IritisIritisTreatment/EducationTreatment/Education
• AnalgesicsAnalgesics• NSAIDsNSAIDs• Cycloplegics to Cycloplegics to
paralyze ciliary paralyze ciliary muscle and spasmsmuscle and spasms
• Darkened Darkened environmentenvironment
• Rest eyesRest eyes• Warm compresses Warm compresses • Shield eyes or dark Shield eyes or dark
glassesglasses• Follow-upFollow-up
Periorbital CellulitisPeriorbital Cellulitis
Infection of the cells around the eyesInfection of the cells around the eyes A major ophthalmological emergency A major ophthalmological emergency
and is potentially life threateningand is potentially life threatening May occur after trauma such as May occur after trauma such as
laceration or an insect bitelaceration or an insect bite Pneumococcal, staphylococcal, Pneumococcal, staphylococcal,
streptococcalstreptococcal
Periorbital CellulitisPeriorbital Cellulitis
Symptoms/AssessmentSymptoms/Assessment• Marked periorbital Marked periorbital
edema and erythemaedema and erythema• Pain: severe that is Pain: severe that is
aggravated by aggravated by movement of eyemovement of eye
• Conjunctival infectionConjunctival infection• FeverFever
• Visual acuity: Visual acuity: DecreasedDecreased
• Decreases pupil Decreases pupil reflexesreflexes
• Paralysis of EOMParalysis of EOM• DiagnosticsDiagnostics
CT scan CT scan CultureCulture Gram stainGram stain Blood cultureBlood culture
Periorbital CellulitisPeriorbital Cellulitis
Treatment/EducationTreatment/Education• Referral to Referral to
ophthalmologistophthalmologist• BedrestBedrest• IV therapyIV therapy• IV antibioticsIV antibiotics• Warm compressesWarm compresses
GlaucomaGlaucoma
Acute angle-closure glaucoma occurs Acute angle-closure glaucoma occurs when the distance between the iris when the distance between the iris and the cornea becomes inadequate and the cornea becomes inadequate or is blocked completelyor is blocked completely
The aqueous fluid produce is greater The aqueous fluid produce is greater than the amount leaving through the than the amount leaving through the canal of Schlemmcanal of Schlemm
Emergency SituationEmergency Situation May lead to irrecoverable blindnessMay lead to irrecoverable blindness
GlaucomaGlaucomaSymptoms/AssessmentSymptoms/Assessment
• Red eyeRed eye• Severe, sudden-onset, Severe, sudden-onset,
deep, unilateral paindeep, unilateral pain• Intense HAIntense HA• Decrease visual acuityDecrease visual acuity• Halos around lightsHalos around lights• N/VN/V
• Abdominal painAbdominal pain• Hazy, lusterless Hazy, lusterless
corneacornea• Pupils poorly reactive Pupils poorly reactive
or fixedor fixed• Increased intraocular Increased intraocular
pressure (>20 mm pressure (>20 mm Hg)Hg)
• Rocklike harness Rocklike harness appearanceappearance
• DiagnosticDiagnostic TonometryTonometry
GlaucomaGlaucoma
Treatment/EducationTreatment/Education• Referral to Referral to
ophthalmologistophthalmologist• AnalgesicAnalgesic• AntiemeticAntiemetic• Pilocarpine Pilocarpine
eyedropseyedrops• Osmotic diureticOsmotic diuretic• Supportive and Supportive and
informative informative environmentenvironment
Central retinal occlusionCentral retinal occlusion
Blockage of the the retinal artery by Blockage of the the retinal artery by thrombus or embolusthrombus or embolus
True ocular emergencyTrue ocular emergency• Prompt recognition and intervention Prompt recognition and intervention
must be obtained within 1-2 hours of must be obtained within 1-2 hours of onsetonset
Central retinal occlusionCentral retinal occlusion
Symptoms/AssessmentSymptoms/Assessment• Sudden unilateral loss Sudden unilateral loss
of visionof vision• PainlessPainless• History of:History of:
Thrombus or embolusThrombus or embolus HTNHTN DiabetesDiabetes Sickle cell diseaseSickle cell disease TraumaTrauma
• Visual acuity is Visual acuity is limited to light limited to light perception in perception in affected eyeaffected eye
• Pupil reaction: Pupil reaction: dilated, dilated, nonreactive in nonreactive in affected eyeaffected eye
Central retinal occlusionCentral retinal occlusion
TreatmentTreatment• Referral to Referral to
ophthalmologist ophthalmologist • Digital massage of Digital massage of
globe by MDglobe by MD• Supportive Supportive
environmentenvironment
• Possible IV Possible IV therapytherapy
AnticoagulantsAnticoagulants tPAtPA Low-molecular Low-molecular
weight Dextranweight Dextran Admission and Admission and
possibly surgerypossibly surgery
Surgical Ocular EmergenciesSurgical Ocular Emergencies
Corneal AbrasionCorneal Abrasion Partial or complete removal of an Partial or complete removal of an
area of epithelium of the corneaarea of epithelium of the cornea Most common eye injury seen in the Most common eye injury seen in the
ERER Common causes: FB, contact lenses, Common causes: FB, contact lenses,
exposure to UV light exposure to UV light
Corneal AbrasionCorneal AbrasionSymptoms/AssessmentSymptoms/Assessment
• Mild to severe painMild to severe pain• Foreign body sensationForeign body sensation• PhotophobiaPhotophobia• Normal to slightly Normal to slightly
decreased visual acuitydecreased visual acuity• Injected conjunctivaInjected conjunctiva• TearingTearing• Abnormal Fluorescein Abnormal Fluorescein
stainstain
Corneal AbrasionCorneal Abrasion
TreatmentTreatment• Topical analgesicTopical analgesic• Topical ophthalmic Topical ophthalmic
antibioticantibiotic• Tight patch to Tight patch to
affected eye for 12-affected eye for 12-24 hours24 hours
EducationEducation• Follow-up careFollow-up care• Proper patching Proper patching
techniquestechniques• Instillation of medsInstillation of meds• S/S of infectionS/S of infection• Use extra Use extra
precaution with precaution with activities requiring activities requiring depth perceptiondepth perception
Extraocular Foreign BodyExtraocular Foreign Body
Can enter as a result from Can enter as a result from hammering, grinding, working under hammering, grinding, working under cars, or working above the headcars, or working above the head
““Something going into my eye”Something going into my eye” Metal, sawdust, dust particlesMetal, sawdust, dust particles Metal can form a rust ring on the Metal can form a rust ring on the
corneacornea
Extraocular Foreign BodyExtraocular Foreign Body
Symptoms/AssessmentSymptoms/Assessment• PainPain• Foreign body sensationForeign body sensation• TearingTearing• RednessRedness• Normal to slightly Normal to slightly
abnormal visual acuityabnormal visual acuity• Fluorscein stain Fluorscein stain
abnormalabnormal• FB visualizedFB visualized
DiagnosticsDiagnostics• Magnifying lensMagnifying lens• Fluorescein stainFluorescein stain• Slit-lampSlit-lamp
Extraocular Foreign BodyExtraocular Foreign Body
TreatmentTreatment• Topical anestheticTopical anesthetic
Topical anesthetic Topical anesthetic inhibit wound inhibit wound healing and are healing and are toxic to corneal toxic to corneal epitheliumepithelium
• Gentle irrigation Gentle irrigation with NSwith NS
• FB removal with FB removal with moist cotton swab, moist cotton swab, needle, eye spud if needle, eye spud if irrigation irrigation
• Patch both eyes to Patch both eyes to reduce unsuccessful reduce unsuccessful consensual consensual movementmovement
• Possible admissionPossible admission
Extraocular Foreign BodyExtraocular Foreign Body
EducationEducation• Instillation of Instillation of
medsmeds• Patching Patching
techniquestechniques• Follow-up careFollow-up care• Provide Provide
preventative preventative informationinformation
Retinal DetachmentRetinal Detachment Separation of the retinal layers, with Separation of the retinal layers, with
accumulation of serous fluid or blood accumulation of serous fluid or blood between the sensory retina and the retinal between the sensory retina and the retinal epitheliumepithelium
Leads to decrease blood supply and oxygen Leads to decrease blood supply and oxygen to the retinato the retina
Most common cause: degenerative changes Most common cause: degenerative changes in the retina or vitreous body of the elderlyin the retina or vitreous body of the elderly
Sports direct head traumaSports direct head trauma
Retinal DetachmentRetinal Detachment
Symptoms/AssessmentSymptoms/Assessment• Gradual or sudden Gradual or sudden
deterioration of vision deterioration of vision unilaterallyunilaterally
Cloudy, smoky visionCloudy, smoky vision Flashing lightsFlashing lights Curtain or veil over Curtain or veil over
visual fieldvisual field
• No painNo pain
DiagnosticDiagnostic• FundoscopyFundoscopy• Visual acuityVisual acuity• Slit-lamp examSlit-lamp exam
Retinal DetachmentRetinal Detachment
TreatmentTreatment• Referral to Referral to
ophthalmologistophthalmologist• Patch both eyes or Patch both eyes or
shielding to reduce shielding to reduce eye movementeye movement
• Bed rest, lying Bed rest, lying quietlyquietly
• Supportive and calm Supportive and calm environmentenvironment
• Admission or transferAdmission or transfer
Orbital fractureOrbital fracture Fracture of the orbit without a Fracture of the orbit without a
fracture of the orbital rimfracture of the orbital rim Common cause: blunt trauma from Common cause: blunt trauma from
fist, ball, or nonpenetrating objectfist, ball, or nonpenetrating object These fractures are associated with These fractures are associated with
entrapment and ischemia of nerves entrapment and ischemia of nerves or penetration into or penetration into
a sinusa sinus
Orbital fractureOrbital fracture
Symptoms/AssessmentSymptoms/Assessment• Hx of blunt traumaHx of blunt trauma• DiplopiaDiplopia• Facial anesthesiaFacial anesthesia• PainPain• Sunken appearance of Sunken appearance of
the eye the eye• Limited vertical eye Limited vertical eye
movement movement
• EOM abnormalEOM abnormal• CrepitusCrepitus• Periorbital edema, Periorbital edema,
hematoma, hematoma, ecchymosisecchymosis
• Subconjunctival Subconjunctival hemorrhagehemorrhage
• Look for other Look for other injuriesinjuries
Orbital fractureOrbital fracture
DiagnosticsDiagnostics• Visual acuityVisual acuity• FundoscopyFundoscopy• CT scanCT scan• X-raysX-rays
OrbitsOrbits FacialFacial Waters’Waters’
Treatment/EducationTreatment/Education• Ophthalmological Ophthalmological
consultconsult• AnalgesicsAnalgesics• AntibioticsAntibiotics• Ice packIce pack• Refrain from blowing Refrain from blowing
nosenose• Follow-up careFollow-up care• Possible admission or Possible admission or
surgerysurgery
Chemical BurnsChemical Burns
True ocular emergencyTrue ocular emergency Distinction between acid and alkali Distinction between acid and alkali
exposure must be madeexposure must be made Immediate irrigationImmediate irrigation
Chemical BurnsChemical BurnsSymptoms/AssessmentSymptoms/Assessment
• PainPain• Variable degree of Variable degree of
visual lossvisual loss• Chemical exposureChemical exposure• Corneal whiteningCorneal whitening
Chemical BurnsChemical Burns
TreatmentTreatment• Referral to Referral to
ophthalmologyophthalmology• Irrigate with NS for Irrigate with NS for
20-30 minutes20-30 minutes• Administer Administer
cycloplegic cycloplegic • AnalgesicsAnalgesics• Eye patchEye patch• TdTd
HyphemaHyphema
Blood in the anterior chamber from Blood in the anterior chamber from the iris bleedingthe iris bleeding
Usually result of blunt traumaUsually result of blunt trauma Significant risk of secondary bleeding Significant risk of secondary bleeding
in 3-5 days with outcomes poorin 3-5 days with outcomes poor
HyphemaHyphema
Symptoms/Symptoms/AssessmentAssessment• Blurred visionBlurred vision• Blood tinged visionBlood tinged vision• PainPain• Visualized blood in Visualized blood in
anterior chamber at anterior chamber at bottom of irisbottom of iris
• Assess for other Assess for other associated injuriesassociated injuries
HyphemaHyphemaTreatment/EducationTreatment/Education
• Have patient sit upright Have patient sit upright or bedrest with HOB 30or bedrest with HOB 30°°
• Patch or shield both Patch or shield both eyeseyes
• Diuretics to decrease Diuretics to decrease intraocular pressureintraocular pressure
• Refrain from taking Refrain from taking aspirinaspirin
• Refer to ophthalmologistRefer to ophthalmologist• AdmissionAdmission
Eyelid LacerationEyelid Laceration
Symptoms/AssessmentSymptoms/Assessment• MOIMOI• Visual disturbanceVisual disturbance• LacerationLaceration• Protrusion of fatProtrusion of fat• Upper lid does not raiseUpper lid does not raise• Assess for ocular Assess for ocular
injuriesinjuries• BleedingBleeding
Treatment/EducationTreatment/Education• Stop bleeding: Stop bleeding:
Avoid direct Avoid direct pressure on the eyepressure on the eye
• Surgical repairSurgical repair• Topical analgesicTopical analgesic• TdTd• Wound careWound care• S/S of infectionS/S of infection• Follow-upFollow-up
Globe RuptureGlobe Rupture
Ocular EmergencyOcular Emergency Penetrating or perforating injuryPenetrating or perforating injury
Globe RuptureGlobe RuptureSymptoms/AssessmentSymptoms/Assessment
• MOIMOI BluntBlunt PenetratingPenetrating
• Sudden visual Sudden visual impairment or lossimpairment or loss
• PainPain• Asymmetry of globeAsymmetry of globe• Extrusion of aqueous Extrusion of aqueous
or vitreous humor or vitreous humor
• Direct visualization Direct visualization of FBof FB
• Irregularities in Irregularities in pupillary borderspupillary borders
• DiagnosticsDiagnostics CT scanCT scan MRIMRI Orbit filmsOrbit films Slit-lamp examSlit-lamp exam
Globe RuptureGlobe RuptureTreatmentTreatment
• Ophthalmological Ophthalmological referralreferral
• Do not open eyeDo not open eye• Keep patient in Semi-Keep patient in Semi-
Fowlers positionFowlers position• Patch/shield affected Patch/shield affected
both eyesboth eyes• IV analgesicsIV analgesics• IV antibioticsIV antibiotics
• TdTd• Calm, supportive Calm, supportive
environmentenvironment• Admission/SurgeryAdmission/Surgery• If impaled object: If impaled object:
Secure it. Secure it.
Do Not Do Not Remove IT!Remove IT!
Questions????Questions????