OCULAR EMERGENCY

Presenters: George Judicate, md4

Edson Nebo , md4
 OUTLINE
Introduction
Definition
Classification
Signs and symptoms
Triage
-history
-physical examination
Diagnosis and management of common ocular
emergency
 introduction
Prompt recognition and appropriate treatment of
ocular emergencies are essential in the primary
care setting when the outcome may depend on
time.
All ocular emergencies should be referred
immediately to the emergency department or an
ophthalmologist.
Careful eye examination and simple tests can
help primary care physicians make decisions
about appropriate treatment and referral
 Definition
Ocular Emergency;-
Are ocular condition that needs quick
identification and hence quick management
to save the patient from further pathologies.
;- It may involve cuts, scratches, objects in the
eye, burns, chemical exposure, and blunt
injuries to the eye or eyelid e.t.c
 CLASSIFICATION
1.according to etiology
2.according to urgent workup
 Ocular Emergencies

Trauma
Non-Trauma

Penetrating Blunt Neuro-

Eye
ophthalmology
 FUTHER CLASSIFICATION
1.IMMEDIATE- within minutes
a)chemical burns
b)central retinal artery occlusion
c)orbital hemorrage
2.VERY URGENT-within few hours
a) Endophthalmitis
b) cavernous sinus thrombosis
c) Microbial Keratitis
d) Orbital Cellulitis
e) Acute Glaucoma
 Classification cont
3.URGENT-within 1day
a) Hyphema
b) lid laceration
c) corneal abrasion
d)orbital fracture
 Nontraumatic Ocular Emergencies
Acute Dacryocystitis
Ocular Emergencies Acute Dacryoadenitis
Acute Hordeolum
Preseptal cellulitis
Spontaneous subconjunctival hemorrhage
Conjunctivitis
Ocular condiitons requiring immediate
Bacterial corneal ulcer
treatment
Viral keratoconjunctivitis
Acute Angle-Closure Glaucoma
Acute hydrops of the cornea
Central Retinal Artery Occlusion
Hyphema
Orbital Cellulitis
Uveitis ( iritis & iridocyclitis )
Cavernous Sinus Thrombosis
Vitreous hemorrhage
Endophthalmitis
Retinal hemorrhage
Retinal Detachment
Central retinal vein occlusion
Toxic Causes of blindness
Optic neuritis
 Ocular burns and trauma
Ocular Burn
Alkali Burns
Acid Burns
Ocular Emergencies Thermal Burns
Burns Due to Ultraviolet Radiation
Mechanical Trauma to the Eye
Penetrating or Perforating injuries
Blunt Trauma to the Eye, Adnexa,& Orbit
1. Ecchymosis of the Eyelids
2. Lacerations of the Eyelids
3. Orbital hemorrhage
4. Fracture of the Ethmoid bone
5. Blowout Fractures of the Floor of the Orbit
6. Corneal Abrasions
7. Corneal & Conjunctival Foreign Bodies
 General signs and symptoms
Bleeding or other discharge from or around the eye
Bruising
Decreased vision
Double vision
Eye pain
Headache
Itchy eyes
Loss of vision,
total or partial, one eye or both Pupils of unequal size
Redness -- bloodshot appearance
Sensation of something in the eye
Sensitivity to light
burning in the eye
 history
It MUST BE THERE but the format depends on that emergent condition
A detailed or comprehensive history is warranted to identify emergent
situations.
An ophthalmologist should be summoned immediately when the patient
has obvious eye trauma; The history and exam can be completed in the
meantime.
In a chemical exposure trauma, however, immediate eye irrigation is
mandatory.
Initial questioning should focus on determining whether the problem is
traumatic, inflammatory or neurovascular.
The technician should ask about prior surgeries or contact lens use, which
may be helpful in determining infectious causes. The medical, family and
social histories can suggest risk factors for inflammatory or neurovascular
etiologies. Query current and recent medications to determine if
antibiotics or topical steroids suggest an infectious etiology.
 History..
Although it may be difficult to determine which symptoms threaten
vision and require emergent care, a careful patient history may
uncover several important symptoms. These include reduced visual
acuity; visual field changes; floaters; photopsia; head, orbital or
ocular pain; changed appearance of the ocular adnexa; ptosis;
diplopia and alterations in pupil size. If the symptoms are severe or
rapidly progressive, urgent referral to an ophthalmologist is
appropriate.
Past ophthalmic and general medical history provide background
for the current symptoms. It is important to determine whether the
current condition could be a recurrence or a complication of a
previous ophthalmic condition. Always ask about any recent
ophthalmic or orbital surgery.
 History
Patient history provides important clues to the diagnosis. The onset and
duration of symptoms, current ocular conditions and immediate ocular
history can often help differentiate particular diagnoses and lead to
appropriate treatment.

In cases of trauma, particular importance must be given to the

environment preceding the injury. Small, sharp, high-velocity objects, for
example, resulting from hammering metal on metal or using a grinder,
often produce penetrating injuries.
An accident or a fall may cause blunt trauma and presents different issues.
Particular care should be given to noticing the presence of foreign bodies,
chemosis, corneal haze and blood or pus in the anterior chamber of the
eye.
If a full-thickness corneal injury is present, aqueous humor may be seen.
This requires emergency attention.
The presence of a pupillary defect is an important diagnostic sign. Pupil
examination must be completed before any dilating agents are used.
 examination
Depends on situaition
Quick physical examination
Emergent TEST
-VA
-RETINOSCOPY
- FUNDOSCOPY
-CT SCAN
Diagnosis and management of
common occular emergency
 Chemical burn

True ocular emergency

Both acid and alkali burns can be blinding
- Acid burns tend to coagulate proteins, limiting
the depth of penetration.
- Alkali burns can rapidly penetrate the cornea,
causing damage to intraocular structures.
Chemical Burn
Treatment should be instituted
IMMEDIATELY, even before talking
history

Emergency Treatment:
Saline Copious irrigation (until neutral
pH i.e 7.3-7.7):, may range from a few
liters to many liters (more than 8 to 10 L

Lids should be retracted and

fornices swabbed for particulate Tap water
matter

Once pH is stabilized
Cycloplegic agent
Broad-spectrum
antibiotic
 Lid laceration

Eyelids dont have fat

Take care check lid margin

Orbital fat usually protrudes through

septal lacerations
Fat in the lid laceration confirms the
diagnosis
High incidence of globe penetration
and intraocular foreign bodies
High risk for orbital cellulitis Medial injuries may affect lacrimal
passages
Management of
Lid Lacerations

R/O associated ocular injury

Remove superficial FB
Rule out deeper FB
laceration repair
Give tetanus prophylaxis
 Corneal FB
Often metallic foreign body following
work injury

foreign body sensation, tearing, red,

or painful eye.

Remove foreign body

Evert the eyelid to
rule out additional
FB

Topical AB Linear epithelial defects suggestive of foreign

body under the eye lid
 Treatment:
Periorbital Cellulitis (Preseptal Cellulitis) Hospital admission
Warm, indurated, erythematous eyelids only for IV Cefuroxime

Orbital Cellulitis (Postseptal Cellulitis)

Warm, indurated, erythematous eyelids
only

emergent orbital and sinus CT

Fever, toxicity, proptosis,

painful ocular motility,
limited ocular excursion
 Retrobulbar hematoma
APD,
Acute orbital compartment syndrome 2
to blunt or penetrating trauma Proptosis

Hemorrhage into closed space of orbit Ophthalmoplegia

Diminished vision
IOP leading to vision loss from optic
nerve damage / retinal ischemia IOP

Immediate lateral canthotomy and cantholysis

indicated if IOP > 40mmHg or vision loss
 Acute Angle Closure Glaucoma (AACG) -
Pain (sever brusting ) Conjunctival injection (ciliary flush)

Halos (around lights) Corneal edema

Nausea/vomiting Mid-dilated, fixed pupil

IOP ( stony hard)

Medical Tx
Reduce production of aqueous humor
Topical -blocker (timolol 0.5% - 1- 2 gtt)
Carbonic anhydrase inhibitor (acetazolamide 500mg iv or po)
Systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min)
Or increase outflow
Topical -agonist (phenylephrine 1 gtt)
Miotics (pilocarpine 1-2%)
Topical steroid (prednisolone acetate 1%), 1 gtt Q15-30 min x 4, then Q1H

Definitive Tx
Laser peripheral iridectomy
 Penetrating / Ruptured Globe

Corneal or scleral lacerations

Hypotony (not always present)
Severe chemosis & hemorrhage
Intraocular contents may be outside the globe
Limitation of extraocular motility
Shallow anterior chamber
Irregular pupil
Penetrating / Ruptured Globe
Penetrating / Ruptured Globe : Management

Stop examination
Shield the eye (do not patch)
Give tetanus prophylaxis
Give systemic antibiotics
Do not apply eye ointment or eye drop
Film orbit if IOFB cant be R/O
Refer immediately to ophthalmologist
 references
Medscape.
Online notes-slide share
Khurana
google
 THE END

GRACIAS