Ocular Emergencies

1. Ocular Emergencies

2. 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 OCULAR EMERGENCIES

3. Assessment • History / MOI • Time of occurrence • Treatment before arrival • Abnormal eye appearance • Visual acuity • Snellen’s • Visual Fields • Finger count

4. Assessment • Tearing • Itching • Discharge • Medical History • Ocular • Systemic • Medication • Always use contralateral eye for comparison

5. Assessment • Spasms of eyelid • Lesions, FB, Penetrating wounds • Pupils • EOM • Position and alignment of eye

6. Assessment • Conjunctiva and sclera for color and inflammation • Edema of lids, conjunctive, and/or cornea • Blood • Opaque, gray-white area of cornea • Hazy cornea

7. Assessment • Palpation • Intraocular pressure: Do not do if there is concern regarding globe

8. 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

9. 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

10. Diagnostics • Direct ophthalmoscope • Tonometry • Fluorescein staining • Slit-lamp exam • Laboratory • Cultures • CBC • Coags

11. Diagnostics • Radiology • CT scan • Soft tissue/orbit films for foreign body • Facial bones • Skull films

12. Priorities • ABCs • Prevent further damage • Prevent or minimize complications • Control pain • Relieve anxiety or apprehension • Education

13. Penetrating ocular trauma Chemical burns of the eye Severe lid laceration Glaucoma Central retinal artery occlusion Retinal detachment Orbital fracture Hyphema Periorbital cellulitis Consultation Criteria

14. 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

15. 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

16. Age-related Pearls Geriatric • Decreased accommodation to distances • Decreased lacrimal secretions • Cataracts: at age 80 1 in 3 are affected • More likely to experience glaucoma, detached retina, and retinal bleeds

17. Medical Ocular Emergencies

18. Conjunctivitis • Inflammation of the conjunctiva • Causes: • bacterial/viral inflammation • allergies • Chlamydia • chemical burns • FB • flash burns • Irritants • URI

19. 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

20. 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 Conjunctivitis

21. Iritis • Inflammatory process that includes the iris and sometimes the ciliary body • Predisposing conditions: rheumatic disease, and syphillis

22. 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

23. Treatment/Education Analgesics NSAIDs Cycloplegics to paralyze ciliary muscle and spasms Darkened environment Rest eyes Warm compresses Shield eyes or dark glasses Follow-up Iritis

24. Periorbital Cellulitis • Infection of the cells around the eyes • A major ophthalmological emergency and is potentially life threatening • May occur after trauma such as laceration or an insect bite • Pneumococcal, staphylococcal, streptococcal

25. Symptoms/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

26. Treatment/Education Referral to ophthalmologist Bedrest IV therapy IV antibiotics Warm compresses Periorbital Cellulitis

27. 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 Situation • May lead to irrecoverable blindness

28. Symptoms/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

29. Treatment/Education Referral to ophthalmologist Analgesic Antiemetic Pilocarpine eyedrops Osmotic diuretic Supportive and informative environment Glaucoma

30. 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

31. 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

32. 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 Central retinal occlusion

33. Surgical Ocular Emergencies

34. Corneal Abrasion • Partial or complete removal of an area of epithelium of the cornea • Most common eye injury seen in the ER • Common causes: FB, contact lenses, exposure to UV light

35. Symptoms/Assessment Mild to severe pain Foreign body sensation Photophobia Normal to slightly decreased visual acuity Injected conjunctiva Tearing Abnormal Fluorescein stain Corneal Abrasion

36. 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 Corneal Abrasion

37. 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 particles • Metal can form a rust ring on the cornea

38. 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

39. Treatment Topical 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

40. Education Instillation of meds Patching techniques Follow-up care Provide preventative information Extraocular Foreign Body

41. Retinal Detachment • Separation 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

42. 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

43. Treatment Referral to ophthalmologist Patch both eyes or shielding to reduce eye movement Bed rest, lying quietly Supportive and calm environment Admission or transfer Retinal Detachment

44. Orbital fracture • Fracture of the orbit without a fracture of the orbital rim • Common cause: blunt trauma from fist, ball, or nonpenetrating object • These fractures are associated with entrapment and ischemia of nerves or penetration into a sinus

45. 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

46. 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 Orbital fracture

47. Chemical Burns • True ocular emergency • Distinction between acid and alkali exposure must be made • Immediate irrigation

48. Symptoms/Assessment Pain Variable degree of visual loss Chemical exposure Corneal whitening Chemical Burns

49. Treatment Referral to ophthalmology Irrigate with NS for 20-30 minutes Administer cycloplegic Analgesics Eye patch Td Chemical Burns

50. Hyphema • Blood in the anterior chamber from the iris bleeding • Usually result of blunt trauma • Significant risk of secondary bleeding in 3-5 days with outcomes poor