Ocular Emerg
Ocular Emerg
Ocular Emerg
Ocular Emergencies
{
Review ocular anatomy
Understand basic ophthalmic workup
Know differential for:
Red eye
Recognize and manage common ocular
emergencies
Objectives
Anatomy of the Eye
www.jaapa.com
Near vision card
Penlight with blue filter
Topical anesthetic
Fluorescein strips
Topical mydriatic
Useful Tools
Visual acuity - Snellen eye chart, counting fingers, light
perception
CN II – VII - Pupils, visual fields, EOMs, facial droop
Eye Exam
suspected rupture, history of glaucoma
Intraocular pressure - Goldman applanation tonometry,
Tonopen
Perform at slit lamp
If not available, use ophthalmoscope
Inspect
Conjunctiva
Cornea
Anterior chamber
Iris
Lens
Anterior Segment
Estimating Anterior Chamber
Depth
Measures the intraocular pressure by
calculating the force required to
depress the cornea a given amount
with a tonometer.
IOP 10-20 is considered normal.
In chronic open angle glaucoma, IOP
can be 20-30, and in acute angle
closure glaucoma, IOP can be greater
than 40.
Tonometry
Measures both the direct and consensual
response of pupil to light.
Step 1: Shine light in right eye. This will
cause BOTH right and left pupils to constrict
via CN III through Edinger-Westphal
nucleus.
Step 2: Then swing pen light to left eye and
check to make sure the left eye
CONSTRICTS. If it constricts, this means that
the LEFT CN II is intact and is causing a
direct pupillary reflex. If it dilates, then this is a
sign that the LEFT retina or optic nerve is
damaged and is called an Afferent pupillary
defect. (APD)
Retinal vessels
Macula
Posterior Segment
Key worrisome clinical findings (ophtho
referral needed):
Pain: Pain in eye often indicates more
serious intraocular pathology (iritis,
glaucoma).
Visual acuity: if decreased, usually more
serious cause.
Pupil: if sluggish, worry about acute
glaucoma
Pattern of redness: CILIARY FLUSH
(Redness worse near cornea, usually serious
intraocular cause: iritis or glaucoma).
Ciliary Flush
Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by
the American Academy of Ophthalmology
DO YOU HAVE PAIN?
Biggest distinguishing Main differential of red
factor between emergent eye:
and non-emergent Conjunctivitis
Do you wear contacts? (infectious/noninfectious)
(increased risk of Trauma, Foreign body
keratitis-corneal infection) Subconjunctival
hemorrhage
Do you have any Angle closure glaucoma
associated symptoms? Iritis/uveitis
Red
Eye: Key historical
Decreased vision
photophobia/diplopia
Kerititis
Scleritis, episcleritis
questions
flashes/floaters
Halos/N/V/Abd pain
Any above require referral
Orbital Blowout Fracture
Signs & Sx’s:
Enophthalmos
Diplopia
Impairment of eye
movement 20 to EOM
entrapment, orbital
hemorrhage or nerve
damage
Orbital emphysema
Infraorbital n. anesthesia
Treatment
Apply 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
Corneal injuries
Seidel’s test:
Concentrated
fluorescein is dark
orange but turns bright
green under blue light
after dilution.
This indicates aqueous
leakage which is
diluting the green dye.
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 lenses
Avoid patching
Management of Corneal
Injury
Penetrating trauma
leads to corneal or
scleral disruption
and extravasation of
intraocular contents.
Can lead to:
Irreversible visual loss
Endophthalmitis -
inflammation of the
intraocular cavities
Ruptured globe
Signs and symptoms:
pain, decreased vision
hyphema
loss of anterior chamber
depth
“tear-drop” pupil which
points toward laceration
severe subconjunctival
hemorrhage completely
encircling the cornea.
Diagnosis: positive
Seidel’s test, clinical
exam.
Ruptured Globe
Ruptured Globe
Management
Stop the examination
Cover with metal eye shield or
styrofoam cup. DO NOT PATCH.
Consult ophthalmology immediately
Do not perform tonometry.
CT head and orbit to evaluate for
concomitant facial/orbital injury.
Tetanus toxoid
Antibiotics: Cefazolin + ciprofloxacin
provides good coverage.
Antiemetics and analgesics decrease risk
of Valsalva or movement which could
increase IOP.
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2 weeks
*If dense, circumferential bloody chemosis is
present, must rule out globe rupture
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2 weeks
*If dense, circumferential bloody chemosis is
present, must rule out globe rupture
Traumatic Eye Injuries
Subconjunctival Hemorrhage
Disruption of conjunctival blood vessel
Etiology
Trauma
Sneezing
Gagging
Valsalva
Will resolve spontaneously within 2
weeks
*If dense, circumferential bloody chemosis
is present, must rule out globe rupture
Traumatic Eye Injuries
Conjunctival Abrasion
Superficial abrasions
Treatment: 2-3 days of erythromycin ointment
Ocular foreign body should be excluded
Corneal Abrasion
Tearing, photophobia, blepharospasm, severe
pain
Fluorescein: dye uptake at defect site
Rule out foreign body
Treatment:
Cycloplegic
Topical Tobramycin, Erythromycin, or
Bacitracin/polymyxin drops
Contact lens wearers: Cipro, Ofloxacin, or
Tobramycin drops
Tetanus shot
Ophthalmology consult within 24 hours
Treatment:
Place the pt upright to allow
inferior settling of blood
Exclude ruptured globe
Dilate the pupil with atropine
Measure intraocular pressure – if >
30 mmHg apply topical Timolol
Emergent Optho eval